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**
PRACTICAL GYNECOLOGY
MONTGOMERY
Practical Gynecology
A COMPREHENSIVE TEXT- BOOK
FOR STUDENTS AND PHYSICIANS
BY
E. E. MONTGOMERY, M.D., LLD.
I ft ri-'^S" U oK GYNECOLOGY, JFFPKR50N MEDICAL COI-LHGK ; GYNECOLOGIST TO THR JSPFERSON MEDICAL
C< •lI.EGE AND ST. JOSKPH's HOSPITALS; CONSULTING GYNECOLOGIST TO THE PHILADELPHIA
LYING IN CHARITY AND THE KENSINGTON HOSPITAL POR WOMEN
XCbitO 1?ex>i8eO EOition
WITH FIVE HUNDRED AND SEVENTY-FOUR ILLUSTRATIONS, THE GREATER
NUMBER OF WHICH HAVE BEEN DRAWN AND ENGRAVED SPECIALLY
FOR THIS WORK, FOR THE MOST PART FROM ORIGINAL SOURCES
PHILADELPHIA
p. BLAKISTON'S SON & CO
I0I2 WALNUT STREET
1907
• « «
Copyright, 1907, by P. Bij^kistos's Son & Co.
M. P. PKI.U COMPANY
b b • »
•
»• •
• •• 4
• •• •
• •
*. * * .
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• • • ••
.ZC' /
TO
®r, TWl. 13. Marber,
MY CONSCIENTIOUS INSTRUCTOR AS QUIZ-MASTER AND HOSPITAL CHIEF.
AND MY GENEROUS FRIEND,
THIS BOOK IS RESPECTFULLY DEDICATED.
.^2862
PREFACE TO THE THIRD EDITION.
This book has been carefully revised for the third edition, and
some seventy pages of new material have been added. Micro-
scopic diagnosis, gynecic bacteriology, and the pathology of
carcinoma uteri have been rewritten.
The subjects of Etiology and Blood Examination have been
added.
Of the new illustrations Nos. 42, 295, 471, 472, 473, 474. 480,
481, 482, 484, 486, 488, 492, 511, 512, 519, 520, 532, 533, and
556 were prepared by Miss S. L. Clark, and Xos. 78, 79, 415,
416, and 417 by Miss E. A. Cantner.
I desire to express my indebtedness to Dr. P. B. Bland for
having written the blood examination and microscopic diagnosis,
and for valuable suggestions in the pathology of cancer; and
to Miss E. A. Cantner for preparation of the index,
Philadelphia, March 25, igo/.
vii
PREFACE TO THE SECOND EDITION.
In presenting a second edition of this work, I desire to express
my sincere gratification over the generous and flattering recep-
tion the first edition has obtained from the medical press and
the profession.
Many changes have been made in the arrangement of the
different divisions which experience has led me to believe will
prove of benefit to the student. Malformations are confined
to congenital conditions, while the lesions of parturition are
treated under the designation of Traumatisms. Disorders of
the Fallopian tube and the ovary are more specifically treated
in Inflammation. The specific treatment of the various de-
viations is discussed in close relation with each subject. The
division comprising genital tumors has been extensively changed
in the consideration of myomata and malignant growths.
It has been my purpose in the entire revision to increase the
usefulness of the work to the student by treating, in closer detail,
the later operative procedures, and in order to accomplish this the
greater part of the work has been rewritten, which has added
some seventy pages. The illustrations have been increased in
number and many of them redrawn. New illustrations made
from material secured from my own practice have been largely
substituted for the microscopic drawings of the former edition.
I here take occasion to express my thanks to Mr. H. J. Shan-
non for the care and painstaking skill with which he has cor-
rected many of the old drawings and constructed several new
ones, notably those illustrating the Doyen operation for uterine
myomata; to Miss S. L. Clark for drawings of microscopic sec-
tions from which the following illustrations were prepared, figures
48 and 49 a and b, 126, 130, 132, 133, 296, 299, 300, 302, 306, 307,
510, 513, 531, 534, 535, 549; to Miss Karin M. Hall for drawings
for figures 301, 310, 311; to Professor W. M. L. Coplin, M.D.,
ix
X PREFACE TO THE SECOND EDITION.
for his kind supervision of the preparation of the microscopic
drawings and for many valtiable suggestions; to Drs. J. M.
Fisher, John C. DaCosta, Wilmer Krusen, and C. P. Noble for
the loan of specimens from which illustrations were prepared.
I am indebted to Dr. P. Brooke Bland for the preparation of
the slides from which the microscopic illustrations were made, for
correction of the manuscript, and for assistance with the index ; to
Miss E. A. Cantner for the rearrangement and preparation of the
index and table of contents. The publishers deserv^e my un-
stinted praise for their generous expenditure for redrawing the
old and in the preparation of new illustrations, and for their
ptirpose to present the work in an attractive form.
It is my sincere hope that this edition shall render the phy-
sician more efficient in lessening the ills of women and adding
comfort and pleasiire to their lives.
Philadelphia, Septefnber i§, igoj.
PREFACE TO FIRST EDITION.
I will oflfer no apology for presenting an additional text-book
upon gynecology.
This work has been under consideration for the last fifteen
years, and much of it has been several times rewritten. An
effort has been made to make it a comprehensive work upon the
subject, giving the experience and methods of the most careful
men, while my own experience has been utilized to indicate that
which I have found most useful and worthy of acceptance.
Each general subject is considered with reference to its influ-
ence upon the entire genital tract, and the work is divided into
sections rather than chapters. This course, although a departure
from the ordinary text-book arrangement, is that which expe-
rience has demonstrated to be most effective in impressing the
subject upon the student, and would seem to me preferable to
him who uses the book to refresh his knowledge upon any par-
ticular subject. The illustrations are arranged solely with the
purpose of rendering clear the text and to promote the work of
diagnosis and treatment. For their excellence and character I
am greatly indebted to the generosity of the publishers and to
the skill and patience of their artists, Messrs. Shannon and Von du
Lancken. To the kindly oversight of Dr. Robert L. Dickinson
is due much of the exactness of the drawings. Acknowledgment
is due Miss Eleanor A. Cantner for her ability in the preparation
of preliminary sketches and of the index.
Should it be the means of lightening the work of the student,
of making more clear the pathway of the busy practitioner, and,
most of all, of benefiting suffering women through improved
methods of diagnosis and treatment, I shall feel well repaid for
the many days and nights of labor which it has cost
The Author.
Philadelphia, August, IQOO.
XI
TABLE OF CONTENTS.
IWTRODUCTION.
SECTION. pa<;k.
1 . Definition and Antiquity, i
2. Theories i
3. Foundation i
4. Purpose I
ETIOLOGY.
5. Importance of Etiology, 2
6. Classification, 2
7. (A) Hereditary and Congenital Causes, 3
8. (B) Hygienic Causes, 5
9. (C) Sexual Caiises, 7
10. (D) Traumatic Causes, 8
1 1 . (E) Infective Causes, 10
12. (F) Causes Incident to Age, 11
13. Difficulties in Study, 12
14. Obser\'ation, 12
1 5. Exercise of Judgment 13
16. Value of Notes 13
17. History, 13
DIAGNOSIS.
18. Subjective Symptoms, 14
19. Causes of Error, 14
20. Method of Procedure, 14
2 1 . General Svmptoms 15
22. Visceral >reuralgias, 15
23. Neuralgia 15
24. Motor and Sensory^ Paralysis, 15
25. Disorders of Nutrition 16
26. Chlorosis, 16
27. Anemia, 16
28. Local S\Tnptoms 16
20- Rectal Reflexes 17
30. Vesical Reflexes 18
3 1 . Genital Symptoms, 18
32. Hemorrhage 18
3.V Pain 19
34. Seats of Pain 19
35. The Iliac Pain, ig
36. Lumbar Pain, 20
37. Hypogastric Pain, 20
^H. The Accessorv Seats of Pain, 20
30. The Anal or Perineal Pain 20
40. Vaginal Pain, 20
4 1 . Pelvic Pain, 20
42. Leukorrhea 20
43. The Secretion from the Fallopian Tubes and Cavity of the Uterus. . . 20
44. The Secretion of the Vagina and Vulva, 20
• • •
xui
XIV TABLE OF CONTENTS.
SECTION. PAGE.
45. Catarrhal Discharge, 21
46. Origin of Discharge, 21
47. Discharge Simulating Abscess, 21
48. Other Sources for Purulent Discharges, 21
49. Cervical Discharge, 22
50. Vaginal Discharge, 22
51. Effect of Age upon the Discharge, 22
52! Physical Signs, 22
53. Senses Employed 22
54. Examination 23
55. Pehac Examination, 23
56. Abdominal Examination, 23
57. Preliminaries, 23
58. Positions, 23
59. The Dorsal Position, 23
60. The Lateral Position 24
61. The Semiprone or Sims' Position, 24
62. The Genupectoral Position 25
63. The Trendelenburg Position, 26
64. The Erect Position, 27
PELVIC EXAMINATION.
65. Inspection 27
66. Simple Touch 27
67. Preparation. 27
68. Procedure, 27
69. Bimanual Procedure 30
70. Difficulties 30
7 1 . Virgins 30
72. Rectal Touch 31
73. Simon's Method 33
74. Vaginal Section, 33
75. Precautions 34
76. Instrumental Examination, 34
77. Probes,. 35
78. Precautions 37
79. Speculum, 37
80. The Tubular Speculum, 37
8 1 . Valvular Speculum 38
82. The Univalve or Duck-bill Speculum, 41
83. Uterine Fixation and Dt wnward Traction 43
84. Dilatation of the Uterus 43
85. Dilatation by Tents 44
86. Divulsion, 45
87. Gradual Dilatation 46
88. Incision of the Cervix, 46
8g. Complete Bilateral Incision of the Cervix 47
90. Dilatation bv Gauze Packing, 48
91. Microscopic Examination 48
92. Collection of Tissue, 49
93. Test Excision, 49
94. Test Curetment 50
95. Disposition of Tissue, 52
96. Examination, 52
97. Preser\^ation of Gross Specimens and Slides 58
98. Failure 60
QQ. Bacterioloj::v of the Genital Tract, 60
100. Parasites o{ the Genital Tract 61
loi. Natural Agents of Immunity 62
102. Loss of Protection, 62
103. Parasites, 63
TABLE OF CONTENTS. XV
StCTlON. PACE.
104. Staphylococcus 63
105. Streptococcus 64
loh. The Gonococcus, 65
107. Bacillus Coli Communis, 68
108. Bacillus Tuberculosis 68
109. Syphilis and Chancroid 70
no. Bacillus Typhosus. 71
111. Smegma Bacillus, 72
112. Bacillus Pyocyaneus 72
113. Bacillus Aerogenes Capsulatus, 72
114. Diphtheria Bacillus, 72
115. Pneumococcus 73
116. Diplococcus of Siegelman, 73
ANIMAL PARASITES.
17. Pediculosis Pubis or Inguinalis, 73
18. Acarus Scabiei 73
19. Oxyuris Vermicularis 73
20. Ascaris Lumbricoides 74
2 1 . Tenia Echinococcus 74
22. Collection of Fluids and Secretions 75
2^. Blood Changes 76
24. Examination of the Blood, 76
25. The Specimen. 76
26. Method of Collection 77
27. Microscopic Examination of Fresh Specimen, 77
2S. Fixation for Staining, 78
20- Staining, 78
30. Counting the Corpuscles, 80
31. Estimation of Hemoglobin, 81
^2. Composition of the Blood 82
33. Er\'tnrocytes 83
34. Color Index 83
35. Relation of Hemoglobin to Surgery, 84
36. Normal Number of Red Cells, 84
37. Increase in the Number of Erythrocytes, 85
38. Pathologic Alteration of the Erythrocytes, 85
30. Platelets 85
40. Hemoconia 85
4 1 . Leukocytes 86
42. Leukocytosis, 87
43. Leukoc\^osis of Digestion, 87
44. Leukocytosis of Pregnancy and Parturition, 87
4 5 . Thermal and Mechanical Agencies, 87
40. Terminal Leukocytosis, 87
47. Pathologic Leukocytoses 88
48. Post -hemorrhagic Leukocytosis 88
40, Leukocytosis (Phagocytosis) 88
50. Inflammatory Leukocytosis, 88
5 1 . Malignant Leukocytosis 89
52. Toxic Leukocytosis, 89
53. Experimental Leukocytosis, 89
54. Bacteremia, 90
55. Bacteria Found in Blood 90
56. BUxhI Culture 90
57. Blood Coagulation 91
58. Exploration of the Urethra, Bladder, and Ureters, 91
ABDOMINAL EXAMINATION.
1 50. Preliminaries, 96
160. Inspection 97
XVI TABLE OP CONTENTS.
SECTION. PACE.
i6i. Palpation, 98
162. Difficulties 99
163. Percussion 99
164. Auscultation 99
165. Exploratory Puncture, 100
166. Tapping, or Paracentesis Abdominis, 100
167. Aspiration, 10 1
168. Exploratory Incision, 102
THERAPEUTICS.
:69. Classification, 102
70. Extension, 102
71. Infection, 102
72. Terms, 102
73. Sterilization Methods, 103
74. Sterilization of Instruments, 104
75. Sponges 105
76. Ligature and Suture Material, 106
77. Dressings, 108
78. Operator and Assistants, 108
79. Precautions 109
:8o. Room and Environment no
:8i. Examination and Preparation of Patient, no
82. Special Preparation in
:83. Irrigating Tubes 112
:84. Gauze, 113
85. Antisepsis of the Cervix and Uterine Cavity, 113
86. The Use of Tents n4
:87. Abdominal Section, 114
:88. Indications for Anesthesia, 115
89. Agents Employed 115
90. Administration 117
91. Local Anesthesia, 118
92. Preliminary Details of Operation, 119
93. Arrangement 120
94. Positions of Operator and Assistants, 120
:95. Clothing of Patient 120
:96. Incision 121
97. Adhesions 124
:98. Toilet of the Peritoneum 125
:99. Drainage, 125
200. Objections to Drainage, 126
201. Gauze Drain 128
202. Where Placed 1 28
203. Postural Drainage 128
204. Closure of the Wound 129
205. Dressing 131
206. Postoperative Treatment 131
207. Comfort of Patient 132
208. Vomiting 133
209. Tympanites 134
210. ShocK 135
211. Anodynes 135
212. Internal Hemorrhage 135
213. Peritonitis 135
214. Wound Infection 136
215. Parotiditis. 137
216. Ileus 137
217. IMilcbitis 138
218. Precautions in the L"se of the Hypodermic Syringe 138
219. Catheterization, 139
TABLE OF CONTENTS. XVU
SECTION. PAGR.
220. Removal of Sutures, 139
221. Getting Up, 140
222. Plastic Operations, 140
MEDICAL TREATMENT.
223. General Treatment, 140
224. Specific Remedies 141
225. Rest and Exercise, 142
LOCAL THERAPEUTICS.
226. Baths 143
227. Douche 143
228. External Applications, 144
229. Counterirritants, 144
230. Bloodletting 144
23 1 . Local Apphcations, 145
232. Various Agents 145
233. Astringents, 1 46
234. Caustics, 146
235. Tampons 146
236. Massage 147
237. Pelvic Massage, 147
ELECTRICITY.
238. Forms. 149
23Q. Franklinism, 149
240. Galvanism, 149
241. Apparatus for Application, 150
242. Method of Procedure, 151
243. Indications 152
244. Contraindications, 152
245. Faradic 152
246. Sinusoidal 153
247. ROntgenic 154
248. Finsen Light 155
249. Electrocautery'- and Light, 155
EMBRYOLOGY AND ANATOMY OF THE GENITO-URINARY
ORGANS OF THE WOMAN.
250. Development of the Genito-urinary Organs, 156
251. Division of the Genitalia 159
252. The External Genital Organs, 159
253. The Mons Veneris, 159
254. The Labia Majora, 159
255. The Labia Minora 160
256. The Clitoris 161
257. The Vestibule 162
2 58. The Hymen 1 64
250. The Fourchet 165
260. The Muscles of the Perineum, 165
261 . The Perineal Fascia 1 68
262. Pelvic Diaphragm 1 70
263. Perforations 171
264. Internal Genitalia 172
26^. The Vagina, 172
266. The Uterus 178
267. The Fallopian Tubes 184
268. Ovaries 186
269. The Parovarium, 191
XVm TABLE OF CONTENTS.
RKCTION. ^ PAGK.
270. Urinary Organs and Rectum, iqi
271. The Urethra 191
272. The Bladder, 192
273. The Ureters, 194
274. The Rectum 194
275. Pelvic Peritoneum 197
276. Pelvic Connective Tissue 200
277. The Vascular Supply, 201
278. The Lvmphatic System 208
279. Consideration of the Pelvic Organs and Structure Studied as a Whole, 211
PHYSIOLOGY.
280. Functions 212
281. Puberty, 212
282. Nubility, 213
283. Menstruation and Ovulation, 213
284. Menopause 221
285. Copulation, 223
286. Fecundation 223
MALFORMATIONS.
287. Classification; Definition, 223
288. Bifidities 224
289. The Degrees of Division 224
290. Double Uterus, 225
291. Unequal Development of the Two Sides. 226
292. Absent Uterus, 228
293. A Rudimentary Uterus 228
294. Fetal and Infantile Uteri, 229
295. Congenital Prolapsus Uteri, 230
296. Accessory or Trihd Uteri, 230
297. Absent or Rudimentary Tubes, 230
298. Accessory Tubal Ostia, 231
299. Anomalies in Length, 231
300. Absent or Rudimentary Ovaries, 231
301. Supernumerary Ovaries 231
302. Accessory or Constricted Ovaries, 231
303. Displacements, 231
304. Defects of Round or Broad Ligaments 231
305. Complete Absence or Rudimentary Development of the Vagina 232
306. Unilateral Vagina, 235
307. Double V^agina 235
308. Atresia of the Genital Canal, 237
309. Lateral Atresia, 240
310. Absence of the Vulva, 241
311. Infantile Vulva 241
312. Defects in Xymph?e, 241
313. Defects of the Clitoris 241
314. Defects of the H>Tnen, 242
315. Hermaphroditism 243
316. Gynandria 244
317. Ahdrogyna 245
3 1 8. Atresia of the Urethra and Vagina 246
310. Hypospadias 246
320. Epispadias 246
321. Duplication of the Bladder, 248
322. Open Urachus 249
323. Irregular Exit of Ureter 249
324. Abnormal Communications 249
TABLE OF CONTENTS. xix
TRAUMATISMS.
SECTION. PAGE.
325. Injuries of the Genital Organs, 250
326. External Violence 250
327. Coition, 251
328. Parturition, 252
329. Injuries of the Body of the Uterus, 253
330. Injuries of the Cervix Uteri, 254
331. Symptoms of Laceration of the Cervix, 255
332. Diagnosis 255
333. Treatment, 257
334. Complications, . . .• 257
335. Trachelorrhaphy 259
336. Amputation of the Cervix, 261
337. After-treatment, 263
338. Lacerations of the Vagina, 263
339. Fistulae 264
340. Etiology, 264
341. Symptoms, 265
342. IMagnosis, 265
343. Prognosis 267
344- Treatment 267
345. Cauterization 268
346. Preliminary Treatment, 268
347. Visicovaginal Fistula, 268
348. Flap-splitting or Flap-sliding, 270
349. Flap Formation, 275
350. After-treatment 277
351. Closure of the Vagina; Colpocleisis ; Episiostenosis, 278
352. Urethrovaginal Fistula, 279
353. Vesico-uterine Fistula 280
354. Hysterostenosis or Hysterocleisis, 281
355. Vesico-uterovaginal (Cervical) Fistula, 282
356. Ureterovaginal-ureterocervical Fistulae, 283
357. Accidents of the Operation and Results, 287
358. Rectovaginal Fistula, 289
359. An Anovulvar Fistula, 290
360. Preliminary and After-treatment 290
361. Enterovagmal Fistulae, 291
362- Cerv'i CO- vaginal Fistula 291
363- Lacerations of the Pelvic Floor 291
364. Causes 292
365. Degree or Extent, 293
366. The Results. ^ 294
367. Treatment 295
368. Bv Primary Operation, 296
369. TJie Advantages of the Primary Procedure, 297
370. Contraindications, 298
371. The Intermediate Operation 298
372. Secondary Operation, 299
373. After-treatment, 323
374. Choice of Operation 325
INFLAMMATIONS.
375. The Recognition of the Development of the Genital Tract, 326
376. Micro-organisms as a Cause 327
377. Natural Protection against Infection 327
378. How Immunity is Lost 327
370. Inflammation and Its Varieties 327
380. The Causes of Inflammation 328
381. Characteristics of Inflammation 329
Classification of Iniiammation, 330
Vulvitis and Its Varieties, 331
Causes, 331
Vulvitis, Simple or Catarrhal, 332
Follicular Vulvitis, 332
Venereal Vulvitis 332
Eruptive Diseases of the Vulva, 334
Phlegmonous Vulvitis 335
Diphtheric Vulvitis, 335
Diagnosis of Inflammatory Disease of the Vulva, 335
Treatment, 336
Edema and Gangrene, 338
Bartholinitis 339
Pruritus VulvjE 341
Kraurosis Vulvae, 343
Vaginismus, 345
Vulvo- vaginitis, 347
Vaginitis, Elytritis, or Colpitis 348
Varieties 350
Pathology, 350
Etiology, 351
Symptoms 351
Diagnosis 352
Prognosis 353
Treatment 353
Urethritis 354
Hyperemia 354
Acute Catarrhal Urethritis 355
Chronic Catarrhal Urethritis 356
Follicular Inflammation 356
Ulceration 357
Vesico-urethral Fissure, 357
Diagnosis of Urethral Inflammations, 358
Treatment of Urethral Inflammations 359
Cystitis, 361
Symptoms of Acute Cystitis 362
Symptoms of Chronic Cystitis, 363
Cystitis of Gonorrheal Cirigin, 363
Tubercular Cystitis 363
Diagnosis of Cystitis 363
The Prognosis of Cystitis, 367
Treatment 368
Ureteritis, 372
Acute Ureteritis 372
Chronic Ureteritis 373
INFLAMMATION OF THE CERVIX AND BODY OF THE
UTERUS.
427. Classification 374
428. Endocervicitis, Chronic Cervical Catarrh 375
42Q. Causes ' 379
430. Symptoms 37Q
43 1. Physical Signs 380
432. Diagnosis 380
433. Prognosis 381
434. Treatment 381
435. Acute Metritis and Endometritis 384
436. Pathologic Alterations 385
437. Varieties and Their Source 385
438. Symptoms 386
439. Diagnosis 387
TABLE OF CONTENTS. XXI
SECTION. PAGE.
440. Prognosis, 389
441. Treatment, 389
442. Chronic Endometritis, 394
443. Symptoms, : 396
444. Diagnosis 397
445. Treatment, 398
446. Chronic Metritis, 400
447. Etiology, 402
448. Symptoms 403
449. Physical Signs and Diagnosis, 404
450. Course and Prognosis, 405
45 1 . Treatment 405
452. Inflammation of the Fallopian Tube, 411
453. Symptoms 418
454. EHagnosis 419
455. Prognosis 420
456. Inflammation of the Ovary, 421
457. Symptoms, 424
458. Diagnosis, 425
459. Treatment of Inflammation of the Appendages, 425
460. Pelvic Inflammation 430
461. Varieties 430
462. Pelvic Cellulitis, Parametritis, or Periuterine Phlegmon, 430
463. Etiology 432
464. Symptoms 433
465. Physical Signs 433
466. Diagnosis 436
467. Prognosis 438
468. Treatment 438
460. Pelvic Peritonitis, Perimetritis, Perisalpingitis, or Perioophoritis, .... 440
470. Etiology 440
47 1 . Pathologic Anatomy, 444
472. Symptoms, 446
473. Diagnosis 447
474- Prognosis 448
475. Treatment 449
DISPLACEMENTS OF THE PELVIC ORGANS.
476. Changed Relations of Structures of Vulva 466
477. Physiologic Movements of the Uterus and the Forces by which it is
Sustained 467
478. Pathologic Changes and What Constitute Them, 469
470. Classification of Displacements, 471
480. Ascent 472
481 . Diagnosis, 473
482. Descent, or Prolapsus, 473
483. Etiology 475
484. Symptoms 477
485. Diagnosis 481
486. Prognosis 485
487. Treatment • 488
488. Urethrocele 499
48Q. Dislocation of the Uterus, 500
400. Diagnosis 50a
4QI. Torsion 501
402. Anteversion 501
403. Etiology 502
404- Symptoms. 502
405. Diagnosis 502
4Q(S. Treatment 502
4Q7. Retroversion 504
TABLE OF CONTENTS.
498. Etiology 504
499. Symptoms, S^S
500. Diagnosis 506
501. Lateral Version, 506
SOI. Anteflexion 506
503. Etiology soS
504. Symptoms 50S
505. Diagnosis 509
506. Treatment, 509
507. Retroflenon, 514
508. Etiology, - 516
509. Symptoms S'6
510. IXagnosis 518
SI I. Treatment of Retroversion and Retroflexion, 510
SH- Lateral Flexion 546
513. Complications Associated with Displacements S46
514. Prognosis of Displacements. S47
SIS- General Treatment 547
516. Summaiy 54S
517. Inversion of the Uterus, $50
518. Etiology 553
519. Symptoms 554
jai. Treatment 557
jaa. Displacements of the Appendages 564
523. Symptoms S6s
534. Diagnosis, 56s
515. Treatment, 566
GENITO-URINARY HEMORRHAGE.
Sa6. Hemorrhage a Symptom 566
527. Site and Varieties 566
5»8. Hematuria and Its Causes.. 567
539. Svtnptoms and Diagnosis S^7
530. Treatment. 568
531. Genital Hemorrhage or Bleeding 569
Sja. Diagnosis S70
533. Treatment, 572
534. Vulvar Hematoma or Hematocele, 573
535. Vaginal Hematoma or Thrombus, , . , , S73
536. Diagnosis, 575
537. Treatment, . , 575
538. Periuterine Hemorrhage 576
539. Causes S76
S40- Symptoms S77
541. Extrapentoneal Hematocele 578
S4J. Symptoms 578
S43- Diagnosis S79
544. Prc^nosis 580
545. Treatment 580
EXTRA-TTTERIHE PREGNAHCY.
546. Definition S8a
547. Causes SRj
548. Varieties, 584
549. Course and Progress 'qSs
550. Svmptoms qo6
SSI- diagnosis. 599
SS". Differential Diagnosis 604
553. Prognosis. 608
554. Treatment, 609
TABLE OF CONTENTS. XXUl
GENITAL TUMORS.
SECTION. PACK.
555. Definition 621
556. Classification, 62 1
VULVA, VAGINA, AND BLADDER.
557. Characteristics of Benign Neoplasms, 622
558. Unclassified, 623
559. Hernias 623
560. Hydrocele, 624
561. Erectile or Vascular Tumors, 625
562. Urethral Caruncle, 626
563. Varicose Veins, 628
564. Edema, 628
565. Elephantiasis, 628
566. Tumors of the Vulva 629
567. Serous Cysts, 629
568. Sebaceous Cysts 629
569. Blood Cysts, 629
570. Neuroma of the Vulva, 630
57 1. Simple Vegetations, 630
572. Fibroma and Myxoma 633
573. Lipoma 633
574. Enchondroma, 633
575. Malignant Disease of the Vulva, 633
VAGINA.
576. Cysts of the Vagina, 637
577. Fibroid Tumors and Polypi, 638
578. Papillomata 639
579. Malignant Neoplasms, 639
BLADDER.
580. Tumors of the Bladder, 642
581. Mucous Polypi, 642
582. Myoma 643
583. Carcinoma 649
UTERUS.
584. Fibromyomatous Tumors, 650
585. Pathologic Anatomy, 652
586. Microscopic Appearance, 652
587. Varieties, 653
588. Submucous Fibroids, 654
589. Interstitial, Mural, or Centric Fibroid Growths, 657
590. Subperitoneal Growths, 660
591. Fibromyoma of the Cervix 662
592. Etiology, 664
593. Symptoms, 667
504. Diagnosis of Myomata, ' 671
595. Differential Diagnosis of Myomata, 674
596. Alterations and Degenerations, 681
597. Mixed Growths: Enchondroma, Sarcoma, Osteoma, and Carcinoma, . 686
5q8. Complications, 687
599. (a) The Influence of the Myoma upon Conception, 690
600. (b) The Influence of Pregnancy upon the Myoma, 691
601. (c) The Influence of the Myoma upon Pregnancy, 692
602. (d) Influence upon Labor, 693
603. Course and Prognosis 693
604. Treatment 696
605. (a) Medical Treatment, 697
XXIV
TABLE OP CONTENTS.
8BCTIOM.
PACB.
(7^ Castration, 718
(8) Ligation of the Vessels, 719
(9) Myomectomy, 720
(10) Enucleation, 720
(11) Partial Hysterectomy, or Supravaginal Amputation of the
Uterus, 723
(12) Panhysterectomy, 729
Summary, 734
Accidents during Operation, 737
Causes of Death Following Hysterectomy, 740
Puerperal Tiunors; Physometra, 741
Hydrometra, 742
Hematometra, 742
Pyometra, 742
Hydatid Cysts of the Uterus 742
Mucous Polypi of the Uterus 742
Malignant Tiunors, 743
Classification, 744
Anatomic Classification of Carcinoma, 744
Development of Squamous-cell Carcinoma, 746
Histology of Squamous-cell Carcinoma 748
Adenocarcinoma of the Cervix, 749
Histology of Adenocarcinoma, 751
Adenocarcinoma of^the Body, 752
Histology of Adenocarcinoma of the Body of the Uterus 754
Dissemination of Carcinoma 756
Clinical Forms 762
Etiology, 764
Symptoms 767
Physical Signs 772
Complications, 773
Diagnosis 775
Duration of Cancer. 781
Prognosis 782
Treatment 783
(A) Operable. — Partial Vaginal Operations, 784
Total Extirpation of the Uterus 786
Vaginal Hysterectomy, 790
Accidents of vaginal Total Extirpation, 797
Abdominal Hysterectomy, 799
Comparative Advantages of the Two Proceedings 805
The Sacral Method, 806
The Perineal Method 813
The Mortality of Abdominal and Vaginal Operations 814
Duration of Recovery, 814
Recurrence 815
(B) Inoperable 818
Pregnancy Complicating Carcinoma 829
Summary, 830
Chorio-epithelioma Malignum 832
TABLE OF CONTENTS. XXV
SECTION. PAGB.
663. Endothelioma Uteri 835
664. Sarcoma Uteri 836
665. Varieties 836
666. Pathology 836
667. Etiology 841
668. Symptoms, 84a
669. Duration, 845
670. Diagnosis, 846
67 1. Recurrence, 849
672. Treatment, 850
673. Treatment Following Operations for Malignant Disease, 850
FALLOPIAN TUBES.
674. Tumors (Benign), 85a
675. Fibroma or Myoma, 85a
676. Fibrocyst 853
67 7. Enchondromata, 853
678. Dermoid of the Tube, 853
679. Cysts of Small Size, 853
680. PoItous 854
681. Papillomata 854
682. Malignant Tumors, 85 5
683. Sarcoma, 855
684. Chorio-epithelioma Malignum, 856
BROAD LIGAMENTS.
685. Cysts of the Broad Ligament, 856
686. Echinococcus Cysts, 857
687. Parovarian Varicocele; Phleboliths, 858
688. Lipomata, 858
689. Fibroma, 858
690. Malignant Growths, 858
OVARIAN TUMORS.
691. Characteristics, 859
692. Classification, 859
693. Small Residual Cysts, 861
694. Simple or Follicular Cysts; Hydrops FoUiculorum, 86a
695. Cysts of the Corpus Luteum, 863
696. Tubo-ovarian Cysts, 863
697. Glandular Proliferating Cysts 864
698. Pedicle 865
699. Structure 868
700. Papillary Proliferous Cysts, 872
701. Dermoid Cysts 873
702. Parovarian Cysts, 875
703. Solid Ovarian Tumors, 876
704. Fibromyoma 876
705. Sarcoma of the Ovary, 877
706. Carcinoma of the Ovary, 877
707. Endothelioma of the Ovary, 878
708. Etiology 878
709. Natural Progress, 879
710. Symptoms 880
711. Complications, 880
712. Degenerative Changes in the Cyst-walls 887
713. Diagnosis, 888
714. Exploratory Puncture, 90 1
715. Exploratory Incision 902
716. Treatment. 902
717. Ovariotomy, 903
XXVI TABLE OF CONTENTS.
SECTION. PAGE.
i8. Indications, < 903
19. Contraindications, 904
ao. General Considerations, 905
21. Operation, 906
22. Incomplete Operation, 916
23. Rupture of the Cyst, 917
24. Hemorrhage, 918
25. Visceral Injuries, 918
26. Prognosis, 920
27. Intestinal Complications, 921
28. Causes of Death, 922
List of Authors Quoted, 923
Index, 929
LIST OF ILLUSTRATIONS.
FIG. PAGE.
1. Chadwick Table, 23
2. Dorsal Position 24
3. Sims' Position. Proper Method of Holding the Speculum 25
4. Genupectoral Position. Organs Shown in Outline, 25
5. Trenaelenburg Position, 26
6. Proper Position of Fingers for Examination, 28
7. Hall Section of the Pelvis with Patient Erect, Showing Normal Posi-
tion of Uterus {Deaver) 29
8. Bimanual Examination 31
9. Recto-abdominal Palpation, 32
10. Recto- vagino-abdominal Palpation. Index Finger of One Hand in
the Rectum, Thumb in the Vagina, and the Fingers of the Other
Hand over the Abdomen, 33
11. Rectovesical Palpation. Sound in Bladder, 34
12. Simpson's Sound, 35
13. Sims' Probe, 35
14. Whalebone Probe, 35
15. Spring Probe Covered with Rubber, 35
16. Introduction of the Sound, 36
17. Feij^uson's Speculum 37
18. Milk-glass Specula, 38
19. Nott's Speculum, 38
20. Higbee's Spectda (three sizes), 39
21. Talley's Speculum, 39
22. Goodell's Speculum, 39
23. Sims' Speculum, 40
24. Proper Method of Holding Sims' Speculum. The Cervix Brought
into View with the Tenaculum 40
25. Sims' Depressor, 41
26. Goodell's Tenaculum, 41
27. Self-retaining Sims' Speculum, 41
28. Simon's Retractors, 42
29. Edebohls' Speculum, 42
30. Edebohls' Speculum in Position, 42
3 1 . Double Tenaculum Forceps, 43
32. Traction upon Uterus with Double Tenaculum during Digital Exam-
ination by the Rectiun, 43
^^. Hollow Laminaria Tent, 44
34. Uterine Forceps — Dressing, 44
35. Dilated Tent Showing Constriction from Internal Os (Thomas), 45
36. ElUnger's Dilator, 45
37. Goodell's Modification of ElUnger's Dilator 45
38. Pratt's Dilators, 46
39. The Method of Dilatation with the Graduated Bougies 47
40. Kuchenmeister's Scissors, 47
41. Douche Curet, 49
42. Tissue removed by Test Curetment, 51
43. Cabinet with Trays and Card Index for the Preservation of Slides 59
44. CopHn's Method of Indexing and Preserving Slides 60
45. Same as Fig. 44 Folded with Slide Enclosed, 60
46. Staphylococcus Pyogenes Aureus (Coplin), 64
xxvii
XXVni LIST OF ILLUSTRATIONS.
FIG. PAGB.
47. Streptococcus Pyogenes (jCoplin), 64
48. Secretion from Gonorrheal Vaginitis, Showing Gonococd 65
49. Secretion of Simple Vaginitis Showing Various Forms, 66
50. Bacillus Coli Communis (Coflin) 68
51. Bacillus Tuberculosis (Copltn) 68
52. Needle for Puncturing Finger 77
53. Hematocytometer, 81
54. Dare's Hemoglobinometer. '82
55. Tallqvist Hemoglobin Scale, 82
56. Needle for Securing Blood, 91
57. Skene's Urethroscope, 94
58. Cystoscopes, 94
59. Kelly's Specula (Urethra), 95
60. Mouse-tooth Forceps for Cotton Pledgets 95
61. Kelly's Evacuator, 95
62. 63. Ureteral Catheters. Metal and Soft, 95
64. Harris' Double Catheter for Obtaining Urine from Kidneys Separately, 96
65. Abdomen Prepared for Examination, 97
66. Nest of Trocars 100
67. Aspirator, loi
68. Arnold Steam Sterilizer, 103
69. Steam-pressure Sterilizer, 104
70. Sterilizer for Boiling Instruments, 104
71. Gauze Pads, 105
72. Irrigating Glass Tube. Open End, 112
73. White's Oxygen Apparatus, which can be Utilized for Anesthesia by
Placing Anesthetic in the Bottle, 116
74. Northnip's Apparatus for Administering a Mixture of Chloroform
and Oxygen, 116
75. Arrangement of Tables and Assistants in Operating Room, 121
76. Abdominal Wall Incised; Peritoneum Picked up by Dissecting For-
ceps, 122
77. Peritoneum Incised, 122
78. Crescent Incision Exposing Aponeurosis, 123
79. Aponeurosis Excised, Showing Pyramidalis Muscles, 123
80. Scalpels, 124
81. Pressure Forceps, 124
82. Dissecting Forceps — Long Bladed, 125
83. Glass Drainage-tubes, 126
84. Uterine Syringe for Cleaning Drainage-tube, 126
85. Tube Forceps for Cotton Pledgets, 126
86. Gauze Wick in Drain, 127
87. Mikulicz Drain, 127
88. Gauze Drain Covered ^"ith Rubber Tissue 128
89. Curved and Straight Needles, 129
90. Needle Forceps, 129
91. I. Peritoneum Nearly Closed with Continuous Catgut. 2. Silkworm-
gut Sutures through All Structures above Peritoneum. 3.
Aponeurosis being United with Continuous Suture of Catgut, .... 130
92. Silkworm-gut Sutures Tied, 130
93. Butt Uterine Scarifier, 144
94. Aluminium Uterine Applicator 145
95. Long Glass Pipet, 145
96. Insufflator — Straight Stem, 146
97. Tampon 146
98. Position of the Fingers in Pelvic Massage, 148
99. Portable Galvanic Battery with Galvanometer 150
100. Intra-uterine Electrode with Movable Insulating Cover 151
101. Vaginal Electrodes of Different Sizes, 151
102. Faradic Battery, 153
103. Bipolar Uterine Electrode, 154
104. Vaginal Electrode — Bipolar, 154
LIST OP ILLUSTRATIONS. XXIX
FIG. PAGE.
105. Human Embryo at end of Thirty-five Days (jCoste), 157
106. Coalescence of Muller's Duct, '. 158
107. 108, 109. Progress of Development of the Genitalia, 158
1 10. Virgin Vulva: Labia not Separated (Deaver), 160
111. Virgin Vulva: Labia Separated, Showing the Hymen Unruptured
{Deaver), 161
112. Hymen Crescens, i6a
113. Hymen Annularis, i6a
1 14. Hymen Serratus, 163
115. Hymen Infundibularis, 163
116. Hymen Biseptus, 164
117. Hymen Cribriformis, 164
1 18. Laceration of the Hymen, 165
119. Muscles of the Female Perineum (Deaver), 166
120. The Under Surface of the Levator Ani Muscle (Deaver) 171
121. The Upper Surface of the Levator Ani Muscle (Deaver), 17a
122. A Mesial Section: the Body Erect {Deaver), 173
123. A Mesial Section: the Body Recumbent, 174
124. Arteries and Nerves of the Female Perineum {Savage), 175
125. Anterior Wall of Vagina Showing Columnae Rugarum {Byford, after
Savage), 176
126. Horizontal Section of the Vagina and Urethra of an Infant, 177
127. Median Section of Uterus from Side to Side through the Fallopian
Tubes. Mode of Junction of Vagina and Uterus (Savage) 179
128. Virgin Uterus. Median Section (Byford, after Sappey), 181
129. Mucous Membrane of Uterine Body Showing Follicles (Mann) 181
130. Section of Normal Endometrium, 182
131. Virgin Os and Cervix (Sappey), 183
132. Section of Fallopian Tube tlirough the Isthmus, 185
133. Section of Tube through the Ampulla near the Isthmus 186
134. Section of Ovary, Showing Graanan Follicles iyVyder), 188
135. Large Corpus Luteum in Association with an Ovarian Dermoid. Re-
moved from an Unmarried Woman who had Never Been Pregnant
(StUton), 190
136. Vesicovaginal Septum and Base of Female Bladder. Anatomic Re-
lations of Ureters at Their Entrance into the Bladder. Contents
of Alar Ligament (Savage) 193
137. Superior View of the Pelvic Cavity (Deaver), 196
138. Curved Dotted Line Shows Covering of the Anterior Uterine Wall by
Peritoneum (^inter), 198
139. Posterior Surface of Uterus Showing Extent of Peritoneum; also Fal-
lopian Tubes, Ovaries, and Ovarian Ligaments (Winter) 198
140. Vertical Transverse Section of the Pelvis, Showing Peritoneal Pouches
(Luschka), 199
141. Distribution of the Uterine and Ovarian Vessels, 202
142. Arteries of the Female Pelvic Organs (Savage), 203
143. Distribution of the Pudic Artery to the Structures of the Perineum
(Deaver), 204
144. Relation of the Urethral and Vaginal Venous Plexuses to the Veins
of the Clitoris and Bulb; The Right Side of the Pelvis Re-
moved by a Section in Front, through the Pubic Body, About
an Inch Jrora the Symphysis, and, Behind, through Sacro-iliac
Joint (Savage) 205
145. Veins and Erectile Venous Plexuses of the Female Pelvis (Savage), . . 206
146. Erectile Organs and Veins of the Female Perineum (Savage) 207
147. The Lumbo-iliac Lymphatics and Glands. Lymphatics of the
Gravid Uterus and Appendages (Savage), 208
148. Nerves of the Unimpregnated Uterus with the Nerves of the Clitoris
(Savage), 210
14Q. Changes of Uterine Mucous Membrane during Menstruation (Wyder), 216
150. Degrees of Division of the Genital Tract 224
151. Uterus Bicomis (Auvard), 224
XXX LIST OF ILLUSTRATIONS.
■
FIG. PAGB.
52. Uterus Bicomis Unicollis (-4m. Sys. Gyn.) , 225
53. Uterus Bifidus {Auxxird), 226
54. Uterus Didelphys (Am. Svs. Gyn.) 226
55. Uterus Unicornis {Auvara) 227
56. Atresia of Rudimentary Horn with an Accumulation of Menstrual
Blood (Auvard) 227
57. Uterus Bipartitus or Duplex (Byford) 228
58. Uterus Biseptus (Couriy), 229
59. Absent Vagina 232
60. Line of Incision for Formation of Flaps, i. 2. Flaps from Labia
Minora which are Split and Used to Line the Vagina, 233
61. Flaps Outlined in Fi^. 160 Sutured in Place, and I>enuded Surfaces
which have Furmshed Flaps to Line Posterior Wall 234
62. Sims' Glass Dilator 235
63. Double Vagina {Photograph taken from patient of Dr. J. M. Fisher), . . 236
64. Imperforate Hymen 237
65- Hematocolpos 238
66. Hematometra 239
67. Hematocolpometra 240
65. Enlarged Clitoris 242
tq. Apparent Hermaphroditism — {American Journal of Obstetrics) 244
70. External Genital Oreans of Madame Le Fort {Auvard) 244
71. Outline of Internal Organs of Madame Le Fort {Auvard), 245
72. AndrOTXTia {Pos^) 246
73. Impei&rate Anus. Communication between Rectum and Vagina. . . 247
74. Congenital Defect of Vagina. Communication with the Rectum 247
75. Coi^enital Absence of the Urethra. Communication of Bladder
with the Vagina 248
76. Communication of Rectum and Bladder viiih the Vagina 248
77. Suprapubic Opening of Vagina and Urethra 249
7S. Knives lor Denudation 252
7Q. Cur\*ed Scissors 252
So. Retractor 252
Si. Blunt Hook 253
Si. Needle-holder 253
S3. Needles 253
$4. Needle \^-iih Loop for Suture •. . . . 253
55. Slight Fij;:?ure of Cervix 255
56. Extensive Laoc^ration of Cervix ^^MukJc^ 255
57. Bilateral Liict^ration o: Cer\-ix v-WntuV 256
SS. Slight StelUte LaoerativMi of Cer\-ix yMuKde"^ 256
So. Exter.siw StelUto Liicoration of Cervi.\ y?*fu*iit'^ 256
00. Laceration vM Cervix >\*ith H\'pertrophy and E version of Cer\-ical
Mi:c\n:s Mc:v,bra:io y^MstKJe^ 256
01. Blur.: anvi Shar]'» Curets 258
ci. Edges V*: Laceration Turned by Tetvaoulum Hcv"»ked into Each Lip,. . 259
05- IVnudation of l.^ux*nitt\i Cervix. 260
04. Surtaoos IVnudevi Ready lor Ur.:on 260
05. Suture* Iv.tTwiuvt^i 260
CO. Sutures Tusi 260
C-- lX^,:Vie Fla'p .Xir.putation o: t^» Cer^-:x ^.4«'J»-j 261
cS. Sutures l-.i:r^xiuoevl v.Afc:o*;r 261
Wour.vi C\'ni!evi. . . .... 261
oc
j-cs: So-hrvVior 5 Sincle Flap Oivra::or.. . 262
r-c:. ^c^.^X:o^*s O-jVratior. Co-.u^^Vtci;. 263
re I ivher-jo Shonv-'if Variv^us f':*:;:*.v 265
set- L.»rce Vc>:vN^\ .ic''-^* Fistula Ax::h lVo'..\rtsc o: the Anterkw Vesical
\VaV. :h:\^uc^ the i'^wr.inc 266
1^4. rVr.uo.av.v'u »": :V.c K^'^cos o: :^^o F'.>;.:'..\ 267
fi-c? Sutures iV.:r»xv.:K>f\'. 268
*c<» Wv^ur;.^. C*v\<jiv; S69
»o7. Metbvxi c^: Suvanr^ to IVx^rease the rcrjs;or. utv^r. the Suture*, 270
LIST OF ILLUSTRATIONS. XXXI
PIG. PAGB.
208. Showing Continuation of Suturing to Close Fistula with Incisions to
Decrease Tension with Suture Introduced on Left Side to Close
the Secondary Opening, 271
209. Wound Closed, 271
210. Fistula Preparatory to Splitting into Vesical and Vaginal Flaps, 272
211. Demonstration of Flap-splitting 272
212. Suture Introduced into Vesical Flap, 273
213. Suture Tied in Vesical Flap Introduced in Vagina, 273
214. Wound Closed, 273
215. Sutures Introduced to Close Vesical Surface, as Suggested by Wal-
cher, 274
216. Flap-formation as Suggested by Ferguson, 275
217. Flap Turned in and Vesical Opening Closed, 276
218. Introduction of Vaginal Sutures 277
' 219. Section Showing Projection upon Vesical Surface, 278
220. Self-retaining Catheter, 278
221. Vesico-uterine Fistula, 278
222. Colpocleisis, 279
223. Closure of Fistula after Its Exposure by Incision through Anterior
Vaginal Fornix, 280
224. Fistula Closed into Vagina. Uterine Opening Remains, Which Will
Close of Itself 281
225. Section Showing Suture for Hysterocleisis, 281
226. Closure of Fistula within Cervical Canal after Splitting Cervix, 282
227. Hysterocleisis 283
228. Anterior Lip of Cervix Utilized to Close the Fistula, 284
229. Vesico-uterovaginal Fistula in which the Posterior Lip of the Uterus
is Utilized to Close the Opening, 284
230. Vesical Wall Loosened and Sutured. Vaginal Wall Sutured in Oppo-
site Direction, 285
231. Operation for Ureterovaginal Fistula, 286
232. Vaginal Implantation of the Ureter into the Bladder, 287
233. Abdominal Transplantation of Ureter for Ureterovaginal Fistula,. . . . 288
234. Ureteral Anastomosis 289
235. Sagittal Incision for Rectovaginal Fistula, 290
236. Lauenstein Suture in Rectovaginal Fistula through Rectal Wall 290
237. Rectal Wall Closed by Transverse Line of Sutures; Vaginal by Ver-
tical Line of Sutures, 291
238. Rectovaginal Fistula Closed in Operation of Perineorrhaphy 292
239. Rupture of Perineum into Rectovaginal Septum, 293
240. Cystocele, 294
241. Rectocele, 295
242. Right and Left Curved Scissors 296
243. Incomplete Rupture of the Perineum 297
244. Simon-Hegar Method of Denudation 297
245. Sutures Introduced to Close the Wound, 298
246. Grarrigues* Modification of the Hegar Operation, 299
247. Upper Part of the Wound Closed; Last Sutures Introduced 300
248. Wound Completely Closed, 300
249. Lauenstein Suture, 301
250. Rectum and Vagina Closed with Lauenstein Suture 301
251. Hildebrandt's Method of Suturing 302
252. Hildebrandt Suture Closed, 303
253. Heppner's Figure-of-8 Suture 304
254. Martin Suture to Close the Rectal Opening 305
255. Martin Suture Continued, 305
256. Denudation for Freund's Operation 306
257. Sutures Inserted in Rectal Wall and Lateral Vaginal Angles, 307
258. Vaginal Angles and Rectal Wall Closed. Suture in Place for Peri-
neum 307
25Q. Denudation Completely Closed 307
260. Emmet's Operation. Surface Denuded and Lateral Sutures in Place, 308
XXXU LIST OF ILLUSTRATIONS.
FIG. PAGE.
261. Emmet's Operation. Lateral Angles Closed and Perineal Suture
Introduced, 309
262. Emmet's Operation Completed, 310
263. Emmet's Operation for Complete Laceration, 310
264. Suture to Unite the Ends of the Sphincter, 310
265. Outerbridge's Suttire 311
266. Cleveland's Suture, 312
267. Dudley's Operation with Interrupted Sutures, 312
268. Dudley's Operation Completed, 313
269. Denuoation for Martin's Operation, 313
270. Vaginal Surfaces United; Perineal Sutures in Place, 314
271. Bischoff's Operation, 314
272. Splitting Vaginal Wall Preparatory to Suture (Andrews), 315
273. Introduction of Sutiu^ in Retracted Flap (Andrews), 316
274. Suture Tied; the remaining Surface to be Closed by Transverse Su-
tures (Andrews), 317
275. Incision for Tait's Operation for Incomplete Laceration, 318
276. Line of Incision for Tait's Operation for Complete Laceration, 319
277. Appearance of Surface after Formation of Flaps, 319
278. Outline of Flap to be Turned down to Form Raw Surface for Union.
Flap thus Formed to Protect from Fecal Infection (Ristine), 320
279. Flap Turned down. Sphincter Closed and Sutures Introduced (Ris-
tine) 321
280. Outline for Simpson's Operation, 322
281. Sutures Introduced in Simpson's Operation, 323
282. Denudation for Fritsch's Operation 324
283. Catgut Sutures for Union of the Rectal Wall, 325
284. Incision for Duke's Operation 325
285. Incision Separated in Vertical Direction, 326
286. Incision United by Transverse Sutures 326
287. Follicular Vulvitis (Thomas and Munde), 333
288. Cyst of Bartholin's Gland (Auvard), 339
289. Kraurosis Vulvae 344
290. Urethra Laid Open with Probes. Distending Skene's Glands. Poste-
rior Wall Di\'ided (Byfard. after Skene) 357
291 . Reflux Catheter 361
292. Double-current Catheter. 371
293. Simple Papillar>* Erosion of the Cer\'ix 376
294. Simple Papillar\' Erosion \\-ith Enlarged Follicles, 376
295. Extensive C\'stic Disease of the Cervix 377
296. Chronic En<focer\'icitis 378
297. Lines of Incision for Contracted or Pinhole Os (Thomas and Munde), 382
29S. Union of Vaginal and Cervical Mucous Membranes 382
290. Interstitial Endometritis 393
300. H\-pertrophic Glandular Endometritis, Showing Increase in Size and
Numbers of Glands 394
301. Hypertrophic Glandular Endometritis, Vertical Section through the
Mucous Membrane 395
302. PohTwid Masses Associated with Chronic Endometritis 396
303. Membranous Dysmenorrhea 397
304. Uterus Dilated with Graduated Boujries 409
305. Uterine Ca\'ity Packed with Gauze after Dilatation 410
300. Acute Salpingitis 412
307. Chronic Salpingitis Showing Agglutination of Folds 413
30S. Extensive 1 us Collections with General Adhesions 413
30Q. Pyos;\lpinx 414
310. Section from Wall of Pus Tul">e 415
311. Single Fold from Wall of Pus Tube Enlarged 415
31^. Distended Pus Tubes Removed trv^m Young Girl 416
313. Convoluted Fallopian Tulv fn'»m lVris;ilpingitis 417
314. Incot!iplete InilaiTun.itory Closure of the Fallopian Tube. Portions
of Fimbriae Unretracted 417
LIST OP ILLUSTRATIONS. XXXUl
nC. PACE.
315. Double Tubo-ovarian Collection, 418
316. Hydrosalpinx, 419
317. Double Pyosalpinx Showing Adhesions to the Rectum, to the Uterus,
and on the Right to the Appendix, 420
318. Peri-oophoritis. Tube and Ovary Encysted, 423
319. Resection of Tube, 428
320. Operation of Resection of Tube Completed, 428
321. Exudation in Broad Ligament from Pelvic Cellulitis, 434
322. Exudation of Cellulitis over Rectum, 435
323. Induration from Peritonitis, 449
324. Induration from Pelvic Cellulitis, 450
325. Intestines Held Back by Gauze. Patient in Trendelenburg Posture,. 454
326. Three-pronged Vulsellum, 456
327. Vs^inal Incision for Pus Collection in the Broad Ligament, 457
32&. Incision through Vagina with Thermocautery in Vaginal Excision of
the Uterus, 458
329. Clamp Forceps for Securing the Broad Ligament, 459
330. Deschamps Needle Ligature Carrier, 459
33 1. Drawing down the Fundus (Landau), 460
332. Application of the Clamp Forceps to the Lower Portion of the Broad
Ligament (Landau), 461
333. Ligation of the Broad Ligament in Vaginal Hysterectomy, 462
334. Upper Portion of the Broad Ligament Secured by Clamp Forceps
(Landau), 463
335. The Introduction of Gauze after the Removal of the Uterus, 464
336. Closure of the Vaginal Wound by Sutures, 465
337. Landau's Method of Delivering the Uterus after Its Complete Median
Section 466
338. Uterus Displaced by Distended Bladder, 467
339. Uterus Disp^ced by Impacted Rectum, 468
340. Scheme of Dislocated Uteri (Dudley), 469
341. Uterus pushed up by Tumor in Douglas' Pouch 470
342. Uterovaginal Prolapse, 471
343. Vagino-uterine Prolapsus, 472
344. Vagino-uterine Prolapsus with Hypertrophic Elongation of the Cervix
(Auvard) 473
345. Uterus Detached Showing Hypertrophic Elongation of the Cervix
(Auvard), 474
346. Vulvar Appearance of Vagino-uterine Prolapsus, 475
347. Pseudoprolapsus. Cervix within the Vagina 476
348. Pseudoprolapsus. Cervix Protruding from the Vulva, 477
349. Anterior and Posterior Colpocele, 478
350. Cystocele, 479
351. Prolapsus with Both Rectocele and Cystocele, 480
352. Irreducible Prolapsus. The Tumor Contained Uterus and a Large
Pyosalpinx. Ulceration of the Cervix, 48 1
353. Prolapsus without Protrusion of the Vaginal Walls, 482
354. Determination of the Position of the Uterus by Bimanual Palpation, 483
355. Recognition of the Uterus with Thumb and Fmgers of One Hand, . . . 484
356. Diagnosis of Position of the Uterine Body by Rectal Touch, 485
357. Hypertrophic Elongation of the Cervix. Anterior Vagina Everted,
while Posterior Retains Its Normal Position (Auvard), 486
358. Enterocele through the Posterior Vaginal Fornix 487
359- Vagino-uterine Prolapse Complicated by Proliferating Epithelioma, . . 488
360. Ring Pessary, 490
361 . Disc Pessary, 490
362. Smith-Hodge Pessary, 490
363. Mund6 Pessary, 490
364. Hoffman Soft-rubber Pessary 491
365. Zwank Pessary, 49 1
366. Gehrung Pessary, 491
367. Hewitt Cradle Pessary, 491
XXXIV LIST OF ILLUSTRATIONS.
FIG. PAGE.
368. Anterior Colporrhaphy. Anterior Vaginal Wall Removed, 493
369. Wound Closed, 494
370. Stolz's Purse-string Suture (Pozei), 495
371. First Stage of Dudley's Bilateral Denudation of the Vaginal Walls
for Prolapsus (Dudley), 497
372. Dudley's Operation Showing Denudation upon One Side of the Vagina
(Dudley) 498
373. Urethrocele, 499
374. Anteversion of the Uterus, 501
375. Sims' Operation for Anteversion (Auvard), 503
376. Abdominal Belt, 504
377. Retroversion, 505
378. Slight Degree of Anteflexion, 507
379. Acute Anteflexion, 507
380. Thomas Anteflexion Pessary, 510
381 . Stem Pessary, -. . 510
382. Section Showing Thinning of Cervical Walls at the Angle of Flexion, 511
383. Anteflexion Associated with Contraction of Uterosacral Ligaments,. . 511
384. Dudley's Operation for Anteflexion, by Incising and Suturing the
Posterior Lip (Dudley) 513
385. Completion of Dudley's Operation, by Transverse Denudation and
Suturing of the Anterior Lip, 514
386. Nourse's Operation by Splitting the Cervix and Resuturing the In-
cisions, 515
387. Operation Completed 515
388. Retroflexion of Slight Degree 516
389. Retroflexion of Extreme Degree, 517
390. Retroflexion Following Version, 517
391. Retroflexion Produced by Fibroma of Anterior Uterine Wall, 518
392. Retroflexion the Sequel of Inflammatory Adhesions (Thomas and
Munde), 518
393. Retroflexion Simulated by Posterior Uterine Myoma, 519
394. Retroflexion Simulated by Small Ovarian Cyst in Posterior Culdesac, 519
395. Anteflexion and Retroflexion Simulated by Pelvic Exudation, 520
396. The Retroverted Uterus Replaced; Patient in Dorsal Position, 521
397. Schultze's Method of Replacing an Adherent Retroverted Uterus,... . 522
398. Second Step in Replacing Uterus by Schultze's Operation, 523
399. Schultze Pessary, 525
400. Proper Position of the Pessary, 525
401. Faulty Position of the Pessary, 526
402. Schultze's Sledge Pessary 527
403. Alexander Operation: Round Ligament Exposed (Edebohls), 528
404. Round Ligament Being Drawn out (Edebohls) 529
405. Round Ligament Sutured (Edebohls) 530
406. Continuous Catgut Suture Uniting Internal Oblique Muscle to Pou-
part's Ligament (Edebhols) 531
407. Return Layer of Suture Bringing External Oblique Muscle in Apposi-
tion (Edebohls), 532
408. Wylie's Operation for Shortening the Round Ligaments within the
Abdomen (Am. Sys. Gyn.), 533
409. Mann's Operation for Intra-abdominal Shortening of Round Ligaments
(Am. Sys. Gyn.), 534
4x0. Dudley's Operation of Desmopycnosis (Am. J. Obs.), 535
411. Dudley's Operation Completed (Am. J. Obs.) 535
412. Gilliam -Ferguson Operation. Round Ligament Seized through
Stab Wound 536
413. Round Lij^ament Dra\\Ti through the Abdominal Wall 537
414. Section Showing Position of the Uterus with Completion of the
Operation 537
415. First Step in my Modification of the Gilliam Operation for securing
Round Ligament Support 538
LIST OF ILLUSTRATIONS. XXXV
FIG. PAGB.
416. Second Step, Showing Ligament Fixed with Hemostat while Tempo-
rary Ligature is Camed Beneath Anterior Leaflet of Broad Liga-
ment with a Deschamps Needle, 539
417. Operation Completed. Diners from Gilliam-Ferguson in having no In-
ternal Sutures, 540
418. Sutures Introduced for Ventro-suspension, 541
419. Partial Inversion of the Uterus, Snowing Three Degrees {Auvard),. . . 551
420. Intravaginal Inversion; Three Degrees (Auvard), 551
421. Extravaginal Inversion; Three Degrees {Auvard), 552
422. Nonpuerperal Inversion. Fibroid Tumor Attached to the Fundus
Uten, 552
423. Palpation of an Inversion of the First Degree {Auvard), 553
424. Palpation of an Inversion of the Second Degree (Auvard), 554
425. Appearance of Inversion of the Third Degree, 555
426. a. Inversion of the Uterus, b. Fibroid Polypus, c. Fibroid Poly-
pus, with Stenosis of the Cervical Canal, 556
427. a. Submucous Fibroma, h. Partial Inversion, c. Partial Division
of the Uterus, 557
428. Prolapsus Uteri without Inversion, 558
429. Inversion of the Uterus, Extravaginal, 558
430. Central Taxis {Auvard), 559
431. Lateral Taxis (Auvard), 560
432. Peripheral Taxis (Auvard), 561
433. The Use of the Air Pessary to Reduce an Inversion {Auvard), 561
434. Reduction of Inversion with White's Apparatus {Thomas), 562
435. Intraperitoneal Dilatation of the Uterus {Thomas), 563
436. Incision of the Posterior Uterine Wall Preliminary to Reduction of an
Inversion, 564
437. Prolapsus of Ovary and Tube behind Uterus 565
438. Intraperitoneal Hemorrhage (Auvard) 577
439. Extraperitoneal Hematoma (Courty), 578
440. Tubal Pregnancy {Sutton), 584
441. Tubo-ovanan Pregnancy, 585
442. Tubo-uterine or Interstitial Pregnancy, 585
443. Tubal Abortion, 586
444. Complete Rupture of a Tubal Sac, 592
445. Incomplete Rupture of Gestation Sac, 592
446. Ectopic Gestation Sac Ruptured Showing Fetus, 601
447. Large Ectopic Gestation Sac 605
448. Anterior Labial or Inguinal Hernia, 624
449. Posterior Labial Hernia 625
450. Urethral Canmcle, 626
451. Prolapsus Urethrae 627
452. Varicose Veins of the Vulva {Dr. W. Krusen) 628
453. Vulvar Vegetations 631
454. Elephantiasis of the Vulva 632
455. Fibroid of Labium 633
456. Cancer of the Vulva, 634
457- Appearance of the Vulva after an Operation for Cancer of the Vulva, 635
458. Cysts of the Vagina 638
459. Myoma of the Anterior Vaginal Wall {Dr. J. C. Da Costa), 639
460. Primary Cancer of the Vagina, 640
461. Microscopic Section; Myoma Uteri {Coplin) 653
462. Liomyoma of the Uterus {Coplin), 654
463. Submucous Myoma (Polypoid), 655
464. Sessile Submucous Myoma, 656
465. Submucous Myoma (occupying Uterine Cavity, 656
466. Submucous Myoma Extruded into the Vagina, 657
467. Voluminous Myomata Occupying Anterior and Posterior Walls
{Auvard) 658
468. Circumscribed Interstitial Myomata {Auvard), 659
469. Local Interstitial Myomata {Auvard), 659
XXXVl LIST OF ILLUSTRATIONS.
FIG. PAGE.
470. Uterus Opened, Showing Multiple Interstitial Mvomata, 660
471. Sectioned Surface of Uterus Showing Several Fibroid Tumors 661
472. Serous Surface of Same Specimen, 661
473. Uterus Incised Containiiu? Interstitial Fibro-myomata, 66a
474. Uterus Incised Showing General Circumscribed Fibro-myomata,.*. . . . 663
475. Subserous Myomata, 664
476. Pedunculated Myoma of the Cervix 665
477. Sessile Myoma of the Cervix, 666
478. Bicomate Uterus. Both Comua Containing Myomata 670
479. Intraligamentary Myoma, 673
480. Large Desmoid Tumor of Abdominal Wall Weighing Upon Removal
19J Pounds, 677
481. Histologic Section of Desmoid Timior, *. 678
482. Myoma Uteri with Large Intraligamentary Fibromata, 681
483. Fibrocystic Tumor of tne Uterus {Auvar^ 683
484. Submucous Fibromyoma Undergoing Cystic Change, 684
485. Myoma of the Body and Cancer of the Cervix, 68$
486. Uterus Incised Displaying Numerous Fibro-myomatous Growths and
Incipient Cancer of the Cervix, 686
487. Myoma Uteri Complicated by Pyosalpinx 688
488. Uterus Containing Several Fibroid Tumors Complicated by a Large
Tubo-ovarian Cyst, 688
489. A. Myoma Which, from the Associated Ascites, Had Been Mistaken
for Pregnancy, 689
490. Tumor Shown after Removal, 690
491. Myoma Complicated by Pregnancy 691
492. Uterus Containing Large Fibroid Tumor and Three Months' Fetus, . . 692
493. Incision of Cervix to Expose Intra-uterine Myoma, 706
494. Cervix and Capsule Incised, the Latter Pushed Back, 707
495. Removal of Mvoma by Torsion of Its Pedicle, 709
496. Incision of Pedicle of Myoma 710
497. Enucleation of Tumor through the Vagina 711
498. Interstitial Tumor Exposed by Vertical Incision of the Anterior Lip,. 712
499. Myoma of Anterior Wall Exposed by Transverse and Vertical Incision, 713
500. Myoma of Posterior Wall Exposed by Retro-uterine Incision, 714
501. Removal of Myoma by Morcellement, 715
502. Abdominal Myomectomy {Dudley), 721
503. Abdominal Enulceation of Myomata and Method of Closing the
Uterine Wound {Dudley), 721
504. Supravaginal Removal of Myomatous Uterus {Kelly), 725
505. Cervix Cut Across Preliminary to the Complete Ligation of One
Ligament {Kelly, modified), 726
506. Stump Covered with Peritoneum 727
507. Panhysterectomy. Doyen's Method, 731
508. Cervix Separated from the Vagina, and Being Pulled away from the
Bladder and Ureters, 732
509. Mucous Polypi, 743
5x0. Squamous-cell Carcinoma of the Cervix 746
511. Squamous-cell Epithelioma of the Uterus, 754
512. Adenocarcinoma of the Cervical Canal, 755
513. Adenocarcinoma of Body of the Uterus, 756
514. Cauliflower Growth Involving the Vaginal Part {Winter), 757
515. Cancerous Ulceration of Intracervical Canal {Auvard), 758
516. Cervical Wall Infiltrated while the Vaginal Portion is Largely De-
stroyed {Veil), 759
517. Circumscribed Cancer of Body of Uterus {Auvard) 760
518. Diflfuse Cancer of Uterine Body 761
519. Adenocarcinoma of Uterine Body 761
520. Incipient Adenocarcinoma of Uterine Mucous Membrane, 762
521. Entire Cavitv Covered with Nodular Growths 762
522. Communication between Bladder, Vagina, and Rectum {Auvard), 763
523. Cer\^ical Canal Destroyed by Progress of Disease 764
LIST OF ILLUSTRATIONS. XXXVll
riG. PAGB.
524. Uterus Removed from an Umnarried Woman Twenty-two Years of
Age 771
525. Formation of Flap to Cover Diseased Surface Preliminary to Opera-
tion, 789
526. Ligation of the Anterior Trunk of the Internal Iliac, 803
527. Skin Incision for Sacral Resection, 807
528. Sacrum Resected ; Rectum Exposed, 808
529. Rectum Pushed Aside; Uterus Exposed, 809
530. Patient from Whom Uterus, Ovaries, Posterior Wall of Vagina,
Perineum, and Five Inches of the Rectum Have Been Removed, 812
531. Chorio-epithelioma of the Uterus, 832
532. Chorio-epithelioma Malignum {Noble and Tracy), 833
533. Histologic Section of Chorio-epithelioma, 833
534. Endothehoma of the Uterus, 835
535. Sarcoma of the Body of the Uterus, 837
536. Fibroma Undergoing Sarcomatous Change (Auvard), 847
537. Papilloma of the Fallopian Tube {Doleris), 854
538. Broad Ligament Cyst {Sutton), 856
539. Broad Ligament Cyst, with Torsion of Its Pedicle, 857
540. Laige Ovarian Tumor, 860
541. Small Residual Cysts {Dudley) 861
542. Cyst of the Corpus Luteum, 862
543. Tubo-ovarian Cysts, 863
544. Large Ovarian Cyst. Patient Upright, 864
545. Ovarian Cyst. Patient Recumbent, 865
546. Pedicle of an Ovarian Cyst (Doran), 865
547. IntraUgamentary Ovarian Cyst, 866
548. Cyst Embedded in the Pelvis, 867
549. Adenocystoma of Ovary, Showing Papillary Formation, 868
550. Areolar Ovarian Cyst, 869
55 1 . Unilocular Ovarian Cyst (Winter), 870
552. Multilocular Cyst (Doran), 871
553. Small Papillary Ovarian Cyst, 872
554. Papillary Tufts upon Inner Wall of Cj^st (Doran) 872
555. Surfaces of Ovaries Infected with Papillary Vegetations {Doran) 873
556. Papillary Ovarian Cyst, 874
557. Dermoid Ovarian Cyst, 875
558. Fibromyoma of Ovary {Veii), 876
559. Sarcoma of the Ovary {Veit), 876
560. Torsion of the Pedicle, 882
561. Dermoid Which Had Lost Its Original Relations and Was Nourished
by Adhesions from the Omentum 884
562. An Ovarian Cyst .beneath a Pregnant Uterus 886
563. Desmoid Tumor of Abdominal Wall, 889
564. Relative Zones of Dullness and Resonance in Ascites, 891
565. Relative Zones of Dullness and Resonance in Ovarian Cyst, 892
566. Hegar's Method of Determining Relation of Tumor to the Uterus
(Winter), 894
567. Cyst Forceps, 906
568. Wall Incised; Cyst Exposed, 907
569. Cyst Punctured and Bein^ Withdi^wn, 908
570. Withdrawal of Sac, Showing Adhesions 909
571. Ligatures Introduced through Broad Pedicle, 910
572. Interlacing of Sutures to Prevent Splitting of Pedicle, 910
573. Sutures Interlaced and Tied, 912
574. Splitting of Pedicle when Sutures are Tied without Interlacing, 915
Text-book of Gynecology.
INTRODUCTION.
1. Definition and Antiquity. — Gynecology comprises the study
of the diseases peculiar to women. The description of the sound
and various forms of specula, specimens of which have been
fotmd in the ruins of Pompeii and Herculaneum, and directions
given in manuscripts for the treatment of special conditions,
make it evident that the ancients possessed some knowledge
of the disorders of the female genital tract, but it can not be
disputed that the greatest progress in the development of the
science occurred during the last half of the nineteenth century.
2. Theories. — The study of the progress of the science is
not without interest and profit, and in its development we wit-
ness the pendulum swing from one extreme to another. The
origin of disease is based upon local inflammation by one; by
another it is ascribed to constitutional conditions of which the
local condition is only an expression. The cervix has been
considered the offending portion of the tract, and its inflammation
the cause of every trouble. The ovaries have been accused of
dominating the other organs, and producing in them secondary
or reffex phenomena. Displacements of the uterus, particularly
the flexions, have been, and still are, asserted to be the main
source of the disorders of the pelvis. The tubes have been
indicated as the instigators of the function of menstruation,
and consequently to pathologic lesions of these organs are at-
tributed the majority of abnormal conditions of the genital tract.
3. Foundation. — ^An analysis of the different theories discloses
that the truth is contained, not in one but in a proper com-
bination of all. The influence of one organ upon another due
to the arrangement of vascular and nerve supply is significant,
and a proper appreciation of the subject is reached only after a
very careful study and analysis of all the phenomena presented.
4. Purpose.— It should not, upon the one hand, be considered
the true province of the student of gynecology to ascertain that a
patient has a uterus which should be subjected to the routine use
1 1
2 GYNECOLOGY.
of Speculum, sound, and applicator; nor, upon the other, that the
recognition of the existence of ovaries and tubes justifies the con-
clusion that every symptom of distress or discomfort from which
the patient complains must indicate in them a pathologic lesion
which will of necessity justify their sacrifice. The gynecologist
should be one who will be assiduous in the study of the history
of disease; ready to discern its cause; careful in eliciting the
subjective symptoms, and proficient in determining physical
signs, who will exercise correct judgment in comparing and
analyzing the knowledge thus secured, and has such in-
tegrity that the patient may feel assured she will not be treated
for diseased conditions which are not present.
He must be so conservative that he will sacrifice no organ
whose physiologic integrity is capable of being restored ; so bold
and courageous that his patient shall not forfeit her opportimity
for life or restored health through his failure to assume the respon-
sibility of any operative procedure necessary to secure the object.
ETIOLOGY.
5. Importance of Etiology. — A knowledge of the causes
which result in the production of disorders of the genital tract
are essential to the ready recognition of their character and to
the employment of proper measures for the relief of the suffer-
ing victim. The study of the forces which combine for the
production of genital disorders are especially complex, for they
comprise not only the actions of the diseased, but also of those
with whom she is associated and those who have been her pro-
genitors. Here, truly, we see the sins of the parent visited upon
the children not only to the third, but to many generations.
6. Classification. — The causes of disease are difficult to clas-
sify, and are sometimes divided into two great classes, the pre-
disposing and exciting. When considering some particular
class of disease, as, for instance, inflammation, such classification
can readily be arranged, but when we come to consider all the
disorders to which the genital organs are subject, it becomes
more difficult to assert what are predisposing and what are ex-
citing. In one individual the diseased state can be directly
traced to abnormalities in development; in another to defects
in her manner of life; a third may have had disease brought
to her through lier sexual life, and a fourth suffer from injuries
incident to reproduction.
The following seems sufficiently compreliensive :
(a) Hereditar\^ and congenital.
(b) Hygienic.
ETIOLOGY.
(c) Sexual.
r .-•• V .. ••T
((i) Traumatic. ' " "
(e) Infective. '- /"5';-;
if) Causes incident to age. '. . ^ ' . ;
7. (a) Hereditary and Congenital Causes. — It seems impos-
sible, yet is demonstrated day by day that the atoms suppliied
by the male and female which unite to set up processes of coil-
struction for a new life contain within their minute compass the
impetus which is to lead to the development of traits and char-
acteristics similar to those possessed by their progenitors.
These traits and characteristics involve not only shade,
form, and color, but mental and moral attributes. Imperfections
and imfortimate traits which are common to the parents are
intensified in the offspring. A knowledge of such transmission
is employed by the stock raiser to improve his herds. Only
such males are employed as will improve and correct the rec-
ognized defects of his herd. While it is impossible to introduce
in the relation of the sexes of the human race the precision of
the stock breeder, it cannot be denied that the production of
healthy offspring is too rarely the motive for such union. Family,
position, and wealth are more frequently considered essential
than are good health and good morals upon the part of the elected
husband. The worn out roue, the debauched or decrepit son
of wealth are preferred to the virile young man who has his
fortune to make. A feeble or sexually exhausted male united
to a cold, dispassionate woman with no, or but little, inclination
to maternity must result in the production of offspring with
still lower sexual virility. Sterility, defective sexual and phy-
sical development, and lessened powers of resistance are likely
to characterize the offspring of such a union. Intemperance
in eating and drinking, overwork, exhaustion from indulgence
in the exigencies of fashionable life, and a tendency to marked
fat production in one or both parents, lessens virility and vitality
in the children. Intensification of pre-existing traits, the oc-
currence of vicious tendencies, lessened resistance to certain
constitutional diseases as tuberculosis, the gouty diathesis, and
malignant degenerations may be transmitted from parent to
child and are known as hereditary causes of disease. Not infre-
quently from careful hygiene, improved environment, and other
favorable conditions such tendencies may not make their ap-
pearance in one or more generations and apparently become
intensified in one less favorably situated. The most marked
influence upon the sexual life of the individual will be rec-
ognized in the study of the development of the ovum. Dtiring
its progress of development the ovum is subjected to vari-
ous disorders which may lead to arrest or deranged formation
4 GYNECOLOGY.
of the Structures of the genital tract, dependent, of course,
upon the period or stage of development in which this may
take place. Should the change occur before the separation of
the Miillerian ducts and the genital bodies from the WolflBan,
there may be an absence of the structure upon the side affected,
so that kidney, ovary, tube, and one horn of the uterus are want-
ing. In the later stages of development one or both Mullerian
ducts may be affect^, resulting in absent, rudimentary or
defective uteri. The ducts may fail to coalesce or form ap-
parently well developed uteri and vagina, with a septum between ;
or the coalescence may be partial. Failure to coalesce causes
the development of separate and generally rudimentary uteri
and vagina. Partial coalescence may involve only the vaginal
portion of the tubes, with the two horns of the uterus com-
pletely separated, making a double uterus, or it may be a bi-
comate uterus joined together with a common neck; or the
division may be in the fundus of the uterus only. In the devel-
opment of the tubes, the inflammatory process which results
in the arrest of development may affect one tube only, while
the other goes on to full development. The rudimentary duct
may encircle to some degree the well developed organ. Such
a condition may result in the development of a uterus which
is unequal to the proper performance of its fimctions and en-
danger the life of the woman in a subsequent gestation, or the
horn may be so well developed as to carry on its functions with-
out the abnormality being suspected until some operative pro-
cedure discloses the actual condition. The rudimentary horn
may in some cases be associated with an atresia of the corre-
sponding vagina. Such a condition would not attract attention
until subsequent to puberty, when fluid unable to escape would
accumulate in the defective tube, forming a more or less defi-
nite tumor. Such a tumor may be situated to one side of the
vagina, but more frequently pointing somewhat anterior to the
well formed canal. In a patient coming under my observation
the woman had given birth to two children and was at that time
a victim of a large interstitial fibroid growth in the uterus.
Examination revealed a pouch to the anterior and right of the
vagina, the character of which was not recognized imtil during
the operation, when it was foimd that it was the blind pouch of
a rudimentary^ uterus. The septa dividing the vagina pro-
duced no appreciable influence and are unlikely to be discovered
until after the marriage of the individual. The septum pro-
duces so small a tube as to lead to discomfort and pain during
the marital relations and to obstruction during parturition.
The amount of obstructic^n, of course, in the latter will depend
upon the thickness and firmness of the septum. Generally it
ETIOLOGY. . 6
is torn through the greater part of its extent during parturi-
tion. Occasionally, subsequent to parturition, a bridle or
remnant of this septum will be found connecting the anterior
and posterior wall of the vagina, the remaining portion of it
having either been torn through or sloughed away as a result
of parturition. The defective development may involve the
lower part of the genital tube, affecting the vagina and vulva.
Thus, there may be an absence of the urethra, a condition of
hypospadias, in which the urethra opens into the vagina. The
portion of the vagina may have undergone atresia or the vulvar
orifice of the vagina may be closed by an imperforate hymen.
These conditions are not likely to produce symptoms imtil the
woman has reached and passed the period of puberty, when
the occurrence of the menstrual mohmina without the pres-
ence of a discharge indicates something abnormal. If the con-
dition is not recognized a tumor will ultimately develop as a
result of the retention of the menstrual discharge. The de-
formities may affect the labia majora, the labia minora, the
former being thin, a slight amoimt of fatty tissue, or the inguinal
canal may remain open, permitting the secretion from the
peritoneal cavity to descend into the sac, forming a hydrocele,
or the intestine pushed down, causing hernia. The labia minora
may be elongated or may be almost absent. The clitoris may
be defective in its development or be so large and hypertro-
phied as to lead to doubt as to the sex. This malformation may
aflEect the genital organs of either sex, giving rise to imcertainty
as to the sex of the individual imder consideration, when it is
known as hermaphroditism. True hermaphroditism, the presence
of both organs in the same individual, probably does not exist.
Pseudohermaphroditism, or a condition in which the organs
of one resemble the other sex, are quite frequent. Malforma-
tions of this character, which have occurred during the progress
of the development of the ovum, are known as congenital con-
ditions in contradistinction to those we have been considering
as hereditary.
8. (b) Hygienic Causes. — Woman is like a flower. To reach
the highest development she must generously absorb the rays
of the sun and drink deeply of pure air. Unfortunately, the
tendencies of civilization have been to deprive her of these
essentials at the period of life when she is in most need as she
enters into womanhood. Her male companions, wdth whom
until this time she has enjoyed almost equal freedom, are still
permitted to enjoy the freedom of Nature, while she is con-
demned to interest herself with indoor pursuits. No longer
allowed to romp and play she is doomed to practice being a
lady. Stiffly and often tightly dressed, she is compelled to
6 GYNECOLOGY.
assume the attitude and thoughts of a mattire woman, and
what exercise she secures is taken so sedately as to be tmworthy
of that designation. At the period of life when the development
of her sexual fimctions are making the greatest draft upon her
nervous system, she is confined closely to her books and music,
securing the accomplishments and embellishments which are
to be her capital. At an early age she is introduced to society,
and if fortunately (?) situated her life becomes a continuous
whirl of parties and entertainments entailing late hours, irregu-
lar meals, imdue exposure, excitement, and a continual appeal
to the emotions. Her social position demands that the natural
contour of the body be distorted by tight dresses, which dis-
place the viscera from their normal relations, increasing intra-
abdominal pressure, and driving the pelvic organs to a lower
level. The circulation in these organs is necessarily influenced
by the interference with the venous return, thus causing stasis.
The compression of the lower part of the chest interferes with
the expansion of the lungs, with the action of the stomach,
heart, and liver, so that the processes of nutrition are affected,
and the individual suffers from anemia, neurasthenia, defective
action of the digestive tract, and disturbances of the ftmctions
of the genital organs. The faults enumerated are still further
enhanced by enveloping the central portion of the body with
skirts supported from the waist, while the extremities are clad
in network hose and thin shoes or slippers, and the neck, chest,
and arms bare. She ordinarily will go fairly clad and make
the above changes in the coldest weather; occupying crowded
rooms, subject to drafts, and this regardless of the menstrual
periods. Should it be surprising that serious pelvic disorders
are frequent? That pel\4c disease is the rule rather than the
exception? The usual life of the yoimg woman precludes regu-
larity in the performance of her functions. The evacuation of
her bowels and bladder are neglected. Retention of the con-
tents of these viscera produce repeated displacements of the
uterus which finally become permanent ; the failure to evacu-
ate the bowels causes a toxemia which profoundly influences
nutrition and produces toxic symptoms, in which the pelvic
organs have a considerable part.
Want of general cleanliness necessarily lias a marked influ-
ence upon tiie health and nutrition of the individual. The
skin takes a very active part in the processes of elimination
and must be kept in good condition by proper and systematic
bathing to do effective work. Neglect of local cleanliness re-
sults in the decomposition of the accumulating secretions from
the vaginal tract, and the sweat and sebaceous glands of the
vulva, which are to some degree soiled with urine. Such an
ETIOLOGY. 7
accumulation forms an excellent culture fluid for micro-organisms
and diseases of the vulva and vagina are thus produced. The
retention of the smegma beneath the prepuce of the clitoris
leads to irritation and adhesions between it and the glans, to
irritation of the bladder, frequent micturition, wetting of the
bed, to nervous disorders, sometimes convulsions, and frequently
to masttirbation.
9. (c) Sexual Causes. — With the development of puberty
the sexual instinct dominates the female organism. Her view-
point of life changes. However exalted her ambition to attain
eminence in some imusual line the impetus to maternity cannot
be extinguished. Less passionate, less lustful than man, she
yet clings with greater constancy and devotion to the companion
of her choice. Her more limited sphere of action in life; her
more delicately organized nervous system, renders her especially
susceptible to the influence of the emotions. While the sexual
desire or eroticism varies in individuals, the majority of women
Weld to the sexual relation through a desire to please the man
rather than from any sexual inclination, from a desire to gratify
rather than to be gratified. Many women experience no sense
of pleasure dxiring or as a result of the sexual act, and regard
it as only a means to an end, viz., the retention of the affections
of her companion and the production of offspring. Some women
experience so much physical discomfort during the act and such
a degree of nervous irritation following it as to cause them to
regard the approach of the male with absolute disgust and re-
pugnance. The Ufe of a woman of the latter class with an
erotic man — a man who is so selfish as to care only for his own
gratification — ^becomes a **hell on earth.*' She considers herself
a sexual slave, bound to a man whose only regard for her is as
an instrument to minister to his passion. Whatever regard
she formerly entertained for him soon becomes dissipated.
Constant dwelling upon her sense of wrong and fretting against
the bonds which envelop her, leads not only to the production
of local disorder but to melancholia, hysteria, neurasthenia,
and even mental derangement.
Stimulation of eroticism by bad literature, by intimate
association with the opposite sex, or by onanism, are prolific
in the development of local disease. Ix)ng engagements, unless
occasioned by separation, are prejudicial in that the frequent
hyperemia produced by repeatedly awakened and unsatisfied
longings causes chronic oophoritis.
Equally disastrous is the union of a young erotic woman
with an old and especially impotent man.
The most potent factor to-day in the production of pelvic
disease is consequent upon efforts to avoid maternity. Nature
8 GYNECOLOGY.
has her revenge upon those who would violate her laws.
When the natural result of the marital relation is avoided by
withdrawal of the penis before the act is completed both parties
to the act are injured. The incomplete discharge causes the man
an irritation which produces a sensation of discomfort and tmrest
that leads to more frequent coition and consequent nervous
exhaustion, or neurasthenia for both participants. The con-
tinuous engorgement without the salutary influence of the com-
pleted orgasm and the failure of impregnation produces a con-
tinued hyperemia which renders the soil favorable for the de-
velopment of the various pehdc inflammations. The deliberate
indtdgence of the sexual appetite with the premeditated inten-
tion of avoiding its legitimate result, begets a lowered moral
attitude toward the sexual relation. The woman who con-
tinually avoids the possibility and responsibility of maternity
becomes little more than her husband's mistress, indeed, it may
often be questioned whether she is regarded so highly. If
her sexual appetite be strong and she resents the apparent
neglect of her husband, it does not become a long step for her
to become the mistress of another. A woman so lost to the
purpose of the marital relation will not hesitate to employ, or
have employed, agents for the arrest of pregnancy when it occurs
in spite of the precautions observed. Abortions or repeated
abortions necessarily induce disorders of the pelvic or-
gans. Nature makes her provision for the evacuation of the
uterine contents when the fruit has matured and earlier separa-
tion finds it unprepared to easily resume normal relations.
Involution is less rapid and prone to be incomplete. Subin-
volution, descent, displacements, chronic endometritis and
metritis, periuterine inflammation, and tubal and ovarian disease
are consequences of such interference. The genital organs may
become so crippled as to render subsequent conception impossi-
ble, or so irritated as to render the uterus unable to supply the
necessary nutrition to mature the implanted ovum and abortion
becomes the habit.
10. (d) Traumatic Causes. — The injuries to which the genital
tract are subject may be accidental, the result of violent efforts
at intercourse, consequent to parturition, or the result of opera-
tive procedures. The accidental injuries are comparatively
infrequent, and, while capable of producing cicatricial changes,
are generally insignificant in their ultimate effects. Coition
has produced laceration of the perineum, tearing off of a rigid
and resistin^£i[ hymen, tearing of the vagina, and the formation
of rectovaginal fistula. The act of coition is most likely to
produce severe injun' in the ver\^ young r^r in the elderly virgin.
The greater majority of injuries occur from lesions of parturi-
tion. These mav involve the bodv of the uterus, the cervix,
ETIOLOGY. 9
the vagina, perinetim, or pelvic floor, and the adjacent viscera.
The lesion may be in the nature of a tear with healthy tissue
which if kept free from infection soon heals, leaving only a more
or less well marked cicatricial band, or as a result of long con-
tinued pressure or bruising, is followed by extensive sloughing
and loss of tissue, which, if recovery occurs, must be attended
by deformity. Lesions of the genital canal are favored by
malformations of the bony and soft part of the pelvis; small
and contracted genital canal, imdersize or malposition of the
fetus, rigid and imyielding muscular structtire, an inordinate
amotmt of fat in the maternal tissues. Enfeebled muscular
action and ineffective labor pains by which the tissues are sub-
jected to long continued pressure between the bones of the
fetal head and those of the pelvis, and the rash and unskilful
employment of manual and instrumental manipulation. The
prompt and skilful resort to assistance has greatly lessened
the frequency of severe lesions. It is true lacerations of the
cerv'ix and pelvic floor may be relatively more frequent imder
early interference, but such lesions are easily repaired and pro-
duce far less serious consequences than the extensive destruc-
tion of tissue resulting from protracted labor
Any lesion of the pelvic floor becomes an avenue for the
entrance of infection. Extensive lacerations of the cervix and
pelvic floor interfere with the process of involution so that the
organs are much longer in reaching the normal, which may be
prevented by various sequelae. In laceration of the cervix,
in addition to subinvolution, the cervical lips are frequently
separated, the posterior may undergo involution while the an-
terior becomes hypertrophied. Increased secretion occurs from
the cervical glands or superficial inflammation may lead to
stenosis of the gland ducts and distention of the Nabothian
glands imtil the entire cervix has undergone cystic degeneration.
In some cases the torn surfaces may become cicatrized, filling
up the angles of the tear with wedges of cicatricial tissue, in
which the ner\^e tendrils are imprisoned and pinched, produc-
ing various reflex phenomena. Occasionally the pressure of
the cervix against the posterior wall of the vagina will lead to
turning of the lips, the posterior upward and the anterior down-
ward, in which position they are held by indurated tissue within
the injtired surfaces. The resulting endocervicitis, thickened
mucosa, and distended glands produce ectropion of the mucosa,
which increases the separation of the lips.
That this condition is an incentive to the occurrence of
carcinoma of the cerv^ix is made evident by the fact that this
is most frequently found in the cerv^ix and in the cervices of
women who have given birth to one or more children. Laccra-
10 GYNECOLOGY.
tion of the pelvic floor in slight degree lessens the support of
the viscera and retards involution, and the combination of de-
creased support and increased weight of the superimposed
viscera promotes descent, displacement, and chronic inflamma-
tion. Laceration through the sphincter leaves the intra-ab-
dominal pressure unantagonized and renders the patient imable
to control the contents of the lower bowel. The enforced de-
privation of society by this condition not infrequently results
in melancholia and mental disttirbance. Fistulous openings
between the genital canal and the adjacent viscera produce con-
stant soiling of her person with urine or feces, irritating the
skin of the vulva and of the thighs, and make her a source of
distress to herself and her friends.
The discussion of the traumatic causes of pelvic disorder
is incomplete if some consideration is not given to those which
result from operative procedure. They are mostly the result
of want of skill, improper technique, inexperience, and faulty
judgment. No man should tmdertake pelvic stirgery who has
not had large opportunity for obser\^ation in diagnosis, and a
careful training in surgical technique. Every surgeon is sad-
dened by seeing patients who had not been seriously ill prior
to a cureting, with conditions demanding sacrificial operations,
women bemoaning the loss of ovaries, who from the history evi-
dently did not require such a sacrifice. Patients with fistulse,
hernia, adhesions, intestinal constrictions, living Hves of miser\'
and discomfort, who could have been readily restored to health
had their operators been better trained.
II. (e) Infective Causes. — Inflammatory diseases of the
pelvis are with extremely rare exceptions the result of the pres-
ence of micro-organisms. Those which are the most frequent
in their baleful influence are the gonococcus, the staphylococcus,
pyogenes aureus, the streptococcus, the bacillus coK communis,
and the bacillus tuberculosis. The retention of portions of
tissue which are exposed to the atmospheric air through the
introduction of the saprophites cause putrefaction and through
the absorption of the resulting toxins develop high tempera-
ture. The condition is denominated sapremia as contradis-
tinguislied from the multiplication of septic germs which pro-
duces septicemia.
The gonococcus is without question the most prolific source
of infection and invades the vulvo-vaginal glands, the vagina,
cer\'ix, body of the uterus, the tubes, the ovaries, and the pehic
peritoneum. Its (K^currcnce in a severe degree makes uncer-
tain its subsequent cure. Certainly no case is cured in the sense
of restoration to normal relations, nor can we be certain that
the subscfiuent symptoms will be in the form of sequelae, for
ETIOLOGY. 11
numerous cases occur demonstrating recurrence of the disease
without opportunity for fresh infection. Such attacks burst
forth, following sexual excess, intemperance in eating or drink-
ing or after exposure. Experiences of this character have been
manifested when previous examinations of its secretions have
demonstrated that the gonococcus was absent. Recent re-
searches have seemed to demonstrate that the gonococci lapse
into forms indistinguishable from pus cells or leukocytes and
return to their characteristic form when galvanized into activity
by some irritation. Such an explanation accounts for the re-
infection in the previous victim and its transmission by him
to others.
The gonococcus renders the soil by it infected more favorable
for the reception and nutrition of other micro-organisms. The
simultaneous action of some other organism with the gono-
cocctis is known as a mixed infection. The retention of decom-
posing products and the occurrence of sapremia is also favorable
for the development of the graver forms resulting in sepsis.
Infection from the staphylococcus, or streptococcus, is always
grave. Its progress depends upon the vinilence of the infec-
tion and the vital resistance of the patient. It may become
promptly localized or rapidly infect the blood and ultimately
result in death. The bacillus coli communis is most Ukely to
expend its baneful influence upon the peritoneum of the ad-
jacent structures. The tubercle bacillus may affect any portion
of the genito-urinary tract. Next to the limgs it probably
most frequently invades the peritoneum.
12. (f) Causes Incident to Age. — The most superficial obser-
vation reveals that the age of the woman renders her more sus-
ceptible to certain forms of disease. Some disorders are prone
to occur at certain ages.
The period prior to the manifestation of puberty is especially
free from disorder. This is a period of quiescence. Even dur-
ing this period we find the individual suffering from gonorrheal
infection, producing vulvo-yaginitis, a condition requiring
prompt treatment to prevent its extension to the uterus and,
indeed, to the appendages, causing irrecoverable alterations.
Ovarian growths occasionally manifest themselves during this
period. With the advent of puberty the disorders multiply.
Malformations render their existence recognizable in retention
of menstruation, from atresia, vagina or uterus, or imper-
forate hymen. A poorly developed uterus may be unable to
readily perform its functions, so the patient suffers from dysmen-
orrhea and sterility. During the years of active menstrual
life, the chaste unmarried woman suffers from endometritis,
oophoritis, the occurrence of myomata, and chronic inflamma-
12 GYNECOLOGY.
tion of the ovary. Ovarian tumor and occasionally carcinoma
may be manifested. The latter in the virgin is most likely to
affect the body.
The married woman, while possibly slightly less susceptible
to myomata, suffers from infection, producing endometritis,
metritis, salpingitis, oophoritis, and periuterine inflammation,
either perimetritis or parametritis, or the two combined. She
is more prone to cervical carcinoma from the injuries the cervix
receives during parturition. Infections are much more prone
to be fotmd in such patients from their greater exposure in the
contingencies incident to the sexual relations, the possible inter-
ruption in the course of pregnancy, and the increased exposure
at the period of partxirition.
Carcinoma, while possible at any period, is more prone to
manifest itself at or near the menopause, ovarian cystomata
are more frequent during this period, but may occasionally
develop before or after the period of menstrual life. Subse-
quent to the menopause carcinomata, prolapsus, and senile en-
dometritis are the affections most frequently seen.
13. Difficulties in Study. — The discussion of etiology has
demonstrated the difficulties in the study of gynecology, but
will be found no less marked where the student essays a correct
diagnosis. Probably no department of medicine interposes
greater barriers to its accomplishment. In the study of the dis-
eases of women much must depend upon proficiency of touch,
which is acquired only by extensive practice. The delicacy
and proficiency of this sense varies so greatly in different indi-
viduals that it is difficult to convey an adequate idea of the
relative hardness or softness of the structures under observa-
tion.
The ovaries and tubes in which important lesions occur
are in many patients quite inaccessible to the ordinary methods
of examination. Pathologic lesions must often, then, be the sub-
ject of inference or speculation, rather than capable of absolute
demonstration. To render the study of symptoms more difficult,
the suggestion that she must subject herself to examination is
repugnant to the modesty of every woman, and the disease ex-
ists in organs so sensitive that manipulation can not be repeated
by a number of i)ersons in succession. The patients who are
wilUng to be brought before a class of students and subjected
to such examination are exceedingly few, consequently many
practitioners must enter u])on their vocation with but Uttle or
no practical knowledge of the sul)jcct.
14. Observation. — The cultivation of habits of close observa-
tion is of the utmost importance. The observing physician will
generally be able to determine with considerable accuracy the cir-
ETIOLOGY. 13
cumstances, condition, and diseased state of the patient from her
conduct, manner, and general appearance. Thus, a woman with
an abdominal enlargement who enters a physician's office with a
face presenting the rosy hue of health, and appears well notirished,
would nattually be suspected of stiff ering from a physiologic rather
than a diseased condition, and would be pronoimced pregnant;
while such an enlargement associated with a pale countenance,
an emaciated face, thin cheeks, and sunken eyes would be re-
garded as indicating an ovarian growth. This special association
of the features is known as facie s ovariana, and is of value in
forming the diagnosis. The conduct and deportment of the
patient will frequently annoimce whether she is married or
single ; her manner of walking or sitting, the existence of a pelvic
inflammation.
15. Exercise of Judgment. — Errors in diagnosis are most fre-
quently the result of hasty conclusions fotmded upon insufficient
investigation. The recognition of the existence of some lesion
is at once accepted as an explanation for all the distressing
symptoms. The accurate diagnostician will not come to a con-
clusion until a careful and thorough examination of every organ
capable of producing such symptoms has been made.
16. Value of Notes. — The yoimg physician should accustom
himself to taking notes of his office cases ; he thus forms the habit
of more careful and systematic investigation of every patient,
accumulates data from which he is enabled to formulate more
definitely judicious plans of treatment, and, probably most im-
portant of all, has the means of refreshing his mind from time to
time as to the condition of any particular patient.
17. History. — The notes should record the name, residence,
age, condition of patient, married or single, family history, per-
sonal history (as previous sickness, duration of present illness,
supposed cause, progress, and symptoms).
Menses: first appearance, regularity, duration, what changes
have since occurred; present habit, date of last menstruation.
Pain, whether it precedes, accompanies, or follows the periods,
its character, severity, and where experienced.
Leiikorrhea: amount of discharge, duration, continuance,
color, consistence, and effect upon the parts with which it comes
in contact.
Number of children or miscarriages: character of labor and
convalescence and the influence upon subsequent health.
Coition: painful, sensation, frequency, methods employed to
avoid conception.
Interrogation of other organs: regularity of alvine dejections,
frequency of micturition, digestion; pain in head, in lumbar
region, in groins, down the limbs, etc.
i
14 GYNECOLOGY.
The inquiry need not, possibly should not, in all cases pursue
the order here laid down. In some instances it will be better to
permit the patient to tell her own story ; in others it will be neces-
sary to guide her course by an occasional judicious question, or
to assume the position of questioner, and patiently endeavor to
secure a complete history. While the appearance and the char-
acter of the symptoms may indicate a certain interpretation, the
physician should reserve his judgment as to the condition until
the testimony of subjective and objective symptoms has been
completely secured, and then arrive at the diagnosis after their
careful analysis.
DIAGNOSIS.
i8. Subjective Sjrmptoms. — The subjective symptoms are
those which are elicited from the patient or her attendants. As
already asserted, the difficulty experienced in determining the
physical signs frequently make these symptoms of great value.
Every such symptom, however, must be carefully weighed, as
both patient and attendants are prone to exaggerate the charac-
ter and severity of symptoms or may err in observation and
in interpretation.
19. Causes of Error. — Lisfranc* writes: *'By their almost
latent state, their great variety of symptoms (often very transi-
tory), their sympathetic eflfects on all parts of the economy, and
their immense influence on the nervous system, uterine diseases
are peculiarly apt to lead medical practitioners into errors of
diagnosis."
The reason for these errors is the difficulty in imderstanding
their cause. The uterine symptoms are not always the most
prominent, are slowly developed, and do not always attract the
attention of the patient. Not infrequently is the physician con-
sulted for disorder of the stomach, of the heart, or of the liver;
for vomiting, nausea, want of appetite, or diarrhea ; for neuralgia
or hysteria ; for a train of evils having their origin in poverty of
the blood, as chlorosis, anemia, emaciation, and exhaustion — all
of which may be symptomatic manifestations of an obscure
uterine malady.
20. Method of Procedure. — The examiner should proceed
from general to local symptoms so systematically as to bring
the patient to the conviction upon the completion of the exii mi-
nation that the only logical outcome is a physical investigation
of her pelvic organs.
**' Clinique Chirurgicale de la Pitie," vol. 11. p. 182, Paris, 1842.
DIAGNOSIS. 15
21. General. Sjrmptoms. — In many women the general or
constitutional symptoms are so predominant, as to wholly ob-
scure the diagnosis and cause both patient and physician to
believe that organs other than those of the pelvis are directly
at fault. The symptoms of which complaint will be most fre-
quently made are gastric, such as gastralgia, nausea, vomiting,
per\'erted appetite, anorexia, and regurgitation associated with
a clean tongue. Nausea and obstinate vomiting are likely to
be associated with ovarian disease. Intestinal indigestion,
indicated by gaseous distention, the formation and absorption
of toxins, produces disturbed sleep, unpleasant dreams, perver-
ted nutrition, and neurasthenia. Nervous anesthesia affects
portions of the lower extremities, as over the front of the thighs.
It is especially prone to extend to and involve the clitoris, geni-
tals, and vagina, when all sexual desire and pleasurable sensa-
tion during coition become lost. This condition is particu-
larly associated with retrouterine inflammation complicating
retrodisplacement.
22. Visceral Neuralgias. — The bladder and rectimi are not
alone the seat of pain, but remote organs are also affected, such
as the liver, stomach, intestinal canal, and heart. Patients not
infrequently suffer from symptoms which cause them to believe
themselves the victims of a serious disorder of the heart, which
entirely disappear upon proper treatment directed to a pelvic
lesion.
23. Neuralgia in the lumbar and dorsal regions, — intercostal
neuralgia of the left side, — leading the patient to fear the exist-
ence of organic heart disease, is common. The trifacial nerve
may be involved, producing the sensation of a nail being driven
into the head. Sympathetic pains are frequently noticed in the
heart, with a sensation of swelling, especially marked during
menstruation. I have often observ^ed intense pain in the
breast associated with a chronic inflammation of the correspond-
ing ovary. The pain is usually ameliorated or absent during
menstruation, but aggravated during the menstrual intervals.
24. Motor and sensory paralysis is not an infrequent con-
comitant of uterine disorder. It is sometimes difficult to rec-
ognize its cause. Occasionally it is unquestionably due to
hysteria, but numerous cases can be cited where the replacement
of a retroverted uterus has resulted in the rapid restoration to
health of patients who were apparently suffering from complete
paraplegia. I have seen a patient in whom the incoordination
of motion was so marked as to lead to the diagnosis of advanced
locomotor ataxia recover without a vestige of the disorder
subsequent to an amputation of a hypertrophied and inflamed
cervix and the repair of a relaxed pelvic floor.
16 GYNECOLOGY.
25. Disorders of Nutrition. — Every physician is familiar
with the profound influence upon the processes of nutrition fre-
quently engendered by the occurrence of pregnancy. It does
not seem tmreasonable to anticipate that the substitution of
a pathologic lesion for a physiologic condition will exert equal
if not greater disturbance of these processes and an impoverished
condition of health necessarily results. The conditions which
will most frequently occur are chlorosis, anemia, and general
debility.
26. Chlorosis is foimd in poorly nourished girls, who suffer
from it at puberty, or in women during pregnancy, and is often
a result rather than the cause of the pelvic disorder.
27. Anemia may occur at any age. In the earlier periods
of life it may be both a consequent and a cause of pelvic disease.
It is especially associated with chronic inflammation of the uterus
and appendages. It is marked in uterine myomata of the inter-
stitial and submucous varieties, in the various forms of maUg-
nant disease, and in chronic inflammation of the urinary tract.
Repeated and prolonged hemorrhages, continuous leukorrhea,
loss of rest from pain, or from frequent micturition are contrib-
uting causes. The condition is indicated by loss of color in
the skin, transparency of the tissues, local edema, frequent
weak pulse, and general debility. These disturbances of nutri-
tion are accompanied not only by general debility, but also
by progressive emaciation, until the disorder producing them
has been corrected. Under the influence of the diseased con-
dition the patient becomes prematurely aged. The head is
stooped, the limbs are bent, the features are drawn, and she
presents a look of suffering; the flesh is soft and flabby; the
coimtenance is expressionless, the complexion pale and faded,
especially when leukorrhea has been long continued and profuse.
The paleness is different from that of ordinary anemia ; it causes
the characteristic appearance that has been recognized under the
name of fades uterina (Courty). Emaciation may not always be
present; on the contrar}^ the patient may sometimes be corpu-
lent, particularly when amenorrhea, rather than leukorrhea or
hemorrhage, occurs. The obesity is sometimes so great as to lead
the patient to believe herself pregnant, and not infrequently,
while suffering severely, she is congratulated by her acquaint-
ances upon her excellent appearance.
28. Local Symptoms. — Disturbances of function and dis-
agreeable sensations which are directly traceable to the genital
organs and the structures in immediate association with them
are designated as local symptoms.
These symptoms comprise: discomfort in sitting, a sensa-
tion of weight and ])rcssvire in standing or walking, heat and
DIAGNOSIS. 17
burning in the vagina, pain upon movement, tenderness to
pressure over the abdomen, frequent and painful micturition,
more or less profuse discharge, absent, too frequent, irregular,
and painful menstruation, pain during the act of coition or even
upon touching the vulva, and a sensation of distress and aching
following the sexual relation. Reflex phenomena from the
rectum or bladder, or, on the other hand, sympathetic irri-
tation of the uterus, when either of the former organs is the
seat of disease, are very common, and the frequency of their
occurrence can be appreciated when we remember that the
ner\'e supply to the uterus, rectum, and vagina is derived from
the cervico-uterine ganglia of the hypogastric plexus.
29. Rectal Reflexes. — It is not unusual to find that during
menstruation women suffer from diarrhea, proctitis, and rectal
tenesmus. The pelvic vascular system is so general that en-
gorgement or inflammation of the uterus w411 not fail to produce
congestion in the other pelvic organs; and in any marked in-
flammation of the organ, associated with displacerrient, and par-
ticularly in retrodisplacements, the hemorrhoidal vessels will
be found to be distended ; thus, hemorrhoids in the female very
frequently result from the presence of retrodisplacements of
the uterus, and these should never be subjected to operative
treatment until the displacement has been corrected. In
anteversion the cervix will frequently be found to project against
the anterior wall of the rectum, and can be readily distinguished
through this viscus. When the cervix is inflamed, the im-
pingement of hard fecal matter against the organ not infrequently
causes severe pain. In some cases this pain is experienced
only during menstruation. The most frequent functional dis-
order of the rectum is constipation; partly from neglect, and
partly from want of nerve irritation, the bowel becomes filled with
fecal matter, the watery portions are absorbed, and hard, dense,
scybalous masses form, which are evacuated with difficulty, and
possibly only after repeated enemata. The muscular coat of the
bowel becomes distended, loses its tone, and results in a form
of paralysis; fecal matter undergoes decomposition, is partly re-
absorbed, and causes the condition which Barnes has denominated
as copremia, in which the skin is of a sallow, dirty hue, presenting
ill-smelling secretions; the patient suffers from dyspepsia, flatu-
lence, and pyrosis — a condition akin to that known as uremia.
The violent efforts at evacuation of the bowels lead not only to
the formation of hemorrhoids, fissure, sometimes fistula, but they
may, through the increased intra-abdominal pressure, cause dis-
placement of the uterus and the vagina. When fissures exist, the
pain during defecation is so great that the patient is likely to per-
18 GYNECOLOGY.
mit the bowels to go unevacuated rather than endure the result-
ant pain.
30. Vesical Reflexes. — The relation of the bladder to the
uterus is more intimate than that of the rectum, and consequently
this organ is much more likely to be affected in inflammatory
conditions of the uterus. Retention of the urine may be pro-
duced by pregnancy or by pelvic growths, such as fibroid tumors
or tumors of the ovaries. Sometimes also, as a result of irritation
of the orifice of the vagina, a condition known as vaginismus
occurs. The pain maybe so great as to produce a spasmodic
contraction of the sphincter of the bladder. The most usual
fimctional derangement of the bladder, however, is freqtient
micturition. It may occur as the result of reflex irritation from
the pelvic organs, or in consequence of pressure from the uterus,
produced by the presence of a tumor or by a pregnant uterus or a
displaced organ in which either the fimdus rests forward upon the
bladder or is turned backward, causing the cerv'ix to press against
the latter. Either of these conditions may lead to functional
derangement of the bladder, so marked as to cause the patient to
suspect the existence of disease of that organ, or, as she will more
probably say, disease of the kidneys.
31. Genital Symptoms. — The symptoms attributable to the
genital organs are derangements in the performance of their
functions. The particular symptoms are disturbances of men-
struation, such as a decreased, an increased, or an irregular
menstrual flow, the existence of sterility, the presence of pain
and excessive discharge ; consequently, in determining the history
of the patient, if she is married, we endeavor to elicit information
regarding previous pregnancies and the character of the labors.
Sterility in a woman who has been married for a number of years
is an indication of some abnormal condition. It may be due to a
malformation, to functional disturbances, to actual disease, or
to efforts to avoid the responsibility of maternity. It should be
remembered, however, that there are cases of relative sterility.
The most unvarying function of the uterus is that of menstruation,
consequently some disturbance in the performance of this func-
tion is one of the first indications of the existence of uterine dis-
order. Amenorrhea is a term employed to designate absent
or greatly docroasod menstrual flow; menorrhagia the flow,
which tlumgh regular, is increased, and the menstrual period
lengthened: metrorrhagia a flow that does not correspond \\4th
the regular jxTiods; while liysjjietiorrlica indicates the existence
of pain occurring at the beginning of, during, or immediately
following the menses. These conditions will be considered
more fully later.
32. Hemorrhage is by no means a constant symptom of
DIAGNOSIS. 19
Uterine disease. Its significance varies according to the amount
of blood lost and the time of life at which it occurs. During the
earlier periods of menstrual life it is not uncommon for the menses
to be very profuse, as a result of defective development of the
ovaries or ovarian hyperemia. When hemorrhage occurs in
women wiio have borne children, it may be produced by inflam-
mation of the mucous membrane of the uterus —hence a hemor-
rhagic endometritis. Hemorrhage is a usual symptom of
fibroid growths of the submucous variety. Uterine polypi,
whether due to a fibroid growth or to vascular growths upon the
endometrium, are a very prolific cause near the climacteric. The
occurrence of hemorrhage subsequent to the menopause should
always cause the physician to suspect the possibility of malignant
disease in either the mucous membrane of the cervix or the body
of the uterus. When hemorrhage occurs during or following
pregnancy, it is probably due either to a threatened abortion or
to retention of portions of the fetal envelopes. It should not be
forgotten, however, that hemorrhage may occur from cystic
disease of the ovaries, and in some cases in which the pelvic
organs present no lesion, as from valvular disease of the heart,
Bright's disease, and obstruction of the portal circulation of the
liver. The occurrence of hemorrhage should always be re-
garded as an important danger signal, and should be considered
as demanding careful investigation to elicit its cause.
33. Pain is a very frequent symptom, and may be associated
with the menstrual function, when it is known as dysmenorrhea,
or may be independent of it. When it occurs during coition, it
is called dyspareunia (Barnes). It may be dependent upon,
first, vaginismus; second, chronic nervous irritabiHty due to in-
complete or awkwardly performed first coitus; third, inflam-
mation; fourth, tumors; and fifth, malformations.
34. Seats of Pain. — Courty describes six seats of pain, three
of which are principal and three accessory. The principal seats
are, first, the iliac regions; second, the loins; and, third, the
hypogastrium.
35. The iliac pain is the most frequent ; it is felt in the region
of the iliac fossa, and extends from it to the hypogastric and
lumbar regions, particularly toward the pelvic brim and cavity.
This pain is most often felt upon the left side. It is probably due
to tension of the broad ligament, and occurs upon the left side
more frequently on account of the arrangement of the circulation
through the veins. The left ovarian vein enters the left renal
at a right angle, and passes behind the sigmoid flexure of the colon
to reach it. The frequent impaction of this portion of the gut
with feces would account for the obstructed circulation.
Courty ascribes pain in this region, however, to the inclination
20 GYNECOLOGY.
of the uterus to the right ; hence any increase in size of the organ
causes a gradual dragging upon the left broad ligament.
36. Lumbar pain, generally spoken of as backache, is felt in
the lower part of the lumbar region, sometimes extending to the
region of the kidneys, and, in others, and more frequently, down
over the sacrum. In some cases the abdomen is encircled as
with a belt of pain. This pain is usually ascribed to traction
upon the uterosacral ligaments. It is doubtless not infre-
quently due to retention of secretion within the cavity of the
uterus, by which that organ is obliged to go into labor in order to
secure its expulsion. Its presence indicates disease of the cervix ;
when it is particularly marked in the sacrum, it is the probable
result of retrodisplacement of the uterus.
37. Hypogastric pain is experienced above the pubes, and,
more than any other, seems to have its origin in the uterus. It
is elicited artificially, rather than occurring spontaneously.
Patients who do not experience it ordinarily, complain as soon as
pressure is made over the lower portion of the abdomen. This
pain is greatly aggravated in walking, so that the patient not in-
frequently experiences the necessity of support over the hypogas-
trium by means of a belt or by placing the hands in front, partly
for support and partly for protection against injury.
38. The accessory seats of pain Courty ascribes first to the
anus or perineum; second, to the vagina or cervix; and, third,
to the cavity of the pelvis.
39. The anal or perineal pain is usually produced by a retro-
uterine tumor or retroflexed uterus. Patients with hypertrophy
of the cervix not infrequently suffer pain in the anus or perineum
while walking or riding, and often when sitting.
40. Vaginal pain is not so frequent. It is felt in women who
have inflamed uteri, particularly during an orgasm.
41. Pelvic pain results usually from inflammation about the
uterus or from inflammation of the tubes, fixation of the ovaries,
or when organs have become cystic or the seat of pus collections.
42. Leukorrhea. — Leukorrhea, or whites, is a term given to
discharges other than sanguineous that occur from the genital
tract. To appreciate the significance of a discharge as an indica-
tion of disease, we must recognize the character of the normal
or physiologic secretion.
43. The secretion from the Fallopian tubes and cavity of the
uterus is a thin, whitish alkaline fluid; that from tjie cervdcal
glands is also alkaline, but is very viscid, tenacious, and trans-
parent like white of egg.
44. The secretion of the vagina and vulva is whitish, made
up of a serous fluid intermixed with scaly epithelium. The
DIAGNOSIS. 21
vulvar discharge also contains oil-globules from the sebaceous
glands. The secretion of both vagina and vulva is acid.
The superfluous discharge from the cervix is coagulated by
that of the vagina, forming a smeary material at the upper.part
of the vagina, and will be found to coat over the surface p£-a
pessary. When the cervical fluid is in excess, it may pass from
the vagina unchanged and perfectly transparent.
Another discharge or secretion is that which takes place from
the vulvovaginal glands during coition or under excitement.
This is a clear, viscid discharge. In very erotic women this dis-
charge is ejected upon the approach of a person of the opposite
sex, and nocturnal discharges occur during erotic dreams.
It is sometimes difficult to determine whether a discharge is
the result of over -stimulation of a physiologic secretion, or is pro-
duced by a pathologic condition.
45. Catarrhal Discharge. — A profuse discharge is not an
infrequent result of exposure to cold. An increased secretion
from the uterine glands occurs instead of the ordinary nasal flow.
A hypersecretion which results from the hyperemia of the preg-
nant uterus may be considered physiologic.
In some imdeveloped and strumous young women a leukor-
rhea occurs as a substitute for the menses. In many individuals
a slight leukorrhea, preceding or following the menses, has no
abnormal significance.
46. Origin of Discharge. — The source of origin of an abnormal
discharge can be determined to some degree by its appearance
and character. When from the cavity of the uterus, it will be a
thin, watery fluid, loaded with ciliated columnar epithelium, and
containing also pus and blood-corpuscles, according to the extent
of the disease.
47. Discharge Simulating Abscess. — The discharge may be
a continuous flow, but more frequently it is intermittent, due to
defective drainage from swelling of the mucous membrane of
the outlet, which leads to dilatation of the cavity and not in-
frequently of the orifices of the tubes. The uterus then empties
itself only by occasionally going into labor to evacuate its con-
tents. Such a fluid, loaded with pus and blood-corpuscles,
coming away in gushes, leads the patient to believe that an
abscess has formed and been evacuated. Patients will not
infrequently inform you that they have abscesses form and
discharge at short intervals. The conditions described, however,
may not be the only explanation. An accumulation in a tube,
the uterine end of which is still patulous, may occasionally drain
through the uterus. Such a condition has been denominated
hydrops tubes profluens,
48. Other sources for purulent discharges are found in the
22 GYNECOLOGY.
ruptiire and escape into the vagina of the contents of a tubal
or peritoneal abscess, of a suppurating ovarian tumor, of an
extra-uterine pregnancy sac, or of an abscess about the vermi-
form appendix.
49. Cervical Discharge. — The discharge from the cervix is
usually very viscid and tenacious ; it may be clear and transparent,
or clouded by desquamated epithelium and filled with pus-cells,
when it is yellowish or greenish-yellow in color, or it may be
a dirty brown from admixture with blood-corpuscles.
The cervix will usually be dilated and patulous, its membrane
thickened, abraded, and covered with papillae.
50. Vaginal Discharge. — A thin, serous discharge flows from
the vagina in simple inflammation; in more severe attacks it is
loaded with epithelitun, and the vagina is red and inflamed and
has apparently shed its entire epithelial coat. When due to
gonorrhea, the discharge is profuse, purulent, ichorous, irritating
to the external parts, and attended with a burning sensation
during micturition.
51. Effect of Age upon the Discharge. — The significance of the
discharge is also dependent upon the age and physical condition
of the patient. Prior to puberty it is usually due to irritation of
the vulva, and is thin and serous, resembling that from eczema.
After puberty, in the immarried, it is generally vaginal. In the
more mature and in married women it is usually uterine.
As the individual approaches puberty the vulvar discharge
becomes more oleaginous from the secretion of the sebaceous
follicles. Not infrequently, in uncleanly persons, the secretion
from these glands is so abundant that it decomposes and sets up
an inflammation similar to the blennorrhea of the male. Prior to
or following the climacteric a thin, watery flow, of a sweetish,
sickening, or decayed-flesh-like odor, should be considered a
strong premonition of cancer of the uterus.
52. Physical Signs. — The careful study and analysis of the
subjective phenomena may afford an approximate idea of the
disorder present, but the diagnosis should not be attempted
until the objective symptoms, or physical signs, have been in-
vestigated.
53. Senses Employed. — In the study of the physical signs all
the senses except that of taste are employed :
The sight is used in inspection of the abdomen and external
genitalia and in examining the internal organs by the use of the
speculum.
The touch is practised in abdominal palpation and percussion,
in simple vaginal or rectal touch, in conjoined manipulation, and
in the use of sound or catheter.
The hearing is employed in percussion and auscultation.
The smell is exercised in the examination of discharges.
I
DIAGNOSIS.
54- Examination.— The investigation of the physical signs
is called an examination and may be made through the vagina,
rectum or urethra, or a combination of one or more of these
■with pressure over the abdomen.
55. Pelvic examination comprises inspection, touch, and in-
strumental investigation.
56. Abdominal examination may be classified under inspec-
tion, palpation, percussion, auscultation, and exploratory punc-
ture or incision.
57. Preliminaries. — The verba! examination should have been
so conducted that upon its completion the patient will be im-
pressed with the fact that a physical examination is the only
logical conclusion. The examination may be made upon a sofa
or a common bed, as would be the custom when made at the
home of the patient; but in office practice it will be found more
convenient to have provided a suitable table or chair. The
choice of table will depend
upon the custom and conve-
nience of the operator. One
made by Codman & ShurtlefE,
of Boston, known as the
Chadwick table, is very satis-
factory. (Fig. 1.) In the
first examination for the con-
sideration of obscure condi-
tions the clotliing should be
loosened and corsets removed.
so that the abdominal walls
can be completely relaxed.
The bladder and rectum
should be empty. The latter
suggestions are very important in order to permit the normal
relations of the uterus and its adnexa to be determined. Fecal
accumulations have been mistaken for ovarian and tubal en-
largements or inflammatory exudates. A distended bladder has
been confounded with an ovarian tumor. The patient should
be so placed for examination that the pelvis will be exposed to
a good light.
58. Positions.— ^The patient may be placed m one of six
positions for examination: viz., (1) dorsal; (a) lateral; (3) semi-
prone (Sims); (4) genupectoral ; (5) Trendelenburg; (6) erect.
Of the positions named, the dorsal and Trendelenburg are the
most important.
55. The Dorsal Position. — The patient lies upon her back,
with the limbs flexed and feet placed upon supports. The feet
be on a level with the buttocks or placed on supports a
\
24
GYNECOLOGY.
fcwt higher. The latter affords greater relaxation to the ab-
dominal muscles. The clothing is lifted over the knees. The
lower part of the body has been previously covered with a
sheet, which is folded about the widely separated limbs, and
permits the inspection of the vulva. (Fig. 3.) This position
permits the ready practice of the bimanual examination,
and is the most favorable for vaginal and abdominal palpation
and for the use of the valvular and Edebohls' specula. For
operative procedure the dorsal position may be favorably modi-
fied by strongly flexing the legs upon the body, in which posture
they may be retained by assistants, or the employment of a
suitable leg holder.
60. The Lateral Position. — The patient lies upon the left
side, with the limbs at a
right angle to the body.
This position was formerly
much used by English gy-
necologists, and was pre-
ferred because it permitted
examination to be made
without danger of touching
the tender structures at
the anterior part of the
vulva. This position was
thought less \Tilgar, and it
allowed the finger to follow
more readily the cur\-e of
the sacrum and to reach
with greater ease the highly
situated cervix. Its chief
advantage, however, is in
permitting more minute in-
\-estigation of the lateral
fornices of the vagina. In
abdominal palpation it alTords increased opportunity to recog-
nize changes of position of tumors and displacements of the
viscera, particularly uf the kidney.
61. The Semiprone or Sims' Position fPig. 3I. — The patient
is placed upon the left side and chest, with the left arm behind
her, the left leg partly extended, the right being flexed at a right
angle to the body. The intra-abdominal pressure is neutralized.
The mobility of the uterus is readily determined, replacement
more easily accomplished, and some anteflexions recognized as
the organ falls fonvani that are not apparent in any other posi-
tion. The chief value of the position is in the use of the Sims'
speculum.
62. The genupectoral position (Fig. 4). also called the knee-
chest position, is one in which the patient rests upon the chest and
The left side rif her face rests upon her left hand. The
;, 3. — Sims* PosiiLPu. ProjxT .Mcthtid oi Holdni!; ilie Speculum.
thighs are at right angles to the surface of the table. The chief
value of this position is in replacing a retrodisplaced uterus or
I. — Gcnupeclora! Position, Organs Shown in Outlint
prolapsed ovary, or for elevating from the pelvis a more
onpacted tumor.
or less ^1
26 GYNECOLOGY.
63. The Trendelenburg Position. — The patient lies upon her
back and on a plane inclined at an angle of 45 to 60 degrees, with
the feet and legs over a flap of the table. (Fig. 5.) Heavy patients
should have additional support by the appHcation of shoulder
pieces. Pryor modified the position by supporting the patient
from the shoulders and flexed the legs upon the body for the pur-
pose of examination of the pelvic viscen-i free from the intestines,
which gravitate u]jward when free to do so. This posture is
of especial value in cystoscopic investigation of the bladder.
The greatest \-alue of the Trendelenburg posture is in the free-
dom of view aflnnlcd in abdominal section, permitting the
operator to employ the sight as well as touch in the manipulation.
PELVIC EXAMINATION.
27
I
I
I
64- The erect position is of limited application. The patient
stands with feet separated, with one hand resting upon the
shoulder of the physician, while lie sits or kneels before her and
introduces the index-finger into the vagina. The chief value of
this position is in determining the amount of downward displace-
ment of the pelvic contents and in securing ballottement in the
early stages of pregnancy.
PELVIC EXAMINATION.
65. Infection. — The patient is placed in the dorsal position.
(Section 53.) In the first examination of every patient a visual
examination should always precede the practice of touch. By
carefully arranging the clothing this can be done without shock-
ing the sensibility of the most modest. It affords information as
to the cleanliness of the patient ; the presence of pediculi ; venereal
warts or sores; malformations; traumatisms; eruptions upon the
%*ulva; tumors of the labia majora; elongation and thickening ot
the labia minora; hypertrophy of the clitoris; elongated or ad-
herent prepuce; lacerations of the perineum; presence of hemor-
rhoids, ulcerations, or fissures ; urethral caruncle ; anomalies of the
hymen; cystocele; rectocele; prolapse of the uterus; and the
quantity and character of vaginal discharge. Inspection maybe
a simple preliminary to the touch.
66. Simple Touch. — The pelvic floor presents three apertures
or perforations: the urethra, the vagina, and the anus — through
either one or all of which an exploration may be made. The
\'Bgina is the route usually chosen as affording the best oppor-
tunity for securing the most extended information,
67. Preparation. — The hands should be carefully cleansed.
Independent of any possible danger of conveying infection, the
educated woman will be doubtful of the physician who proceeds
to her examination with unclean hands and nails. The latter
should be cut close. Either hand may be used in examination.
In some cases it may be desirable to use first one and then the
other. When the vagina is sufficiently roomy, two fingers should
be introduced. This affords additional length and surface for
touch- The fingers should be lubricated with soap or some un-
guent, such as carbolized alboline. The soap is preferable, for
in washing it is removed with the secretions ; but in some patients,
however, it aggravates any existing irritation.
68. Procedure. — The physician ^with one hand separates the
vulva in order to avoid carrying up the hair, and holds the '
separate as he proceeds to make the digital investigation
back the perineum, the finger or fingers more easily
he labia ^fl
Press- fl
y enter, ^|
as GYNECOLOGY.
and witliout impinging against the anterior delicate structures.
The perineum maybe depressed with the index finger while the
middle finger is inserted above it, thus permitting the employ-
ment of two fingers with but little discomfort. Tlie unemployed
fingers of the hand can be carried back, either extended or
closed, but the latter shortens the distance accessible to touch.
(Fig. 6,) The touch affords information as to the presence of cysts
in the labia ; the size of the vagina ; relaxation of its walls ; condi-
tion of its mucous membrane; amount of secretion; the con-
tents and tenderness of the rectum : inflammation and projec-
tion of the urethra; tenderness, prohipse, and distention of the
bladder; and relation of the uterus to the vaginal axis. In
its nortTuil position the cervix luoks backward, 'the axis of the
uterus being nearly at right angles to that tif the vagina. The
situation, size, and density of the cervix are recognized. It
may be nnrmal, lacerated on one or both sides, or present a
number of fissures — a stellate laceration. Its lips may be soft
and velvety, frfim enlarged ixipilkc; nodular, from enlarged
or cystic Nalmthian glands: widely everted and dense, from
chronic infiainmation following laceration; enlarged and indu-
rated, from chnmic inflammation or malignant infiltration; en-
larged, friable, or excavated in epithelioma. The os will be a
slightly transverse depressed dimple when normal, or when
30 GYNECOLOGY.
A mass in the posterior fornix, if continuous with the cervix,
the axis of which is parallel to that of the vagina, is a retro-
version of the uterus. If there is an angle between it and
the cervix, the condition may be a retroflexion of the uterus, a
tumor of the posterior uterine wall, an enlarged ovary or tube, or
an inflammatory exudate. Digital examination also affords an
idea of the mobility of the uterus, but the investigation is con-
fined to the lower segment.
69. Bimanual procedure, also called the conjoined manipu-
lation, or vagino-abdominal touch, affords definite informa-
tion. In every examination the introduction of one or two
fingers into the vagina should be associated with the application
of the fingers of the other hand upon the abdomen. The external
hand may be placed about midway between the symphysis and
umbilicus, pressing downward upon the anterior abdominal wall.
It may be moved from one side to the other, in order to examine
the contents of the pelvis. This procedure enables us to outline
the size, shape, density, and situation of the uterus, and to deter-
mine the presence of growths in its walls and its relation to other
pelvic growths or to inflammatory deposits. The normal tube is
rarely palpable. When it is readily perceived, it has been the
seat of an inflammatory condition. The ovaries are more
easily recognized. To arrive at a definite conclusion in an
obscure case, it is better to introduce into the vagina one or
two fingers of the hand corresponding to the ovary to be palpated,
as the extreme rotation necessary to bring the sensitive surface of
the finger in contact with a small mass diminishes the sense of
perception. (Fig. 8.)
70. Difficulties. — The bimanual examination is rendered diffi-
cult by a large deposit of fat in the abdominal wall and by
rigidity of the abdominal muscles. The latter is sometimes so
marked that the patient can not relax the muscles, and the deter-
mination of the pelvic condition is unsatisfactory. When this
is due to nervousness, much can be accomplished by allaying the
patient's fears and securing her cooperation. Have her breathe
with the mouth open, fill her lungs, and then expel the air, while
the hand over the abdomen depresses the wall during expiration,
and thus secures an outline of the pelvic organs. The procedure
may sometimes be rendered less diflicult by diverting the patient's
attention through inquiries regarding other symptoms- When
the resistance can not be overcome, or the sensitiveness arises
from an inflammatory condition, or the abdominal walls are very
fleshy, an anesthetic may be necessary.
71. Virgins. — It is often a serious question to determine when
an examination should be made upon a young unmarried woman.
It should be the rule to avoid sucli an examination, unless the
PELVIC EXAMINATION. 31
symptoms are of such a character as to indicate the existence
of conditions which endanger her health. The regular occurrence
of menstrual molimina. without the appearance of bloody dis-
charge, after the age when puberty should be expected, must be
considered an indication for a physical investigation. In many
patients requiring a digital examination the procedure can be
accomplished through the rectum. Where a vaginal examina-
tion by the finger seems indispensable, the discomfrirt can be
lessened by carefully lubricating the examining finger and
directing the patient to bear down as it is being intnxluced
72. Rectal Touch. — (The rectal touch, recto-abdominal [Fig.
q], rectovagino-abdominal, or rectovesical touch.) The routine
practice of digital examination by the rectum in the first in-
vestigation of a patient is to be commended. The finger should
be carefully washed after removal from the vagina and before its
introduction into the rectum, and vice versfi. Neglect of this
SZ GYNECOLOGY.
precaution may lead to a severe proctitis from the introduction
of infectious material. The anointed finger, first directed for-
ward, and after its entrance carried backward, is gently rotated.
It enables us to recognize the condition of the rectum ; the pres-
ence of fissures; hemorrhoids, ulcerations; contractions of the
sphincter ; sensitiveness of the coccyx ; encroachment upon the
bowel by the uterus ; the condition of the posterior surface of that
organ; the presence of inflammatory exudate in the pelvis;
malignant infiltration of the broad ligaments or peritoneum;
and the position of the uterus, when we desire to avoid a vaginal
examination of the virgin. The rectal procedure promotes the
replacement of the displaced t)rgan. The correction of malposi-
tions is facilitated by tlic introduction of the middle finger into
the rectum and of the indcx-fmger or thumb into the vagina.
(Pig. lo.) The conjoiiifd rect:d mcinipulation is known as the
recto-abdominal, tlie rectovaginal, the rcctovagino-abdominal,
or the rectovesical, according to llio position of the fingers of the
two hands. The absence or presence of the uterus in congenital
PELVIC EXAMINATION 33
atresia vaginalis may be detennined by rectovesical touch ; that
is, the introduction of the finger into the rectum and of a sound
(F^. ii), bougie, catheter, or finger of the other hand through
the urethra. It is rarely that it will be necessary to explore the
bladder with the finger.
73. Simon's method consists in the introduction of the whole
hand into the bowel, and is capable of affording additional in-
Pig. 10. — Recto vagino-abdominal Palpation. Index- finger of one hand i
rpctum, thumb in the vagina, and the lingers of the other hand ovi
abdomen.
formation as to the condition of the pelvic organs. Such serious
injuries have resulted from its practice, however, that it is now
considered an unjustifiable procedure, unless the surgeon has an
exceedingly small hand.
74. Vaginal Section. — Ferguson advocates exploration of
the abdominal viscera by an incision through the posterior
34 GYNECOLOGY.
vaginal fornix as preferable to the exploratory abdominal in-
cision. It is true that such an investigation can frequently
be made; that it avoids the prolonged convalescence from an
external incision, but its practice will frequently result in a
weakened pelvic floor which will subsequently prove an in-
effective barrier to vaginal hernia.
75. Precautions. — It would be tmwise to dismiss the subject
of bimanual examination without a word of caution. The pro- ■
cedure should always be exercised with care not to do injiuy.
Anxiety to arrive at a correct diagnosis may lead to rupture
of a tubal collection or an ectopic gestation sac, and to the
necessity for prompt operation to save life, I have seen two
patients, and have been informed of others, in whom examination
has been followed by rupture of ectopic gestation sacs, with
death from internal hemorrhage.
/^^^
76. Instrumental Examination. ^The order generally rec-
ommended ftjr the employment of instruments has been : First,
the use of the sound and then of the speculum. The difficulty,
however, in rendering the \-agina. sterile has justly led to the
reverse procedure. The S(jund is a long, flexible instrument,
twenty-five centimeters in length, two or three millimeters in
diameter, terminating in a bulbous end, and generally has a
slight elevation about six centimeters from its end, which in-
dicates the normal length of the uterine cavity. For conveni-
ence in measurement its pjstcririr surface is marked by a scale
in inches or centimeters. The instrument should be perfectly
smooth, having no notches or indentations which may serve
PELVIC EXAMINATION.
35
to retain infection. It is made of silver, or copper (silver or
nickel plated), and should be sufficiently flexible to admit of
its being readily bent. The handle should be roughened upon
one side so that the concavity of the instrument can always
Fig. 12. — Simpson's Sound.
be determined. Such an instrument is known as Simpson's
sound. Sims advocated the use of a finer and more flexible
instrument, known as the probe.
77. Probes are made of metal, hard rubber, and whalebone.
Fig- 13- — Sims' Probe.
The metal probe may be made of twisted steel and covered
with a rubber sheath, rendering it more flexible. (Fig. 15.)
The uses of the sound or probe are to ascertain the patency of
the cer\'ical canal, the depth of the uterus, its width or capacity,
flimmiiilinilllilli^^^
Fig. 14. — Whalebone Probe.
the thickness of its walls, the presence of intra-uterine tumors,
the condition of the mucous membrane, the direction of the
uterine canal, and the mobility of the uterus. In treatment
it has been used to replace the displaced uterus. The experi-
Fig. 1$. — Spring Probe Covered with Rubber.
enced physician will be able to obtain much of this knowledge
fully as effectually by the bimanual examination, and in the
majority of cases the disadvantages of the instrument greatly
36 GYNECOLOGY.
outweigh the value of the information obtained by its use.
It affords knowledge as to the patency of the canal which can
not otherwise be determined ; in all other instances the omis-
sion of its use is preferable to its employment. It is true it
is capable of affording information as to the direction of the
uterus when the situation of that organ is rendered doubtful
by the presence of inflammatory exudate, but in such cases
its use is contra indicated. Our inability to secure an aseptic
vagina should lead to the introduction of the instrument through
the speculum, ami then only after the vault of the vagina has
been carefully mojiped with absorbent cotton wet with a 2 per
cent, solution of formalin. It is almost impossible to introduce
the instrument without injurinj^ the mucous membrane of the
uterine cavity, an injur\' which will alTord a fa\'orable culture-
field for the development of germs which are found in the \-agina,
or, exceptionally, even in the cervical canal. Such injuries
explain the inflammatory irritation following the use of
the sound and still further demonstrate the wisdom of dis-
PELVIC EXAMINATION 37
contintiing its employment for replacement of the uterus. When
it seems desirable to use the sound without the speculum, the
vagina should be previously scrubbed and two fingers
introduced to the cervix, by which the sound is guided into
the OS. (Fig. i6.) No force should be employed and the in-
strument should have such a curve as will permit it to pass
readily in the direction which a bimanual examination has dem-
onstrated should be that of the uterine cavity.
78. Precautions. — The date of the last menstruation must
be known, and the use of the instrument should be avoided when
there is the slightest suspicion of pregnancy. It should not be
employed in the presence of acute inflammation or when inflam-
matory exudate or old infiltrations can be determined. Its em-
ployment in a case of malignant disease may lead to dangerous
hemorrhage. In the uterus softened and rendered friable by
inflammation the sound may penetrate its wall and enter the
abdominal cavity. This accident produces no inconvenience
unless the instrument carries infection. The sound may also
pass into a Fallopian tube.
This is more likely to occur
in a bicomate uterus. The
instrument should be scru-
ptdously clean, indeed,
should be sterilized by
boiling, or when this is
inconvenient be removed Fig- 17— Ferguson's Speculum.
from a 5 per cent, solution
of carbolic acid prior to its use. " After its use the instrument
should be sterilized by heat.
79. Speculum. — A patient placed in the dorsal position, with
the limbs separated, reveals the mons veneris, with the larger
labia. The latter are separated by a cleft or slit — the rima
pudendum. Frequently the labia minora are elongated, and
they, with the clitoris, are prominent. The posterior commissure
may have been injured, and, instead of a slit, we will have a
triangular opening, through the posterior part of which projects
the vaginal wall. In lacerations of the pelvic floor its posterior
segment may be drawn back, permitting one or two inches of
the vagina to be inspected. By hooking back the vagina with
two fingers the cervix can frequently be seen. The necessity
for satisfactory inspection of the uterus led to the invention of
the speculum. A great variety of instruments for this pur-
pose have been devised, but all may be classed in two divisions:
the tubtdar and the valvular.
80. The tubular speculum^ known as the Ferguson speculum,
may be made of glass, wood, rubber, celluloid, or metal. The
38 GYNECOLOGY.'
instrument is cylindric, the external end with a flange, the inter-
nal beveled, and having one long side. (Fig. 17.) Glass instru-
ments may be made of milk-glass (Fig. 18), as the German
speculum, or such covered with quicksilver, and over this a
coating of pitch or rubber. Such specula can not be sterilized
by heat; glass is brittle, easily broken, and is subsequently use-
less. They are very ser-
viceable in making appli-
cations to the cervix, but
only the wooden instru-
ments are utilizable for the
use of the actual cautery.
The application of medica-
ments to the uterine canal,
or the use through it of
the sound, are to be con-
demned. The tubular
speculum is not self -retain-
able. Its range of appli-
cation is so limited that it
is now infrequently used.
To introduce this instru-
ment the physician separates the labia with the left hand and
holds the speculum with the right thumb and middle finger on
either side and the index-finger upon its upper surface. The
longer side is placed against the posterior commissure of the
vulva, which is depressed, and the speculum is pushed upward
and backward, at the same time rotating the instrument so that
its shorter side does
not impinge against
the tender anterior
structures. The
situation of the cer-
vix has been pre-
viously located by
the touch. If the
cer\-ix is not brought
at once into the field
of the speculum, it
can usually be ex-
posed by rotating
the instrument. When this procedure fails, it may be drawn
into the field by a tenaculum. If the cervix is large, only a
part of it can be exposed at one time, and consequently a dis-
torted idea of the condition is frequently obtained.
81. Valvular Speculum. — The valvular speculum may have
■Nott's Specului
PELVIC EXAMINATION.
Pone or more valves, and is called univalve, bivalve, trivalve,
I and quadrivalve. according to the number of its blades. These
I
— Talley's Specului
ula afford a much better exposure and are self-retaining;
iherefrire, they have largely
supplanted the tubular in-
strument. The quadrivalve
instrument is non" rarely
useiJ. as it affords but shght
additional advantage over
the bivalve, and besides it
is difficult to keep clean.
The Nott (Fig. 19) and
Nelson specula liave three
blades and afford an oppor-
tunity to inspect the an-
terior vaginal wall. The bivalve speculum is the most satis-
factory (or general use. Of the great variety of specula. Hig-
bee's (three sizes) (Fig.
20). Talley's (Fig. 21).
and Goodell's (Fig. 2a)
are probably the most
satisfactory. The
blade should be from
7.5 to II centimeters
in length. When the
vaginal portion of the
cervix is short, the
Higbee speculum, which has a long posterior blade, will not ex-
■ the OS. In such cases the Goodell or Talley s ''" ~"""
40
GYNECOLOGY,
blades of equal length, are better. The speculum is introduced
by separating the vulva with the fingers of the left hand, while
the instrument, held
in the right, is intro-
duced with its trans-
verse diameter parallel
to the long diameter
of the vulva. As the
widest diameter of the
vagina is at right an-
gles to that of the
vulva, the instrument
is rotated and car-
ried upward, directing
the blades behind the
cervix, the position of which has been previously determined by
a digital examination. As the blades are separated the cervix is
—Sims' Specului
generally exposed. In marked antevorsion it may be necessary
to use a tenaculum to bring the cer\-ix into view. The speculum
ELVIC EXAMINATION.
41
is a therapeutic instrument, although it confirms the diagnosis
which has been made by digital examination.
8a. The univalve or duck-bill speculum (Fig. 33), introduced
by Sims, is used with the patient in the semiprone position. The
instrument has two blades at either end of a handle, which are
about 10 centimeters long, the smaller blade being 1.5 centime-
Fig, ij, — Sims' Depressor.
t
Fig.:
— Goodell's Tenaculum.
ters and the large blade 4 centimeters in width. To introduce
this instrument the physician raises the buttock, passes the blade
with its width parallel to the vulva, and after its entrance
rotates it with the handle directed backward. The assistant
then holds the other blade with the right hand, using the in-
strument as a retractor. (Fig. 24.) His elbow is held against
his hip, while the left arm
rests upon the patient,
the hand elevating the
buttock- Care must be
exercised to follow the
curve of the sacrum or
the instrument will slip
out. As the perineum is
drawTi back the vagina is
ballooned by the atmos-
pheric pressure and the
cervix and upper vagina
are exposed- When the
vagina, is large, with re-
laxed walls, the cervix
may be obscured from
\-iew. The depressor
(Fig. 25) to push back
the anterior wall or a tenaculum (Fig. 26) hooked into the cervix
overcome the difficulty. The univalve speculum affordi
exposure of the cervix and upper portion of the vagina
any other form of instrument. Its particular disadvantage
it is not self-retaining, and in office practice requires
■Self -retaining Si
■ds a A
Lgina M
itage ■
uires V
42
GYNECOLOGY.
the assistance of a nurse. Various devices (Fig. 27) have been
instituted to render it self-retaining, but they require con-
siderable time for their use. In operating with the patient in
the semiprone position, the irrigating fluid and blood run
forward, between the patient's limbs, and hence render it
Fig. 2S. — Simon's Retractors.
difficult to keep her person and clothing clean. The Sims
speculum can be used with the patient in the lithotomy
position, but it is uncomfortable to "hold. The Simon posterior
and side retractors serve a similar purpose. (Fig. 38.) The
perineal retractor known as the Edebohls speculum (Fig. 29) is
Fig. 19. — E'lfboliU' Sficculum. Fij;. 30. — Edebohls' Speculum in Posi
the most satisfactory. With the patient upon her back, and the
limbs acutely flexed, the perineum is retracted and held back
by a weight attached to the instrument. (Fig. 30.) The cervix
and the upper and anterior vagina are thus exposed to manipu-
lation.
PELVIC EXAMINATION.
43
I
8j. Uterine Fixation and Downward Traction. — Reference
has already been made to the use of the tenaculum to bring the
cer%-ix into the field of the speculum. The same instrument, or,
better, a double tenaculum known as bullet-forceps (Fig. 31),
gtiided to the cer\'ix by the finger, may be used to fix the organ,
or in some cases to exert traction (Fig, 32) upon it during digital
Double Tenaculum Forceps.
examination. Such a procedure enables us to examine through
the rectum the whole posterior surface of the uterus and even to
pass the finger o\-er its fundus. It is utilized in replacing the
retro\^erted and retrofiexed organ and in differential diagnosis
of abfiominal and pelvic growths.
84. Dilatation of the Uterus. — It is frequently necessary to
I
explore the cavity of the uterus, either to complete the diagnos
o( a condition rendered probable by other procedures or as a
jffcfiminary to an operation. The method of operation may '
di^Tdcjd into two classes: (i) Bloodless — tents, di\*u]sion, a
gradual dilatation; (2) by incision of the external os and bilateral
incision of the cer\-ix. Before the practice of any of these ™-"-
ay be ^k
and ^1
ateral ^|
- pro- V
44
GYNECOLOGY.
cedures the presence of inflammation in the organ or vestiges of
inflammatory exudate about it should be excluded. The existence
of such conditions presents an element of serious danger.
85. Dilatation by Tents. — The use of tents was formerly very
popular and a general method of dilatation. The materials used
for this purpose were sponge, laminaria, tupelo, slippery elm,
decalcified ivory, and gentian root. The sponge has the greatest
dilating power, but is the most difficult to render aseptic and to
maintain in that condition. The frequent unfortunate sequelae
that followed their use have largely led to their discontinuance.
Fig. 33. — Hollow Laminaria Tent.
The laminaria (Fig. 33) and tupelo tents are the most used. The
former may be introduced in nests. Their dilating power is
enhanced by having them hollow. A number of small ones to fill
up the canal is to be preferred to one large tent. They may be
rendered aseptic by subjection to a dry heat of 250° F. The
tent should be placed in an envelope before its introduction into
the sterilizer, and the envelope should be broken only when it is
to be used. The tents may also be rendered safe by immersion
prior to their use in a saturated solution of iodoform in ether.
Pozzi advocates their immersion in equal parts of carbolic acid
and alcohol. They may l)e ])lacc(l in 95 per cent, carbolic acid
Fig» 34- — Uterine Forceps — Dressinjj.
for a few minutes and afterwards washed in alcohol before in
sertion. I i)refer imniersin*]: the laminaria tent in tincture of
iodin for a few minutes l)eforc its emi^loyment. The vagina
and cervix should be carefully eleansed with an antisejHic
solution; the cervix is seized through the sj^eeulum with bullet
forceps, while the tents are lield in (Fig. 34) dressing forceps,
and introduced, one after another, until the canal is filled.
Care must be exercised to mold the tents to the curve of the
canal, and no force should be emjiloyed in their intnxluction.
The tents should project from the external os, and should be
PELVIC EXAMINATION.
45
I
held in place by a tampon of iodoform gauze. They should
be removed at the end of ten or twelve hours. They are removed
by pulling upon a string fastened to the end of the tent. Re-
iDO\~al is sometimes rendered difficult by irregular dilatation;
the internal os, being more resistant, causes an hour-glass-
P'K- 35- — Dilated Tent Showing Consti
from Internal Os.
shaped distention. (Fig. 35.) The tent is removed by plac-
ing the finger against the cervix during traction. The irreg-
ular dilatation is less likely to occur with a tupelo tent, though
its dilating power is not so great. Pain during the dilatation
can be relieved by the use of from two to five grains of acetanilid
Pig. 36. — Ellin ger's Dilator.
or from i- to ^ of a grain of codein. The removal of the tent
should be followed by careful antiseptic irrigation, after which
another tent or series of tents may be introduced. The use of
the tent affords an opportunity to make a digital exploration of
the uterine cavity, and is of advantage in small submucous
Fig. 37. — Goodeil's Modification of EUinger's Dilator.
fibroids, in suspected epithelioma, and in retained products after
abortion.
86. DivnlsiOQ consists in the rapid dilatation of the uterine
1 C3xial by the various dilating instruments. The preferable
Iscniineats are the parallel bar dilators, such as the Ellingei
iterine ^
Die in- ^1
.llinger ^M
46
GYNECOLOGY.
(Fig. 36), with the Baer and Goodell modifications (Fig. 37);
the latter, with its roughened blades, is a powerful instrument.
The vagina and cervical canal are carefully cleansed, and
through the speculum the cervix is seized with a double tena-
culum and stretched with small dilators, and subsequently with
the large instrument to the extent of two or three centimeters,
if desired. The principal objection to the procedure is that the
pressure is confined to the lateral surfaces of the cerv'ix and,
therefore, may lead to laceration.
87. Gradual dilatation is accomplished by the use of graduated
bougies, made of steel or hard rubber. The former are prefer-
able, as they can be steriHzed by heat. The Pratt series of
bougies, which have two bougies to each handle, making eighteen
in the set, the maximum being No. 43, will be useful. (Fig. 38.)
Each bougie is two milHmeters larger than the preceding. After
thorough cleansing of the vagina and cerv^'ix the Edebohls specu-
lum is introduced,
the cervix is seized
with vulsellum or
double tenaculum,
and the bougies are
used one after an-
other, up to the
largest size. (Fig.
39.) Care should be
exercised not to
puncture the uterine
wall. This accident
is more likely to oc-
cur in acute flexions;
the point of the. in-
strument makes so much pressure upon the thin convex wall
near the flexion that it finally ruptures. Rupture or i)erf ora-
tion of the uterine wall is not of infrequent occurrence, and
when done by the bougie is of but little significance. The
tear by the parallel bar dilators is much more serious, as the
wall of the uterus is torn, just as wide as the dilators have sepa-
rated. Through such an opening, omentum or a knuckle of intes-
tine may be drawn into the uterine cavity. It is sometimes ad-
vised to precede this method by the use of a tent, but it does not
seem necessary. The dilatation can be accomplished by the bou-
gies in shorter time than by divulsion.
88. Incision of the Cervix. — The external os, when very rigid,
or when the cervical canal is partly dilated by an extruding
fibroid, may be incised. This procedure may be resorted to for
abortion in the absence of proper dilating instruments. An
Fig. 38. — Pratt's Dilators.
PELVIC EXAMINATION.
47
nsion from i centimeter to 1.5 centimeters should be made
irith scissors upon either side. As the ordinarj- scissors slip off,
Itbe Kuchenmeister scissors (Fig. 40} are more effective. The
■ procedure is most readily accomplished by grasping each lip with
Ftg. 39- — The Method of Dilatation with the Graduated Bougies.
a double tenaculum and incising on either side with a knife. The
operation completed, the incised cervix should be closed with
sutures.
89. Complete bilateral incision of the cervix is rarely indicated,
Fig. 40. — Kuchenmeister 's Scissors.
as other meastu"es of less severity can be utilized. The operation
may be supplemented, if necessary, by ligation of the uterine
arteries. The vessels may be secured by drawing the cervix
m^ ciiff and passing a ligature -with a strongly cur\-ed needle.
ition A
?rine ^k
to ^1
edle. ■
48 GYNECOLOGY.
Care should be exercised to keep close to the uterus and not to
carry the ligature forward of a line tangent to the anterior cir-
cumference of the cerv^ix, in order to avoid ligation of the ureter.
A second ligature is passed upon the opposite side, when the
cervix can be incised with a knife to the vaginal fornix on either
side without danger of hemorrhage. Although generally advised
that ligation should precede incision, it is unnecessary. Hemor-
rhage does not always occur, and when it does, the bleeding
vessels can be seized with forceps and then ligated. If the finger
can not be passed through the internal os, the canal can be still
further enlarged with a probe-pointed bistoury. After ex-
ploration or operative procedure the cervix should be carefully
sutured. The lateral ligatures should be removed in two or three
hours, or in a shorter time if there is any reason to fear that the
ureter has been ligated. The prolonged retention of the ligatures
would result in sloughing of the vagina.
go. Dilatation by Oauze Packing. — VuUiet has devised a pro-
cedure for prolonged dilatation, which he denominates a * 'method
of dilatation by progressive plugging.*' It consists in repeated
plugging of the cervical canal with medicated gauze. Strips of
gauze, after the uterus has been carefully cleansed, are packed
into the cervical canal until it is completely filled. These are
permitted to remain for forty-eight hours, when they are re-
moved, and if the uterus is not then dilated sufficiently to admit
the finger, the cavity is again cleansed and packed. Pieces of
compressed sponge have been used for a similar purpose, and,
from their increase in size under moisture, are probably more
effective. The only source of anxiety is the uncertainty as to
their being absolutely sterile. This plan of procedure may be
carried over a series of days or weeks, without inflammatory re-
action. It is, however, not effective in cases of rigid cerv^ix,
and the same purposes may be accomplished by a more rapid
dilatation.
Qi. Microscopic Examination. - It is evident from the pre-
ceding that careful investigation of tissue changes is often neces-
sary to confirm, and add to, the data secured by inspection and
touch. The microscope here proves an important diagnostic
factor. It throws light upon obscure conditions, and affords
opportunity for the recognition of the incipient stages of lesions
so insidious and grave, that were the investigator deprived of the
information it affords the accurate diagnosis would frequently
come too late for radical treatment. Through the microscope
the knowledge of the histolc^gic structure of the genital organs has
been secured, and it is apparent that it would prove equally val-
uable in betraying pathologic alterations in the course and prog-
ress of disease. Consequently, it not only proves a valuable aid
PELVIC EXAMINATION.
49
I
in methods of diagnosis, but also upon the result of its findings
definite ideas concerning the prognosis are based, and suitable
methods of treatment instituted.
92. Collectioa of Tissue. — ^Tissue collected for microscopic
examination is procured by test curetment and test excision.
Occasionally sufficient tissue can be expressed from the genital
tract or escape in discharges, from which reasonably satisfactory
microscopical examinations can be made. Generally, however,
only small particles of tissue escape and these usually indicate the
existence of marked degenerative changes, and. therefore, the
tissue must necessarily be so altered by necrobiotic processes as
to render positive microscopic diagnoses uncertain and difficult.
Test excision is employed in cases of suspected disease in the
lower part of the genital tract and cervix. The test curetment is
performed in cases of suspected disease in the interior of the cor-
pus uteri. In certain conditions these two methods of collecting
tissue may ^\ith distinct advantage be combined.
93. Test Excision.- -The method of collecting tissue from
either the vagina or the cervix by test excision must be regarded
—Douche Curel.
as 3 surgical operation and, therefore, the patient should be as
carefully prepared as in preparation for a plastic operation. The
bowel and bladder empty, the patient should be placed in the
dorsal p<5sition upon the table, the parts thi.'roughly cleansed, and
the cer\'ix exposed by introducing Edebohls' sjxK-ulum or suitable
retractors into the vagina ; the cervix grasped with double tenac-
ula. one uptm each side or upi".>n the anterior and posterior lip;
gentle traction is made to fix the cerVix nearer the vaginal orifice.
With sharp scissors or scalpel a triangular or V-shaped piece of
ibe cervix is so excised as to secure both healthy and diseased
structure and a portion of the mucous nTembrane fining the cervi-
cal canal. The wound left from the excision should be closed with
one or two sutures of catgut. Closure of the wound is followed
bv irrigation of the parts with warm sterile salt solution, the vagi-
nal canal is lightly packed with iodof(.>rm gauze, and a sterile peri-
neal occlusion dressing applied. It is better, in the majority of
. , to employ general anesthesia for test excision, although it
1 be done by anesthetizing the surface with a four percent, solu-
50 GYNECOLOGY.
tion of cocaift applied on a cotton tampon. Infiltration anesthe-
sia would permit of painless excision, but it destroys the cell
structure and would, consequently, be misleading. Each step of
the procedure for test excision should be executed with the utmost
delicacy. This can not be too strongly emphasized in order to
avoid disturbing the architectural construction of the tissue and,
therefore, alteration in the living histological cell picture. Un-
fortunately, many surgeons collect tissue for investigation by the
microscopist in so careless a manner that by the time the tissue
reaches the pathologist's hands its structure is so changed as to
render intelligent study almost impossible.
The excised tissue should be washed in running water and care-
fully inspected with the naked eye, and also with a magnifying
glass ; by which its color, consistence, and general structure can
be recognized and noted. During this examination the question
can be determined as to what course shall be pursued in fixing and
preparing it for a more complete examination. As the tissue will
undergo marked change in this process of fixing, it is wise that a
drawing should be made and the direction in which the future sec-
tions are to be cut determined. Abel advises that excised por-
tions be divided so that one part can be examined while fresh, and
the other be prepared for finer sections.
94. Test Curetment. — In employing the curet to secure mate-
rial for examination the same precautions concerning antisepsis
and thorough preparation must be obser\'ed as in doing test exci-
sion. The operation is performed as follows : the patient under
general anesthesia, in the dorsal position, the vulva and vaginal
canal are thoroughly sterilized. Tlie cervux is exposed by an
Edebohls' speculum or suitable retractors, the anterior cer\^ical lip
fixed with double tenacula, tlie cervical and uterine canals are deli-
cately and carefully dilated. The utmost caution should be prac-
ticed in every step of the i)rocedure and undue force must posi-
tively be avoided in order to prevent injury- ()f the tissue cells and
distortion of the histology of the collected tissue, which would
render microscopic examination imsatisfactory. Dilatation is
best accomplished by i'ratt's graduated dilators. By their use
rapid and uniform dilatation is secured, with but little congestion
or traumatism to the endometrium. Laminaria tents also serve
excellent purj)(.)se for dikftation. I )ilatati«.)n with tents should be
done with all suri^ical cleanliness. ( )ne or tw( > are introduced and
allowed to remain for a ]>erio«l uf twelve hours; when, if sufficient
dilatation is not secured, a nest, comprisin<>: three or four tents, is
introduced and all( »\ved to remain twelve h< airs more. Dilatation
by tents has the i^reat advantage lliat it i)er7nits digital explora-
tion of the uterine cavity. This ex])lMrati<'n, however, should
follow the curetment. f()r the ])revi<»us introduction of the finger
PELVIC EXAMINATION.
51
would, to a certain degree, disarrange and render unsatisfactory
the endometrium for microscopical examination. Tent dilatation
has the disadvantage of requiring twelve to twenty-four hours for
its performance, but this additional time is often compensated by
the information afforded the exploring finger, because digital exam-
ination of the uterine interior may disclose lesions which the curet
has failed to reveal. In the employment of either of the methods
described a high degree of dilatation should be secured. The uterus
is cureted with a long, sharp douche curet having an acute angle.
Removed bj- Test Curctment.
Ii is well to start the curetment at a fixed point, either the poste-
rior or lateral wall, and with long successive sweeps, proceed from
the fundus to the cervical opening, remo\'ing the membrane to the
muscle structure. As the tissue escapes from the uterus it should
becoflected by an assistant in a sieve made of paraffin paper. (Fig.
43.) The coUection of cureted tissue on sterile gauze is to be con-
demned, as the tissue adheres to this material, and in its removal
the individual elements are torn and distorted. The tissue thus
collected is examined microscopically and any peculiarities re-
oorded, after which it should be immediately transferred to a fix-
g solution unless frozen sections are preferrefi.
52' GYNECOLOGY.
95. Disposition of Tissue. — The injuries resulting from undue
and careless handling of tissue after test excision or curetment has
been previously mentioned and can not be too strongly empha-
sized. Surgeons often fail to realize the value of avoiding careless
manipulation of the specimens and frequently unwittingly destroy
the living cell construction by prolonged exposure of the specimen
to the air and to injudicious handling. The advantages of imme-
diately fixing the tissue after removal are many. The wrapping
of any specimen or specimens in gauze, as already mentioned, is to
be positively condemned. Tissue so treated soon dries, the gauze
becomes firmly adherent to it, and in its removal tears and disar-
ranges the surface cells. In case the fixative agent is not at hand,
cureted or excised tissue can, without harm or injurj'', be tempo-
rarily placed in paraffin paper, although it is decidedly advan-
tageous to have fixative agents prepared and ready for the recep-
tion of the material prior to its removal. By such means the
individual cell elements are permanently fixed as they cx^cur in
life, and the microscopist is thus enabled to satisfactorily study
the cell chemistry and general cell construction of the specimens.
After the specimens are placed in fixative agents the vehicle con-
taining them should be numbered and properly labeled. The
label should contain the name of the patient, her age, the date of
operation, the character of the operation, the part from which the
tissue is obtained, together with a brief history.
96. Examination. — The specimens may be examined as teased
specimens, or be cut with the freezing niicro^me. The latter
course is preferable, as it interferes less with the relations of the
structures, and, consequently, permits a more correct judgment
as to the condition.
By teasing, the elements are separated from each other when
it is impossible to decide whether the surface epithelium sends
processes into the tissues or whether a simple hyperplastic or
destructive process exists — points of the greatest importance in
arriving at a correct diagnosis.
The fresh specimen should be cut with the freezing microtome,
but the sections should not be too thin, as they are likely to
tear in subsequent manipulation.
Each section is removed from the knife with a camel's-hair
brush and placed in distilled water. To prevent the sections from
being torn in transmission to the slide, it is better that the latter
be pushed under the section as it swims in the fluid and be gently
held w4th a glass rod.
The section, having been carefully spread upon the slide, is
then covered with a fine cover-glass. The latter is grasped at one
edge with forceps, the other side brought at an acute angle upon
the fluid covering the surface of the slide and gently released, re-
PELVIC EXAMINATION. 53
moving the superfluous fluid with blotting-paper. The section
can now be studied with high or low power, but when unstained is
best placed upon a dark under layer.
Specimens so studied have the advantage that we see the cells
as they were during life, and the character of the normal tissue
or any degenerative process can thus be recognized.
The specimen may be subjected to various microchemical
reactions which will afford valuable information. The section
may be rendered more transparent by a drop of a 2 or 3 per cent,
solution of acetic acid placed under the edge of the cover-glass.
A piece of blotting-paper held at the other side causes it to
penetrate the section quickly. Fatty tissues may be removed
by the similar use of alcohol, chloroform, or ether.
Elastic fibers are rendered prominent by caustic soda in a
I to 3 per cent, solution. A marked swelling of the contractile
elements of the smooth and striated muscles and of the nuclei
occiirs, and the homy substance becomes transparent. A 33
per cent, solution of caustic potash is especially valuable as a
preservative. Red blood-cells preserve their form well in such a
solution.
Infarctions or plethora of blood-vessels are in no way so well
observed as in fresh specimens. They may be permanently pre-
served by replacing the salt solution with glycerin, or preferably
with a 55 per cent, solution of potassium acetate. Pick's method
presents the best procedure for preserving frozen specimens, and
consists in the use of alum-carmin combined with formalin.
The alum-carmin of Grenach (4 to 5 per cent, of carmin) is
added to Schering's formalin 10 to 100, which should be kept in
a dark-colored bottle.
Pick's process is as follows:
1. Preparation of the frozen section with Jung's microtome.
2. Transference of the section into a 4 per cent, formalin
solution for one-fourth minute.
3. Formalin-alum-carmin, two to three minutes.
4. Washing in water, one-half minute.
5. Eighty per cent, alcohol, one-half minute.
6. Absolute alcohol, ten seconds.
7. Carbol-xylol, one-half minute.
8. Canada balsam.
Coplin says that his experience convinces him of the necessity
for thoroughly fixing all tissues before attempting to section
them, otherwise the results are always open to criticism, because
the distortion incident to congelation masses; maceration; and
the difficulty of removing the infiltrates produce conditions which
would mislead the most experienced observer. He advises the
following fluids:
54 GYNECOLOGY.
1 . Flemming^s solution, which consists of a i per cent, aqueous
solution of chromic acid, 25 volumes; i per cent, aqueous solution
of osmic acid, 10 volumes; i per cent, aqueous solution of acetic
acid, 10 volumes; water, 55 volumes.
All water in stock solutions and final mixtures must be dis-
tilled. Small pieces (five-tenths — i cm. cube) will undergo
stifficient fixation in from one-half to two hours. After this
process is complete they should be washed in running water for
six hours.
2. Hermann's solution : i per cent, aqueous solution of platinic
chlorid, 15 volumes; 2 per cent, aqueous solution of osmic acid,
2 volumes; glacial acetic acid, i volume.
3. He regards corrosive sublimate solution as the most useful
fixing agent for general use, although for pure cell study the first
two solutions are probably better. It consists of 125 gm. of
corrosive sublimate dissolved in a liter of 0.5 per cent, solution
of sodium chlorid in water. Small pieces fix in this solution in
from one-half to two hours. The used solution is filtered back
into the stock solution, while the hardened tissue is washed in
water, or preferably in 70 per cent, alcohol. This solution is of
advantage because of its cheapness, keeping qualities, and
simplicity of technique.
In the process of fixing with any of the plans, the quantity
of fluid should several times exceed the volume of tissue to be
fixed.
It is important for purposes of diagnosis that the tissues
should not only be properly fixed, but that sections should be
made with as little disturbance of cell relation as possible. At-
tention must also be given as to the direction in which sections
shall be made through the tissues. Sections parallel with the
surface of a mucous membrane are of but little value, as they cut
across glands and afford no indication of the true character of
epithelium. The most serviceable are the vertical or slightly
oblique.
Embedding. — A small piece of tissue may be prepared for
section-cutting by being embedded in either gelatin, celloidin, or
paraffin.
Glycerin-gelatin. — Ten grams of the finest gelatin are placed
in a clean vessel and covered with water. After four to six
hours the water is poured off, and the mass liquefied by a mod-
erate heat. While stirring with a glass rod, ten grams of glycerin
and five drops of carbolic acid are added, and the mixture left
in a wide-mouthed bottle. To embed a specimen, a piece of
this mass is taken and liquefied by heat. A thin layer is poured
upon the surface of a cork, the specimen placed upon it, and then
covered with a mantle of gelatin which soon becomes hard.
PELVIC EXAMINATION. 55
After being immersed in absolute alcohol for twenty-four
[ hours good sections can be made.
CelloiJin.^-The specimen is placed for twenty-four hours in
absolute alcohol, and the same length of time in sulphuric ether.
It then remains twenty-four hours in a tight bottle containing
thin celloidin. At the end of this period it is placed in a thick
solution, a small opening being left so that the alcohol and ether
evaporate very slowly. In a few hours a semi-solid mass has
formed, a block of which containing the specimen is cut out,
fastened with thick celloidin upon cork or wood, after which
it remains for twelve hours in a 70 to 80 per cent, solution of
alcohol, when it has the proper consistence for section-cutting.
Paraffin. — Abel prefers to stain the specimen preparatory to
embedding in paraffin. The specimen, hardened in alcohol, is
placed in the staining solution. This may be Bohmer's hem-
atoxylin, eosin, or safranin. It should remain in a weU-filtered
solution two to eight days, according to its thickness. It is
removed from the staining solution to 70 per cent, alcohol for
twenty-four hours, then is dehydrated in absolute alcohol. It is
placed in xylol for twelve hours to prepare it for saturation with
paraffin. The specimen is placed in a mixture of equal parts of
xylol and paraffin, in which it remains for twenty-four hours.
subjected to a continuous temperature of 37° C. in a paraffin
oven, after which it is kept in paraffin at a temperature of 48°
to 50" C. The latter is then permitted to solidify at the room-
temperature, when a paraffin block of suitable size containing the
specimen is cut out and fastened to a cork or a piece of wood with
paraffin, after which it is ready for cutting.
The sections thus secured are thinner than those secured by
any other method,
Section'Cutling.—Sections, are preferably cut with a microtome
and should be of equal thickness. A thickness of fifteen to
twenty microns will be satisfactory.
The sections are conveyed with a camel's-hair brush to a basin
containing dilute or absolute alcohol; the celloidin sections to
a 70 per cent, solution of alcohol, the gelatin sections to absolute
alcohol. The sections are very much shriveled by the alcohol
and should be placed in water for several minutes before being
iransferred to the staining fluid.
The paraffin sections can not be transferred from one vessel
to another; it is better to treat them on the slide. Abel applies
I one drop of a solution of collodion in alcohol upon a slide, and
m this the section, pressing it down with filter-paper. The
afiin is dissolved out with xylol, and covered with equal parts
i xylol and Canada balsam, and over this the cover-glass is
" Xly placed.
I
56 GYNECOLOGY.
Staining, — We will consider only those methods which are
most effective in rendering prominent the histologic structiires we
are desirous of utilizing in the diagnosis. PicroUthiocarmin and
hematoxylin are both very satisfactory.
The picrolithiocarminy introduced by Orth, is prepared by
imiting one part of lithiocarmin (a cold saturated solution of
lithium carbonate in which carmin powder has been dissolved in
the proportion of 2.5 grams of the latter to 100 grams of the for-
mer solution) with two parts of a saturated solution of picric
acid. This stain is best suitable for specimens which have been
hardened with alcohol. The section is placed in the staining
solution by a spatula and remains five to ten minutes, from which
it is conveyed for one to two minutes to a solution of alcohol
(70 per cent.) one hundred parts, hydrochloric acid one part, then
washed in dilute alcohol and dehydrated in absolute alcohol.
The specimen is made clearer by oil of cloves, oil of bergamot, or
xylol. It is conveyed to the slide and spread out free of folds.
It is then mounted in Canada balsam. Homy cells, fibrin,
hyaline substances, and red blood-corpuscles take on a yellow
color. The nuclei of the epithelium become a pale pink, fibrillar
tissue remains undyed, affording a clear picture of the specimen
stained. Hematoxylin stain is prepared by Coplin after Delafield
as follows: Dissolve 4 gm. of hematoxylin cr>'stals in 25 c.c. of
strong alcohol; add this solution to 400 c.c. of a cold, filtered, sat-
urated aqueous solution of ammonia alum; expose to light and
air for several days. Filter and add glycerin 100 c.c. and methyl
alcohol 100 c.c. This preparation is allowed to stand in the light,
with the bottle loosely corked; this mixture turns dark purple or
almost black. After assuming this color it should be filtered and
placed in tightly stoppered bottles. Before being used it should be
largely diluted, and if i)roperly prepared this stain will last for
years. The great objection to Delafield's mixture is that it re-
quires time f< )r ri]vning ami therefore can not be used immeiliately
after being made. Harris has overcome this objection by prepar-
ing the mixture as follows: Dissolve i gm. of hematoxylin in
TO c.c. of alcc^hol and add the resulting solution to 200 c.c. of dis-
tilled water in which 20 gm. of ammonia or potassium alum have
previously been dissolved. This fluid is heated in a flask to boil-
ing, at which time i gm. of mercuric acid is added. The solution
darkens (ripens) at once and is now ready for use, but should
always be diluted. From this stock solution an acid hematoxylin
may be pre])arcd by adding 4 c.c. of glacial acetic acid and 30 c.c.
of glycerin to 70 c.c. to the ])rimany^ solution. This acid prepara-
tion has the great advantage of rendering overstaining almost
impossible.
Hematoxylin Stainiui;. To use the hematoxylin stain of Dela-
I
I
PELVIC EXAMINATION. 57
field or Harris the sections cemented to the slides are cuvered with
the diluted stain from five to fifteen minutes. They are then
washed in water, dehydrated in alcohol, cleared with creasote, and
mounted in Canada balsam. Coplin states that a better result is
obtained by placing enough distilled water in a staining dish to
immerse the slide on end, to this sufficient hematoxylin is added
to tinge the water mther deeply. The sections adherent to the
slides are permitted tri remain in this solution twelve to twenty-
four hours. They are then cleansed in water and treated as di-
rected prevHously. Hematoxylin stains the nucleus purple and
gi^-es a faint tint to the protoplasm shapes. Definition of the pro-
loplasm can be secured by following the hematoxylin staining by
placing the slides and section in an 0.5 alcoholic solution of eosin
for one or two minutes. The excess of water is removed and sec-
tion washed in alcohol, cleared in creasote, and mounted in balsam.
This method stains the nuclei purple and the surrtiunding proto-
plasm pinkish, besides, the eosin stains the erythrocytes pres-
ent. One of the very i>est contrast stains is that suggested by
Van Geison, which is composed of the following:
Acid fuchsin (i per cent. &C)ueous Eolution), 15 c.c.
Picric acid (saturated solution), 50 c.c.
Water jo c.a
In using this stain the sections are first stained with hematoxy-
lin, washed in water, followed by applying the Van Geison stain
for four or five minutes, dehydrated in alcohol, cleared in xylol,
and mounted in xylol balsam. By this method the connective
tissue appears rwi or pinkish red, the cell protoplasm yellow, the
nuclei dark brownish or reddish purple.
Hematoxylin stain is prepared by dissolving i gram of
hematoxylin in 30 grams of absolute alcohol. To a solution of
powdered alum (0.5 to i gram in distilled water 30 cm.) the above
preparation is added drop by drop and shaken until the fluid
takes a deep violet color.
Celloidin-embedded sections remain longer (ten to twenty
minutes, according to size and thickness) in the solution than
sections prepared by other methrxls. and are placed in alcohol con-
taining hydrochloric acid until they begin to assume a red tint,
from which they are removed to 70 per cent, alcohol. They are
placed in absolute alcohol until the mantle of celloidin Vjegins to
curL Care must be exercised that all the celloidin is not dissolved
or the finer sections would fall to pieces. The section is made
transparent in oil of bergamot or in xylol. Should the celloidin
mantle at this stage become cloudy or milky, the section should
be placed in absolute alcohol until it clears. With a spatula the
section is placed upon a shde and mounted in xylol-Canada
after removing the oil with filter-paper. This method
58 GYNECOLOGY.
gives splendid staining of the nuclei, the protoplasm is slightly
stained, the celloidin not at all. The diagnosis of malignant
conditions is greatly enhanced by staining the elastic fibers.
For this purpose Taenzer's orcein stain is employed. The
sections are taken from water and kept in this solution from six
to twelve hours or longer (Grubler's orcein 0.5, alcohol 40.0, aq.
dest. 20.0, hydrochloric acid gtt. xx), then placed for a few seconds
in hydrochloric acid alcohol fhydrochloric acid o.i. 95 per cent,
alcohol 20.0, aq. dest. 5.0J, where they become differentiated and
are washed in water. After five to ten minutes' dehydration in
absolute alcohol, they are cleared in oil and mounted in Canada
balsam.
The elastic fibers appear as an intense red upon a pale pink
background.
Wei^ert's juchsin-resorcin stain is made by taking 200 c.c. of
the following mLxture: Resorcin 2.0, fuchsin i.o, distilled water
100. o, and bringing it to a boil in a porcelain vessel, when 25 c.c.
ferri liq. sesquichlor. (German Pharmacopeia) are added, the
whole boiled while stirring for two to five minutes longer. The
muddy mass thus formed is permitted to cool and then filtered.
The portion which runs through the filter is thrown away, and
the deposit left upon the filter until it ceases to drip.
The filter with its contents is removed from the funnel,
placed in a bowl, and boiled under constant stirring with 200 c.c. of
94 per cent, alcohol. While boiling the filter-paper is removed
and the solution is permitted to cool, after which it is filtered and
the filtrate brought to 200 c.c. by the addition of alcohol. After
adding 4 c.c. of hydrochloric acid the solution is ready for use.
The sections are placed in this solution for twenty minutes
to one hour, washed in alcohol, and cleared in xylol.
The elastic fibers are stained dark blue, almost black, on a
quite light background. The nuclei may be stained with a
carmin preparation.
97. Preservation of Gross Specimens and Slides. — In order to
keep a complete cnse record it should be the rule to preser\-e the
gross specimens and slides containing sections therefrom. Many
agents have been recommended for the preserv-ation of gross
specimens. Alcohol is j)erha])s the reagent most commonly em-
ployed, Vmt by its use the density of the specimens is altered, the
color entirelv lost, and i^eneralcaitlineindilTerentlv retained. For-
malin has recently gained considerable i)rominence as a valuable
preservative. A ten ])er cent . Sf )lution (:>f the commercial prepara-
tion is usually em])loye(i. Specimens prepared by this method
can be used with a higher dei^^ree of satisfaction for histologic
study than tlmse ]>re]»are(l with alrohol. Specimens when not
too large can also he ])reserve«l in formalin va])or by placing them
PELVIC EXAMINATION.
\
in an air tight jar containing a bed of cotton which has been pre-
viously moistened with pure formalin. The specimen should be
placed upon the cotton and covered with filter-paper moistened
with the reagent. For the retention of the color of gross speci-
mens no method possesses such advantages as those afforded by
the use of Kaiserling's solution. Two solutions are necessary and
are composed of the following ;
Soi-uTioK A.
Pormalic 250 c.c.
Nitrat« of potassium,-- — - 10 gm.
Acetate o( potassium 30 gm.
Water r fiter.
SOLUTIOM B.
Acctat« of potasnutn soo gra.
Glvcerin 400 c.c.
Water aooo c.c.
Pormalin, to point of saturation.
The specimen prior to being placed in the preservative is
lightly washed with running water to remove adhering blood and
is then placed, according to size, from one to twenty-four hours in
Solution A, at the end of which period it is changed to a fresh
Solution A. in which it is allowed to remain from two to thirty-six
hours. It is then washed in
running water from fifteen min-
utes to one hour and placed in
eighty per cent, alcohol in order
to cause a reappearance of the
color. Unless the color shows
signs of returning the specimen
is transferred to ninety-five per
cent, alcohol, in which it is
allowed to remain until the color
IS fuUy restored. After the color
is thus restored the specimen is
placed in Solution B and at tlif
end of twenty-four to furty-
eight hours it should be placed
in a fresh portion of Solution B. ' ' lw.i liuu'x k.r u'li'iVi-LTva^on
In preser\-auon of slides the 'if sii.li?>.
best results are obtained by using
a. card index system. Special histologic or slide cases are made
I containing trays for the slides and also a card index as shown in
Fig. 4j. By using this method the shde is labelled and numbered
and tbe number corresponds to the number on the index card
1 winch contains the name of the patient, her age, date of occupa'
■boo, name of organ from which tissue was remove<.l, nnd
60 GYNECOLOGY.
logic diagnosis. An ingenious slide card index has been devised
by Coplin. (Figs, 44
and 45.) The slides
are properly labeled
and numbered and
then placed in the
card and secured by
scaling the free end
of the card x'aper.
The inde.K card is
marked in the same
manner as that de-
scribed above. The
cards containing the
slide are preserved in
dust proof drawers.
This method offers
the advantage that
the shde can not lie
separated from the
name of the patient,
and from its ingeni-
ous arrangement
can be submitted to
microscopic exami-
nation without re-
movalfromthecard.
g8. Failure. — Examination may fail to reveal the true
character or presence of disease, because the section was made
through the adjoin
m. its- MIS. a. n. juur u,i9M.
TISSUE TBON unniiiB son.
KtlH. mta. IffFBSRlFHie BUWULAR EMNieTStTia.
ing healthy tissue.
Tlie examination
may also pnne un-
satisfactory and
worthless as a result
of mutilation and
distortion of the
specimen inci<lent to
undue manipulation
and carelessness in
collection and fnjm
improper tcclmique
in preparation for lUiscd.
study.
99. Bacteriology of the Genital Tract. - 'flic importance of
careful bacteriologic examinations of the secretions of the geni-
Foldod wilh Slide En-
I
PELVIC EXAMINATION. 61
tal tract can not be overestimated. Careful bacteriologic an-
alyses of the genital secretions not only increases the clinical in-
terest of a case, or special cases, but stimulates scientific re-
search, and, therefore, renders the case records complete and
more worthy of preser\-ation. Furthermore, scientific bac-
teriologic examinations of the secretions of the genital tract
will enable us to diagnose definitely the provocative factor
in conditions which might otherwise remain obscure. We
are also enabled to determine the specificity, sterility or viru-
lence of inflammatory accumulations and thus become better
qualified to ad%'ise and institute proper metho<:!s of treatment
and interpret, to a certain degree, the probable outcome of a
given case.
lOO. Parasites of the Genital Tract.^ Parasites, both of animal
and vegetableorigin.asinall other cavities of the body, are found
in the genital tract. Of course, here, as elsewhere in the body,
bacteria or vegetable parasites preponderate and are the most
provocative of harm. In health, micro-organisms inhabiting
the genital canal are limited to the structures oi the vulva and
the vaginal canal. Furthermore, even in this part of the geni-
talia, they are found in minimum numbers and attenuated in
virulence. The special organism cultivated and described by
Doderiein is found more or less constant in the vaginal canal
and has been termed the acid vaginal bacillus of Doderiein.
It is said to generate lactic acid and is a rod-shaped bacillus of
the anaerobic type whose discoverer believes it to be a protective
force against the invasion and action of pathogenic germs.
He further believes that even if pathogenic bacteria gain
entrance to the vagina their virulence is attenuated by the
presence of this germ. This micro-organism flourishes in the
normal acui secretion of the vagina, and if the acidity of the
vaginal secretion is destroyed it disappears and other bacteria
enter. It has been demonstrated by Stroganolt that micro-
organisms are more numerous in the vagina preceding and
following menstruation. It has been discovered that the in-
fectious properties of bacteria are diminished as they ascend
the vaginal canal and approach the cervix. In. the newborn
the vaginal canal is entirely bacteria free, but soon after birth
their presence can be demonstrated, In the normal individual.
according to Kronig, Menge, and Whitridge Williams, it is not
poGsible for bacteria to exist long in the healthy vaginal secre-
tSoo. Kronig demonstrated the germicidal action of vaginal
secretion by introducing various organisms into the vagina of
a normal individual. At the end of two days the vagina be-
came entirely bacteria free. Streptococci were the first to suc-
cmnb. staphylococci and pyocyanei living twice as long. Dur-
62 GYNECOLOGY.
ing pregnancy it is asserted that the acidity of the vaginal secre-
tion is increased and that bacteria are not present. Williams,
in ninety-two pregnant women, found the skin staphylococcus
twice, never the streptococcus. Kronig, in forty-eight pregnant
women, did not find any. From extensive obser\''ations it is
asserted, therefore, that pyogenic bacteria, when fotmd in the
puerperal genital tract, have been introduced from without.
From a bacteriologic standpoint the healthy genital canal can
be separated into three portions: the inferior portion, com-
prising the vulva and vagina to the cervix, containing bacteria ;
the middle comprises the cervical canal between the external
and internal os and, as a rule, is free from bacteria. The remain-
ing portion is formed by the uterus, tubes, and ovaries and is
entirely free from germs. Menge, in his investigations of uteri
removed in Zweifel's clinic, was not able to cultivate germs on
any ordinary culture media. The external os can then be
said to be the boundary line between that part of the genital
tract containing micro-organisms (vulva and vagina) and the
part bacteria free (uterus, tubes, and ovaries). The vulva and
the vaginal canal always contain bacteria, and Edgar found in
twenty-eight pregnant women and two parturient women pyo-
genic bacteria present in forty per cent.
1 01. Natural Agents of Immunity. — It has been demonstrated
that parasites of many varieties, both animal and vegetable,
are found more or less constantly in the lower portion of the
genital canal in the ncjrmal healthy woman. They are present,
however, only in small numbers and with attenuated speci-
ficity. This is because Nature provides natural agents for
protection or securing immunity. The protective powers of
the normal genital canal are found, i, the acid secretion of the
vagina which is decidedly inimical to pathogenic bacteria; 2,
the dense arrangement and phagocytic action of the wall of
stratified epithelium lining the vagina is also hostile to invading
micro-organisms; 3, the plug of coagulated secretion commonly
found in the os externum, while not truly germicidal, does act
as a barrier against the entrance of germs into the uterine cavity
and structure? above. Tlie restraining and destructive influ-
ence exerted by the bacillus of Doderlein against invading
pathogenic bacteria lias been mentioned.
It may, therefore, Ije asserted that so long as the vaginal
epithelium remains healthy and intact, the natural secretions
normally generated and the vaginal bacilli present, pathogenic
bacteria may be found, but their excessive production is in-
hibited and their destnictive influence allayed.
102. Loss of Protection. — Certain conditions alter the normal
acid secretion of the vagina, rid the canal of its protective micro-
PELVIC EXAMINATION. 63
organisms, and change the epithelial wall and permit thereby
the proliferation of infectious micro-organisms and the generation
of their poisons. Traumatisms produced by manipulation,
indelicate examinations, raw surfaces left by operation, and in-
juries resulting from labor afford gateways for the introduction
of infectious germs into the absorbing tissue tracts. The natural
bacterial secretion of the vagina is rendered neutral or alkaline
or wholly destroyed by increase of discharges from above, such
as takes place during menstruation, during parturition, and in
alterations of general health. Repeated examinations and per-
sistent douching also destroy the antiseptic properties of the
vaginal canal.
103. Parasites. — I have already indicated that parasites of
all varieties, both animal and vegetable, are foimd in the genital
tract. I stated that the vegetable were, of course, the most
frequent and most powerful for harm. The following table
shows the varieties of parasites most frequently foimd :
Vegetable (Bacteria).
Staphylococcus pyogenes aureus Smegma bacillus.
Staphylococcus pyogenes albus
Streptococcus pyogenes. Bacillus typhosus.
Staphylococcus pyogenes. Bacillus pyocyaneus.
Gonococcus. Bacillus aerogenes capsulatus.
Bacillus coli communis. Bacillus diphtheria.
Bacillus tuberculosis. Pneumococcus,
Organism of syphilis. Diplococcus of Siegelman.
Organism of chancroid.
Animal.
Pediculosis pubis. Ascaris lumbricoides.
Ascaris scabiei. Taenia echinococcus.
Oxyuris vermicularis.
104. Staphylococcus. — The staphylococcus pyogenes aureus is
perhaps the micro-organism most commonly found in localized
suppurative processes, and, according to Coplin, Curry found it
present in fifty-two of one hundred and fifteen abscesses. The
staphyloc(x:cus pyogenes albus was present in twenty-nine, f Fig.
46.) The tendency of the staphylococcus is to cause local sup-
purative lesions, although it may produce general pyemic infec-
tion and fatal septicemia. I recall one case of fatal stapliylococ-
cemia in which pure cultures of sta])hylococci were found in the
blo<.'>d following a plastic operation on the i)crineum and cervix.
This germ is found singly, in pairs, in fours, and in short chains,
but generally in irregular clusters or grai^e-like bunches. It grows
in all ordinary culture media at a temi)eraturc between 20° C. and
40*^ C. It rapidly liquefies gelatin and in the i)r()ccss of growth the
colonies fall to the bottom of the medium, assuming a bright
orange yellow color, hence its name. Tlic cuhure colonies arc at
64
GYNECOLOGY.
first small and of a white hue, but by the third day they assume
the characteristic golden yellow or orange color. The staphylo-
coccus stains by all the common anilin dyes, but does not respond
to Gram's method. The staphylococcus and its kin are perhaps
the most frequent cause of local inflammation and suppuration of
the uterus and its appendages and of the pelvic peritoneum. A
special feature of this germ is its strong attractive chemotactic
influence upon leukocytes, particularly the polynuclcar cell. In
two thousand and ninety-eight cases of purulent salpingitis three
hundred and seventy-four were found to be due to puerperal sep-
tic infection, mostly of staphylococcic origin.
105. Streptococcus. — The streptococcus pyogenes generally
occurs in chains. It is the most virulent of all the pyogenic ccx^ci
and measures one-half to one micron in diameter. (Fig. 47.) It
grows well at a temperature of from 30° C. to 40° C, but does not
Fig. 46. — Staphylococcus Pyogenes
Aureus. From Pure Culture in
Bouillon. (Zeiss, 2 mm., Oc. c.)
Fig. 47. — Streptococcus Pyogenes.
From Culture in Bouillon.
(Zeiss. 2 mm. Obj., Oc. c.)
grow readily below 20° C. and is killed in ten minutes at 52° C. It
grows on all common culture media, appearing as small elevated
circular colonies of a grayish-white color. It does not liquefy gel-
atin. The streptococcus stains with the common anilin dyes
and is positive to Oram's meth^Kl. This germ is found in spread-
ing inflammatory processes, with or without suppuration,, in
serious phlegmonous and erysipelatous conditions and suppura-
tions, in serious membranes and joints. Streptococci are also
found in malignant endocarditis and suppurative periostitis.
Thev are found in inflammatorv disease of the mucous membrane,
particularly the mucous membrane of the throat, where they
cause a pseudo-diphtheritic inflammation. In puerperal perito-
nitis they are found in a condition of purity, and this organism is
undoubtedly tlie most frequent cause <.)f puerperal septicemia.
The streptrx:occus is less l(;cal in its acti<jn and far more virulent
PELVIC EXAMINATION. 65
than the staphylococcus. In septic peritonitis and puerperal
septicemia the organism is easily conveyed to the vaginal canal or
uterus from without, and it is transported from the vagina or the
uterus to the pelvic peritoneum through the lymph channels,
blood-vessels, and by penetration of the uterine wall. The late
Dr. Pryor asserted that the passage of this germ through the
uterine wall should be counted by hours and not days. Sections
of puerperal septic uteri demonstrate that Dr. Pryor was not in-
correct in this assertion, for in nearly all cases the organism can be
recognized microscopically throughout the tissues of the uterus,
Doderlein, in his investigations of the vaginal secretions of nearly
two hundred women, found only one-half normal. The remainder'
were b2icteriologically abnormal. In ten per cent, of the normal
Fig. 48.— Secretio:
cases the streptococcus pyogenes was present, and inoculations
with the secretions from fifty per cent, of these revealed that
they were pathogenic for animals. Secondary abscesses in the
lymphatic glands are more frequently caused by streptococci
than by staphylococci. The virulence of the streptococci varies.
106. Gonococcus. — The gonococcus was first described by
Neisser in 1879, and later cultivated in sohdified senmi by Bumra
and others. It has been definitely determined to be the specific
cause of gonorrhea. The gonococcus under the microscope re-
sembles in appearance two coffee-beans placed side by side, with
an unstained oval interval. Sternberg applied the term "biscuit-
shaped" coccus. (Fig. 48.) Irregular and degenerative forms of
the germ are, however, seen. This germ is sometimes difficult to
66
GYNECOLOGY.
cultivate on artificial culture media. (Fig. 48.) It grows slowly
on human blood serum or acid urine agar and blood-smeared agar
or on Wertheim's media, appearing, at the end of twenty-four or
forty-eight hoiirs after inoculation, as small, irregular, rounded
colonies of a grayish-yellow color. The margins of the colonies
are undulated and sometimes show small projections. Colonies
vary in size and tend to remain separate. They reach their maxi-
mum size on the fourth or fifth day, and, according to Muir and
Ritchie, on the ninth day or earlier die. The germ stains readily
with the basic anilin dyes, but does not stain by Gram's method.
The gonococcus is foimd in large numbers in pus of acute gonor-
rhea, both in the male and female. It, for the most part, is con-
tained within the leukocytes. In the earlier stages it is also foiuid
Fig. 49. — Secretion of Simple Vaginitis, Showing Various Forms of Organisms
Found and Preponderance of Epithelial Cells.
a, Bacilli; b, Streptococci; c. Staphylococci; d, Pus-cell.
outside the pus-cells, but when the discharge is wholly purulent
the greater portion are found within the pus-cells. Gonococci are
also foimd in purulent secretion of gonorrheal ophthalmia and
throughout the genital tract when these organs are the seat of
Neisserian infection. The tendency of the organism is usually to
remain and cause local genital lesions. It is not alone responsible
for disseminated genital infections, but is also responsible for
generalized or systemic lesions, and has been found in pure
culture in the blood. Gonococcemia usually results from infec-
tions of the genito-urinar}'' organs, but cases have been recorded
where blood infection has occurred from gonorrheal ophthalmia.
Cases of endocarditis, endarteritis, suppurative arthritis, and gen-
eral pyemia have resulted from the absorption of the organism.
The gonococcus is, unfortunately, found present to an alarming
PELVIC EXAMINATION. 67
degree, and in the female is undoubtedly the most destructive of
all the pyogenic cocci, and when once implanted on the mucosa of
the female genital tract, is rarely, if ever, eradicated. Sanger, in a
series of nineteen himdred and thirty cases, reports two himdred
and thirty suffering from gonorrheal infection. A committee ap-
pointed by the American Medical Association found that in pelvic
disorders of women reqtiiring surgical interference forty per cent.
were of the specific diplococcus origin. In the gynecological
wards of Jefferson Medical College Hospital one in five or twenty
per cent, of operations are performed for lesions resulting from the
action of the gonococcus. Andrews, discussing the etiology of
salpingitis from a series of statistics collected from twenty-eight
sources, shows that in six hundred and eighty-two suppurative
tubes the gonococcus was found present one hundred and fifty-
five times in three hundred and eight cases in which micro-organ-
isms were demonstrated. In three hundred and seventy-four the
pus was sterile, and he believed that many of these were primarily
of gonorrheal origin. Kleinhaus, in two himdred and eighteen
pus tubes, f otmd the gonococcus present seventy -four times. The
large number of sterile tubes fotmd was explained by the fact that
the gonococcus disappears early from pus, and it is, moreover,
extremely difficult to demonstrate the micro-organism in the tubal
wall. The gonococcus, however, does not always disappear from
the contents of the pus tubes early, because cases have been re-
ported of old-standing pus tubes being operated upon, followed
by suppurative peritonitis in which pure cultures of gonococci
were obtained. The gonococcus, while violent and destructive in
action, is perhaps the most prolific cause of chronically invalided
women and also the causative factor in destroying the structure
of the uterine mucous membrane, rendering it unfit for lodgment,
maintenance, and successful maturation of a fertilized ovum.
It is also productive of great harm in the appendages of the uterus
— the tubes and ovaries — ^working such changes in these organs as
to demand their total sacrifice or cause such structural alterations
as to prevent the proper performance of their especial functions.
Despite the virulent influence which the gonococcus exerts upon
the generative organs of women, it, however, rarely causes death.
It is frequently responsible for violent attacks of peritonitis with
alarming symptoms, but the inflammatory changes usually re-
main localized and do not spread as infections of this membrane
do when caused by the staphylococcus, or more particularly, the
streptococcus. This is due to the fact that gonococci find a
natural habitat and favorable nutrition in the cells and fluids of
the mucous membrane lining the genital tract, particularly the
cervix and Fallopian tubes, whereas the endothelial cells of the
peritoneum and the peritoneal fluid are, to a certain degree, hostile
68
GYNECOLOGY.
and phagocytic to the gonococci, thus destroying many and driv-
ing others into a localized field of battle.
107. Bacillus Coli Communis, — This organism is foimd
present normally in the intestinal canal. It is very similar,
morphologically, to the tjrphoid bacillus. The colon bacillus is
usually found in mixed infections, though pure infections by this
organism do occur. Andrews, in his bacteriologic statistic
study of pus tubes, found that the colon bacillus was present
in 2.5 per cent. (Fig. 50.) This germ is frequently respon-
sible for inflammatory disorders of the intestinal canal and sup-
purative processes in the peritoneal cavity. It is often found in
inflammation of the urinary passage, such as cystitis, pyelitis,
and pyelonephrosis. Colon suppuration of the organs in the
pelvis (Joes occur, and Reed says that it is responsible for a cer-
Pig' 50- — Bacillus Coli Communis.
From Pure Culture in Bouillon.
(Zeiss, 2 mm. Obj., Oc. ^r.)
Fig- 51- — Bacillus Tuberculosis.
(Zeiss, 2 mm., Oc. c)
tain percentage of cases of ovarian abscess. He claims that the
diseased organ as it becomes adherent to the bowel affords an
opporttmity by the contiguous surface for the introduction of
the germ. Roberts states that suppuration of ovarian cysts,
especially after twisting of the pedicle and the resulting adhesions
to the bowel, has a similar explanation, and many suppurative
infections of the abdominal incision can be traced to this germ.
108. Bacillus tuberculosis, discovered by Koch in 1882, is a
rod-shaped bacillus, one and one-half to three and one-half microns
long, one-fourth to one-half micron thick. It grows readily upon
solidified blood serum and glycerin agar. It develops slowly —
does not appear for two or three weeks after inoculation. (Fig.
51.) The colonies are of a creamish color and somewhat granu-
lar. This becomes more marked as the growth ages, and, accord-
ing to Coplin, the surface of the colony takes on a bread-crumb
PELVIC EXAMINATION. 69
appearance. The bacillus stains with most of the basic anilin
dyes and by Gram's method. It takes the stain slowly but
securely, and is with difficulty decolorized. It resists strongly
the decolorizing action of mineral acids in common with certain
other organisms belonging to the acid-fast bacteria. Primary
tuberculosis of any part of the genital tract is rare, though tuber-
culous lesions may occur in any portion. The Fallopian tubes
are the organs most frequently infected, and next in order of
frequency are the uterine body, ovaries, vagina, cervix, and
\'\ilva. Tuberctdous infection of the vulva and vagina is rare,
and is usually secondary to infection from the uterus. Tubercu-
losis of the vagina is frequently associated with or is secondary to
tuberculous inflammation in other portions of the genito-urinary
tract, as the bladder, bowel, peritoneum, or distant organs, as the
lung or joints. Primary vaginal tuberculosis, however, has
been reported by Friedlander. It has been demonstrated
that the freedom of the vulva and vagina from tuberctdosis is
due to the resistance of the squamous epithelium to bacterial
invasion. Tuberculosis of the vulva and vagina (lupus), while
extremely rare, is a very destructive disease. In one case under
my observation in the terminal stages the entire vulva was
totally destroyed, establishing fistulous communication between
the vagina and recttim and vagina and bladder. I have fre-
quently seen rectovaginal fistulae as a result of tuberculous
disease of the rectum. Tuberculous infection of the uterus also
is rarely a primary disease : it is generally associated with or is
secondary to tuberculous lesions in the tubes, peritoneum, or
some other structure of the body. Tuberculosis of the uterus
and the organs above occurs with greater frequency than is
clinically observed, as careful postmortem examinations of
individuals dying from pulmonary tuberculosis has proved,
yet Martin, in sixteen hundred examinations of the uterine
mucous membrane, found only twenty-four instances of tuber-
culous lesions in the uterus. According to Spaeth, tuberculous
infection of the cervix constitutes about five per cent, of the
cases of genital tuberculosis in women. The Fallopian tubes
are the most frequent seat of genital tuberculosis. In a total
of one htmdred cases of pyosalpinx collected by. Andrews ten
per cent, were tuberculous. The infection is usually secondary
to tuberculous foci elsewhere in the body. In primary tuber-
cular salpingitis the bacilli are introduced from without, and
attack the tube by ascending the genital canal. Secondary
infection of the tubes usually results from tuberculous peritonitis,
but it may also result from metastatic deposition through the
blood- or lymph- vessels. Infection may be conveyed by contigu-
ity of structure from a tuberculous ulcerating intestine to an
70 GYNECOLOGY.
adherent tube. Meyer reports fifty-seven cases of primary
tuberculous tubal disease out of sixty-seven cases of genital
tuberculosis. Orthmann states that primary tubal tubercu-
losis occurs in eighteen per cent, of all cases of genital tuber-
culous infection in women. Rosthom, in eighteen hundred
and fourteen cases of inflammatorv disease of the tubes, found
tuberculous infection to be the exciting cause in twenty-nine.
Tuberculous infection, particularly of the tubes, occurs in young
children and in virgins. All cases of tuberculous peritonitis,
however, are not necessarily associated with tuberculous inflam-
mation of the tubes or uterus. I have operated on several cases
of tuberculous peritonitis in yoimg women, and in most of these
careful obser\^ation failed to reveal any marked tuberculous
process in these organs, yet some of the cases were of long dura-
tion. It is stated by certain investigators that pre-existing
gonorrheal infection of the tube predisposes to tuberculous
disease. Infection of the ovaries by the tubercle bacillus is
exceedingly rare, one or two cases of primary ovarian tuber-
culosis having been recorded, but in the vast majority of cases
it is secondary to tuberculous infection of the Fallopian tubes,
peritoneum, and intestines. In forty-eight cases of ovarian
tuberculosis Orthmann traced the infection to the tubes in
twenty-six and the peritoneum in twenty-two. Infection of
the peritoneum by the tubercle bacillus occurs in men, women,
and children. The disease may occur in the acute miliary, the
caseating, or a chronic fibroid form. The disease is most fre-
quent in women, and the relative frequency given by different
obser\'ers is from fifty to ninety-eight per cent. It usually
occurs in young women between twenty and thirty years of
age, though the infection occurs at all ages. Tuberctdous peri-
tonitis was found two hundred and eighty-four times in thirteen
thousand four hundred and twenty-two autopsies studied by
Grawitz and Brum, and the Mayos, in five thousand six hundred
and eighty-seven operations, found it present eighty-nine times.
Osier found that in abdominal operations for tuberculosis lapar-
otomy was performed twice as often in females as in males. An
interesting feature of tuberculous infection of the peritoneum
is the unusual occurrence of extensi\'e lesions in other portions
of the body.
109. Syphilis and Chancroid.- The organisms of chancroid
and chancre have not been definitely demonstrated, though a
characteristic bacillus was discovered and described first in
chancroid .by Ducrey in 1889. Unna, in 1892, described the
appearance of this bacillus in prepared histologic sections of
the soft sores. It appears as small oval rods measuring one
to two microns in length and half a micron in thickness. It is
PELVIC EXAMINATION. 71
usually present with other organisms in the purulent discharge
from the surface of the specific sore. It stains readily with
basic anilin dyes, but decolorizes rapidly. It has not been
successfully cultivated outside of the body. Regarding the
specific organism of syphilis, much definite knowledge can not
be given. Lustgarten, in 1884, described an organism which
he discovered m a primary sore and in the lesions of internal
organs. It resembles somewhat the tubercle bacillus, occurring
in slender rods from three to four microns in length. It stains
with the basic anilin dyes and is easily decolorized by mineral
acids. Lustgarten's bacillus has not been Cultivated outside
of the body. Many other micro-organisms have been described
as present in syphilitic lesions, but the causative relation of
bacteria in the production of this disease has not been fully
determined.
no. Bacillus Typhosus. — The typhoid bacillus may be found
in any part of the genital tract during typhoid infection, and
for months, or even years, after subsidence of fever. It is found
in acute infectious inflammations of the endometrium, and Pfan-
nenstiel reported three cases of post-typhoid ovarian abscess.
Several other cases have been reported. The typhoid bacillus
has been found in suppurating ovarian cysts several months
after the primary typhoid infection. It is probable that the
bacilli reach the ovarian structure by passing through the in-
testinal wall. Typhoid infection of the vulva and vagina also
occurs, and, according to Keen, the lesions usually occur as dis-
tinct vulvar gangrene and gangrenous ulcerations in the vagina.
He collected eight cases, seven of which were in yoimg persons
from seventeen to twenty-seven years of age, and one of thirty-
four years. In six of the cases there was gangrene of the labia,
extending sometimes to the perineum and thigh. Fistulous
communications between vagina and bowel were established.
The gangrenous ulcers were commonly located on the posterior
vaginal wall. Ulceration of the anterior vaginal wall is also
reported, with the formation of vesicovaginal fistula. In some
of the cases great distortion of the vagina developed from cicatri-
zation, and in one case complete occlusion, resulting in retention
of menstrual fluid which required operation for its liberation.
Keen reported a patient under his observ^ation with both recto-
vaginal and vesicovaginal fistulae. Typhoid infection of the
uterus during pregnancy frequently occurs and generally results
in the expulsion of the fetus. Typhoid bacilli have been found
in the placenta, and Keen studied a case reported by Freund
and Le\y in which spontaneous abortion occurred at the fifth
month. The patient was in the declining stages of typhoid in-
fection. Bacilli were found in the blood of the placenta, in the
72 GYNECOLOGY.
spleen, and in the heart of the fetus. Other similar cases have
been reported.
111. Smegma Bacillus. — This micro-organism normally in-
habits the secretions of the external genitals, and may be found
in the urine associated with particles of detached smegma.
The germ is not pathogenic. Morphologically it resembles
somewhat the tubercle bacillus, but is shorter and differs tinc-
torially in that it is not an acid-fast bacillus, and, therefore, is
readily decolorized by the mineral acids.
112. Bacillus pyocyaneuSy a short, rod-shaped, motile organism
which measures one to one and one-half microns in length by one-
half micron in width, grows readily in nearly all culture media
at a temperature of 20° C. to 37° C, liquefying gelatin, and in
the process of growth the colonies assume a greenish hue. It
is foimd in green pus and in the discharge of the intestinal dis-
orders of infancy. It has been found in suppurative peritonitis,
otitis media, endocarditis, and other affections.
1 13. Bacillus aerogenes capsulatus is a gas-producing bacillus,
measuring three to six microns in length and one to one and
one-half in thickness. It is truly anaerobic, grows in all culture
media in chains of three and four, and generates gas and acid
in the process of development. It has a distinct capsule. The
germ has been found in emphysematous gangrene, in cases of
emphysematous vaginitis, and in the uterus in puerperal septic
infection. The distention of the puerperal uterus with gas, which
sometimes occurs (physometra) , is, no doubt, due to the presence
of this micro-organism.
114. Diphtheria Bacillus. — Infection of the genital canal with
Klebs-Loefller bacillus while rare, occasionally occurs, and cases
of diphtheritic infection of the vulva, vagina, and uterus are
reported. Infection generally occurs during the puerperium
and is implanted on injured tissues. The infectious process
presents the same pathologic anatomy as noted when occurring
in the throat, and responds likewise to the administration of
antitoxin. The poison, when implanted upon abraded structures
rapidly generates the characteristic false membrane, which hastily
spreads over the entire vagina and even into the uterus and tubes.
Diphtheroid infection frequently results from the presence of
the streptococcus and other pathogenic bacteria, partictdarly
the former, following labor, but the membrane formed by the
streptococcus develops in patches and is confined to abraded
surfaces (Edgar) ; therefore, if the entire genital tract is covered
by the pseudo-membrane, true diphtheria is suggested. Infec-
tion of the genital tract by the bacillus of diphtheria is usually
conveyed by the attending physician, and it follows, therefore,
that no case of labor should be attended by men who are at
PELVIC EXAMINATION. 73
the same time caring for patients suffering with diphtheritic
infection.
1 15, Pneumococcus. — The diplococcus of Frankel has been
found in suppurative conditions of the female genital tract,
particularly of the Fallopian tube. Andrews, in his cases col-
lected from literature, foimd the pneumococcus present fourteen
times, thirteen times in pure culture and once mixed with other
germs. Pnetimococcic infection of the genital canal, however,
does not bear any definite relation to pneumonia. The infec-
tion usually has been introduced from without into the lower
genital canal. The pneumococcus has been fotmd in suppiua-
tive processes of the ovary; it has been reported to have been
collected in pure culture from an ovarian abscess.
116. Diplococcus of Siegelman. — This organism occurs in
pairs and somewhat resembles the gonococcus. It is smaller
and is further differentiated from the gonococcus in that it
accepts Gram's stain. The germ was discovered by Siegelman
in several cases of pruritus vulvae in which there was no other
demonstrable cause. Siegelman attributes, therefore, the so-
called cases of idiopathic pruritus vulvae to the action of this
coccus.
ANIMAL PARASITES.
117. Pediculosis Pubis or Inguinalis. — The ordinary crab
lotise is generally foimd in the hair of the pubic region, sometimes
in the axilla, and occasionally in the eyebrows. Careful ex-
amination will reveal the parasite near the roots of the hairs,
with its head downward and buried in the follicle. The spores
will be found deposited on the hair shafts. In the pubic region
this parasite is responsible for intense pruritus, resulting in
hj'peremia and excoriation from scratching.
118. Acaxus scabieiy the itch-mite, while found on the tender
skin areas of the body, is frequently present in the skin of the
lower abdomen and vulva, inducing intense itching with ex-
coriation and abrasions of the skin from constant scratching.
119. Ozyuris Vermicularis. — The ordinary seat or pin worm
inhabits the colon and recttim. From these regions it wanders
to the vulva and vagina and may wend its way into the interior of
the uterus, Fallopian tube, and ovaries. Mano, quoted by An-
drews, reports a case of a large cyst of the ovary and two small
cysts of the tube in which were fotmd the eggs of this parasite.
Mano believes that the parasite reached the tube and ovary by
traveling from the recttim, the vagina, and uterus. The pin
worm is found at all ages, but commonly in children. The
parasite causes intense pruritus, which is always worse at night,
74 GYNECOLOGY.
due to its nocturnal migration. From the itching and scratch-
ing, excoriations and inflammation of the vulva result, and even
perirectal abscesses may form.
120. Ascaris lumbricoideSy the ordinary round worm of the
intestinal canal, is the most common animal parasite found in
himian individuals. It usually occurs in children and occupies
generally the upper portion of the small bowel. From this
region they migrate through the various channels connected
with the alimentary canal, and even penetrate the intestinal
wall. Cases are recorded where they have completely occluded
the biliary passages, and traveled through the Eustachian tube
and projected from the external ear. They have been foimd in
the vagina, uterus, tubes, and free in the pelvic cavity. J. H.
Koch found the ascaris in an abscess in the pouch of Douglas.
The portal of entr\'' was through a fistulous communication
from the rectum. Bizzozero found the ascaris in the right
Fallopian tube ; the parasite had entered the tube by traveling
through a perforation in the rectal wall.
121. Taenia Echinococcus, or Dog Tapeworm. — This para-
site inhabits the intestinal canal of the dog and wolf. The
adult worm is composed of five segments. The first segment is
slender and continuous with the head ; the second is the shortest ;
and the posterior segment, the longest, is frequently more than
half the length of the parasite. The adult worm is not foimd
in the human individual. The larvae of the parasite are taken
into the alimentary canal of the individual, or in the female
they may enter also by way of the vagina. When conveyed
by the alimentary canal the embryos are hatched and these
wander into the tissues of various organs, forming a cyst, the
hydatid cyst. In Iceland, where human beings and dogs live
together in closely confined quarters, echinococcus disease is
endemic. The liver is the organ most frequently affected,
being involved in fifty per cent, of the cases. Echinococcus
cysts may develop in any part of the body. The disease is
more frequent in women than in men, and Finsen found that
in two hundred and forty-five cases seventy per cent, occurred
in women. In the pelvis the disease is usually situated in the
cellular tissue of the posteri(^r pelvis and also in cellular tissue
anterior to the uterine body. Cases have been reported where
the cysts have developed in the uterine body proper. Hydatid
disease develops in tlie Fallopian tube, and Doleris collected
eighty cases of hydatid disease of the tube from the literature^
one of which, his own, was possibly primary in the tube. Primary
echinococcus infection of the ovary is rare, though a few cases
have been reported. The diagnosis of this condition is made
positive by finding the hooklets or scoliccs. A cystic tumor con-
PELVIC EXAMINATION. 75
taining fluid of comparatively low specific gravity (i 005-101 2)
and non-albuminous, or containing only a small trace of albumin,
and neutral in reaction should be suggestive of echinococcus dis-
ease.
122. Collection of Fluids and Secretions. — To make a positive
diagnosis of certain infectious conditions and to determine
the character of the specific infectious agent present, it is neces-
sary to collect specimens of the secretions or fluids and submit
them to careful bacteriologic analyses. Microscopic and bac-
teriologic examinations, however, of secretions and fluids from
the genital tract should not be the only bases considered in
making a diagnosis, but should be regarded as an additional
resource for establishing the diagnosis. Bacteriologic examina-
tions of the secretions can be made with carefully prepared
cover-glass spreads from the vulva, vagina, and cervical canal,
and the orifices of the various communicating glands, such as
Bartholin s and Skene's. Spreads should also be prepared
from secretions expressed from the urethra. The preparation
of the spreads should not be left to the nurse, but should be
made by the physician himself. Cover-glass specimens are pre-
pared from the vulva by transferring the secretion from the parts
with an applicator provided with a small swab of sterile cotton
or the ordinary platinum needle, the end of the needle proper
being rolled together in order to afford a larger collecting surface.
This is applied to the part containing the secretion and then
transferred to the cover-glass. Specimens may be secured
from the vagina and cervix in a similar manner, though material
from the cervix should be obtained after exposing the cervix
with a speculum, when the secretion can be collected as it escapes
directly from the cervical canal. It is important in preparing
cover-glass spreads to collect secretion from the parts most com-
monly the seat of infection, such as the orifice of the urethra,
orifice of Skene's and Bartholin's glands, and from the cervical
canal. In long-standing infections of the cervix the germs are
found to inhabit the glands; so to demonstrate their presence,
therefore, the glands should be punctured and the contents
collected on a cover-glass as they emerge at the site of ptmcture.
In infecting culture media inoculations should be made with
the suspected secretion from the different parts of the tract,
not one part alone, and several cultures should be prepared. It
is important in collecting discharges for bacteriologic exami-
nation that the patient should not receive any antiseptic douche
for at least a period of twenty-four hours before the collection
is made. This procedure destroys the microscopic value of
secretions and, therefore, renders examination practically worth-
k'ss. Cover-glass spreads can also be employed in private prac-
76 GYNECOLOGY.
tice — both in office work and in outside practice. The secretions
and fluids can also be collected in especially prepared glass pi-
pets, the material being drawn into the pipets with a syringe,
after which the ends of the tubes are hermetically sealed. With
the secretion contained the pipets should be enveloped in
cotton or other protecting material and conveyed to the patholo-
gist for examination. It is also always important in preparing
cover-glass spreads, cultures, or secretion tubes to letter or
number each in order to designate the organ from which the
collections were made. Fluids from cysts are sometimes col-
lected and examined microscopically to ascertain their true
character, but only in hydatid disease can we definitely assert
the true nature of the lesion by finding the booklets of the para-
site. Secretions of the genital tract are, as a rule, only collected
and examined to determine the presence and virility of bacteria
present, although sometimes particles of benign or malignant
neoplasms may be discharged, which are collected and studied
intelligently, but usually only very small pieces of tissue are
thus obtained, and from these positive microscopic diagnoses
can not be made. Moreover, sections of material escaping
in secretions are generally so altered by necrobiotic processes that
the recognition of their true character is necessarily rendered
extremely difficult.
123. Blood Changes. — The importance of careful scientific
blood analyses in the diagnosis of various gynecologic affections,
particularly those of an inflammatory character, is now so
generally recognized, as evidenced in the recent medical litera-
ture, that the insertion of an article on this department of medi-
cine seems necessary. The systematic and careful examination
of the blood in certain gynecologic affections will reveal definite
clinical facts that can not be positively elucidated by any other
means. Gynecologic diagnoses, however, must be made by
utilizing all clinical methods of examination, and too much value
should not be placed on any one method.
124. Examination of the Blood. — The blood is examined
microscopically to ascertain the number and character of the
corpuscles and their relative proportion, to estimate the amotmt
of hemoglobin, and to determine the presence or absence of para-
sites. The examination further involves :
(a) The estimation of the specific gravity.
(b) The estimation of the alkalinity.
(c) The determination of the rapidity of coagulation.
(d) Spectroscopic examination.
(e) Bacteriologic examination.
(/) The determination of the serum reaction.
125. The Specimen. — The blood for examination is usually
PELVIC EXAMINATION. 77
obtained from the finger-tip or the lobe of the ear, the finger-tip
being preferred in most instances because of its special con-
venience. In patients nervous and easily disturbed the lobe of
the ear should be employed, because it is not so sensitive as the
tip of the finger. The region selected, however, should always
be freely cleansed and kept separate from any area of infection
or other pathologic condition.
126. Method of Collection. — The part selected to ftmiish the
specimen should be thoroughly cleansed, first with sterile water
and then with alcohol. During the cleansing the parts should be
rubbed briskly with a towel to dry the part, and at the same time
cause a free determination of the blood to the parts selected. A
puncture is made with a specially prepared needle (Fig. 52) or,
what is undoubtedly of better service, a pen with one nib broken
off. The part to be ptmctured is supported by the thumb and
index-finger of the left hand, and slight pressure is made upon it.
The patient, if nervous, is directed to refrain from observing the
operation, and then with a quick, firm prick the skin is punctured.
Eh". Coplin objects to the continuous employment of one instru-
ment for puncturing
or pricking the skin,
and recommends the
use of a pen such as
I have described and
which is used in my Fig- 52.— Needle for Puncturing Finger.
service. A three-
cornered needle or an ordinary surgical or sewing needle may be
employed in an emergency. All the instruments used in the
examination of the specimen should have been previously ar-
ranged. Several cover-glasses and slides should be included, and
these should be carefully cleansed and dried. After the first few
drops of blood have been wiped away the summit of the next
drop as it oozes from the pimcture is touched lightly with a
cover-glass which is placed blood side downward upon the sur-
face of a clean glass slide or upon another cover-glass and
drawn apart. The first method is employed if the specimen is
to be examined in the fresh state, and the second if the speci-
men is to be fixed and stained. The study of the fresh specimen
can be prolonged by excluding air from the film. This is done
by sealing the margin of the cover-glass with a thin layer of cedar
oil or vaselin. After the cover-glass is placed upon the slide
pressure must be avoided in order to prevent distortion of the
cells.
127. Microscopic Examination of a Fresh Specimen. — The
fresh specimen thus prepared is examined with both low and high
power lenses. The one-twelfth oil immersion, however, is the
78 GYNECOLOGY.
lens ustially employed. The changes to be looked for in the
erythrocytes, according to DaCosta, are any decrease in the
number of these cells or an abnormal increase of them, corpuscular
richness in hemoglobin, recognized when the cells appear as
pale, washed-out bodies (abnormal viscosity, their tendency to-
ward rouleau formation, presence of deformities, and the occur-
rence of structural degenerative changes, and the presence or
absence of parasites). The first change in the leukocytes to be
noted is whether their number is greater than normal, but too
much stress should not be placed upon an apparent increase, as
it may be due to a reduction in the number of erythrocytes, and,
therefore, the impression would be deceptive. To one familiar
with the appearance of the various forms of leukocytes in a fresh
specimen a differential count is possible. Degenerative changes,
ameboid movement, and pigmentation of these cells may be
observ^ed in examining a fresh specimen.
The parasites found in fresh blood are those of the Plas-
modium of malarial fever, the spirillum of Obermier, and the em-
bryo of the filaria sanguinis hominis. Foreign bodies, such as
fat droplets, extracellular bodies, and, rarely, Charcot's bodies,
may also be observed.
128. Fixation for Staining. — Cover-glass films are fixed usually
by heat, placing the glasses in a hot-air oven at a temperature
of 125*^ to 140° C. for twenty to thirty minutes. Special small
ovens are constructed on the principle of hot-air sterilizers for
the fixation of films. The films can also be fixed by placing
them upon a copper plate supported over a flame and protected
from air, and also by making three or four circular turns with
the films through a flame from a Bimsen burner, as in fixing
bacteria. Placing the cover-glass films in equal parts of alcohol
and ether for half an hour secures excellent fixation.
129. Staining. — i\fter the films are properly fixed they are
grasped in cover-glass forceps and the stain is then applied with
a dropper. By using Kalteyer's cover-glass forceps the film may
be immersed in a dish containing the stain. SMes containing
fixed blood should be placed in jars containing the stain as in
staining tissue on slides. In staining fixed specimens and blood
for microscopic investigation it is better, when possible, to com-
pound preparations which will stain the largest number of ele-
ments in the prepared blood film. This method is spoken of as
panoptic staining. Tlie stain most frequently used and perhaps
endowed with special properties is the Ehrlich triacid stain.
This stain should be made from concentrated aqueous solutions
of the dyes. The stain is comjH)se(l as follows:
I. Saturated aqueous solution of orange G:
PELVIC EXAMINATION. 79
Oranee G, 6 gm.
Distifled water, loo c.c.
2. Saturated aqueous solution of acid fuchsin:
Acid fuchsin (fuchsin S), 9 gm.
Distilled water, i oo c.c.
3. Saturated aqueous solution of methyl green:
Methyl green (00 crystal), 6 gm.
Distilled water 1 00 c.c.
These solutions keep fairly well, but the mixed stain pre-
pared from them is not a lasting one and, after a period of two
or three weeks, usually does not act well, but even then an
experienced investigator will recognize the deficient dye, and can
add the required stain. Films stained by Ehrlich's method will
show the stroma of the red cells an orange hue; the nuclei of
the white cells greenish-blue; the neutrophile granules violet or
lavender, and the eosinophile granules copperish red. Nucleated
red cells of normal size, according to DaCosta, stain deep purple
or black ; those of normal size (normoblasts) and those of large
size (megaloblasts) pale or greenish-blue. The basophile gran-
ules do not take the stain and appear as a dull white coarseness
in the cell protoplasm. The methylene-blue eosin stain, introduced
by Wright, is one of the most satisfactory now in use, and the one
introduced by Jenner is also of value. Preparations ha\'ing
qtialities similar to the Wright and Jenner stains have been advo-
cated by other men. The chief advantages claimed for these
agents are that no special fixation of films is required and that
blood plates and basophilic granules and the malarial parasites
are all well stained by these preparations. The Wright stain is
employed as follows: (i) Cover thin, air-dried films with stain
for one minute. (2) Add to the stain water, drop by drop, until
an iridescent scum forms on the surface ; for seven-eighths inch
square cover-glass films four to eight drops of water usually suf-
fice. Allow the diluted stain to act for two or three minutes.
(3) Wash with water until the film becomes pink or yellow in
color. (4) Blot with filter-paper, dry in air, and mount in balsam.
Under the microscope the erythrocytes will appear orange or
pink ; nuclei of leiikocytes and erythroblasts a dark blue to lilac ;
cytoplasm of lymphocyte robin 's-egg blue; hyaline cell, pale to
dark blue ; neutrophile granules, reddish lilac ; eosinophile gran-
ules, pink; basophile granules, blue to royal purple; blood plates,
pale blue with dark lilac or blue granules. iVfter washing off
Ehrlich's stain. Dr. Hewes recommends that a saturated aqueous
solution of methylene-blue shoukl be used as a stain for several
minutes. Cabot says that any one who has used this Ehrlich
80 GYNECOLOGY.
methylene-blue stain will never employ any other for clinical
purposes. The blue counterstain also brings out clearly the out-
lines of the parasite against the yellow of the corpuscle. Many
other methods of staining blood specimens have been rec-
ommended, but the stains thus enumerated will serve practically
every clinical purpose.
lodophilia. — The behavior of leukocytes to iodin, originally
described by Ehrlich and Gabritschowsky , is a decided progressive
step in the clinical examination of the blood. This reaction of
the leukocytes to iodin is called iodophilia, while the cells taking
the iodin are spoken of as iodophiles. The reagent employed to
obtain the iodin reaction is a syrupy mixture, composed of the
following elements:
Iodin, I
Potassium iodid, .- 3
Aqua dest., 100
Gum arabic sufficient to make S)rrupy mixtiure.
This syrupy solution is placed upon an air-dried film of blood
for two or three minutes. The excess is then drawn off and the
cover-glass placed blood side downward on the slide. Under the
microscope the red cells, leukocytes, and blood plasma of a normal
specimen are found to stain a imiform pale yellow. In a positive
iodin reaction the leukocytes stain brown, either diffusely or
in a granular or network distribution. As a rule, variable sized
granules, ranging in color from brownish yellow to a deep brown,
are fotmd, which, in location, are intracellular or extracellular.
These brownish, granular bodies are found within the poljmuclear
leiikocytes. The presence of iodophilia may be generally con-
sidered indicative of a septic or suppurative process. It is not,
however, a positive sign of the presence of pus. DaCosta says
that a reaction is positive in all purulent collections, and that the
reaction persists as long as the suppurative focus exists. It is
present in puerperal sepsis and other forms of septicemia. It is
not foimd in piu^e tuberculous formations, and, therefore, the
presence of iodophilia in all other forms of abscess may be the
deciding factor in the differential diagnosis of pus acctmitda-
tions. This peculiar reaction of the leukocytes to iodin is also
a valuable diagnostic agent in other diseased conditions which
are of more interest to the general practitioner than the gyne-
cologist.
130. Counting the Corpuscles. — The instrtunents employed for
coimting the corpuscles are called hemocytometers. An instru-
ment devised by Thoma is the one in most common use, and is
regarded as the standard for blood counting. It consists of two
graduated pipets for diluting and mixing blood, and a counting
chamber in which a measured volume of diluted blood is placed
PELVIC EXAMINATION.
81
for the purpose of counting the corpuscles under the microscope.
(Fig- 53-) One of the pipets is intended for counting the
erythrocytes or red cells, and, therefore, is spoken of as the red
pipet or erythrocytometer. The other pipet, used for count-
ing the leukocytes or white cells, is called the leukocytometer.
The pipets are graduated in order to secure accuracy in dilution.
The blood is drawn into the tubes to an indicated point, and then
the diluting solution. The tube is thoroughly agitated in order
to mix the blood completely with the diluent. For ordinary
counting a one-half of one per cent, or a one per cent, solution of
sodium chlorid is used as a diluting agent for the erythrocytes,
and a one per cent, or a one-half of one per cent, aqueous solu-
tion of acetic acid is used as the diluting agent for the leukocytes.
This acid solution is used in order to dissolve out the erythrocytes
F'S- S3- — Hematocy
and at the same time render clear the leukocytes. Diluting fluids
are also used to secure different shading of the corpuscles dur-
ing the process of counting. The most satisfactory for this pur-
pose is Toisson's solution, composed as follows:
Methyl-violet 0.035 gni-
Sodium chlorid i.o
Sodium sulphate, S.o "
Glycerin 30,0 c.c.
Distilled water 160.0 "
Or the following solution of Sherrington may be employed:
Ehrlich's purified methylene -blue, o.t gm.
Sodium chlorid i.a "
Neutral potasdum oxalate i.i "
Distilled water 300.0 "
131. The Estimatioa of Hemoglobin. — The estimation of the
percentage of hemoglobin is determined by the hemoglobinometer.
Several instruments have been devised for this purpose, but the
82 GYNECOLOGY.
hemoglobinometer originated by Dr. Dare is one of the best.
(Fig- 54-) It is of simple construction, easy of manipulation, and
answers every purpose well. The instrument of von Fleischl is
also extensively used, but it is more complicated and requires
more time in manipulation than
the Dare instrument. The Tall-
qvist hemoglobin scale is simple
and good for use in emergency.
It is composed of a book (Fig. 55),
Fig. 54, — Dare's Hemoglobinometer.
~ , Milled wheel acting by a friction
bearing on the rim of the color disc.
S. Case inclosing color disc, and pro-
vided with a stage to which the
blood chamber is litted. T. Movable
wing which is swung outward during
a color scale forming the first
leaf, and the remaining leaves
being composed of absorbent
paper. This apparatus, how-
e\"er, is only approximately
accurate.
132. Composition of
Blood. — The normal circula-
ti ng blood is composed of two
portions. The first, the liquid
portion, known as the liquor
sanguinis or blood plasma,
and a solid portion, which is
composed of corpuscles or
blood-cells. The plasma is a
straw-colored fluid with a specific gravity ranging from 1026 to
1030. It is alkaline in reaction and contains approximately ten
per cent, of solid matter, of which three-fourths are proteids and
the remainder fibrinogen, scrum-albumin, and serum-globulin.
for the observer's eyes, and which
acta as a cover to inclose the color
disc when the instrument is not in
use. U. Telescoping camera tube,
in position for examination. V.
Aperture admitting light for illu-
mmation of the color disc. X. Capil-
lar^ blood chamber adjusted to stage
of instrument, the slip of opaque
glass, W, being nearest to the source
of light. Y. Detachable candle-
holder. Z. Rectangular slot through
which the hemoglobin scale indi-
cated on the rim of the color disc is
PELVIC EXAMINATION. 83
The corpuscles are of two varieties: i, Erythrocytes, or red cells;
2, leukocytes, or white cells. Besides these, two other elements
are found: namely, the blood plaques or platelets, and the
hemoconia, or **Muller's dirt.'* The salts of the blood consist of
sodium chlorid, potassium chlorid, sodium carbonate, sodium
phosphate, magnesium phosphate, and calcium phosphate. Of
these, the sodium chlorid is the most abtmdant and forms from
sixty to ninety per cent, of the total amount of mineral matter.
133. Erythrocjrtes. — The erythrocytes or red corpuscles in
man are thin, non-nucleated, biconcave discs. From seventy to
eighty per cent, of the red cells have an average diameter of
7.5 microns. Of the remaining twenty per cent, about one-half
are slightly larger and the remaining slightly smaller. Unduly
small red corpuscles are called microcytes, and when these are
abundant in the circulating blood, the condition is spoken of as
microcytosis. Unduly large red cells are known as macrocytes ;
regular shaped erythrocytes, as found in certain diseases, are
called poikilocytes, and where this is marked, the condition is
denominated poikilocytosis. The term ** blast " is applied to red
cells containing nuclei. The normal red cells containing nuclei
are called normoblasts, small cells containing nuclei microblasts,
and the extremely large cells containing nuclei macroblasts.
Poikilocytes containing nuclei are called poikiloblasts.
The hemoglobin or coloring-matter of the blood is a highly
complex albuminoid substance contained within the stroma of
the red blood-cells. It forms about nine-tenths of the total bulk
of the erythrocytes, and its special ftmction is to convey and dis-
tribute oxygen to the tissues in its passage through the capillary
circulation. The normal percentage of hemoglobin is fixed at
one hundred, but in estimating this element in individuals
apparently normal, one hundred per cent, is rarely obtained.
One hundred per cent., however, is considered normal, and this
means that every one hundred gm. of blood contains approxi-
mately fourteen gm. of hemoglobin. A reduction in the per-
centage of hemoglobin is called oligochromemia. This condition
characterizes, as a rule, all the primary and secondary anemias.
It is usually associated with a diminution in the number of red
cells. Pronounced reduction in the hemoglobin is present in
chlorosis, pernicious anemia, leukemia, and in the secondary
anemias — ^those resulting from hemorrhage, acute and chronic
infections, malignant disease, and general systemic exhausting
diseases. A slight reduction (ten to fifteen per cent.) usually
occurs a few days prior to menstruation.
134. Color Index. — The normal color index or valeur globu-
hire of the blood is the amount of hemoglobin in the individual
red cell.
84 GYNECOLOGY.
135. Relation of Hemoglobin to Surgery. — Many investigators
have asserted that it is dangerous to administer an anesthetic or
operate upon patients when the hemoglobin is below thirty per
cent., while others claim that forty per cent, should be fixed as
the minimum safety. In my experience the standard thus fixed
is too high, and I believe that with a hemoglobin percentage of
twenty per cent, anesthesia can be induced and operations per-
formed with wisdom and safety. I have operated upon several
patients successfully with a hemoglobin percentage ranging be-
tween twenty and thirty per cent. In one patient, indeed, the
percentage was but nineteen. This patient was suffering with
extensive malignant disease of the uterus. I performed a com-
plete hysterectomy and the patient made an uninterrupted re-
covery. I would not, however, insist that it is wise to operate in
all cases where the hemoglobin percentage is inordinately low.
J believe it better, when the condition of the patient will permit,
to wait and employ means to increase the hemoglobin richness
of the blood, but where this can not be done, particularly in cases
of progressive exhaustive disease, I believe operation indicated
despite the presence of a low hemoglobin percentage. One of
the principal objections, however, to operation on patients with
profotmd oligochromemia is the failure of the wotmd to tmite
readily. In one patient upon whom I operated for uterine carci-
noma and who had only twenty per cent, of hemoglobin, the tissues
failed to tmite, and with the removal of the sutures the abdominal
incision separated, exposing the intestine. Low hemoglobin per-
centage also predisposes patients to shock, infection, and in all,
convalescence is prolonged and disturbed.
The normal nucleated red cell is regarded as an immature
form of the erythrocyte, and is found normally in the bone-mar-
row, and only in the peripheral blood when special demands are
made upon the blood-making organs for cellular elements, as in
certain pathologic states, particularly the anemias of both the
primary and secondary varieties.
136. Normal Number of Red Cells. — At ordinary sea level and
in the adult normal individual the average ntunber of red cells to
the cubic millimeter of blood is five million in man and four mil-
lion five hundred thousand in woman. In the robust, healthy
person this number may be increased to five million five hundred
thousand, six million, or more. Altitude above the sea level raises
the count. Concentration of blood from various causes will also
increase the number of ery^hrocvtes. The influence of menstrua-
tion, childbirth, lactation, and digestion is to cause a temporary
decrease in their number. Prolongation of exercise reduces the
number. In the newborn the red cell count is high (seven to
eight millions).
PELVIC EXAMINATION. .85
137. Increase in the Number of Ersrthrocjrtes. — An increase in
the number of erythrocytes above what is fixed as the normal
standard is called polycythemia. A decrease in the number is
known as oligocythemia.
138. Pathologic Alterations of the Ersrthrocytes, — Ameboid
movements are said to have been observed in the red cells in cer-
tain pathologic states of the blood. Disassociation of the hemo-
globin from the stroma is also observed in certain diseased
states. In most inflammatory conditions and in the profound
anemias a hyperviscosity of these elements is observed. De-
formity of shape and size of the red corpuscle is noted in all the
severe anemias. The terms applied to the alteration in size and
shape were mentioned in discussing the physiology of these cells.
Polychromatophilia or abnormal staining reaction occurs in
several forms of anemia, and is particularly noted in pernicious
anemia and myelogenous leukemia. Nucleation of red cells is
noted in various pathologic conditions, and the various forms of
nucleated red cells (erythroblasts) have been mentioned. Gran-
ular changes of the protoplasm in the red cells occurs in certain
pathologic states, but is most constant in chronic plumbism.
This granular change is present also in pernicious anemia, leu-
kemia, carcinoma, malaria, septicemia, and chronic suppuration.
The granules in the erythrocyte are basophilic, and they may be
distributed throughout the cell or aggregated in smaU masses.
The size of the grantdes varies. The presence of basophilic
granulating erythrocytes is spoken of as basophilia.
139. Platelets. — The blood platelets or blood plaques are
small spherical bodies, somewhat smaller than the erythrocyte.
They are of a pale yellowish tint and measure one to four microns
in diameter. They are non-nucleated bodies and react to both
basic and acid stains. Their normal ntmiber to the cubic milli-
meter of blood is fixed at from one hundred and eighty to four
hundred thousand, and by some men their number is fixed at
eight hundred and sixty thousand. They are non-nucleated and
do not contain hemoglobin. Many observers claim that they
have their origin in extruded particles of the erythrocytes, while
others believe they originate from the nuclei of leukocytes. They
are the chief constituents of white thrombi. These bodies are
increased in most of the anemias. They are present in pneu-
monia, tuberctdosis, and other conditions. They are diminished
in purpura, hemophilia, and in acute infections.
140. Hemoconia. — In normal and pathologic blood, elements
have been described by Muller to which he applies the term
•*hemoconia'* or **blood dust." This material is present as small,
round, colorless granules which measure from one-fourth to one
micron in diameter. These bodies are retractile and have the
86 GYNECOLOGY.
power of moleciilar action, but no true ameboid movement.
Their presence in the blood is not of special diagnostic or prog-
nostic value, though by some men they are believed to bear some
relation to the process of immunity. Their true origin is not
known. Some claim that they are products of the erythrocyte,
while others present evidence to show that they are granular
bodies derived from neutrophile and eosinophile leukocytes.
Hemoconia is also found in pus and in hydrocele fluid.
141. Leukocjrtes. — The leukocytes or white blood-cells are
pale, nucleated bodies, the greater portion being larger in size
than the red cells, but, imlike the red cells, they are found in
several varieties. The proportion of leukocytes to erythrocytes
varies, but it ranges approximately between one of the red cells
to five or six hundred of the white cells. The size of the normal
leukocytes varies from seven to twelve microns. The general
outline while at rest is an irregular ellipse. The total number
of leukocytes in a cubic millimeter of normal blood is given at
from four to ten thousand. The mean normal average has been
set at seventy-five hundred per cubic millimeter. The ntunber of
leukocytes present in the blood varies to a considerable degree
tmder physiologic conditions. Several varieties of white cells
are found in stained specimens of fresh blood. The different
varieties and the percentage present and the ntimber per cubic
millimeter in the normal blood are given in the following table:
Variety. I^rcentage. Cubic Muximjeter.
Polynuclear neutrophiles, 60 to 75 3000 to 7500
Small lymphocytes, 20 to 30 1000 to 3000
Large lymphocytes and transitional
forms, 4 to 8 200 to 800
Eosinophiles, 0.5 to 5 25 to 500
Basophile rarely exceeds 0.5 25
As stated before, these percentages vary greatly under both
physiologic and pathologic conditions.
Decrease in the number of leukocytes is called leukopenia,
or hypoleukocytosis. Leukopenia occurs in certain of the in-
fectious diseases, such as typhoid fever, measles, influenza,
malarial fever, and also in uncomplicated tuberculosis. It is
also present in certain of the primary anemias and in some
secondary'' anemias. In conditions characterized by an increase
in the num1)er of leukocytes a reduction is sometimes noted.
This is due to the overwhelming influence of the toxin and is
said to be of grave significance. It signifies the patient's in-
ability to combat the infectious x>rocess. Leukolysis, or the de-
struction of leukocytes, most marked in the polynuclear cell,
occurs in suppurative processes. Pus-cells are polynuclear cells
altered by the action of bacterial poisons.
PELVIC EXAMINATION. 87
142. Leukocytosis. — This theory teaches that the circulating
blood contains certain bodies (chemotactic) of a chemical nature
which have an attractive and repellent influence upon the phago-
c\tes. Chemotaxis is both positive and negative — positive when
the cells are attracted by chemotactic bodies and negative
chemotaxis when the cells are repelled by these substances.
Leukocytosis may be defined as an increase in the number of the
white cells over the normal ntimber in the peripheral circulating
blood. The increase may be absolute and relative in the poly-
nuclear cell with a relative decrease of the other forms, or the
increase may be general in all varieties alike, but the increase
never involves a diminution of the polynuclear forms ; therefore
leukocytosis is of two kinds: (i) That in which the relative pro-
portion of the different varieties to each other is unchanged; (2)
that in which the increase is made up solely or largely by a gain
in the polynuclear leukocytes. Leukocytosis may be temporary
or permanent. The latter is spoken of as chronic leukocytosis.
Leukocytosis is divided into — (i) physiologic leukocytosis; (2)
pathologic leukocytosis. Physiologic leiikocytosis is classified
under the following heads: leukocytosis of the newborn; leu-
kocytosis of digestion; leukocytosis of pregnancy and parturi-
tion ; leukocytosis due to thermal and mechanical agencies ; and
leukocytosis of the moribtmd state. Physiologic leukocytoses
are generally of short duration and are characterized by only a
moderate increase in the leiikocytes. The causes of physiologic
leukocytosis are said to be an tmequal distribution of the cells
in favor of the peripheral vessels and upon the temporary con-
centration of the blood.
143. Leukocytosis of Digestion. — Leukocytosis of digestion
rarely reaches a high count, but after a meal rich in pi-oteids
the count may rise to thirty-three per cent. Ten thousand cells
may be considered the average, according to Cabot, three or four
hours after a rich meal.
144. Leukocjrtosis of Pregnancy and Parturition. — Leuko-
cytosis occurring in pregnancy is most marked in primiparae.
Thirteen thousand is considered an average count, and is
quite constant. In multiparas it occurs in only about fifty per
cent, of the cases. Leukocytosis of the parturient state may
endure for several weeks and is important for the reason that it
may be mistaken for a pathologic leukocytosis.
145. Thermal and Mechanical Agencies. —Thermal and me-
chanical leukocytosis results from blood concentration, and this
is due to vasomotor contraction with increased arterial tension.
146. Terminal leukocjrtosis, or leukocytosis of the moribund
state, occurs in many cases. It is not present if death is sudden
or rapid. It seems to be analogous to the preagonal rise of
88 GYNECOLOGY.
temperature. The increase in ordinary cases occurs in the
polynuclear cell.
147. Pathologic Leukocytoses. — Pathologic leiikocytoses are
classified as posthemorrhagic, inflammatory, malignant, toxic,
and experimental. The exact cause of pathologic leukocytoses
has not been determined, but the general belief at the present
time is that the increase is due to chemotactic influence.
148. Posthemorrhagic Leukocjrtosis. — Leukocytosis results
from loss of blood, is rapid in its development, and of short dura-
tion. The count may reach sixteen to eighteen thousand. The
increase, as a rule, is in the polynuclear cell.
149. Leukocytosis (Phagocytosis). — The fimction of leiiko-
cytosis i^ to protect the individual against infectious micro-
organisms and their toxins. It is one of nature's methods of
antagonizing and rendering inert micro-organisms and their
poisons. Cells having this power are called phagocytes, and
they exert their force in two ways: (i) By mechanically destroy-
ing the infectious generators of bodies (bacteria); and (2) by
the generation of chemical products (alexins) which are an-
tagonistic to the bacterial poison and destructive to bacteria
also.
150. Inflammatory Leukocjrtosis. — This variety of patho-
logic leukocytosis, as its name implies, is associated with suppura-
tive, septic, or inflammatory processes. It should not be, ac-
cording to Cabot, described as infectious leukocytosis, for the
reason that in many of the infectious diseases the leukocytes
are not increased. Furthermore, in certain infectious diseases
there is an actual diminution (leukopenia) in the niunber of
white cells. The extent or degree of leukocytosis depends:
(i) Upon the reaction of the patient; and (2) upon the virulence
of the invading micro-organisms. Therefore, a high leukocy-
tosis usually indicates good reaction and strong resistance upon
the part of the patient and is considered a favorable prognostic
sign. Persistent hypoleukocytosis in the presence of infection,
however, indicates lessened tissue reaction and virulent infec-
tion. The leukocytic count in inflammatory conditions varies
greatly. It is not imusual to find a leukocytosis of forty-five
thousand, forty-eight thousand, or fifty thousand, and even
greater. The individual cell most prominent in inflammatory
leukocytosis is the polynuclear leukocyte, and this type forms
from ninety to ninety-five per cent. In other cases the in-
crease is found in the lymphocyte. Leukocytosis in inflamma-
tory diseases of the female genital tract is quite constant and of
value as a diagnostic aid in pelvic conditions. A leukocytosis
ranging from twelve thousand to eighteen thousand as a rule
indicates suppurative disease in the adnexa, if other causes can
PELVIC EXAMINATION. 89
be excluded. Pankau believes that a leukocyte coimt of ten
thousand indicates suppuration in the appendages. DaCosta
found in thirty-four cases of pelvic abscess, ovarian abscess,
and pyosalpinx, an average leukocyte coimt of fifteen thousand
five himdred and forty-eight per cubic millimeter. Of course,
the increase in the number of leukocytes will depend upon
the degree and limitation of the suppurative process. If an
abundance of the toXic material is absorbed from the pelvic
lesion and the resistance of the patient is good, the increase will
be marked, while if the lesion is enveloped by a non-absorbing
inflammatory wall, the count will be low.
151. Malignant Leukocjrtosis. — According to Julliard, in
malignant disorders leukocytosis is not present early, but is
associated with ulceration, necrosis, and absorption of specific
toxic matter. When generahzation of malignant neoplasms
occurs, the leiikocyte count rises, providing the patient still re-
tains powers of reaction. The effect of malignant disease on
the letikocytes will depend upon: (i) The position of the ttrnior;
(2) its size ; (3) rapidity of growth ; (4) the occurrence of metastases ;
(5) the resisting power of the individual; and (6) the degree of
necrotic change. In cancer of the uterus the leukocytes are,
as a rule, slightly increased. In seven cases reported by Cabot
a leukocytosis was observed in five which ranged from sixteen
thousand eight htmdred to thirty-four thousand. In the two
remaining cases no decided alteration was noted in the number
and appearance of the leukocytes. It may be said, however,
that malignant leiikocytosis is generally moderate, and, accord-
ing to DaCosta, coimts of less than twenty thousand are the
general rule. Malignant leukocytosis is generally most pro-
noimced in sarcoma.
152. Toxic Leukocytosis. — Increase in the leukocytes due
to uric-acid diathesis, quinin poisoning, illtmiinating gas poison-
ing, intestinal intoxication, nephritis, chloroform narcosis, and
the ingestion of certain chemicals is spoken of as toxic leuko-
cytosis.
153. Experimental Leukocytosis. — This is an increase in
the number of leukocytes due to the administration of certain
drugs. Artificially induced leukocytosis or leukotaxis has been
resorted to in order to increase the local and general resistance
of individuals against infection. Petit endeavored to increase
infection resistance of the peritoneum by the injection of heated
horse serum, and for the same purpose Miktdicz employed on
patients preparatory to operation injections of nucleinic acid
hypodermically. I have used the latter for this purpose, but
am unable from my experience to assert any beneficial influence.
The increase produced by artificially induced leukocytosis occurs
90 GYNECOLOGY.
in the poly nuclear cells, which is asserted to be from nine to
four himdred and twenty-five per cent.
154. Bacteremia. — Bacteremia is defined as the presence of
micro-organisms in the circulating blood. Normally the blood
is regarded as bacteria-free, yet recent investigations show that
even under normal conditions bacteria exist in the blood. The
condition has been denominated ''latent microbism." This
mild bacteremia is wholly consistent with health, because the
bacteria present are small in number and not virulent, and,
therefore, can not do harm unless the individual is weakened
in resistance and the bacteria become virulent.
155. Bacteria found in Blood. — A large number of bacteria
have been isolated from the circulating blood. Among the most
important are:
I. The pyogenic bacteria. .
(a) Staphylococcus pyogenes.
(b) Streptococcus pyogenes.
(c) Gonococcus.
(d) Pneumococcus.
(e) Diplococcus intracellularis meningitidis.
Other bacteria f oimd in the blood are :
Bacillus anthracis.
Bacillus coli communis.
Bacillus influenzae.
Bacillus leprae.
Bacillus mallei.
Bacillus pestis.
Bacillus tetani.
Bacillus tuberculosis.
Bacillus typhosus.
Besides these vegetable parasites, certain animal parasites
are found in the blood, the most important of which are the ma-
larial Plasmodia, the embrj^o of the filaria, and spirilla of Ober-
meyer.
156. Blood Culture. — The blood secured for bacteriologic
examination should be aspirated by pvmcturing a superficial
vein which has been exposed by an incision, and not by ptmc-
turing the vein through the skin. Examination of prepared
cover-glass films is unsatisfactor\^ In obtaining the blood
the veins in front of the elbow- joint (median basilic or median
cephalic) may be selected. The tissues of the part should be
thoroughly sterilized in order to rid them of the common dermal
bacteria. ^Vccording to DaCosta, fluid culttu'e media are pref-
erable to the solid. One-half cubic centimeter of blood should
be drawn for each culture, and about one htmdred parts of media
to each part of blood should be used. A special needle can be
PELVIC EXAMINATION. 91
secured for withdrawing the blood {Fig. 56), but in an emer-
gency a sterile antitoxin or hypodermic syringe may be em-
ployed .
157. Blood CoagulatioD.— The coagulation of the blood
under normal conditions is stated to occur, as a rule, in about
five minutes, but, according to the personal obser\'ations of
Cophn, a considerably longer time is required. Several methods
are recommended to determine time of coagulation, but none
are entirely satisfactory. A convenient method is that utilized
by Milieu, which consists in placing a large drop of biood on a
thoroughly clean slide, which after a few minutes is tilted toward
a \-ertic;d plane to determine whether the shape of the drop is
changed thereby. The hemogilometer of Biffi or the coagu-
lometer of Wright may also be used to determine the time of
coagulation. A proper knowledge of the coagulability of the
blood is important to the sui^eon in certain conditions requiring
surgical intervention, and
this will govern him in ^SS^r'^T^'". ""■. '3?i^
adopting and carr^'ing out tt"' ''■'■ — —■ —— - ""^^
the proper course. The ■■' ^^
coagulability of the blood is
decreased in cases of ob-
struction of the biliary pas-
sages, as in cholelithiasis
with or without icterus, in
acute exanthemata, in pur-
pura, hemophilia, and other
forms of blood dyscrasia. I
recall two deaths resulting
from uncontrollable oozing
after operations upon patients suffering from jaundice produced by
cholelithiasis. Therefore, before operating upon patients suffering
from lesions associated with decreased coagulability of the blood,
proper treatment should first be instituted to restore the blood
to as near a normal condition as possible, and thus increase the
Kifety of operative interference.
158. Exploration of the Urethra, Bladder, and Ureters. — The
bladder can be explored by the introduction of the finger through
the urethra, but the dilatation required is so great that, notwith-
standing every precaution which can be exercised, the procedure
must necessarily often be followed by loss of sphincter control.
A careful urethral and \'esical examination may be made de-
sirable by frequent and painful micturition, by admixture with
the urine of blood, pus, desquamated epithehum, fragments of
tissue, and the presence of bacteria. Limitation of the inflam-
mation to the urethra is indicated by a pain and burning during
92 GYNECOLOGY.
the act of urination, followed by comparative comfort (unless
complicated by cystitis) unaccompanied by frequency of micturi-
tion. Inspection will reveal the orifice of the inflamed urethra
as red, pouting, and angry. Frequently by pressure along the
course of the canal from above downward a drop or two of dirty
or purulent fluid will be expressed. When the inflammation
involves the w^all of the urethra, it can readily be distinguished
upon palpation of the anterior vaginal wall as a distinct cord-
like projection. Skene's urethral endoscope is of value in de-
termining the condition of the urethral mucous membrane. (Fig.
57.) It discloses points of inflammatory redness, desquamated
epithelium, thickened membrane, and fissures of the internal
urethral orifice. The instrument should not be unduly large,
as the distention of the urethra obscures pathologic alterations.
Irritation and inflammation of the bladder is indicated by fre-
quent and painful micturition and violent tenesmus tuireheved
by urination. The attacks may recur and appear to be induced
by exposure to colds, as drafts, changes of temperature, damp-
ness, indiscretions in diet and drinking, and by excessive venery,
or the discomfort may be more or less continuous. The distress-
ing symptoms may have arisen from infection which has reached
the bladder from the urethra, the kidney through the vesical walls,
or from the presence of foreign bodies, as calculi, fragments of
catheter, or extraneous bodies which have been inserted into the
urethra in the process of onanism. The existence of the various
neoplasms may be manifested by similar symptoms. Inflam-
mation of one or both ureters is prone to be associated with pain,
which may be referred to the bladder. Incontinence of urine
association with a forcible dejection of the fluid in small quantities
is especially characteristic of inflammation of the ureter. Ex-
amination of the urine is of particular value in the determination
of the lesions of the various portions of the urinary tract. In
urethritis and functional irritation of the bladder, the urine will
be clear and free from deposits. In cystitis, ureteritis, and pyel-
itis the urine may be loaded with sediment, which under the
microscope will be found to consist of blood and pus corpuscles,
renal and vesical epithelium, portions of tissue, crystals of the
various salts, and in some cases casts of the uriniferous tubules.
The determination of the portion affected by the character of
the desquamated epithelium is impracticable. The examination
of the urine secured after careful irrigation of the bladder; or,
better still, after the catheterization of the ureters, not only
differentiates renal from vesical conditions, but affords informa-
tion as to the state of the individual kidney. If after irrigation
of the bladder the urine secured is clear and comparatively free
from sediment, it is a fair inference tliat the disorder is confined
PELVIC EXAMINATION. 93
to the bladder; and, on the contrary, the continuation of pus,
blood, and desquamated epithelium in the urine is an intimation
that the upper urinary structures are the seat of disease or are
actively involved by it. Inflammation of the bladder causes the
secretion of a large quantity of mucus, and the urine contains
but little albumin, while in inflammation of the pelvis of the
kidney the proportion of albvimin is comparatively large. Pyel-
itis is distinguished from nephritis by the absence of tubular
casts. Bloody or high colored urine is not uncommon in acute
inflammation of the kidney or bladder. Hemorrhage from the
urinary tract may occur from a variety of causes and from any
portion of the tract. From the urethra it may occur indepen-
dently of urination as a few drops or clots in the first discharge
of urine, or after the completion of micturition. Vesical hemor-
rhage may cause the urine to be bright red or appear as almost
pure blood, according to the severity of the hemorrhage. When
very profuse, the bladder may become filled with clot, so that the
patient is unable to void urine, and the presence of the clot
interferes with catheterization. Free bleeding from the kid-
ney may be seen with the cystoscope (see Fig. 58), and makes
its exit from one of the ureters as pure blood or distinct casts
of the ureter may be found in the urine, and the patient gives
a history of having had severe pain over the kidney and along
the ureter corresponding to the side from which the hemorrhage
has occurred. Pain is a characteristic symptom. It is felt above
the symphysis in cystitis, along the affected ureter in ureteritis,
or over the affected kidney in pyelitis, or where the kidney con-
tains a' calculus. The hypogastric region is tender to pressure,
in cystitis the tenderness being more noticeable upon sudden
withdrawal of the hand after deep pressure when tubercular
cystitis exists. The bladder may be palpated by one or two fin-
gers in the vagina and the hand over the abdomen. The inflamed
bladder will be thickened, contracted, and very tender. Calculi
and neoplasms may thus be recognized. The inflamed and
thickened ureter is easily recognized upon one side or upon both
sides when bilateral. The shortened ureters stand out as firm,
dense cords. Not infrequently in such cases the pressure along
the tireter may cause a sudden discharge of urine, which may
reach the person of the investigator. The inflamed kidney is
readily palpated when the patient assumes the dorsal position
with the limbs flexed. The physician stands upon the affected
side, places one hand upon the back beneath the ribs, and pushes
gently forward, while at the same time the patient is asked to
take a long breath and allow it to be expelled quickly. Pressing
the thumb of the hand beneath the ribs in front during expiration
the enlarged kidney may be felt to have slipped upward, or, where
94
GYNECOLOGY.
it is quite movable, may be held below the fingers. In thin
patients the kidney may thus be easily distinguished. Care must
be exercised, however, that a prolapsed or malformed liver is
not mistaken for the kidney. During the first week in July,
1906, 1 saw a woman who, I was convinced after an examination
under an anesthetic, had a very movable kidney, but examina-
tion through an atxiominal in-
cision, which was made for short-
ening the round ligaments, re-
vealed the fact that the supposed
movable kidney was a tongue-
like projection from the anterior
margin of the liver which, through
the abdominal wall, greatly re-
sembled in size and shape the
kidney. Pawlik and Kelly de-
vised specula through which the
bladder could be inspected and
medications applied to the most
affected portion. The orifices of
the ureters could be inspected
and the ureteral catheter em-
ployed. They require the urethra
to be dilated, sometimes close to
or beyond the limit of safety, in
order to afford opporttmity to
inspect and properly treat the
affected structures. Of late
Fig. 57. — Skene's Urethroscope.
Fig. 58. — Cystoscopes.
years the procedure of Nitze, in which the illuminating lamp is
introduced within the bladder, and to add to its effectiveness the
image is magnified, renders the investigation more satisfactory.
The bladder is distended with water or air, preferably the former,
when the entire cavity can be carefully inspected. The elec-
tric illumination can be obtained through a transmitter from
PELVIC EXAMINATION.
95
the street current or the dry cell battery may be employed. An
instrument not larger than a No. 30 bougie, French scale, is
sufficient for every ptirpose in the inspection of the bladder and
catheterization of the tireter. Such an instrument may be em-
ployed without an anesthetic ; the bladder may be irrigated and
Fig. 59. — Kelly's Specula (Urethra).
Fig. 60. — Mouse-tooth Forceps for Cotton Pledgets.
Fig. 61. — Kelly's Evacuator.
Figs. 62 and 63. — Ureteral Catheters — Metal and Soft.
filled through the tube, after which its escape is perfected by
the introduction of a magnifying lens. The cystoscopic inspec-
tion is of value, as it discloses the condition of the vesical mucous
membrane, permits the differentiation of desquamation and
catarrh from gonorrheal and tubercular cystitis, and has demon-
96 GYNECOLOGY.
strated the dependence of obstinate cystitis upon torpid ulcera-
tion of the vesical mucous membrane. It permits the inspection
of the inflamed, pouting orifices of the ureters and allows the
determination of the affected kidney by the observation of blood
or pus coming from the orifices of the corresponding ureter. It
has permitted the recognition and dislodgment of calculi situ-
ated in the lower end of the ureter. The condition of the
ureter and kidney is also determined by passing through the
posterior slit of the cystoscope a long, soft, ureteral catheter.
Fig. 64. — Harris' Double Catheter for Obtaining Urine from Kidneys Separately.
This procedure permits the exploration of the ureter and the
accumulation of the urine for examination, affording an oppor-
tunity to determine whether one or both kidneys are involved.
By a wax-tipped bougie, as suggested by Kelly, the presence of
a calculus can be recognized in the ureter or in the pelvis of the
kidney. The segregator, as devised by Harris, of Chicago, will
permit the accumulation of the urine from the kidneys in separate
receptacles, but it is inferior to the use of the tu-eteral catheter
through the cystoscope.
ABDOMINAL EXAMINATION.
iSQ. Preliminaries, — An examination from the diaphragm
to the pelvis should be made of every woman who presents
symptoms which indicate that she is suffering from pelvic disease.
Such an investigation will reveal ptoses of the abdominal viscera,
tumors, hernia, disease of the gall-bladder or appendix, and
other conditions which otherwise would be overlooked. The
ABDOMINAL EXAMINATION. 97
patient must have her clothing so adjusted that the entire sur-
face of the abdomen can be exposed. She should lie in the
dorsal position, upon an examining chair, bed, or table, with
her limbs slightly flexed. A sheet is thrown over her lower
extremities and drawn over the symphysis, when the clothing
is raised and her abdomen exposed.
i6o. Inspection. — An investigation of the external surface of
the abdomen is of great value. The Hnea nigra, linea striata, and
increase of pigment about the umbilicus and lower abdomen are
signs indicative of a previous or present pregnancy. These dis-
Fig. 65. — Abdomen Prepared for Examinati
colorations having once occurred are never effaced, and are conse-
quently of significance only during a first pregnancy. The linea
striata are red or purple, when recent ; white and glistening, when
old. They are caused by overstretcliing of the skin, hence may
result from any abdominal enlargement. Discolorations from
blisters and counterirritants or scars from leech bites and wet-cups
are indications of previous inflammation. The superficial abdom-
inal veins are enlarged by any pressure upon the deeper vessels,
and the enlargement occurs in pregnancy, in fibroid, ovarian, and
Other large tumors. The subcutaneous tissues become edema-
tous in general dropsy and from acute abdominal inflammation.
98 GYNECOLOGY.
The abdominal enlargement is symmetric, irregular, or nodu-
lar ; the abdomen is flattened and broadened in ascites, narrowed
and projecting in pregnancy, myomata, and ovarian cysts. The
tumor is spheric, most prominent above to the right in pregnancy,
rises abruptly, attaining the greatest prominence near the um-
bilicus in ovarian cystomata, and is less likely to be symmetric
in myomata. The surface of the skin is smooth and glistening
from internal enlargement, and hangs in folds over the symphysis
in obesity. A very dependent mass may be due to the protrusion
of a large tumor between the separated recti muscles, or to a des-
moid tumor of the abdominal walls. A large projection from the
median line may be caused by a ventral hernia. Frequently the
movements and outlines of the intestinal coils may be recognized.
Fetal movements, contraction of muscles, and peristaltic action
of the intestines can often be seen. Enlargements in the upper
abdomen are due to growths in the liver, distention of the gall-
bladder, enlargement of the kidney, or malignant disease of the
ascending or transverse colon. In the median line the liver,
stomach, pancreas, or transverse colon may be the seat of origin.
Above, upon the left side, it may be the spleen, the left lobe of
the liver, the cardiac end of the stomach, or the left kidney; and
below, the descending colon. Ptosis of the stomach and liver
can frequently be recognized. In the lower abdomen the genital
organs are the seat of the majority of abnormal growths. A tu-
mor in the right inguinal region should always awaken a suspicion
of appendiceal inflammation or malignant disease of the colon.
i6i. Palpation. — ^Palpation maybe practised during the exer-
cise of the preceding step. It consists in placing the hands, pre-
viously warmed, upon the bare abdomen, and gently moving
them from side to side, now close together, or again bringing the
entire abdomen between their grasp. The tips of the fingers or
the entire hand may be applied. Palpation enables us to recog-
nize the presence of an abnormal growth: its situation, mobility,
density, and relation to the abdominal viscera. Its dimensions,
smoothness or irregularity, are recognized by carefully outlining
the tumor. The relations and mobility of the growth are deter-
mined by changing the position of the patient.
The patient generally should be placed upon her back, with
the limbs flexed and the head and shoulders slightly elevated.
The confidence and cooperation of the patient must be obtained
in order to secure relaxation of the muscles. It is necessary to
proceed with the utmost consideration and gentleness, as rough,
hasty, and inconsiderate palpation causes muscular rigidity and
defeats the object. Pelvic abnormalities may require vaginal
touch in conjunction with palpation, which has already been
discussed under the bimanual examination. (Section 69.)
ABDOMINAL EXAMINATION. 99
162. Difficulties. — Information may be difficult to secure
by palpation because of a large deposit of fat in the abdominal
walls or rigidity of the muscles from fear or actual tenderness.
The patient can in general be so reassured as to permit the in-
vestigation to be satisfactorily accomplished. In inflammatory
collections it is often necessary to exercise care in the procedure
to avoid rupture of the mass and the escape of its contents into
the peritoneal cavity.
163. Percussion, though described separately, may be prac-
tised in conjunction with the two preceding steps. It consists in
eliciting resonance or dulness by mediate or immediate percus-
sion. Fluctuation is recognized by placing a hand upon one side
and striking upon the abdomen, more or less remotely, with the
finger-tips of the other. A long wave indicates that the fluid is
free or contained in a large sac. A short or indistinct wave is
produced by fluid contained in a sac with nvimerous partitions or
septa. The chief value of percussion is in determining solid or
fluid ttunors from distentions of the abdomen by gas or ascites.
The ability to elicit resonance and dulness is utilized in the
diagnosis between free fluid within the abdomen and that con-
tained within a cyst. In the former a zone of resonance is
elicited over the stmimit of the distention, while the remainder
of the surface will be dull. The zone of resonance changes with
the position of the patient, while in a cyst there is dulness over
its surface and resonance above, and generally upon one side.
In the latter the relative outline of the zones of resonance and
dulness do not vary with change of position. The solid or cystic
tumor, as it increases in size, pushes the viscera upward and to
the opposite side; hence the situation of the zone of resonance.
Resonance at the stunmit of the swelling in ascites is due to gas
in the intestines, floating them to the surface. Should the
mesentery be too short, from inflammation or great abdominal
distention, to reach the surface, percussion gives dulness; while
deeper pressure displaces the intervening layer of fluid, and again
affords resonance. In localized peritoneal accumulations percus-
sion aids only in defining their botmdaries, and presents the sen-
sation of fluctuation.
164. Auscultation is practised directly by placing the ear over
the abdomen, with a towel or sheet intervening; and, indirectly,
through the medium of a stethoscope. The former enables the
physician rapidly to find the sound, the latter to study it
minutely. Auscultation is of limited application. It enables us
to hear the fetal heart-sotinds, the bruit produced by the rush of
blood through the uterine sinuses, and various sounds induced by
gas and liquids in the intestines. The fetal heart-sounds are
characteristic of pregnancy ; the bruit is heard in pregnancy and
100 GYNECOLOGY.
fibroid tumors alike. Efforts have been made to diagnose the
seat of intestinal obstruction by the gurgling noise in the intes-
tines, but our knowledge of the normal sounds is not sufficiently
definite to enable us to make it of much value.
165. Exploratory Puncture. — Exploratory operations for the
purpose of diagnosis may be one of two classes: puncture and
incision. Puncture is divided into two procedures: tapping and
aspiration. The former is applicable to the diagnosis and treat-
ment of ascites ; the latter, where it is desirable to lessen the size
or to determine the contents of a cyst.
166. Tapping, or paracentesis abdominis, was at one time the
only method of treating abdominal collections of fluid, whether
free or confined within a cyst. The instruments used should
consist of a trocar and cannula, about J of an inch in diameter, to
which a rubber tube may be attached. If Wells' blunt cannula
is used, a bistoury must be employed to make the incision. The
patient is placed upon her side near the edge of the bed ; a point
is selected in the median line, about midway between umbilicus
and symphysis, which percussion has demonstrated to be free
from intestine ; and the surface is frozen by the application of ice
Fig. 66. — Nest of Trocars.
and salt or a spray of ethyl chlorid. An incision is made through
the skin, and the trocar is plunged, by a quick, rotating thrust,
into the peritoneal cavity. The finger is held upon the instru-
ment to govern the distance it is to be introduced. The trocar is
withdrawn and a rubber tube is applied to the cannula to convey
the fluid into a receptacle. The complete evacuation of the fluid
is secured by pressing upon the abdomen toward the cannula.
Arrest of the flow by the intestines floating against the end of
the cannula can be obviated by changing its position. As the
contents are evacuated the entrance of air into the abdomen may
be prevented by keeping the end of the rubber tube submerged.
The cannula is withdrawn and a piece of aseptic gauze is placed
over the opening and held by a small strip of plaster. The
withdrawal of a large quantity of liquid is frequently followed by
symptoms of syncope. The patient should be kept in the
horizontal positicm, and, if necessary, given whisky or brandy
(fSj), spt. amnion, aromat. foj, well diluted, per oram, strychnin
sulphate (gr. ^^ to 3V) » ^tropin sulphate (gr. j^^^), hypodermically,
hypodermic injections of an ascfHic ergot, or inhalations of a few
drops of amyl nitrite.
ABDOMINAL EXAMINATION.
101
167. Aspiration should be the procedure chosen when it is
desired to evacuate the contents of a cyst. The use of the trocar
favors the entrance of air and of pathogenic germs, and its open-
ing permits the escape of the cyst-contents into the peritoneal
cavity, which not infrequently promotes the development of peri-
tonitis. The contents of a cyst should consequently be entirely
removed if the wall has been perforated. The use of the hy-
podermic syringe for the withdrawal of a small quantity of fluid
for examination is reprehensible. The patient encounters a
greater risk from the escape of a portion of the contents of a
tense cyst through even a small opening than can be compen-
sated by any advantage derived from an examination of the
fluid. For aspiration two instruments may be used, one of which
will hold a few ounces, in which the needle is connected with
the reservoir; the other, used in large accumulations, consists
of a large air-pump connected by
tubing with a needle, a quart bottle
inter\-ening. {Fig. 67.) Rapid suc-
tion exhausts the air in the bottle
and causes the fluid to run until the
cyst is emptied or the bottle filled.
Strong suction when the cyst is
nearly empty draws its sides into the
needle and stops the flow. The with-
drawal of the contents of the cyst is
an advisable procedure when the
pressure of the tumor is so great as to
obstruct the circulation and lead to
dyspnea, decreased renal secretion,
and more or less anasarca. The
operation in such cases, by facilitat-
ing restoration of secretion, promotes a favorable result in subse-
quent removal of the cyst. The procedure may be necessary, also,
to prolong the life of the patient until a skilled operator can be
secured. Broad-ligament cysts are occasionally cured by aspiration.
It affords an opportunity to clear up the diagnosis in otherwise
obscure cases. Two conditions particularly can be determined
by microscopic examination of the fluids. Hydatid disease is
recognized by finding even a single booklet. Mahgnant disease
is determined by finding the presence of blood-corpuscles or
particles of malignant tissue. The blood is mixed with the fiuid.
To examine it, the fluid should be drawn into a clean vessel,
covered, and permitted to stand for twelve hours, when the
blood-corpuscles will be found at the bottom or adherent to the
sides of the vessel. Tapping and aspiration should always be
done through the abdominal walls, never through the vagina or
Fig, 67. — Aspirator.
102 GYNECOLOGY.
rectum, on account of the more difficult antisepsis and consequent
greater danger of infection.
1 68. Exploratory incision in cases of difficult or doubtful
diagnosis is a most effective method for making known the con-
dition, but should be very infrequently practised. The more
carefully the sense of touch is cultivated, the less frequently will
an incision be required. The position of a patient who has
nerved herself to undergo an abdominal operation, only to ascer-
tain that her trial and suffering have been without avail, is most
distressing, and is not calculated to lead the surgeon frequently
to repeat it in cases of extremely doubtful character.
THERAPEUTICS.
169. Classification. — Gynecologic therapeutics may be divided
into general and local, medical and surgical, and the time will
not be misemployed if we consider the subject from the stand-
point of preventive and curative.
170. Extension. — A cursory consideration renders it evident
that the capable gynecologist must be versed in general medicine,
and must be able to distinguish affections of the genital organs
from disturbances of other organs and to recognize the indica-
tions and contraindications for special methods of procedure.
171. Infection. — We need but to review the consideration of
micro-organisms presented under diagnosis to appreciate the im-
portance of combating infection in its various manifestations.
Not infrequently deaths following operations are attributed to
heart failure, shock, pyelonephrosis, and pneumonia, when they
are without question due to infection. Infection is more likely
to reach a wound from unclean hands or instruments than
through the atmosphere.
172. Terms. — The study of such conditions has originated
the terms sepsis, antisepsis, and asepsis. Sepsis, of course, in-
dicates the existence or sequela of infection; antisepsis, the use
of agents which are either destructive to bacteria or hinder their
baneful influence. Asepsis comprises the exercise of such means
as shall exclude from the field of operation all pathogenic germs
and their products. The latter is the ideal procedure, but when
we have to deal with agents so intangible that it requires a micro-
scope to discover their presence, and when it is absolutely im-
possible to preserve aseptic or sterile everything that may come
in contact with the affected tissues, a combination of the two
methods seems the wiser plan of procedure.
Sterilization means the entire destruction or removal of
germs. Complete sterilization of everything is an ideal asepsis.
THERAPEUTICS. 103
173. Sterilization Methods. — The most effective agent for
sterilization is the flame, but this can rarely be used because of
its destructive influence upon the temper of instruments. It is
employed to destroy worthless and dangerous objects, such as
soiled dressings.
Heat may be employed in the dry and moist forms. The
vegetative bacteria are destroyed by comparatively low tem-
peratures, from 106° F. to 150° F. The spore-bearing bacilli
require a higher temperature and stronger chemical solutions.
Sterilization by dry heat is infrequently employed, for the
reason that a temperature of 284° F. for three hours is required to
insure the destruction of
the spore-producing micro-
organisms (Robb). It is
rendered unavailable, not
only by the time required,
but it is injurious to in-
struments and destruc-
tive to ligatures and dress-
ings.
An effective and easy
method of sterilization is
by the use of steam, which
requires an apparatus from
which the air can be ex-
pelled and the temperature
maintained evenly at 212°
F. A convenient and cheap
apparatus for this purpose
is an Arnold copper steril-
izer. (Fig. 68). The most
effective sterilization is
accomplished in a steril-
izer which employs super-
heated steam under pressure.
to 230° F. at a pressure of 15'
Fig. 68.— Aniold Stfam Sleriliier.
Steam at a temperature of 220°
insures the sterilization of large
packages, but to prevent reinfection the sterilized packages
should be thoroughly dry before removal from the sterilizer.
The sterilizing apparatus is usually so constructed that steam
can be turned out of the central chamber into the surrounding
jacket and thus insiu"e the drying of the contents of the chamber.
Ligatures and sutures may also be sterilized in the same way,
but much more effectively by boiling. Silk will not stand long
or repeated boiling without becoming friable. The towels,
sheets, and operating gowns should be subjected to what is
called the fractional method. This consists in placing the
104
GYNECOLOGY.
material in the sterilizer for one hour the first, and one-half
hour each succeeding, day for two days. They should be care-
fully protected until used. When dry and properly protected,
they ivill remain aseptic for an indefinite time.
174. Sterilization of Instruments. — The instruments for ex-
amination and operation should be capable
of being thoroughly cleaned, and after every
operation should be cleansed in hot water
and boiled before the next operation. They
should be placed in trays dry, or upon a
sterile table. It was formerly the custom to
place instruments in a five per cent, solu-
tion of carbolic acid. If the instruments
are properly cleansed, the use of this agent
is unnecessary, and in many operative pro-
cedures, particularly those upon the peri-
toneal cavity, it is objectionable, in that it
causes irritation of the delicate structure of
the peritoneum. The instruments should
be sterilized before beginning an operation.
Davidson says five minutes' boiling in water
destroys all germs, but if the instruments
have been used in pus or about gangrenous
cases it is important that we should exercise still further precau-
tions to render them absolutely sterile. They may be boiled for
half an hour in a five per cent, solution of carbolic acid. The
water should be boiling before the instruments are placed within
it' or they will rust. Rust-
ing can be prevented by
using a one per cent, solu-
tion of carbonate of soda.
This method of jjrocedure
affords a ready means of
sterilizing an instrument
which has been dropped
during an operation. It
has the advantage that any
vessel can be used. The in-
strument trays— preferably
of glass or porcelain, as be-
ing most readily disinfected
— should be sterilized by
heat, or, after careful washing with soap and hot water, should
be filled to the brim with i : 500 solutiim of bichlorid. Trays
should be emptied and washed out with plain sterilized water
before the instruments are placed in them.
for Boiling Instruments.
THERAPEUTICS. 105
175. Sponges. — Sponges require more care and attention
than any other part of the operation, I formerly used gauze
pads made by taking a yard of gauze and folding it six or eight
times, so that it made a pad from six to eight inches square. All
selvage edges were turned in and whipped over by continuous
suture. These pads were boiled for half an hour, dried, and kept
in sterile vessels ready for use. They were again boiled im-
mediately before the operation. They were inexpensive, and,
therefore, could be thrown away after each operation. The
majority of operators now use dry gauze for sponges: pieces of
gauze a yard in length are so folded that the raw edges are not
exposed. They are done up in packages or placed in a metal
receptacle so arranged that steam will pass through them, and
are subjected to sterilization by the fractional method. They
should be kept protected from dampness or any possible source
of infection until used. The person who dispenses them at the
operation should only handle them with a sterilized metal in-
strument. The greatest care must _„__
be exercised to make certain that p, -.-..— - ,-- —— --
all pieces of gauze are accounted ■ . Jj ^.^.J^-^-^-v^ — j-51 J
for before closing the abdominal k ^- IR |
ca\'ity. It is advisable to assign M """' "1 jBj i
two persons to the sponges. One jli 1 iF |
gives them out, and as she does so fl m |l ^
counts them. The second person M ■■ .■L-.—JP'
accumulates and counts the sponges --^Sui 1 AAaiHBaHtlii^
after removal from the wound. Fig. 71.— Gauze Pads.
The tally of sponges issued and re-
ceived should agree before the wound is closed or the operator
should satisfy himself by very careful examination that none
are retained. An aseptic sponge may be retained without
delaying the healing of the wound and become encysted, but
later may form an abscess and open externally into the vagina,
bladder, or rectum. Occasionally a large vessel may be eroded
and a fatal internal hemorrhage occur. When the operator is to
depend upon uncertain assistants, it is better to return to smaller
pieces of gauze, which can be washed and used over and over
during the operation. When the operator prefers sponges, a
good, fine, tough Turkish sponge should be chosen, using a definite
number each of round and flat sponges. They should be care-
fully cleansed by being placed in a towel or bag and pounded
with a cane until as much as possible of the dust and sand
is removed. Then they are placed in water acidulated with
muriatic acid sufficient to give a strong acid taste, in which
they remain for twelve hours. This dissolves out the sand
and' earth. The sponges are then washed in green soap through
106 GYNECOLOGY.
a number of waters until they become perfectly clean, after
which they are placed in a five per cent, solution of carbolic
acid. A good plan of procedure in cleansing sponges is to
place them in a solution of hyposulphite of soda — a pound of the
salt to a gallon of water for each dozen sponges. Add to this an
ounce of muriatic acid or half a pound of oxalic acid. The addition
of the acid to the soda results in a double decomposition, in which
sulphurous acid and sulphur are set free. The acid bums out
the organic material in the sponge and at the same time bleaches
it. Sponges should not be permitted to remain in this solution
longer than from five to ten minutes. They are then washed
in water until there is no longer any whitening of the water with
the sulphur. They may then be placed in a five per cent, solu-
tion of carbolic acid. When the sponges have been used, they
may be washed and used again, unless they have been soiled by
contact with some special poison or infectious material, when
they should be thrown away. In recleansing the sponges they
should first be washed in cold water to remove the blood, then
soaked in a solution of washing soda, half a pound to the gallon,
and afterw^ard in a solution of hyposulphite of soda and oxalic
acid. The solution in which the sponges are kept should be
changed every two or three weeks. The marine sponge is now
rarely used because of the difficulty in maintaining it in an
aseptic condition. The dry sterile gauze is almost as effective for
drying a bleeding surface. It can be kept sterile and is much
cheaper, so there is no temptation to reemploy it.
176. Ligature and Suture Material. — Methods for Its Prep-
aration and Preservation. — The material used by the majority of
operators is silk. Pozzi recommends that it shall be boiled with
carbolic acid, 50 : 1000, wound upon glass reels, and kept in this
solution, which should be changed every week. Not too latge a
quantity should be prepared at a time, as the nearer to the opera-
tion, the less irritating it is. Hegar uses iodoform silk, which is
immersed twenty-four hours in iodoform 20 grams, ether 200
grams. This is dried, wound upon bobbins, and kept in glass
boxes. Silk may also be boiled in a sublimate solution (i : 1000).
Nilson recommends that suture material for superficial stitches
should be boiled in wax and carbolic acid, as it is thus less likely
to become infected. Apropos of this method, I used a suture of
this kind in closing the lacerated perineum of a patient immedi-
ately following labor. Sutures were removed a week later. Two
years subsequently, during examination of this patient, I noticed
a dark speck or groove upon the perineum, and on closer in-
spection found it to be a ligature that had not been removed.
It was raised up, cut, and withdrawn, when it was found that it
occupied a groove, which was completely cicatrized and ap-
THERAPEUTICS. 107
parently was not irritated. The possibility of infection of silk
when used upon the stump of a suppurating tube, or in a pelvic
cavity when suppuration is present, and the long-continued sinus
that results until the ligature itself has discharged, have led me
to prefer some material for ligation that is more certain to be
absorbed and will not remain in the tissues so long. I have had
occasion to open a sinus and remove a large ligature from a
patient upon whom the operation had been done four years be-
fore, and the abscess did not form for three and one-half years.
Consequently, for some time I have used nothing but catgut for
ligatures and internal sutures. This material, when carefully
prepared, is perfectly safe, and we have no reason to feel that the
patient will experience inconvenience after convalescence occurs.
Patients in whom no suppuration has occurred, nor sinus resulted,
have subsequently suffered from pressiu^e upon the nerve-fibers
by an encysted ligature, requiring reoperation a year or more
later for removal of the ligature in order to secure relief. Catgut
for ligature is prepared as follows: No. oo. No. o, and No. 2 cat-
gut, as obtained from the shops in long pieces, is placed in ether
or benzin for a number of days, or even weeks, to extract the fat.
It is removed from this and tightly wrapped upon wooden blocks
or glass tumblers, and placed for thirty hours in a solution of
dichromate of potash:
B . Potassii dichromat. , 1.5
Acid, carbolic, \ *x ,^ ^
Glycerin. / ** '°-°
Aqua 480.0
The dichromate is dissolved in the water, and the carbolic acid
and glycerin are added.
The previous fixing of the gut before its immersion in the
solution is very important, as it otherwise becomes hopelessly
t\^4sted and entangled. After removal from the solution the
strands should be wrapped upon previously prepared boards
about a meter long, and while so wrapped they should be care-
fully dried. From these boards it is cut in meter lengths, and
the pieces are tightly wrapped upon glass drainage-tubes. Each
tube contains two pieces of gut. These tubes are placed in a
1 : 1000 solution of sublimate in water for eight hours. This
solution is poured off and replaced by a i : 500 solution of sub-
limate in alcohol (90 per cent.), in which the catgut remains
for twenty-four hours. From this solution the tubes are lifted
by sterile forceps into absolute alcohol, to each half pint of which
one dram of sterile glycerin has been added. The tubes are
removed from this solution for use. Any unused catgut after
an operation is not replaced.
The No. 2 gut is employed for ligatiu^es, the No. 00 and No. o
108 GYNECOLOGY.
for sutures. Gut so prepared is, in my experience, unirritating,
and a satisfactory material for ligatures and sutures.
When it is not desired to harden the catgut or there is no
need for its remaining in the tissues for such a length of time,
the solution of dichromate of potash may be omitted. Boeckman
suggests the following method of rendering the catgut safe for
use. The gut, after being cleansed in ether, hardened if desired,
and thoroughly dried, is cut into desirable lengths, wrapped in
waxed paper, sealed in small envelopes, and subjected to a tem-
perature of a little above 284° F. for four hotirs. Pus-forming
germs are destroyed at low^er temperatures, but spore-bearing
germs, as anthrax, so common in the intestine of the sheep, are
killed only at the higher temperature. The envelopes remain
unbroken until the catgut is desired for use. A number of
manufacturers now put up catgut in alcohol or chloroform,
sealed in glass tubes, in which it is kept free from contamination
until desired for use. It is thus prepared plain or chromicized.
By some it is marked 10-, 20-. and 40-day catgut, but experience
has taught me not to place reliance upon such promises. In the
acid secretion of the vagina none of it is likely to last more than
ten days or two weeks. Silkworm-giit forms an excellent suttire,
is clean, not readily infected, and is easily taken care of. It may
be boiled for ten minutes prior to the operation.
177. Dressings. — Gauze medicated with various germicidal
or inhibitory agents has been advocated, but it does not present
any advantages over the sterilized gauze. The latter is non-
irritating, and serves every purpose. It should be sterilized by
subjecting it to steam, the fractional method, of course, being
employed. It should be sterilized one hour the first day, the
second day half an hour, and the third day the same length of
time, then dried in a hot oven and placed in a closed vessel, and
kept carefully wrapped until it is used.
178. Operator and Assistants. — Personal cleanliness should
be a matter of conscience. A person with nasal catarrh or bad
breath from decayed teeth or foul stomach is disqualified to be
either an operator or assistant. This is particularly true in
peritoneal operations. Even the slightest examination should
not be undertaken unless the hands and nails are carefully
cleansed, in order to insure against the introduction of infectious
material, and in every operative procedure the hands and arms
should be scrubbed with soap and hot water, giving thorough
attention to the condition of the nails. The longer the hands are
scrubbed with soap and water, the less active are the germs that
inhabit the surface beneath the finger-nails. After thorough
washing with soap and hot water, the nails should be scraped and
the washing again repeated. The fingers, and especially about
THERAPEUTICS. 109
the nails, should be scrubbed with a piece of sterile gauze wet
with a 1 : 500 solution of bichlorid in 70 per cent, of alcohol, and
subsequently washed in sterile water. Probably still better is a
solution suggested by Charles Harrington, of Boston, which con-
sists of commercial alcohol (94 per cent.), 640 c.c. ; hydrochloric
acid, 60 c.c. ; water, 300 c.c. ; corrosive sublimate, 0.8 gram,
in which the hands and arms should be bathed for thirty seconds
to a minute after having previously thoroughly washed them with
sterile soap and hot water. I have used this solution for the
last year and a half with very gratifying results. Niu*ses and
assistants who are to take part in the operation and handle
sponges or dressings should be required to exercise rigidly the
same precautions, and should be taught the importance of care-
fully avoiding contact with any nondisinfected article; and if
they should accidentally touch a door, basin, clothing, the face,
or any nonsterile object, they should again scrupulously cleanse
their hands before coming in contact with dressings or instru-
ments. Kelly advocates, subsequent to scrubbing the hands in
soap and hot water, that they should be placed in a solution of
permanganate of potash (4: 1000), and this stain removed by
H-ashing in a concentrated solution of oxalic acid, then in lime-
water, and finally in sterile water. Fiirbringer suggested that
the hands and arms should first be washed with soap and hot
water, then vdth bichlorid, preferably the acid solution, subse-
quently with alcohol at 90 per cent. An effective method of
cleansing the hands is to wash them with equal parts of sodium
carbonate and calcium chlorid to which water is gradually added.
The chlorin set free is the effective agent. There are but few
persons, however, whose hands will endure the employment of
this method of cleansing several times daily. Before examining
a case of cancer where there is considerable decomposing material,
it is well to anoint the fingers with turpentine, and then with
vaselin, as in this way the disagreeable odor is more readily re-
moved from the fingers. It would be better for the operator to
wear rubber gloves or draw a condom over two fingers before
examining cases of cancer or other infectious cases. The im-
possibility of rendering the hands absolutely sterile, the varying
susceptibility of different individuals to the influence of infectious
germs, makes the habitual wearing of rubber gloves a prudent
policy. Certainly, surgeons engaged in general surgical practice
would do wisely to wear rubber gloves when operating within
the peritoneal cavity. Gloves should always be worn when the
operator has recently examined or operated upon patients who
were suffering from some infectious disease.
179. Precautions. — During the progress of an operation the
operator should have, conveniently situated, two vessels, one
110 GYNECOLOGY.
containing a solution of i : looo acid sublimate, and the second
sterile water, into which he can occasionally dip his hands.
In operations within the abdomen it is better that the bichlorid
should be removed by sterile water. He should wear clean Unen
and should have his clothing entirely covered by a sterilized
apron. When there is much fluid, as in plastic operations on the
vagina, in which continued irrigation is practised, the clothing
should be covered with some Waterproof material beneath the
apron. Where conditions will permit, it is better that the surgeon
should make a complete change of attire, both in the interests
of his own health and for the safety of his patient.
1 80. Room and Environment. — The room and surroundings
of the patient should receive careful consideration. The room
should be well lighted and ventilated and thoroughly cleaned;
be free from matting, hangings, and everything that is likely to
retain dust; in fact, no more furniture should remain in the room
than is absolutely necessary. The operating room should be one
whose walls can be thoroughly washed and carefully cleansed;
its furniture should be made of metal and glass. When the opera-
tion is to be performed in a dwelling, the room should be carefully
scrubbed with a carbolic-acid solution (50: 1000) two days in
advance. In a private house where the rooms are old or their
condition at all suspicious, they should be disinfected with a
formaldehyd apparatus. It was formerly the practice to operate
under the carbolic acid spray, but it was fotmd to have a pre-
judicial influence upon the peritoneum. Until quite recently
some operators still kept a spray in the room for the moisture
and to secure the beneficial influence of the carboUc acid, but
the drug is so disagreeable and injurious to many patients that
the practice has been discontinued. Sterilized water should be
at hand in carefully covered vessels, and when antiseptic solu-
tions are used, they should be designated so that no mistake can
be made.
181 • Examination and Preparation of Patient. — An examina-
tion should be made of the urine, as to its specific gravity,
quantity of urea, presence or absence of albumin or sugar,
approximate quantity of solids, and where the conditions in-
dicate it, the microscope should be employed. A fair estimate
of the amount of solids may be obtained by Haine's modification
of Haeser's method, viz. : * ' Multiply the last two figures of the
specific gravity by the number of ounces of urine passed in
twenty-four hours, and this product by one and one-tenth."
This estimate includes urea and all other solids. The quantity
will depend upon the avoirdupois of the patient. Etheridge
has prepared the following table :
THERAPEUTICS.
Ill
WXXOBT.
90 pounds
100 ••
no •*
120
130
<«
Urinasy Solids.
789 grains
854 *'
916
974
1028
Weight.
1 1
<i
140 potinds
150
160
170
180
( c
«<
l<
Urinary Solids.
1078 grains
1150
1 198
1237
1260
*(
<i
1 1
The performance of the respective functions of the heart and
lungs should be investigated. Frequently an examination of
the blood will be of service. While a low percentage of hemo-
globin does not preclude operation (as I have performed a
hysterectomy upon a patient with recovery in whom the hemo-
globin was only 20 per cent.), it has, however, an important in-
fluence upon the healing of wounds and the convalescence of the
patient. A careful blood examination is valuable, therefore,
in the prognosis of operative conditions associated with anemia.
The bowels should be thoroughly evacuated ; this is particularly
important when a plastic operation is to be performed upon the
rectovaginal septum. The diet should be regulated according
to the proposed operation. In peritoneal and intestinal opera-
tions milk and other foods containing much waste should be
excluded.
A thorough evacuation of the bowels should be secured by
the administration of half an otince of Rochelle or Epsom salts,
or two drams compotmd licorice powder, or half a bottle of
magnesium citrate two nights previous to and the morning
preceding the day set for the operation. A large rectal enema
of soapsuds should be given the preceding night. The patient
should be kept in bed for twenty-four hours prior to a serious
operation. She should be given a general bath twice daily for
two days, with special attention to washing the external genitals,
the anus, and the depression of the umbilicus. Vaginal ir-
rigation with 1 : 2000 sublimate solution should accompany each
bath. The abdomen and genitalia should be shaved the evening
before the operation and the abdomen should be washed with
tincture of green soap and hot water, the flesh-brush being
diligently applied. If the patient is uncleanly or the skin is oily,
the stirface should be washed with ether, then with soap and
water, and finally with a (i : 1000) sublimate solution. This
washing should be repeated on the morning of the operation,
and the abdomen should then be covered with a pad saturated
with sublimate solution, which should be retained by a bandage,
to be removed when upon the operating table. In all cases it is
desirable that the field of operation should be again thoroughly
scrubbed after the administration of an anesthetic, with soap and
hot water, the superfluous soap being removed with alcohol.
182. Special Preparation. — Vaginal Operation, — The first step
should consist in a careful cleansing of the vagina. For this
112 GYNECOLOGY.
purpose a combination of creolin with green soap is very effectual,
using creolin, one or two drams, green soap, one or two otmces, to
the quart of hot water. The vaginal canal should be thoroughly
scrubbed with this solution, introducing two fingers wrapped
with gauze. This procedure will remove all debris which may
have lodged in the crypts and folds of the vagina. The solution
should be removed by washing with sterilized water and then
with alcohol. Creolin is not so effective an agent in sterilizing
the vagina as the acid sublimate solution, but it has the advantage
that it leaves the vagina soft and flexible, which is an important
consideration in obstetrics as well as in all operative procedures
upon the vagina. The bichlorid and carbolic-acid solutions,
on the other hand, have a constringing effect upon the vagina,
which renders it less elastic.
183. Irrigating Tubes. — All the cannulas used for the ptirpose
of cleansing the vagina should be made of glass (Fig. 72), as they
are more readily cleansed, are less likely to contain infectious
material, and are sufficiently cheap to permit them to be thrown
away when used in suspicious cases. If injections are used by
Fig. 72. — Irrigating Glass Tube. Open End.
the patient, there should be no central opening of the nozle, for
the reason that it may be introduced directly into a patulous
cervical canal, and fluid thrown with force into the cavity results
in severe uterine colic. Indeed, fluids have been thrown into
the uterus and forced by uterine contraction through the tubes,
which caused serious, if not fatal, pelvic inflammation. There
is no special advantage in having a curv^ed cannula or tube for
irrigation. The nozle used by the physician in an operation
should have but a single orifice, and that should be a central one.
After irrigation has been practised, pressure should be made
upon the fourchet, to insure the entire escape of fluid. It is
sometimes advised that the irrigation should follow the ex-
amination or operation, but we can not too strongly impress
upon the student the fact that the genital canal sometimes con-
tains dangerous germs, and that antisepsis must precede as well as
follow an operation. In cancer or sloughing fibroids we may,
in addition to the ordinary disinfection, require the use of de-
odorizing agents. For this purpose a three to five per cent,
solution of thymol or two or three tablespoonfuls of Labarraque*s
solution to the quart of water may be used.
THERAPEUTICS. 113
184, Gauze. — ^After the uterus and vagina are carefully
cleansed, the canal can be packed, if preferred, with iodoform or
other antiseptic gauze which will remain sweet for a number of
days. Iodoform is preferable to the simple sterilized gauze. To
prepare it, ten layers of plain gauze are sterilized by boiling, pref-
erably in a solution of carbonate of potash, washed, then soaked
in a solution consisting of iodoform 50, glycerin 100, and ether
700 parts, after which the gauze is passed through a wringer and
dried in a darkened, isolated room at a temperature of 85° F.
When dry, it is placed in tin boxes. This gauze should always
be sterilized before its use. This can best be accomplished by
heating it to the tempera tiure of 250° F., by which both germs
and their spores are destroyed. It should be remembered that
iodoform is not a germicide. Its value is in its reductive in-
fluence upon the ptomains and leukomains, by which their
deleterious effects are arrested. Iodoform is poisonous to some
patients. Sometimes it produces high temperature, irritation
of the skin, and a smoky, darkened urine, and in others, extreme
disturbance of the digestive tract. In such idiosyncrasies one
of the other forms of antiseptic gauze should be preferred. These
comprise borated, salicylated, carbolized, formalized, and acetan-
ilid gauze. Sublimated gauze can be made by first boiling it in
a solution of carbonate of potash (20: 1000), then an hotir in a
(i : 1000) sublimate solution, when it is dried in a sterilizing oven
and preserved in closed glass jars. Salol and iodol are infe-
rior in their action to iodoform. Carbolic acid is unreliable.
Aristol, an agent that is made by the combination of thymol
and iodin, is probably preferable to iodoform. It has the ad-
vantage of the absence of disagreeable odor. The powder is
very dry, not rapidly soluble, and coats over and protects the
surface.
185. Antisepsis of the cervix and uterine cavity is secured by
intra-uterine injections of sublimate solution, carbolic acid,
dioxid of hydrogen, or, preferably, formalin (1:1000). Of the
solutions of mercury, the acid sublimate is preferable, for the
reason that it does not form an albuminate of mercury by com-
bination with the serum of the blood, and is less likely to be
absorbed and to produce a toxic effect. This agent is not so
dangerous as in obstetrics, unless there has been a large denuded
surface. In such cases its use should be followed by an injection
of sterilized water. I prefer a hot i to 2 per cent, solution of
sodium chlorid or a 2 per cent, solution of the sodium bicar-
bonate for irrigation of the uterine cavity during or following a
curetment. It is fully as efficient as the stronger germicidal
agents, and if a perforation should occur, or fluicl pass through
the tubes, this fluid will prove innocuous in the peritoneal cavity.
8
114 GYNECOLOGY.
In intra-uterine injections a double catheter shotdd be employed,
in order that the return flow may not be obstructed. It may
be made of hard rubber, glass, celluloid, or metal; the last-
named are more likely to be acted upon by the mercury salts.
If the uterine cavitv is well dilated, the double tube will be
unnecessary. After the cavity is carefully cleansed it may be
packed with an iodoform gauze tampon, or a pencil of iodo-
form may be introduced. Von Hacker recommends the follow-
ing: Iodoform, 5 drams; gtmi acacia, glycerin, starch, each, 30
grains ; mix, make pencils, introduce into the cavity of the uterus.
When these pencils give rise to uterine colic, it may be pref-
erable to dust the cavity with iodoform through an insufflator,
or, still better, the use of aristol by the same means.
In sloughing fibroids or intra-uterine cancer the cavity should
be irrigated with an acid sublimate solution (i : 2000), followed
either by sterilized water or a solution of chlorid of sodium (6:
1000). In operations upon the vagina or cervix continuous
irrigation may be practised, using for this purpose a solution of
carbolic acid (5 : 1000), sublimate (i : 2000), formalin (i : 1000),
or, better, chlorid of sodium (6 : 1000). The irrigation washes
away the blood, renders unnecessary the use of sponges, and the
surfaces are constantly kept bathed with the antiseptic fluid.
It is the preferable procedure in all operations upon the vulva,
vagina, and cervix.
186. The Use of Tents. — In dilating the uterus the sponge,
tupelo, or laminaria tents, although careftdly disinfected, are not
without danger. Pozzi recommends the latter tent, but he first
immerses it in a saturated solution of carbolic acid and rectified
spirits, or in a solution of iodoform and ether with a tenth part
alcohol. In my judgment the best method of rendering the tent
safe is to immerse a laminaria or series of such tents in the
official tincture of iodin for a few minutes prior to its introduc-
tion into the uterine cavity. The objection to the use of tents is
the difficulty in previously sterilizing the uterine canal. Unless
it is thoroughly done, as you would in the performance of any
operation, the patient is in danger of subsequent inflammatory
attacks. For this reason, in the majority of dilatations, I prefer
to use the bougies and accomplish rapid dilatation in preference
to the slower procedure with the tent.
187. Abdominal Section. — The peritoneum is a membrane
exceedingly susceptible to the influence of all chemic agents, and
its delicate structure would be injured or destroyed by any agent
of sufficient strength to have a germicidal influence ; consequently,
our aim should be rather to procure asepsis than antisepsis.
.Assistants must be personally clean. They should have taken a
thorough bath on the morning of the operation and should have
THERAPEUTICS. 115
seen no case of contagious disease prior to its performance. They
should remove their coats and vests, bare their arms to above the
elbows, thoroughly scrub their hands and arms with soap and hot
water, and wash in disinfectant solutions. Their clothing should
be covered with clean sterile linen. They should subsequently
avoid shaking hands or touching any objects not disinfected.
The greatest safety against infection will be secxured by the opera-
tor and his assistants wearing rubber gloveS.
1 88. Indications for Anesthesia. — The use of some anesthetic
is necessary in the performance of many operations, and is of
great advantage in all. In the virgin, in nervous patients, or
those in whom the abdominal and pelvic organs are very tender
from the presence of inflammation, the administration of an
anesthetic renders an examination much more satisfactory to
the physician and less distressing to the patient.
189. Agents Employed. — In an examination it is tmdesir-
able that the patient should be long under the influence of an
anesthetic or should have a large quantity administered. Ether
and chloroform are objectionable, first, because of the length of
time required to secure insensibiUty and recover consciousness;
second, the subsequent nausea and vomiting, which frequently
last for hours. Nitrous oxid gas is an agent which produces
prompt imconsciousness, and from which the patient as promptly
recovers, but it requires a special, quite expensive, and rather
unwieldy apparatus.
Bromid of ethyl is almost as rapid in its effects as the nitrous
oxid, requires but a small quantity, the patient regains con-
sciousness almost immediately after the inhalation is discon-
tinued, and its use is much less frequently followed by nausea
and vomiting. It can be administered in one's office, and the
patient, shortly after return to her home, feeling but little the
worse for her experience. This agent is very satisfactory for
short operations, such as opening abscesses or dilatation of
the urethra or anus. In very nervous patients it may precede
the administration of ether or chloroform, whereby the stage of
excitement and struggling is avoided. With the assistance of
Dr. P. B. Bland, during 1902-03, I made some experiments with
the chlorid of ethyl and found it to act very satisfactorily in pro-
ducing quick anesthesia. I employed the drug for anesthesia
in a number of serious operations. In one patient I did a
hysterectomy under its use, the time occupied for anesthesia
being fifty minutes, without any unpleasant symptoms. With
a suitable inhaler it can be effectually employed with tlie ad-
ministration of a very small amount of the agent. It has not
seemed to produce any imcomfortable sensations following
the operation, although the anesthesia is not as profound and
116 GYNECOLOGY.
durable as that induced by other anesthetics.* For prolonged
operations ether and chloroform are to be preferred. Ether is
generally recognized as
the safer drug. In the
very young or the aged
it is less satisfactorv-
than chloroform, and
probably not so safe.
Chloroform should be
preferred in the pres-
ence of renal disturb-
ance and when the pa-
tient is suffering from
emphysema or chronic
bronchitis. Some of
the French surgeons
advocate the adminis-
tration of \ of a gr. of
sulphate of morphin
and T^TF of a gr. of
sulphate of atropin
hypodermically about
twenty minutes prior
to the administration
of chloroform, and they claim: (i) that it increases the safety by
PiS' 73- — White's Oxygen Apparatus, which can
be Utilized for Anesthesia by Placing Anes-
thetic in the Bottle.
Fi£' 74- — Northrup's Apparati
diminishing the danger of syncope; (2) that the patient is much
e h»d n death from ethyl chlorid and would
THERAPEUTICS. 117
less likely to suffer from nausea and vomiting; (3) that the
patient, having taken a smaller amount of the vapor, recovers
consciousness more quickly.
Scopolamin-nwrphin narcosis. — A combination of these drugs
was advocated by Schneiderlin in 1900 as a means of rendering
patients sufficiently insensible to pain to permit of the per-
formance of the various surgical procedures. Recently they
have been extensively employed. Korff, who administered the
combination in two hundred cases, advised scopolamin hydro-
bromate -^^ milligram, w4th morphin sulphate 25 milligrams,
divided into three doses, to be given hypodermically, three
hours, one and a half hours, and half an hour before the
operation. The first dose renders the patient drowsy, the sec-
ond puts her to sleep, and the final one renders her insensible to
pain. Scopolamin-morphin narcosis has been advocated as lessen-
ing the danger of anesthesia. The employment of a combination
of drugs, though capable of rendering the patient unconscious for
hours, cannot be considered as free from danger, and the results
seem to show that the procedure should be avoided in persons
with weak vessels and enfeebled heart action. It has been
claimed that the preliminary administration of -j-J-jj- grain of the
scopolamin hydrobromate with ^ of a grain of morphin would
enable the administrator to give much less of the ordinary an-
esthetic, and in the majority of cases the patient will be free
from the postoperative nausea and vomiting. The experience
of nearly one himdred cases at the Jefferson Hospital cUnic has
demonstrated that a greater number of patients having this pre-
liminary injection will suffer from nausea and vomiting than
when ether is given alone. The only advantage which I would
concede it is that where the patient is nervous and fearful of the
operation, she is so doped before she comes to the operating room
that she is oblix^ous to everything and takes the anesthetic with
but little difficulty. The administration of a mixture of chloro-
form and oxygen, obtained by passing oxygen through a bottle
of chloroform to the inhaler, decreases the danger of this agent
and accomplishes anesthesia with the minimum quantity of the
drug, without discomfort, with lessened nausea, and with slight
subsequent distress. (Figs. 73 and 74.) The patient does not
have the blanched appearance of the face, and rapidly recovers
when its administration is suspended. I do not feel it neces-
sary to describe the administration of the anesthetic further than
to caution that false teeth and foreign bodies should be removed
from the mouth.
190. Administration. — The patient should be directed to
breathe deeply. She should be reassured by the physician,
both in speech and manner. Talking upon the part of the
118 GYNECOLOGY.
administrator or attendants should be avoided. The ptilse,
respiration, and condition of the pupil should be continually
observed^ Dilatation of pupils, blanching of the face, arrested
or stertorous breathing, and sudden feebleness of the ptdse
should indicate the temporary withdrawal of the vapor. Con-
tinued syncope, particularly in chloroform narcosis, requires
resort to artificial respiration, and often suspension of the pa-
tient with head downward. The administrator of the anes-
thetic should be provided with a hypodermic syringe, solutions
of strychnin and atropin, and some nitrite of amyl. The latter
agent is of advantage because of its rapid action as a primary
heart stimulant, and its influence in dilating the arterioles by
its action upon the vasomotor system. When chloroform is
largely given, a bellows and mask, by which the Itmgs can be
inflated with air, will not infrequently be effective in saving
life. In suspended respiration forcible pulling upon the tongue
acts as a respiratory stimulant. The inhalation of vinegar
following anesthesia appears to lessen the tendency to nausea.
191. Local Anesthesia. — General anesthesia is attended with
danger in renal disease, in marked pulmonary changes, in fatty
degeneration of the heart, and in atheroma of the large vessels.
In such cases, and when general anesthesia is objectionable,
local anesthesia may be employed. Freezing by ice and salt,
by ether, or by ethyl chlorid spray may be utilized, but its
application is limited. Continuous irrigation with carbohc acid
has a benumbing effect upon the mucous surfaces, by which
pain is obtunded.
Cocain, — The most effective agent for local anesthesia is
one of the cocain salts. In operations about the genitals or
anus it is preferably given hypodermically, and for this pur-
pose the phenate of cocain is the most satisfactory. It is slower
in being absorbed, and is less likely to be a source of infection
from the presence of micro-organisms. Some have advocated
eucain in preference to cocain, as it is less volatile and hence
more readily sterilized. It is also less likely to cause depression.
Stovain, a synthetic preparation, is claimed to be free from the
depressing and toxic effects incident to cocain. The injections
should be made with a one or two per cent, solution, using as
much as from one to three grains of the drug. The injection pro-
duces anesthesia for the distance of half an inch from th^ point of
the needle; consequently a number of injections may be re-
quired. This method of anesthesia has been effective in am-
putation of the cervix, trachelorrhaphy, and operations upon
hemorrhoids and fistula in ano. The drug sometimes has an
alarmingly depressing effect. This symptom, it is said, may
be avoided by combining nitroglycerin in the injection. When
THERAPEUTICS. 119
s)maptoms of depression occur, resort should be had to strychnin,
atropin, alcoholic preparations, and nitroglycerin.
Schleich, of Germany, after considerable experimentation,
has suggested three solutions for infiltration anestliesia. The
basis of all is a solution of two parts sodiiun chlorid, one-fourth
part morphin hydrochlorate, in water one thousand parts,
to which, for what is called the stronger solution, two parts
cocain hydrochlorate are added — one part for the mediimi
and one-tenth part for the weaker solution. The water and
salt are sterilized by heat. A larger syringe than usual is used.
The site for operation is careftdly cleansed ; then, after niunbing
the surface with an ethyl chlorid spray, a puncttire is made
and fluid injected tmtil a wheal the size of a dime is raised;
the needle is introduced in its margin, and so continued until
the entire length of the proposed wotmd is completed. The
first ptincture is the only painful one. The insensibility of
the skin lasts for from fifteen to twenty minutes.
Spinal anesthesia is secured by the injection of one to two
grams of a sterilized (2 per cent.) solution of cocain into the
spinal cavity. The injection is made between the limibar
vertebrae, and on a line level with the crests of the ilia. A
long needle is introduced, the entrance of which into the spinal
canal is indicated by the escape of spinal fluid. This form
of anesthesia has been largely practised by Tuffier, of Paris,
who has observed no untoward symptoms and has found it
very satisfactory in all operations below the diaphragm. In
a patient who had had one kidney removed and the remaining
one so diseased as to render the employment of a general anes-
thetic unwise, under this method I opened up a sinus which
extended down to the vertebrae and into the pelvis without
pain to the patient, and without the depression and horrible
nausea which had been associated with her previous operations.
A second patient, a young girl, had a large necrotic ovarian
cyst, a portion of one lung consolidated, and a mitral murmur
with beginning cardiac insufficiency — factors which made her
condition very unfavorable for ether or chloroform narcosis;
spinal anesthesia was employed, and I was able to remove
the tumor without pain, and the patient had an uninterrupted
recovery.
192. Preliminary Details of Operation. — The presence of
the patient, anesthetized, in the operating room presupposes
the thorough preparation, detailed in the previous paragraphs.
A stifficient number of well-drilled assistants should have their
duties assigned, so that the operation may proceed without
confusion or delay. Instnunents, ligatures, dressings, sterilized
water, and sponges have been prepared. In abdominal opera-
120 GYNECOLOGV.
tions the number of sponges or pieces of gauze should be known,
. so that they may be accotmted for before the wotmd is closed. It
is also important to have a definite number of instruments, as
both sponges and instruments, especially hemostatic forceps,
have been left in the abdominal cavity. Every step of the opera-
tion, to the minutest detail, should be conscientiously watched,
for, as the chain is only as strong as its weakest link, so an
otherwise perfect aseptic procedure may fail through a single
flaw.. I have seen the most careful preparations for an opera-
tion, and the operator place his silk sutures upon a syringe box ;
an assistant stroke his mustache, a nurse use her handkerchief,
or stroke her hair, each instance being a break which imperils
the result.
193. Arrangement. — The instruments shotdd be placed at
the right of the operator, so that he can reach them as needed.
The sponges should be in the care of a nurse upon the opposite
side. The sponges or gauze pads should be removed from the
receptacle and passed to the operator or his assistant by the
ntirse with a pair of forceps. After being used they should
be placed in a basin. The nurse dispensing the sponges should
keep an accurate account of the number given out, with which
those returned should correspond. The wotmd should not be
closed until it is certain all sponges have been removed. It is
well to have one large, broad piece of gauze for walling off the
intestines, or several smaller pieces may be employed and the
end of each secured with a pair of forceps. A basin of sterilized
hot water should be alongside the instrtmients for the hands
of the operator, and his principal assistant should have another.
194. Positions of Operator and Assistants. — In an abdom-
inal section I prefer to stand on the patient's left, with my
assistant opposite; the second assistant gives the anesthetic; a
third looks after the instruments, ligatures, and sutures. One
nurse attends to the sponges, a second changes the water in
the basins, especially in those for the hands of the operator
and assistant, prepares sterilized water or salt solution for
irrigation, and counts the pads which have been used and re-
turned, which count should tally with the one made by the
nurse dispensing them. A third may be ready for emergency and
have the dressings ready upon the completion of the operation.
195. Clothing of Patient. — The patient will be better to
have all clothing removed, in order to prevent it becoming
soiled during the operation. Separate and clean blankets should
be wrapped about the upper part of the body and the lower ex-
tremities. These should be covered with sterilized towels, and
over all a sterilized sheet, in the center of which an opening has
been prepared for exposure of the field of operation.
THERAPEUTICS. 121
196. IncisioiL — The linea alba is chosen for the site of in-
cision in the majority of cases of abdominal section. A cut,
varying in length from two to twelve inches, according to the
condition for which the operation is done, is made with a sharp
NURSe WITH
SPONGES
0P€ BATING ROOM
FROM ^BOVt^
NURSC AT
/NSTRUMENT
TABLE
Pig. 75. — Airangernent of Tables and Assistants in Operating Room.
knife. When the abdomen is moderately distended with a
growth, the first sweep of the knife should reach the fascia
over the peritoneum. The operator and his assistant with
122
GYNECOLOGY.
long dissecting forceps pick up the peritoneum and cut it be-
tween them, thus avoiding injury to the cyst, or, when the
abdomen is undistended, a knuckle of intestine.
As soon as the peritoneum is opened, the atmospheric pres-
sure carries the intestine out of the way, when the incision may
be completed with a knife or with probe-pointed scissors, in-
troducing two fingers as a guard. Should considerable bleeding
occur after the first sweep of the knife, it can usually be con-
— Abdominal Wall Incised ;
Peritoneum Picked up by Dis-
secting Forceps.
^'S- 77- — Peritoreum Incised.
troUed by pressure with a gauze pad. When this is insufficient,
the bleeding vessels should be seized with hemostatic forceps.
The lengfth of the incision has been a prolific source of dis-
cussion. It has but little influence upon the result. It should
be sufficiently long to permit the object of the operation to
be accomplished with ease and as little irritation as possible.
A long incision, if properly united, will be as firm as a short one.
A combined transverse, or better, crescent-shaped and vertical
incision, was reported at the International Congress on Obstetrics
and Gynecology, held in Geneva in August, 1896, also described
THEKAPEUTICS.
in a paper by Kustner in an article in September of the same year,
and has been largely practised by Stinison and Cumston in this
country. It consists of a crescent -shaped incision just above the
Kg. 78. — Crescent Incision Exposing Aponeurosis.
Fig. 79. — Aponeurosis Excised. Showing Pyramidalis MuecIcb.
symphysis, and, where possible, confined to the hair surface. It
extends through the skin, superficial fascia, and aponeurosis.
These tissues are drawn up, separating the aponeurosis from its
124
GYNECOLOGY.
attachment to the pjrramidalis muscles. The rectus muscles are
separated in the m^ian line, and the peritoneum incised verti-
cally. This incision permits free access to the pelvic viscera, and
is satisfactory unless a large growth is present, which will require
a longer incision. The advantages of the procedure are that the
subsequent growth of the hair hides the incision ; the probability
of hernia is lessened, as the suture closing the peritoneum and
muscle wall is at right angles to that of the aponeurosis. The
disadvantages are: the increased bleeding from cutting across
Fig. 80. — Scalpels.
vessels and the inability always to avoid the occurrence of hema-
toma either below or above the aponeurosis. Where there is
much disposition toward oozing, it is better to insert one or two
small drains for the first two days.
197. Adhesions. — In inflammation complicating a cyst it
may be difficult to determine when we are through the perito-
neum. In case of doubt it is better to continue the incision
until the cyst is opened, when the line of tmion can be more
readily determined. It is well to remember that at the um-
bilicus the peri-
toneum is closely
united to the over-
lying tissue, and this
fact may be utilized
in cases of uncer-
tainty. As far as
possible, separation
of adhesions should
take place under the eye, by drawing them down to the incision.
Vascular adhesions and ever>'' bleeding vessel should be secured
with forceps or should be ligated.
With the application of forceps the ntunber of necessary
ligations will be reduced, as the pressure will often prevent
subsequent bleeding. The wound should not be closed if any
large bleeding points are present. In short, firm intestinal adhe-
sions the greatest safety is assured by keeping close to the cyst.
In some cases it may be necessary to cut into the cyst, leaving a
portion attached to the intestine, always taking the precaution,
Fig. 81. — Pressure Forceps.
THERAPEUTICS. 125
however, to remove its inner, secreting surface. Frequently the
worst adhesions the operator will meet are associated with infec-
tive processes in the tubes, ovaries, or in relation to myomatous
growths of the uterus. In both of these conditions the adhesions
maybe so firm as to require the use of the scissors for their separa-
tion. All bleeding vessels should be secured and where possible
the raw surfaces sutured.
198. Toilet of the Peritoneum. — In the removal of large
C)'sts care should be exercised that their contents do not escape
into the abdomen. If the contents are uncontaminated, con-
sisting of thin serous fluid, it should be removed by sponging
only. It is difficult for me as an operator to get over early
impressions. My education leads me to resort to abdominal
irrigation, preferably with normal salt solution, whenever
infection is possible, but experience has demonstrated that
patients do equally well when pus is sponged out with dry gauze
pads as when irrigated. It is a serious question whether the
measures we often institute in the name of toilet of the perito-
neum are not more prejudicial than helpful. When irrigation is
Fig. 82. — Dissecting Forceps — Long Bladed.
done, it is most eff^ectively accomplished by pouring the belly
full of normal salt solution, churning it about, pressing it out,
and removing the remainder with sponges. All bleeding points
must be secured. If there is oozing from the surface, sponges
wrung out of hot water should be packed firmly upon it until the
operation is completed, when they can be removed. If bleeding
still continues, the surfaces should be sponged with a hot solution
(10 per cent.) of ferripyrin, sprayed with a 4 per cent, solution
of antipyrin, or infiltrated with a solution of one part (i : 1000)
adrenalin chlorid to three parts sterile water. Should hemor-
rhage be persistent, a gauze pack affords an efficient means of
control.
199. Drainage. — The question of drainage was formerly a
momentous one. Keith's rule that it should be used only when
there was something to drain was a good one, but with improved
methods of technic we can depend more and more upon the
natural absorptive power of the peritoneum. The employ-
ment of the glass drainage-tube, which was formerly a matter
of routine, is now more honored in the breach than in the ob-
ser\'ance. When a glass drainage-tube is employed, it should
126
GYNECOLOGY.
be from six to eight inches long, with a niimber of small perfo
tions at the lower extremity. These openings should be sm
otherwise portions of intestine or omentum slip into them s
become strangulated or render the removal of the tube pa
fully difficult. The openings should be smooth, and should
beveled at the expense of '
outer sxirface. The lower t
of the tube should be open; '
external end should be p
vided with a flange, over wh
a piece of rubber dam n
be placed to prevent soiling
the dressings. The caliber
the tube should not exceed o
third of an inch. The use
the drainage-tube required most exacting care upon the p
of the nurse and the physician. Every precaution had to
exercised to prevent it becoming a gateway for the entrance
infection. It needed to be cleaned every half hour or ofte
Fig. 83. — Glass Drainage-tubes.
Baiio
Fig. 84. — Uterine Syringe for Cleansing Drainage-tube.
SO long as there was any discharge. This was accomplisl
by the use of a suction tube which reached to the bottom
the tube, or, better, by tube forceps and pledgets of sterili:
absorbent cotton. By either method micro-organisms in la
niunber, in spite of every precaution , found ready entrance. T
Fig. 85. — Tube Forceps for Cotton Pledgets.
frequent cleansing of the tube was avoided by passing a strip
sterile gauze to its bottom, which acted as a wick.
200. Objections to Drainage. — The glass drain was obj
tionable because: (i) It obliged the patient to remain ui
her back; (2) unless carefully placed it caused sufficient pi
sure upon the rectiun to produce ulceration and even a fe
THERAPEUTICS. 127
fistula; (3) it increased the difficulty in maintaining the wound
aseptic, and afforded ingress to pathogenic germs, either through
its cavity or along its sides; (4) it rendered the abdomen weak
and increased the danger of ventral hernia; (5) it endangered
the formation of a
anus which was long
in closing. The fre-
quency with which
drainage was thought
to be required, it was
found, could be les-
sened by the introduc-
tion of large quantities of normal salt solution, by which the
infectious material was diluted and rendered more readily con-
trolled by the peritoneum. Later experience has demonstrated
that such cases do equally well by careful walling-off of pus col-
Fig. 8.
—Gauze Wkk in Drain.
Mikulicz Draiti,
lections with gauze before they rupture and then thoroughly
removing the pus and blood with dry gauze. The peritoneum,
if given an opportunity, will take care of infection; the means
128 GYNECOLOGY.
which have been employed for the removal of infection have
crippled the antagonistic processes of the peritoneum.
201. Gauze Drain. — Drainage has been accomplished by
a twist of gauze, or, where there was much oozing, by gauze
pressure. The Mikulicz drain consisted of a piece of gauze
with a string tied to its center, placed in the bottom of the
pelvis, within which strips of gauze were packed. These strips
were ordinarily marked, to designate the order in which they
were introduced. The pain in removing was greatly decreased
by covering it with rubber tissue except at its extremity. Drain-
age, whether by tube or gauze, is of but short duration, and
its influence is confined to a limited area. Lymph exudate
soon walls it off as a foreign body from the general ca\'ity.
The gauze is very efficacious as a tampon. Its pressure arrests
hemorrhage and promotes the formation of exudation, which
closes oozing vessels and bars the avenues for the entrance of
infection.
202. Where Placed. — The drain, whether glass tube or
gauze, was generally placed in the lower angle of the wound.
Fig. 88. — Gaxize Drain Covered with Rubber Tissue.
though it could be placed between sutures at whatever part
of the wound was most favorable.
203. Postural Drainage. — The uninjured peritoneum is a
very active absorbing surface, and Clark utilized the knowl-
edge of this fact to avoid the introduction of a drain by ele-
vating the foot of the bed eighteen inches for from twenty-
four to thirty-six hours, by which the fluid gravitated away
from the injured surfaces. The danger of infection w^as lessened
by active irrigation with a large quantity of normal salt solution
before the wound was closed. The activity of any pathogenic
material remaining within the abdomen was diminished by
dilution, through the retention of a considerable quantity of
the solution when the wound w^as closed.
This position also decreases the pain following an operation
by the lessened quantity of blood sent into the vessels of the
elevated pelvis. The pendulum has now swung backward, and
w^e elevate the upper part of the body and favor the accumula-
tion of fluid in the pelvis, from which it is removed by gauze
wicks through the abdominal wound, or, better still, by an open-
THERAPEUTICS.
129
ing into the vagina. The latter channel of egress should be
employed whenever possible, because it favors by posture the
evacuation of the most dependent portion of the tract and the
danger of sinus or hernia is lessened.
204. Closure of the Wound. — Before the sutures are intro-
duced, the omentum is generally drawn over the intestines.
Formerly, when extensive adhesions or purulent discharges
were present, the belly was left filled with a sterile normal salt
solution. While we now urge the dry gauze sponge, it is yet
difficult not to re-
sort to the flushing
with normal salt
water when abscess
cavities are rup-
tured. The wound
can be closed by
throu g h -and-
through interrupted
sutures or with
buried sutures in separate layers. The interrupted sutures of
silk, silkworm-gut, and silver wire or chromic catgut are intro-
duced through the entire thickness of the abdominal wall,
about three-fourths to one inch apart, including one-eighth
of an inch of the peritoneal and one-fourth of the skin surface
on each side. Each suture is secured with a pair of hemostats,
and after all are introduced, the gauze pad placed over the
intestines is removed, the cavity is inspected, and the sutures
are tied. Care must be exercised that a knuckle of intestine
Fig. 89. — Ciirved and Straight Needles.
Fig. 90. — Needle Forceps.
or a piece of omentum is not caught by the sutures. The most
important consideration for the future of the patient is the
union of the aponeurosis, for upon its accurate union depends
the subsequent strength of the abdominal wall.
While the single suture for all the structures will frequently
afford a good wall, it too frequently results in a weakened ven-
trum which gives way with increasing corpulency and becomes
the site of hernia. After many trials with different methods of
suturing I have accepted the following routine as affording
9
130
CIV.VIiCOLOKY.
uniformly ihc lit-st results. Bojjin i.'xu;mal lo the apiineun-sis
■at the upper unfile nf the wound, curry a Xo. i chnimic tat-
put suture thnm^h ull the tissues below the a[x.>neun isis :tt the
rijiht side (if tlio wnuntl, secure the end of the suture by hemnstat,
and ask the ussistunt to niuinlain at least three inehes of it ex-
ternally. With tissue foreeps pitrk up and jKiss the suture
thmujjh the peritoneum only upon the left side. The subse-
Clnsid wilh Cotiliiiiiuiis V:
;;ut. 2. Silkwnrm-gul Sut\ii
throu^rli ,ill Ktrutluri'S aim
(juenl turns of ihf suluiv are eonlined tn the peritoneal marinns
of the Wound uniil the lowiT an^^de is reached, when the suture is
broujjht thnai^;h the aponeuMsisal ihe left side of the ineisinn.
(Fii;, <)i.i Willi iht.- Re\crdin neu-illc silkwonn-gut sutures are
now passeii almui one-half 1" ihree-fourths of an inch u(«rt
throuj^h all llic sirueuuvs above ihe peritoneum, und the ends
THERAPEUTICS 131
secured wdth pressure forceps. After drying the surface, begin
at the lower angle of the wound with the remaining portion of
the catgut suture, which closes the peritoneum and returns,
closing the aponeurosis only xmtil the upper angle is reached,
when tie to the end at the right side of the wound. This method
insures the accurate apposition of the aponeurosis and the res-
toration of the rectus to its normal sheath. The silkworm-gut
sutures are now tied with moderate pressure, insuring the obliter-
ation of dead spaces, and places the muscle surface of the wound
in a splint until the iinion can be secured. The ends of the silk-
worm-gut sutures should be left long. (Fig. 92.) Left long, they
promote drainage from the wound and facilitate their removal.
The combined crescentic and vertical incision is closed by a con-
tinuous suture for the vertical incision, which includes the peri-
toneum and edges of the recti muscles. This suture of chromic
catgut is only drawn sufficiently tight to hold the surfaces in
apposition. A second continuous suture brings in apposition
the edges of the aponeurosis, and a third will hold in contact the
skin edges. This suture may be subcuticular, but a continuous
suture through the skin edges, unless drawn tight, is equally effi-
cient and more quickly introduced. The skin edges accurately
apposed and the incision confined to the hair surface the scar is
completely obscured in a few months. Great care must be
exercised to control all bleeding vessels and, where there is a
disposition to oozing, drainage should be installed to prevent the
formation of a hematoma and its subsequent infection.
205. Dressing. — ^After the wound is closed it is washed
with alcohol and a sterile towel is pressed upon it, while the
remaining surface of the abdomen is being cleansed and dried.
The wound surface should be dressed with several layers of plain
sterile gauze. When the sutures are left long, the first pieces of
gau2:e should surround them and the remaining portions be
placed over the ends. The gauze should be covered with a pad
of gau2^ and cotton or wood wool. The dressings are held in
place w4th tapes attached to pieces of plaster, three on each
side, and, finally, a sterilized bandage. The use of the tapes
alTords a ready access to the wound without annoyance to the
patient.
206. Postoperative Treatment. — The struggle for life is too
often, both by the laity and physicians, regarded as won when
the operation has been completed, but in many cases this period
but indicates the beginning of a grave battle. It is true that
much may be done to lessen the trials of the after-period by care-
ful study and preparation of the patient for operation, by the
greatest expedition in the operation consistent with the most
132 GYNECOLOGY.
conscientious discharge of every detail of the procediire, the
limitation of the amount of the anesthetic, and the early and care-
ful regulation of the circulation. After the operation has been
begun or half completed is no time for the surgeon to stop and
hold a consultation as to what shall be the next step. He must
have prepared himself by study, meditation, and experience for
every possible complication and be ready to meet it when it
arises. Postoperative or after-treatment comprises the con-
sideration and exercise of those details which promote comfort,
advance the convalescence, and enhance the restoration of the
individual to normal health. Much of this work he must dele-
gate to her attendants, but by his watchfulness and advice they
must be governed. He should not himself, or allow others to,
fall into the habit of following a routine treatment, but it should
be directed to meet the necessities of the individual case. Under
the old method of treatment where many cases had a glass
drainage-tube inserted, it was necessary that the patient should
be restrained to the dorsal position. Unless the patient is exceed-
ingly nervous, very restless, apparently suffering intense pain, it
is better to give no anodyne. WTien she is nervous or com-
plaining, an enema of tincture of valerian fSij, with tinctura
opii deodorati gtt. 20 to f 5 j, may be given.
207. Comfort of Patient. — The patient is transferred from
the operating to the private room, where she is placed in bed,
covered warmly, protected from draft, and kept quiet; the room
should be darkened. If the operation has been protracted
or the patient is depressed, hot- water bottles should be placed
about her to maintain the body heat. These bottles should
be tightly corked and a blanket should be placed between them
and the skin. The patient, unable to understand or to make
known her discomfort, may be badly burned if such precautions
are not exercised. It should be recognized that the patient
profoundly shocked has a lowered resistance, which will cause her
to burn at a lower temperature than would occur in health. As
she reco\'ers, it becomes very irksome to remain in one position.
An attentive nurse can greatly add to her comfort by passing her
hands under the patient so that the cool air reaches the heated
back, by changing her from one side of the bed to the other, and
by keeping the clothing under her smooth and dry. Unless there
is some special contraindication, as the presence of a drainage-
tube, she may be turned upon her side. Indeed, the early and
frequent turning of the patient will prove beneficial. It pro-
motes peristalsis, favors the early passage of flatus, and lessens the
danger of unfortunate intestinal adhesions. The nurse should
support the patient's back and limbs with pillows. One of the
earliest symptoms of which the patient complains is intolerable
THERAPEUTICS. 133
thirst. It is better to limit the quantity of Hquid for the first few
hours to small quantities of hot water — a half ounce every hour,
given with a horn spoon, as the china cup would bum the hps.
Ice should not be given ; it increases the thirst and the patient
will not be content without a piece constantly in her mouth.
Both mouth and stomach soon become irritated. When the
patient does well, she can have a cup of tea or coffee on the
morning following the operation, small quantities of ice- water
or soda-water, equal parts of effervescent vichy and orange-
juice, a teaspoonful of beef-jtiice every three hours; and on
the second day light food, and by the end of the week a generous
diet.
208. Vomiting should be an indication to discontinue every-
thing by the mouth. Enemas of warm water, six to eight
ounces, may be given to assuage thirst, and when the patient
is in need of nourishment, nutrient enemas may be given every
three or four hours. Nausea and vomiting occur very fre-
quently after an operation and may continue several days.
The ejected material may be the fluid which has been ingested,
or bile, mucus, or the contents of the small intestine. The
application of a mustard-plaster and an enema of 30 grains
of chloral and i dram of potassium bromid in 2 ounces of warm
water will often be sufficient to quiet the irritability. If the
patient is constantly retching, it is better to give a large draft
of water with i dram of bicarbonate of soda, a cup of weak
tea, or some soda-water.
Professor Hare has suggested 2 grains of acetanilid and
i of a grain of caffein citrate, to be repeated in two hours. I
have found this formula of advantage in vomiting following
etheri25ation. Other remedies of more or less value are : cocain
(4 per cent, solution), 3 drops every hour; tincture of nux
vomica, 2 drops every hour; 2 drops of compound tincture
of iodin and ^ of a grain of carbolic acid every hour; or i
drop of Fowler's solution every half -hour. The earlier the
bowels can be evacuated, the sooner will the offensive material
be removed; hence the most effective treatment will be the
administration of a saline, or, when it cannot be retained,
the use of calomel alone or in combination with bicarbonate of
soda (gr. j-ij of the latter to from -J—] gr. of the former) every fif-
teen minutes until gr. j-iss of calomel are taken, when magnesium
sulphate one dram in syrup of ginger and cinnamon water is
given every hour until the bowels are moved. In frequent
vomiting a seidlitz powder is very etlicient, for if vomited, it
generally empties the stomach, and when retained, starts the
current through the canal. The powder should not be given in
the usual manner, but the sodium carbonate portion should be
134 GVNECOLOGV.
dissolved in water fSiij, tartaric acid dropped upon this dr\''
and given immediately. The patient should be encouraged to
retain this as long as possible. If vomited, the stomach is well
cleansed and generally a portion of the drug passes the pylorus
to exercise a good influence upon the intestine. A second pow-
der may be given in the same manner a half-hour later if the first
is ejected.
If the intestine is distended and has not yielded to enemas or
to the purgatives suggested, and the patient is constantly vomit-
ing small quantities of dark fluid, nothing will give quicker or
more lasting relief than irrigation of the stomach through a
stomach-tube. When it is evident that the vomiting is an indi-
cation of peritonitis, it is wiser to discontinue purgatives and
be content with lavage. No food, not even water, should be
given by the mouth, and peristalsis should be arrested by small
doses of morphin hypodermically. Rectal feeding may be re-
quired because of irritable stomach and the enfeebled condition
of the patient, and especially in conjunction with the treatment
suggested for peritonitis.
Peptonized milk or broth may be given every three or four
hours. When the patient is much depressed, a normal salt solu-
tion and whisky or bovinin in combination may be given. When
rectal feeding is i)ractiscd, the bowel should be irrigated once
or twice dailv.
209. Tympanites may be the result of a passive collection of
gas in the intestines, or may indicate tlie development of peri-
tonitis. The early passage of flatus is always an encouraging
symptom. The sensation of distention may be promptly met
by the use of an enema of —
Magnesium sulph.,"!
Glvcerin, \ a& 5 j.
Water. J
If relief is not secured, an enema of two tablespoonfuls of
turpentine beaten up with the yolks of two eggs and strained
into a quart of soapsuds should be administered. Keith recom-
mends an enema consisting of six grains of quinin dissolved in
four drams of whisky and two ounces of warm water, to be
given every two hours until three doses have been administered.
This prescription stimulates the nerv^e-centers and favors peris-
talsis. The most effective agent to influence increased peristalsis
is an enema consisting of an otmce of powdered alum dissolved
in a quart of hot water. If peristaltic action is marked, but
reversed, lavage should be employed, a hypodermic injection of
morphin given, and followed, after a rest of three or four hours,
by a repetition of the quinin.
THERAPEUTICS. 135
210. Shock. — Severe shock should be combated by the use
of artificial heat, enemas of coffee and stimulants, suppositories
of ice, elevation of the foot of the bed, bandaging the limbs, and
the injection of normal salt solution into the buttocks, beneath
the scapula, or directly into a vein. A hypodermic injection of
stnxhnin (gr. ^V~i) should be given according to the urgency of
the condition, and followed by some aseptic preparation of ergot.
Ergone in 20-minim doses is valuable, or it may alternate
m'th (i : 1000) solution adrenalin chlorid, 20 minims every two
hours. Atropin sulphate (gr. y^^) twice daily will be serviceable
in controlling the vessels. Where the loss of blood has been great,
the renal secretion arrested, or shock profound, the intravenous
injection of two to three pints of a one per cent, salt solution is
the most effective agent which can be employed .
211. Anodynes. — The patient should be encouraged to bear
the pain without an anodyne. When the pain is very severe,
it may be allayed by the rectal use of chloral, 30 grains in two
ounces of warm water.
When the patient is very much distressed, it may become a
choice between morphin and restlessness; and a hypodermic in-
jection of from l to {- of a grain should 1)C given. Morphin
decreases peristalsis and favors tympanites, and consequently
should, if possible, be avoided. Whenever it is ex'ident that
peritonitis has developed, that ])urgatives are ejected as fast as
given, moq^hin with lavage should be considered our sheet anchor
and be given for effect, giving an initial dose of gr. \~\-, and fol-
lowing with yV "to ^ every three hours.
212. Internal hemorrhage, if the technic is perfect, should
not occur. Its existence will be indicated by ])aleness of lips,
feeble or absent pulse, sighing respiration, and clammy perspira-
tion. The use of strychnin or the injection of salt solution
favors the increase of hemorrhage. The only proper treatment
is the prompt reopening of the wound and the ligation of the
bleeding vessel.
213. Peritonitis. — Peritonitis is dependent upon infection and
will (X^cur early or late according to its virulence. The aim of the
<jperator is, of course, to avoid the possibility of its occurrence,
but the patient may in many instances have been infected prior
to the performance of the operation, and all the skill of the opera-
tor could not have removed the sources for further development.
It is likely to occur in acute gonorrheal and septic infection of
the tul)es and pelvic structures, in large accumulations of blood,
either prior to or subsequent to the operation, which have been
infected from their juxtaposition to the intestines, soiling of
the peritoneal cavity by the contents of dermoid, glandular, and
papillary' ovarian cysts. Peritonitis is characterized by in-
136 GYNECOLOGY.
creasing tenderness of the abdomen, decreased peristalsis, tym-
panites, frequent vomiting, especially when occurring on the
second and third days; rapid, feeble, thready pulse, more or
less elevation of temperature. The vomited material may be
considerable, quantities of dark-greenish, bitter, and oftentimes
foul-smelling fluid— apparently a much larger quantity vomited
than the patient has taken. The tongue is dry, the patient com-
plains of intense thirst, is constantly crying for water and ice.
The administration of purgatives in these cases is generally in-
effective, for the reason that the patient vomits or regurgitates
everything as soon as taken. Enemas are of little value, as they
only empty the lower bowel. The proper plan of treatment is
to wash out the stomach with stomach-tube, give the patient
a hypodermic injection of morphin, gr. \ or ^^ repeating this
in doses of gr. yV ^^ i every two or three hours, keeping the
patient under its influence. As all efforts at increasing the per-
istalsis are ineffective, we aim to place the intestines in a splint,
remove the offensive material from the stomach and upper part
of the intestine by lavage. Under this course we will frequently
see patients that seem to be almost moribxmd become quiet,
comfortable, resting easily; after two or three days there will
be a profuse evacuation of the bowels and the patient go on to
recovery. The strength of the patient during this period shotdd
be maintained by hypodermic injections of ergone, strjxhnin,
hypodermoclysis of normal salt solution in the breasts and the
buttocks, and rectal feeding. If there is reason to suppose that
an accumulation of fluid within the abdominal cavity has oc-
curred, a vaginal incision should be made for its evacuation or
the abdominal wound reopened and drained by gauze wicks.
Ha\dng begun this treatment for peritonitis, the attendant should
not be in too great haste to secure the evacuation of the bowels,
as oftentimes the flame may be relighted by the too early ad-
ministration of a purgative.
214. Wound Infection. — It is the aim of the operator to se-
cure healing of the wound by first intention, and every safeguard
is thrown about the operative procedure in order to secure this
object. Occasionally, however, in spite of all precautions the
wound becomes infected from the material that is taken out of
the abdominal cavity, or in closing the wound a vessel is punc-
tured and hemoiThage of considerable quantity takes place into
the tissues directly over the peritoneum. If the depth of the
wound does not contain pathogenic germs, such an accumulation
is Hkely to become infected from its close proximity to the intestine,
and three to six or even ten days after the operation the patient
may develop a temperature, complain of more or less tender-
ness over the abdomen; the parts will be swollen. Where the
THERAPEUTICS. 137
abdominal walls are thick it will be difficult to recognize and
detennine the existence of any acciimtilation. It is better in
these cases, however, where careful examination discloses the
absence of any trouble within the pelvis or other portion of the
body to accotmt for the elevation of temperature, to make an
exploratory pxmcture through the structures sufficiently deep
that it may reach the space between the muscle wall and peri-
toneum. If the operator fears to penetrate the peritoneimi after
making the incision through the aponeurosis, he can enlarge the
opening by introducing a grooved director. The early evacua-
tion of such an accumulation will prevent the suppuration and
burrowing of the pus and will promote more rapid convales-
cence. The infection in some cases may have been carried into
the depths of the wound in the removal of the sutures.
215. Parotiditis. — Inflammation of the parotid gland is a
complication of rather infrequent occurrence. It formerly, how-
ever, occurred so frequently that it was considered that there
was some intimate relation between this gland and the pelvic
structures that caused metastasis of inflammation to it. It is
now recognized, however, that its inflammation and infection are
due only to the fact that this gland is more susceptible to the
influence of some forms of bacteria than other structures of the
body. Then, too, it is recognized that in the majority of in-
stances the infection reaches the gland through the mouth and
is due to local rather than general conditions. Where the patient
is suffering from peritonitis or septic conditions, with dry tongue,
decreased amoimt of saliva, the patient should be carefully
watched and the mouth kept clean to prevent the entrance of
infection to this gland. Where the gland shows signs of develop-
ing inflammation, the most effective treatment is to apply at
once an ice-bag over the infected gland, keeping it constantly
applied, thus limiting the amotmt of the inflammatory process,
and where suppxiration has occurred, the prompt evacuation of
the pus by an incision.
216. Ileus. — Ileus is an obstruction of the intestine that may
take place one or two weeks after an operation is performed. It
develops by nausea, vomiting, which goes on to the ejections of
stercoraceous material, intense pain, profound depression, shock,
rapid pulse, haggard, anxious expression, and, if unrelieved, is
likely to terminate in the collapse and death of the patient. It
is due to paralysis of a portion of the intestine from infection,
from adhesions constricting and making difficult the passage of
contents of the intestine through the tract, and twisting of the
gut, forming what is known as a volvulus or intussusception.
If the patient is not relieved by lavage and hypodermic injection
of morphin, the wound should be reopened and the condition
138 GYNECOLOGY.
overcome. In the majority of cases the mere opening the abdo-
men, freeing the adhesions, reestablishing the caliber of the
gut, will be sufficient to accomphsh relief. This procedure, how-
ever, should be done early, as otherwise the patient will be so
exhausted that it will be ineffective.
217. Phlebitis. -Phlebitis generally affects the saphenous
vein, sometimes extending into and involving the femoral and
iliac. This infection may occur at a later date in a patient who
otherwise has exhibited everv indication of a normal convales-
cence. A week or even two weeks after the operation has been
performed the patient complains of intense pain in the calf of
one leg, most frequently the left. The pain extends up along the
course of the vein and most frequently is associated with tender-
ness over the saphenous and the iliac veins. The patient should
be kept perfectly quiet, the limbs should be raised, bandaged,
first smearing over the course of the vein some ichthyol and bella-
donna ointment, taking ichthyol and extract of belladonna aa
3j, lanolin 5 j, wrapping well the limb with cotton, and apply-
ing a bandage, making moderate pressure its entire length. The
limb should then be elevated and kept more or less immobile by
placing a sand-bag on either side of it. An ice-bag should be
applied over the saphenous and iliac veins. Even after the acute
symptoms have subsided the i)atient should be kept in the re-
cumbent position and the limb perfectly quiet, as it is impossible
to say in any individual case what may be the termination. A
clot in the vein may become organized, obliterating the vein.
It may break down, indicating suppuration and the formation
of a localized abscess. Fragments of the clot may disintegrate,
be carried into the circulation, and form emboli, blocking up the
circulation to important viscera and giving rise to a fatal termi-
nation. The nutrition of the patient should be maintained to
the utmost degree.
218. Precautions in the Use of the Hypodermic Syringe. —
In the use of the hypodermic syringe there are four sources
of infection: (i) The hands of the operator; (2) the instrument;
(3) the fluids to be injected; and (4) the skin of the patient.
The syringe is difficult to keep aseptic. The metal instrument
may be boiled in a soda solution. If you have a glass instru-
ment, the piston should be withdrawn and it and the barrel
should be placed in a five per cent, solution of carbolic acid;
the needles, if platinum, may be passed through an alcohol
flame, but ordinary needles would be destroyed, and, therefore,
they should be boiled. Solutions of atropin, morphin, cocain,
strychnin, and ergotin favor the development of bacteria, and
when kept for some time, will be found swarming with micro-
organisms. Cocain may be kept in a (i : 10,000) bichlorid
THERAPEUTICS. 139
solution; the others named may be preserved by the addition
of a few drops of carbolic acid to the ounce of solution. Prob-
ably the safest method is to make up the solution of morphin,
atropin, or strychnin from tablets, which can be dissolved by
boiling without affecting the action of the drug.
219. Catheterization. — No procedure, fraught with so much
discomfort to the patient when carelessly employed, is so fre-
quently performed with so little consideration as is the use of
the catheter. We have to regard not only the distressing
s\Tnptoms produced by infection of the urethra and bladder,
but also the serious results of extension of the disease to the
ureters and pelves of the kidneys. Fortunately, the female
urethra is short, and permits the use of a glass catheter, which
can be kept clean. The instrument should be scalded before
and after being used, and should be kept in a five per cent,
solution of carbolic acid during the inter\^als. It should be
free from cutting edges.
The labia should be separated to expose the urethral orifice,
when the vestibule should be sponged with a solution of boric
acid or sterile water. The catheter should be gently introduced,
being held between the thumb and middle finger of one hand,
while the index-finger is placed over its opening to prevent the
premature discharge of urine. The instrument is carried up-
ward and backward as the patient lies upon her back, and when
it enters the bladder, as is evident bv the absence of resistance
and the appearance of urine in the instrument, its external end
should be brought over the receptacle between the limbs of the
patient. Should the quantity of urine be larger than the reser-
voir will hold, the finger placed over the end of the catheter will
permit it to be emptied and replaced. The bladder can be com-
pletely emptied by making pressure over the lower abdomen
with the unoccupied hand. With the discharge of the last
urine the finger should be again placed over the end of the cathe-
ter to prevent the urine flowing over the vulva or soiling the bed.
WTien pressure has been made over the abdomen, the finger
should be so placed before the removal of the pressure as to prevent
the aspiration of air into the bladder. Should the urethra be-
come painful or irritation of the bladder occur from frequent
use of the catheter, the bladder should be irrigated with a hot
boric-acid solution. After an abdominal operation the catheter
need not be used for twelve hours tmless the patient experiences
much distress.
220. Removal of Sutures. — The sutures in an ordinary case
should be removed about the seventh to the tenth day. If
the patient has had a complicated convalescence, the union
will not be so firm, and it would be better not to remove them
140 GYNECOLOGY.
until the end of two weeks. If the sutures are pulling and
causing pain, a part of them may be removed. The same care
regarding cleanliness and avoidance of sources of infection should
be practised as in the operation. Leaving the sutures long (see
Fig. 92) will facilitate their removal and dispense with the neces-
sity for forceps to lift up the knot. All the sutures should be
cut before any are withdrawn, then the long ends may be gath-
ered up and, bracing the wotmd with the fingers of the other hand,
they may all be withdrawn at once, thus giving the minimum
of discomfort. The woimd should be dressed as in the begin-
ning.
221. Getting Up. — In imcomplicated cases the patient may
be allowed to sit up at the end of two weeks. In complicated
operations or in disturbed convalescence the patient should be
kept recimribent for three weeks or more. When the patient sits
up it should be for but fifteen or twenty minutes, and preferably
in a chair, as the strain is less than if she is supported by a bed-
rest. The time should be increased daily.
222. Plastic Operations. — In plastic operations the same
precautions as to cleanliness must be observed. Sponging can be
replaced by the use of continuous irrigation. The parts may
be dusted with acetanilid or iodoform and boric acid. The parts
shotild be dressed with sterilized gauze held in place by a bandage.
Vaginal irrigation should not be practised during the first
forty-eight hours subsequent to an operation, for it interferes
with the sealing of the wound by plasma. The patient should
be confined to bed at least two weeks, and in perineal operations
three weeks are preferable. In combined uterine, vaginal, and
perineal operations the internal sutures, if nonabsorbable, should
remain for three or four weeks. I prefer chromic catgut for all
plastic work, for the reason that the patient is spared the dis-
comfort of the removal of sutures, and the newly united tissues
are not subjected to the strain.
MEDICAL TREATMENT.
223. General Treatment. — In every case of genital disease it is
very important that the various organs of the body shotdd be care-
fully in\'csligated as to the proper performance of their functions.
It is a hopeless task to attempt to treat the disease of one organ
of the body as if it were not an integral part of the whole, and
capable of producing reflex effects upon organs near or remote,
or of being itself the seat of reflex conditions. Engorgement of
the hepatic system and the consequent hemorrhoidal congestion
must be corrected. This is eflected by purgatives, laxatives, and
MEDICAL TREATMENT. 141
alteratives. The patient should have calomel (gr. -^) or podo-
phyllin (gr. ■^) at night, followed the next morning by a Seid-
Ktz powder, Rochelle or Epsom salts, phosphate of soda (5ij),
or a wineglass of Himyadi J^nos or Friedrichshall water. If
the liver is particularly sluggish, frequent applications of hot
w^ter over the hepatic region should be made. Ammonitmi
chlorid or potassitun iodid internally may be of service.
EiBficient action of the kidneys should be secured by the
use of diuretics, or want of action should be compensated by
increased action of the bowels and skin. As anemia is a frequent
accompaniment, the administration of the reconstructives, such
as qtiinin, strychnin, arsenic, mercury, the bitters, and, in proper
subjects, when the system has been prepared, the use of iron.
Because of the profoimd effect this class of diseases exert
upon the nervous system, the antispasmodics have foimd favor.
In many cases the valerianate of zinc, asafetida, and the bromid
salts will prove very grateful. In very nervous and anemic
patients the cold pack, followed by massage, will be exceedingly
beneficial. The state of the stomach, the heart's action, and the
character of the respiration should always receive consideration.
224. Specific Remedies. — The remedies which may be con-
sidered as specifically uterine in their action are ergot, hama-
melis, hydrastis canadensis, and viburnum prunifolium.
Ergot is generally given in hemorrhage. It acts in two ways :
(i) By stimulating the nonstriated muscle-fiber of the blood-
vessels, increasing the rapidity of the circulation; (2) its direct
action upon the uterine muscle, by which compression is made
upon the vessels and a mass within the uterus is gradually
extruded.
A satisfactory prescription is —
B . Ext. ergot., f^j
Ext. hamamelis, \ a& f5cc M
Tr. cinnamomi, f *^ ^^^' ^'
SiG. — f 5j every two or three hours.
This combination is generally more effective than the ergot
used alone. If the contractions are painful, one or two drops of
the fluidextract of cannabis indica will be of benefit.
Hamamelis and hydrastis undoubtedly owe their action to
the large amount of tannic acid they contain. Hydrastin or
hydrastinin, in doses of from J to J of a grain, is more effectual
in controlling hemorrhage than the fluidextracts.
Vibumtmi prunifoKum has been greatly vaunted as a remedy
for the relief of dysmenorrhea or the arrest of threatened abor-
tion, but I have never been able to obtain any perceptible value
from its use.
The extract of thyroid gland seems to exercise a specific
142 GYNECOLOGY.
influence upon the uterine mucous surface. In women who are
very obese and have associated with the condition amenorrhea,
or very scanty flow and sterility, the administration of the
thyroid extract, in addition to the reduction of flesh, increases
the flow, and frequently appears to overcome the sterility. The
late Dr. E. H. Coover, of Harrisburg, found thyroid extract very
effective in allaying the pain of advanced carcinoma of the
uterus. He also thought that it had an influence in delaying
the progress of the disease. This opinion seems in harmony
with the observations of Beatson and others in carcinoma of
the mammary gland.
Thyroid extract is frequently of value in producing an im-
provement in the conditions which occasion uterine hemorrhage,
whether these be from interstitial endometritis, submucous
fibroma, or carcinoma. Marked changes in the nutrition and
the reduction in the size of myomata have been claimed for
the use of this drug, but experience does not seem to justify
them.
Adrenalin, or extract of the suprarenal gland, through its
action upon the involuntary muscular fiber, exerts a decided
influence upon the uterine circulation. It is consequently a
valuable addition to our armamentarium for the control of
hemorrhage.
Apiol and the manganese salts cause a hyperemia of the
uterine mucous membrane, as indicated by increased normal
menstrual flow and its return in amenorrhea.
225. Rest and Exercise. — It is very difficult to fix definite
rules to guide a patient as to the amount of either rest or exer-
cise she should take. What one person may regard as a pastime,
another will consider violent exercise. Women with inflam-
matory or engorged uteri are benefited by certain hours of rest
each day. The recumbent position permits the blood-vessels
to secure relief. Not infrequently relief is enhanced by ele-
vating the foot of the bed or by resting the pelvis upon a firm
pillow. In predisposition to hemorrhage from fibroid growths,
the patient should be kept in bed for a few days prior to and
during the menstrual period. Rest is obligatory in all acute
inflammatory troubles. Some patients will, however, have
to be stimulated to take exercise; they are disposed to go to
bed on the slightest provocation, and remain so long that
their muscles become flabby and the vessels grow feeble; the
patient becomes bedridden, and every effort of exertion is at-
tended with real or imaginary pain. Such patients may require
resort to massage and electricity to enable them to resume
their ordinary duties.
Judicious use of the bicycle or encouragement to play golf
LOCAL THERAPEUTICS. 143
will be found most valuable auxiliaries in nervous patients
who are dominated by imaginary aches and pains. The in-
creased oxygenation and elimination without doubt free the
patient from the cause of her distress.
LOCAL THERAPEUTICS.
226. Baths. — The sitz-bath of hot water in inflammatory
and congestive conditions is capable of giving great comfort.
This should be followed by rest, and it would be contraindicated
where there was a tendency to hemorrhage or in a possible preg-
nancy. In neurotic patients, a systematic course of hydro-
therapy will frequently prove restorative when all other means
have proved futile.
227. Douche. — The value of the hot douche was made
known by Emmet. It should be given with a gravity syringe
while the patient is in a recumbent position; the more pro-
longed, the larger the quantity, and the higher the temperature
(115° to 120° F.), the more enduring will be the effect. The
ordinary fountain syringe, a large vessel with a tube leading
from its lower end, or an ordinary pitcher with a rubber tube
carried to and held at its bottom by a weight, may be used.
Instead of the ordinary rubber, wooden, or metal nozle, a glass
end-piece is preferable, as it can be more readily cleansed.
When preferred, the water may be medicated with astringents,
such as alum, sulphate of zinc, acetate of lead, hydrastis, or
hamamelis; or with antiseptics, as boric acid, carbolic acid
(two to five per cent.), or permanganate of potash (one to two
per cent.). The difficulty of saving the clothing from staining
renders the use of the latter agent less frequent. Creolin (one
to four per cent.) and acid sublimate (i : 5000 to i : 2000) are
valuable. The antiseptic injections are of especial value in
vaginal discharge, more particularly when of a specific character.
The advent of menstruation is considered as contraindicating
irrigation, but it may be resumed before it ceases, partictilarly
when the odor is offensive or the parts are irritated, using plain
water at a temperature of 100® F. If the vaginal discharge
is particularly offensive, as in malignant disease, a douche
of thymol solution, one or two per cent., is a most excellent
deodorizer.
Astringent douches are used in excessive vaginal secretion,
but should not be used when the patient is wearing a pessary,
as the salts are deposited upon the instrument, roughen its
surface, and thus increase the irritation.
Rectal douches may be employed to cleanse the bowel
144 GYNECOLOGY.
and for the relief of inflammation of the rectal mucous membrane
or for their effect upon the neighboring pelvic organs. The
close proximity to the uterus and broad ligaments, and the
ability to retain the fluid longer in contact, make the use of
the rectal enemas of hot water of especial value. Medicated
enemas are used to unload fecal accumulations for the relief
of tympanites, and to medicate local inflammations.
Vesical douches are used for the rehef of inflammatory dis-
ease of the bladder and urethra.
228. External Applications. — In acute inflammatory con-
ditions the popular plan of treatment is to employ hot applica-
tions, but we have in the ice-bag a far more efficient means
of allaying pain and of Umiting the area of inflammation. Its
persistent application will in many cases secure resolution in
what would otherwise prove a serious disorder. The ice-bag
over the sacrum affords prompt rehef of dysmenorrhea of the
congestive form.
229. Counterirritants are productive of benefit in the more
chronic forms of disease. Painting the skin over the lower
F'ig. 93. — Butt Uterine Scarifier,
abdomen with tincture of iodin is more frequently resorted to.
It may be repeated and continued so long as the skin will bear
it. The irritation is increased by the addition of croton oil.
R. 01. tiglii f.^j
Tr. iodi f3ij
vEtheris, f 3 V. M.
SiG. — Apply with brush externally.
It produces a crop of pustules, which should be allowed to
dry before the application is repeated.
The most effective procedure is the application of a bhster
over the seat of pain or to the inflammatory exudate two or
three times a month, but this should not be practised when
the patients are much depressed or very anemic.
230. Bloodletting. — The general abstraction of blood is
now rarely practised. Doubtless there are many cases in
which a good bleeding would cut short a severe illness or abort
an inflammatory attack. The local abstraction of blood by
the use of a scarifier or by puncturing the cervix will often
prove effective in relieving the pain of engorgement and in
promoting absorption and resolution of inflammatory conditions.
LOCAL THERAPEUTICS. 145
231. Local Applications. — A few years ago the routine
treatment was the introduction of solid silver nitrate into the
uterine cavity, the use of fuming nitric acid, and other power-
ful caustics. Such treatment cured by destroying the glan-
dular tissue of the part. Milder measures are now practised.
It should be an accepted rule that no intra-uterine medication
should be practised unless the uterine canal is freely open to
permit of thorough drainage.
Applications to the uterine cavity are made by wrapping
a probe or applicator with absorbent cotton, which, after being
Fig. 94. — Aluminium Uterine Applicator.
saturated with the medicinal agent, is carried into the canal.
A few drops of the medicinal agent may be introduced by the
long pipet. In the use of either procedure it is desirable that
the cervix shall be freely opened and the uterus in good posi-
tion. If not, the medication will produce uterine contractions
which will result in violent colic. Such attacks not infrequently
are followed by severe inflammation of the adnexa and even
of the peritoneum. To render intra-uterine treatment of value,
the plug of thick mucus which generally fills up the diseased
Fig' 95- — Long Glass Pipet.
cervix must first be removed, in* order to permit the contact
of the medicinal agent with the affected surfaces.
232. Various Agents. — The agents generally applied locally
may be classified as antiseptic, astringent, and caustic. The
antiseptic applications are the combination of carbolic acid,
creasote, iodin, and iodoform. Useful preparations are:
B . Acid, carbolic, 3 ss
Tr. iodi, f .^ j. M.
B . Creasoti, ]
Glycerin., > SlSl f 5 ss.
Alcohol., ) M.
B . Iodin (crystals), q.s. ad sat.
Acid, carbolic. (95 per cent.), f 5 j. M.
B . 40 per cent solution argyrol.
10
GYNECOLOGY.
An astringent effect can be secured by a combination o£
tannin, as:
Acid, tann
Tr. iodi, . .
Glycerin.,
The most frequent applications are the tincture of iodin
and Churchill's tincture.
Iodoform may be used in the form of crayons, as an oint-
ment, or as a powder, with the insufflator. The various as-
Fig. 96. — Insufflator — Straight Stem.
tringents may be applied in powder alone or in combination
with boric acid, iodoform, or acetamlid.
233. Astringents. — The most available astringents are alum,
borax, sulphate of copper and sulphate of zinc, the tincture
of the chlorid of iron, fluidextract of hydrastis, and fluid-
extract of hamamelis. The solid substances are best used in
mild solution. Some of these agents when used without dilution
are strongly caustic.
234. Caustics.— Crayons of sulphate of zinc (fifty per cent.)
are very effective for caustic pur-
poses, and are used in aggravated
forms of endometritis. Still more
effective is the chlorid of zinc in
crayons (thirty-three per cent.).
Liquid caustics are nitric acid,
acid nitrate of mercury, sulphuric
acid, hydrochloric acid, chromic
acid, solution of zinc chlorid, solu-
Fig. 97.— Tampon. tion of silver nitrate, tincture of
iron chlorid, carbolic acjd, and crea-
sote. In my ju<l!fmcnt tlic more active caustics are rarely re-
quired, and very frequently their employment is followed by
cicatricial changes mote grave than the original condition.
235. Tampons made of absorbent cotton, lamb's wool, or
gauze afford an efficient method of treating the cervix. The
best tampon is composed of a combination of gauze and cotton
or lamb's wool. It should have a thread attached, by which it
can be withdrawn. The tampon may consist of simple sterilized
LOCAL THERAPEUTICS. 147
material, or may be medicated with antiseptics, astringents,
st\T)tics, anodynes, or alteratives. The principal purpose of the
tampon is to sustain the uterus at a higher level, which relieves
the patient from the dragging pains due to want of support of
a hea\T organ, and the change of position improves the circu-
lation; the addition of an antiseptic permits it to be retained
for a longer period without becoming foul. Sublimate, from
its tendency to irritate the vagina and vtdva, can not be satis-
factorily used. Carbolic acid, boric acid, and iodoform are most
satisfactory. The addition of glycerin is of value. By its affinity
for the watery portions of the blood it produces a profuse dis-
charge, which depletes the vessels and favors the absorption
of exudates. Boroglycerid, glycerite of tannin, and a ten to
twenty per cent, solution of ichthyol are popular applications
upon the tampon, but the patient should be cautioned, in the
use of the two latter, to wear a napkin in order to prevent hei
clothing from becoming stained.
Besides supporting the uterus, the tampon may be used
to control hemorrhage or discharge; to complete the diagnosis,
through the discharge which it induces; to assist in maintain-
ing the uterus in a normal position; and to prepare the way
for the use of a pessary.
236. Massage. — General massage affords an effective means
of promoting nutrition and of improving the condition of pa-
tients suffering from chronic pelvic troubles. It increases
the number and the activity of the red blood-corpuscles, carries
oxygen to the remote tissues and organs, facilitates oxgenation
and combustion, and favors absorption, but, best of all, it im-
proves the nerve tonus. Many patients are incapacitated by
illness, by aggravated pains, or by disinclination to take exer-
cise. Judiciously regiilated massage accomplishes the con-
stitutional changes ordinarily effected by exercise, free from
its possible deleterious influences. Slowly the individual is
rehabilitated, and as she gradually and insensibly resumes
her self-control, she is emancipated from the preexisting un-
forttinate nerve phenomena.
237. Pelvic Massage. — The beneficial results of massage
in local inflammations of joints and superficial portions of
the body justified the hope that it might be practised with
advantage in the conditions of acute and chronic exudations
within the pelvis. It has been systematized into a recognized
procedure, known as pelvic massage, largely through the study
and experiments of Thure-Brandt, a Swedish masseur.
It is practised by having the patient lie upon her back upon
a couch or table, with her buttocks close to its edge ; the limbs
are flexed upon the body. One or two fingers of the left hand
148
GYNECOLOGY.
are introduced into the vagina, with which the uterus is gentK'
pushed forward against the anterior abdominal wall. The-
fingers of the right hand are placed upon the abdomen, and
are moved in a circulatory or rotatory manner over the sur-
face, or, rather, moving the surface with them in this manner.
(Fig. 98.) The greatest gentleness must be exercised in the
beginning, increasing the pressure as the patient becomes
FiR. 9.'
Massage.
reassured or as the pain is lessened. As we progress, the fin-
gers may be made to dip down, to push off and separate ad-
herent organs, and to follow lines of cleavage indicating in-
flammatory adhesions. Tlic .seances var\- in length from five
to fifteen minutes, the slinrier time being preferable in the
earlier applications, and they should be repeated from three
times weekly tn once daily. The exercise of this procedure
ELECTRICITY. 149
will be found to produce a rapid alteration in inflammatory
accumulations, setting free the uterus and its adjacept organs.
The procedure will be indicated in all subacute and chronic
inflammations of the pelvic organs unassociated with pus-for-
mation; in displacements, when fixed by inflammatory adhesions;
in subinvolution and hypertrophy of the uterus, from chronic
interstitial inflammation; and in relaxation of the pelvic floor
induced by increased weight of the pelvic organs.
It is contraindicated in the presence of pus-formation,
whether contained in the tubes or within the pelvic tissues.
Massage is rendered difficult by thick abdominal walls,
and in nervous, hysteric women. In the latter, however, much
may be done by gentle procedure \mtil the patient's confidence
and cooperation are sectired.
ELECTRICITY.
238. Forms. — The immense influence exerted by the use
of electricity in the development of the arts and sciences nat-
urally has led to its study and utilization in the treatment
of disease. The various electric currents were early employed
in an empiric way in gynecology. It remained for Apostoli,
however, to formulate plans for their more accurate dosage
and systematic use. The principal forms in which the electric
current is generated and applied are Franklinic, galvanic,
faradic, sinusoidal, and R6ntgenic.
239. Franklinism. — Franklinism, or the static ciurent, is
the employment of electricity generated by friction. It is
not generally used, but is an excellent nerve stimulant and
coimterirritant, from the use of which great benefit has been
claimed in cases of hysteria and neurasthenia. It has afforded
the greatest service to patients in whom the local pelvic lesions
are slight or difficult to recognize while the element of pain
is a marked factor. It Has been employed with advantage
in amenorrhea, dysmenorrhea, ovarian, lumbar, or lumboabdom-
inal neuralgia, vaginismus, hyperesthesia, and various neu-
rasthenic conditions. The seances may be continued from
six to thirty minutes. The number of applications is indefinite.
240. Galvanism. — The galvanic current has an extensive
field for its application in the treatment of diseases of the pelvic
organs. As a therapeutic agent its effects are recognized as
polar, interpolar, and general (Martin). The polar effects are
acid and alkaline at the respective poles. In very strong cur-
rents the action becomes caustic. The positive pole is a power-
ful sedative to the sensory nerves, and acts as a vasoconstrictor
150
GYNECOLOGY.
of the blood-vessels in its vicinity. As a result of the accumu-
lation of certain salts from the metal electrode employed, it.
proves destructive to germs. The negative pole with current
of proper density causes liquefaction of the tissues, and if the
current is very strong, it exerts an alkaline caustic action.
It is a powerful irritant to the sensory nerves of the parts, and
also acts as a vigorous vasodilator of the blood-vessels. Inter-
polar action consists of electrolysis and cataphoresis, or transfers
Fig, 99.— Portable Galvanic Battc-ry with Galvanometer.
all fluids in bulk from the positive to the negative pole. Gal-
vanism in its general effect, when forced through a portion
of the body, acts as a tonic to the entire system. The beneficial
influence of the agent in gynecology is most effectively dis-
played in the treatment of chronic endometritis, pelvic inflam-
matory exudates, and in some varieties of fibroid tumors.
241. Apparatus for Application. — The investigations of
Apostoli demonstrated that the application of high powers
ELECTRICITY.
151
of electricity resulted in the destruction of tissue in which
acid materials were found about the positive pole, while alkalies
collected at the negative. The former caused a dry, brownish
eschar; the latter, a soft, watery, elastic slough, which did
not contract. The resistance of the skin required for the use
of high powers a large, inactive electrode externally. Apostoli
devised and employed a moist clay pad. Other operators
have used a bladder or other animal membrane filled with
a salt solution, or a large metal disc covered with wet cotton
or a towel for the external electrode. The internal electrode
Fig. loo. — Intra-uterine Electrode with Movable Insulating Cover.
may be vaginal or intra-uterine. The former may consist of
a Imob or a nest of knobs, from which a suitable one can be
selected and attached to a gutta-percha-covered metal rod.
The intra-uterine electrode may consist of a platinum wire
or a steel rod instilated to within one or two inches of its end.
The insulating sheath of gutta-percha or celluloid may be mov-
able and thus permit a variable surface to be subjected to the
application.
A battery, either portable or stabile, will be required, cap-
able of generating a current of from 200 to 400 milliamperes,
and so arranged that the strength of the current can be gradually
Fig. 10 1. — Vaginal Electrodes of Different Sizes.
increased. It should be provided with a galvanometer or a
milliamperemeter to measure the current; a rheostat, by which
the strength of the current can be governed; a commutator,
to permit a change of poles without removal of the electrodes
(as a reversal of the poles can not be made without shock,
the precaution should be exercised greatly to reduce the in-
tensity of the current before such a change is made).
242. Method of Procedure. — ApostoH's employment of the
electric current requires a careful examination and an accurate
diagnosis. If a growth, careful measurement from various
fixed points should be made in order to be able to determine
152 GYNECOLOGY.
the results of treatment. The hands, genitalia, and electrodes
must be thoroughly cleansed or disinfected.
Before the external electrode is applied the skin should be
carefully examined and all broken places covered with collodiot
or plaster; otherwise the electrode will be unendurable.
The internal electrode should be introduced without the
speculum. The patient should be apprised that there wil]
be a slight burning, and that there may be a bloody discharge
subsequently. Her clothing should be loosened, her corsets
removed, and the bladder and lower bowel emptied. The
application should not follow a full meal.
While the electrodes are being introduced, the current should
be closed, and gradually opened subsequently. The first ap-
plication should be carefully made for the purpose of determin-
ing the patient's sensibility. The pole used for the active
or intra-uterine electrode must depend somewhat upon the
existing conditions. The positive pole, possessing the most
electrolytic action, and being an effective hemostat, should
be employed for hemorrhage. The negative pole acts like an
alkali, is the most painful, and is used to decrease the size oi
a growth or to enlarge a stenosed canal. The duration of the
applications may vary from three to ten minutes. The num-
ber of applications for an individual case is difficult to fix —
generally from twenty to thirty. Their frequency is dependent
upon the condition, varying from every eighth day to two oi
three times weekly.
243. Indications. — The employment of galvanism is advocated
in amenorrhea, dysmenorrhea, and menorrhagia; in chronic
inflammation dissociated with suppuration; for the arrest oi
hemorrhage, relief of pain, and decrease of size in myomatous
growths of the uterus, particularly in the submucous and inter-
stitial varieties; and for chronic ovarian inflammation. This
agent seems particularly valuable in women stiffering fron:
bleeding fibroids near the menopause, in whom the conditions
render a radical operation tmjustifiable.
244. Contraindications. — ^According to Apostoli, the galvanic
current is contraindicated in the following conditions: (i)
Hysteria; (2) intestinal catarrh; (3) pregnancy; (4) malignant
degeneration of a tumor; (5) fibrocystic tumors; (6) suppurative
inflammation of the adnexa. To these, Schaeffer would add
any acute or subacute inflammation of the pelvic viscera, a
very hard or fully matured tumor, an excessively large growth,
a submucous growth which is pedunculated, enfeebled heart
action, and acute nephritis.
245. Faradic. — The current of induction has a primarj
and a secondary current. One pole may be applied in the
ELECTRICITY. 153
vagina or the uterus; the other, over the abdomen. Apostoli
advised a bipolar electrode in which the negative and positive
poles were placed in the same electrode, with a band of non-
conducting material between them. In this way the current
of electricity was limited to a greater extent to the tissues de-
sired to be affected. This method of procedure was less painful.
The primary current is one of quantity ; the secondary one of
tension. The latter is dependent upon the length and fineness
of the wire. The current of tension is effective in subduing
pain, such as ovaralgia, abdominal pain in hysteric women,
raginismus, and pain from pelvic inflammation. It proves
Faradic Battery.
to be an emmenagog. It may be applied thtee times weekly,
or even daily, each sitting lasting from ten to thirty minutes.
The electrode is first introduced; the current is then opened
slowly, and gradually closed before the electrode is removed.
This is necessary in order to prevent severe pain.
346. Sinusoidal. — Apostoli employed a current introduced
by d'Arsonval, known as the sinusoidal. The patient is placed
upon an insulated couch beneath which is a large coil of wire
through which a current of 450 millJamperes is passed. The
patient is enveloped in an electric atmosphere in which the
effects will depend upon the number of alternations in a second,
the degree of electromotive force, and the quantity of current.
154
GYNECOLOGY.
It acts more particularly upon the muscular structures with-
out inducing pain or disagreeable sensation. Its employ-
ment modifies nutrition by an increased absorption of oxygen
and the greater elimination of carbonic acid. The current
exerts a marked analgesic effect, which frequently induces
the disappearance of painful symptoms. It is consequently
of benefit in dysmenorrhea, but has displayed its beneficial
effects to the greatest extent in the treatment of peri-uterine
inflammations and pelvic exudates, in the resorption of which
it is one of the most effective means at our disposal.
Fig. 103. — Bipolar Uterine Electrode.
-f . Positive pole. — . Negative pole.
247. Rdntgenic. — This term is applied to peculiar rays of
light which are engendered by light under electric excitement,
being transmitted through tubes of very high vacuum. The
discoverer of this phenomenon, Professor Rontgen, of Wurz-
burg, designated these rays as the :jf-rays. The influence of
the discovery of a procedure capable of transillumination of
the structures of the body can hardly be estimated. The
^-rays have proved both diagnostic and therapeutic aids. They
can be generated through the employment of the static machine,
Fig. 104. — Vaginal Electrode — Bipolar.
the induction coil, batteries, and the electric-lighting main.
The essential portions of the apparatus are the vacuum tube
and fluorescent screen. The latter consists of a lightly con-
structed tight box, somewhat similar in shape to the stereo-
scope. The small end has an aperttu^e which is made to fit
tightly over the eyes and bridge of the nose. The inner sur-
face of the broad end is covered with a uniform layer of fine
crystals of a fluorescent material, generally barium platino-
cyanid or calcium tungstate. Not only is the operator able
to inspect the internal structtu-es of the body, but he is also
ELECTRICITY. 155
able to record what he sees upon a sensitive photographic
pkte for the benefit of others.
The employment of the procedure has afforded information
of value in the diagnosis of obscure cases, notably in pregnancy
and ectopic gestation. The beneficial influence of the rays
in the treatment of superficial malignant and tubercular con-
ditions suggests the hope that it may be equally effective in
arresting the ravages of these disorders when they involve
the deeper structures. The rays are found to exert a more
destructive action upon the less resisting malignant cells than
upon the healthy tissues. If subsequent investigation shall
demonstrate the correctness of this view, which now seems
probable, the operator who does not follow his radical opera-
tion with the employment of the Rontgen rays to destroy in-
fectious germ-cells which have possibly lodged in the neighbor-
ing lymphatic spaces and vessels will fail of doing full justice
to the interests of his patient. In carcinoma of the cervix
the depth from the siuiace of the tissues involved renders the
application more difficult, and requires special care to pro-
tect the superficial structures from bums which would delay
and arrest the necessary treatment.
In deep-seated cancer my observation and the careful anal-
ysis of that of others lead me to believe that not sufficient
benefit is derived from the employment of the ^-rays to com-
pensate for the discomfort of the applications and the occasional
dermatitis arising from their employment. In superficial cancer,
tuberculosis, obstinate eczema, acne, and pruritus the rc-rays
have proved of advantage, but in malignant disease of the
deeper structures their employment should not precede surgical
measures in operable cases.
248. Finsen Light. — The Finsen light consists of the ultra-
violet rays, which are invisible to our vision and are capable
of refraction and concentration. They exist largely in sun-
light, but may be artificially produced from the arc light. Glass
is a non-conductor to these rays, therefore it is necessary to
construct a plate or disc of quartz, or, still better, of trans-
parent rock-salt. The Finsen light differs from the Rontgen
rays in being very destructive to bacterial life, while the latter,
if it has any effect, rather facilitates bacterial growth. The
application of the Finsen light must, under present conditions,
have a limited application in gynecology, because it causes
an anemia of the tissues upon which it is purposed to exert its
influence.
249. Electrocautery and Light. — The employment of elec-
tricity as a means for the production of heat for cautery ptu*-
poses has won a well-recognized place through the work of
156 GYNECOLOGY.
Byrne with the galvanocautery, and later its ingenious applica-
tion by Skene and Downes to electrothermic hemostasis.
The power can be secured by batteries of large size, by
storage cells, or, better, from the street main through a trans-
former. Dr. Downes has modified and improved the instru-
ments devised by Skene. He applies a special form of angio-
tribe to the broad ligaments, which, when raised to a dull red
heat, divides and cooks the tissi;es, thus rendering ligatures
unnecessary.
The great advantage of this procedure is in hysterectomy
for cancer of the uterus, as it enables the removal of a large
amount of possibly infected tissue. The malignant cells which
have been carried into the parametritmi are supposedly less
resistant to the effects of heat than healthy tissue. There-
fore it seems reasonable to infer that some of these are de-
stroyed by the electrothermic measures which would other-
wise survive to cause relapse if other methods of operating
had been employed.
The same class of batteries enumerated for cauterj*" pur-
poses may also be employed for electric lights. The electric
light is especially useful in inspecting the urethra, bladder,
ureters, and rectum. The electric light in a cystoscope can
be introduced through the urethra and the entire cavity of
the bladder exposed, the orifices of the ureters recognized, and
any changes in the structure of the bladder are readily observed.
The instrument may be employed to irrigate the bladder by
closing its end; the bladder can be distended with air or gas,
thus determining the capacity of the organ. Loss of structure,
thickening, growths, and other changes in its walls are also
perceived. It can also be employed for local medication and
for catheterization of the ureters. The electric hght can be
employed to illuminate the rectum through long or short proc-
toscopes, the vagina by an attachment to a speculum, and
even to look into the uterus, but as the latter canal has to be
previously dilated, the instances are rare when its illiunination
will be of practical service.
EMBRYOLOGY AND ANATOMY OF THE GENITO-URIKARY
ORGANS OF THE WOMAN.
250. Development of the Genito- urinary Organs. — Some
knowledge of the origin and processes of development of the
organs is necessary to a proper understanding of the condi-
tions in which they have failed to attain the normal. The
embryonic period may be di\4ded into five periods or stages.
EMBRYOLOGY. 157
The first period extends to the eighth week. Up to the fifth
week from fecundation there is developed no sexiaal indication.
The primordial kid-
ne)'. the Wolffian
body, the duct of Mul-
ler. and the Wolffian
duct, from which the
genital organs are
to be developed, are
found one upon each
side of the median line.
A cloaca is situated at
the site of the future
vulva, into which the
urachus and intestine
open. From the ex-
tonal surface of each
Wolffian body a struc-
ture known as the
genital gland develops,
which subsequently
becomes either the tes-
ticle or ovary. Simul-
taneously, the cloaca
is divided by a projec-
tion— the genital emi-
nence or tubercle —
which is marked by
the genital furrow or
groove. Their appear-
ance at the eighth
week affords no clue as
to the probable sex.
Tlie Second Period
(Eighth to the Twelfth
Week).— The Muller-
ian ducts coalesce, and
the septum disappears
in their lower two-
thirds, while the in-
sertion of the round
ligament indicates the
point of division be-
tween the tube and
the uterus. The cloaca, by the development of the perineum,
is divided into two portions — the urogenital sinus and the anus.
Fig. I OS.-
I. Tongue.
-Human Embrj'o at End of Thirty-five
Days. — (Coste.)
2. Aortic Bulb. 3. First permanent
aortic arch. 4. Second aortic arch. 5. Third
aortic arch, or ductus Botalli. 6. The two
filaments to the right and left of this fi^
are the pulmonary arteries. 7. The ti
the superior vena cava and tne right aiygos
vein. 8. The common venous sinus of the
heart. 9. Left auricle of the heart. 10.
Right ventricle. 11. Left ventricle. i».
Lungs. 13. Stomach. 14. Left omphalo-
mesenteric vein. 15. Wolffian body. 16.
Right omphalomesenteric vein. 17. Intes-
tine. 18, i8. Umbilical a-'
biltcal vein.
GYNECOLOGY.
The third period (twelfth to twentieth week) witnesses the
fusion of the uterine horas; the appearance of the arbor vita in
the cavity of the uterus; the formation of the cervix; enlarge-
1 06.— Coalescence of MoUer'
ment of the perineum ; and development of the vagina, which
opens into the urogenital sinus and forms the vestibule of the
vagina, in which the hymen appears. The genital tubercle, which
of Development of the Genitalia.
Fig. 108.— CI. Cloaca. Fig. 109,— Su. Urogenital
B. Bladder. R. sinus. R. Rectum,
Rectum. V. Va- separated from the
gina. — {Sckrdder.) former by the peri-
neum. B. Bladder.
V. Vagina, u. Mtk-
thra.— (SeAriJd#T.)
has been large, is reduced to the proportions of the clitoris, and
the edges of the genital fissure become the nymphae.
The fourth period extends from the twentieth week to the
Progres;
Fig, 107. — All. Allantois.
R. Rectum. M. Mul-
ler's duct. X. In-
dentation of the skin
which forms the
an us. — (Schroder . )
ANATOMY. 159
end of fetal life. During this period the fundus of the uterus
increases in size ; folds form in the vagina, as well as in the cervix,
and the labia majora become fuller and more rounded.
Tlie fifth period comprises the time from birth until puberty.
The uterus increases in size and thickness ; the uterine mucous
membrane, which up to the sixth year is folded like that of the
cerm. becomes smooth. The vagina is elongated, and the
vTilva is larger and more rounded.
251. Division of the Genitalia. — The special generative
organs of the woman are situated in the pelvis in close associa-
tion with the bladder and urethra, the rectum, and the anus.
The female genitalia are divided into two classes : the external
and internal organs, the former of which, with the vagina, form
the organs of copulation, and the latter the reproductive organs
proper.
252. The external genital organs are, enumerated from
before backward, the mons veneris, the labia majora, the labia
minora, the clitoris, the vestibule, perforated by the meatus
urethrae extemus, the orifice of the vagina, surrounded in the
virgin by the hymen, the fourchet, the fossa navicularis, and
the perineum, situated between the vulva and the anus. The
external genitalia are also called the vulva, pudendum, or
cunnus; the cleft between the labia majora is known as the
rima pudendum.
253. The mons veneris is a cushion of fat situated over
the pubes, covered with thick skin which is abundantly sup-
plied with hair. The hair protects the vulva from the per-
spiration of the body. When the nude woman is erect, the
mons veneris is the only portion of the genitalia visible.
254* The labia majora are skin folds which unite in front
of the mons veneris. Posteriorly they thin off and terminate
about one and one-half inches in front of the anus. Externally
they are covered with short, crisp hair, which is continuous
with that of the mons veneris. They are profusely supplied
with sebaceous and sudoriferous glands. Their internal sur-
faces lie in contact and present a smooth, moist surface which
resembles mucous membrane. The apposition of the labia
majora, slightly separated by the labia minora and clitoris,
forms the cleft of the vulva, the rima pudendum. Each labium
contains a sac-like structure called the dartoid. This is anal-
•ogous to a similar structure in the male scrotum. The round
ligament, and in the fetus an open canal, called the canal of
Nuck, terminates in this dartoid sac. Occasionally the latter
remains open in the woman and permits the formation of a
hydrocele. In fat subjects these folds contain a large quantity
of adipose cellular tissue.
160 GYNECOLOGY.
255. The labia minora are situated between the labia
jora, slightly projecting beyond their level, and are much :
prominent anteriorly. Upon wide separation they are set
be continuous with the fourchet, and form the posterior
missure. Anteriorly they bifurcate and form two folds
anterior, which passes in front of the clitoris and form
prepuce or hood ; the second passes behind the glans cl:
Sijiarattd. — {Frotii Deawr.)
and forms the frenulum. The labia minora, also called
nymphas, have a smoother, but slightly roughened surface,
free convex, sometinu-s notched, borders. Frequently
openings or perforations will be seen. The size of the nyr
varies greatly according to the age and race. They pi
considerably beyond the vuha in the young child, but, c
ANATOMY. 161
to the increase in size of the labia majora as puberty approaches,
they are rendered less apparent. In the Bushwomen the
labia minora frequently become so long that they reach to
the knees, and are then spoken of as the Hottentot apron.
The skin is covered with a stratified pavement epithelium,
aniilar to that of the true epidermis. They are plentiftilly
supplied with sebaceous glands, especially at the base of the
fokk, where they form a crowded layer upon the inner surface-
In the brunette the pigment deposit is frequently so great as
ing the Hymen Unruptured.
to make them noticeably dark. The skin folds contain a small
amount of connective tissue. During the act of coition the
labia minora draw the glans clitoris against the male organ.
256. The clitoris, as in the male, is an erectile organ, having
its origin from the posterior surface of the ischiopubic rami,
arising on either side as a crus clitoridis or corpus cavemosmu.
These unite to form one body in front of the symphysis. The
organ is secured to the symphysis by the action of the sus-
pensory ligament, and its circulation is influenced by the ischio-
cavemosus muscle, in which respect, therefore, it resembles
162
GYKECOLOGy.
the penis. The corpora cavernosa are enveloped by
investment and separated by a median septum of (
tissue composed of fine trabectilae, in which the mus
ments predominate. The free extremity of the clitoris i
at the anterior part of the vulva, about one-half inc
the anterior extremities of the labia majora. The
surmounted by a median tubercle known as the glans
The glans is more or less covered by the prepuce, which
by the anterior folds of the labia minora or nymp
glans is imperforate and is generally but slightly d
Fig. 113. — Hjinen Ann
When it appears enlarged, the other parts of the v
generally be found small and ill developed.
257. The vestibule is, by some anatomists, desi
the entire space between the labia minora, which, pri
rupture of the hymen, includes its external surface
this portion largely disappears after successful coil
completely after parturition, it seems better to confine
to the portion ordinarily called by that name, whii
space bounded on each side by the labia minora, and p
by the anterior border of the vagina. This triangu
has the glans clitoritHs at its apex. At its center,
posterior border, is a rounded, pouting orifice — th(
urethrffi extemus. The openings of the ducts of two clusters
of large mucous follicles are also found in this situation. One
of these groups lies immediately behind the clitoris, and when
the ducts become occluded, a cyst is formed. The other group
is near the sides of the meatus. Mucus is secreted very freely
by these follicles under any persistent local irritation. In
the \'irgin a grooved ridge is found which, according to Pozzi,
represents the corpus spongiosum of the male and is known
as the vestibular band. The orifice of the meatus urethrfe
is situated behind the clitoris in the posterior part of the vesti-
bule, and about one inch in front of the fourchet. It ordi-
— Hymen Sciratus.
Fig. 115.— Hj'mfn Infundibularis.
narily presents a longitudinal or starred slit, the borders of which
are slightly notched and projecting. Occasionally its mucous
membrane bulges, forming a ring-like margin. Within the
elevated margins of the meatus and slightly posterior to its
center is found a minute opening, on each side, which usually
is not easily detected in healthy subjects ; but following gonorrhea
or leukorrhea they may be readily recognized. These openings
are the orifices of Skene's ducts, which are parallel to the ure-
thra and about two centimeters in length. Thev should be
recognized, as they are sometimes so large that a catheter
may enter one of the canals instead of the orifice of the urethra.
164 GYNECOLOGY.
358. The hymen is a thin membrane acting as a sort oi
diaphragm between the internal genital parts, on the one side,
and the external parts and orifice of the urethra, on the other,
which is revealed by separation of the labia minora. (Fig. iii.)
Its external surface resembles the structure of the latter, while
the internal presents not infrequently the rug^ of the vagina.
When the labia are not forcibly separated, the hymen appears
as a vertical slit with its lateral edges in contact. With the
labia held apart, however, the opening is usually crescentic
with its concave margin anterior. (Fig. 112.) Sometimes it is
annular with a central opening. (Fig. 113.) The hymen may
Hymen Cribrifonnis.
present a \-ariety of forms and openings, such as the labial
form, in which the lateral folds may be mistaken for the labia
minora; the Jinguiformis, which presents a tongue-shaped
projection posteriorly, and the falciform, which has a some-
what long and wide orifice. The free edge of the hymen may
be smooth, denticulated, or serrated. (Fig, 114.) Its structure
may be thick and fleshy, and present irregular folds resembling
fimbri£e. The infundibular form (Fig. 115) presents a fiumel-
shaped appearance with the margins looking downward and
backward. There may be two openings, the septus or biseptus
ANATOMY. 163
{Fig. ii6), or a number of openings, as the cribriform (Fig. 117}.
The membrane is usually thin and easily torn, but occasionally
it is so firm that it withstands the most strenuous efforts at
coition, and, therefore, will require incision before the sexual
act can be accomplished. The hymen usually ruptures during
the first coition, and occasionally its tear is followed by pro-
ftise and often dangerous bleeding. (Fig. 118.) The greater
portion of the hymen is destroyed during the process of par-
turition, the remainder shrinking together to form small masses
at the vaginal outlet. These masses are known as the carun-
culffi myrtiformes. The number, form, and situation of these
caruncles vary extremely. Generally
there are three. One is situated at
the posterior part, the others at the
sides of the entrance to the vagina.
Both surfaces of the hymen are cov-
ered with pavement epithelium. The
hinen guards the entrance to the
^-agina.
359. The fourchet is a continua-
tion backward of the labia minora in
the form of a thin fold, and is rend-
ered prominent by the separation of
the vulva. Between this fold and
the hymen is a boat-shaped depres-
sion called the fossa navicularis.
Between the fourchet and the anal
opening is an intervening space cov-
ered with integument, some four cen-
timeters in length, which is called
the perineum.
260. The muscles of the perinetmi
are exposed by the removal of the
skin, the superficial fascia, and a
layer of the deep fascia. The mus-
cles thus mapped out are : The erec-
tor clitoridis; the bulbocavernosus and the transversus perinei,
paired muscles; and the sphincter am and levator ani, which are
single. The erector clitoridis arises from the anterior margin of
the rami of the pubes and ischium and is inserted by two ten-
dinous expansions, one above the junction of tlie crura into the
body of the clitoris, and the other below and in front. The bulbo-
cavernosi muscles arise from the tendinous raphe and anterior
aponeurosis of the perineum, and are separated by the vagina,
around which they course, to be inserted by a thin slit into the crus
of each side in front of the erector clitoridis. The outer tibcrs of the
166 GYNECOLOGY.
muscle wind inward beneath the erector muscle to reach the upper
part of the bulb near its isthmus. A portion of the m^ian
fibers are apparently derived from the sphincter and pass up-
ward to the clitoris, over the pubes, and are lost in the super-
ficial fascia. Other fibers form a delicate muscular arch in
front of the body of the clitoris. The action of the muscle is
to compress the bulb of the vagina and to some degree act as
a sphincter of the vagina, though Savage assigns the latter
Fig. 119. — -Muscles of llie Femali; I'c.
function to a portion of the levator ani. The relation of a
portion of the fibers to the sphincter ani produces a figure-
of-8 action upon the tivo orifices, which it is important to re-
member in operations upon the sphincter. The transversus
perinei muscles arise one on each stde from the tuberosity of
the ischium, and arc attached to the anterior aponeurosis of
the perineal septum, the perineal body, and the skin of. the
perineum in front of the anus. The sphincter ani arises from
ANATOMY. 167
the tip of the coccyx and is attached in front to the tendinous
raphe of the perineum, where it meets the fibers of the bulbo-
cavernosi. Its fibers, closely attached to the skin, decussate
in front of the anus, while some fibers appear to pass com-
pletely around it. The muscle is pierced by radiating fibers
from the longitudinal muscular coat of the rectum, and is in
dose relation with the levator am and internal sphincter. This
muscle forms the external sphincter and is voluntary in its
action. The levator ani is the principal muscle of the pelvic
floor. It arises from the back* of the body and horizontal
ramus of the pubes, the pelvic fascia (white line), and the spine
of the ischium. From its origin the muscle sweeps downward
and inward and is attached in the middle line from before
backward as follows: To the vagina, to the rectum, to its fellow
of the opposite side, and, finally, to the tip of the coccyx. The
pubic fibers blend with the posterior half of the upper border
of the sphincter vagince. This muscle is more readily exposed
from above.
The vulvovaginal gland with the bulb of the vestibule are ex-
posed in the dissection already described. The former is a
racemose gland, of which there is one situated on either side
of the vagina and posterior to its orifice. It is analogous to
Cowper's gland in the male. It is also known as the vulvar
gland of Bartholin, or, according to Huguier, the vulvovaginal
gland. It is about the size of an almond, but varies in different
individuals and even upon the two sides. Occasionally glan-
dular nodules are seen, which seem to be detached from the
gland and scattered in the surrounding muscle. Within, the
gland is in close relation with the vagina, to which it is adherent
by tense cellular tissue, while externally it lies beneath the
bulbocavemosus muscle. Its excretory duct, about one centi-
meter long, is directed from below upward and from without
inward and opens in the angle between the hymen and the wall
of the \adva. When the hymen has disappeared, its orifice
is foimd in the corresponding angle between the carunculae
myrtiformes and the wall of the vulva. It is usually difficult
to detect, but sometimes presents an orifice which will admit
a probe. This gland furnishes the secretion which is manifest
under the influence of sexual excitement or during coition.
The bulb of the vestibule is a venous mass which is situated
along each side of the vagina and the vestibule. It is related
within to the vagina, vestibule, and urethra, and is covered
externally by the bulbocavemosus muscle. The bulbs unite
beneath the clitoris by a venous connection, the pars inter-
media. Kobelt says the injected bulb is nearly four centi-
168 GYNECOLOGY.
meters long, one centimeter wide, and from nine-tenths to one
and one-tenth centimeters thick. Its external surface is convex,
its internal surface concave. The bulb is a part of the erectile
tissue of the female genital organs and is analogous to the cor-
pus spongiosum in the male.
261. The perineal fascia or the fascia of the pelvic floor
consists of the following:
1. The superficial fascia.
2. A deep layer of the superficial fascia.
3. The triangular ligament, composed of two layers.
The superficial fascia is a continuation of the general fascia
of the body. It consists of two layers — ^an outer, more or less
loaded with fat, which is continuous with the same layer over
the buttocks, thighs, and abdomen; an inner, more resisting
membranous investment descends from the abdomen, narrowed
to the width of the pubes, but spreading out so as to envelop
the anterior perineal triangle at its base — the perineal septum.
The abdominal portion of the fascia is firmly adherent to Pou-
part's ligament; the perineal portion to the outer margin of
the ischiopubic rami and the inferior margins of the septum,
while the pubic portion is attached along a curved line of the
bone, which indicates the origin of muscles of the anterior part
of the thigh.
A tubular prolongation extends backward from the margin
of the external inguinal ring on each side of the vagina, nearly
to the posterior vulvar commissure, and is knowTi as the pu-
dendal sac. With its fellow of the opposite side, when envel-
oped with their cutaneous coverings, the two sacs form the
labia majora. The pudendal sac contains more or less fatty
tissue, and the terminal fibers of the round ligament of the uterus
are also lost in it. The sac may be the seat of hydrocele from
a patulous canal of Nuck, or a hernia may develop by a descent
of a section of gut or omentum through this canal. The in-
jection of air into the sac gives a similar appearance to that
induced by hernia. The fascia passes around the transverse
perineal muscles to form the anterior layer of the triangular
ligament. This union forms the ischioperineal ligament — ^a
very firm aponeurotic band attached to the outer ends of the
rami of the ischii in front of their tuberosities.
The deep fascia, or triangular ligament, has two layers —
an anterior, or superficial, and a posterior, or deep. The super-
ficial is attaclied to the rami of the pubes and ischium, and
to the so-called transverse ligament of the pelvis, which lies
immediately behind the subpubic ligament, from which it is
separated by an opening for the dorsal vein of the clitoris.
ANATOMY. 169
Behind, it is united with the superficial, as well as with
the deep, layer of the pelvic fascia. The deep layer is also
attached to the rami of the pubes and ischium, and joins the
obturator fascia covering the lower portion of the anterior
surface of the levator ani muscle. In front it is continuous
with the vesicorectal fascia; and behind, with the dense anal
fascia which covers the under stirface of the levator ani muscle.
The junction of the three layers of fascia behind forms the
ischioperineal ligament, which marks the boundary-line be-
tween the urogenital and anal regions.
The upper stirface of the levator ani muscle is covered by a
fascia called the pelvic, which is a continuation of the iliac.
The pelvic fascia is attached to the iliac portion of the ilio-
pectineal line and to an obUque line upon the posterior surface
of the pubic bone, from above and within the obturator foramen,
to just below the symphysis. It covers the inner surfaces of
the ilium and ischium about halfway down the pelvic wall, until
it reaches the so-called tendinous arch, which extends from the
spine of the ischium to the pubic bone and below the obturator
canal. This portion covers the obturator muscle, and is known
as the obturator fascia. A thinner prolongation extends back-
ward, and is known as the pyriform fascia.
The pelvic fascia spKts into two layers at the tendinous
arch— an upper, called the vesicorectal fascia, which extends
over the levator ani muscle, and a lower layer, which follows
the obturator intemus muscle to the inner edge of the ischio-
pubic branches, and retains the name of obturator fascia.
jBelow the insertion of the levator ani muscle is given off an
investment, which is called the anal fascia. In conjunction
with the portion of obturator fascia below the tendinous arch
it serves as a Uning for the ischiorectal fossa.
The vesicorectal fascia, from its insertion upon the pelvic
waD, passes inward and downward and covers the upper sur-
face of the levator ani to the base of the bladder, the vagina,
and the rectum. In front, near the middle line, a thicker part
of this fascia forms the anterior true ligaments of the bladder,
or pubovesical ligaments.
A ligament of the rectum arises from the ischial spine and
is attached to the side of the rectum. It presents a double
layer of fascia with intervening loose connective tissue, and
permits a sliding movement of one part over another.
A study of the relations of the pelvic structures to the layers
of the fascia results in the following, according to Hart and
Barbour:
170 GYNECOLOGY.
da: I
Superficial hemorrhoidal vessels and
Between the skin and superficial fascia: \ nerves.
Superficial perineal artery and nerve.
! Trans versus perinei.
Bulbocavemosus.
Erector clitoridis.
Transverse perineal blood-vessels and
*.^.«.. *«ww.«, «,«x* w«w «,..v^*.w* s.^j^M. V nerves,
of the triangular ligament : J Venous plexuses.
/ Bulbs of the vagina.
I Pudendal sacs.
\ Dorsal artery and vein of clitoris.
C Compressor urethrae.
Between the layers of the triangular J Vagina, in part,
ligament: j Urethra, in part.
V Pudic vessels and nerves.
262. Pelvic Diaphragm. — The structures already described
as the soft parts, consisting of the pelvic fascia and the muscular
structures, constitute the pelvic diaphragm, of which the most
important structure is the levator ani. (Fig. 120.)
The origin and insertion of this muscle have been given.
It is generally described as two muscles, the levator ani and
the coccygeus, but as there is practically no separation, this
seems an imnecessary distinction. Savage divides it into
three, the pubococcygeus, the obturator coccygeus, and the
ischiococcygeus, but this division seems inappropriate when
we recognize the fact that none of the muscular fibers arising
from the pubes reach the coccyx. The anterior portion of
the muscle is covered by the muscles and structiu*es of the
external genitalia. The posterior portion is enveloped with
the fascia and covered with the following additional layers:
the skin; the adipose tissue filling up the ischiorectal fossa,
and known as the ischiorectal fat. The boundaries of this
irregular triangular space are the levator ani, covered by the
anal fascia on the inner side, and the obturator intemus muscle,
covered by the obturator fascia on the outer side. The lower
surface is bounded by the anterior edge of the gluteus maximus
muscle and the greater sacrosciatic ligament behind, the trans-
versus perina^i muscle in front, and the sphincter ani upon the
inner side. The apex of the triangle is at the spine of the isch-
ium. Behind, the two fossa communicate by the loose adipose
tissue back of the rectum, and also by the pelvic fascia. In
front, the fossa is limited by the line of junction of the super-
ficial and the deep fasciae.
The posterior fibers of tlie levator ani pass behind the rectiun
and are continuous with those of the opposite side. Other
fibers are attached to the tip and side of the coccyx.
Action. — The pelvic diaphragm strengthens the pelvic floor,
and, in association with its two enveloping layers of fascia.
ANATOMY. 171
forms a strong support for the uterus and bladder. Obser-
vation of the movements of the floor, with the employment
(rf Sims' speculum, reveals a rhythmic movement synchronous
with respiration. The anterior pelvic segment goes down-
ward and backward during inspiration and upward and for-
ward with expiration. The muscle serves to raise up the rectum
during defecation and draws the anus toward the symphysis.
Fig..
—The Under Surface of the Levator Ani Muscle.— (Dea
■r.)
The fibers between the rectum and vagina influence tlie size
of the vaginal orifice.
163. Perforations (Fig. 121).— The pelvic floor is perforated
by three slit-like openings, two of which, the vagina and ure-
thra, have axes parallel with the conjugate diameter of the
brim. The rectum for a part of its course is similar, but turns
backward at the lower part, where it is separated from the
vagina by the perineal body. The axis of the anus is at right
angles with the plane of the brim. Transverse section of the
pel\TS through the middle and lower third of the vagina shows
it folded in the shape of a letter H, with a short lateral and
172
GYNECOLOGY.
a long transverse bar. The urethra presents a transverse [slit,
and the rectum an anteroposterior fold.
264. Internal Genitalia. — The internal genitalia are: The
vagina, the uterus, the Fallopian tubes, the ovaries, and the
parovarium.
265. The vagina is a musculomembranous canal, lying be-
tween the bladder and the rectum, and extending from the
vulva to the uterus. ■ It is fixed below by its attachments to
the pelvic floor, and above surrounds the cervix, with which
it is continuous. The direction of the vagina varies with the
position and the condition of the adjoining organs — the bladder
Fig, III.— The Upper Surface of the 1.
Ani Muscle. — (Dtaetr.)
and the rectum. In the erect position it forms an angle of
about 60 degrees with the horizon, and is parallel with the
conjugate diameter of the brim of the pelvis. (Fig. 122.) Its
walls are irregularly triangular, with the widest point at the
upper part, where the utenis enters, which in the nullipara
measures 3 or 4 cm. ; in multiparse. 6 or 7 cm. The anterior
wall is the shorter, 5 cm. long, while the posterior is 7.3 cm.
In the normal condition and with the bladder empty, the cervix
enters the vagina at h right angle. This angle is rendered
more obtuse by distention i,.if the bladder or by an accumulation
of feces within the rectum. The \-agina is attached to the
cer\^ix about 1.5 cm. from the external os, and forms with
the cer\"ix a sulcus front and back. The former is known as
the anterior, and the latter as the posterior, vaginal fornix.
The anterior and posterior vaginal walls lie in contact, and,
upon mesial section, present a slit with a slightly convex line
directed anteriorly. Transverse section is represented by an
H-shaped slit, the lateral arms of which are convex upon their
inner aspect, with the horizontal limb bending shghtly anterior.
GYNECOLOGY.
The vagina in multiparEe is capable of wide distentioi
is of quite variable shape. The anterior vaginal wall is i
with the posterior surface of the bladder by loose conn
tissue, which permits its dissection, though separation
occurs. The urethra is more intimately associated wit
wall; however, it presents no diificulty in dissection.
I
! ANATOMY. 175
The mucous membrane of the anterior wall is thrown into
numerous folds or projections, called the rugie, which are more
marked toward the vulva and decrease in size as the upper
end of the canal is approached. There are also temporary
foldings, which disappear as the vagina is distended. The
rugs consist of a series of transverse ridges, which extend
Pig. 1*4. — Arteries and Nerves of the Female Perineum. — (Savage.)
1. Internal pudic. a, 3. Inferior hemorrhoidal. 4. Transverse perineal. 5.
Superficial perineal or vulvar. 7. Profunda branch to the clitoris. 8.
Artery of the bulb. g. Dorsal artery to the clitoris. 10. Inferior
heiii(»Thoidai nerve to sphincter and lower rtctum. 11. Posterior super-
ficial. II. Posterior muscular. 13. Trunk bf the nerve. 14. Anterior
superficial brancheatothe vulva. 15. Anastomotic. 16. Pudendal branch
of (17) the smaller sciatic. 18, 18. Continuation of pudic ending in nervous
sheath for the clitoris. 19. Outer terminal branch of the ilio-inguinal
nerve. A. Anus. M. Urinary meatus. C. Clitoris. L. Greater sacro-
tciatic ligament. V. Vagina. O. Coccyx. A, Gluteus maximus. b.
Superficisu sphincter, e. Anterior edge of ischiococcygeus. d. Superficial
transverse muscle. e. Bulbocavemosus muscle. /. Slip of anterior
aponeurosis of perineal septum, g. Upper portion of erector clitoridia
muscle, j. Adductor magnus. k. Gracilis muscle. T. Nerve-fibrils to
inteeument.
obliquely upward and outward from the longitudinal stem,
known as the anterior column.
The transverse projections are composed of secondary
ridges, covered with papillae. The anterior column generally
begins behind the meatus, and disappears in the upper third of
the vagina; occasionally, its lower portion is divided into two
176 GYNECOLOGY.
parts by a longitudinal groove, the opposite halves of which
subsequently unite. The rug^ are especially marked in yoiing
children and virgins, and largely disappear in the multipara.
The posterior wall also presents a column with transverse rugE,
but less marked than upon the anterior.
The upper part of the vagina presents, when distended,
a dome-like appearance, in which the posterior fornix is twice
the depth of the anterior, owing to the
higher attachment upon the cervix.
The lateral fomices have no especial
depth, and only connect the anterior
and posterior. As the patient advances
in years the vaginal walls atrophy and
the rugae gradually disappear.
The wall of the vagina consists of.
three layers: an external connective-
tissue layer ; a middle, of unstriped
muscular fiber ; and an inner, of mucom
membrane. The exterior layer binds the
uterus to the stirrounding structures
and supports the plexus of vessels and
lymphatics. The muscle structure con-
sists of longitudinal and circular fibers,
intricately interlaced. A bundle of
striated muscle-fibers is described by
Luschka as surroimding the lower end
of the vagina as well as the urethral
orifice, which he calls the sphincter
vaginge.
The mucous membrane, which ex-
tends from the free edge of the hymen
to the cervix, over which it is reflected
Fig. 125^.— Anterior 'vyall to the external OS, varies in thickness
from I to li mm. It is of a rosy-red
color, but may vary from a light pink
to a dark-purple or slate color. The
latter color is especially characteristic
of pregnancy. The mucous membrane
is closely attached to the subjacent
muscular layer, and is thrown into the already mentioned rug«e.
The surface is co\-ered with numerous papiike, which are greatly
increased in size by pregnancy.
The mucous surfaces are covered with an acid mucus, which
is also markedly increased during pregnancy.
The thickness of the vaginal wall is greater below, where it
is about one centimeter, while at the upper part it is not over
1 25. — Anterior Wall
of Vagina. Showing
Column ie Rugarum. —
{Byjord, after Savage.)
. Anterior columns of
the vagina. U, Ure-
thral orifice. M. Cer-
ANATOMY. 177
fire millimeters. The difEerence in thickness is due to the varia-
tion in the muscular wall.
A microscopic section of the vaginal wall presents an ex-
ternal layer of fibrous tissue, enveloping large veins, which belong
to the vaginal venous plexus. These are surrounded by bundles
of smooth muscle-fibers suggestive of erectile structure. Accom-
panying the veins are large lymphatics, some of which are "dis-
Fig. i»6. — Horizontal Section of the Vagina and Urtthra of an Infant,
a. a. Skene's glands b h h h Urethral glands the analog of Littrc's glands
in the male
tended to form sinuses. A middle or muscular layer is also
present, in which the outer fibers seem divided transversely, the
inner ones being longitudinal.
The mucous membrane consists of a firm basement mem-
toane in which are numerous elastic fibers. It is covered by
several layers of stratified pavement epithelium. (Fig. 126.)
In addition to the large folds into which the mucosa is thrown,
178 GYNECOLOGY.
it forms secondary elevations, or papillae, in each of which
is a capillary loop. These loops are single near the fornix,
but present a more complicated network near the introitus.
The rugae consist of large venous plexuses surrounded by
btmdles of muscle-fibers, as in cavernous tissue.
The lymphatics are abundantly supplied to the mucosa.
Lauenstein has described lymph-follicles similar to those in
the intestine.
The existence of mucous follicles or glands in the vagina
is denied ; the mucus is believed to be an exudation from <;he
vaginal surface.
The nerves ramify throughout the walls, commtmicate
with one another and with the ganglia, and terminate in end-
bulbs beneath the epitheliimi.
266. The uterus, or womb, is a hollow, thick-walled, mus-
cular organ, of a truncated shape, which occupies the upper
part of the cavity of the pelvis and projects by a portion of
its cervix into the vagina. It is situated between the bladder
in front and the rectum behind. The fundus is usually just
below the level of the plane of the brim of the pelvis, and about
two centimeters in front of the sacrtun. The position of the
uterus is dependent upon the condition of the surroimding
organs. When the bladder is empty and the rectum imdis-
tended, the uterus is slightly anteflexed, and occupies a posi-
tion at a right angle to the axis of the vagina. The fimdus
is directed forward and upward, and the cervix downward
and backward, toward the rectum. A distended bladder
raises the fundus and decreases the uterovaginal angle. A
similar change of position is induced by rectal accumulations
which push tlie cervix forward. It necessarily is diffictilt
then to determine between a physiologic and a pathologic
position. We may call any position abnormal in which the
organ becomes fixed and its range of mobility lessened. The
uterus presents, from above, a pear-shaped appearance, slightly
flattened from before backward, and the posterior surface is
the more convex.
The length of the virgin uterus is from 5 to 7.5 cm.; its
breadth at the orifices of the Fallopian tubes, 5 cm.; and its
walls are about i cm. thick. The weight of the nonimpreg-
nated uterus is from about 300 grains to i^ ounces. The organ
is divided into two portions — the body and the cervix. The
body, pyriform in shape, about 4 cm. long, is surmounted,
above a line drawn through the orifices of the Fallopian tubes,
by a rounded portion — the fundus. The cervix, cylindric
in form, is about 3 cm. long and terminates below in the vaginal
portion. Schroder divides the cervix into three parts — the
ANATOMY. 179
Upper and lower, called the supravaginal and infravaginal por-
tiMS, which are separated by an intermediate portion — a
division which is of significance in the study of uterine dis-
[dacements.
The attachment of the vagina to the uterus is much higher
behind. When the patient occupies the dorsal position, with
the limbs well drawn up, the vagino-uterine junction is upon
a plane vertical to the horizon. The infravaginal portion of
Rj. 117. — Median Section of Uterus from Side to Side throug)i the Fallopian
Tubes. Mode of Junction of Vagina and Uterus. — {Savage.)
1 0terine cavity, b. Cervical canal, showing folding of Its mucoiis membrane.
d. Internal uterine (mucous) coat. c. Os externum uteri, e. Uterine
•perture to Fallojiian tube. f. Fallopian tube near uterus, g. Round
ligxment. V. Vagina.
the cervix is especially interesting to the g)-necologist, as it
is the only part of the uterus which is visible upon inspection,
and fully accessible to palpation. It varies extremely in size
and shape, according to the age and sexual relations of the
individual. In the virgin it presents a conoid projection,
nearly one centimeter long, with an opening in its apex, known
as the external os, or os tinc^. The os is a transverse slit,
about two or three millimeters long, and it di\-ides the cervix
180 GYNECOLOGY.
into an anterior and a posterior lip. The anterior lip is the
longer.
With the advent of sexual acti\'ity the cervix changes.
In the nulliparous married woman it becomes softer and larger,
the conoid shape is less marked, and the os stands more widely
open. In the multipara, even when lacerations have not oc-
curred, the cervix is large and soft, and the os presents a trans-
verse slit — more frequently an irregular opening. Inflam-
matory lesions cause the cervix to become still larger, with
eversion of the mucous membrane, erosion of the surface, en-
largement of the papillae, and an irregular opening.
With the cessation of menstruation, and especially in women
who have borne a large number of children, the vaginal cervdx
disappears and the os is flush with the fornix of the vagina.
The junction of the triangular body and conoid cervix is
called the isthmus. The anterior surface is flattened; the
posterior, quite convex. The upper border of the uterus is
rounded, and forms the fundus. The lateral uterine borders
are obscured by the folds of the peritoneum, known as the broad
ligaments. The upper part of each ligament is occupied by
the Fallopian tube; below this, the round ligament; and still
lower, the ovarian ligament.
The arteries, veins, and lymphatics of the pelvis pass through
the broad ligament.
The uterine canal in the virgin (Fig. 128) is about five centi-
meters long: sliglitly longer in the multipara. The cavity
of the cervix is cylindric, wider in the center and narrower
at each end, with the external os below and the internal os
above.
The cavity of the body is triangular from side to side, but
the anterior and posterior surfaces lie in contact. At the apex
of each angle of the triangle is found an opening, on each side
the orifices of the Fallopian tubes, and below the internal os.
The uterine wall has a thickness of a little more than one
centimeter. The uterus has three layers — an external (serous),
a median (muscular), and an internal (mucous membrane).
The serous or peritoneal covering is not complete, and, there-
fore, will be considered with the peritoneum.
The muscle-fibers are best studied in the pregnant uterus,
and may be di\'ided into three layers. The external is most
distinct, and consists of a fine, thin layer over the anterior
and posterior surfaces, from which prolongations are sent off
into the broad ligament. The posterior fibers form the ovarian
ligament, and the anterior the round ligament. Some of the
fibers also furnish the longitudinal muscular structure of the
Fallopian tul)e. These fibers are wanting upon the sides of
ANATOMY. 181
the uterus. The middle layer is by far the thickest, and con-
sists of interlacing fibers, transverse and longitudinal, which
are continuous with those of the vagina. This layer com-
prises the principal part of the wall, and contains the blood-
vessels. The latter are embedded in a network of fibers, and
may be recognized with the naked eye upon cross-section.
Their intimate relation to the muscle and tissue is recognized
by their remaining open when divided trans^'ersely.
The inner layer consists of
circular fibers, which are most
marked at the internal and
ratemal os, where they form
F«- iiS.—VirKin Uterus, Median
Section,— (Sy/J'^. ajter Sappey.)
'..interior surface. 2. Vcsico-uter-
ine pouch. 3, 3. 4. Si 6. Posterior
surface. 7. Cavity of corpus.
8. Cavity of cervix, g. Os in-
ternum. 10, II, Vaginal por-
tion of cervix. II. i». Vagina.
Fig. 139. — Mucous Membrane of
Uterine Body Showing Folli-
cles.—(Wo -m.)
d, d, d. Simple or double culdesac
of these follicles, a. a, a. Thin
cup-shaped orifice upon the mu-
cous membrane.
a sort of sphincter, and at the cornu of the uterus, from which
they are extended into the Fallopian tubes.
The connective tissue of the uterus is thickly interspersed '
between the muscle-fibers, and especially along the course of
the vessels. The mucous membrane of the uterine cavity
rests directly upon the muscle layer without any intervening
sabmucosa, and its glandular structure projects between the
muscle-fibers. In the cervical cavity, where the mucosa is
thrown into folds, a distinct areolar layer intervenes between
it and the muscular wall. The uterine mucosa is one milli-
182
GYNECOLOGY.
meter in thickness at the fundus, but becomes thicker near
the center of the cavity. It is smooth and velvety, of a
grayish-red color, and presents no folds, unless in the imme-
diate vicinity of the tubal opening, and there but a s%ht
folding. Under a glass can be seen numerous small depressions
or openings — the orifices of the glands. The free surface of the
mucosa is covered with a single layer of columnar epithelial cells,
Fig- ijo, — Section of Normal Endometrium, Note two glands to right some-
what enlarged.
a. a. Glands penetrating muscular Eubetance.
which are supplied with cilia. The mucosa is filled with glands
of the tubular variety, which penetrate its entire thickness,
and frequently their external extremities are embedded in the
muscular layer. (See Fig. 1 29.) The direction of these tubules
is more or less oblique. They often exist as sinuous or spiral
single tubes, but more frequently divide into two or more
ANATOMY. 183
branches near their lower ends. Upon longitudinal section
tbey exhibit a basement membrane lined by a single layer
of prismatic ciliated cells with single large nuclei situated near
thar bases. (See Fig. 130.) These glands largely increase
with the approach of puberty, and become elongated during
menstruation, and especially in pregnancy. The mucosa is
supplied with large plexuses of capillaries and lymphatics.
The latter, in the form of lymph-spaces, are directly connected
ftith the lymph-sinuses and vessels of the deeper layer. The
termination of the nerve-filaments in the mucosa has not been
determined, but the action of the glands indicates their reception
of nerve-filaments, as in similar
structures of other parts of the
body.
The cervical mucosa, thicker
than that of the body, is thrown
into several folds, known as the
arbor vitae, or plicas palmatas,
and is separated by a submucosa
from the muscular wall. This
arrangement of the mucosa ends
sharply at the internal os, and
is best observed in the virgin
cenix. The mucosa differs from
the lymphoid structure of the
body in hvaing a firm, fibrous
basement membrane, sur-
mounted by cyhndric epithelial
cells. These cells, according to
De Sinety, are ciliated only
upon the summit of the ridges,
while the epithelium covering
the intervening surfaces is nonciliated. The glands are of the
racemose variety, consisting of branching ducts. They are
lined with nonciliated cuboid epithelium, resting upon a struc-
tureless basement membrane. They open upon the free surface,
upon and between the folds, and secrete a clear, viscid, alkaline
mucus. The ovula Nabothi are those glands of Naboth which
luve formed small cysts after occlusion of their ducts.
The structure of the cervical wall differs from that of the
body in the increase of fibrous tissue, which is intimately inter-
woven with the miiscle-fiber, and in the lessened supply of blood-
vessels.
The external os presents a sharp line of demarcation separating
tbeone-layeredcylmderepithelium of the cavity from the multiple-
layered pavement epithelium of the vaginal portion.
184 GYNECOLOGY.
267. The Fallopian tubes, or oviducts, are two tortuous canals
which arise from each side of the fundus uteri. They vary
in size and length, occupy the upper margin of the broad liga-
ment, and extend outward almost to the pelvic brim. The
length of the tube is from 7.5 cm. to 12.5 cm., the right tube
usually being the longer.
They are first directed outward, then backward, and finally
inward, giving the appearance of a shepherd's crook. The
tube presents for our study: i, in the uterine cavity a narrow,
ftinnel-like opening, the ostium uterini tubae; 2, the section
of the canal found in the uterus, pars uterini; 3, the narrow
portion proximal to the uterus, the isthmus tubae; 4, a wider,
longer, more tortuous portion, the ampulla tubae, which ter-
minates in, 5, a distinct trumpet-shaped end, the infundibular
tub«, provided with numerous fimbriae, and, 6, a distinct open-
ing from the ampulla, the ostium abdominale tubae. The line
of differentiation between the pars uterini, isthmus, and am-
pulla is not sharply defined. The isthmus is the narrowest
portion and is about two centimeters long. The diameter
of the isthmus is about two millimeters, and its lumen will
scarcely admit a bristle. The ampulla is the more widened
part; it extends outward and backward, has an external di-
ameter of from six to eight millimeters, and its lumen a
diameter of two or three millimeters.
The fimbriated extremity — also called the pavillion, or in-
fimdibulum, from its funnel shape, and the morsus diaboli
(devil's mouth) — is a trumpet-shaped opening, surrounded
by primary and secondary fimbriae, which resemble the tentacles
of the sea anemone. The primary fimbria are the larger proc-
esses, four or five in number, from which arise the eight or
ten secondary processes.
The longest fimbria (fimbria ovarica) anchors the tube to
the ovary and has a furrowed groove, which facilitates the
passage of the ovum to the tubal orifice. The broad ligament
is continued to the lateral wall of the pelvis by a small fibrous
band, known as the infundibulopelvic ligament.
The tube, upon repeated section, will be foimd to have
varying dimensions, and frequently its course is tortuous —
almost convoluted. It has two openings — the uterine and
the abdominal. The latter is more distensible than the remain-
ing portion of the tube, is somewhat trumpet-shaped, and
affords a communication with the peritoneal cavity.
The tube consists of four coats or layers: the external, a
serous, which is separated from the muscular by a subserous
coat,, the tunica adventitia; next a muscular; and lastly the
internal — ^the mucous membrane.
ANATOMY. 185
The external serous covering is incomplete, that portion
of the tube toward the broad Ugament being incomplete for
the inner two-thirds of the tube. The remaining third is sur-
rounded by the peritoneum, which covers the external surface
of the fimbrias, while the internal is lined by the mucosa. The
tunica adventitia envelops the muscular layer, allowing the
peritoneal to slip over its abdominal end. The musciJar coat
ronasts of longitudinal and circular fibers. The former is
continuous with the outer ; the latter, however, is predominant
and the continuation of the inner muscular layer of the uterus.
The muscular structure is more largely developed at the prox-
imal than at the distal end of the tube, and the circular fibers
Fig. 131. — Section of Fallopian Tube through the Isthmus.
^.i. Sbo?is the linn and compact structure of the longitudinal folds in this
portion of the tube,
are particularly well marked at the isthmus, where they form
what is called the sphincter tubas. The tubal mucosa is quite
thick, thrown into longitudinal folds, very vascular, and of a
bright red color. In the isthmus the mucosa presents simple
f(Ms, which become more complex in the ampulla. Hennig
has counted from three to five primary folds, which have be-
t^'een eight and ten smaller plica; between each pair of the
fonner. The secondary folds are less marked near the abdom-
inal extremity, where the longitudinal folding is apparent
to the naked eye.
The mucosa has a single layer of ciliated columnar epithe-
lium upon two or three layers of supporting cells, which are
186 GYNECOLOGY.
round or pyriform. The cells abruptly terminate at the ends
of the fimbrias, where the mai^n between the columnar and
pavement epithelium is distinctly marked. The tubal mucosa,
like the uterine, has no distinct submucous layer, but unlike
the latter, it is without glands, and is covered with a thin layer
of grayish mucus of a distinctly alkaline reaction.
268. Ovaries. — The ovaries, the germ-bearing organs of
the woman, and the analogues of the male testicle, are a pair of
small bodies, situated one upon the posterior surface of each
broad ligament, below the tube and at each side of the uterus.
The ovaries occupy a position at the level of the brim of
the pelvis, or partly below and partly above its plane.
The axes of the ovaries lie obliquely to the pelvis, with a
slight inclination forward. In the erect position they rest
upon the posterior surface of the broad ligament.
The Fallopian tube is situated in the broad ligament above
the ovary and partly encircles it, while the roxmd ligament is
in front and occupies the anterior fold of the broad ligament.
In front of the ovary, between it and the tube, is the parovarian
structure, or the organ of Rosenmuller. The inner or uterine
extremity of the ovary is connected with the uterus by some
muscle-fibers, about three centimeters long, known as the
ovarian ligament; the outer or tubal extremity is connected.
ANATOMY. 187
above, with the end of the tube through the fimbriae ovarica,
and below, with the infimdibulopelvic Hgament.
The ovary presents a flattened, ovoid appearance, with its
broad end directed externally and the pointed end toward
the uterus. The anterior, straight or flattened surface of the
ovary is fixed by a short serous duplication, the mesovarium,
to the posterior surface of the broad ligament. The posterior
convex margin is free. Its size varies with the age of the in-
dividual, the fimctional activity of the organ, and the occurrence
of menstruation or pregnancy. The ovary attains its greatest
size about six weeks after parturition (Hennig), and never
reaches its former size in the subsequent involution.
Following the menopause, it shrinks to one-half or one-
third of its dimensions during active sexual life. Luschka gives
its dimensions as: length, 4 cm.; width, 2.2 cm.; thickness,
1.3 cm. It weighs from 60 to 135 grains.
The color of the ovary is a pinkish-gray, becoming some-
what darkened as menstruation approaches. Immediately
after ovulation a dark swelling follows, due to the accumulation
of blood. As absorption progresses the color changes and
the mass becomes yellow, and later presents only a whitish
cicatrix. Before puberty the ovary is smooth, but subse-
quently it becomes irregular, from the cicatrices following
repeated rupture of cysts, or nodular, from the presence of
matured folhcles that have failed to rupture. Following the
menopause, the ovary becomes a pearly-white, irregular, almost
cartilaginous mass, about one-half or one-third its former size.
The ovary is situated upon the posterior surface of the
broad ligament, with its pointed end connected with the uterus
by the ovarian ligament. The ovary, by its pointed end, is
directed toward the ligament, and its stroma extends inward
upon the latter, while the external ovarian end is blimt and
large. The posterior stuface of the ovary projects through
the peritoneum and is uncovered by it. The union of the
columnar epitheUum of the ovarian surface with the pavement
epithelitmi is readily recognized as a white line, and is called
the white line of Farre.
Sections of the healthy ovary show two kinds of tissue, a
central or medullary and a cortical or peripheral portion.
The latter covers the entire stuf ace of the ovary boimded by
the Une of Farre, but projects to its greatest depth (two to
three millimeters) at the central portion of the convex surface.
The central structure has a pinkish-gray or rosy color, is of
soft consistence, and has a moist, glistening appearance. It
is of a white or grayish-white color, more or less firm in con-
sistency, and contains numerous small vesicles. The smaller
188
GYNECOLOGY.
vesicles are situated near the surface, while larger cysts are
situated deeper. Some of these reach the size of a pea, and
may project more or less beyond the free surface. The sac-
wall is frequently so thin that the vesicles rupture under the
lightest pressure. This layer also contains numerous depres-
sions or scars, the result of repeated ovulation.
The cortical layer of the ovary, or that part which projects
through the peritoneum, is covered by a single layer of short.
Graafian Follicles,— (tVjrf#r.)
columnar epithelium, called by Waldeyer the germinal epithe-
lium. This terminates abruptly at the white line, where the
pavement epithelium of the peritoneum begins. Before puberty
young ova are represented by large spheroid cells, with mark^
nuclei, which form in the columnar cells. Ingrowths of the
germ epithelium into the uriderlying stroma are occasionally
seen, which form the ovarial tubes of Pfluger.
Immediately beneath the epithelial layer, and quite insepa-
rable from the underlying stroma, is the tunica albuginea — a
ANATOMY. 189
thin, dense layer of fibrous tissue, which contains a few smooth
muscle-fibers. It is not completely developed until the third
year, and undergoes changes with age and inflammation until
it becomes thickened and of almost cartilaginous hardness,
which renders its rupture exceedingly difficult. Such alterations
from inflammatory changes are a cause of the formation of
retention cysts, and of the development of that condition known
as cystic disease of the ovaries. The structure of the ovary,
as already noted, is divided into a cortical and a medullary
portion, although they differ but little in structure except that
the latter is softer and more vascular. In the cortical layer
lie the Graafian follicles, embedded in connective tissue inter-
spersed with some muscle-fibers. A large number of these
follicles, variously estimated at from- 36,000 to 400,000, are
found in each ovary. Whether so large a number exists is
difficult to determine, but it remains evident that nature has
amply provided for the reproductive function.
The ovarian stroma is the framework or bed in which the
follicles rest and are nourished. Each Graafian follicle has a
wall, which consists of a tunica fibrosa of thin fibrous tissue,
within which is a more delicate membrane, called the tunica
propria; the latter contains many granular cells and a fine
network of capillary vessels. This tunica propria is lined with
several layers of epithelial cells, called the membrana granulosa.
These cells are separated from the tunica propria by a struc-
tureless membrane. These epithelial cells form a thickened
mass upon one side, which projects into the cavity— -the discus
proligerus. The cavity of the follicle is filled with a clear,
serous fluid, called the liquor folliculi. It is formed by lique-
faction of the cells of the membrana granulosa.
The Graafian follicle, when mature, is one millimeter in
diameter. Embedded in the discus proligerus is found the
o\nun, which has been called the typical cell; it measures from
0.2 to 0.3 mm. It is a yellow, spheroid body, enveloped by
a thin, delicate membrane, — the vitelline membrane, or zona
pellucida. — doubtless formed from the innermost cells of the
discus proligerus. Within this membrane is contained the
vitellus, a network of granular, fibrillated protoplasm containing
numerous fat-globules. In the outer portion of this network
is a light spot, which consists of fine, fibrillated protoplasm,
which contains in its meshes a granular material inclosed in a
distinct membrane. This structure is known as the nucleus,
or germinal vesicle. Within this is contained a small, highly
rrfracting, granular body, known as the nucleolus, or germinal
spot.
The Graafian follicle is surrounded by a vascular network;
190
GYNECOLOGY.
as it matures, the liquor folHculi increases, the cyst becomes
tense, approaches the surface, and the tunica albuginea be-
comes thinned and finally ruptures, permitting the ovum to
escape. The cavity of the follicle fills with blood, which coag-
ulates and forms a clot. Later, this clot presents an external
yellowish color, while its
center is of a reddish-
gray hue. The clot
gradually becomes or-
ganized, contracts {by
which it is thrown into
folds), and is gradually
absorbed. ' The clot thus
formed is known as the
corpus luteum. The
ovary of a normally
menstruating woman will
be found to contain a
number of corpora lutea
in various stages of retro-
gression. The structure
generally disappears by
the end of the twelftl;
week, excepting a smal
cicatrix, which remains.
When pregnancy oc-
curs, the corpora lutea dc
not continue to form, but
the one corresponding U
the last menstruation be-
comes much larger anc
remains longer. It con-
tinues to increase, anc
after the first montl
forms a large yellow
clot, which gradually be
comes decolorized anc
more highly organized
resulting in a white
fibrinous clot surroundec
by a vellow ring, Tlic corpus luteum of pregnancy is known a;
tiie corpus luteum verum, while those which occur with ordi
nary o\'ulation are called corjiora lutea spuria.
Later in the ]>regnancy, the time of which is not exactl)
known, it becomes contracted, and at its termination forms ■
mass about 0.5 cm. in diameter.
Fig. 135. — Lnrgy Corpus Luteum in Associa-
tion with an Ovarian Dermoid. Re-
moved from an Umnarried Woman Wlio
Had Never Been Pregnant. — (SiiUon.)
I. Twisted pedicle, i. Corpus luteum. 3.
Old clot. 4. Integumentary surface of
dermoid.
ANATOMY. 191
When the corpus luteum has lost its color and most of its
blood-vessels, and is mainly composed of a mass of fibrous tissue,
it is called a corpus albicans. Frequently, from the retention of
pigment, it is dark in color, and is known as a corpus nigricans.
Clark has shown that the corpus luteum finally disappears by the
process of hyaline degeneration. Extravasations of blood, or
apoplexy of the ovary, we shall see later, are not infrequent, and
occasionally may result in the complete destruction of the organ
and the formation of a blood-sac — an ovarian hematoma.
269. The Parovarium. — Between the outer end of the tube
and the ovary is situated a triangular group of small tubules,
known as the parovaritun, or the organ of RosenmuUer — a
remnant of the Wolffian body.
The structure corresponds to the epididymis in the male.
The apex of the triangle is directed toward the ovary. This
organ is of especial importance to the gynecologist, as it can
be the seat of a number of growths. It consists of from six
to thirty spiral tubules, which at their base open into a single
transverse tube. This transverse tubule corresponds to the
canal of Gartner in the lower animal. Cysts are frequently
found associated with the tubules; the most common is the
hydatid of Morgagni, or appendix vesiculosa, the pedicle of
which arises in a point of the mesosalpinx, near the fimbria
ovarica. The occurrence of this cyst is the rule rather than
the exception, and it consists of a tough, connective-tissue
wall with a well-developed vascular system, and is lined with
pavement epithelium. It has a pedicle one-third centimeter
long and contains clear fluid. The parovarium is entirely
a rudimentary structure and has no function.
270. Urinary Organs and Rectum. — Our knowledge of the
relations of the pelvic organs will be incomplete without a
study of the analogy of the urethra, bladder, and ureters, as
well as of the rectum and anus.
271. The urethra is a canal, from 2.5 cm. to 4 cm. long,
which forms .the outlet to the bladder. It lies embedded in
the anterior vaginal wall, from which it can readily be separated.
It is slightly curv^ed upward, with its concavity forward. Upon
cross-section the urethra presents a transverse slit near its
vesical end and a stellate folding toward the external meatus.
The diameter of the urethra is 0.6 cm., and it is quite distensible.
When not distended, the urethral mucous membrane is more
or less corrugated throughout its length, owing to the sphincter-
jike action of the surrounding muscle-fibers. The urethra
is attached to the pubic arch by the pubovesical ligament,
and penetrates the triangular ligament, between the layers
192 GYNECOLOGY.
of which it is surrotmded by the fibers of the compressor ure-
thrie, or muscle of Guthrie.
It is also, together with the vagina, influenced at its lower
end by the bulbocavernosus muscle. Its external opening
is known as the external meatus, and close inspection of its
orifice will reveal a number of small openings about it — the
orifices of the glandula; vestibulares minores. Within the
meatus are two small openings — the orifices of the tubules,
described by Skene. They correspond to the lacuna magna
in the fossa navicularis of the penis.
They are described by Skene as tubules which extend for
a distance of nearly one centimeter parallel with the urethra.
As a result of inflammation they can be so dilated that they
will admit a No. i probe, and even the point of a catheter.
The urethra is neariy parallel with the bladder, but when
the woman is erect, it is nearly vertical.
The urethral mucous membrane, like that of the vestibule,
is of the pavement variety. The glands are lined at their
mouths with pavement epithelium, which soon changes into
the columnar variety,
272. The bladder is situated in the anterior part of the
pelvis, between the symphysis pubis in front and the vagina
and uterus behind. Its shape is constantly changing with
the accumulation and evacuation of the urine. When empty,
the urethra forms the stem of a Y, the anterior limb of which
is the longer. Between the urethra, the anterior surface of
the bladder, and the symphysis is a triangular space filled with
the retropubic fat. The bladder, when moderately distended,
becomes rounded; and when full, oval. The female bladder
holds less than that of the male, and differs from it also in having
the transverse diameter longer than the vertical. The bladder
is divided into three portions: the body, the base, or fundus,
and the neck. Skene defines the first as that portion which lies
above a plane formed by the ureteric openings and the center
of the symphysis pubis. The portion below is the fundus, or
base, which includes the trigone, or space between the orifices
of the ureters and internal meatus, and the bas fond, the space
immediately behind the ureters. The thickened surface about
the urethral orifice is the neck; which is the most dependent
portion when the body is erect.
The bladdcr-wall consists mainly of muscular structure.
The wall, dependent upon the amount of distention, varies
from 0.5 to I cm. The muscular structure consists of lon-
gitudinal and circular fibers, the former mostly confined to
the anterior and posterior surfaces. They may be traced
from the vesical neck and pubes in front, where they are called
ANATOMY.
193
the musculi pubovesicales, to the summit, where some of the
fibers accompany the urachus.
The circular fibers are more marked near the vesical orifice,
where they form the sphincter vesicee.
Fij. 136. — Vesicovaginal Septum and Base of Female Bladder, Anatomic
Relations of Ureters at Their Entrance into the Bladder. Contents of
Alar Ligament. — (Savage.)
'1 1. Ureters, a, i. Uterine artery. 3, 3. Uterine veins. 4. Dotted line
indicating the vaginal end o£ the uterine cervix. 5. Internal meatus
urethra. 6. Ligamentous process of fascia of pubococcygeus muscle and
vesicopubic muscles. 7. 7. Pubococcygeus muscle. U. Uterine body. 0.
Ovary, utero-evarian muscular ligament, and grooved Fallopio-ovarian
fimbrii. T. Fallopian tube and fimbriie inverted. M. Parovarium. P.
Pubic arch. V. Body of bladder.
The muscular layer is partly covered externally by the
peritonetmi, which will be discussed later, and internally by
•he mucous membrane, with which it is loosely connected by
194 GYNECOLOGY,
a layer of fibrous and elastic tissue. Because of this loose
connection the mucous membrane is thrown into folds when
the bladder is empty, except at the trigone, where it is more
intimately connected with the submucous layer and is much
thinner.
The mucous membrane in life presents a rosy pink appear-
ance, and is continuous with that lining the urethra and ureters.
Its epithelium consists of three or more layers of epithelium
resting upon a basement membrane. The superficial ceils are
squamous, but are smaller than the vaginal. The inferior
layer is composed of columnar epithelium with long processes,
while the middle one is made up of pyriform cells. The mem-
brane is supplied with a rich plexus of fine capillaries and nerve-
fibers ; the latter are not marked in the trigone.
The bladder is but poorly supplied with lymphatics, and
they communicate with the glands near the internal iUac artery.
273. The ureters are the urinary ducts through which the
urine is carried to the bladder. Their course, previous to
crossing the iliac arteries, is nearly parallel. The left ureter
lies behind the sigmoid flexure of the colon. In their subse-
quent course the ureters extend downward, backward, and
outward, along the lateral walls of the pelvis. At the spine
of the ischium they bend downward, forward, and inward to
the bladder, passing behind the uterine arteries, and about
I to 1. 5 cm. on each side of the cervix. The distance between
the ureters where they enter the bladder is 5 cm. They pass
obliquely through the vesical wall and enter the bladder 2
cm. below and external to the cervix, where their orifices are
still 4 cm. apart, but united by a prolongation of the longitudinal
fibers of the ureter, known as the interureteric ligament. This
ligament forms a transverse ridge between the two orifices,
and serves as the base of the vesical triangle.
274. The Rectum. — The rectum is the lower extremity of
the large intestine, and begins with the termination of the
sigmoid flextu-e, at the level of the third sacral vertebra, to end
with the anus. The rectum in its course from the third sacral
vertebra is directed downward and forward behind the cervix
uteri and vagina, parallel with the latter, until it turns directly
backward at the anus. The relation of the rectum to the pelvic
structures naturally divides it into two portions, the pelvic
and the perineal portion. The pelvic portion begins opposite
the third sacral vertebra and ends at the insertion of the levator
ani into its wall. The perineal portion Hes between the muscle
and the anus. The space formed by the de\dation of the rectum
from the line of the vagina is occupied by the perineal body.
The portion of the rectum involved in this deviation, which
is about 2.5 cm. long, is known as the anus.
ANATOMY. 195
The entire length of the female rectum is twenty centi-
meters. The canal is less curved than in the male, and its caliber
is greater. The longitudinal muscular bands so characteristic
of the colon are absent.
The rectum, artificially distended, shows a very large sac,
immediately above the anus, which decreases as the sigmoid
flexure of the colon is approached. This very dilatable portion
is called the ampulla, and when empty, the anterior surface
lies in contact with the posterior, so that upon transverse section
it presents a transverse slit.
The anal orifice is quite dilatable. The anus forms an
aperture which closes with its lateral surfaces in contact. The
orifice is fiuther obstructed by eight or ten longitudinal folds
of the mucous membrane. These folds are called the * * coliunns
of Morgagni," and the depressions between them, the ** sinuses
of Morgagni." These corrugations are produced by the con-
traction of the sphincter, and disappear when the anus is dis-
tended. Above the anus are three ring-like zones which are
superimposed over each other. The first is the zone of the
rectal columns and the intervening sinuses. The mucous
membrane upon the surfaces of the coliunns is covered with
pavement epitheliiun, while in the depressions cylindrical
epithelitim similar to that of the bowel above is fotmd. Lie-
berkuhn's crypts are seen only in the upper portion of this
zone. Its boimdary is often recognized as a distinct line, the
linea ani rectalis (Hermann). The middle zone has a smooth,
bright mucous membrane covered with pavement epithelitim
and small papillae. The lower zone is the cutaneous zone.
This has the homy epitheliiun well supplied with pigment
and also the connective-tissue sublayer characteristic of the
ddn. We find here papillae, hair, and sebaceous glands, ad-
joining the large convoluted glands of the intestine. The
submucous layer consists of a structure of quite dense con-
nective tissue, in which are situated the blood-vessels, nerves,
and lymphatics. Its laxity permits the mucous membrane to
glide over it. The mucous membrane of the rectum above the
anal canal has three or four large permanent transverse or ob-
lique semilunar folds which often project quite a distance into
tte lumen of the bowel. These folds, according to Gant, are
crescent-shaped, capable of some vertical motion, and extend
about one-half to two-thirds the circumference of the rectum
and project into its lumen from three-fourths of an inch to an
inch and a half. They are situated obliquely to the long axes
of the bowel. They are slightly cup-shaped with the con-
cavities looking upward. With the bowel distended the free
margins of these valves are prominent and readily seen through
196
GYNECOLOGY.
the proctoscope. They are called Houston's valves,
number of them is variable; usually there are three. In
ceptional cases there may be five, six, or even seven. T
location is fairly constant. The upper valve is situated
the junction of the sigmoid and the rectum on the left re
wall. The middle, which is the most prominent, occu
the right anterior wall opposite the base of the bladder an
Fig- 137-— Superior View of the Pelvic Cavity.— (Dfatt-r.)
three inches or more above the anus. The lower valve is situ
on the left side and a short distance below the middle vi
With the patient in the knee-chest posture and the rec
well inflated one can often see, by the aid of the proctosc
all these valves at the same time. They generally form a
of spiral stairway which gives a rotatory motion to the :
mass as it progresses toward the anus.
ANATOMY. 197
The rectal wall is composed of three coats — the peritoneal,
the muscular, and the mucous membrane.
The arrangement of the serous coat. will be considered with
the peritoneum, but it should be remembered that a portion
only of the rectum is enveloped by peritoneum. The mus-
cular layer consists of longitudinal and circular fibers, but
the former are more generally distributed, and not collected
into bands, as in the colon. The circular fibers are deeply
situated, and are more marked just above the anus, where they
fonn a distinct ring, nearly half an inch in width, which is rec-
ognized as the internal sphincter. The submucous layer
consists of a layer of quite dense connective tissue in which
are situated the blood-vessels, nerves, and lymphatics. Its
laxity permits the mucous membrane to glide over it. The
mucous membrane is continuous with that of the intestine,
although much thicker and more movable than that of the
colon, an4 its great vascularity causes it to have a bright pink
or even red color.
The mucous membrane is lined with columnar epithelium,
and contains a large number of Lieberkuhn's follicles, but no
villL The mucous membrane at the anus abruptly changes
bom the colunmar to the pavement epithehum of the slan,
which fonns the so-called white line.
375, Pelvic Peritoneum. — That portion of the serous lining
ol the abdominal cavity which is situated within the pelvis,
and envelops the pelvic organs, is known as the pelvic perito-
neum. Upon examination of a mesial section it will be seen
to leave the anterior abdominal wall about three centimeters
above the symphysis and be reflected upon the fundus of the
bladder. It covers the posterior surface of the bladder to
the level of the internal os, and as much of the lateral surface
as lies behind the obUterated hypogastric arteries. (Fig. 138.)
From the bladder it crosses over to the uterus, the anterior sur-
face, fimdus, and entire posterior surface of which it invests. (Fig.
139.) Laterally from the anterior surface it extends outward
upon a plane perpendicular to the pelvic brim, and is attached
to the lateral wall of the cavity, thus forming the anterior fold
of the broad ligament. The peritoneal investment posteriorly
extends over the uterus and upon the upper part of the vagina,
nearly three centimeters below the uterovaginal junction.
The lateral prolongation of this portion forms the posterior
border of the broad ligament. The broad ligament contains
the roimd hgament in its anterior fold; the Fallopian tube
in its superior border, between the anterior and posterior folds ;
and its continuation from the termination of the tube is known
as the infundibulopelvic hgament, the integrity of which is
198 GYNECOLOGY.
of importance in maintaining the ovary, and even the uterus,
in position. Resting upon and projecting from the posterior
fold, when the patient is erect, is the ovary, which is attached
to the uterus by the ovarian ligament. The anterior and
posterior leaflets of the broad ligament are separated, in addition
to the structures named, by considerable loose, vascular, con-
nective tissue, and afford entrance for the ovarian and uterine
arteries and nerves, and egress for the veins and lymphatics,
while its base is penetrated by the ureter on its way to reach
the bladder. From the vagina the peritoneum is reflected
backward, to be attached to the anterior surface of the rectum
and to the tissues in front of the sacrum. Above the promon-
tory of the sacrum it is continuous with the posterior abdom-
inal peritoneum.
The reflection of the peritoneum over the uterus and its
extension as the broad ligaments upon each side divide the
pdvis into two culdesacs — the anterior, or vesico-uterine,
and the posterior, or uterorectal. The posterior ctildesac is
further divided by a prolongation of muscular structure from
the sides of the uterus backward to the iliosacral synchondrosis,
over which the peritoneum is reflected. This forms a deep,
cup-shaped cavity directly behind the uterus, which is known
as the pouch of Douglas. This pouch dips deeper on the left
side, and sometimes extends to the upper border of the perineal
body. When the bladder is empty and the nonpregnant uterus
lies forward, the coils of small intestine usually occupy this
pouch, except at its very lowest point, and intra-abdominal
P'il-Mo. — Vertical Transverse Section of the Pelvis, Showing Peritoneal Pouches.
— (Luschka.)
I.I. Levator ani muscle.
pessure sometimes causes its dissection downward until a
distinct hernia occurs behind the uterus. On either side, ex-
ternal to the uterosacral ligaments, is a fossa, which is known
M the para-uterine pouch. This has been called by Polk the
retro-ovarian shelf. On the side wall of the para-uterine pouch
the ureter may be seen beneath the peritoneum. This space
is occupied by the small intestine. During pregnancy the para-
uterine pouch is lifted up to the pelvic brim, while Douglas'
pouch remains unaffected. From before backward, we may
find the following pouches or depressions : first, the pubo\'esicaI ;
200 GYNECOLOGY.
second, the vesico-abdominal, which is seen only during dis-
tention of the bladder, and varies in depth according to the
point at which the serous lining of the abdominal wall is re-
flected. The vesico-uterine pouch is bounded in front by the
bladder; posteriorly, by the uterus. This pouch varies less
than the others, on account of the firm attachment of the perito-
neum to the anterior surface of the uterus. In the empty
bladder the bottom of this pouch is about three centimeters
distant from the anterior culdesac of the vagina, and the pouch
rises somewhat as the bladder falls. The study of the female
peritoneum renders it evident that it differs from that of the
male in not being a closed sac, as it communicates with the
uterine mucous membrane through the orifice of the Fallopian
tubes, and is again perforated by the ovaries, which project
through it. The close relation of the peritoneum to the pelvic
viscera renders any change in this structure perilous to the
normal situation and relation of these organs. Inflammatory
changes result in thickening and cicatrization, which produce
temporary, if not permanent, displacements. The fixation
of the uterus, compression of the ovaries, and obstruction of
the orifices of the Fallopian tubes are necessary sequels of
such alterations. The peritoneum, according to Luschka,
serves as a sort of diaphragm, dividing the pelvic cavity into
two portions : the one above may be called the intraperitoneal
space, and that below, the subperitoneal. In the latter is
situated the greater part of the pelvic connective tissue.
276. Pelvic Connective Tissue. — The pelvic connective tissue
is a loose cellular tissue, which acts as a padding for the support
and safety of the pelvic organs. This structure is continuous
with that which exists in other portions of the body. It appears
in the pelvis in two varieties: first, as a loose tissue, distributed
in an irregular manner around and between organs and between
the layers of the broad hgaments, where it acts as a support to
the blood-vessels and folds of the peritoneum; second, as firm,
well-defined laminse or planes entering into the formation of the
pelvic floor. These have already been described under the name
of pelvic fascia. The connective tissue is continued behind the
symphysis as the retropubic fat, and there lies in front of the
bladder. Between the base of the bladder and the vagina it is
rather firmly connected. On the posterior surface of the vagina
there is a very loose layer connecting it with the rectum. A
large mass is found on each side of the cervix uteri, forming under
the broad ligaments what is known as the parametrium, which
is united in front and behind by a much thinner layer. Over the
body of the uterus the connective tissue is very slight and con-
tains no fat. The rectum and vagina are embedded in consider-
ANATOMY.
2011
able masses of this tissue. From the uterus and the parametrium
a thin layer extends between the leaflets of the broad ligament,
and ser\-es as a support for the vessels. The chief mass of this
tissue is situated around the cervix, and extends downward
axound the \-agina to the insertion of the levator ani muscle.
The distribution and relation of the pelvic connective tissue have
been studied in different ways. The most valuable method is by
the examination of frozen or spirit-hardened pelves, by which the
position of the tissue, its amount, and its distribution are recog-
nized. Injections of air, water, and plaster-of-Paris have been
made beneath the pelvic peritoneum in order to determine the
lines of cleavage in the pelvic connective tissue and the directions
in which pus would be likely to burrow. Konig made investiga-
tions upon the bodies of women who had died shortly after labor
from nonpuerperal disease. When an injection is made between
the layers of the broad hgament, high up in front of the ovary,
it first passes into the tissue at the highest part of the side wall
of the true pelvis; then into the iliac fossa, lifting up the peri-
toneum ; follows the course of the psoas, and passes but slightly
into the hollow of the iliac bone; finally, it separates the peri-
toneum from the anterior abdominal wall some little distance
above Poupart's ligament, and from the true pelvis below it.
Second, when the injection is made beneath the base of the
broad ligament and in front of the isthmus, the deep lateral
tissue becomes filled first; then the peritoneum is lifted from the
anterior part of the cervix uteri. Separation extends to the tissue
in the bladder, and ultimately along the round ligament and the
inguinal ring, where it separates the peritoneum along the line
of Poupart's ligament and enters the iliac fossa. Third, an in-
jection at the posterior part of the base of the broad ligament
fills the tissues around Douglas' pouch, and then follows the
course as first described.
377. The Vascular Supply. — The pelvic organs and perito-
neum are supplied through the ovarian, uterine, vaginal, and
internal pudic arteries. The ovarian arteries, analogues of the
spermatic in the male, arise from the abdominal aorta just
below the renal branches and pass downward o\-er the psoas
muscles beneath the ureters, enter the broad ligaments, and
pass to the side of the uterus, near which each divides into two
branches. The upper supplies the fundus uteri, and the lower
anastomoses at the side of the uterus with the anastomotic branch
of the uterine artery. In its course the ovarian artery gives off
branches to the ampulla of the Fallopian tube and to the isthmus,
and also numerous branches to the ovary. A small branch
is given off to the round ligament. The uterine artery springs
from the anterior division of the internal iliac, passes downward
es downward i
mi
200 GYNECOLOGY.
second, the vesico-abdorninal, which is seen only during dis-
tention of the bladder, and varies in depth according to the
point at which the serous lining of the abdominal wall is re-
flected. The vesico-uterine pouch is bounded in front by the
bladder; posteriorly, by the uterus. This pouch varies less
than the others, on account of the firm attachment of the perito-
neum to the anterior surface of the uterus. In the empty
bladder the bottom of this pouch is about three centimeters
distant from the anterior culdesac of the vagina, and the pouch
rises somewhat as the bladder falls. The study of the female
peritoneum renders it evident that it differs from that of the
male in not being a closed sac, as it communicates with the
, uterine mucous membrane through the orifice of the Fallopian
tubes, and is again perforated by the ovaries, which project
through it. The close relation of the peritoneum to the pelvic
viscera renders any change in this structure perilous to the
normal situation and relation of these organs. Inflammatory
changes result in thickening and cicatrization, which produce
temporary, if not permanent, displacements. The fixation
of the uterus, compression of the ovaries, and obstruction of
the orifices of the Fallopian tubes are necessary sequels of
such alterations. The peritoneum, according to Luschka,
serves as a sort of diaphragm, dividing the peK-ic cavity into
two portions: the one above may be called the intraperitoneal
space, and that below, the subperitoneal. In the latter is
situated the greater part of the pelvic connective tissue.
276. Pelvic Connective Tissue.— The pelvic connective tissue
is a loose cellular tissue, which acts as a padding for the support
and safety of the pelvic organs. This structure is continuous
with that which exists in other portions of the body. It appears
in the pelvis in two varieties: first, as a loose tissue, distributed
in an irregular manner around and between organs and between
the layers of the broad ligaments, where it acts as a support to
the blood-vessels and folds of the peritoneum; second, as firm,
well-defined laminae or planes entering into the formation of the
pelvic floor. These have already been described under the name
of pelvic fascia. The connective tissue is continued behind the
symphysis as the retropubic fat, and there lies in front of the
bladder. Between the base of the bladder and the vagina it is
rather firmly connected. On the posterior surface of the vagina
there is a very loose layer connecting it with the rectum. A
large mass is found on each side of the cervix uteri, forming under
the broad ligaments what is known as the parametrium, which
is united in front and behind by a much thinner layer. Over the
body of the uterus the connective tissue is very slight and con-
^^ tains no fat. The rectum and vagina are pmbprtdpH in fymgtHtw-
ANATOMY.
201
I
I
able masses of this tissue. From the uterus and the parametrium
a thin layer extends between the leaflets of the broad ligament,
and ser\'es as a support for the vessels. The chief mass of this
tissue is situated around the cervix, and extends downward
around the vagina to the insertion of the levator ani muscle.
The distribution and relation of the pelvic connective tissue have
been studied in different ways. The most valuable method is by
the examination of frozen or spirit-hardened pelves, by which the
position of the tissue, its amount, and its distribution are recog-
nized. Injections of air, water, and plaster-of-Paris have been
made beneath the pelvic peritoneum in order to determine the
lines of cleavage in the peK^ic connective tissue and the directions
in which pus would be likely to burrow. Konig made investiga-
tions upon the bodies of women who had died shortly after labor
from nonpuerperal disease. When an injection is made between
the layers of the broad ligament, liigh up in front of the ovary,
it first passes into the tissue at the highest part of the side wall
of the true pelvis; then into the ihac fossa, lifting up the peri-
toneum; follows the course of the psoas, and passes but slightly
into the hollow of the iliac bone; finally, it separates the peri-
toneum from the anterior abdominal wall some little distance
above Poupart's ligament, and from the true pelvis below it.
Second, when the injection is made beneath the base of the
broad ligament and in front of the isthmus, the deep lateral
tissue becomes filled first ; then the peritoneum is lifted from the
anterior part of the cervix uteri. Separation extends to the tissue
in the bladder, and ultimately along the round ligament and the
ingxiinal ring, where it separates the peritoneum along the line
of Poupart's ligament and enters the iliac fossa. Third, an in-
jection at the posterior part of the base of the broad ligament
fills the tissues around Douglas' pouch, and then follows the
course as first described.
277. The Vascular Supply.— The pelvic organs and perito-
neum are supplied through the ovarian, uterine, vaginal, and
internal pudic arteries. The ovarian arteries, analogues of the
spermatic in the male, arise from the abdominal aorta just
telow the renal branches and pass downward over the psoas
muscles beneath the ureters, enter the broad ligaments, and
pass to the side of the uterus, near which each divides into two
branches. The upper supplies the ftmdus uteri, and the lower
anastomoses at the side of the uterus with the anastomotic branch
of the uterine artery. In its course the ovarian artery gives off
branches to the ampulla of the Fallopian tube and to the isthmus,
and also numerous branches to the ovary, A small branch
is given off to the round Hgament. The uterine artery
1 of the internal iliac, passes
au orancn ^^^h
■ry springs ^^^^^1
downwarc^^^^^H
200 GYNECOLOGY.
second, the vesico-abdominal, which is seen only during dis-
tention of the bladder, and varies in depth according to the
point at which the serous lining of the abdominal wall is re-
flected. The vesico-uterine pouch is bounded in front by the
bladder; posteriorly, by the uterus. This pouch varies less
than the others, on account of the firm attachment of the perito-
neum to the anterior stirface of the uterus. In the empty
bladder the bottom of this pouch is about three centimeters
distant from the anterior culdesac of the vagina, and the pouch
rises somewhat as the bladder falls. The study of the female
peritoneum renders it evident that it differs from that of the
male in not being a closed sac, as it commtmicates with the
uterine mucous membrane through the orifice of the Fallopian
tubes, and is again perforated by the ovaries, which project
through it. The close relation of the peritonetun to the pelvic
viscera renders any change in this structure perilous to the
normal situation and relation of these organs. Inflammatorj-
changes result in thickening and cicatrization, which produce
temporary, if not permanent, displacements. The fixation
of the uterus, compression of the ovaries, and obstruction of
the orifices of the Fallopian tubes are necessary sequels of
such alterations. The peritoneum, according to Luschka,
serves as a sort of diaphragm, dividing the pelvic cavity into
two portions : the one above may be called the intraperitoneal
space, and that below, the subperitoneal. In the latter is
situated the greater part of the pelvic connective tissue.
276. Pelvic Connective Tissue. — The pelvic connective tissue
is a loose cellular tissue, which acts as a padding for the support
and safety of the pelvic organs. This structure is continuous
with that which exists in other portions of the body. It appears
in the pelvis in two varieties: first, as a loose tissue, distributed
in an irregular manner around and betw^een organs and between
the layers of the broad ligaments, where it acts as a support tc
the blood-vessels and folds of the peritoneum; second, as firm,
well-defined laminae or planes entering into the formation of the
pelvic floor. These have already been described under the name
of pelvic fascia. The connective tissue is continued behind the
symphysis as the retropubic fat, and there lies in front of the
bladder. Between the base of the bladder and the vagina it is
rather firmly connected. On the posterior surface of the vagina
there is a very loose layer connecting it with the rectum. A
large mass is found on each side of the cervix uteri, forming tmdei
the broad ligaments what is known as the parametriimi, which
is tmited in front and behind by a much thinner layer. Over the
body of the uterus the connective tissue is very slight and con-
tains no fat. The rectum and vagina are embedded in consider-
ANATOMY. 201
able masses of this tissue. From the uterus and the parametrium
a thin layer extends between the leaflets of the broad ligament,
and serves as a support for the vessels. The chief mass of this
tissue is situated around the cervix, and extends downward
around the vagina to the insertion of the levator ani muscle.
The distribution and relation of the pelvic connective tissue have
been studied in different ways. The most valuable method is by
the examination of frozen or spirit-hardened pelves, by which the
position of the tissue, its amotmt, and its distribution are recog-
nized. Injections of air, water, and plaster-of-Paris have been
made beneath the pelvic peritoneum in order to determine the
lines of cleavage in the pelvic connective tissue and the directions
in which pus would be likely to burrow. Konig made investiga-
tions upon the bodies of women who had died shortly after labor
from nonpuerperal disease. When an injection is made between
the layers of the broad ligament, high up in front of the ovary,
it first passes into the tissue at the highest part of the side wall
of the true pelvis ; then into the iliac fossa, lifting up the peri-
toneum; follows the course of the psoas, and passes but slightly
into the hollow of the iUac bone ; finally, it separates the peri-
toneum from the anterior abdominal wall some little distance
above Poupart's ligament, and from the true pelvis below it.
Second, when the injection is made beneath the base of the
broad ligament and in front of the isthmus, the deep lateral
tissue becomes filled first ; then the peritoneum is lifted from the
anterior part of the cervix uteri. Separation extends to the tissue
in the bladder, and ultimately along the roimd ligament and the
inguinal ring, where it separates the peritoneum along the line
of Poupart's ligament and enters the iliac fossa. Third, an in-
jection at the posterior part of the base of the broad ligament
fills the tissues around Douglas' pouch, and then follows the
course as first described.
277. The Vascular Supply. — The pelvic organs and perito-
neum are supplied through the ovarian, uterine, vaginal, and
internal pudic arteries. The ovarian arteries, analogues of the
spermatic in the male, arise from the abdominal aorta just
below the renal branches and pass downward over the psoas
muscles beneath the ureters, enter the broad ligaments, and
pass to the side of the uterus, near which each divides into two
branches. The upper supplies the fundus uteri, and the lower
anastomoses at the side of the uterus with the anastomotic branch
of the uterine artery. In its course the ovarian artery gives off
branches to the ampulla of the Fallopian tube and to the isthmus,
and also numerous branches to the ovary. A small branch
is given off to the round ligament. The uterine artery springs
from the anterior division of the internal iliac, passes downward
202
GYNECOLOGY.
and inward toward the cervix uteri, then upward between
layers of the broad ligament in a very tortuoiis course,
anastomoses with the lower branch of the ovarian. This por
is sometimes called the anastomotic branch, or the puerp
branch, as by its tortuous course it permits the vessel tc
straightened out during the enlargement of the uterus in p
nancy. The primary branches given off by the uterine ar
are separated from the peritoneuni only by a thin layer of mm
fibers. These give off secondary branches, which penetrate
muscular wall in a direction at right angles to its mucous la
They anastomose freely and end in capillary loops in the mu<
membrane. The vaginal branches spring direct from the a:
Fig. 141. — Distribution of the Uterine and Ovarian Vessels.
nor trunk of the internal iliac, but sometimes are given off f
the uterine or the middle hemorrhoidal. A special branch of
uterine artery to the cervix joins with its fellow of the oppc
side to form the circular artery of the cervix, and with
vaginal branches forms the azygos artery of the vagina.
tensive anastomoses take place between the vessels of the O]
site sides. The entrance of the vessels by the broad ligan
enables us in extirpation of the uterus to control hemorrl
by ligation of the latter. The anterior division of the inte
iliac also affords the blood-supply to the bladder and rect
The perineal region is supplied by branches from the inte
—Arteries of the Female Pelvic Organs.^(.Savage,)
Right
iferior. receives right a
3. Abdominal aor
. iliac artery. 1
Obturator branch
id left common iliac
El. 4. Inferior
. External iliac artery, j. Epigastric
' epigastric artery. ' ' "'""
External
artery. ;.
, Internal iliac
«rter}-. crossed in front by h, the ureter. 10. Uterine artery. 11. Obtu-
rator artery; its course is along with and below m, the obturator nerve.
L. Round ligament. 11. Inferior vesical artery. 13. Vaginal branch
from it. 14. Uterocervical artery. 15. Artery of the Fallopian tube.
18. Vaginal artery. 17, 17, 17. Spermatic arteries, tg. Pudic artery.
)o. Superior vesical artery. 31. Inferior hemorrhoidal artery, joined at
ij, another inferior vesical branch. 33. Posterior division of internal
iHac artery, terminates in (14) iliolumbar lateral sacral, and (»s) gluteal.
t6. Sciatic arteries. B, Bladder, u. Urachus. V. Vagina undistended,
resting on R, the rectum. O. Ovary. T. Fallopian tube. 15. Fallo-
pian branch. U. Uterus. L. Round ligament. S. Sacral articular sur-
face of sacro-iliac symphysis. P. Pubic symphysis, articular surface, a,
Pyriformis muscle, b. Gluteus maximiis muscle, c, Obturatococcygeus
muscle, p. Spine of the ischium, f. Psoas muscle, g. Linea alba.
h, h. Ureters, i. j, k, 1. Trunks of sacral nerves resting on the pyriformis
muscle, m. Obturator nerve, q. Peritoneum covering the transversalis
(ucta
204
GYNECOLOGY.
pudic artery — a branch of the anterior trunk of the internal
iliac. It passes out through the greater sciatic notch and enters
through the lesser, passing around the spine of the ischium. In
its course it lies upon the internal obturator muscle, and is
inclosed with the pudic nerve in a canal fonned for it by the
obturator fascia. It gives off the following branches :' The in-
ferior hemorrhoidal; the transverse perineal; the superficial per-
ineal'or vulvar artery, which is much larger than the corre-
Fig. 143. — Distributio
T.)
0 the Structures of the Perineum.
sponding branch in the male^the artery of the bulb ; the profundi
branch to the crus clitoridis; and the dorsal artery of the clitoris.
The round ligament rccei\'es a small branch from the epigastric
arter\-, which anastomoses with the branch from the ovarian.
The venous distribution of the pelvis is very abundant, and occurs
in the form of numerous plexuses, which freely communicate
with one another. These \'eins are provided with valves. Con-
sequently hemorrhage from an injured part will be very profuse
ANATOMY. 205
when the whole pelvic vascular system is engorged, as, for
instance, during pregnancy. Dissection discloses a vesical plexus
which lies external to the muscular coat of the bladder. At the
lower part of the rectum the hemorrhoidal plexus is found
dilated beneath the mucous membrane. The distribution of
the veins of the labia is similar to that of the arteries. From
the superficial portion they drain into the pudic, which com-
^H- 144. — Relation of the Urethral and Vaginal Venous Plexuses to the
Veins of the Clitoris and Bulb. The Right Side of the Pelvis Removed
by a Section in Front, through the Pubic Body, about an Inch from the
Spnphysis, and. Behind, through Sacro-iliac Joint. — (Sin/age.)
°. Bladder partially inflated, and b (vis) , ureter cut just before it enters the
bladder. V. Vagina distended. P. Section of pubis. R. Rectum. C.
Clitoris. S. Sacrum. 1. Bulb, i. Its urethral venous process. 3. Lower
(fferent veins. 4. Dorsal vein of the clitoris. 5. Urethral venous plexus. 6.
Commencement of vaginal venous plexus. 7, 8. (), 10. Sciatic and gluteal
veins corresponding to arteries. 11. Uterine veins assisting to form the
uterovaginal venous plexus, ri. Obturator vein. 13. Internal iliac vein.
4. PjTiformis muscle, b. Larger sciatic ligament, c. Pubo-, obturato-,
ind ischio-coccygeal muscles, d. Suspensory ligament of the clitoris,
e. Bulbovaginal gland. /, f, f. Roots of sacral plexus of nerves.
nimiicates with the common iliac vein. The large veins from
the labia minora open into the pars intermedia above. The
blood returns from the glans and body of the clitoris through the
dorsal vein of the clitoris, which communicates with the vesical
plexus. The vaginal plexuses are situated, one in the submucous
tissue and the other external to the muscular coat. They com-
municate with the hemorrhoidal and vesical plexuses, receive the
GYNECOLOGY.
blood from the veins of the bulb, and empty into the interna
iliac vein. The uterine plexus is very complex, and empties int
the ovarian veins. The right ovarian vein enters the inferic
Fig. 145. — Veins and Erectile Venous Plexuses ot the Female Pelvis. — (5ava|
B. Bladder. R. Rectum. L. Round ligamfnt. U. Uterus. O. Ovary,
Vagina. S. Sacro-iUac articulation. K. Kidney. T. Fallopian tu
P. Pubic symphysis, a. Pyriformis muscle, o. Gluteal muscle«.
Ischiococcygeus muscle, d. Internal obturator muscle, e, e, Pat
muscles, f. Linea alba, g, g. Ureters, h. Obturator nerve, i. '.
temal inguinal ring, site of canal of Nuck, i. Abdominal aorta.
Inferior mesenteric artery. 3, 3. Common iliac arteries. 4. Exten
iliac artery. 5. Vena cava. 6. Renal veins. 7, 7. Common iliac vei
8. External ihac vein. g. Internal iHac artery. 10. Gluteal. 11. II
lumbar, ii. Sciatic. 13. Pudic. 14. Obturator. 15, 16. Epigast
veins. 17. Uterine vein. 18. Vaginovesical venous rete. 19. Sperma
veins. 10. Bulb of the ovary. 3X. Vein to round ligament, la. Pal
pian veins.
ANATOMY. 207
vena cava; and the left, the left renal vein. The right ovarian
vein has a valve where it pierces the coat of the inferior vena
cava, while the left has none. To this arrangement is attributed
the greater frequency of pain and disease in the left ovary. The
oiarian or pampiniform plexus lies between the folds of the
^. 146. — Erectile Organs and Veins of the Female Perineum. — (,Savagt.)
'<>;. Crura clitoridis. i, i. Bulb of the vagina. 3. Vestibular intcrcom-
iDunicating branches. 5. Superficial perineal and obturator veins. 6.
Veins of communication with superficial epigastric veins. 8, 9, 10. Pudic
Tdn and primary branches. M. Urethral orifice or meatus. V. Vaginal
«perture. A, Anus. T, Tuberosity ot ischium. O. Coccyx, G. Vulvo-
vaginal gland.
woad ligament and communicates with the uterine plexus. The
ovarian plexus opens into the inferior vena cava. At the hilum
of the ovary is situated the collection of veins known as the
Imlb of the ovary. The vesical, hemorrhoidal, and vaginal
plexuses, with the pudic veins, empty into the internal iliac
Vein, which joins the inferior vena cava. From the hemorrhoidal
20S
GYNECOLOGY.
plexus there is a communication with the portal system thro
the superior hemorrhoidal vein,
278. The Lymphatic System, — This comprises: first,
lymphatic glands; second, the lymphatic vessels. The lym
7. — ^The Lumbo-iliac Lymphatics and Glands. Lvmphatics o
Gravid Uterus and Appendages. — (Sat/ag*.)
I, a. Superior lumbar glands, 3. Inferior lumbar glands. 4. Sacrallymf
glands, s- External and internal lymphatic glands. 6, Common
e' inds. 5, 7. Spermatic lymphatic plexus, a. Left renal vesseL
ft renal vein, c. Left spermatic vein. d. Left spermatic v«
covered by their lymphatic plexus, e. Aorta, f. Common iliac tt
g. Ascending cava. h. External iliac artery and vein, m, n. Ur
o. Right common iliac vein. p. lliacus muscle, s. Psoas muscle
Ovary reversed, showing lymphatics between it and its bulb.
atic glands are: (A) the inguinal glands, which lie parall<
and just below Poupart's ligament; (B) the pelvic glands,
147.) These comprise: (a) a gland situated at the isthmus v
(b) the hypogastric or iliac glands, which lie beneath the pe
ANATOMY. 209
neum, in the space between the internal and external iliac vessels ;
(c) the sacral glands, situated on the lateral aspect of the anterior
surface of the sacrum and the mesorectum ; (d) a gland or small
coDection of glands at the obtiirator foramen, known as the
obturator gland of Guerin. All these glands discharge into the
lumbar glands, which lie in front of the lumbar vertebrae, and
finally into the thoracic duct. The lymphatics of the external
genitals form an extensive network on the internal aspect of
the labia majora, over the labia minora, around the vaginal and
urethral orifices, the vestibule, and the clitoris, and all these
discharge into the inguinal glands. As a consequence, sjrphilis
or cancer affecting the vulva or lower fourth of the vagina causes
involvement of these glands. In the upper three-fourths of the
vagina and cervix uteri the lymphatics open into the hypogastric
glands. This is true not only of the lymphatics of the upper
three-fourths of the vagina and cervix, but also of the lymphatics
of the bladder. The lymphatics of the uterus pass through the
broad ligaments with those of the ovary and tube and enter
the lumbar glands. Some of the uterine lymphatics pass along
the round ligaments to the glands of the groin. Leopold, in
investigating the lymphatics in the imimpregnated uterus, re-
gards the mucous membrane of the organ as a lymphatic siuiace
consisting of lymph-sinuses covered with endothelium. The
lymph passes from these spaces into the vessels of the muscular
ooat, and flows into the larger vessels which enter the broad
Hgaments. The distribution of these vessels and their extensive
character accotmt for the rapidity with which septic matter
is absorbed from the uterine cavity and explain the various
nmtes by which bacteria can pass through lymphatic canals or
penetrate the blood-vessels.
The lymphatics of the rectum he in the mucous and muscular
layers and communicate with the glands of the mesorecttun or
the sacral glands.
Nerves. — The nerv^es distributed to the pelvic organs are
derived from the spinal and sympathetic. The branches from
the spinal ner\'es consist of the inferior hemorrhoidal branch of
thepudic, from the fourth and fifth sacral, and of the coccygeal
nerves. These nerves supply the levator ani, sphincter, and
coccygeus muscles ; the muscles of the perineum and clitoris are
supplied by branches from the internal pudic, which nerve ter-
minates in the nervous plexus of the glans clitoris. (Fig. 148.)
The hypogastric plexus, derived from the sympathetic, lies be-
tween the common iliac arteries, and distributes branches, which
are reinforced by others from the lumbar and sacral ganglia
and sacral nerves, to form the inferior hypogastric plexuses,
one of which is situated on each side of the vagina. These
14
GYNECOLOGY.
plexuses distribute filaments to the vagina, uterus, Fallopian
tube, and ovary. The pelvic, splanchnic, and hypogastric
nerves are motor and sensory to the bladder ; the pudic is motor
It;. 148. — Nerves of Ihe Unimpregnated Uterus with the NiTVes of the Clitoris.
— (Savage.)
, HypOEastric ple.-jus. 1. Rtcta] branch of inferior mesenteric ple-"tiis. 3. A
lumbar ganglion of tht- syiniiathetic, 4. Spermatic plexus, supplies Fal-
lopian tube, ovary, and part of the uterus, 5. Branches from third and
fourth sacral, aiding to form 6, 7. right inferior hypogastric plexus. 8.
Uterine filaments. 9. Vesical plexus and branch. 10. Trunk of great
sacrosciatic nerve, ii. Muscular branch of the fourth sacral nerve. i».
Trunk of pudic nerve. 13. Continuation of 12 into dorsal nerve of the
clitoris. R. Rectum. U. Uterus. B. Bladder. D. Transversiis perinei
muscle cut across. S. Section of ilimii. P. Section of symphysis.
ANATOMY. 211
to the Sphincter ; and all the nerves of the vagina and clitoris
are sensory to the skin of the perineum, and especially so to the
mucous membrane of the glans clitoris. The terminal filaments
in the uterus are found in the nuclei of the imstriped muscle.
Those of the mucous membrane are said to end in the ganglia.
End-bulbs have been foimd in the clitoris and vagina. In the
ovary the nerves pass to the Graafian follicle and to the walls
of the membrana granulosa.
279. Consideration of the Pelvic Organs and Structure
Studied as a Whole. — In the upright position the plane of the
brim of the pelvis is at an angle of 60 degrees to the horizon.
The fimdus of the uterus lies just below this plane, with its
axis at right angles to it, and consequently at right angles to
the vagina, which is parallel to the brim of the pelvis. In
the upright position the internal abdominal pressure is directed
against the symphysis and the posterior surface of the fundus
of the uterus when in its normal situation.
The uterus, as we have seen, is freely movable — swung
in its position in the pelvis by the ligaments. The broad liga-
ments maintain it in the center of the pelvis, and by their position
and relation serve to assist in maintaining it in an anteflexed
position. The round ligaments are an additional stay, and
when of normal resiliency, draw the fimdus forward. The
other ligaments are the uterovesical and the uterosacral. The.
former, are formed by the reflection of the peritoneum from
the bladder to the uterus ; the latter, while consisting of folds
of peritoneum, also contain muscle-fibers, which are derived
from the superior muscular layer of the uterus. The function
of the latter filaments is to hold back the cervix, while the
intra-abdominal pressure maintains the fundus forward. De-
viations from the normal inclination of the pelvis, from the
normal resiliency and tone of the ligaments, from the proper
relations and support of the vagina, increase in the weight
of the uterus, and increased intra-abdominal pressure, are all
factors in the production of uterine displacements, especially
that form characterized by descent. The plane of the outlet
of the pelvis when the patient is erect forms an acute angle
in front with the horizon. The tirethra, the vagina, and in
the upper part of its course the rectum, are parallel to the
plane of the brim of the pelvis. The lower portion of the rectum
turns acutely backward and forms an axis at right angles to
that of the vagina. This portion, the anus, looks backward
^d downward; consequently the introduction of the finger
or of the nozle of a syringe must be directed forward and up-
^suxi, or directly toward the vagina, and after passing into
the anus, is carried upward and backward. On median vertical
212 GYNECOLOGY.
section the vagina will be seen to be a mere slit, slightly S-
shaped, the lower part of which presents the convex surface
of its posterior wall anteriorly. The pelvic floor is consequentiy
divided into two segments, the anterior and upper of which
rests upon the more fixed posterior segment. The rectum
at the anus is found to form an anteroposterior slit.
Intra-abdominal force first causes pressure of the anterior
segment upon the posterior, and then a sliding backward of
that portion of the inferior segment in front of the anterior
wall of the rectum.
PHYSIOLOGY.
280. Functions. — The important functions of the genital
organs are the processes associated with reproduction. These
comprise the alterations in the organs by which menstruation
is established, repeated monthly, and finally discontinued;
the relation of the sexes in copulation; the fecundation of the
ovum, its subsequent nutrition, and the procedure by which
the matured product attains a separate existence,
1. The transition from child to woman, indicated by the
appearance of menstruation, is denominated puberty.
2. The completion of development, which fits the individual
for the processes of maternity, is called nubility.
3. The deposit of the vitalizing principle of the male within
the body of the female occurs through the act of copulation,
and its union with the ovum is known as fecundation.
4. The nutrition of this vitalized structure and its subse-
quent course of development are recognized as gestation.
5. The processes by which the matured product is afforded
a separate existence are known as parturition.
The first three of these divisions and their variations from
the normal comprise the field of gynecology.
281. Puberty. — The completion of the developmental proc-
ess that results in the estabHshment of menstruation and
ovulation has been called puberty. It marks the transition
from the child to the woman, and occurs between the thirteenth
and fifteenth years. The age of the individual differs under
varying circumstances. Puberty occurs earlier in the natives
of hot climates than in those of the north, and earlier in the
Latin races than in the Anglo-Saxon. City girls mature at an
earlier age than those raised in the country, and those raised
in affluence sooner than the poor. The occurrence of the phe-
nomena of menstruation prior to the age of thirteen is called
precocious puberty. Such instances are not infrequent. Iso-
lated cases occur in which it appears at a very early age. Rein
PHYSIOLOGY. 213
reports the case of a girl of six years whose pubes were covered
with hair and who menstruated regularly for a year. The
"New York Medical Record/' i6, xi, 1895, presents a report
of a girl who gave birth to a child when ten years of age.
Retarded or delayed puberty is caused by chlorosis, plethora,
or some congenital condition of the genital tract. Numerous
cases are recorded where women have given birth to children
prior to the establishment of menstruation; in other words,
ovulation occtu^ without the usual manifestation.
The advent of puberty is manifested by other characteristics
than menstruation. The figure becomes more rounded, from
an increase of adipose tissue. The breasts enlarge and fre-
quently become painful. Hair grows upon the mons veneris
and labia majora. Under this process occtirs increased blood
formation, the development of glandular structure, particularly
in the uterus and the mammary gland, and, especially, marked
changes in the nervous system. ** There is," Christopher
Martin says, ** a remarkable transformation in the psychic,
emotional, and mental life of the girl. The current of her
thoughts is mysteriously changed. Hopes and yearnings un-
known before thrill and agitate her, and life acquires a new
and deeper meaning. These profound and subtle changes
are not so difficult to understand if we accept the view that
puberty means the sudden bursting into activity in the midst
of the nervous system of a hitherto dormant center.'*
The glandular development of the mammae may be so rapid
and at times so irregular as to simulate a tumor. The period
of Ufe should prevent error.
282. Nubility. — The advent of puberty indicates that the
conditions and ftmctions are established that will permit pro-
creation, but the structures are not sufficiently developed
to render the individual suited for favorable reproduction.
Experience has demonstrated that the mortality is much greater
among those who come to the completion of gestation prior
to the age of twenty. Women coming to early maternity
niature early, reach the menopause at an early age, and are
prematurely aged.
283. Menstruation and Ovulation. — Menstruation — also called
the menses, the monthlies, the courses, the turns, the sickness,
^d the periods — has been defined by Sutton as the * * periodic
discharge of blood from the uterus, accompanied by the shed-
ding of the epithelium of the body and fundus, as well as of
that lining the utricular glands near their orifices.*'
Ovulation is the discharge of an ovum from a matured Graa-
fian follicle. These two processes are considered here in co-rela-
tion, though we have no positive proof that they are co-depen-
214 GYNECOLOGY.
dent. We have, however, determiiiati\'e evidence that they are
occasionally independent of each other. The not infrequent
occurrence of pregnancy prior to the advent of puberty and sub-
sequent to the climacteric is an indication that ovulation can
occur without menstruation.
The recent investigations of Frankel seem to justify him in the
presentation of the following theory regarding the corpus luteum
and its influence upon the menstrual function: i, the corpus
luteum is a gland with an internal secretion capable of being
always formed afresh in the (functional) ovary; 2, the corpus
luteum carries psychic nutritive impulses to the uterus, especi-
ally as concerns the endometrium, in the connective tissue of
which it excites extreme hyperemia and hyperplasia; 3, it effects
the adhesion of the impregnant ovum, or, failing this, it excites
menstrual secretion. The acceptance of the above hypotheses
renders the periodical occturence of menstruation and its varia-
tions more intelhgible than any other which has been presented.
Menstruation, in the majority of women, occiu-s every twenty-
eight days, and the flow lasts from two to eight days. The
intervals may vary from twenty-one days to five or six weeks.
It does not always occur at an absolutely definite date in the
same individual.
The quantity of blood lost is difficult to determine. The
average amount is estimated at from three to five ounces. It
has been mentioned that the flow varies in duration from two to
eight days. A flow shorter than two or longer than eight days
in duration indicates an abnormal condition. Absent or greatly
decreased flow is known as amenorrhea. The prolonged or ex-
cessive flow is called menorrhagia. When the function is asso-
ciated with severe pain, it is pronoimced dysmenorrhea. The
menstrual dischai^e is not pure blood, but consists of a dark
bloody fluid, thin and slimy in character, which contains, as
revealed by the microscope, blood-corpuscles, leukocytes, epi-
thelium, and stroma. The normal menstruation is not clotted,
due to the adnuxture of the secretion of the uterine and cervical
glands. It is only when the flow is excessive or the gland secre-
tion deficient that clots are present.
Menstruation occurs only in women and in certain monkeys ;
it is apparently limited to those animals that maintain the erect
position.
Menstruation involves between thirty and thirty-five years
of the life of the woman, known as the period of active sexual
life, beginning from the thirteenth to the fifteenth years and
continuing from the forty-fifth to the fiftieth. The filial cessa-
tion, like its advent, may be advanced or retarded by various
causes. Each menstrual period is generally preceded by some
PHYSIOLOGY, 215
premonitory symptoms, a sense of weight, pressure, or uneasi-
ness extending dowTi the Umbs, a sense of exhilaration, an in-
creased vascular tension, and, Belfield asserts, an increase of
weight which may exceed one pound an hour for several hours,
the woman gaining seven to nine poimds in twenty-four hours.
This increment, he says, is due, i, to increased absorption of oxy-
gen, and, 2, to decreased elimination. With the establishment
of the flow she suffers from depression, languor, malaise, dis-
inclination for exertion, either physical or mental, and, according
to Belfield, decrease in weight. Many women will exhibit a
tendency to the occurrence of gastro-intestinal disturbance,
formation of toxins developing an autointoxication, which will
produce mig^ine, aggravate nervous manifestations, chorea,
epilepsy, and will cause delusions. Epilepsy and insanity are
frequently so marked and recur so regularly with the menstrua-
tion as to lead the family and physician to believe the disorders
are the result of diseased conditions of the pelvic organs.
During the menstrual process the uterus and pelvic viscera be-
come engorged with blood; the uterus is enlarged, turgid, and
sensitive; the capillaries rupture, some upon the surface and
others within the mucous membrane. The uterine epithelitmi be-
comes desquamated ; dtuing the process of engorgement the glands
have become filled with epithelitmi, which is discharged from
the external portion of the gland. Many of the cells are lique-
fied, increasing the quantity of mucus. With the establish-
ment of the flow the engorgement is relieved and the general
disturbance subsides. After the termination of the period
the mucous surfaces are gradually regenerated from the epi-
thelial tissue remaining in the glands, imtil, at its culmination,
the process is again renewed. According to Napier, this des-
quamation and regeneration of the structures from the utric-
ular glands, and the accumulation of glandular products in
the uterine glands and the ovaries, stands in a causative relation
to menstruation. The menstrual discharge is supplied by the
entire cylindric epithelitmi-lined mucous membrane. My own
researches, confirmed by those of many others, are stifficient
to demonstrate that the Fallopian tubes as well as the uterus
take part in the menstrual flow. It is not imreasonable to sup-
pose that the presence of bloody fluid in the tube is of value in
promoting the nutrition of the fecimdated ovum and that the
consequent distention of the tube facilitates the passage of the
ovum to the uterus. Many ingenious theories for the recurrence
of menstruation have been advanced, but whether we accept
tte hypothesis advanced by FrSiikel or not, it can not be denied
that the ovaries are its cause, for the following reasons : i , The
ovary fiunishes the ovtmi, which it is the ftmction of the uterus
216 GYNECOLOGY.
to retain and nomish until its product is ready for a sepa
existence, hence the producer rather than the retainer sh'
dominate the function; 2, the entire removal of ovarian st
ture invariably results in the cessation of menstruation; 3,
removal of the ovaries is generally followed a couple of 1
later by the occurrence of a vaginal discharge which can no
distinguished from the ordinary menstruation. The disch
is tmdoubtedly due to the pressure of the Hgature upon the ne
which supply the ovaries; 4, Strassman's experiments ol
jecting the structure of the ovary with sterilized water •
followed two days later by a discharge from the uterus w
in every way resembled menstruation. The occasional cx
fence of blooily discharge after the removal of both ovaries
been held to negative our second proposition, but my experi
leads me to doubt the regular recurrence of menstruation
the complete removal of both ovaries. An occasional bl
discharge from tlie genital tract after the extirpation of
ovaries means nothing more than that there has been ;
local congestion which has been thus relieved.
PHYSIOLOGY. 217
It is only when the ovaries and utricular glands attain a
development that renders their secretion capable of exerting a
dominating influence upon the general economy that puberty
occurs, and the process continues until these structures begin
to atrophy and cease to exert their governing cotu'se. Napier
denies the probability of the period being induced by ovulation,
and cites the occurrence of the latter without menstruation,
and the continuation of menstruation after the removal of
both ovaries, as presimiptive evidence. Many other theories
are advanced for the periodic occurrence of menstruation.
Johnstone believes in a special menstrual nerve plexus, situated
near the comua of the uterus ; but this structure has not been
recognized by any other observer.
The alteration of the uterine mucosa which 00010*8 during
menstruation prepares it for the reception and nutrition of
the fecundated ovum. The fact that gestation occurs with-
out an intervening period is no contravention of this supposition,
but only a demonstration that the preparation can occasionally
occur without the shedding of blood.
The nerve influence leading to the increase of the liquor
foUiculi, and the liquefaction of the cells of the membrana
granulosa, promote the multiplication of cells in the mucosa
which is followed by menstruation. The coexistence of these
processes is seen in the formation of a corpus luteum syn-
chronous with menstruation. The course of menstruation is
averted by pregnancy. Menstruation continues during pregnancy
only with the rarest exceptions, and the fimctional activity
of the ovaries is suspended during lactation. Neither ovulation
nor menstruation is likely to occur during lactation. Many
women prolong the period of lactation for the purpose of render-
ing themselves less susceptible to fruitful coition.
Menstruation, it is seen, is one of the important functions of
the genital tract, hence diseased conditions of the internal geni-
talia generally manifest themselves by disturbances of this
function.
The disturbances of the menstrual fimction are: amenorrhea,
dysmenorrhea, menorrhagia, and metrorrhagia; arid, we may
add, vicarious menstruation.
Amoiorrhea is a term applied to an ahnost or complete
cessation of bloody flow: Occasionally the vascular tension is
insufficient to result in the rupture of vessels and the discharge
of blood, but causes increased secretion from the uterine glands
^hich, with the desquamated epithelitmi, produces a profuse
leukorrhea that supplants the menstrual flow.
Amenorrhea is congenital when puberty is much prolonged
beyond the period of its usual occurrence, and is due to defective
218 GYNECOLOGY.
development, chlorosis, anemia, or mechanical obstruction;
constitutional, when profoimd blood changes exist or diseased
conditions are present which are calculated to reduce vascular
tension; mechanical, when an obstruction, congenital or ac-
quired, exists to prevent its exit ; due to disease of the ovaries,
when these organs have become destroyed or their function has
been arrested. Finally, it is a symptom of the existence of preg-
nancy.
Chlorosis and anemia, as factors in the production of amenor-
rhea, are generally easily recognized by the appearance of the
patient. Blood examinations will be of special value, however,
to determine the degree of anemia and the extent and gravity
of the defective development or the degenerative changes in the
blood-corpuscles .
Chlorosis generally occurs in the yoimg. The patient may
present an appearance of full flesh, but is white or greenish- white;
the lips are pale, and the ears transparent ; the pulse is rapid, and
she breathes rapidly upon the slightest exertion. The menstrual
Aqw is supplemented by the profuse leukorrheal discharge al-
ready mentioned. Chlorosis and anemia may frequently be the
precursors of tuberculosis, hence the wide-spread dread of this
symptom upon the part of the laity.
Disease of the ovaries, in the form of glandular cystoma of
both ovaries, will sometimes result in this symptom. I say some-
times, for it is only when the entire structure of the ovary has be-
come disorganized that it occurs, and menstruation may con-
tinue to be regular and pregnancy may occur when both ovaries
are the seat of cystomata. Another change in metabolism, due
to ovarian disease, the pathology of which has not as yet be-
fully recognized, results in an early menopause. The woman
ceases to menstruate at thirty years or younger. She looks well
She will give a history of rapid gain in flesh, thirty or forty pounds
in a year, and of a gradual decrease in, or sudden arrest of, the
menstrual flow. She may have had one or two childen or never
have been pregnant. That the condition is not always as-
sociated with destroyed fimction of the ovaries is evident from
the fact that in some of these patients under regulated diet and
suitable treatment the menstruation returns and the sterility
is overcome.
When amenorrhea is produced by mechanical causes, it may
be primary or acquired, and the obstruction may occur at any
part of the genital canal, although when in the tube it may not
preclude an external flow, while resulting in a partial retention.
Such a patient will present the appearance of good health, will
exhibit periodically menstrual moUmina, and later an abdominal
swelling may become visible. In the primary form the patient
kl
PHYSIOLOGY, 2] 9
has never had a visible menstrual flow; in the acquired, there
tBually is a history of a difficult or instrumental labor or some
injury to the genital tract, after which there was no visible flow,
though efforts to menstruate had recurred. In both classes of
cases the possibility of pregnancy should be considered and may
be suspected, but in the primary the patient should be given
the benefit of doubt until examination has rendered pregnancy
certain.
The diagnosis will be difficult only when the obstruction is at
the internal os. Even in such cases the distention of the uterus
> is likely to be more spherical, and the uterine wall thinner and
yet more tense, than when the distention is due to pregnancy.
Should the examiner be imcertain, he may postpone the diag-
nosis for another month.
The amenorrhea of pregnancy is generally easily recognized
by the healthy appearance of the patient and the usual physical
signs associated with pregnancy.
Dysmenorrhea, as a symptom of pelvic disease, is the most
frequent disturbance of the menstrual function, and, possibly,
as a result of the training and manner of life of our women, is
becoming more frequent. It indicates painful flow, consequently
the expression of intermenstrual dysmenorrhea is a misnomer.
We commonly make the classification into congestive or in-
flammatory, obstructive or mechanical, ovarian, and nervous
dysmenorrhea, but such an arrangement is misleading. It is
very doubtful whether obstruction ever is much of a factor in
its production. Some of the cases in which I have found dys-
menorrhea most marked were in women in whom the uterus was
very patulous and a sotmd could be carried to the fundus with-
out any difficulty. On the other hand, women with tmcompli-
cated anteflexions of marked degree have menstruated without
pain.
To appreciate fully the significance of this symptom we must
remember that the uterus is an erectile organ, whose walls are
subject, as in all other involuntary muscle structure, to rhythmic
contractions. Any inflammation of this organ, whether in its
mucous membrane, muscle-wall, or serous covering, must to a
certain degree render the performance of the menstrual function
painful. In cases in which the canal is patulous in the inter-
menstrual intervals the myometrium is imdoubtedly the seat
of the inflammation, and the painful spasm resembles the oc-
currence of chordee in the male. This symptom is provoked or
aggravated by faulty or defective development of the uterus, by
flexions, chronic metritis, perimetric inflammation, rhetimatism,
gout, and neurasthenia. Its existence demands careful investi-
gation for its cause, and it should not be forgotton that frequently
220 GYNECOLOGY.
much more will be accomplished by the treatment of the con-
stitutional condition than by local applications. The experienced
physician has recognized that the neurasthenic patient will often
perform none of her fimctions painlessly, and it can be readily
appreciated that such a patient will require but little disturbance
of the pelvic organs to occasion pain during the course of menstrua-
tion. Ovarian dysmenorrhea is hardly an appropriate term, for
the reason that the ovarian pain is usually felt with greatest in-
tensity some days or a week prior to the flow, and should be
considered as an indication of chronic inflammation of those
organs.
Recently much attention has been directed to the theories
of Fleiss and Schiff as to the nervous or reflex dysmenorrhea
attributed to what are denominated the genital spots in the nose.
The mere fact that cocain solution can be applied to the nasal
mucous membrane and afford relief is not proof positive that the
surface thus touched was the cause of the symptom. Cocain
given internally or hypodermically would be equally effective,
but is not a safe remedy for frequent employment.
Membranous dysmenorrhea is a form of painful menstruation
in which a more or less well-defined cast of the uterus is discharged.
It is usually associated with pain as intense as if the woman were
undergoing an abortion. The cast contains the epithelial layer
of the endometrium, often showing partial casts of the gland
tubules, and also contains a croupous exudate. We need but
to recur to the phenomena of menstruation with its desquamated
epithelium to appreciate that this condition is the result of a more
severe and chronic inflammation.
The condition is recognized by the association, with labor-like
pains, of the discharge of shreds of membrane or an entire cast
of the uterine cavity. The false membrane may occur but occa-
sionally or at every period. Its occurrence indicates lowered
vitality and a profound neurotic state.
Menorrhagia and metrorrhagia are terms used to indicate,
respectively, excessive menstrual flow at the regular periods and
bloody flow without any periodicity. The symptom may begin
as menorrhagia and end in metrorrhagia. It may occur at any
time between puberty and the menopause, and metrorrhagia
may follow the latter. The symptom may be the result of con-
stitutional conditions interfering with vascular tension, either
locally or generally, as in hepatic, cardiac, or renal disease, caus-
ing obstruction in the zymotic fevers, scurvy, and other con-
stitutional conditions. It may be produced by pelvic conditions
outside the uterus, as in cystic degeneration of the ovaries, in-
traligamentary cysts, fibroid growths, ectopic gestation, or peri-
uterine inflammation; from uterine involvement, as in threat-
PHYSIOLOGY. 221
cned abortion, retained fetal products after labor or abortion,
interstitial inflammation of the uterine mucosa, interstitial or
submucous myomata, malignant conditions, such as epithelioma
of the cervix, adenocarcinoma of the cervix or body, endothelioma,
sarcoma, or chorioepithelioma.
Vicarious menstruation indicates a discharge of blood from
some other stirface than the uterine endometrium. It may occiu*
from the nose, ears, anus, or nipples, or as petechias or purpura
beneath the skin. Its occurrence is readily understood when
we consider the preparation for the menstrual flow characterized
by increased vascular tension. The vessels which are weakest
are the first to rupture, and the released tension prevents the
rupture of the endometrial vessels, hence the absence of the genital
flow. The symptom is recognized by its periodicity and the
absence of regular menstruation.
284. Menopause. — The conclusion of menstrual activity is
recognized as a critical period in the woman's existence. It is
variously denominated the menopause, the climacteric, and the
change of life. The menstrual life of the woman lasts, upon an
average, nearly thirty-five years, so that the menopause should
occur between the forty-seventh and the fiftieth years. Its
occurrence may be accelerated or retarded by various causes.
Premature menopause occtu's prior to the age of thirty-two,
and may be induced by shock, severe illness, prolonged anxiety,
overstudy, mental affections, disease of the ovaries, — such as
destruction of the ovarian stroma by double ovarian tumors, —
sepsis, chronic disease of the appendages, and some forms of
metritis.
Early menopause occurs between the ages of thirty-two and
forty-two. It occurs early in the virgin, and earlier in blonds
than in brunets. Fat women reach the menopause early. A
rapid increase in adipose tissue is associated with some cases of
premature menopause. Occasionally the menopause occurs at
an early age without any assignable cause.
Retarded or Delayed Menopause, — The occurrence of the meno-
pause is distinctly affected by heredity.
It may be delayed by child-bearing, by the presence of uterine
growths, and by the presence of malignant degeneration. Rob-
ertson reports the case of a woman who ceased to menstruate
for twelve months at the age of fifty, when the flow returned
and continued until her death at seventy. Saxonia speaks of a
nun who had a return of her menstruation at the age of one hun-
dred, which continued regularly until she died three years later.
The term menopause is employed to designate the period of
the change. The average duration of the menopause is about
two and one-half years. A few fortunate persons continue to
222 GYNECOLOGY.
menstruate regularly until a certain period, when the flow dis-
continues, never again to recur. Others continue irregular for
six months, when it ceases. Generally a patient will notice that
the periods are getting more scant, until finally she misses one
or two periods; then menstruation recurs for a while, to agaia
subside, thus continuing irregularly for one or two years. The
irregularity may be prolonged over a period of four or five
years. While, as a rule, the intervals are longer, the periods
may occtir more frequently, with intervals of but twenty-one or
even fourteen days.
The flow may be increased, and occasionally hemorrhages
occur without any assignable cause.
Excessive or prolonged bleeding should always be a cause of
anxiety, and should lead to a careful examination in order to
determine its cause. The cause should not be assigned to change
of life tmtil careful investigation has eliminated every other
source. The occurrence of menstruation is attended with the
elimination of certain materials from the blood.
Chemic changes in the blood and tissues are constant, and the
elimination of the albuminoids during menstruation is demon-
strated by a more marked alteration of the blood following
menstruation than the mere blood-loss would produce.
When menstruation is arrested by anemia or pregnancy, we
see in the skin marked deposits of pigment and other materiak
that would be eliminated by its occurrence.
When the menopause occurs suddenly, the retained products
produce an intoxication which results in various nervous per-
versions. It is a very usual, occurrence to witness various vaso-
motor disturbances, such as sudden sensations of heat ; flushings;
waves of blood rolling up to the face, accompanied by a sensation
of giddiness, suffocation, or oppression; cold, clammy perspira-
tion ; shooting neuralgic pain ; headaches ; fullness of the vessels
of the head and neck; palpitations; gastric irritation; diarrhea;
irritability of temper; melancholia; and disturbed mental bal-
ance.
In sudden production of the cUmacteric after radical opera-
tions the vasomotor disturbances are frequently so distressing as
to render the condition for which the operation was performed
preferable.
Treatment. — The more distressing vasomotor disturbances can
be ameliorated by the employment of tonics, good food, rest,
massage, and the application of the galvanic and Faradic cur-
rents; the administration of the bromids, asafetida, and other
nerve sedatives ; the regulation of the bowels; and the promotion
of digestion.
Picrotoxin in -^^-grain doses three times daily seems to exert
a specific influence in some cases.
MALFORMATIONS. 223
285, Copulation is that act of tinion of individuals of the
two sexes by which the vitalizing principle of the male is depos-
ited in the genital organs of the female. The sexual desire of
the woman is much less marked than that of the man. Fre-
quently she has no sexual sensation, and the act is even repug-
nant, but she yields to the man's embrace from her wish to
gratijfy his desire. Such a woman, mated to a man of impetuous
inclination, often becomes a sexual slave. The clitoris and the
tissues about the vestibule are erectile, and take part in the
orgasm, during which a secretion is ejected from the vulvo-
vaginal glands.
Imperfect or unsatisfactory copulation is a prolific soiu"ce of
disease. Efforts to avoid the legitimate results of copulation,
like all violations of nature's laws, visit their penalty upon both
the offenders, but most heavily upon the woman.
286. Fecundation. — The union of the spermatozoid with the
ovum and the successful fertilization of the latter are known as
fecundation. Its occurrence does not require that the woman
should share in the pleasurable sensation of copulation ; indeed,
it can follow in spite of the fiercest resistance upon her part.
The spermatozoids, the active fertilizing agents from the man,
require no assistance from the woman, but by a vermicular
motion can make their way to the ovinn in the internal organs.
There has been much discussion over the probable point
at which fertilization occurs and as to the ability of the sper-
matozoa to penetrate the narrow isthmus of the Fallopian
tube against the waving cilia, the function of which is to pro-
mote a ciurent toward the uterus. The demonstration that
they do overcome these obstacles in the sheep and other lower
animals, and are fotmd swarming over the ovary, and the fre-
quent occurrence of ectopic gestation in the woman, should
be accepted as a sufficient demonstration that they make the
voyage. It is most probable that fecundation results in the
tube, from which the vitalized ovum passes into the uterus,
which is prepared for its reception.
Impregnation is more likely to occur during or immediately
bflowing menstruation; less likely, immediately preceding the
low; and the woman is least susceptible in the mid-interval.
Independent of organic conditions, there is a marked differ-
nee between individuals as regards their susceptibility to im-
regnation.
MALFORMATIONS.
287. Classification; Definition. — A genital malformation is
ly dexnation from the normal form and structure of the fe-
224
GYNECOLOGY.
male reproductive organs. As the processes of development
are not completed until puberty, such deviations may arise
from the arrest or distortion of growth at any one of the periods
we have already considered in the study of the formation of
these organs, As the majority of instances of abnormality
are due to prenatal causes, they are justly considered, there-
fore, as congenital. In a former edition I considered the various
lesions of parturition under the head of acquired malformations,
but will now discuss them under the designation of traumatisms.
288. Bifidities. — The development of the uterus and vagina
from the coalescence of the two Mullerian ducts naturally
Fig. 150. — Degrees of
Division of t^i
Genital Tract.
leads, upon arrest or faulty continuation of the process, to a
partial or a complete separation of these organs into two canals.
Such a bifid development may be either equal or unequal.
This double development may result in the formation of two
canals by a simple partition or septum through what seems
one body, or a partial or complete separation into two bodies.
289. The Degrees of Division.— The most frequent form
of malformation is the presence of a more or less complete
septum between the two sides of the uterus and vagina. This
partition or septum in the uterus may, according to its extent,
consist of five degrees. The first (I, Fig. 150) will present
MALFORMATIONS. 225
a mere outline which projects from the fundus. Such a con-
dition is rarely recognized during life, unless opportunity is
afforded for digital exploration of the uterine cavity. In the
sicond degree (II, Fig. 150) a septum extends through the body
to the internal os. This form can be recognized following
delivery or abortion, but otherwise may give no indication of
its presence. The occurrence of pregnancy may cause its
destniction. In the third degree (III, Fig. 150) the body and
oava are divided by the septum into two distinct canals.
The fourth degree (IV, Fig. 1 50) affords a septum, which is
incomplete only in the vagina, and the fifth (V, Figs. 150 and
158) presents a complete uterovaginal septum, forming two
Fig. isa. — Uterus Bicomis UnicoUis.
canals. The one canal may be readily overlooked, or coition
inay occur in either side indifferently.
J(K>. Double TJteniB. — The division of the organ into two
portions may be more or less complete, and consequently may
form three classes :
First, the division of the fundus by a groove and two lobes,
loioftTi as the uterus bilobularis, uterus bicomis arcuatus, or
uterus bicomis unicoiUs (Fig. 151), the latter especially when
but one cervical canal exists (Fig. 152).
Second, the body di\'ided into two distinct portions, the
double uterus bicomis (Barnes) — uterus bifidus; it may have
a single or two cervical canals (Fig. 153).
Third, two separate organs exist, each with one tube and
ovarj-, uterus didelphys (Fig. 154). The bodies diverge, each
IS
GYNECOLOGY.
half being held to the corresponding side by the short bi
ligament.
Fig. i54.^UU-nis Didclphys.
291. Unequal Development of the Two Sides. — The
canals of Muller may be incompletely developed, and t
MALFORMATIONS.
odiice asymmetric organs of varying form. The one canal
ly be completely atrophied, while the other presents a well-
fiR- 'SS' — Uterus Unicorni
veloped horn — the uterus unicornis. (Fig. 155.) Generally,
; absence of one horn is associated with absence of the corre-
Miding tube and ovary. The horn may be rudimentary
partly developed, per-
tting the occurrence of
instruation and even
^nancy. Such a horn
not generally prepared
■ the maintenance of
! fecundated ovum to
: completion of gesta-
n, and may result in
Jture prior to the sixth
mth. In some cases
i occurrence of such
pregnancy is quite as
[^erous to life as a
sal gestation, from
lich it can not, pre-
)us to operation, be
ierentiated. 1 have
in instances in which
one-homed uterus had
SSed successfully p^g ijg^Atrcsia of Rutiiim-ntary Horn with
lOUgh more than one an Accumulation of Menstrual Blood.
^nancy and the ab-
Tmal condition was only discovered by accident. Atresia in
e canal of a rudimentary or partly developed horn may exist,
id lead to an accumulation of the menstrual secretion and the
22S GYNECOLOGY.
formation of a tumor. (Fig. 156.) The diagnosis of suchacon-
dition is exceedingly difficult, and can be determined only during
an operative procedure. The accumulation may rupture into the
vagina, but usually at such a height as to leave a portion of the
sac dependent and undrained, and, therefore, Hkely to become
infected and lead to septicemia. When the condition is recog-
nized, the treatment should be that for retained menstruation,
which will be described later. The development of a one-homed
uterus may be associated with a double cervical canal. — uterus
biforis, — a condition which may cause embarrassment during
labor. The septum when discovered may be pushed to one
side, or, if necessary, be cut
between two sutures (Pom)-
When torn, it has caused
severe hemorrhage,
292. AbsentUterus.— En-
tire absence of the uterus is
rare, and is almost always
associated with absence of
the other genital organs,
particularly of the vagina.
The determination of the
condition is difficult.
The introduction of the
index-finger of one hand into
the rectum, and that of the
other or of a catheter into
the bladder, enables the op-
erator to explore thoroughly
the pehis. Failure to recog-
nize the organ may be due to
its rudimentary condition 01
its displacement to one side,
and we can assert its entire
absence only when we have been able to explore the pelvis
through an abdominal incision or during an autopsy.
203. A rudimentary uterus may exist in the form of a slight
thickening over the surface of the bladder, as two undevelopec
canals in the form of a T, — the uterus bipariilus (Fig. 157),—
when the vagina is frequently absent or may be partly developed
deepened by coition, or may exist as a small culdesac continuou
with the urethra, which has been dilated by repeated effort
at coition. Menstruation is generally absent; ovulation ma;
occur without molimina, or there may be the occurrence o
hematometra.
When the vagina is well developed and menstruation occurs
—Uterus Biparti
MALFORMATIONS. 229
the condition may remain undiscovered. The rudimentary
diaracter of the organ can be determined by bimanual palpation
or by palpation through the rectum and the bladder, as has been
described. The occurrence of painful moHmina may require
castration.
194. Fetal and infantile uteri are instances in which the organ
has b^n arrested during the fifth stage of its development. The
uterus is small, the cervix two or three times the length of the
hody, and an acute anteflexion of the body probably exists.
The infantile uterus differs from the fetal in that the arbor
viti arrangement of the mucous membrane no longer extends
to the fundiis. Menstruation rarely occurs, and sexual desire
may be absent. The external
genitals may be poorly or well ,
de\'eloped. The breasts not
infrequently are normal.
Treatment. — The existence
of a malformation is an indica-
tion of defective development
and presents a condition in
which the function of the af-
fected organ must be more or
less impaired-
The presence of a septum
through the uterus and vagina
may be a cause of dyspar-
eunia, due to the diminished
aze of the vaginal canal. It
need not produce distress or
danger during gestation, but
not infrequently the cervical
and raginal septa may cause
dj-stocia.
The vaginal septum should
be cut through its entire
length and the edges of each wall sutured to prevent readhesion.
The division of the septum by the thermocautery has been advo-
cated as saving the time necessary for suturing. The cervical
septum can be crushed by forceps, which should be left
in place to produce necrosis of the compressed tissues. Such
septa do not generally withstand the first gestation, but are
broken down in the course of labor. I ha\'e twice seen a bridle
of tissue attached to the lower portions of the anterior and
posterior vaginal walls, which were without doubt remnants of
an originally more complete septum.
The division of the uterus into two equally developed por-
230 GYNECOLOGY.
tions does not usually call for treatment. The investigation of
a large number of such cases demonstrates that pregnancy has
frequently occurred without appearing to produce difficulty in
parturition. This necessarily depends upon the development of
the separate comua.
In one patient upon whom hysterectomy was done for inter-
stitial myomata her history revealed that she had given birth to
two children, apparently without any unusual phenomena. The
operation disclosed that she had a rudimentary horn upon one
side, which had its own cervical canal and opened into a blind
pouch for a vagina, which was situated between the existing
vagina and the bladder.
It is my purpose upon the next opportunity to split the adjoin-
ing cornua of a partially bifid uterus, and after coaptating their
edges, suture the surfaces so as to establish one cavity. It may be
questioned how such a reconstructed organ will endure the course
of a gestation, but if pregnancy can go to full term in one horn
of the uterus, the organ thus formed should be more capable of
performing its physiologic functions. Where the uterine comua
are unequally developed, the danger is from conception occur-
ring in the rudimentary comu. The recognition of the exist-
ence of such a pregnancy should be considered ample justifica-
tion for its extirpation by operation, Where both cornua are
rudimentary and the patient suffers from menstrual mohmina,
the abdomen should be opened and the ovaries removed. Simi-
lar advice is proper when the uterus is absent.
The fetal and infantile uteri frequently present conditions
in which the function of menstruation is performed irregularly
and attended with severe pain. The probability of the patient
becoming pregnant and carrying the fetus to full term is depend-
ent upon the degree of development. Under the stimulation of
the marital relation such uteri occasionally increase in size.
More frequently the individual complains of irregular and painful
menstruation and is sterile.
295. Congenital prolapsus uteri is an exceedingly rare con-
dition, and is usually associated mth other forms of defective
development, as spina bifida.
296. Accessory or trifid uteri have been reported. Hollander,
in 1894, found a second uterus lying in front of the norma] organ,
between it and the bladder. It was a simple cervix with two
orifices, having neither adnexa nor round ligaments. Depage
describes a trifid uterus which probably arose from a diverticulum
of one of the ducts of Muller.
397. Absent or Rudimentary Tubes. — Absence of the Fal-
lopian tubes is a rare occurrence, and is associated with a similar
condition of the ovaries and uterus. The absence of one tube is
MALFORMATIONS. 231
of more frequent occurrence ; a unicomate uterus is generally
found. A rudimentary tube is generally the result of an attack
of fetal peritonitis. The tube may be a simple cord and yet
have well-developed fimbria. The fimbria may be independent
of the openings.
298. Accessory tubal ostia are frequent. Ferraresi found six
openings upon one tube, all of which were surroimded by fimbria.
These openings are generally near the end, but may occur near
the middle of the duct. They are probably due to failure in
closure of the groove in the germinal epithelitmi or to splitting
of the Mullerian duct after it has closed.
299. Anomalies in Length. — The normal tube is from ten
to twelve centimeters long ; in ovarian or broad-ligament cysts
and in ovarian hernia one tube may be found from sixteen to
eighteen centimeters long.
300. Absent or Rudimentary Ovaries. — Absence of ovaries
is an exceedingly rare condition, requiring an inspection of the
abdominal cavity to confirm the suspicion. Absence of one is
less rare, and is associated with a tmicomate uterus, and occasion-
ally with absence of the corresponding kidney. The rudi-
mentary state is more frequent, and may be fetal or adult. It
may contain no glandular tissue, or the presence of tmclosed
Pfiuger's tubes may lead to a suspicion of a testicle. The con-
dition may be produced by oophoritis or peritonitis during fetal
or adult life, or by the twisting of a pedicle.
301. Supemtmierary ovaries are very rare. Von Winckel
found a third ovary in front of the uterus. Tufts of ovarian
stroma have been described. The occurrence of menstruation,
and even of pregnancy, after the supposed removal of both
ovaries has been reported, but it is more probable that in all
such cases there has been failure to remove the entire structiu^e
of both glands.
302. Accessory or constricted ovaries are more frequent.
A portion of the ovary may depend from the main body by
a more or less well-marked pedicle ; as many as two or three
have been found associated with one ovary.
303. Displacements. — The descent of the ovary may have
occurred, and the organ may be situated above the brim of
the pelvis. The presence of the ovary in the sac of a hernia
is a lesion often difficult of accurate recognition and productive
of serious distress.
304. Defects of Round or Broad Ligaments. — Absence of
the round ligament is generally associated with absence of the
uterus in whole or in part. I saw one patient in whom the
muscular structure of the round ligament was completely ab-
sent. The fold of the broad ligament, in w^hich the round
232
GYNECOLOGY.
ligament would He, presented a thin, corrugated margin.
persistence of the canal of Nuck results in the formatior
hydrocele, which may attain to considerable size in the
majora. The broad ligaments may be absent, extremely :
or unequal in length and thickness. They may contain
which are relics of the parovarium.
305. Complete Absence or Rudimentary De7elopnie
the Vagina.— In complete absence of the canal no tra
vaginal tissue wi
found between th(
turn and the blf
These two organs
contact, with conne
tissue only intervt
{Fig. 1 59-) In the
mentary vagina a fi
cord may exist, in
ing the site of the
of MuUer, the de-
ment of which has
arrested in an early
of fetal life. We
have a complete al
of one of the segme
the vaginal canal,
an incomplete de'
ment of the other
these cases of abs<
rudimentary vagin
uterus may be er
absent, reduced to e
mentary nodule, 01
or less defective in
velopment. Rarel
a well-developed ■
be found associate*
absence of the v
In some patients T)
ovaries are present without any manifestation of menstrual
mina. Occasifmally, there are periodic pains at the times of 1
tion. Cases ha\'e been reported of vicarious hemorrhages frc
ferent portions of the body, associated with extreme pains
supposed menstrual periods, when a well -formed uteru
present. The vulva may also be absent, but is more freq-
well formed, presenting a funnel-shaped depression 1
well-developed nymphjE. The hymen may be perfectly r
MALFORMATIONS. 233
and the urethra at times may be dilated by the eflforts that have
been made to effect coition. It is difficult to determine why it
should be the lower portion of the vagina that most frequently
is present in cases of arrested development. It is probably due to
an abnormal elongation of the vestibular canal. This pouch,
in the absence of the vagina and uterus, has been found to
be two or three centimeters in length and sufficiently wide to
admit the finger. These dimensions are very considerably
increased by sexual efforts. The opening is generally closed by a
pearly, reticulated membrane
with a cicatricial appearance.
The central portion of the vagina
may be absent, or the two por-
tions may be separated by a
membrane of variable thickness,
which at times is perforated.
One patient came under my ob-
servation in whom there was a
membrane dividing the upper
and lower halves of the vagina,
and 3 small opening situated at
one side, which permitted the
menstrual discharge to escape.
The incision of this inembrane
exposed a good-sized cavity
above, and by cutting out a por-
tion of this septum, the two
mucous membranes of the upper
and lower halves were sutured
t(^ether, to form a good-sized
vagina. In patients with absent
vagina the condition should be
determined by a finger in the
rectum and a catheter or a sound
in the bladder. Combined rectal
and vesicaltouch enables usto rec-
ognize the presence of the uterus
and its degree of development.
7"rfa(iK(r»(.— Absence of all or a part of tlie vagina affords
different indications according to the development of the uterus.
If the latter organ is normal and the symptoms of menstrual
molimina have existed, with a uterus increased in size, the
presence of hematometra should be suspected, and interference
should be employed. If there is no uterus and welI-de\-eloped
o\'aries are present, associated with painful sensations, the
eohdition may be considered a sufficient indication for cas-
).— Line of Incision for For-
mjition of Flaps.
I. Flajjs from liibia minora which
are split and usid to line the
vagina.
234
GYNECOLOGY.
tration. Absent vagina renders the person sexually i
petent, and it becomes a serious question as to whether a \
shall be established for sexual purposes. The operatic
the formation of a vagina was first performed by 1
sat. It is performed by making an incision through tht
var surface, using chiefly the fingers in the division t
soft parts, and pn
ing step by step
tearing and dissi
combined. The
of the operator or
assistant should bf
in the rectum ail'
sound in the hh
These organs can hf
readily recognized
their injury av
When a depth of
six to eight centir
has been reached, •
peritoneum openec
second step of the t
tion should be perfo
which is the inves'
of the funnel thus ■
lished with integi
to prevent cicatricii
traction. The skii
mucous membrane
adjacent parts mi
employed for this
pose. When the
minora exist, thej
be split and utilize
the lining of the ai
portionof the canal
flaps may be taker
the vulva and inner
the thighs to line it
terior wall. (Figs. 1 60 and 161.) Afterthe sutures are appli
cavity is packed with iodoform gauze, and the packing is re'
or renewed until cicatrization is complete, when the cana
subsequently be kept open by a glass plug. (Fig. 162.) Ie
cases attempts have been made to establish cicatrization ■
glass plug in the newly created canal, without any atten
line it with mucous membrane. Such a canal, however,
II. — ^Flaps outlined in Fit;. 160 Sutured
Place, and Dtnuded Surfaces which
Have Furnished Flaps to line Posterior
Wall.
MALFORMATIONS. 235
ceedingly difficult to keep open, because it is liable to contrac-
tion even though an obturator is constantly worn. The lining
of such a canal has been accomplished by following the opera-
tion by one upon another patient for redundant vagina, and
utilizing the vaginal tissue removed to form a lining membrane
for the newly created vagina. The tissue should be sutured
over a glass plug (Fig. 162), or, preferably, over the end of a
d^htly distended bivalve speculum, which is introduced into the
canal with the prepared hood of membrane, and as the speculum
•is withdrawn, some iodoform gauze is lightly packed through it,
keeping the membrane in place. During the preparation of the
vaginal lining the cavity should be packed with gauze, and the
packing introduced with the hood should be removed at the end
of a week. If the tissues by this time have united, it should be
irrigated, removing any tissue which has not retained its vitality.
In the patient represented by Figs. 160 and 161, after forming
the wall of the anterior portion by splitting the labia minora,
I transplanted a flap from the posterior part of each thigh,
which fortunately became
attached, and a very
satisfactory vagina was
formed.
In making the dissec-
tion for the vagina, no
hesitancy should exist in
opening through the peri- Fig. 162.— Sims' Glass Dilator.
toneum. By making such
an opening the presence and size of a rudimentary uterus are
more readily determined and the latter organ affords a safe
point for the fixation of the flaps to line the constructed vagina.
I have no question that the employment of a portion of the sig-
moid or ileum, as advocated by Baldwin, of Ohio, will prove the
most efficient vagina. Such a procedure requires necessarily
an abdominal incision, as the culdesac of the bowel must be
restored by the anastomosis, throwing out the loop utilized for
the vagina.
306. Unilateral vagina is due to arrest of development in
cme of the ducts of Miller, the other forming the vagina. Such
a condition may be suspected when the canal is extremely narrow.
In cases of double vagina there may be incomplete development
ofone of the ducts.
307. Double Vagina (Fig. 163). — In this condition the
septum divides the entire vagina, when the uterus is also double
or divided. Occasionally, the septum in the uterus does not ex-
tend through the external os, while that of the vagina terminates
Wow it. The hymen may have two openings, simulating double
236
GYNECOLOGY.
vagina. Coition generally occurs through the larger of the two
conduits; occasionally it takes place in either one. When the
partition of the vagina is partial, the superior portion of the
septum will be lacking. When the uterus is double, the upper
portion of the vagina is often found to contain the septum, while
fusion has been complete below. The septum is usually thick
and fleshy, resembling the rectovaginal partition, or it may be
very thin, and even
perforated in places.
Partition of the vagina
is not incompatible
with normal lahor.
Dunning has reported
cases in which the two
vaginee were separated
by a septum that be-
gan just above the
vulva and extended to
the interval between
the two small cervices.
The separation of the
uterus into two parts
was demonstrated by
the use of the soiuid.
Pregnancy occiured
upon the right side,
and as the uterus en-
larged, the septum dis-
appeared. During
labor the vaginal por-
tion was torn from top
to bottom and only
the lower portion per-
sisted. An incomplete
septum may form an
obstacle to the passage
of the child's head.
When it does so, it
should be incised. In one patient under my obser\'ation there
had been a vaginal septum, which was destroyed during a
previous labor, and there remained a bridle extending from the
anterior wall of the vagina back to the posterior commissure,
which hung below the \'ulva. Twice have I cut through the
septum the entire length of the vagina, and sutured the surfaces
on each wall, so that a single canal was formed. This course 1
MALFORMATIONS.
237
considered ■wise, as it decreases the discomfort during coition and
lemoves a cause of dystocia in the event of pregnancy.
308. Atresia of the genital canal is either congenital or
acquired. The latter will be discussed farther on in these
pages. Congenital atresia may affect any portion of the canal,
but is more likely to occur within the vagina or near its orifice
at the Junction of the vagina and vestibular canal. Next in
frequency is the atresia of the internal or external orifices of
the cer\'ical canal, although the congenital closure of these
otifices is comparatively not nearly so frequent as is the ac-
quired. Vulvar atresia is not un-
, common. It is produced by im-
perforation of the hymen or ag-
glutination of the labia minora
or majora. In the latter there is
usually an orifice in front through
¥hich the mine and menstrual flow
can escape. Such conditions are
often unrecognized until after the
establishment of puberty, when the
occurrence of periodic distress in
the pelvis, colic-like pains, sensa-
tion of weakness, bearing down,
and irritability of temper indicate
an effort to establish the menstrual
flow. The continuance without
discharge, and later the develop-
ment of a tumor in the median
line, should awaken the suspicion
ot the attendant to the possibility
of obstruction to the menstrual dis-
charge and of its accumulation
within the genital canal. The mere
inspection of the parts discloses the
imperforation of the hymen. (Fig.
164) Atumorwillprotrudefrom the vulva; there is difficultyor
ahnonna] frequency in micturition, more or less obstruction in
evacuating the bowels is experienced, and a smooth, purplish sur-
face is seen at the vulvar orifice. If the obstruction is situated in
the vaginal canal, the vulvar protrusion will not be so marked.
The introduction of the finger into the canal, however, dis-
closes the accumulation. It is more definitely determined by
the finger in the rectum, when the globular tumor encroaching
upon that organ is recognized. Pressure over the abdomen
causes a sensation of elasticity or indistinct fluctuation. When
the vagina is absent, the accumulation forms in the upper part
■Impcrf orate Hymen.
238
GYNECOLOGY.
of the vaginal canal or within the uterine cavity. An accumu-
lation in the vagina is known as a hematocolpos ; in the uterus,
as a hematometra ; in the Fallopian tube, as a hematosalpiiii;
in both uterus and vagina, as a hematocolpometra ; and when tbe
distention also involves the tube, it becomes a hematocolpo-
metrasalpinx.
The symptoms are : absent menstruation, although the patient
experiences each month discomfort, a sense of fulness or engorge-
ment in the pelvis, with the usual nervous manifestations which
awaken the anticipation that menstruation is about to make its
appearance. A symmetrical enlargement of the lower abdomen
appears, which from its contour has been mistaken .by the care-
less obsen'er for preg-
nancy. The history of
the case, with a careful
physical examination
of the patient, should
establish the diagno^
When the obstruction
occurs at the internal
OS with a normal cer-
\'ix and roomy vagina,
the diagnosis becomes
more difficult. The
mere fact that a giil
has never menstruated
does not exclude the
possibility of pr^-
nancy. In the latter
will be found mam*
mary changes, an en-
larged and softened
cervix, increased va-
ginal secretion, swell-
ing, and a <lusky appearance of the vagina and vulva. In the
accumulation of blood these symptoms are absent and the cervix
remains small, rather firm, and hard. As the accumulatin
increases the cervix becomes softened, the uterus thinner, form-
ing a thin-walled sac which affords distinct fluctuation.
rrctj/Mi^Mi.— Operators were formerly very much averse to
evacuating the fluid of such a collection. The fluid is thick,
chocolate colored, and quite slimy, due, of course, to the
retention of the blood and mucous secretions of the canaL
It formerly was advised that a small pinhole orifice should
be made through the opening in the hymen, to allow the dis-
charge to continue slowly for several days. Such a procedure
Fig. 165.— Hematocolpos.
MALFORMATIONS. 239
ahnost surely resulted in infection of the material and produced
an inflammatory condition of the genital canal which not in-
faequently caused the death of the patient. The enormous dis-
tention of the tissues renders them extremely anemic, and the
removal of the pressure naturally permits an engorgement,
which can readily result in inflammation. The most satisfactory
method of treatment, however, consists in a free incision to
evacuate the contents of the cavity ; remove the stringy mucus
with the finger, and then thoroughly irrigate with a weak
intiseptic solution, such as a two per cent, sixlium bicar-
bonate, three per cent, sodium chlorid. bichlorid of mercury
{1:4000). or formalin (1:1500). A large quantity of the solu-
tion should be em-
ployed ; the irrigation
to be followed, when
o£ the two latter so-
lutions, by a douche
of normal salt solu-
tion. Finally, when
the quantity of fluid
ei'acuated is large,
the ca^-ity should be
lightly packed with
iodoform gauze to af-
ford moderate pres-
sure upon the sur-
face, to prevent en-
gorgement, and to
gn-e the structures
something upon
which to contract.
WTien the accumula-
tion occurs above an
obliterated or absent vagina, a trocar can be employed to reach
thefluid, guided through the intervening structures with a finger
in the rectum. The opening made by the trocar is then enlarged
to pennit a free evacuation, and the treatment already ad\'ised
should be employed. When the accumulation occurs in the
tttems from obliteration of the external os, it will often be diffi-
wlt to determine the site of the latter. The cervix should be
«tposed, and if we can not determine the situation of the former
OS. a puncture should be made with the trocar, which opening
skmld subsequently be enlarged in order to permit the evacua-
tion of the uterine contents. The cavity is then irrigated and
packed with gauze. If the obliteration has developed at the
iniemal os, the remaining cervical canal affords
240 GYNECOLOGY.
through which the puncture can be safely made. The caoal
having been dilated and the cavity thoroughly irrigated, the
latter should be lightly packed with gauze.
In all cases in which the obstruction is found in the uterine or
cervical wall, measures should be instituted to seciire subse-
quently a patulous canal, otherwise the obstruction will be re-
produced. The better plan of procedure will be to suture the
internal and external surfaces of the uterus.
The one element of danger in these operations occurs when
the Fallopian tube is distended with an accumulation and is
fixed by extensive adhesions. The dragging upon the thin
tube which occurs from the contraction of the empty uterus
Fig. :67. — Hematocolpometra.
may cause its rupture and the escape of its contents into the
peritoneal cavity. Extreme care should be exercised in a
hematosalpinx not to make much pressure upon the abdominal
surface while the sac is being emptied. Whenever the sac has
disappeared with insufficient discharge from the uterus, or when
it has disappeared before the opening into the collection has
occurred, an immediate abdominal incision should be made to
cleanse the peritoneum and remove the offending sac,
309. Lateral Atresia. — Atresia may take place in one-half of a
divided vagina or uterus. When it occurs in a portion of the
vagina, a lateral tumor will project into the vaginal canal, which
will be so elastic and obscure as to render doubtful the fact
whether it is a pelvic cyst or a lateral hematocolpos. Such
MALFORMATIONS. 241
»ses are less dangerous than atresia of the entire half of
the vagina, as the accumulation will probably ruptiu-e into
and discharge through the existing vagina. The opening, how-
ever, will be high, permitting serious symptoms from infection
and the development of a pyocolpos. It is generally advised
to make a free incision and pack such a cavity with iodoform
gauze, but I much prefer to excise a large section of the wall
and unite the mucous surfaces of its cut edges so that the
two chambers become one. When the atresia has occxirred in
one half of the uterus, the diagnosis is difficult. It is not always
situated to one side of the developed horn, but may curve about
it. The accumulation may then be accessible through the vagina,
or may be exceedingly difficult to reach. When accessible, it
should be opened through the vagina. When inaccessible
bdow, the tumor should be removed by an abdominal incision,
as for pyosalpinx.
310. Absence of the vulva is generally associated with a
similar condition of the vagina and uterus, although this de-
fect may exist with a normal development of the other genital
organs. It then probably results from coalescence of the
labia majora. The latter are generally absent in exstrophy of
the bladder, and may also be found so in other malformations.
The nymphae can be absent and the clitoris so imperfectly
developed that the site of the vulva presents a mere slit or
flattened surface, upon which the lu^ethral orifice opens.
311. Infantile vulva is foimd in weak, sickly women, who
have suffered from prolonged ill health prior to puberty, and
is generally associated with an imperfect development of the
uterus and tubes. The mons veneris and labia majora will be
bereft of, or sparsely covered with, hair.
312. Defects in Nymphae. — ^Absence of the nymphae is in-
frequent, and is accompanied by incomplete development of
the clitoris. More frequently they are thin, flabby, elongated,
and pointed. Occasionally they are perforated by small open-
ings. Hypertrophy of the nymphae is much more frequent.
The nymphae project beyond the labia majora; in the Bush-
women of Africa they form large folds, which reach nearly to
the knees, and are known as the Hottentot apron.
313. Defects of the Clitoris. — The clitoris may be so enor-
mously developed as to cause the sex of the individual to be
questioned. In exstrophy of the bladder and absence of the
sjinphysis it may be bifid or rudimentary. It is rarely absent.
Frequently, from congenital conditions or from neglect of
cleanliness, the smegma is retained beneath the prepuce, pro-
ducing such irritation and adhesions that the glans clitoris is
compressed and prevented from attaining its normal size. The
16
242
GYNECOLOGY.
adhesions become so firm as to render their separation difficult
The existence of adhesions and the retention of smegma are
capable of producing quite as marked ner\'Qus phenomena as the '
analogous condition in the male, some of which are: irritable
bladder, nervous disturbances, masturbation, absence of sensa-
tion, and convulsions. The occurrence of such symptoms should
direct attention to the clitoris as a possible cause.
Treatment. -When the clitoris is so large as to interfere with
coition, a portion of it may
have to be removed, but
the operative procedure
should, if possible, be so
designed as to retain. the
glans as the seat of sensa-
tion. If theglansiscovered
by an a<lherent prepuce,
it should be thoroughly
exposed by pushing back
the prepuce. The adhe-
sions can readily be broken
up with a probe or a
grooved director. \\Tien
the prepuce is so long as
to form a hood and com-
pletely envelop the gians,
it should be retracted by
removing an elliptic piece
(if integument about half
an inch above the cHtoris,
with the long diameter o£
— -_ the ellipse parallel to tlw
.^ ^v» *-"l^ft of the vulva. This
M^B^K <lenuded portion should
^^^B^H be closed b}' sutures intro-
'^^^^^^ duced in its long axis,
The length of the denuda-
ifis,--r:iiiiir!j(ii Clitoris. tion necessar\'' depends
•■ upon the projection of the
The prc]>uce may be dissccto<l away and the cut edges
sutured so that the glans subsequently remains exposed. A better
procedure is U* remove the msirgin of the prepuce around the
glans. The cut edges should then be united with catgut sutures.
314. Defects of the Hymen. — The hymen is composed of
tissue analogous to the corpus spongiosum in the male. It
partly closes the \-aginal orifice, and has upon its superior surface
the foldings of the mucous surface of the vagina. It is generally
prepuce.
MALFORMATIONS. 243
crescentic (Fig. 112), with the concave margin anterior. It
can present an annular opening (Fig. 113); two openings, sepa-
rated by a septiim (Fig. 116); or a number of openings (Fig.
117) — the cribriform. It sometimes resembles in appearance
the infantile form, when it is infundibuliform (Fig. 115), or its
edges may be dentated (Fig. 114) or serrated. Its normal
situation is just within the vulva, where it is exposed by sepa-
lation of the labia. In the colored race its situation is higher.
Its opening in the marriageable woman will easily admit the
tip of the finger. Atresia has been described. (Section 308.)
Supernumerary hymen have been reported, but these are prob-
ably congenital bridles in the vagina. A congenital absence
of the hymen must be questioned. The hymen is generally a
thin membrane, which ruptiu-es during the first coition (Pig. 118)
and sloughs away after confinement, leaving as remnants the
carunculae myrtiformes. The laceration may be central pos-
terior, triangular, or stellate. After a single coition the torn
surfaces may unite. I have seen two patients in whom the
hymen was so firm as to form an actual barrier to coition, re-
quiring incision to render the act possible. Cases are reported
where it did not rupture during labor, or offered such an ob-
stacle to delivery as to require incision. Its laceration is not
usually attended with bleeding, but occasionally it is, however,
followed by severe, and even dangerous, hemorrhage.
Incision is made with bistoury or scissors, while the labia
are widely separated. Two posterior lateral incisions are
preferable to a single posterior. Hemorrhage, if severe, should
be controlled by a vaginal tampon, or, preferably, by a suture.
315. Hermaphroditism is a condition in which there is a real
, or apparent union of the two sexes in the same individual.
It is doubtful whether the organs of both sexes exist complete
in any one individual, although there are numerous instances in
^ch the penis has been found well developed, with a testicle
upon one side, while within were found a uterus and an ovary
upon the other side of the body. The case represented in figure
169 presents characteristics of the two sexes, but, like many
other such cases, requires a microscopic examination to demon-
strate the presence of both ovaries and testicles in the same
individual.
I Pseiidoherjnaphrodiiism is a condition in which there is
' ^h an apparent union of the sexual organs of the two sexes,
or such a malformation, or defective development of the male
organs or excessive development of those of the female, as to
^lender the determination of the sex of the individual during
Sfe difficult, if not almost impossible. Pseudohermaphroditism
w divided into masculine and feminine, according to the pres-
GYNECOLOGY.
ence of testicles or ovaries. The females resembling
form a class known as the gynandria, while the man resen
the female is classed as an androgynus.
Fig. 169. — Appai
316. Gynandria.— The external organs of the femal
semble those of the male. The clitoris is large, with pc
fusion of the labia majora, not infrequently of the labia m
simulating the scrotum and concealing the vulvar op
This resemblance is still more striking when there is asso
an ovarian hernia into the labium majus. The internal c
MALFORMATIONS. 245
nay be irregularly developed. The hypertrophy of the clitoris
does not necessarily change its form, and may arise in women
who are addicted to masturbation. The labial fusion may
be so firm as to require incision.
An example of this class is Madeline Le Fort (Auvard)
(Fig. 170), who was declared to be a female by Bficlard when
she was six years of age. The clitoris was very large ; a groove
upon the under surface led to a depressed urethra in the cleft
of the \-iilva. The vagina was replaced by a small conduit,
from eight to ten centimeters long, bordering upon a well-
fij. 171. — Outline of Internal Organs of Madame Le Fort.— (.Auvard.)
loniied Uterus. (Fig. 171.) Menstruation occurred at the eighth
,vear. and escaped from an orifice situated at the root of the
ditoris. Her general appearance was strongly masculine,
^d she was sexually indifferent.
317. Androgyna. — ^This class predominates, and its individuals
are frequently monorchid or cryptorchid males, presenting ex-
^^1 characteristics of the female, such as enlarged breasts,
■n* penis may be perfect, but the nondescent of the testicles
Wd a median depression in the scrotum resembling the labia
'"ajora will give a distinctly feminine aspect. Arrested devel-
GYNECOLOGY.
opment of the penis, hypospadias, and fissure of the scrotum
greatly increase the resemblance. (Fig. 172.) Such persons
are generally dressed, reared, and educated as girls, and have
been married without being aware of their true sex.
The determination of sex is of great importance. It re-
quires careful consideration of the size, shape, and general
configuration of the body. The testicle may be small, and
be retained within the abdominal cavity. The seminal secre-
tion is generally sterile. The breasts resemble the feminine,
as do also the buttocks and thighs. The larynx is not promi-
nent and the beard is scanty or absent. The rectal touch,
with the catheter in the bladder, may fail to reveal either
uterus or prostate. The mental condition is
generally feeble or poorly balanced. When
careful examination fails to render the sex
certain, the individual should be classed as
a male. Independent of increased freedom
and larger opportunities for acquiring a live-
lihood, the imperfect male is Jess likely to
enter upon the marriage relation. When
the sex of the indi\'idual is in doubt no
operation for correction of the condition
should be done, unless preceded by an ab-
dominal section to ascertain the character of
the internal genital organs.
318. Atresia of the urethra and vagina has
been noted, but a fetus with this condition
is nonviable.
319. Hypospadias is much more rare in
the female than in the male. The vestibule
is absent and the orifice of the urethra is
not visible to inspection. Generally, the
apparent hypospadias is really a persistence
of the urogenital sinus. The urethra can be wholly absent, and
the bladder may present a crescentic opening into the vagina.
It is often associated with prolapse of the bladder-wall, and incon-
tinence is usually present.
320. Epispadias is still more rare. It presents four varieties:
(i) The corpus spongiosum is divided, and the urinary sinus
is situated in the posterior surface of the clitoris; (2) added
to the former condition there is a partial defect of the anterior
urethral wall; {3) the anterior wall of the urethra is entirely
absent, the cfitoris is bifid, and the labium minus is attached
on either side to a portion of the glans clitoris, while the pubic
symphysis may also be defective ; (4) exstrophy of the bladder.
in which the anterior wall of the abdomen, with that of the
Androgy-
MALFORMATIONS. 247
bladder, is absent and the posterior vesical wall protrudes.
The ureters open upon the surface, and the parts are constantly
soiled with urine. M
The first form of epispadias is very rare, the last most fre-
quent. WTiile vesica] ectopia is prone to result in disease and
^'t '7 J.— Imperforate Anus, Communication between Rectum and Vagina.
^k- I ?4,— Congenital Defect of Vagina.
ith the Rectum.
obstruction of the ureters, which lead to hydronephrosis and
*^ly death, nevertheless histories of patients have been re-
ported who have reached old age. The occurrence of epi-
*P3dias and associated incontinence is not inimical to the oc-
248
GYNECOLOGY.
currence of conception, and cases of pregnancy at full
are recorded,
Treatment.^-The urethra may be established by den
and suturing the surfaces, but failure to secure a good ■
is frequent. Ectopia of the bladder is difficult of corre
ith the Vag
It is preferable not to attempt an operation during in;
owing to the friability of the tissues and the probabil-
sutures cutting through. Transplantation of the ureter
the rectum probably affords the most satisfactory so
of the problem.
321. Duplication of the bladder has been found asso
with a similar condition of the genitalia.
MALFORMATIONS. 249
31a. Open Urachus. — Permeability of the urachus and dis-
chai^ of urine from the umbilicus are a result of congenital
closure of the urethra, but sometimes occur independently. It
is much more frequent in boys than in girls.
333. Irregular Exit of Ureter. — Opening of the ureter into
the \-agina has been described, but these are probably cases
in which the supposed vagina is really a rudimentary bladder.
I had an opportunity to examine a young woman in whom the
bladder was rudimentary and the vagina formed a receptacle in
which urine accumulated and prevented incontinence becoming
complete, Baum describes an accessory ureter which opened at
the side of the urethra. He operated by making an incision
above the symphysis, cutting through the bladder upon the
P'g' '77- — Suprapubic Opening of Vayina and Urithra.
""^ter, which he divided, tying the distal end, while the other
*'as brought into the bladder. The procedure overcame the
""continence.
324. Abnormal Communications. — Errors in development
l^ay produce imperforation of one of the canals which per-
forate the pelvic fascia or result in the union of two or three
of them. In any case the cause is analogous: t. e., failure to
?ttomplish the union between the superficial and deep organs.
Imperforations of the anus and urethra are vital, calling for
prompt attention of the surgeon. Imperforation of the vagina
o^been considered. (Section 305.) The communications may
be:
1. Rectovaginal, (Fig. 173.) The vagina and urethra are
"J'nnally developed. The anus is imperforate and, therefore,
tne fecal material is dischai^ed by a rectovaginal opening through
^-agina.
the
I St
k th
L
250 GYNECOLOGY.
2. Vaginorectal. (Fig. 174-} The rectum and urethra are
nomnaUy developed, excepting the opening into the former
from the incomplete vagina.
3. Vesicovaginal. (Fig. 175.) The rectum and vagina are
norma! in appearance, but the urine escapes through the latter,
the urethra being absent.
4. Rectovaginovesical. (Fig. 176.) The rectum and bladder
both communicate with the vagina. The urethra is generally-
absent. The anus may or may not be perforate.
5. Suprapubic opening of vagina and urethra. (Fig. 177.)
This condition is extremely rare.
TRAUMATISMS.
325. Injuries of the genital organs of sufficient gravity to
produce temporary or permanent structural changes, to in-
fluence the subsequent health and comfort of the patient, are,
for the most part, limited to lesions of the vulva, vagina, and
cervix.
The causes productive of such conditions may usually be
assigned to one of three general classes, viz. :
1. External violence.
2. Coition.
3. Parturition.
326. External Violence. — The cases of injury from external
violence are comparatively infrequent.
They occur in a variety of ways.
A woman standing upon a chair or step-ladder falls astride
the back, or upon the post or round of the chair.
Bov6e reports the case-history of a young girl who fell from
her bicycle upon the lamp bracket and sustained a complete
laceration of the perineum. Lacerations may be produced
by sliding dovm bannisters and striking against the newel
post, by sliding from a haystack or haymow, falling upon the
handle or prong of a fork or upon a hay-knife. Howe men-
tions a young woman who thus shd upon the handle of a fork,
which entered the vagina and penetrated the abdominal cavity
twenty-two inches, and from which she ultimately recovered.
Curran cites the case of a patient in whom the horn of a goat
entered the anus and tore through the vagina. Girls have
been impaled upon barrel staves, fence pahngs, or the sharp
stump of a sapling. A chamber or slop-jar breaking under
the patient has been the cause of injury. The fracture of a
_'.ass-ball pessary in the efforts at its removal has produced
vaginal laceration and even fistula. Royster reports two cases
TRAUMATISMS. 251
of complete laceration of the perineum in young girls, which
were caused by the finger of the obstetrician while they were
yet within the body of the mother. The injury may be a free
incision, a ragged laceration, or a severe contusion. The in-
cision may be produced by striking upon a blunt object, the
sharp edge of the rami cutting through the overlying tissues.
Large vessels may be ruptiu-ed without the skin being broken,
when a severe hemorrhage will occur into the tissues. In
the former case the hemorrhage will be open; in the latter,
concealed.
Treatment. — The injiu-y of vessels and the resulting hemor-
rhage into the tissues are called pudendal hemorrhage (see Vulvar
Hematoma). This may demand evacuation, and the resort
to measures for the control of the bleeding vessels.
Severe hemorrhage following an injury should demand
an inspection of the Injured part and the resort to measures
for its control. Where a good-sized vessel is bleeding, the
wound, if necessary, should be enlarged and the vessel ligated.
Frequently the hemorrhage can be controlled by the sutures
which are employed to close the wound. General oozing from
a ragged opening is often best controlled by gauze pressure.
The wound must be carefully cleansed and maintained in an
aseptic condition.
327. Coition, as is well known, causes a rupture of the mem-
brane— the hymen — which guards the vaginal opening. Lacera-
tion of this structure is usually central and posterior. It may,
however, be bilateral. Occasionally, as has been seen, the
hymen is so firm as to resist all attempts at coitus, and, there-
fore, will require incision before the act can be accomplished.
The entire vaginal canal is more or less dilated by the repe-
tition of the sexual act, as is evidenced by the enlarged and
roomy canal which distinguishes the nulliparous from the
virgin vagina. Severe lacerations of the vulva and vagina the
result of sexual intercoiu-se are rare, except when produced
by rape of young girls. Instances are reported, however, in
which injuries of gravity have been produced, as the tearing
off of the hymen, the perforation of the posterior vaginal wall,
fte rupture of the perineum, the formation of rectovaginal
fistula, and perforation of the posterior vaginal fornix. Such
^juries are more likely to occiu- in those who come to the fiirst
^tus late in life, or in whom there have been premature atrophic
changes. Skrobanski, however, cites a young peasant, aged
twenty-two years, in whom the first coitus caused a rupture
pf the perineum, two centimeters in depth, but without enter-
^ the rectum. R. Abrahams reports the history of a woman.
252
GYNECOLOGY.
twenty-six years old, in whom a rectoperineal fistula
produced which permitted the introduction of two fingers.
Occasionally the first coitus is followed by a hemor
so active as to endanger the life of the woman. The blc
is best controlled by the introduction of a suture to ir
the spurting vessel.
Treatment. — Injuries resulting from the sexual ad
rarely of sufficient importance to demand surgical interfej
Fig. 178. — Knives for Denudation.
Fig. 179. — Curved Scissors.
Fig. 180. — Retractor.
If severe, the treatment will depend upon the charactei
extent of the injury. An extensive laceration should be sut
The sexual act should be discontinued until the injured
have fully recovered, and it then should be practised wit
utmost gentleness and care.
i 328. Parturition. — Maternity is not without its pei
The great majority of the injuries to which the genital 0
are subject occur during or as the result of labor. Th
juries are due to faulty anatomic conditions, as distorted p
TRAUMATISMS.
253
rigid, unyielding muscles, inflamed and undilatable cervices,
abnonnal positions of the fetus, disproportion between its size
ind that of the pelvis, violent uterine contractions, long-delayed
ind feeble contractions, and premattire or too long postponed
instnimental or manual interference.
The long-continued pressure of the fetal head impacted
in the pelvis is probably even more disastrous than the pre-
mature delivery by the application of forceps. Indeed, vesico-
Fig. 1 8 1. —Blunt Hook.
Fig. 182. — Needle-holder.
Fig. 183. — Needles.
Fig. 184. — Needle with Loop for Suture.
^^ginal fistulae, which were of frequent occurrence prior to
^^ educated use of the forceps, now rarely come under ob-
^'ation. The injuries are of great variety, and affect the
uterus, — both body and cervix, — the vagina, the vulvar out-
*^' and particularly the perineum.
329. Injuries of the body of the uterus may occur in the
form of lacerations of the anterior or posterior wall, in a vertical
^^ transverse direction, and may be slight or sufficiently large
254 GYNECOLOGY.
to permit the escape of the fetus and placenta. After an abor-
tion, the softened uterine wall is occasionally perforated by
the curet or placental forceps or both, and through such a per-
foration loops of intestine have entered the uterine cavity,
been drawn through the os, and subjected to serious injury.
Injuries of this structure are not confiiied to parturition alone,
but the walls of the inflamed or flexed nonpuerperal organ are
frequently perforated by the use of the sound or bougie. In
removal of fibroid growths, the weakened wall can be ruptured
and the tumor projected through it, or the fundus uteri can
become inverted and be incised dtiring the removal of the growth.
Treattnent. — For the proper course of treatment in rupture
of the uterus during labor the student is referred to one of the
text-books on obstetrics. Perforation of the uterus in the
effort to evacuate decomposing placenta or membrane foUow-
ing an abortion should demand careful subsequent observation.
In such cases the danger of perforation is so great that the
retained fragments should be removed, if possible, by the finger,
and placental forceps should only be used with the finger as
a guide. Evidence of perforation as presented by bringing
a coil of intestine to the os should require careful replacement
of the knuckle of the intestine and a certain determination
that it has been pushed entirely through the uterine wound,
after which the uterus should be packed with iodoform gauze.
Any appearance of shock, disturbance of temperature, or
continued and severe irritation of the stomach should be recog-
nized as an urgent indication for abdominal section. Perfora-
tion of the uterine wall by sound or bougie, unless associated
with infection, has but little significance. Care should be
exercised, however, not to irrigate with irritating fluids, and
drainage of the uterus should be secured by gauze. The lacera-
tion of the uterus during removal of fibroid growths should be
considered an indication for immediate suturing of the wound
through an abdominal section.
330. Injuries of the cervix uteri are described under the
term laceration. Laceration of the cervix is the most frequent
lesion of labor. It is exceedingly rare for a woman to undergo
her first parturition without tearing of one or both sides of the
cervix. The tear may vary from a slight fissure, which com-
pletely disappears during convalescence, to an extensive lacera-
tion, extending to or into the vaginal fomices.
Lacerations of the cervix are unilateral, bilateral, stellate,
and through the anterior or posterior lip. The bilateral is
the most frequent. The unilateral is more frequently found
upon the left side, owing to the greater preponderance of the
left occipito-anterior position. Lacerations can occur into the
I TRAUMATISMS. 255
oeDuIar tissue laterally, or into the bladder in front, and in the
latter cause a vesico-uterine fistula. (See Section 353.) ITie
cicatrization of a lateral tear may produce a band or bridle which
tilts the fundus uteri to the opposite side.
331. Symptoms.- — Laceration of the cervix presents no special
a specific indications of its existence. The symptoms are
those produced by the complicating conditions. The lesion
causes subinvolution and a consequent increased weight. A
bearing-down sensation, discomfort in standing or walking,
and pain in the sacrum and iliac regions are common. The
lower level maintained by the organ and the traction of the
vaginal wall upon its lips lead to separation of the latter,
eversion of the cervical mucous membrane, thickening of the
tissue from its exposure, and fixation of the everted lips. Ir-
r^ular or excessive menstruation, or metrorrhagia, is not
9
Fig. iSj. — Slight Fissure of Cervix.
infrequent. Bleeding is excited by locomotion, coition, or
sexual excitement. The endometritis causes a profuse leu-
korrhea, which constitutes a double drain. The cicatricial
bands and the everted lips not only permit a depression of the
uterus in the pelvis, but produce either lateral version or retro-
version, according to the unilateral or bilateral character of
Uie lesion. With cicatrization of the lacerated surfaces, not
infrequently the scar tissue in the angles of laceration causes
pressure upon the nerves, producing profound neurotic or
reflex phenomena. Not infrequently the presence of neu-
"^henia may be created by pressure of the cicatricial tissue
"Pon the nerve filaments. Pressure with the finger against
'*^ indurated tissue aggravates the reflex phenomena.
. 331. Diagnosis. — A laceration of the cervix is readily recog-
""^ by the finger, but its apparent presence must not be
256 GYNECOLOGY.
accepted as proof positive of previous pregnancy, for a congenital
fissure can exist which will permit as marked an eversion of the
lips as would be produced by a deep bilateral tear. The fiiigcr
will disclose the condition of the lesion, the extent of the cicatri-
w
zation, the eversion of its lips, the presence of erosion (dis-
closed by its soft, velvety feel), or the existence of eversion of
the cer\-ical mucous membrane. Inflammation and obstnic-
lion of the glands of Naboth will he revealed by small, shot-lite
masses studding the cer\'ix. As the finger is passed upward the
®
Fig. 1 Qo. — Laceration of Cervix with
Hypertrophy and Eversion of
Cervical Mucous Membrane. —
(Munde.)
lips will be found to spread out, like the top of a celery stalk,
but hard, dense, and fixed.
The bivalve speculum, in drawing upon the anterior vaginal
wall, aggravates the eversion. The tubular speculum flattens
the surface, removes all trace of the fissure, and leads to its being
TRAUMATISMS. 257
mistaken for granular erosion. The Sims or some retraction
speculum affords the best exposure. Seizing each lip with a
tenaculiun and drawing them together discloses the extent of
the tear. (Fig. 192.) The surface of the tear is covered with
exuberant granulations, which bleed upon the slighest touch
(Fig. 190), and the profuse discharge renders the differentiation
from epithelioma sometimes exceedingly difficult. The diagnosis
may be established by the results of treatment.
333. Treatment. — Immediate examination after labor to
ascertain the extent of laceration is generally impracticable, be-
cause the cervix is so drawn out and thinned that it is difficult
to determine the lesion. The majority of small lacerations close
spontaneously tmder the employment of ordinary antiseptic pre-
cautions. The existence of severe arterial hemorrhage should
require an examination to ascertain its source, and when found,
is best controlled by suturing the lacerated surfaces. Not
every laceration demands an operation, and if not done within
a week, three months should pass before it is repaired. I quite
agree with Dickinson that the period of choice for operation is
five to seven days following the occurrence of the lesion, for at
this time involution has taken place sufficient to permit the lesion
to be disclosed, and operation at this stage favors normal involu-
tion thereby, and lessens the danger of the occurrence of endome-
tritis and other complications. Small fissures which are in-
clined to close or have cicatrized do not require an operation.
When the lesion is complicated with endometritis, the latter
should be treated. Operation in slight cases is to be condemned,
as it obstructs drainage and may cause the extension of disease
to the tubes and pelvic peritoneum. Repair is indicated iii
deep laceration, in eversion with hypertrophy and cystic degen-
eration of the mucous membrane, in cicatricial formation at the
angles of the fissure producing reflex phenomena, and in sub-
involution and endometritis. In addition to slight lacerations
and those which have cicatrized, surgical interference confined to
this lesion is contraindicated in tubal or peri-uterine disease.
334. Complications. — The presence of endometritis, associated
^th marked eversion and hypertrophy of the mucous mem-
brane, requires treatment prior to the operation for laceration.
The patient's diet should be regulated, constipation corrected,
and appropriate measures instituted to relieve the accompany-
ing anemia ; she should be permitted to take a vaginal douche of
hot water containing an ounce of rock-salt to the quart twice
daily. The cervix should be scarified or punctured, thus securing
depletion. All obstructed Nabothian glands should be punc-
fured and the gland cavity painted with Churchill's tincture of
Jodin, a combination of tincture of iodin and creasote (2: i),
17
258 GYNECOLOGY.
iodin crystals dissolved in 95 per cent, carbolic acid solution,
silver nitrate (3j to fSj), zinc chlorid (3 j to f 5 j), solution of
argyrol, or pyroligneous acid. The superfluous material should
be sponged away and a tampon of gauze and cotton applied be-
neath the uterus. By raising the organ to a higher level the
sensation of weight or heaviness is removed and the circulation
is improved.
The tampon may consist of plain sterilized gauze and cotton or
medicated gauze (iodoform, carbolic or boric acid, or thymolized).
Sublimated gauze should not be used, because it causes pruritus.
The tampons may be medicated with preparations of glycerin,
li . Alum., 5 j
Acid, carbolic, 2 iv
Glycerin., 3 xij
a fifty per cent, solution of boroglycerid, the official iodofonn
ointment, or a ten per cent, solution of ichthyol. In place of
the glycerin the tampon may be medicated with an ointment,
such as twenty-five per cent, of ichthyol in lanolin. The local
treatment, followed by a tampon, should be applied twice a week,
Fig. 191. — Blunt and Sharp Curets.
and the latter removed at the end of forty-eight hours, to be
followed by a vaginal douche of half a gallon of hot salt w^ter
(temperature from 110° to 120° F.) twice daily. The douches
are preferably given with a fountain (gravity) syringe, while the
patient is in a recumbent position on a bed-pan ; although in
those cases in which the cerv^ix and the neighboring tissues con-
tain a large amount of inflammatory exudate the bulb (David-
son) syringe, by force of its current, exercises a salutary influence
in promoting absorption. A profuse discharge of glairy mucus
from the surface should be removed with a blunt curet. The
curet presses the mucus-collections from the cervical glands and
permits the application to come directly in contact with the
diseased surface. The medicament may be applied by means
of a cotton-wrapped probe, or be carried into the canal wit!
a pipet. (Fig. 89.) Intracervical applications should not Ix
made, however, unless the cervical canal is quite patulous, sc
that the fluid or increased serous discharge can readily escape
If the canal is obstructed by hypertrophied and everted mucous
membrane, gauze packing (Section 90) or the use of a laminaria
TRAUMATISMS. 259
tent (Section 85) will render the application more effective and
fife. Irregiilar bleeding or profuse leukorrhea should indicate
flie use of the sharp curet (Section 91), after dilatation (Section
87). The uterus should be irrigated during or following curet-
ment with a disinfectant solution, bichlorid, 1:3000; formalin,
1:1000, a hot soda solution, 4 drams to z pints, or preferably
with normal salt solution, and swabbed with a saturated solution
of iodoform in ether. If for any reason there is much bleeding
following the procedure, the uterine canal should be packed
with iodoform gauze.
335. Trachelorrhaphy (that is, neck-sewing), or hystero-
tiachelorrhaphy (that is, womb-neck sewing), is the operation
de\Tsed by Emmet for the relief of laceration of the cervix.
Patient, prepared (Section 182) and anesthetized (Section 190),
is placed upon a table in the
Hthotomy position, with a
perineal pad beneath her
buttocks to carry the irrigat-
ing fluid into a slop-jar at
the end of the table. Each
leg is held by an assistant
or secured by a leg-holder.
The following sterile instru-
ments (Section 1 74) have
been placed in a tray upon a
table at the operator's right :
a scalpel or bistoury; curved
scissors ; long, rat-toothed dis-
secting forceps; two double
tenacTila; a retraction spec-
uhun (E^ebohls'); six pres-
sure forceps; a needle-holder;
four strong needles, curved and bayonet -pointed, each threaded
»ith a loop of silk to serve as a suture carrier. A smaller tray
win contain the suture material. My preference for sutures is
chromic catgut, which has the advantage that it does not have
to be removed (Section 176). The nurse at the operator's
left should have charge of the sponges. These should pref-
erably be sterilized gauze, though absorbent cotton wet with sub-
limate solution, I : 2000, can be employed. A fountain syringe,
ffled with hot normal salt solution or some disinfecting fluid,
should be suspended, so that the field of operation can be sub-
jected to constant irrigation. The final preparation of the patient
(Section 182) completed, the cervix is exposed with a speculum,
Md each hp so seized with a double tenaculum as to turn in
■Reverted edges when the lips are apposed. (Fig. 193.) The
GYNECOLOGY.
assistant upon the operator's left holds the anterior lip by the
tenaculum and controls the irrigation tube ; the one upon the
right attends to the necessary sponging. The posterior lip &
held by the weight of the tenaculum. With the knife the
operator cuts through the cicatricial angle, and in a bilateral
B
laceration with scalpel and forceps denudes a correspondii^
surface upon each lip, first upon the left, then upon the right.
The knife is preferred to the scissors, as tlie denudation can be
made more evenly and with less bruising of tissue. The de-
nudation is, of course, limited to one side in a unilateral tear.
A strip of undenuded mucous membrane, one centimeter wide,
should be left in each lip for the future cervical canal (Fig, 193).
■Sutures Introduced,
Fig. 196, — Sutures Tied,
and the precaution should be exercised not to encroach upo
the vaginal surface of the cervix in the removal of the tissut
In deep lacerations the circular artery may be opened in tl
denudation. It should be seized with pressure forceps, an
the first suture should be so introduced as to control it.
TRAUMATISMS. 261
The sutures are placed by introducing the needle about
three millimeters from the vaginal edge of the wound, bring-
ing it out at its cervical mai^n, introducing it at a simil£ur
point in the other lip, and bringing it out in the vagina. Or-
dinarily, three sutures will be sufficient upon each side. Occa-
sionally the laceration will be so deep that the angle suture
{Auvard.)
can not be properly placed by passing the needle as we have
just described. It is then preferably introduced from within
outward, which can be done by carrying the ends of the suture,
by means of the carrier, through first the posterior and then
the anterior lip, or with two need-
les threaded with carriers, each passed
from within outward, the one ante-
rior and the other posterior. One
caiiier is passed through th% loop of
the other and drawn out. The loop
thus carried through serves to carry
the suture. The sutures are tied, super-
ficialsutures are introduced, if needed,
and the vagina is thoroughly irrigated,
if bleeding should continue, a suture
should be introduced well above the
denudation to control the bleeding
'"essel. Avoidance of subsequent hem-
orrhage is particularly desirable if a plastic operation is also to
bepttformed upon the vaginal outlet,
336. Amputation of the cervix is to be preferred when the
Wrvix is much elongated and hypertrophied, when the mucous
Dienibrane has become extensi\-ely hypertrophied and everted,
and when cellular proliferation justifies the suspicion of incipient
nialignant degeneration, although when the latter condition is
Fig. igg.^Woiind Closed.
262 GYNECOLOGY.
established, completehy sterectomy would be the better
piorsue.
The amputation can be made by the double or si
method for each lip. The instruments and prepara*
similar to those given in the previous section (Section ;
Double Flap Operation. — The lips of the cervix a
and separated by double tenacula; an incision is madt
angle to the point at which it is desired to make the am
A Wedge-shaped piece is removed from each lip, forr
vical and vaginal flaps. Two sutures are then intro
each lip, uniting th>
and vaginal muco
branes. On each i
ture is passed in
the anterior vagi
cer\'ical flaps, out
the similar poster
and external to 1
sutures as are insi
necessary to brin,
position the raw
The sutures are
superficial suture
duced, if neces!
adjust the edgei
wound nicely. 1
accurate the adj
the less will be tl
quent contraction.
Single Flap A
Schroder's operat
sists in making tl
dation at the ex
the internal or
portion of each 1
operation is f
Single Flap Opcra-
when the cervical muccjus membrane is so t
trophied as to render its retention for the formation
undesirable. In this, as in the former operation, a latera
is made and the lips are everted. Instead of a cervii
transverse incision is made into the lip from within
at the level of the lateral incision, cutting half thri
lip ; then a vertical incision to the junction of the cer
vaginal mucous membranes. Two sutures unite the en-
flap to the corresponding cervical mucous membrane,
remaining raw surfaces are adjusted by lateral suture
TRAUMATISMS. 263
337. After-treatment. — The after-care does not differ in
the various operations upon the cervix. In the use of the
diromic catgut suture no provision is made for its removal,
but it is important to preserve it from becoming infected. Un-
less the vaginal outlet is to be the seat of an operation, the
vagina shoidd be loosely packed with gauze, which shoiild be
removed in two or three days. The patient is kept in bed
for two weeks, and then gradually permitted to resume her
ordinary duties. Any pain should be relieved by the application
(rf an ice-bag to the abdomen. The patient should void her
urine, and the catheter should be used only when it is impos-
sible for her to empty her bladder while in the recumbent pos-
ture. Secure an evacuation of the bowels at least each alter-
nate day. Avoid vaginal douches for the first forty-eight
hours, afTording the plasma
opportunity to glue the appos-
ing surfaces ; then use a douche
of hot sublimate solution
(1:3000), formalin (i : 1500).
ora I per cent, saline solution
twice daily.
Direct the patient to avoid
Kony or much exercise during
the next menstrual period,
and not to resume the sexual
relation for one month.
338. Lacerations of the
Vigiiia. — Small tears of the
anterior, posterior, or lateral
wall of the vagina are not
* infrequent, and result in ci-
catrices which produce more or less disturbance of the pelvic
functions. Separation of the muscular wall can <K'Cur without
lesion of the mucous membrane. Not infrequently the entire
vagina is crowded away from its muscular attachments, so
that it subsequently appears as a relaxed sac, falls into folds
which drag upon the cervix, displace the uterus, or, when it is
fixed, produce hypertrophic elongation of tlie cervix. The most
frequent lesions are at the vaginal outlet, and involve that por-
tion of the pelvic floor known as the perineum. These lesions
of the vagina are so intimately associated with, and dependent
upon, the condition of the perineum that their treatment will
be discussed with the lesions of the latter, under the head of in-
juries of the pelvic floor. Lesions of the genital canal, especially
"f the cervix and vagina, may be induced by long-continued
pressure of the head of the child during a protracted labor. The
264 GYNECOLOGY.
loss of tissue vitality will necessarily be dependent upon the
severity and duration of the pressure.
It may involve only the superficial structtires, as an erosion
or superficial sloughing, when the tissues may be regenerated
or, if more extensive, there restilts contraction and stenosis
or partial or complete obliteration of the canal, known as ac-
quired atresia. Acquired atresia most frequently follows in-
juries occurring during parturition, but it can be produced by
irritating injections and severe inflammations. Atresia vagina
often occurs as a sequel of senile vaginitis. In one patient I
found the entire vagina obliterated. The symptoms of such
a condition are necessarily dependent upon the time of life
at which it occurs. When it follows senile vaginitis, it often
produces no symptoms outside those of marital inconvenience.
During the menstrual life of the woman the symptoms are
similar to those of the congenital variety. The patient suflfers
from menstrual molimina and a pelvic ttmior follows. When
the vagina is the seat of atresia, the condition is easily recog-
nized, as is the uterine accumulation, if the obliteration occiirs
at the external os. When the obliteration occurs at the internal
OS, however, and the cervix is apparently normal, the diagnosis
is more difficult, and the disorder may be confounded with
fibroma uteri, malignant disease, or pregnancy. The careful
analysis of the patient's history, associated with the examination,
should afford a reasonable suspicion as to its character.
339. Fistulas. — Deep sloughs involving a portion of the .
genital tract occasionally lead to perforation of one of the ad-
joining viscera, and we then have a fistula. The anterior wall
is the most frequently affected, and, consequently, results in a
urinary fistula, which may involve urethra, bladder, or ureter,
and be associated with extensive destruction of vagina and
cervix. Fistute are divided into urinary, fecal, and genital.
The genito-urinary fistulas are:
1. Urethrovaginal. \
2. Vesicovaginal. /
3. Vesico-uterine. ) (Fig. 202.)
4. Uretero vaginal. I|
5. Utero-ureterine. /
The fecal fistulae are:
1. Ano vulvar. "j
2. Rectovaginal. > (Fig. 202.)
3. Entero vaginal, j
""^ 340. Etiology. — Genital cerv'icovaginal fistulas are most fre-
quently caused by the accidents of labor. These lesions are
of less frequent occurrence than formerly, the result of improved
methods of deliverv% by which the progress of the fetus is expedited
TRAUMATISMS. 2G5
ind the 'maternal parts are saved from long-protracted pres-
Btre. Fistulae are rarely the result of tearing, but generally
toUow a slough. Awkward use of instruments can result in per-
foration of the bladder or the rectum, but such lesions present a
marked tendency toward spontaneous recovery.
Other causes of fistulae are cancer involving the anterior
or posterior vaginal walls, tuberculous disease, surgical opera-
tions, ulceration from the presence of a vesical calculus, the pres-
ture of a pessary, and abscesses or phlegmons.
341. Symptoms. — The presence of a urinary fistula is recog-
nized by incontinence of urine and by the appearance of mine
in the vagina. A fecal fistula will permit the discharge of
Hquid feces and gas. A few days subsequent to her confine-
ment the patient com-
plains of being unable
to retain her urine, or
possibly it may come
with a gush, following
the partial or complete
separation of a large
slough. The parts are
afterward continually
bathed with urine, the
skin becomes reddened
and irritated, and the
salts of the urine are
deposited, increasing
the irritation. The
clothing of the patient
is saturated with de-
composing urine, caus-
ing a disgusting odor.
Partial continence
may be present when the opening is small, when it is situated
high in the vagina, or when it affects but one ureter. The. in-
fluence of a fecal fistula depends upon its size and situation. A
srnall opening may permit the escape of the contents of the intes-
tine only when they are liquid. The odor of the vaginal secre-
ti'>n is exceedingly offensive, so that tlie patient suffers an
^forced retirement.
341. Diagnosis. — Incontinence should at once awaken a
suspicion of a fistula. Large fistulas are rea<lily recognized by
^'aginal palpation. Small fistulfe, associated with cicatricial
f^ntraction of the vagina, are often difficult to expose. The
entire surface of the vagina should be exposed with retractors
"T Wth a Sims speculum under a good light. If the opening
FistulK.
^bO GYNECOLOGY.
is stnall, it will be revealed by injecting the bladder or r
with milk or other colored liquid, when the opening t
observed as the liquid escapes into the vagina.
This procedure affords a means for difEerential dia
between ureteric and vesical fistulse and between the recti
enteric. The escape of clear urine into the vagina wh<
bladder is filled with a colored liquid demonstrates the un
the origin of the f
The introduction of .
teral catheter into th(
and of a sound int
bladder permits the
nition of the inter
septum. If the oper
small and not visibl
the surface and appl;
ting-paper while the
der is being filled.
jjaper will be moistei
the side of the fistula (I
'l"he same object ci
attained by packin
vagina with sterile
and injecting the b
with colored fluid.
staining of the gam
indicate the situation
ojwning. In enteric 1
the vagina is cons
bathed with liquid
and the appearance ■
discharge is not affecl
rectal enemas. Th
an offensive vaginiti
the patient suffers
inanition. In sup]
uretero-uterine fistul
position of the t
should be examine
Sanger's method. (See Section 158.) It has been suggeste
the patient urinate, then sit two hours upon a vessel, w
catlieter is used; and if the quantity thus secured is eq-
that in the vessel, there is a ureteric fistula. The coUectic
been obtained from separate kidneys.
A fistula of cnc nrcicr may be inferred when, in sj:
the periodical passage of urine through the urethra, the 1
TRAUMATISMS. 267
stantly bathed with urine ; a vesical 6stula near the neck
permit of no accumulation of urine, while a small one in
pper part of the vagina may allow soiling of the latter
only when the patient is recumbent. In the upright posi-
;he desire to evacuate occurs before it reaches the level of
stulous opening.
le most ready method of recognizing the ureteric fistula
injecting the bladder
x)lored fluid . The con-
tion of uncolored fluid
e vagina demonstrates
we are not dealing with
ical opening.
0 operation should be
ipted for rectal fistula
mt exclusion of rectal
ure.
*3. Prognosis. — The
)Uity of a fistula de-
s upon its cause, situa-
size, and duration.
e produced by cancer
part of the progress of
lisease, and are incur-
unless the disease can
nnoved. Spontaneous
.'ery of a punctured or
ad fistula is prone to
r under proper cleanli-
but an old sinus with
, cicatricial edges re-
s surgical interference.
)pening in the base of
ladder is more readily
.■ed than one in the
T part of the vagina
me in the urethra.
:o-uterine fistuUe are
cularly difficult, and the ureterovaginal and uretero-uterine
la are most trying.
44. Treatment. — The methods of treating vaginal fistulas as
recognized may be considered as:
. Cauterization.
. Denudation and suture of the edges of the fistula.
. Flap-splitting, flap-sliding, and suture.
. Flap-formation and sutures.
268
GYNECOLOGY.
345. Cauterization is applicable only to fistube of sn
and where but little cicatricial tissue exists. The thermo
is the preferable means, although caustic potash, chlorid
or one of the stronger acids can be employed.
346. Preliminary treatment is important , whatever the
of operative procedure. The urine should be rendered non
ing by the administration of benzoin salts or salol.
B. Ammon. benzoat 3iij
Tinct. hyoscyatni ^3'^
Ext. buchu ad f 3ij.
SiG. — £5 j in water three or tour times daily.
This prescription should be accompanied by the inge
large quantities o£
Salol, gr. ij-iij, n
given with a glass
water three or fou
daily. Hot or s
\"aginal douches sh<
freely employed, su(
solution of sodium
sulphite (oiv, aq.
weak solutions of t
salts. If there is an
tation of the lim
about the orifice ai
the vagina, employ
tion of dilute niti
(gtt. j, mucilage wa
Cicatricial bands sb
incised and stretchi
vaginal walls should
cised, to diminish 1
upon the edges of tb
when sutured. Th
trization may be o\
by having the incisi(
^vhile a Gariel pes
a colpeurynter is
j Bozeman employed
— — ' obturators of plat*
s iiitro.hici.-d. per, which, when
distended the vagi
for (iperation. The intestinal canal
.QS.-Sul
gave more
be tborouphly evacuated.
347. Vesicovaginal Fistula. — Injuries of the vesico
septum are the most frefiuent undoubtedly because the
are more likely to be compressed between the advancir
TRAUMATISMS. 269
le pubic symphysis. The operation of vivifying and sutur-
le edges was revived, perfected, and rendered successful
ms. After thorough cleansing and disinfection of the
1 and the bladder the patient is placed in the semi-
position, upon her back, with her limbs well flexed, or
ne cases the fistula may be rendered more accessible by
g her upon the abdomen and elevating the pelvis. The
rum is retracted and the edges of the opening are rendered
by suitably applied
e tenacula, which are
by assistants. The
lation is performed
knife or scissors, pref-
T the latter, as the
s bleed less. The den-
m is accomplished at
spense of the vaginal
-•e, exercising care to
injury to the vesical
us membrane. The
us membrane is seized
'creeps at one side and
aiudation is performed
the attempt to com-
the circuit with the
irip. Having secured
lual denudation uix)n
des, about one centi-
•in width, the sutures
atroduced. They are
ed about one centi-
■ apart, introducing
bringing them out
: five millimeters from
Iges of the denudation
■ut permitting any su-
0 penetrate the vesical
us membrane. The
es may bo introduced antero]>osteri()r, transverse, X or Y
d, according to the opening, that direction being chosen
1 will prrxluce the least traction upon the tissues. The sutures
be silk, catgut, silkworm-gut, or silver wire, preferably the
■ two. After the sutures are all in place the bladder shouKl
"igated in order to remove all clots, and the sutures should
kI, twisted, or secured with perforated shot, exercising care
3 draw them tight enough to strangulate the inclosed tissues.
270
GYNECOLOGY.
After securing the sutures it is well to inject the bladder to make
sure that no small opening remains. In large fistulas care mud
be taken not to injure or constrict the orifice of a ureter. These
canals may open upon the surface of the fistula, when the vesical
surface of the ureter should be split several days before the opera-
tion and the surfaces be kept open by the frequent use of a probe.
348. Flap-splitting or Flap-sliding. — The loss of structure by
denudation in large fistuk
is not infrequently a serious
sacrifice of tissue, and has
led to the practice of secur-
ing fresh surfaces by spht-
ting the edges of the fistula.
The vesical and vaginal sui- ,
faces are divided throi^h
the cicatrized margin to any
required depth, according
to the size of the fistula.
When the opening is small,
it can be closed by a purse-
string suture. The sutureof
si)k\vorm-gut or silver wire
is passed through the vagi-
nal flap within the vesico
vaginal septum, and brought
out in the vagina directly op-
jxisite its point of entrance,
reintroduced near its exit,
and made to traverse the
remaining side of the open-
ing, and brought out near
the original entrance. This
suture, tied, turns the vagi-
nal flap outward and the
vesical inward. When the
size of the opening renders
it desirable to close it upon
a line, the vesical flaps are
closed with animal sutures, preferably of catgut. The vaginal
flaps may be closed with silk or silkworm-gut,
Walciier advocates first cutting away the cicatricial tissue,
then separating the vaginal and vesical surfaces. This procedure
secures greater mobility of the internal flaps, which are closed
with catgut by the Lauenstein stitch. The needle is introduced
on the raw surface and brought out on the line of demarcation,
midway between the raw surface and the vesical mucous mem-
TRAUMATISMS.
271
vane, and the reverse in the opposing vesical flap. After these
mtures are tied, closing the bladder, the vaginal flaps are sutured.
B. R, Corson (Savannah, Ga.) expedites the formation of the flaps
and the introduction of sutures by the use of a portion of an india-
mbber ball. A strong silk cord is passed through the shank of a
shoe-button which has befin made to pierce the center of a portion
R|. io8. — Showing Continuation of Fig. 309. — Wound Closed.
Suturing to Close Fistula with
Incisions to Decrease Tension
with Suture Introduced on Left
Side to Close the Secondary
Opening.
(rf a rubber ball; this, folded, is carried by forceps through the fistu-
lous opening. Traction upon the string draws down the opening,
Wposmg its edges. The ease with which the vaginal and vesical
portions of the septum can be separated renders flap-splitting a
'■■ery ready method for closing large fistulae. This separation can
te done with impunity, because the circulation of the two surfaces
is not interdependent. The incision through the vaginal portion
272 GYNECOLOGY.
is preferably made upon a vertical line. Beginning a
of the fistijJa, one \
B ^' ^^^^k^ suitably curved scis
"^ serted between the t
as exposed by the v
cision (Fig. 211) ai
completely around
lous opening, and thi
separated by blunt <
The dissection may
with the knife, first
tical incision throug
tula and then disse(
large flap upon either side. The separation may exte
even through the peritoneum, where necessary, to sd
tional tissue to close the
opening. In closing a
large fistula the sutures
in the vesical wall are pref-
erably introduced upon a
transverse line, and as
they are buried they
should, therefore, be of
chromic catgut or of fine
silk. The edges of the
fistula should be inverted
into the bladder. Each
extremity should be se-
cured by a suture, the end
of which, left long and
used as a tractor, permits
the intervening portion to
be rapidly closed with a
continuous suture. These
sutures should not pierce
the epithelial surface of
the vesical mucous mem-
brane. The closure of
the vesical wall should be
followed by distention of
the bladder with a warm
saline solution to make
sure that it is tight. The
vaginal wall should then
be closed by a vertical line
of suturing, which may be continuous or intemipte
Demonstration of Fla;
TRAUMATISMS.
273
operator prefers. In introducing these sutures the bladder sur-
face should be included, to prevent the accumulation of serum
or blood between the surfaces.
The fact that the vagina has been so destroyed that it will
not afford material to cover the vesical wall need not deter the
operator from employing this method, as flaps can be taken
from the labia or from the inner side of the thighs to complete
the vaginal wall.
M. C. McGannon, of Nashville, very ingeniously closed a
fistula in a woman who had a laceration of the rectovaginal
septum half-way to the cervix, and the anterior vaginal wall and
base of the bladder were gone. He dissected the bladder away
from the uterus and pushed the peritoneum off until he could
bring the flap down to the lower segment, and closed it with fine
ea^t. After closing the
bladder, the surface was cov-
ered as much as was possible
with the remaining portion
of the vagina. A lai^e sur-
face was left uncovered for
cicatri2ation. The left ureter
had been included in the
bladder, but the orifice of
the right was situated so
high in the vagina that it
*as inaccessible, but was
subsequently conducted to the bladder by an artificially con-
stnicted condtiit. A year later her condition was good, with
perfect control of the urine.
In extensive fistulas Trendelenburg advocates making a trans-
''*ne incision ten centimeters long through the abdominal
*alls, and a transverse incision through the bladder, just below
the peritoneal junction. The upper edge of the vesical wound
—Wound Closed.
274
GYNECOLOGY.
is temporarily stitched to the corresponding abdominal, ai
lower edges of the bladder are held open with sutures,
edges of the fistula are trimmed and the sutures so intrc
that their ends can be brought out and tied from the v
The anterior vesical wound is closed arotmd a draina^
gauze is placed in the prevesical space, and both are bi
through an opening in the abdominal wound, the remainin
tion of which is closed with sutures.
Bardenheuer formed a flap by transplantation. H'
formed suprapubic cystotomy, and through the abdominal '
dissected the bladder away from the peritoneum as low
fistula, separated the adhesions and cicatricial tissue, de
the edges of the fistula and sutured them from the vagina.
the edges of the fistula were pressed together by the
passed into the bladder through the suprapubic wound.
TRAUMATISMS. 275
nninal wound is plugged with gauze and left open. By
ni^ a vesical flap the operation can be performed through
ragina, as described above.
J40* Flap fonuation is a procedure practised by Ferguson,
i^lucago, and E. Stanmore Bishop, of Manchester, England,
gnson made an incision with a scalpel through the vaginal
£Ous membrane three to six millimeters from the margin
the fistula. (Fig. 316.) This incision completely encircled
Fig. 3 r6. — Flap-formation as Suggested by Ferguson,
i opening and extended to, but without injuring, the vesical
11. The wound was kept free from blood by a stream of
nliied water. This procedure formed a circumferential flap,
ged by the vesical mucous membrane, which, turned into
bladder, formed a roof for the raw surface and was held
iat position by a continuous fine chromic catgut suture
nserted that it did not pierce the mucous wall of the organ.
276
GYNECOLOGY.
(Fig. 2 30.) The narrow strip of vaginal tissue, which from
its density retained the stitches well, became a part of the
bladder -wall. The fistulous opening was thus closed and made
water-tight. The operation was completed by suturing the
vaginal walls with silkworm-gut or silver wire. (Fig. i8i.)
Bishop ingeniously inserts four sutures into the edges of the
flap as constructed by Ferguson, and with a pair of forceps
passed through the urethra drags these sutures, previously
f
Fig. J 1 7. — ^Flap Turned in and Vesical Opening Closed.
knotted, out through that canal. The funnel thus formed is
closed with a suture from the vagina and the vaginal walls are
sutured over it. The advantages justly claimed for this plan
are: first, there is no loss of tissue; second, a broad surface is
secured for apposition; third, there is a projection into the
bladder at the site of the opening which decreases the danger
of leakage and infection; fourth, in case the ureter opens into
TRAUMATISMS.
277
the fistula, it affords an opportunity to turn it into the bladder;
fifth, it decreases the danger of primary and secondary hemor-
rhages; sixth, in large openings it affords the best opportunity
to secure relaxation by incision or sliding flaps; seventh, it is
applicable to fistulas of the bladder, urethra, or rectum.
350. After-treatment.— The vagina, thoroughly cleansed,
should be lightly packed vnth iodoform gauze, which should
remain for two or three days. Continuous drainage should be
Fig. 1 iS. — Introduction of Vaginal Sutui
secured by the introduction of a self-retaining catheter into
the bladder. This should be removed daily, for the purpose
of cleansing. At the end of eight days it should be removed
permanently; but the patient should be catheterized foiu^ times
daily (or the next week. The vagina should be irrigated with
an antiseptic solution twice daily after the third day, and this
should be continued for the greater part of three weeks. The
sutures should be removed on the fifteenth day.
i
276 GYNECOLOGY.
(Fig. 220.) The narrow strip of vaginal tissue, which
its density retained the stitches well, became a part o
bladder-wall. The fistulous opening was thus closed and
water-tight. The operation was completed by suturin)
vaginal walls with silkworm-gut or silver wire. {Fig.
Bishop ingeniously inserts four sutures into the edges o
flap as constructed by Ferguson, and with a pair of fo
passed through the urethra drags these sutures, previ
Fig. 717. — Flap Turned in and Vesical Opening Closed.
knotted, out through that canal. The funnel thus fom
closed with a suture from the vagina and the vaginal wa!
sutured over it. The advantages justly claimed for thi;
are: first, there is no loss of tissue; second, a broad surf
secured for apposition; third, there is a projection int
bladder at the site of the opening which decreases the c
of leakage and infection; fourth, in case the xu^ter open
TRAUMATISMS. 277
istula, it affords an opportunity to turn it into the bladder;
it decresises the danger of primary and secondary hemor-
es; sixth, in large openings it affords the best opportunity
Ecure relaxation by incision or sliding flaps; seventh, it is
icable to fistulae of the bladder, urethra, or rectum.
J50. After-treatment.— The vagina, thoroughly cleansed,
iild be lightly packed with iodoform gauze, which should
iMi for two or three days. Continuous drainage should be
3.— 'Introduction of Vaginal Sutures.
ui^ by the introduction of a self-retaining catheter into
bladder. This should be removed daily, for the purpose
Arising. At the end of eight days it should be removed
nanently; but the patient should be catheterized four times
y for the next week. The vagina should be irrigated with
mtiseptic solution twice daily after the third day, and this
lid be continued for the greater part of three weeks. The
res should be removed on the fifteenth day.
GYNECOLOGY.
351. Closure of the Vagina. ^Colpocle^is. — Episiostenosi
Large fistula in which the base of the bladder is destro
Fig. 2 1 9. — Section Showing Projection upon Vesical Surface.
— Vesico-uterine Fistula.
may be indirectly obliterated by closure of the vaginal ori
thus making the vagina a part of the urinary reservoir,
ring of tissue two centimeters broad is removed from the va^
TRAUMATISMS.
279
In the dissection the parts should be kept on the
and the tissue should be dissected from above down-
A sound in the urethra and a finger of an assistant in
turn will greatly facilitate the denudation of the anterior
sterior walls of the vagina. The sutures should be passed
>elow upward and from above downward, exercising
atest care that neither rectum, bladder, nor peritoneum
)e perforated by the sutures. The denuded surfaces
be brought in ac-
apposition and the ^0^Ktf0
iping of freshened
! with mucous mem-
or sldn should be
'avoided. This pro-
, while it affords a
of reUeving inconti-
jf urine in otherwise
ite csises, has many
antages. Impregna-
no longer possible;
can be practised
hen obliteration has
id high in the va-
The menstrual blood
nfrequently excites
cystitis, resulting in
ephrosis and the for-
i of vesical calculi,
ine may cause metri-
tubal, ovarian, and
writoneal infiamma-
Rectovaginal fistula
«n made to supple-
this operation when
:k of the bladder has
one such injury as to
the patient unable
iin the urine. The
ty of such cases have been unsuccessful, owing to the irrita-
gas and feces and the inclination of the fistula ti j cli ise. The
is very rare which cannot be closed by flai^-sliding, as the
and vaginal surfaces are easily separated and the vaginal
*en deficient can be replaced by flaps from the vulva
oer sides of the thigh.
:. Urethrovaginal fistula is \'ery infrequent. It is char-
ed by the discharge of urine into the vagina during
280
GYNECOLOGY.
micturition. The flap-splitting operation affords the most satis-
factory method of closing it.
353, Vesico-uterine fistula permits the escape of urine
through the external os. It may result from a slough follow-
ing a tedious labor, and from lacerations of the cervix when
the tear has extended through the anterior lip. The tear may
have been incomplete, not extending through the os, or the
I tlirough Antericff
fissure may have healed -with the exception of the communica-
tion between the bladder and cervix. The only condition
with which such a fistula can be confused is the uretero-uterine.
The latter fistula is rare. Upon injecting the bladder with
a colored fluid (a solution of pyoktanin) its emergence from
the OS demonstrates the presence of a vesical fistula; the con-
tinuance of clear fluid, a ureteral. In an opening of consider-
TRAUMATISMS. 281
'. axe the sound will pass directly into the bladder, where
an be recognized by another inserted through the urethra.
Trtatment. — The fistula may be exposed by dilating the
nx with a laminaria tent. In a uretero-uterine fistula this
cedure woiild be accompanied with renal pain, nausea, and
nitiug, due to the obstruction of urine from the kidney
responding to the affected ureter. The fistula may be
raded and closed from the cervical canal, but the opera-
n is attended with difficulty. The preferable procedure is
cut through the anterior fornix of the vagina and dissect
i bladder from the cervix, when the opening can be exposed
i sutured ; the vaginal wound is subsequently closed with silk
or catgut. It is desirable that the
peritoneum should not be opened,
though its incision, with proper
ig. )J4.— Fistula Closed
piia. Uterine Opening Re-
miins. Which Will Close of
ItKU.
ittautions, does not materially affect the result. When the
iadder-wall is thin, Herr advises cutting through the cervix
Jd reinforcing the bladder-wall with cervical tissue. Sanger
iKt the cervix of a patient in whom the sinus opened laterally,
itiired the side on which the fistula occurred, as in an Emmet
wation, and then sutured the other side.
354. Hysterostenosis or hysterocleisis (Fig. 237), the denu-
;lion and suturing of the cervix, is possible, but the menstrual
v may produce serious cystitis, and contraction of the fistula
ly result in severe pain and distress during menstruation.
"Ui tracts will be subject to irritation and descending infection,
idacing upon the genital side, endometritis, salpingitis, and
282 GYNECOLOGY.
peritonitis; upon the urinary, ureteritis and pyelitis. W
we consider that the opening can be exposed by dissecting
bladder from the cervix, one can hardly conceive the selectioi
hysterocleisis as ever justifiable.
355. Vesico-uterovaginal (Cervical) Fistula. — A portion
the cervix, with a considerable portion of the vaginal sept-
may be destroyed, and the remaining walls may be so thin a.
render its closure difficult or dangerous, owing to proxiimt^
Fig. 326.— Cli
of Fistula within Ctrvical Canat after Splitting Cerv
the peritoneum. In such cases the anterior lip of the a
(Fig. 228) may be denuded and turned into the bladder, \
it as a plug to fill up the opening.
When the fistula has developed at the expense of the ant
cervical lip to such an extent that it will not afford suifi'
structure to close the opening, the posterior lip may be fresh
and utilized. (Fig. 229.) This procedure necessarily proc
TRAUMATISMS. 283
ffistiirbance because of the continuance of menstruation, A
preferable method is to separate the vesical wall from the cervix
and secure sliding flaps, which can be closed as in figure 230.
356. Ureterovagiiial-ureterocervical Fistuls. — Lesions of the
meter are less frequent than the other forms of fistulas. Par-
ticipation of the ureter in the vesicovaginal opening is much
more frequent. Ureterovaginal fistulas are more frequently
the result of injuries sustained during the performance of hys-
-Hysterocleisis.
twectomy. The diagnosis has been considered. {See Section
J4»-) The cervical fistula is very rare. The thickened ureter
can generally be traced to the cervix by the finger in the vagina.
Treatment. — Relief from the discomfort produced by these
fistula may be accomphshed by resort to one of several methods,
viz.:
I. Anastomosis through the vagina.
1. Anastomosis through the abdomen.
284 GYNECOLOGY.
3. Ligation of the ureter.
4. Introduction of the ureter into the rectum or colon.
5. Nephrectomy,
ATtastomosis ihrough the vagina may be accomphshed byfiist
establishing an artificial vesicovaginal fistula alongside the ureter.
This opening, and the ureter opened for the distance of neartf
two centimeters of its intraparietal border, are prevented from
closing by the subsequent daily use of the sound. After perma-
nent cicatrization has taken place, the vesicovaginal _ fistula,
which now includes the ureteral, is closed by denudation asd
suturing the new surfaces (Simon). The vesicovaginal fistula
may be formed by an oval incision. A small elastic catheter
can be passed into the bladder, through the urethra, from it
through the fistula into the vagina, and then into the orifice of
Fig. sag, — Veaco-uterovagiiial Fi»-
tula in which the Posterior Lip
of the Uterus is Utilized toOox
the Opening.
the ureter. With the patient in the genupectoral position the
vaginal mucous membrane is denuded around the fistula. To
close the opening, the sutures are placed parallel to the catheter,
which is left in place for several days (Landau) ; or a buttonhole
incision may be made, removing two centimeters of the vesical
mucous membrane in the direction of the ureter ; the vesical and
vaginal mucous membranes are sutured to prevent closure, and
a catheter is introduced into the bladder through the urethra and
into the orifice of the ureter through the vesical fistula. An
annular denudation is made about the fistula, leaving immedi-
ately about it a zone of mucous membrane three millimeters in
diameter. After suturing, the fistula with intact mucous mem-
brane is turned into the bladder, where it forms a gutter-like
TRAUMATISMS.
285
depression, into which the ureter opens (Schede). X. O. Werder,
in a case of double ureterovaginal fistula following hysterectomy,
made a transverse incision through the anterior vaginal wall
into the bladder. The vaginovesical edges of the upper portion
irere sutured together, while the inferior border was united to
the posterior vaginal wall, making a diverticulum to the bladder
■which controlled leakage.
All these methods employ the formation of an artificial
Tesicovaginal fistula, which
Bmst ultimately contract.
As the ureter is a distinct
canal, capable of being dis-
sected out of its bed, there
leems no reason why it
should not be loosened from
dcatricial adhesions, drawn
down, and introduced
through an opening in the
vesicovaginal septum. This
procedure is applicable to
either vaginal or cervical
fistulffi of this canal. In
order to prevent compres-
aon of the ureter a portion
of the bladder-wall should
be e.\cised. The ureter is
introduced into the bladder,
.the wound is carefully closed
with sutures introduced to
fix the wall of the ureter
and thus insure its reten-
tion. Care should be exer-
cised that the ureter is not
compressed, nor much, if
any, of its surface left un-
covered in the vagina. In
urcterocervical fistulse the
covix should be split until
the orifice of the ureter is exposed, when that structure can be
(irawn down and union accomplished in the manner just des-
cribed. Obliteration of the vaginal orifice has been done after
the establishment of a vesicovaginal fistula, but such a course is
both unnecessary and undesirable.
AHosiomosis through the abdomen may be preferable in a nar-
rowed cicatricial vagina, or when the lower extremity has under-
gone inflammatory changes or is so embedded in exudation that it
Fig. 3jo. — Vesical Wall Loosened and [Su-
tured. Vaginal Wall Sutured m Oppo-
site Direction.
286 GYNECOLOGY.
can not be readily brought down. Through the ordinary inciatm
for abdominal section the intestines are drawn aside, exposing
the line of the ureter. In ureterovaginal fistula its situation
can the more readily be recognized by the introduction of a
catheter prior to the abdominal incision. The peritoneum ii
opened, the ureter is raised, its proximal portion is tied and
dropped back, and the central end is introduced through an
incision into the bladder and secured by sutures, as in the vaginal
method. The anastomosis with the bladder should be on the
corresponding side of the pelvis, and with as little tension upon
the canal as possible. Should the ureter be so short as to cause
tension in reaching the bladder, the latter should be drawn up
and anchored by a few
» _ ^^^^^^^^f-.^^i stitches to the side of the
bktL I ^^^H^^^^P ^^j pelvis, so that no traction
Br I ^^^^t^^M^^^'^ n ' ^^^^ ^ made upon the
P j^^^^^^^^^w^f^ ' ureter. In recent injuiyan
W t^^^^E jf^E. i^g? / I anastomosis can sometimes
' }^^^^KL£l _ .Jam ' , . be made between the di-
vided ends of the ureter.
The proximal end should
be introduced into the distal
one and secured by sutures.
(Fig. 234.) If the ends of
the ureter are imfavorable
for this procedure and the
renal portion too short to
permit of its introduction
into the bladder, the ureter
may be tied with a double
ligature and dropped back-
Tlie urine accumiilates in
the pelvis of the kidney until
the pressure equals that of
the blood, when secretion ceases. The ureter may also be intro-
duced into the rectum ur colon. The ureter should pass through
the bowel obliquely. However, this procedure is very likely to
be followed by serious conditions in both the urinary tract and
the intestine. In the former, infection and suppuration of the
pelvis of the kidney are prone to follow. The presence of urine
frequently causes irritation and inflammation (colitis or proctitis)
of the intestine.
Nephrectomy is advisable when the long duration of the fistula
has resulted in extension of infection to the pelvis of the kidney,
and careful examination has disclosed that the other kidney is
capable of carrying on the work of both organs.
Fig.
— Optratiii
Fistula.
[X'tcrovaginf
357- Acddents of the Operation and Results. — Primary hem-
orrhage of a serious character may result from an unusually lar^e
uterine artery, from vascular walls, or from injury of the vesical
— Vu^'iiial Itni'li
tlif BladdcT.
TfiuiMus niL-mliranc, Kithcr ci)iii]>rcssii)ii or sutua- is the best
means fnr its cnnirul, liut its ix-currciift? im]XTi]s the result "f
ihefijicration.
\\\'ihl,iry heiiiorrh-.t^c may take place l>eUYeen ihu third ami
nfl':'' iliiys. ami shouM be cnntn>lleii by the lanipiMi. It may
2SS GYXECOLOGY.
occur into the bladder, and may be discovered only after ti
organ is filled with clot. It gives rise to violent tenesmus, s
its decomposition will be extremely prejudicial to the success
the operation. When it can not be removed by irrigation, inj
a solution of pci)sin or enzymol. If this procedure fails
afford relief, the urctlmi should be dilated and the clot brol
up and removed wiili a blunt curet. If hemorrliage contim
it will be necessary to remove the sutures and search for
bleeding vessel,
Indiision of n ureter will cause nausea, vomiting, lumbar pa
and fever. The suspcctcil suture should be immediately remo'
Peritonitis may result from injury during the denuda'
or suturing, or from infection, when proper precautions h
nut been oliserveil, ur when there is coexisting pyelitis or cyst
Calculi and calcareoits concretions have formed upon si
wire, silk, or even catgut sutures.
The resnlts of the opc'ration are generally most satisfacb
DcatJi is of very infn-quent 'x-currence.
TRAUMATISMS.
2S0
358. Rectovaginal Fistula.^The metho<ls of treatment sug-
gested (Section 344) are equally applicable to the fecal fistulee.
rhe last two methods, flap-splitting and flap-formation, are
pfobably effective and most generally applicable in the great
majority.
In a small fistula a curvilinear or triangular trap-door may
be raised, including the fistulous orifice; the opening in the
^ A
I
A
.6^
%i
H
1 ■;•-■
u
,-J^
3B
^^^-N,^ ^9
i
0
^_
^P
^
^
' \
He
F.fi.
-Ureteral Anas
Wtal wall is closed by very fine (eye) silk, wliicli has been
previously sterihzed, or by chromicizcil catgut: one or several
Uuenstein sutures may be used, being careful not to enter the
f'Ctum. The vaginal flap is then secureil with silkworm -gut
futures. In large fistuke a sagittal incision with lateral flaps
IS most satisfactory. The sutures are introduced as [jreviously
liesenbed. Flap-formation is very serviceable in closing rectal
290 GYNECOLOGY.
fistulfe of considerable size; flap-transplantation is rar
cessful.
359. An anovulvar fistula can be closed from the v
perineum. Such a fistula is incised through its track,
and the entire sinus closed by sutures. It is generally 1
extend the incision to, but not through, the sphincter
close the rectal or anal surface with sutures from the
side, when failure to unite will not endanger the futu
of the sphincter and will enable the operator to secu:
by granulation through gatize packing. Small fistu
the vtdvar outlet can be closed as a part of the opei
perineorrhaphy.
360. Preliminaiy and After-treatment. — The bowelj
be thoroughly evacuated by repeated purging for two
days. During the same period vaginal douches sh
given, and a thorough scrubbing of the vagina with a
of creolin and soap should immediately precede the O]
However, no operative procedure for closing a fistul:
be entered upon until careful rectal examination has
■stratcd the absence of a possible rectal stricture as i1
For several days prior to the operation, and for at leasl
subsequently, the patient should be kept upon an anim
diet, and the use of milk should be prohibited. Thi
tion should be preceded a few hours by thorough i
of the rectum, and continuous irrigation should be j
TRAUMATISMS. 291
during it. After the third day the bowels should be moved
each alternate day. The sutiires of silk should be removed
vpoti the eighth day; silkworm-gut or silver wire may be per-
nritted to remain for fifteen days. The patient should be con-
fined to bed the greater part of three weeks, and the bowels
ihould not be permitted to become constipated for a month.
361. Knterovaginal fistulse have been cured by cauteriza-
tion or by denudation and sutiu^ from the vagina, but closing
the fistulous intestine through the open abdomen is preferable,
when the vaginal opening will need no further consideration.
363. Cervicov&ginal Fistula,
—A cervicovaginal fistula is one
which arises as a result, of rup-
ture of the cervix during labor
fann a longitudinal tear, or the
lover margins of which have
beccooe reunited. The tear may
beaperforation of one lip of the
covix through which the fetus is
otnided, and occurs where the
cenixis hard, rigid, and unyield-
ing. Such a condition of the
ctrvix is sometimes the cause of
theentjie cervix being torn away.
A fittola may also arise from
fwlty methods of repair of the
hceiated cervix. I have seen
ncfa openings on both sides of
the cervix where trachelorrhaphy
has been attempted. The fis-
tula doubtless sometimes arises
from the use of sharp instruments
in attempts at abortion. The
opening of such a fistula is ex-
coriated and filled with mucus.
TTeatmeut.— The correction
of the condition is not always an easy procedure. The pref-
erable plan is to incise the cen,-ix through the opening, denude
the margins, and close as in an ordinary oix-ration of trachelor-
rhaphy, but this is not always practicable and in some cases the
amputation of the cervix may be demanded.
363. Lacerations of the pelvic floor are a frequent lesion of
parturition, and can occur from within outward through the
'■■agina and vaginal portion of the perineum, leaving its in-
tegumental covering intact. The injury is a separation or
tearing-ofi of the muscular fibers from the sides of the vagina.
Rectal Wall Closed by
GYNECOLOGY.
Generally, the tear takes place through the integumei
perineum ; sometimes it may extend through the enti
ture, the sphincter, and up the rectovaginal septu
infrequently it will be found that the injury has been
deep, but on one side of the rectum and anus, and lea
intact. Less frequently it will thus extend on both
the anus.
Naturally, the influence upon the subsequent ap
and function of t
r-^H^p ^^^H must vary with th
^K H * ^H and direction of tli
^BjH '^H tion. A slight la
^mCU ^1 which involves c
^Kl^^ ^1 anterior portion of
^SRAlJK ^M neum, may heal
^HmBIKV ^F producing much, if
formity. A deepe
tion. by the actio
transversus perinei
permits the vagin
to stand open, and
a triangular apj
The failure of th'
cavemosi muscles
antagonize the c
permits the anus
drawn back.
Laceration thn
sphincter necessari
loss of control of tl
contents. (Fig. 2;
The deep lacei
one side of the am
the Ie\'ator ani un
ized, and the p
drawn to the oppo
when the tear exte:
both sides, the an
pressed and drawn backward. The vulva stands open
can look into the vagina from three to five centimeters.
364. Causes. — Injuries of the pelvic floor may ar
from conditions inherent in the mother; second, in ti
and third, in the course and management of the la
the first class may be— (q) too great or too slight an in
of the pelvis, which renders the mechanism of the fe
imperfect; (b) a small vulvar orifice with rigid muse
TRAUMATISMS.
293
large amount of fat in the perineum ; (c) high or anterior situation
of the vulva, making a long perineum, over which the child's
head must be extended.
Second, laceration may result from excessive size of the
fetal head and shoulders or from relative disproportion to
the size of the mother.
Third, laceration may result from — (a) either too rapid or
too tedious labor; (b) vertex presentations when rotation occurs
Fig. 139. — Rupttire of Perineum into Rectovaginal Septi
mto the hollow of the sacrum and an occipitoposterior position
presents a longer diameter of the head at the outlet; (c) face
I^eseotations, in which the longest diameter of the fetal head
presents; {d) either incomplete or excessive flexion; (£) faulty
nianual or instrumental interference.
365. Degree or Extent. — Lacerations of the pelvic floor
■nay be incomplete or complete, and are generally divided
294 GYNECOLOGY.
into four degrees: First, a tear through the fourchet and
slight extent in the perineum ; second, to the sphincter. 1
form the incomplete lacerations, while the complete are: i.
the tear extending through the sphincter; and, fourth, up
rectovaginal septum. A rare form of laceration is the cei
rupture, in which the fetus passes through the perineum v
out tearing either the sphincter or the vulva.
366. The results of the injury are necessarily depen>
Fig. 140. — Cystocele.
upon its extent. The immediate effects are induced bj
action of the injured or antagonistic muscles. The cicat
tissue produces certain reflex nervous phenomena, w
however, are insignificant compared to the mental infli
exerted by fecal incontinence. The laceration causes defe
involution of the vagina and uterus, the defect in the mus
junction of the pelvic floor weakens the action and consec
TRAUMATISMS.
295
.tatice of the pelvic diaphragm. The constantly varying
sure of the bladder and rectum, the increased abdominal
sure consequent upon straining at stool, and the abnormally
^■y uterus lead gradually to displacement downward of that
in, or, if it is fixed by the condition of its pelvic attachments,
jxtrusion of the anterior and posterior walls of the vagina,
. their consequent weight will produce hypertrophic elon-
ion of the cervix. Thus we have cystocele (prolapse of the
tenor vaginal wall, and with it the bladder), rectocele {pro-
•sed posterior wall) , partial or complete prolapse of the vagina,
ihelongation of the cervix, or procidentia, consequent upon the
Teased weight of subinvoluted organs and the diminished
Jport resultant from the lesion under discussion.
367. Treatment. — The proper course of procedure is to so
air the injury as to restore as nearly as jxissible the normal
296 GYNECOLOGY.
condition of the pelvic floor. In slight lacerations restoration
will be secured by keeping the patient quiet and the parts clean.
The operative treatment may be primary, intermediate, or sec-
ondarv.
368. By primary operation is understood the immediate repair
of the laceration, or at least within twelve hours. The tear pre-
sents a large, raw surface, and is frequently found with ragged,
irregular edges. The vagina may have been torn and the soft
parts pushed oflF until the perineum has split either through
the sphincter or to one or both sides of the anus. The method
of repair will depend upon the nature and extent of the lesion.
The necessary instruments w411 be found in an ordinary pocket
case — scissors, dissecting forceps, a needle-holder, and long and
short curved needles. The suture material may be silkworm-gut,
catgut, silk, or silver w^ire. The patient should be placed upon
her back across the bed or upon a table, while an assistant
holds each leg, flexed upon the abdomen. As the parts are
benumbed by the stretching to which they have been subjected
Fig. 242. — Right and Left Curved Scissors.
an anesthetic may be omitted ; but if the patient is very nervous,
one should be employed. A rubber pad or a piece of mackintosh
should be placed beneath the patient to prevent soiling of the
bed and to direct the current of irrigating fluid into a receptacle
upon the floor. Compress the uterus and cleanse it and the
vagina of clots; cleanse the external surface with a disinfectant
fluid, after having trimmed the vulvar hair in order to keep i1
from embarrassing the procedure. Place a pad of gauze or ab-
sorbent cotton beneath the cervix to keep the vagina free fron:
blood. Trim smooth the ragged edges of the tear and proceec
to suture. Fine chromicized catgut is preferable, because it wil
not have to be removed, and it produces less annoyance durinj
the care of the patient than does either silkworm-gfut or silve:
wire. In slight lacerations and vaginal tears the use of the con
tinuous suture is satisfactor>^ In extensive laceration inter
rupted sutures offer advantages. Precautions should be exer
cised to leave no dead spaces in which blood may accimiulate
TRAUMATISMS,
297
beci'iiit' infected, and produce sepsis. In a double tear which
extends upon both sides of the rectum the needle should be
entered from abo\'e, brought out in the sulcus, reentered, and
carried upward through the \'agina] mucous membrane, so that
each suture lifts up the tissue. Care shoulii be exercised to
restore the position of the levator ani muscles by bringing their
toin ends back in position. So far as possible the sutures should
be brought out in tlie vagina, as they thus produce less pain.
F:(. J4.). — [noomjilfte Rui'turt uf thi.'
Peri 111; um.
The necessar>- perineal suturing may be with continuous suture,
inclosing but 'little of the skin.
In laceration of the sphincter make sure that the ends of
the divided muscle are secured and coaptjited by the suture.
^Viien the tear has extended into the rectovaginal septum, the
Sutures mav be bmught out and tied in the rectum, or, what is
prob-iliK- preferable, the Lauenstcin suture may be employed.
'^th buried catgut.
369. The advantages of the primary procedure are: first, if
tu' operation is successful, the patient is spau-c] iIr' nivossiiy of
298 GYNECOLOGY.
a subsequent operation; second, with proper precaution
much less likely to suffer from infection, and convalesi
expedited ; third, the sequelae of unrepaired injuries are a
370. Contraindications.— The primary operation is
indicated when the patient has been exposed to a prolongf
and the tissues have undergone extensive fraying or 1
through prolonged manual or instrumental interference
also contraindicated when there is reason to believe tl
wound has been exposed to some virulent infection. 1
such cases, when the laceration extends through the sp!
Fig. 145
Close the Wound.
the anus and rectal wall should be sutured, in order t(
security to the contents of the bowel.
371. The intermediate operation is performed any tin
twelve hours to a week following the labor. The delay
occasioned by want of proper material at hand, or it :
due to the condition of the patient, who is suffering fro
profound shock that it will seem unwise to resort to anj
diate procedure. Probably the fifth day after labor is tl
favorable period for rejrair of lesiians of the pelvic floor,
TRAUMATISMS. 209
US has at this date sufficiently contracted to render evident
lesion and any loss of vitality of the structures of the pelvic
■ or exposure to infection. The genital tract should be care-
! cleansed, the raw surfaces wiped with a gaiize sponge, any
;ed surfaces trimmed, and the surfaces sutured as for the
oary operation.
37a. Secondary Operation. — This operation is preferably not
formed for at least two months subsequent to delivery, in
Fig. 246.— Garrigues" Moditication of tlic Ilcjjar Operation.
ier to permit involution and cicatrization to become accom-
shed. In preparation, particularly when the tear is complete,
; bowels must be thoroughly e\-acuatcd. Castor oil, a saline,
compound licorice powder sliould be given several days or a
ek before the operation and repeated at intervals of from
aity-four to forty-eight hours, in order to insure thorough
icuation of all hard, scybalous masses. The diet should con-
300
GYNECOLOGY.
sist largely of animal broth, while milk should be absolute
excluded. The evening and morning before the operation tl
lower bowel should be cleansed with large enemas. The k
enema should be given at least three hours before the time fixe
for the operation. Patients should be prepared (Section i8j|
and the following instruments sterilized: a scalpel; right an
left curved scissors, as well as scissors curved on the flat; thre
double tenacula; eight pressure forceps; one long, rat-tootho
dissecting forceps; a needle-holder; and two long and two shor
curved needles, all threaded with carriers. The suture mater
may be silk, silkworm-gut, catgut, or silver wire. In extensi
laceration the silkworm-gut is preferable, for the reasons, fir
that it, being more pliable, causes less pain diiring convalescet
than wire, and, second, it is much less likely to become infect
than either silk or catgut.
Incomplete laceration (Fig. 243) may be repaired by a sim]
denudation of the torn surfaces (Fig. 244). As cicatrization h
TRAUMATISMS.
301
resulted in contraction, it is necessarj- to extend the denudation
ot the vagina above the scar tissue. The further backward the
rent extends, the higher into the vagina the denudation must
be carried. The line of denudation extends posteriorly from the
junction of the mucous membrane and skin at the top of
the old posterior commissure across in front of the anus to a
corresponding point upon the opposite side, while an angle ex-
tentls up tlie vagina above the tear. The completed denudation
presL-nts a resemblance to the body and wings of the butterfly,
wl is designated the Simon-Hegar denudation. (Fig, 244.)
The sutures are introduced about tlirce millimeters from the
"i^rgin of the wound, buried beneath tlie denuded surface, and
b^'Jught out at a corresponding point upon the opposite surface.
The sutures in the vaginal angle are first secured, and then the
[iTintal, (Fig. 245.) The sutures when tied produce less discom-
'■■'rt than if secured by compressing jjcrforated shot upcui their
OyNECOLOGV.
ends. The quill or bar suture was formerly much favon
consisted of a quill placed in the loop of a double sutun
one side, the ends being tied over a second quill upon the
site side, or the ends of a suture were passed through op
Fig. 351. — Hildcbrandt's Method o£ Suturing.
inja bar and secured by shot. The two quills or bars
for all the sutures, while the skin edges were united by
ficial sutures. The suture caused so much pain that it ha
largely discontinued.
TRAUMATISMS- 303
A slight exaggeration of the denudation just described can be
;pplied to the restoration of a complete laceration. The sutures
mst then be vaginal, rectal, and perineal. The latter are intro-
faced after the former are placed. The rectal sutures of catgut
ue brought out into that canal. Care must be exercised in the
introduction of the first perineal suture that it shall accurately
bring the ends of the sphincter ani in apposition.
Garrigues modified the Hegar operation by the following
procedure (Fig. 346): According to the extent of the laceration
and relaxation of the vagina and perineum the vagina is seized
iTth a double tenaculum at a point in the median line more or
■Hildebrandt Suture Closed.
JKs removed from the cervix. A point upon each labium majus
IS secured at such a distance from the clitoris as to permit of
wition. The parts are rendered tense, the points are connected
''y an incision, and the intervening triangular surface is denuded.
""is denudation is carried downward to the margin of the skin
and mucous membrane. With the vulva separated the denu-
ilation presents a triangular surface.
T The denudation is most rapidly accomplished by introducing
iMe blade of curved scissors beneath the membrane at the point
determined upon in the one labium and carrying it around the
^'aginat outlet to a similar position opposite. The central part
304 GYNECOLOGY.
of this incision is picked up with forceps, cicatricial bands cut,
and the finger pushed beneath this flap to the desired height.
The tissues are pushed off laterally, and the triangular section
is removed. It has the advantage that it is more than a denu-
dation. It is a resection, and, therefore, pennits the more accu-
rate union of fascia and muscular structure.
The sutures are introduced from above downward, about sii
millimeters apart, deep and superficial alternating, the latter
Fig. 253, — Hcppner's Figurc-of-8 Suture.
passing only through the edges of the mucous membrane. Th^
four upper sutures are transverse; the remainder dip dowU"
ward at the central portion, and, when tied, lift up the re!axe*i
wall. The sutures are thus introduced and tied one afte*"
another until the remaining denuded surface forms an ellipse*
the upper and lower borders of which are of equal length. (Fig-
247.) Then a silkworm-gut suture (lo) one centimeter abov^
the posterior commissure is carried deeply beneath the woun^i
TRAUMATISMS.
305
rds the mdth of the denudation, and emerges at a similar
pon the opposite side. A second suture (ii) is inserted
' between this suture and the outer margin; passing
1 the denuded surface it emerges upon the vagina to
t of the median hne, is reintroduced, and comes out
distant from the first suture upon the right side. The
ture, introduced near the extremity of the denuded
. appears in the vagina midway between the second
and the external denuded angle, reenters upon the op-
side, and emerges upon the right labium. These three
1 are all introduced and the surface is irrigated, when
re secured.
my judgment, the employment of the continuous chromic
suture is far more satisfactory. It can be so introduced
jft up the pelvic floor, and should include the edges of
/ator ani muscle and the overlying fascia. If the floor
:h relaxed, the muscle and fascia can be sutured sopa-
and the mucous surfaces be closed o\xt it with a con-
306 GYNECOLOGY.
tinuous suture. This method of suturing greatly exf
the operation and has the advantage that it leaves no s
(&g. 355) to be removed.
Lauenstein's Method of Suturing. — This method of
(fucing the sutures was devised to prevent their infectii
the rectal and vaginal discharges. The sutures, of catj
fine sillc, are introduced in the denuded surfaces, inc!
about five millimeters of the tissue intervening betwee
Fig. 156. — Denudation for Freund'a Operation.
borders of the rectal and vaginal mucous membranes 1
tively. (Fig. 249.) These are necessarily buried si
The remaining portion of the denuded surface is clos
silver wire from the perineum, (Fig. 250.)
Hildebrandt makes the denudation trefoil in shape.
251.) The sutures are, for the most part, cutaneous,
vaginal sutures are first introduced ; next the rectal, and, f
TRAUMATISMS.
the perineal."; (Fig. 252.) This method of suturing obliterates
dead space and decreases the danger of abscess.
"!■ ijS. — Vaginal Angles and Rectal Fig. 159. — Denudation Completely
WaU Closed. Suture in Place for Closed.
Hippner accomplishes the same object with a figure-of-8
luture, which closes both vaginal and perineal surfaces. (Fig.
308 GYNECOLOGY.
Martin more rapidly, and with a less complicatec
cedure, meets the difficulty. (Fig. 254.) He, with a
tinuous catgut suture, unites the intestinal wound froi
rectal surface; when he reaches the anus, with the same 1
ina contrary direction he superimposes a layer up to the su
angle of the vagina, and, if the denudation is deep, a third
before the vaginal and perineal surfaces are united, (Fig.
J- Freund has emphasized the necessity of securing s
denudation as would reproduce the original appearai
the tear. This, if there is a cicatrix, which presents the a
ance of 00, the laceration from which it has contractet
be represented by figure 256. He incises the posterior c
of the vagina at a certain distance from the scar and '
the bistoury backward along the sides of this column, c;
scribing the cicatrix in the vagina and upon the labia r
TRAUMATISMS. 300
ffigs. 257, 258, and 259), and completes the denudation as in an
?^nary operation. The line which corresponds to the rectum
* sutured, then each edge of the posterior vaginal column is
™tei to the external mai^n of the denuded surface. The union
™ the lines forms the vulvar and perineal surfaces.
Emmrt'j operation is of especial value in relaxation of the
I Tosterior vaginal wall, and its purpose is to expose the fascia
: 't'^ so to introduce the sutures as to fold in the slack and lift
Vig. »6i. — Emmet's Operation. Lateral Angles Closed and Perineal Sutur*
up the perineum, bringing the parts more completely under
the control of the levator ani muscle. With the labia separated
by the hands of assistants the summit of the protruding recto-
ffile is seized with a double tenaculum; two other tenacula
are placed one upon each of the caruncula, and a fourth upon
the commissure of the vulva. When these are separated,
they constitute a quadrilateral surface. These instruments
are_employed to render the parts tense, and the lines between
GYNECOLOGY.
them are employed as the boundaries of this denudation.
intervening surface is completely denuded. (Fig, 260,)
sutures are then introduced in triangles, beginning in the si
Faultji^r
(;^==^^^ ij Correct^
Fig. 264. — Suture to Unite the Ends of the Sphincter.
TRAUMATISMS.
311
upon either side. The sutures introduced form a double triangle ;
X suture joins the summit of denudation upon each side with
the apex of denudation of the posterior column. This is called
flic crown stitch. (Fig. 261.) A number of perineal sutures
are then used. By this method the majority of the sutures
are within the vagina. The tying of the sutures lifts up the
pel\TC floor and brings the posterior segment of the pelvic
floor more closely in contact with the anterior. (Fig. 262.)
Fig. 265.-^utcrbridEc's Suture
■*oble modifies this operation by carrying his denudation higher
"pon the posterior column, by splitting the fascia and exposing
the levator ani muscles. In suturing, he pulls out the muscle
3nd secures it with not only the lateral, but also the central,
^tures, or those below the crown suture. This brings thu
muscles in contact in front of the rectum and insures a strong
support to the pelvic floor.
312
GYNECOLOGY.
Emmet's operation for complete laceration has for its first and
principal aim the restoration of the sphincter ani. The first
suture is introduced and brought behind the ends of the ton
sphincter, which have been carefully exposed in the denudation.
(Figs. 263 and 264.) As the suture is drawn up and sectired,
the precaution is taken to draw up and place in position the
ends of the sphincter, so that they may be firmly secured. The
remaining sutures appose the denuded surface of the perineum.
Fi^. 866.— Ck-
Oiitcrbridgc modifies Emmet's operation in that he uses bul
three sutures. The first, of medium-sized catgut, by means
of a needle lliroaded with a carrier loop, is passed from the end
of the central undenudcd portion to the summit of the lateral
denudation upon either side. It is thrown over the pubes and
a silver-wire suture is passed from the highest point of the
denudation upon one labium majus beneath the whole wound
across to the coiTcspoiuling point upon the opposite side. (Fig-
265.) The catgut suture is now tied and its ends are passed
TRAUMATISMS. 313
mward to penetrate the skiii upon each side one centimeter
n the lowest point of the denudation. This suture tied,
silver wire is secured. The latter suture is removed upon
eighth day.
Cleveland uses a figure-of-8 suture o£ catgut. (Fig. 266.)
; first suture enters the skin six millimeters from the wound
rgin and midway between the posterior commissure and the
imit of the denudation in the left labium, passes deeply across
.'tween the denuded surface and rectum, embracing the muscles,
id emerges upon the right labium six millimeters from the
otmd margin and, midway between the posterior commissure
nd the point corresponding to its entrance, is reintroduced at
amilar point upon the left labium, and emerges upon tlie right,
irectly opposite its original entrance.
The second suture follows a similar course. It enters the left
*lMmn near the summit of denudation, is buried beneath the
314
GYNECOLOGY.
edge of the denudation to the center of the vaginal column, t
passes downward, and emerges upon the right labium midi
between the summit of denudation and the exit of the first sut'
It is introduced ujKin the left labium at a c()rres]X)nding po
passes across its former course, follows the border of the ri
sulcus, and emerges beneath the right summit.
A suture of wire or silkworm-gut, for support, is paj
through the left labium, about eight millimeters above
donudaliun. jnid ab'Hit the same in the anterior vagina and
riglit 1
Imin-
.1. P. Pii.llcy made a <iuadrila[eral denudation with anj
at thL' sumtnil •>( the reel^eele. laterally at the canmcula, ;
al the ]ii islerir >r eMmiiiissure. The denudation removes only
mueiius layer, preserving the sidmiueous. (Pigs. 267 and 2I
The finger is intrndueeil inin tiie anus and the first sutun
TRAUMATISMS.
315
ased downward and forward to the median line, where it is
■ought out, reintroduced three millimeters from its exit, and
Tried upward and back«'ard to emerge upon the other side
the vagina. This suture is tied, and acts as a fixed point from
hich to work. The remaining sutures, of juniper catgut, are
ade over and over and are introduced in a direction similar
the first, taking care to push up the rectocele with a director
fij. »7».— Splitting Vaginni Wall P
as eatli siitt-h is tightened. As the outlet is apjiroached the
■'■nRleof the sutures is decreased, until. whi'U abreast of the hymen,
ihey art' jiassed transversely. At this point the inside work is
finishetland the suture is made fast. A numbi-n if buried sutures
are passetl through the fibers of ilie separated central tendon.
Tliese extend to the extremity of the rent, when, with a con-
tinuous suture, they return to the puint wlicre the ileep sutures
fegan. After examination of the wound fur bkviling i>uints or
316
GYNECOLOGY.
gaping of the surfaces the wound is dusted witJi iodoform
is not disturbed for four days,
Martin, in extensive relaxation of the pelvic floor, tx
ments the operation upon the vulvar outlet by a denudat
the lateral coltimns of the vagina, leaving a tongue-st
undenuded strip in the median line of the vagina, (Fig:
and 270.) Each lateral denudation is obliterated by conti
P'8- 373-— Introduction of Suture in Retracted Flap, — {Aiuirea
suture, after which the outlet is closed with transverse si
(Fig. 270.)
Bischoff dissects up a flap from the posterior vaginal
which he utilizes in covering over the line of vaginal '
The perineal sutures are passed deeply beneath the flap.
271.)
In the incomplete lacerations with relaxation of the
floor the aim of the operative procedure is to take up the
in J the vaginal wall and restore the support to the
Andrews, of Chicago, does this by first dissecting a
ingle pointed below by a line drawn across the vagina
brtieen the caruncuke myrtiformes and below by the muco-
bt^umental border; second, at the outer angle of this triangle
■ each side a finger is pushed beneath the mucous membrane
lo just beneath the cervix. This line is incised on each side,
pmnitting the central flap to contract (Figs. 272, 273, 274);
flard, from the side of the cervix a suture is introduced through
TRAUMATISMS.
317
f"(. »74.— Suture Tied ; the Rermuninc Surface tc
Sutures. — (A ndrews.)
be Closed by Transverse
[ the wall, carried as a submucous stitch around the central flap
ilraady designated, and tied. This folds the flap beneath and
behind the cervix. This suture straightens or smooths out the
posterior vaginal wall. The remaining portion is united by
transverse sutures. Harris, of Chicago, seeks to utilize the
paboperineal portion of the levator ani to hold the posterior
lament of the vagina against the anterior by dissecting down
318
OVNECOLOGY.
Upon the muscle upon each side, excising a, section, and
the cut surface. The fascia has been denuded over the p
segment and sutures are at once inserted posterior to
tracted muscle.
Hap OperationB.— TatCi oration is the representative
various flap operations. In mcomplete tears the rectum
poned with a sponge or with cotton or iodoform gauze c
Fig- "75- — Incision for Tail's Operation for Incomplete Laceni
with vaselin and furnished with a thread. While an a;
separates the \iilva, two fingers are passed into the rectu
<iering the posterior wall tense. To form the flap, Ta
pointed angular scissors. The point of one blade is i
in the median line at the mucocutaneous junction, and th(
vaginal septum is split to the depth of two centimeta
to the left and then to the right, and is carried forwan
TRAVUATISMS.
310
x> the point at which he wishes the posterior com-
be. (Figs. 375, 276, and 277.) This forms a semir
■wing the mucocutaneous junction. The flap is
by tenacula and further separated to the required
. the borders the incision is carried deeply into the
iue of the perineum and labium majxis. Bleeding
1 by forceps, and later by the pressure of the sutures.
; are passed with the fingers in the rectum as a guide.
transversely across the wound, the skin not being
Four sutures are generally sufficient. The sutures are
sr the wound has been washed with sublimate solution
nd the tampon has been removed,
closes the skin edges with superficial sutures.
>leU laceration the rectovaginal septum is split, form-
.1 and a vaginal flap, depending in extent upon the
320
GYNECOLOGY.
depth of the tear. Sanger advises that it be made wit!
bistoury. These flaps are loosened at either extremity b>
longing the incision upward just within the labia, and c
wani alongside the anus, thus forming a letter H, the ■
verse bar of which is formed by the split in the septum
is at the lower part of the letter. These flaps, when sepa
form a quadrilateral. Great care must be exercised i:
introduction of the first suture, which must include the
of the sphincter ani.
Ristine, of Knoxville, Tenn., in complete laceration (
perineum, begins in the vagina and dissects a flap dowi
to the rectovaginal margin of the tear. This flap is
sufficiently long to insure its projection beyond the anus,
divided ends of the sphincter ani are exposed and united
TRAUMATISMS.
321
BDnronn-giit sutures. (Figs. 278 and 279.) The flap is fastened
onr the line of union and serves to protect it from infection.
Tins flap can be cHpped off at a later date after it has com-
jfctely served the purpose for which it was constructed. The
sme object is secured by Noble, of Atlanta, who loosens and
draws down the anterior wall of the rectum. The tag of tissue
thus formed subsequently contracts.
Fig- '79.— Plap Turned Down. Sphincter Closed and Sutures Introduced.
— (.Risline.)
Simpson's method is somewhat similar to Tait's in the manner
of forming the flaps, but they are sutured separately, forni-
ing the anterior wall of the rectum and the posterior wall of
the vagina, while the inter\-emng funnel-shaped raw surface
ii united by sutures. (Figs. 280 and 281.)
Fritsck's procedure still more closely resembles Tait's in
the splitting of the flaps. (Figs. 282 and 283.) He detaches
322 GYNECOLOGY.
the rectum from the vagina, adds a lateral incision for
sphincter when its ends are retracted, and unites these nt
a provisional stitch, which serves during the operation to rest
the shape of the orifice and to permit the accomplishmi
of reunion. He unites the rectum with catgut, using the Lain
stein suture. The same suture is used to close the vagi
Fig. i8o. — ^Oiitlinc for Simpson's Operation.
and the perineum is completed by suture in superposed pla
or by continuous catgut sutures in terraces.
Alexander Duke, after introducing the left index-fiiy
nearly its entire length into the rectum, with a double-edj
bistoury penetrates the septum a distance of six centimete
as the knife is withdrawn he enlarges the incision latera
to five centimeters. (Fij:^. 284, 285, and 286.) As the late
TRAUMATISMS.
ends of the incision are pressed toward each other a lozenge-
shaped opening appears. The sutures are introduced with a
strong, sickle-shaped needle with eye in point, and silver wire is
preferred for the suture. The needle is introduced just beyond
the end of the incision, and, guided by the finger into the rectum,
is made to encircle the incision, to be brought out beyond its
opposite end. Drawing up this suture will give an idea of the
Simpson's Operation.
number of additional sutures required. The sutures secured,
the distance between the anus and the posterior commissure is
considerably increased, with the formation of a thick perineal
body.
373. After-treatment. — Immediately after operation cleanse
the vulva with alcohol and water, equal parts, dry and apply
a sterile gauze pad which should be retained with a T-bandage.
The nurse should be directed to sponge the parts with the same
324
GYNECOLOGY.
solution, whenever soiled. The patient is unlikely to suffer
pain, unless the laceration has been complete, when a suppository
of opium extract, gr, j, and hyoscyamus extract, gr. ss, can
be employed. The urine should be evacuated spontaneously
and the parts subsequently sponged, as already advised. The
position of the patient may be changed, but she should be
discouraged from making severe efforts. In incomplete lacera-
tions the diet will not require careful scrutiny, but in the coin-
Fig. 5
I tor I'ritsch's Operalio
plete it should be limited during the first week to animal broths,
and subsequently for another week it should be restricted to
articles that are easily digested. Secure an evacuation of the
bowels upon the third day, and at least each alternate day
subsequently. Exercise care that excessive purgation shall
not occur. The sutures, if of silk or silkworm-gut, can t*
removed in from eight days to two weeks. Catgut sutures
need not be disturbed. Obser\-e care in the removal of the
TRAUMATISMS. 325
xs; the patient is preferably placed upon her side before
od light, and an assistant gently separates the buttocks,
ses the ends of the sutures, and facilitates their withdrawal.
) the patient in bed fully three weeks. After the fourth
the vagina may be irrigated once or twice daily with a
fectant solution — sublimate (i: 2000) or formalin (i: 1500).
se her to do but little walking for a month, and interdict
m for two months.
J74. Choice of Operation. — It should be understood that
operation is applicable to every patient. The operation
lid be adapted to the special condition. In incomplete
s, without rectocele, the Simon-Hepar operation is satis-
ory. In patients with rectocele, limmet's nr Dudley's
"ation will serve an excellent purpose. In cases uf complete
ration, without much relaxation of the pelvic flcHir, no
GYNECOLOGY.
procedure presents so many advantages as that described by
Tait and modified by Sanger. If the tissues are redundant
and there is need to afford support, the operation of EmnKt
for complete laceration is the most acceptable.
INFLAMMATIONS.
375. The recognition of the development of the genital tract
from the coalescence of the Mullerian ducts makes it e\'ident
that it is a continuous canal which must be especially vul-
nerable to infection and its manifestation, inflammation.
In experience it is rarely found that the alterations due
to infection are confined to a single portion of this tract. ^
must be admitted, however, that the special structure of certain
portions of the canal renders it more susceptible to the influence
of special micro-organisms and their products. The cylindric
epithelium of the cervical canal is more vulnerable to gonorrheal
infection than is the pavement epithelium lining the vagina.
The recognition of tiie almost continuous uniformity with which
the different parts of the canal become involved from the stnic-
ture primarily infected, and the frequent difiictdty in isolating
the primary site, have caused me to depart from the usual order
in the consideration of this subject, and to discuss infection
and the resulting inflammation as affecting the entire genito-
INFLAMMATIONS. 327
miliary tract, and subsequently to consider the features of its
local manifestations.
376. Micro-organisms as a Cause. — The most important ex-
citing cause in the production of inflammation of the genito-
urinary tract is the influence of micro-organisms. Inoculation of
a mucous surface with a micro-organism may result in an imme-
diate inflammatory reaction, which may subsequently extend to
the neighboring structures by one of three ways: the mucous
membrane, the lymphatics, or the blood-vessels. The original
site of inoculation may be the vulva, vagina, uterus, urethra, or
the bladder surfaces, which are more or less exposed to external
contact, or even the entire tract may be involved.
377. Natural Protection against Infection. — The situation of
the genital tract, the injuries to which it is exposed, and the
opportunities for its infection by various germs render the com-
paratively infrequent occurrence of inflammatory attacks sur-
prising. The immimity against infection is to some degree
secured by the difference in the character of the uterine and
v^inal secretions. It will be remembered that the uterine
secretion is alkaline, while that of the vagina is acid; conse-
quently micro-organisms which would readily flourish in the one
canal are imfitted for the invasion of the other.
378. How Immunity is Lost. — Any condition, then, which
causes these secretions to be less antagonistic, or which leads
the one greatly to preponderate, permits the activity of the
genns and their products to become manifest. Lowered vitality,
cxpc^ure to cold, menstruation, the increased flow after par-
turition or abortion, all render the secretion more alkaline and
establish a more uniform soil for the development of micro-
organisms. Apparently normal conditions may be overcome at
once when the tract has been inoculated with some virulent
poison.
379- Inflammation and its Varieties. — Inflammation has been
defined as an expression of the effort made by a given organism
to rid itself of, or to render inert, noxious irritants arising from
within or introduced from without. Inflammation may be acute
or chronic, diffuse or circumscribed. It is denominated as acute
when associated with pain, heat, burning, more or less swelling
of the tissues, profuse discharge, and constitutional symptoms.
Inflammation is chronic when the condition is somewhat pro-
tected; the pain less severe or but slight; the discharge less in
amount and less irritating to the surrounding structure, and with
^t slight constitutional reaction. Diffuse inflammation may
involve the entire genital tract, as in streptococcic or gonococcic
infection, either of which may extend the entire length of the
genital canal, involving vulva, vagina, uterus, and tubes, and
328 GYNECOLOGY.
even the ovaries, peritoneum, and cellular tissue. The last
form of infection may simultaneously invade the urinary tract,
but circumscribed or local irritation confined to a portion of the
tract is much more common.
380. The causes of inflammation should be divided into pre-
disposing and exciting. The predisposing causes are those which
produce congestion and disttirbance of the normal equilibrium of
the tract and, consequently, promote a favorable condition for
the inception of infection. They may arise from disturbance
of menstruation, involution, and tratunatism. The first in-
cludes the improper hygiene of menstruation, exposure to
cold, fatigue, overexercise, and excessive sexual relation during
the congestion immediately preceding or following menstruation.
Not infrequently persons, to avoid the inconvenience of men-
struation, will take a cold bath, with a view to its arrest. A
prolific cause is neglect or imprudence following abortion,
miscarriage, or parturition. The natural congestion consequent
upon these periods is enhanced by exposure, which permits
infection by various micro-organisms, with the resultant inter-
ference of the normal physiologic results in inflammation and
interference with the normal processes and the subsequent
development of inflammatory changes. Uncleanliness or want of
care upon the part of physician or nurse in a manipulation
during or following labor or an abortion, or in the use of the
uterine or vaginal douche; upon the part of the patient in
handling the parts with unclean hands ; the act of masturbation
or the employment of unclean instruments ; the retention within
the uterus or vagina of portions of placenta, decidua, or blood-
clots following abortion or labor ; the presence of foreign bodies,
such as tampons, tents, stem pessaries, and especially soft-
rubber pessaries, which are very prone to become foul, can
properly be considered as causes. Traumatisms, including
lacerations of the perineum, vagina, and cervix, from the un-
skilful management of abortion or partiuition, rough or unskilful
examination, careless use of the sound or intra-uterine manipula-
tion, without asepsis, and excessive or violent coition, are also
contributing factors. Chcmic and vegetable poisons, such as
phosphorus and the essential oils, may cause acute metritis. A
patient suffering with chronic inflammation may have acute
attacks which are excited by overexertion, sexual excess, opera-
tions, or rough examinations. Inflammation may be promoted
by the presence of uterine displacements, pelvic or uterine
tumors, or profuse inflammatory exudates or morbid processes.
The exciting causes are the pathogenic micro-organisms and
their products. They are the gonococcus, the streptococcus
pyogenes, the staphylococcus pyogenes aureus and aJbus, the
INFLAMMATIONS. 329
bBcillus coli commiuiis, the bacillus tuberctilosis, and the sapro-
phytes from the bladder, rectum, and colon.
Inflammation of the vulva and vagina can be produced
hy the passage through them of a septic discharge from a slough-
ing fibroid, by mahgnant disease of the cer\'ix or uterine body,
by the contents of a pelvic abscess or pus-tube, or by being con-
itantly bathed with feces or urine escaping through fistulae.
Of the various exciting causes named, the most prolific is
gonorrhea. In woman gonorrhea is far more dangerous than
syphilis, for when infection once occurs, the entire genito-
Qmiary tract may become involved, and the individual sub-
«quently suffers from chronic inflammation of the uterus, sup-
puiation of the tubes, inflammation of the peritoneum and
ovaries, as well as cystitis, ureteritis, and inflammation of the
pelves of the kidneys. She not only loses through its influence
her power of reproduction, but develops inflammatory con-
ditions which, if they do not cause a fatal termination, pro-
duce such destructive changes in the pelvic organs as to neces-
sitate their removal in order to prolong life or render it endur-
able. WTiile the recurrence of gonorrhea may not in many
cases cause sterilitv, its existence renders the soil favorable for
the development of sepsis subsequent to abortion, parturition, or
rough and unskilful manipulation. Careless examination, the
introduction of the sound, and other intra-utcrine manipulation
without thorough asepsis are too frequently the causes of ex-
tension of serious pelvic inflammation.
Acute exacerbations are readily produced by overexertion,
fatigue, cold, or rough manipulation when the pelvic organs
are the seat of chronic inflammation.
381. Characteristics of Inflammation. — It should be well
tmderstood that inflammation, in the great majority of cases,
is primarily a product of infection, and, consequently, is not
necessarily to be regarded as a reprehensible process, but, on
the contrary, as an effort to guard and preserve vital structures
from injury and invasion. Its first aim, then, is defensive;
the second, constructive and reparative. These processes are
rften so intermingled as to render differentiation difficult.
The defensive element is more marked in the acute process,
and is associated with proUferation, degeneration, and de-
struction, dependent in degree upon the virulence of the in-
fection and the capabilities of resistance. Efforts are set in opera-
' tionto estabUsh a retaining wall. Blood stasis, cell proliferation,
^d exudation occtir; degeneration and destruction follow.
Such a process causes pain, a burning sensation, elevation of
temperature, extreme sensitiveness, swelling, and more or
less constitutional reaction. The process may terminate in
resolution or go on to suppuration.
330 GYNECOLOGY.
Acute and chronic inflammation are ofttimes mere stages
in the infective process, and the one insensibly fades into the
other. In the latter, defensive action is slight and not marked
by an extensive limiting wall. Naturally, the symptoms a«
less severe, and, as the constructive elements predominate,
as seen in hyperplastic conditions, the neuropathic disturbances
are more marked.
The inflammatory process may begin with a chill, or with ]
repeated rigors, associated with elevation of temperature and
with tenderness over the pelvic organs, often so great as to
render the contact of the clothing or bed-clothes quite imen-
durable, especially when the peritoneum has become involved.
Increased secretion and discharge is an invariable symptom,
necessarily dependent upon the seat and character of the in-
flammation. Disturbance of the functions of the genital organs
also necessarily occurs. In acute attacks the organs are so
sensitive that a digital examination is frequently attended'
with agonizing pain.
The menses may be arrested (amenorrhea) or be greatly
aggravated (menorrhagia), while not infrequently there is
profuse irregular bleeding (metrorrhagia). Increased or ir-
regular flow is more likely to be associated with involvement
of the peritoneum and cellular tissues, because the restdting
exudate obstructs the pelvic venous circulation. The bleeding
occasionally is internal. More frequently, however, there is a
transudation of serum and plasma into the cellular tissues, which
forms the condition known as parametritis or pelvic cellulitis.
382. Classification of Inflammation. — Frequently inflam-
mation will begin in one portion and rapidly involve the stnic-
tures of the entire genito-urinary tract; therefore it is diflicult
to specify any particular organ as its primary site. Further-
more, in other cases the virulence of the micro-organisms may
be so great and the defensive power of the patient so slight
that general infection takes place, and localization, if it occurs,
may be in organs remote from the site of original infection.
The gonococcus is an example of the former, while infection
with the streptococcus illustrates the latter. In the majority
of cases inflammation preponderates in a portion of the genital
canal or pelvic structure, and is named for the part mostly
affected.
Inflammation of the vulva, vulvitis.
ducts and i^^lands of Bartholin, Bartholinitis.
urethra, urethritis.
bladder cystitis.
vagina, vaginitis.
uterus metritis.
lubes salpingitis.
*• ovaries ovaritis or oophoritis
INFLAMMATIONS.
331
I
I
A still more minute classification of inflammation is made
in relation to the particular structure or portion of the organ
involved, as the mucous membrane, the muscular structure,
or the periphery. Thus, with the vagina we may have an
endovaginitis, a parenchymatous vaginitis, and a peripheriil
or perivaginitis. The uterus furnishes an endometritis, a
parenchymatous metritis, a perimetritis, the last involving
the peritoneal covering, and an inflammation of the cellular
tissue, known as parametritis or, better, pelvic cellulitis. The
tube is affected by endosalpingitis. parenchymatous salpingitis,
and perisalpingitis. Inflammation of the serous covering of
the uterus, as announced, is called perimetritis. It is, however,
rare to find this portion of the peritoneum alone involved.
More frequently, the entire pelvic peritoneum, including that
of the uterus, broad ligaments, and tubes, is inflamed, so that
the term pelvic peritonitis affords "a more accurate description.
Inflammation of the pelvic peritoneum rarely occurs without
more or less inflammation of the cellular tissue. It can not
be denied that we may have cellular inflammation without
very extensive involvement of the enveloping peritoneum.
When this occurs, it is known as pelvic cellulitis.
383. VulvitB and its Varieties. — Inflammation of the vulva
varies in degree from a slight erythema to a very severe and
destructive involvement which may result in the formation
of an extensive abscess, or in the destruction of a large portion
of the labium. It is usually divided into simple or catarrhal,
follicular, venereal, eruptive, phlegmonous, and diphtheric.
384. Causes. — Vulvitis is generally produced by infection.
Its development is favored by neglect of cleanliness. The
decomposition of the sebaceous and sudoriferous glandular secre-
tion and of the smegma, which accumulates between the labia
toajora and labia minora and beneath the prepuce of the clitoris,
will often cause an attack of inflammation similar to balanitis
in the uncleanly male. In obese women the decomposing per-
spiration, frequently associated with vaginal discharges, will keep
the surfaces constantly irritated and produce an extremely
offensive odor.
The tendency to inflammation is enhanced by the gouty,
rheumatic, and scrofulous diathesis, and by intemperance ui
eating and drinking, especially the latter. Vulvitis is often
produced by uterine and vaginal discharge, from malignant
disease or from discharging abscesses.
The continual soiling of the vulva with the urinar>' and
fecal discharge associatetl with fistula is productive of vulvar
inflammation and often erosion of the surfaces. Vulvitis
excited and aggravated by masturbation and excessive
1
332 GYNECOLOGY.
coition, from the pruritus occasioned by the presence of piiK
worms, ants, and pediculi: The various eruptive diseasei^
as eczema, herpes, acne, furuncle, warts, and venereal soreii
are productive causes. A severe form of vtilvitis is general^
associated with eczema, and intense prurittis is caused bjf'
the presence of the torulae cerevisiae in diabetic tuine. Inspec-'
tion will reveal whitish tufts over the surface, which arise from
the spores of the oidium albicans. Severe vulvitis with eczema
should always lead to examination of the urine in order to
exclude the presence of sugar. Vulvitis is a frequent complica-
tion in the eruptive and infectious diseases of childhood, such
as scarlatina and diphtheria. It may arise from the extension
of inflammation from the anus or bladder.
385. Vulvitis — Simple or Catarrhal. — In the acute stage
of vulvitis the labia minora, the clitoris, and the fourchet are
swollen and thickened. The parts are red, angry, and dry;
later, they are covered with a profuse purulent discharge of
an extremely offensive odor. This discharge is produced by
an increased secretion of the sebaceous glands mixed ^ith
desquamated epithelium and pus-corpuscles.
Pruritus, as in all forms of vulvar inflammation, is a marked
symptom, and is at times so severe as to prevent sleeping and
force the patient to abjure society. The temptation to scratch
or rub the parts becomes almost irresistible. The contact
of the urine causes smarting or burning. As the disease be-
comes chronic, the surface is not so bright a red; it becomes
abraded ; at points, small ulcers form, the skin is greatly thick-
ened, the papillae become hypertrophied, bleed easily, and are
red; often the surface presents points of excoriation, which
extend upon the vulva into the groins and the inside of the
thighs, when the itching is intolerable. The glands in the
groin often become swollen, and may even undergo suppuration.
386/ Follicular Vulvitis. — The follicular inflammation is
limited to the hair-follicles or originates in the sudoriferous
and sebaceous glands. (Fig. 287.) The surface of the vulva is
studded with small round protuberances the size of a millet-seed
or hemp-seed. These elevations begin as papules, which may
suppurate, forming pustules, which burst and shrivel, or they
may remain as small indurations. The intervening skin is
unaffected.
387. Venereal Vulvitis. — Venereal inflammation of the vulva
is produced by gonorrhea, syphilis, and chancroid. The former
is the most prolific source. Gonorrheal vulvitis is much more
intense than the catarrhal. It particularly involves the ves-
tibule and smaller labia. The latter are very red and ede-
matous, while the external meatus of the tirethra and the on-
INFLAMMATIONS. 333
of the ducts of Bartholin are generally red and swollen.
11 excoriations frequently occur which bleed easily. The
ise is attended with a very profuse purulent secretion, in
h the gonococcus is found. The microscope shows the
pithelial tissue exceedingly vascular and infiltrated with
groups of roiuid cells. The epithelium will be seen in
ing stages of granular degeneration and desquamation.
}cocci penetrate the epithelium and are found in the under-
The inflammation extends to the vagina, not
Fig. tSi. — Follicular Vul"
mquently through the urethra to the bladder, and often
tttholin's glands arc inflamed, occasionally resulting in abscess
raoation. Micturition is followed by intense burning, Vul-
lu due to syphilis occurs in the form of a single sore with
durated base and excavated surface, which is situated upon
* large or small labium or in the neighborhood of the clitoris.
I the secondary stage there are mucous patches similar to
334 GYNECOLOGY.
those found in the mouth. Chancroids produce a more or I
less extensive ulceration, generally involving adjoining sur
faces; syphilis causes indurated enlargement of the inguinal
lymphatic glands, while chancroid is characterized by thd
inflammation and suppuration, causing the condition known
buboes.
388. Eruptive Diseases of the Vulva. — Skin diseases mani-
fest the same characteristics when situated upon the vulvi
as in other portions of the body. The most important, be-
cause the most frequent, are eczema, erysipelas, and herpei
Eczema generally begins upon the labium majus or upon
the mons veneris, from which it extends to the thighs, peri-
neum, anus, and over the buttocks. In the acute stage thB
surface becomes red and swollen, bums, and is covered with
transparent vesicles the size of a pinhead. It is associated
with fever, gastric irritation, and rheumatic symptoms, and
becomes chronic by the end of the second week. Chrome
eczema generally appears in the form of eczema rubrum, and
the surface is covered with pus, dry scales, or crusts. Fissures
form at the fourchet and anus and in the genitocrural folds.
All the symptoms are greatly aggravated at the menstrual
periods. Pruritus is intolerable. The occurrence of eczema
of the vulva is generally associated with the appearance of
the disease upon other parts of the body. It is a frequent
consequence of diabetes mellitus, owing to the irritation of
the sugar-containing luine. It is also an outcome of the rheu-
matic diathesis.
Erysipelas may occur as a primary affection of the vulva
in the new-bom, when it is a very serious disease, frequently
proving fatal. It occasionally occurs periodically with the
catamenia, or may even take the place of the latter. Its oc-
currence diuing the puerperal state is generally an indication
of serious infection.
Herpes manifests itself by the appearance of smaU trans-
parent vesicles, from the size of a pinhead to that of a pea,
which may be few or multiple, discrete or confluent; rarely,
as a single erosion of large extent. The advent of the disease
is characterized by heat, smarting, and an area of redness,
which is covered with agminated vesicles. These vesicles
may fuse and form a large bulla. The vesicles dry ; the edges
of an ulcer are scalloped and its surface is covered with a crust*
beneath which cicatrization is completed within from eight
to fifteen days. The inguinal glands are engorged and pain*
ful, but do not suppurate.
Causes. — Accidental herpes may be caused by syphihs, gonor^
rhea, filth, and constitutional conditions. Congestion is a predis-
INFLAMMATIONS. 335
posing cause. In some women it occurs each month two days
in advance of menstruation; also during pregnancy.
389. Phlegmonous Vulvitis.^Phlegmonous inflammation of
the tissues may result from the catarrhal or may be the result
of violence. It affects the deeper structures and subcutaneous
tissues, resulting in serpiginous ulceration, which may form a
permanent fistulous tract, or the inflammatory area may be so
extensive as to result in the formation of an abscess.
390. Diphtheric Vulvitis. — Diphtheria may, but rarely does,
afEect the vulvar mucous membrane. The so-called diphtheric
vulvitis is an exudation found upon lesions of the vulva and
vagina, produced by parturition, and is the result of septic infec-
tion. Such exudations are also found in grave constitutional
disorders, such as scarlatina, smallpox, and typhoid fever.
In a woman who succumbed to sepsis subsequent to the
delivery of an intra -uterine sessile fibroid, whom I saw prior
to death, the vulva, vagina, and uterus were lined with a diph-
theric exudate.
391. Diagnosis of Inflammatory Disease of the Vulva. —
The diagnosis, especially the differential diagnosis, of the inflam-
matory disorders of the vuh*a is of great practical importance.
Gonorrheal vulvitis is cN'ident from the greater intensity of its
symptoms. It is characterized by an increased burning dur-
ing micturition, profuse purulent discharge, and redness of the
meatus and orifices of the ducts of Bartholin, It has a tendency
to extend to the tubes, ovaries, and peritoneum, as well as an in-
creased inclination to involve the urinary tract. Its recognition
is rendered certain by the discovery of the gonococcus, and the
known fact of exposure to the virus. The absence of the gono-
coccus is not proof positive against the specific character of the
disease, as the germ may have disappeared. Late investiga-
tions seem to show that the gonococcus is capable of assuming
amorphous forms and resuming its original form and virulence
under irritation. Thus are explained the recurrences of the dis-
ease after a debauch, excessive vener>', or exposure to cold in
individuals who are apparently cured. {For method of dis-
covering the gonococcus see Section go.)
The production of vulvitis in the virgin by masturbation is
suspected when the smaller labia and the space between them
and the hymen are co\'ered with small, pointed excrescences; the
nymphas are elongated; the clitoris or its prepuce is irritated;
swelling of the shallow groove between the orifice of the urethra
and the chtoris exists; clear, abundant secretion from the ducts
of Bartholin occurs; and associated with these phenomena thei
is abnormal sensibility ; exaggerated prudery ; and distinct hystei '
symptoms. Discontinuance of masturbation may be assumed
336 GYNECOLOGY.
when the hypertrophied nymphae become soft and no longer
show any indication of inflammation.
Eczema can be recognized by the similarity of its symptoms
to those of the disease when it occurs in other portions of the
body. Finding the cervix covered with whitish tufts should
arouse suspicion of the presence of torula cerevisiae, which is
confirmed by the microscope and the discovery of sugar in the
urine. It is a good plan carefully to examine the urine in every
case of eczema of the \iilva. Herpes is frequently confounded
with chancroid, from which it is distinguished by its early his-
tory. The formation of a vesicle is followed by its rupture,
leaving a raw surface without a thickened inflammatory base
and without loss of substance. The burning is more acute and
the inflammatory symptoms subside more qmckly. The lymph-
atic glands of the groin may become inflamed, but do not
suppurate. The duration of herpes is from eight to fifteen days.
In chancroid the sore has an uneven, fissured base, the edges
of which are sharply defined, and its surface is covered with a
greenish discharge. It presents p)oints of abrasion, and generally
the apposed surface becomes inoculated. Bubo develops in the
groin.
392. Treatment. — In all forms of vuKHtis absolute cleanliness
is essential. In the simple acute variety, absolute rest and the
administration of salines are indicated. Tincture of aconite can
be given in drop doses every one or two hours to decrease inflam-
mation. In all varieties thorough local cleanliness must be
observed. In the simple and follicular forms cleansing and
isolation of the inflamed parts will frequently be sufficient to
establish a cure. The cause of the inflammation, if possible,
should be determined, and, when practicable, remedial measures
should be directed to its removal. Vaginal discharge should be
arrested, and the inflamed surfaces should be protected from its
contact. The rheumatic, gouty, and scrofulous diatheses and
improper habits must be corrected by proper hygienic and con-
stitutional measures. The food should be carefully regulated
and all stimulating and indigestible articles avoided. Alcohol
in any form should be interdicted, excepting in the diphtheric
and phlegmonous varieties. In the acute stages a bland diet or
exclusive milk diet may be advisable.
Catarrhal and Gonorrheal Vulvitis. — The treatment of these
forms is of ^^rcat importance, as in the latter infection may lurk
in the diseased tissues for vears. Cleanliness is secured bv the
employment of the hot sitz-bath several times daily, by anti-
septic fomentations, such as gauze pads moistened with sub-
limate solution, I : 2000 or i : 1000; carbolic acid, i : 20; boric
solution, I : 50; equal parts of boric-acid solution, and of a solu-
INFLAMMATIONS.
tion of subacetate of lead, or g per cent, solution of antipyrin,
placed over the vulva and covered with oiled silk or rubber dam.
In very acute conditions the distress will be much more quickly
ameliorated by the application of lead-water and laudanum. This
application may be kept cold by an ice-bag placed over it. These
applications, whether antiseptic or emolHent, should be frequently
changed, the parts protected from vaginal discharge by a tampon,
and the inflamed surfaces painted several times daily with a
solution of Monsell's salt, i : 8, in glycerin or 20 to 40 per cent.
solution of argyrol; on each alternate day silver nitrate, gr. x
to the fluidoimce. or compound tincture of iodin in water, r to
2, should be used. Protargol, largin, argyrol, and argonin have
been especially advocated as valuable in the gonorrheal form;
alumnol in 2 per cent, solution has also been advocated. Ramon
Guiteras highly recommends mercurol in a per cent, solution.
These agents are more effective in the gonorrheal form. The
sides of the vulva should be separated with absorbent cotton,
surgeon's lint, or prepared cotton. After the subsidence of the
more acute stage the surfaces should be dusted with zinc oxid,
bismuth subnitrate, iodoform, boric acid and acetanilid in equal
parts, lycopodium, starch, talcum, or one of the ^'arious combina-
tions of these powders. Iodoform and tannin in equal parts are
very efficient. Equal parts of alum and sugar afford relief in
pruritus. Buboes and abscesses should be promptly incised
and their cavities steriUzed. In chronic vulvitis, astringents
or caustics may be employed, the latter with the purpose of
promoting sufficient metabolism to take up inflammatory ex-
udate which has led to tliickening of the tissues. Benzoated
zinc ointment is a soothing application, The surfaces may be
dusted with calomel or bismuth subgallate. Gonorrlieal vulvitis
is usually secondary. In chancroid the parts should be kept
clean by frequent washing, the infiamal area isolated by gauze
or lint, and drying powders should be employed, such as iodo-
form, iodoform and tannic acid in equal parts, aristol and desic-
cated alum, 4 to I, calomel and zinc oxid or bismuth subgallate
and acetanilid. In herpes keep the surfaces clean and separated.
Drying powders should be employed.
In follicular vulvitis, in addition to strong antiseptics, alkaline
solutions are eflicient. It may be necessary to shave the parts
and to puncture and cauterize the individual follicles, or, in rare
cases, to excise the affected surface. The ointment of ammoni-
ated mercury, diachylon ointment, or ichthyol in lanolin (J-i :4^
may be useful. Phlegmonous ami diphtheric vulvitis requ
cleanliness, antiseptics, removal of sloughing tissue, and, i
latter, cauterization of the infected surfaces with strong carl
acid.
338 GYNECOLOGY.
Eczema, when acute, must be treated with emollient appli-
cations or starch poultices, and the surfaces should be carefully
cleansed. The bowels should be regulated and constitutional
measures employed for the correction of any disordered condi-
tion. When eczema is associated with diabetes, compresses of
hyposulphite of soda, half an oimce to the pint, shotdd be kept
in contact with the inflamed surfaces. In chronic eczema the
parts should be thoroughly washed with strong potash soap and
hot water. By this measure all crusts and scales are removed.
Where the surfaces are too much irritated, cracked, and fissured
for this plan of treatment, a starch or slippery-elm poultice may
be applied. After thoroughly cleansing the surfaces, the applica-
tion of the following ointments will prove of value:
H . Hydrarg. ammoniat., 5 ss
Lanolin, 3 ij. M.
Ft. irngt.
B . Iodoform 3 j
Zinc, oxid 5 iJ
Lanolin, 5 iij- M.
Ft. ungt.
H . Acetanilid, 3 j
Menthol, 3 ss
Lanolin 3 j. M.
Ft. ungt.
Or diachylon ointment or one of the tar preparations may be
employed. If the irritation is apparently kept up by a vaginal
discharge, use a vaginal tampon. Laxatives shotild be given to
regulate the bowels, and constitutional measures should be em-
ployed for the correction of arthritic, scrofulous, or diabetic con-
ditions, from any one of which the disease may have originated.
393. Edema and Gangrene. — Edema of the vulva is fre-
quently associated with pregnancy. It is common in ascites
as a result of various obstructions of the circulation. It may
follow labor and also result from varix of the external pudic
vein. When one side of the vulva only is involved, infection
should be suspected. Incisions of the vulva or spontaneous
fissures permit the fluid to escape, but increase the danger
of erysipelas, and may be followed by gangrene and slough-
ing of the labia. The swelling in general anasarca is very
great, and may render urination or the use of the cathetel"
very difficult.
A hard edema of one labium can occur from and persis^
after chancre. When it appears in the nymphae or praeputii
clitoridis, it resembles elephantiasis. The condition is known,
as syphilitic hypertrophy of the vulva.
Gangrene of the vulva may be produced by tratmiatisniw
septicemia, and occur in weak and scrofulous infants. Thi^
INFLAMMATIONS. 330
of gangrene in young children is known as noma. It
ictious, and presents a reddened, infiltrated labium and
horous discharge. A vesicle appears, which rapidly be-
i gangrenous.
le treatment of edema is the same as that of the condition
which it arises. That of gangrene or noma consists in
excision, disinfection, and the exercise of measures to
! effectual nourishment.
4. Baitholinitis (Inflammation of the Glands of Bartholin),
lac glands — also known as the vulvovaginal, Duvemey's,
lowper's glands — are racemose glands the size of a b^n,
ed in the labia majora at the
ion of the posterior and middle
i. The duct, two centimeters
agth, opens in front of the
n, with an orifice the size of
head. Catarrh of these glands
e, but hypersecretion is not in-
ent. It is indicated by redness
: the opening of the duct, which
be either dilated or closed, in
itter case forming a retention
The secretion from these
may be thrown ofE in par-
ns, not infrequently in noc-
1 emission. The secretion is
nilarly discharged during erotic
snent.
iflammation can occur in either
land or the duct. It is gener-
due to specific infection, but
arise from streptococcic or
lylococcic forms. In very
e cases it is apt to be a mixed
tion. It is most generally due,
tver, to gonorrhea. Gonorrheal inflammation having been
ed up in the gland, it may subsequently remain dormant,
ifEord material which may not only again infect the patient,
rthers coming in contact with the secretion. Inflammation,
rding to its virulence, may either produce a cyst or result in
levelopment of an abscess. Cysts are either single or multi-
ar, ovoid, with a smooth surface, and seldom transparent;
Mntents are viscid and are colorless or yellow. From mix-
with blood they may become chocolate colored. {Fig. 288.)
cyst varies in size from that of a nut to that of an egg, is gen-
y unilateral, and is most frequently situated on the left side.
340 GYNECOLOGY.
elongated in the axis of the greater lip, and nearer the mucous sur-
face. It seems elastic and compressible rather than fluctuatii^;
gi'^es rise to discomfort in walking and during coition, and can
become inflamed and suppurate. Superficial cysts involving the
duct may attain to the size of a nut ; they are usually situated
at the base of the labium minus, and may project into the
vagina beneath the mucous membrane. A cyst of the gland is
deep, is generally larger, and is located behind the labium majus;
it elevates both labia and its duct is impermeable.
The diagnosis is readily determined. In either solid or
fluid tumors fluctuation is absent, and the transparency is
insufficient. But when the diagnosis is doubtful, it can be
ascertained by puncture. The conditions with which it may
be confoimded are: first, sacculated cysts of old hernial sacs;
second, hydroceles in the canal of Nuck; third, a cyst in front
of a hernia. From hernia, which may be an epiplocele, an
enterocele, or ovarian, it is distinguished by the absence of
succussion in coughing and by the determination of the con-
nection of the mass with the abdomen. Hydrocele may fre-
quently be displaced by pressure, is a larger tumor, gives more j
sensation of fluctuation, and is more translucent. Abscess
may be secondary to the cyst or may originate from primary
inflammation. Swelling and edema are marked over the pos-
terior part of the vulva and about the anus, and the pain is
acute and lancinating. The patient may have more or less
fever; frequently, the urine is retained; fluctuation is distinct,
and, if the abscess is not opened early, its contents may escape
through several openings; pus is abundant and fetid. Fistute
may persist, and may result in a rectovulvar fistula, or a lai|[e
ulcer may be present, associated with purulent secretion or a
hypertrophic induration of the gland, with profuse discharge
of milky, greenish pus. The gland is the last refuge of gonorrh^
inflammation, and is a frequent source of unsuspected infection
for men. It may be confused with anal abscess, phlegmon
of the labium majus, or ftiruncles. In anal abscess there is
more rectal disturbance, a more widely diffused inflammation,
and the mass does not encroach to the same degree upon the
labium. In phlegmon of the labium majus the inflammation
is more external, and encroaches upon the cutaneous rather
than upon the mucous surface. Furuncles are more sharply
defined and present an indurated base.
Treatment. — In early inflammation of the duct the pus may
be evacuated by pressure and injected with a two per cent-
sterile solution of ichthyol or a one per cent, solution of silver
nitrate. The duct may be opened with a lacrimal knife, and
a crayon of silver nitrate or a solution of zinc chlorid (1:50)
INFLAMMATIONS. 341
may be introduced. In cysts, when the contents are evacuated
by puncture, they quickly reappear. Obliteration of the cyst
may be secured by injecting ten drops of a solution of zinc
cUorid (i : lo) after the contents have been removed by as-
piration, or the cyst may be incised and packed with iodo-
form gauze. A preferable procedure would be extirpation.
In order to overcome the difficulty of removing the cyst when
collapsed, it may be pimctured, emptied, irrigated with hot
water, and injected with melted paraffin, and the latter hard-
ened with ice, after which the mass thus formed is easily dis-
sected. The woimd produced by the removal of a cyst should
be closed with sutures. In abscess early free incision at the jimc-
tkm of the skin and mucous surface is important. To ex-
tirpate the gland, wash the cavity with carbglic solution and
pack with gauze. In fistulas it may be wise to extirpate the
g^d, dissect out the fistulous track, and close the cavity with
ca^t sutures.
395. Pruritus Vulvae. — Pruritus is a symptom of all forms
of iiiflammation of the \adva. It results from the presence
of pediculi, pin-worms, eczema, trichiasis; from hemorrhoids,
disease of the kidneys, ureters, bladder, and urethra; from
congestion of the pelvic organs and masttu-bation ; and from
acrid vaginal discharges. It is associated with pregnancy,
menstruation, the menopause, old age, the gouty diathesis,
and general nervousness. It is directly caused by lice, acrid
discharges, and diabetes. In addition to the sources given,
there is a form of pruritus in which the origin remains imdeter-
tmned. This is designated as an idiopathic pruritus. It is,
however, very questionable whether careful examination will
not disclose a demonstrable cause of the disorder. Seeligman,
in an investigation of a large number of cases, found in all a
diplococcus which resembles the gonococcus in appearance,
hut differs from it in its process of growth, and, besides, it takes
the Gram stain.
Symptoms. — Pruritus produces intense itching, and, as a
result of the scratching induced, excoriations are present, and
the hair is often worn off the mons veneris. The patient avoids
company, becomes melancholy, has loss of appetite and sleep
^ increased sexual desire, masturbation is excited, and she
oay become insane. Itching is continuous or occurs only
at intervals it is increased by heat and is much worse at night
or following any exertion. The relation of masturbation to
pruritus is not always readily determined. The habit produces
certain abnormal alterations as a result of the irritation:
^hanges in the endometrium, glandular hypertrophy, ovarian
irritation, increase of secretion, irritation and manipulation
342 GYNECOLOGY.
of the \ailva. A bad circle is engendered; irritation causes
masturbatioti, and this aggravates the inflammation. There
are cases, however, in which most carefiil examination fails
to disclose inflammation of the vulva as a source of the intense
pruritus. These conditions are known as idiopathic pruritus,
and are supposed to be due to nerve irritation. Such cases
do not properly belong under the term inflammation of the
vulva, but they are so rare, and the symptoms are so prominently
associated with vulvitis, that their consideration seems more
appropriate here.
Prognosis. — The relief of the condition depends entirely
upon its cause. In some cases it is exceedingly obstinate.
The removal of the cause, as filth, pediculi, or pin-worms,
results in the removal of the disorder. The prognosis in mas-
turbating alterations is by no means favorable. It may be
exceedingly difficult to overcome the evil habit.
Treatment, — The first aim in the treatment should be to
discover and remove the cause. Upon the recognition of ped- j
iculi the parts should be shaved, and blue ointment should
be applied. A strong sublimate solution, however, is the most
effective agent. The surfaces should be painted with a solu-
tion containing one grain of corrosive sublimate to the ounce
each of alcohol and water. Unless the parts are shaved, this
application must be repeatedly made, for it is necessary to
destroy not only the lice which are present, but also the spores.
If the pruritus arises from the action of the ascarides scabiei
. (the itch insect), sulphur ointment or one consisting of thirty-
five grains of betanaphthol in one ounce of vaselin are efficient
applications. Of course, in the latter condition, the application
must be made to the entire body.
The methods of treatment of eczema and vulvitis have
already been given. When it is evident that the pruritus
has been produced by pin-worms, the parts should be kept
clean and the patient given fluidextract of senna and spigefia
in half -ounce doses; a rectal injection of infusion of quassia,
two ounces to the pint ; half a grain of sublimate to eight ounces
of water; an injection of lime-water or a suppository of five
grains of santonin, are also efficient measures. HemorrhoidSr
glycosuria, and other causes should be recognized and treated.
The diet is important. Alcohol and spiced food should be
excluded. The use of coffee will often cause severe pruritus.
Milk is an excellent basis for the diet. The general health
should be carefully considered. Tonics, such as arsenic and
quinin, should be administered. When the patient is unable
to rest, sleep should be secured by the administration of bro-
mid of potash, 5j-5ij daily, or tincture of cannabis indica, gtt.
INFLAMMATIONS. 343
-XXV, thrice daily. When the measures just named are
insufficient to sectu'e sleep, sulphonal or trional should be
given in preference to opium. Local vaginal injections of hot
ipater; carbolized, sublimated, or borated cotton tampons;
or fomentations of lead-water and laudanum can be employed,
or a saturated solution of bromid of potash may be painted
over the stirface several times daily. Local applications of
diloroform in glycerin (i:8), hydrocyanic acid, two or three
drops to the oimce, or a one per cent, solution of cocain may
be used. A solution of carbolic acid, or a strong solution of
sQver nitrate, followed by cold compresses, may be employed.
Seeligman advocates the use of an ointment containing lo
per cent, of guaiacol in vaselin, and when this is not effective,
it should be increased to 15 to 20 per cent. An ointment con-
taining acetate of lead, chloral, camphor, or chloroform (a
dram to the oimce), combined with vaselin, menthol, or a solid
stick of nitrate of silver, is advised. The following formula may
be employed :
9. Menthol, 3ss
Lanolin, 3 j. M.
Ft. \mgt.
In very obstinate cases the affected skin may be excised. Tam-
pons containing equal parts of sulphurous acid and boroglycerid
«ometimes afford relief. The irritated surfaces may be painted
with a solid stick of silver nitrate or a galvanic current can be
employed. The employment of the Jif-rays has been advocated.
The resort to tobacco smoking has afforded relief when all other
means have failed.
396. Kraurosis vulvse is an obscure form of disease, first rec-
ognized by Breisky, which consists of an atrophy of the smaller
labia. (Fig. 289.) The skin of the vulva undergoes essential
changes. The capillaries of the corium become dilated, the rete
nmcosum gets thin and disappears, while there is a substitution
of a thick homy layer of epithelium, which lies directly upon the
corium. The papillae disappear, the imdulating character of the
sldn is lost, and it becomes stiff and sclerosed, with here and
there points of small cell infiltration. As the disease progresses
the sebaceous and sweat-glands are entirely destroyed. It is called
chronic inflanmiatory hyperplasia of the connective tissue with
inclination to cicatricial shrinking (Peter).
Mars divides kraurosis into two stages: (i) The stage of
rtema, characterized by more or less inflammatory reaction;
(2) the atrophy of elastic and connective-tissue skin layers
^th the formation of scar tissue; but Heller says it may be
nidependent of the inflammatory process. He attributes it
to some chemic irritation or a direct disease of the medullated
344 GYNECOLbGY,
nerves, which leads to atrophy of the muscles, fat, and gla
in the deeper layers of the slan, while a hypertrophic pnx
especially a hyperkeratosis, occurs in the superficial layer.
Causes. — -The cause is unknown. It has been attributet
gonorrhea and pruritus. A preceding inflammatory stage ex
(Martin). Breisky found it more frequently in the -pregoi
Martin and others, in the nonpregnant.
Symptoms. — The surfaces become contracted, presentin
Fig. 2S9. — Kraurosis Vulva
smooth, cicatricial appearance, devoid of glands, with redden
inflamed points, not fully cicatrized. Pruritus is intense ;
causes severe burning and pain upon urination. The surf
is dry, smooth, contracted, often fissured. The labia nun
entirely disappear, and the clitoris becomes a mere pap
The vulvar orifice is contracted, and causes coition to be
ceedingly painful, often impossible. Childbirth results in exl
sive laceration.
INFLAMMATIONS. 345
Diagnosis, — The scratching of this 'disease should be sepa-
ated from that of onanism and pruritus. The gratification
induced by masturbation and the absence of cicatricial changes
distinguish it. In pruritus the tears and superficial injuries
axe more marked and the disease is not so general, while in
kraurosis the border of disease is more sharply defined toward
the healthy skin.
Prognosis. — Its spontaneous recover}'- is very doubtful.
That carcinoma occasionally develops from it is exceedingly
probable.
Treatment, — The disease is exceedingly intractable to treat-
ment. The application of cocain adds to the discomfort. Re-
lief has been afforded by applications of strong carbolic acid,
or of pledgets wet \\4th a solution of lead acetate. The thermo-
cautery has been applied. The most effective treatment is
the excision of the affected tissue, accomplishing union of the
healthy tissue by sutures. Care must be exercised to prevent
narrowing of the urethra.
397. Vaginismus is a term employed to represent an abnor-
mal hyperesthesia of the external genital organs which pro-
duces muscular spasm. It is common in young, nervous, or
hysteric women, and occasionally occurs without our being
able to discover any source of irritation. Generally, a care-
ful examination will disclose an irritable spot in the fossa navic-
ularis; an inflamed and thickened hymen, which has failed to
rupture, or, when it has ruptured, irritable carunculae myrti-
formes; fissures in the fourchet or aroimd the orifice of the
vagina; small ulcerations within the hymen; fissure of the
anus; urethral caruncle or an irritable urethra. Nervous
irritation of the vulva may be engendered by association with
an impotent or partly imp)otent man.
Symptoms. — Dyspareunia, or painful coition, and sterility
are the most marked symptoms. The slightest touch, or even
the approach of the male, may cause powerful spasm of the
sphincter vaginae muscle. I have seen similar spasm occur
at every attempt at urination in a very hysterical woman.
The suffering is so intense as to lead the patient at once to
seek medical advice, or through a sense of delicacy she may
ttidure the distress until it becomes intolerable. She becomes
careworn, anxious, and even hysteric. The ordinary vaginal
examination is often extremely painful. I have, however,
observed patients in whom the pain seemed confined to the
attempts at coition, and they apparently experienced no un-
^isual discomfort during a careful pelvic investigation. Be-
fore attempting digital examination it is well carefully to in-
spect the surfaces and to push the labia apart, when possibly
346 GVNECOLOGy.
the cause will be discovered. Hildebrandt has described a
form of vaginismus due to spasm of the levator ani muscles,
known as superior vaginismus, which is responsible for that
unpleasant complication, penis captivus. It must not be over-
looked that dyspareunia is occasioned by pathologic lesions
of the floor of the pelvis, such as prolapsed, inflamed ovaries
and tubes, inflammation of the cervix, pelvic cellulitis, or peri-
tonitis.
Prognosis as to cure is good.
Treatmeyit. — The first essential in treatment must be the
removal of the cause. When the hymen is thickened and
sensitive, it may be necessary to cut it completely away. Its
mucous surfaces, however, should be sutured, in order to pre-
clude the formation of cicatricial tissue. In irritable fissure
the base should be divided, as in fissure of the anus, or touched
with the thermocautery. Local applications are often effec-
tive, of which one of the best is iodoform in powder or oint-
ment. Its disagreeable odor, which often precludes its use,
may be overcome by rubbing up a few drops of oil of eucalyptus
with each ounce of the powder. Pledgets of cotton soaked
in a four per cent, solution of chloral or in a two per cent, solu-
tion of carbolic acid are useful. Ointments of opium, bella-
donna, or ichthyol often afford relief. Neuromata, irritable
carunculie my rti formes, and urethral caruncula; should be
snipped off. In fissure of the neck of the bladder the urethra
should be overstretched and cocain filaments or pencils should
be used. In obstinate spasm glass dilators or plugs (see Fig.
1 6.^) should be worn for an hour night and morning. The
pain caused by tlie introduction of the plug soon ceases, and
it can be decreased by anointing it with a medicated ointment.
These instruments should gradually be increased in size. When
the dilator can not be worn, recoiu^e should be had to opera-
tion.
Sims divided the superficial fibers of the sphincter vaginae —
the bulbocavemogus muscle. With the patient anesthetized,
two fingers of the left hand are passed into the vagina to stretch
the ostium. An incision about two inches long is made on
each side of the fourchet, extending from half an inch above
the ostium to the raph6 of the perineum. The ostium is thor-
oughly plugged with gauze, which is kept in position by a T-
bandage. This plugging is important to prevent liemorrhage.
The gauze is removed the following day, after which the glass
plug should be worn a portion of each day for several weeks.
For incision, forcible stretching may be substituted. This
is accomplished by introducing the thumbs (Tilt) or several
fingers of each hand (Hegar) and forcibly separating them
INPLAMMATrONS. 347
until the muscular fibers yield under the traction. This pro-
cedure afTords the advantage that it is bloodless and that it
leaves no granulating wound to cause a cicatrix. The gal-
vanic current has proved beneficial. Constitutional treatment
should always be combined with the local measures. Quinin,
arsenic, and strychnin should be given. Outdoor exercise and
change of scene should be encouraged and complete sexual rest
enjoined.
398. Vulvovaginitis is an inflammation of the vnilva and
vagina, most frequently found in young girls, and, in the great
majority of cases, is believed to owe its origin to the presence
of the gonococcus. Robinson,* in fifty-four cases of vulvitis
in children, mostly under five years of age, was able to find
cocci in the pus-cells which corresponded to the gonococci in
forty-one. It may also be induced by want of cleanliness,
by the decomposition of the natural secretions, and by the
entrance of pin-worms where proper cleanliness after stool is
neglected. The importance of the condition is too frequently
underestimated. The infection can extend to the uterus and
even pelvic peritoneum, producing changes which condemn the
individual to suffering all her menstrual life and often render
her sterile. The principal symptoms are pruritus, painful
micturition, and a profuse yellowish, watery discharge, which
constantly soils the clothing of the child and keeps the vulva
irritated. The intense pruritus may readily generate the habit
of masturbation.
The infection may be spread by the hands, towels, linen,
and bath. In children's asylums it is not uncommon to find
large numbers of girls thus affected.
The condition is frequently complicated by ophthalmiat
peritonitis, and arthritis.
Treatment should be energetic. In the acute stage it con-
sists in rest in bed, a light diet, and free evacuation of the bowels.
The urine should be rendered bland, and cold applications
should also be employed. Severe pain and burning can be
obviated by local applications of cocain, several hot sitz-baths,
and careful irrigation two or three times daily.
In irrigation, cocain may be first applied. This can be
followed by alkaline or antiseptic agents, potassium perman-
ganate (1 : 4000 to I ; 1000), silver nitrate (i : 2000), protargol
{0.5 to 1 per cent.), or a ten per cent, solution of argyrol. The
irrigation shtiuld be made through a soft -rubber catheter intro-
duced into the vagina. If the vagina does not drain well, the
hymen should be stretched, to remove any obstruction. After
•"Trans.. Lond, Obst, Soc.," Jan. 4i
348 GYNECOLOGY.
irrigation, the parts should be dried and a mild ointment appliei :
The vulva should be covered with a sterile dressing, which should -
be burned upon removal. The child and her attendant should
be impressed with the danger of carrying the infection to the
eyes.
399. Vaginitis, elytritis, or colpitis is an inflammation of
the mucous membrane of the vagina. The mucous membrane
of the vagina closely resembles the structure of the skin, ha\Tng
few, if any, submucous glands. It consists of connective tissue
surmounted by papillae covered wnth several layers of squa-
mous epithelium. A longitudinal ridge is formed upon the
anterior wall, from which rugae, or folds, like the teeth of a
comb, extend upon each side. This formation is less distinct
upon the posterior wall. The central projections are known
as the anterior and posterior columns. The former generally
terminate below in a rounded protuberance, called the vaginal
tubercle, situated immediately above the meatus urinarius.
Sometimes the anterior column is divided by a furrow into
two portions. The rugae aid in promoting sexual excitement,
and probably contribute to vaginal enlargement during pr^-
nancy and parturition. They disappear toward the upper
part of the canal. The vagina receives its blood-supply from
the vaginal, uterine, internal pudic, and vesical arteries-
branches of the anterior division of the internal iliac. The
vagina is surrounded by a venous network or plexus, which
communicates \\4th those of the vulva, bladder, recttun, uterus,
and broad hgament, and finally empties into the internal iliac
veins.
The lymphatics of the lower fourth communicate with
the superficial lymphatic glands ; those of the upper three-fourths,
with the internal iliac glands.
The nerves are derived from the sympathetic, and form
upon each side of the vagina a plexus which communicates
with the inferior hypogastric.
The arrangement of the epithelium and the absence of
glands render the vagina much less vulnerable to infection
than either the uterus or vulva.
We have already referred to the normal secretions of the
genital tract. D5derlein distinguished between the physio-
logic and pathologic secretions of the vagina. The former
is markedly acid, dependent upon the presence of a bacillus
which produces lactic acid. The latter may be feebly add.
neutral, or alkaline, and contain a variety of micro-organisms—
saprophytic and pathogenic. Probably fifty per cent, of pr^'
nant women have this pathologic secretion, in which germ5
flourish, and from which auto-infection is possible. The demon'
INFLAMMATIONS. 349
Kiation of the truth of this assertion greatly simplifies the
■tody of the processes of infection.
The vaginal discharge becomes alkaline during the menstrual
period, during the puerperium, and in many cases of leukorrhea
—a condition which is more favorable for the growth of micro-
xganisms and the infection of the genital tract. D6derlein*s
UBertion, however, does not correspond with the results of
he researches of Menge, Kronig, and Walthard.
Kr6iiig*s investigations were confined to pregnant and
Hierperal women, and consequently are not a proper subject
or consideration under gynecology further than to note his
nodusion that the distinction between the physiologic and
Athologic secretions is not determinable. He asserts that
in secretions alike contain fto pathogenic germs. All secre-
aons are equally germicidal, though the vitality of the germ
IMers. It takes twice the time to kill the staphylococcus
chat it does to destroy the streptococcus. The vagina infected
irith germs will become aseptic in two or three days. The
otuse of this bactericidal power is as yet tmdetermined. It
is not chemic, because it occurs whether the secretion is faintly
or strongly acid ; it is not believed to be due to a special bacillus,
although some micro-organisms are known to be antagonistic
to others. If it results from leukocytes, it must be due to a
property independent of their contractile power, for the action
continues after their subjection to a heat which would destroy
the latter. The want of oxygen in the vagina will not explain
it, for the staphylococci and streptococci are anaerobic — i. e.,
grow independent of oxygen — and yet are killed. It is not
mechanical, because particles of carbon and mercury are re-
tDoved much more slowly. Possibly all these factors may
unite to establish germicidal action. Kronig presents a very
important practical observation, which is that a solution of
corrosive sublimate for irrigation destroys the germicidal action,
probably by precipitation of albumin, while plain water but
lessens it. A necessary inference is that prophylactic injec-
tions of corrosive sublimate are prejudicial when the secre-
tkm is normal. Menge, in his investigations upon the non-
poerperal, introduced pyogenic micro-organisms into the vagina
in eight women, and found that the vagina cleansed itself from
these organisms in periods varying from two and one-half
Ijours to three days. The factors which compass this germi-
cidal action are various forms of bacteria and their products,
^ acid secretion, possibly serum action, and the absence of
oxygen. This activity is weak in infants, and is lessened by
Jftenstruation and by increased secretion from either the cervix
w the body of the uterus, or even from the vagina. It is de-
350 GYNECOLOGY.
creased when the vulva is pattilous or the uterus prolapsed,!
and at the menopause. I
Walthard has directed attention to the influence of cbaop
of pabulum in restoring the lost virulence of micro-organisms
He inoculated the streptococcus into the ear of a rabbit with-
out tmfavorable results, unless the ear was ligated to lessea
tissue resistance, when a streptococcus from the vagina became
as virulent as those fotmd in puerperal fever. It is possibk
that an innocuous streptococcus may thus be restored by the
tissues during the puerperium, and similarly in gynecolo^
operations in which there is bruising of all the tissues, as in
the enucleation of fibroids.
400. Varieties. — Vaginitis may be divided into simple and
specific (gonorrheal). The latter is exceedingly important
because of its intractability and its tendency to extend. The
distinction between acute and chronic is merely one of degree.
Special varieties named are emphysematous, exfoliative, dys-
enteric, phlegmonous, diphtheric, and senile, but these are un-
necessary distinctions.
The etiology and pathology have undergone some (XMi-
sideration in our discussion of the action of micro-organisms.
Of these, the gonococcus is most important, for upon its dis-
covery will frequently depend the diagnosis. It was discovered
and described by Neisser. The recognition of its presence
in the secretion is diagnostic, but its absence can not be consid-
ered a positive indication that the secretion is of other than
gonorrheal origin.
401. Pathology. — In simple vaginitis slight elevations of the
mucous membrane occur, producing a granular surface. The
granulations are produced by groups of papillae, which are
infiltrated with small cells ; as a consequence, the papillae swell
up and push before them the stratified squamous epithelium
Superficial layers are shed. Later, the surface becomes more
level, from thinning of the superficial covering. With the
vaginitis of pregnancy not infrequently an emphysematous
condition of the mucous membrane is associated. These ele-
vations have been described as cysts containing a gaseous fluid.
The gas consists of air and trimethylamin. Ruge says the
gas is situated in the cellular tissue, Zweifel says the masses
are vaginal glands the ducts of which have become closed.
A similar condition has been observed following the climacteric.
Tlie exfoliative, dysenteric, or diphtheric vaginitis presents
localized patches or an inflammation of the whole vagina.
In the latter condition the mucous membrane becomes so swollen
that it is with difficulty the finger can reach the cervnx, which is
also thickened and covered with an exudation.
INFLAMMATIONS. 351
Senile Vaginitis. — After the menopause the epithelial tissue
is desquamated, the papills atrophy, and the raw surfaces
cause obliteration of a large portion of the vagina. It often
causes curious constrictions of the upper vagina, rendering
the canal frequently cone-shaped, with the small end above,
which discloses the cervical opening as a mere dimple. Bands
of contracting scar tissue are often seen, which divide the \-agina
into loculi. Desquamation of the epithelium occurs. This
is probably produced by defective nutrition, and, later, granu-
lations develop. A loss of elastic tissue also occurs, with an
increase of connective tissue, which results in cicatricial con-
traction. The same process can cause occlusion of the cervical
canal subsequent to the menopause.
Specific Vaginitis. — The most important cause of vaginal
inflammation is gonorrheal infection. This produces an in-
tractable form of vaginitis, which may continue for months,
or even for years. It may extend over the mucous membrane
of the uterus to the tubes, ovaries, and peritoneum, produc-
ing endometritis, salpingitis, pyosalpinx, ovaritis, and pelvic
peritonitis.
402. Etiology.^Vaginitis is produced by gonorrheal infec-
tion; irritating discharges from the uterus; the contents of
perivaginal abscesses; the contact of urine or feces from fis-
tulae; vaginal injections, too hot or too cold, or those contain-
ing injurious chemic agents; badly fitting pessaries; decom
posing tampons; efforts to produce abortion or awkward at-
tempts at sexual intercourse; and the exanthemata ; and it may
complicate typhus fever, smallpox, and scarlet fever. Diphtheric
patches have been observed in a number of diseases, particularly
in the puerperal state. Localized patches are seen in fistulse,
in carcinoma, and about badly fitting pessaries. The disease
is induced by the habits of the patient. The free use of alcohol
produces the granular form of the disease. The gouty or rheu-
matic diathesis is a predisposing cause.
403. Symptoms. — Vaginitis is characterized by a sensation
of burning, heat, and itching in the vagina; pain in the pelvic
floor, increased by exercise; frequent desire to evacuate urine,
with not infrequently scalding. A profuse mucopurulent leu-
korrhea soon occurs. These symptoms are present in both
the simple and specific varieties. In the latter the disease
begins as an acute infection within from twenty-four to forty-
eight hours after exposure, with itching of the urethral orifice,
increased desire to urinate, a sensation of heat about the \
and burning and scalding upon passing urine. Generally,
the tenderness and discharge are moderate ; occasi(aiaU.Vj throb-
j is substituted. The distress is increased by;
352 GYNECOLOGY.
by moving the limbs, and by the slightest touch of the finger.
The iirethral orifice is reddened and slightly swollen, and a drop
of thick mucus or mucopus can be pressed out. After one or
two days the entire urethra is exquisitely tender, and the orifice
is swollen, intensely red, and bathed abundantly with pus.
Pus and blood can be extruded from the vagina by pressure
over the urethra. The hymen, vestibule, and labia become
swollen, edematous, and eroded, and are covered with pus
and exudate. At the end of a week the acute s3miptoms have
subsided, the discharge is abundant, and when the parts are
neglected, they become eczematous and cause a disagreeable
odor. The vulva may regain its normal appearance in two
weeks, while the discharge may continue for three or foiu* weeks,
or even longer. Infection of the vaginal follicles and of the
vtdvovaginal glands is not infrequent. The inguinal lymphatics
become swollen, and may even suppurate. In the early part
of the attack the gonococci are present to the exclusion of all
other forms of bacteria, but later they may entirely disappear.
The disease shows a marked tendency to invade the deeper
and more important organs by the continuous mucous mem-
brane.
404. Diagnosis. — Upon separation of the labia a profuse
discharge is noticed, covering a reddened, thickened, and rough-
ened or granular mucous membrane. The speculum reveals
the vaginal mucous membrane as a red, swollen, smooth, velvety
surface, from which the rugae have disappeared; or the redness,
as well as the discharge, may be present only in patches. The
cervix should be inspected, as the infection generally begins
in it. The differential diagnosis between simple and specific
vaginitis is often difficult. The history of a distinct infection
would be valuable, but it is often too delicate a subject for
interrogation. It may be suspected from the sudden onset
of the attack, associated with urinary symptoms, a protracted
course, and obstinate resistance to treatment. The inflamed
urethra and ducts of the vestibule and the orifice of Bartholin's
ducts, and not infrequently the formation of cysts or abscesses
in the ducts or glands, with swelling of inguinal glands, afford
additional confirmation. The recognition of the gonococcus
by culture and microscopic investigation renders diagnosis
certain. The absence of the gonococcus is not proof positive
of nongonorrhcal origin, for tlic gonococcus may disappear
from the socrotion.
Even wlion the specific origin can be determined beyond
peradventure. camion should be exercised in the expression
of an opini(Mi. as it may cause serious social unhappiness. The
diagnosis of simj^le vaginitis will i:ot be sufficient, but the
INFLAMMATIONS. 363
physician should carefully examine the various structures to
deteimine, if possible, the exact cause. Pelvic abscesses dis-
charging into the vagina have been mistaken for vaginitis.
405. Prognosis. — The ease and rapidity with which vaginitis
can be cured will depend upon the cause. The milder cases
may be confined to the external genitalia, or may disappear
even after the Fallopian tubes have become affected. In
the more severe forms the entire genital tract may be rapidly
involved, and portions of the tract may retain the disease and
reinfect other portions. The general health is impaired in
the chronic cases. The ovum, when it can enter, may find
the uterus unfitted for its retention and, therefore, an abortion
may result. Preexisting gonorrhea is said not to disturb the
first two weeks of the puerperium, but subsequently there is
a marked tendency for the germs to develop renewed virulence
and to in'vade the healthy structure.
406. Treatment.— When the disease is in its acute stage,
the patient should be kept absolutely quiet in bed. Sexual
activity should be suspended, as well for the interests of the
patient as for the prevention of further propagation of the
disease. The diet should be confined to nonstimulating articles.
Alcoholic stimulants, pepper, and various other condiments
should be prohibited. Saline laxatives are advisable, and
the patient should be encouraged to drink largely of emollient
liquids or alkaline waters.
Local applications should consist of hot sitz-baths, alkaline
douches. A saturated solution of boric acid in hot water may be
given for fifteen to twenty minutes out of every two or three
hours during the day, and every four while the patient is re-
cumbent at night. The ordinary fountain syringe ser\'es well,
or a piece of rubber tubing weighted at one end and provided
with a clip and nozle at the other. The weighted end, with
the coiled tube, is placed in a basin of water above the level
of the bed. the clamp applied, and the end of the tube with-
drawn and introduced into the vagina. The clip opened, the
water is siphoned out as long as the external end is kept below
the level of the basin. When the acute symptoms have sub-
sided, douches shotild be given every three hours for the first
two weeks. These douches may consist of solutions of subli-
mate r : 4000, potassium permanganate i : 4000, carbolic acid.
lysol, or creolin, protargol 0.5 to i per cent., mercurol 2 per
cent., sodium chlorid 2 per cent., or sotlium bicarbonate 2 per
cent. After the period mentioned the strength of the fluid
maybe doubled and the frequency of the applications is lessened,
now employing them four times daily. The dry treatment
consists in cleansing the surface with a douche 1 '
354 GYNECOLOGY.
the vagina through a spectilum; dry and pack with borated
or iodoform cotton, and repeat every eight hoiirs until the se-
cretion is checked, after which it is given twice daily. A
dry absorbent dressing must be applied to the vagina every
two hours.
Astringent douches are substituted in chronic cases and
after the subsidence of the acute stage. Cleanse and dry the
vaginal walls and paint with silver nitrate solution (5j : fSj),
followed by a tampon saturated with a solution of bismuth
in glycerin, which keeps the walls separated. Fritsch recom-
mends zinc chlorid (gr. ij : fSj). A one per cent, solution of
lead acetate, zinc sulphate or alum, potassium perman-
ganate (i : 2000), or painting the surface with tmdiluted
tincture of iodin, are serviceable. Acceptable powders are
equal parts of tannin and iodoform, bismuth subnitrate and
chalk, or boric acid and acetanilid of each equal parts re-
tained with a tampon. In senile vaginitis cleanse with a satu-
rated boric-acid solution. Tampons may be saturated with a
0.5 per cent, solution of lead acetate, or strips of lint may be
saturated in a five per cent, solution of carbolic acid in gly-
cerin or smeared with zinc ointment. Vaginal suppositories
of tannin and iodoform, each, five per cent. ; zinc oxid, ten per
cent. ; or lead acetate, two per cent., may be employed. When
the condition is very chronic, spray through a speculum with a
two per cent, solution of silver nitrate. The spray drives the
medicine into the crypts and folds, and is far more effective than
swabbing. I have derived more benefit from tampons anointed
with ichthyol in lanolin (i 14); it causes a desquamation of
the entire epithelium of the vagina and is destructive to the
gonococcus.
407. Urethritis. — Inflammation of the urethra is an ex-
ceedingly painful, but not an unusual, complication of pelvic
abdominal procedures in which the catheter has been employed.
Varieties. — It may be manifest as a simple hyperemia, an
acute catarrhal urethritis, a chronic interstitial urethritis, or
a granular or follicular urethritis. Associated with the ure-
thral inflammation occasionally occur ulceration, fissures, and
a sacculated condition of the urethra.
408. Hyperemia may result from injtiry during a difficult
labor; from uterine displacement and uterine growths affecting
the pelvic circulation; from varicose veins, irregular urination,
excessive coitus, or long-continued irritation. Probably the
most frequent cause of liypereniia, which may continue until
inflammation results, is the repeated use of the catheter. So
probable is sucli a result that the majority of operators prefer,
if ])ossible, to have the patient evacuate the mine unaided.
INFLAMMATIONS. 366
When the employment of the catheter is necessary, the operator
should have the nurse introduce the instrument for the first
time in his presence, so that he can observe what precautions she
employs and determine the ease with which she can accomphsh
the procedure. The instrument should never be introduced by
touch, but always by sight. The vulva and the vestibule are
generally covered with discharge, which may have decomposed
and become infected by micro-organisms capable of producing
serious discomfort when carried into the bladder.
The labia minora should be separated and the vestibule
sponged with absorbent cotton saturated with an antiseptic
solution. The instrument, preferably of glass, should be per-
fectly smooth, with no rough or cutting edges. It should be
boiled, kept in an antiseptic solution, and previous to its use
washed with sterile water. It is then anointed with carbolized
vaselin and carried by gentle pressure upward and backward,
without exercising any force. If the passage of the catheter
is obstructed, withdraw and reintroduce it, as the instrument
may have entered one of Skene's follicles.
Even with the exercise of every precaution the urethra
is often so irritated by the frequent introduction of the catheter
that the patient may suffer more distress than from the con-
dition for which the operation was performed; consequently
whenever the patient can evacuate the bladder unaided, she
should be encouraged to continue to do so, as the contact of
healthy urine with a plastic wound, if the precaution is ob-
ser\'ed immediately to irrigate the latter, is less harmful than
would be frequent catheterization.
In operations upon the bladder which require the urine to
be frequently evacuated, a self-retaining catheter should be
left in place several days. A soft-rubber instrument with
a flange upon its vesical end is most serviceable. It can be
plugged, permitting the urine to collect for two or three hours.
It should not be permitted to remain longer than forty-eight
hours without removal and careful cleansing. The ordinary
glass catheter, with a long rubber tube attached, in my ex-
perience, does equally well.
409. Acute Catarrhal Urethritis. — The mucous membrane
becomes thickened; its papillae are hypertrophied and are
covered with an imperfectly developed epithelium. At points
the latter is desquamated and the papills are enlarged. This
may result in the formation of a polypoid mass, which pro-
jects from the surface frequently by a pedicle — the urethral
caruncle.
The acute disease may arise from long-continued and re-
peated hyperemia or from traumatism, but it most frequently
3/>6 GYNECOLOGY.
results from gonorrheal infection. The urethra is often the
first point affected.
Symptoms. — The onset of the acute attack is at first made
known by itching or smarting of the urethral orifice, as the
contact of the urine gives a sensation of a hot scalding liquid
and urination is followed by intense btuning along the course
of the urethra. The meatus becomes red and swollen, then
dark red and pouting. It is tender to the touch, and pressure
along the urethra causes a few drops of mucopurulent or puru-
lent secretion to be discharged. If the disease does not extend
to the bladder, the symptoms soon subside or disappear.
Diagnosis, — The condition should not be confounded with
cystitis. Urination is not frequent. The pain and distress
are associated with micturition, while in the intervals there is
comparative relief. The tenesmus of urethritis can be con-
trolled ; it is attended with scalding, but is relieved by urination.
In cystitis the tenesmus is uncontrollable, tmrelieved by urina-
tion, and there is no urethral burning.
410. Chronic catarrhal urethritis is very generally an inter-
stitial inflammation. The membrane is tWckened and the
canal narrowed, not infrequently permanently so, which results
in a stricture.
Symptoms, — Urination is frequent. Temporary retention
of urine may, however, be caused by a spasmodic stricture.
The latter is greatly aggravated by frequent coition or pro-
longed exercise. The thickening of the urethra is apparent
upon passing the finger down the anterior wall of the vagina
along its course. A small sound can be passed through the
urethra, while the introduction of a large one meets with re-
sistance and produces severe pain.
411. Follicular inflammation involves the follicles about
the orifice of the urethra and Skene's glands. The latter are
two tubules w^hich will admit a No. 1 probe (French scale),
and are situated in the floor of the female urethra, extending
upward from the meatus about one or two centimeters. In ^
the normal condition the orifices of the tubules are three milli-
pieters within the meatus, but with the urethra slightly pro-
lapsed and the meatus everted, the orifices may be exposed
to view. The upper ends of these canals terminate in a number
of divisions, which project into the muscular wall of the urethra.
(Fig. 290.) These tubules occasionally become so much enlarged
as to permit the introduction of a small catheter. If such an instru-
ment were forcil.)ly introduced, it would tear through the tubule
and establisli a false ])assaij:e. Such a passage might enter
the urethra or pass beneath it into the tissue and thus enter
the bladder. Tlie follicles and tubules about the urethral
INFLAMMATIONS.
357
orifice may become inflamed, with the consequent discharge
d mucus and pus. The mucous membrane may become thick-
ened or the orifices closed. The latter wil result in the formation
of small cysts.
Symptoms. — The symptoms are great tenderness; discomfort
in sitting, standing, or walking; dyspareunia; stinging pain; a
sensation of heat; and frequent and painful micturition. The
orifice of the meatus is partly everted, with red, puffy folds,
which simulate caruncle, and with erosion of the labia minora
and of the edge of the meatus. A few drops of purulent dis-
charge can be extruded by pressure along the urethra.
412. Ulceratioa is produced as a result of traumatism, from
calculi, unskilful use of the catheter, specific
infection, or the presence of the diphtheric
or the venereal poison.
I>uring the passage of a calculus or
while in labor, injury, laceration, or over-
distention of the middle portion of the
canal occurs, with contraction of the mea-
tus. A small quantity of urine and mucus
is retained, which decomposes, and results
in the development of infiammation and
in the production of a condition simulat-
ii^ an abscess.
Symptoms. — The most prominent symp-
tom is dysuria, which becomes chronic.
The meatus is large, of a deep-red color,
granular appearance, and sensitive to pres-
sure. The passage of an ordinan,' sound
is readily accomplished, but is attended
with pain. Sometimes a drop of blood
is discharged. The sacculated form is
associated \\{Xh a copious discharge of pus,
particularly when pressure is made along
the urethra. Even when the discharge of urine is perfectly clear,
pressure will cause a considerable discharge of pus.
413. Vesico-urethral fissure holds an intermediary position
httween cystitis and urethritis, and strikingly resembles both.
Its cause is undetermined. The fissure is situated at the in-
ternal meatus, and resembles a crack in the lip or an ulcer
similar to that which is found in fissure of the anus. The
fissure is usually considered as being situated in the neck, but,
3S a rule, two-thirds of it is in the urethra. Only the upper
*iid of it extends into the bladder. It may occur at any part of
ttie circumference of the urethra, but, according to Skene, it
IS. in the majority of cases, situated upon the right side. In
rgo. — Urethra Laid
Open with Probes,
Distending Skene's
Glands. Posterior
Wall Divided.—
(Byford. after
Skene.)
358 GYNECOLOGY.
length it is from six millimeters to one centimeter, and is from
two millimeters to four millimeters in width at the widest part.
It is deeper at either end. The deepest portion, yellowish-
gray in color, resembles an indolent nicer, while its edges are
red and inflamed. Through an endoscope it looks like a fresh
tear, the edges of which are abrupt, elevated, and indurated.
Its situation explains the attendant discomfort. In any othei
portion of the urethra it produces little inconvenience beyond
a smarting sensation, but at the junction of the bladder Bxni
urethra it is subject to constant though slight pressure, whid
causes severe and continuous pain. The portion of the fissun
extending into the bladder is exposed to irritation from contact
with the tirine, producing a constant desire to urinate, a sen
sation of burning at the neck of the bladder, acute pain durinj
and immediately following micturition, and severe tenesmtis
causing the patient to continue straining efforts after empty-
ing the bladder. The pain and burning immediately follow-
ing micturition are often intense. Subsequently, it partly
subsides, to return with the accumulation of a small quantity
of urine. If the patient resists the inclination to urinate, the
distress is greatly aggravated.
414. Diagnosis of Urethral Inflammations, — The recognition
of inflammation of the urethra is often difficult, because it is
frequently complicated by inflammation of the bladder. Acute
catarrhal inflammation of nonspecific origin usually begins
gradually, and is often preceded by uterine or vesical symptoms,
while the gonorrheal variety appears abruptly, and is preceded
or attended by acute vaginitis or vulvitis.
In both varieties urination is painful. Sharp scalding is pro-
duced by luine passing over the inflamed surface, but the desire
to urinate is not so frequent or -urgent as in cystitis. Often the
urine is long retained, for fear of the pain occasioned by its
evacuation, or started with difficulty, because of the sensation
of scalding as the urine passes over the inflamed surface.
Slight hemorrhage is occasionally noticed, the urethral
origin of which is evident from it being xmmixed with urine, a
few drops oozing from the external meatus subsequent to urina-
tion. Urethral discharge is common, and, except just after
urination, it can be extruded from the orifice by pressing upon
the urethra from the vagina. Microscopic examination of
the discharge may reveal the presence of gonococci, which
determines the nature of the urethritis. Absence of this gennt
however, is not positive proof against the gonorrheal origin.
To exclude cystitis, introduce the catheter, allow some urine
to escape to wash away the mucus introduced with the in-
strument, and retain the remainder, which will be fotmd it^
INFLAMMATIONS, 359
from sediment. Pressure along the urethra from the vagina
is painful in urethritis, while pressure over the bladder, unless
complicated by cystitis, is not vmcomfortable.
Li chronic urethritis the urethra is less sensitive, but it
will be noticed as a somewhat thickened cord when examined
from the vagina.
In granular erosion the pain during micturition is excruciat-
ing, it is associated and followed by tenesmus, and is more
likely to be found in old persons.
The character of the disease is assured by its history and
by the appearance of the urethra. Fissure, urethritis, and
cystitis are distinguished, the latter especially by examination
of the urine. Fissure alone is free from all the products of
cystitis. Urethritis is excluded and the fissure detected by
the use of the endoscope. The endoscope is more satisfactory
than the ordinary open instrument, because it exposes the sur-
face of the fissure, which would be overlooked with the open
end instrument. As a rule, the pain in fissure is more circum-
scribed than in either urethritis or cystitis, and in many cases
more acute.
The maximum of pain in fissure follows urination, while
in cystitis there is a sense of rehef. In urethritis the most
severe pain occurs during the act of urination. It then sub-
sides slowly.
415. Treatment of Urethral Inflammations. — In urethral
hyperemia render the urine bland and unirritating by the
exclusion of acids and stimulants from the diet and by the
administration of saline cathartics. Rehef is enhanced by
giving ten grains of benzoate of ammonia or benzoate of sodium
every three or four hours, and by the employment of hot hip-
baths and hot vaginal douches.
Acute urethritis, whether specific or otherwise, should be
treated upon the same principles as in gonorrhea of the male.
The treatment consists of constitutional and local measures.
Internally, salicylic acid in ten-grain doses lessens the discharge.
Salol, two grains every two hours with a glass of hot water,
renders the urine bland and unirritating. Douche the urethra
frequently with hot water through a reflux catheter (Fig. 29O,
so that the current flows back from a cap on the end of the
instrument. Later, inject from one-half of one to one per cent.
of carbolized water; sublimate, gr. :j\,, to aq., f 5j ; silver nitrate,
gr. i, to aq.. f 5j ; or zinc chlorid, gr. x, to aq. f 5j ; preceded,
when injection is painful, by the instillation of a solution of cocain
with a pi pet.
In making urethral applications it should not be forgotten
that the canal will hold but from ten to fifteen drops. If a
360 GYNECOLOGY.
larger quantity is thrown in by the pipet, it flows into the blad-
der. A strong solution of silver nitrate (gr. x-xv to aq. f5j) may
be applied by a pipet or applicator. The same quantity of a
twenty per cent, solution of argyrol may be employed frequently
with very little discomfort and w4th very beneficial results.
Internally may be administered those remedies which will
have an inhibitory influence through the urine. These so-
called blennorrhagic remedies are: copaiba, cubebs, sandal-
wood oil, urotropin, and aminoform.
The itching of subacute and chronic lu-ethritis may be alle-
viated by applications of different combinations of chloral or
hydrocyanic acid, as in the following prescriptions :
B . Chloral giv
Lanolin, 3 j. M.
Ft. ungt.
B . Chloral.
Camphor, ** ©"• ^^^^
Lanolin, 3 j. M.
Ft. ungt.
B . Acid, hydrocyan. dil 3 J
Plumbi acet ^: *^
Glycerin, f 3 j. M.
These remedies may be brought in contact with the affected
surface by the applicator. A suppository or bacillum of cocain
in cacao-butter, or in combination with lead acetate, will give
relief. These bacilla should be introduced into the urethra
two or three times in the twenty-four hours, preferably after
urinating. In prolonged chronic disease which has resulted
in thickened walls and a more or less contracted canal, the
dilatation of the urethra by bougies once or twice weekly will
be beneficial.
The bougie may be anointed for introduction with mercunc
oleate, the ofticial ointment of mercury, or any other medicinal
agent which will have a beneficial influence upon the mucous
surface. M. Julien, of Paris, applies ichthyol by dipping into
it a cotton-wrapped probe, which is passed and repassed into
the urethra several times. This agent has a destructive in-
fluence upon the gonococcus.
Granular erosion is best treated by brushing pure carbolic
acid or silver nitrate (gr. xv to aq. f5j) over the surface. This
should be repeated in eight or ten days. The urethra should
be previously dilated. L'^ollowing the subsidence of the acute
symptoms, a few drops of a solution of zinc sulphate, gr. 1^^;
fluidextract of hydrastis canadensis, fSj, aq., fSiij, may be usee
twice weekly with a pipet. Mercurol, 2 per cent, solution, b^-
been found very serviceable.
INFLAMMATIONS. 361
In fissure, instillations and injections do harm by increas-
ing the spasmodic contraction of the bladder, and they add
greatly to the discomfort of the patient.
A fissure may be exposed by a fenestrated speculum, and
dusted with calomel, finely pulverized iodoform, or bismuth
Sttbnitrate, or the mitigated stick of silver nitrate may be em-
idoyed. Incision of the fissure, as performed in anal fissure,
is successful. The urethra should have been previously dilated.
Dilatation is one of the most effective methods of treating
fissure. The precaution must be exercised, however, not to
overdilate the urethra and thus produce permanent incon-
tinence.
Follicular urethritis is most effectively treated by splitting
up the tubes their entire length. This may be done with the
thermocautery, or they mav be cauterized with carbolic acid
and subsequently treated with milder agents, as in urethritis.
In such cases, however, splitting up the canal is a prerequisite
to cure.
416. Cystitis is an inflammation of the mucous membrane
of the bladder, and may be either acute or chronic.
Fig. 291. — Reflux Catheter.
Etiology. — The bladder is in intimate muscular relation
with the uterus, as well as dependent upon the same nerve-
centers and ganglia for its nervous distribution. A portion
of the bladder lies in direct contact with the cervix, but in
more close relation with the vagina. It is not surprising, then,
with such intimate relations, that the condition of the bladder
should be affected by disorders of the uterus.
Inflammatory conditions of the bladder, if they have not
originated from disorders of the uterus, are aggravated thereby.
The symptoms of cystitis are more marked during menstruation
and greatly aggravated by metritis. Vesical symptoms are
^gendered by uterine and vaginal displacements, by subin-
volution and hypertrophy, by tumors and pregnancy. The
^in of phenomena thus engendered may be enumerated as:
difficulty in evacuation; retention and decomposition of the
^ne, producing irritation, and finally cystitis. Cystitis may
^ secondary to inflammation of the kidneys, ureters, or urethra.
Chemic modifications of the urine mav result from indiscretions
362 GYNECOLOGY.
in diet, from the administration of irritating drugs, or from
affections of the central nervous system. Inflammation is
produced by traumatisms, injuries from the introduction of a
catheter, or the presence within the bladder of a rough calctdtis.
Without doubt, the most frequent cause of cystitis is ia-
fection. This may result from the deposition of bacteria by
the blood, from the extension of inflammation from neighbor,
ing organs, or the introduction of infection by way of the ure-
thra. The infection is generally introduced into the bladder
from the employment of the catheter. A violent form of cystitis
is produced by retention of tuine. A pregnant retroflexed
uterus which has become impacted in the pelvis, by pressure
upon the neck of the bladder, not infrequently leads to gangrene
and desquamation, or to separation en masse of the entire
vesical mucous membrane. Neoplasms, such as cancer, tuber-
culosis, polypi, and villous tumors, will usually excite a cystitis.
Pathologic Changes,— ^The mucous membrane becomes in-
jected, particularly about the orifices of the ureters and in-
ternal meatus. As the inflammation progresses the entire
mucous membrane is swollen and becomes a bright red. The
epithelium is desquamated and patches of ulceration or hypertro-
phied papillae appear, which bleed easily. Abscesses develop
in the vesical wall. The micro-organism most frequently
found is the bacillus coli communis. Disease is also induced
by the staphylococcus, the gonococcus, and the bacillus tuber-
culosis.
417. Symptoms of Acute Cystitis. — Acute inflammation of
the bladder is characterized by painful micturition; frequent
desire to void urine, with only a few drops discharged at each
attempt; severe vesical, and frequently rectal, tenesmus; a
sensation of fullness or weight in the hjqpogastritun ; shooting
pains in the perineum and anus; and a burning, lancinating
pain, like a hot iron, in the urethra. These attacks may be
almost continuous, or may, after a time, subside, to recur again
in an hour or so. Examination by touch, whether over the
abdomen or by the vagina or rectum, is extremely painful
The urine is scanty, highly colored, and becomes cloudy after
standing. In very severe attacks the urine becomes a dark
red color and contains blood and pus-corpuscles and uric-acid
crystals.
Constitutional disturbances are marked. These are nervous
excitement, insomnia, and anorexia, followed by emaciation
and loss of strength. Uncomplicated vesical inflammation
does not cause elevation of temperature (Guy on). Partial
or complete retention of urine is frequent. Paroxysmal pain
results from vesical distention, and there may be frequent
INFLAMMATIONS.
evacuation or continuous dribbling of urine without at any
time emptying the bladder — an evidence of overflow known
as the incontinence of retention. The course and duration
of the disease are variable: it may subside in a few days or
may continue ahemately better and worse for weeks.
418. Symptoms of Chronic Cystitis. — In chronic inflamma-
tion the symptoms are less pronounced, though similar to
those of the acute disease. Micturition is frequent and pain-
ful, often difhcult. The pain is pronounced at the beginning
of the evacuation, thus leading to delay in starting. Exposure
to cold, dampness, changes of clothing, indiscretions in diet,
or constipation lead to acute or subacute attacks. The urine,
after standing, becomes cloudy, and contains blood and pus-
corpuscles, mucus, and uric-acid crystals. If drawn with the
catheter, it is at first clear, then turbid, and toward the last
pus is apparently discharged. The microscope reveals leu-
kocytes, epithelial cells, tissue d6bris, and salt crystals. When
the urine stands, it becomes alkaline, and bacteria in abundance
are found.
Constitutional Condition. — The patient is easily fatigued,
has no appetite-, loses flesh, develops a cachexia, has repeated
inflammatory attacks associated with fever, repeated chills,
a more or less continuous diarrhea, profuse sweating, and,
finally, a fatal termination results. Such a train of symptoms
and such a termination indicate the presence of an infectious
pyelonephritis as a comphcation,
419. Cystitis of gonorrheal origin is produced by the ex-
tension of gonorrheal infection from the urethra, possibly
through the careless employment of the catheter, but more
frequently from the continuation of urethritis to the bladder.
Its principal symptoms are frequent micturition, agonizing
pain in the acute stages, associated with changes in the quality
of the urine; hematuria is a constant symptom, but is rarely
profuse. These symptoms do not occur in the early stage of
the infection. The disease is tlien generally much milder,
characterized only by tenesmus. In the mucopus of the urine,
from the associated urethritis, the gonococcus may be found.
420. Tubercular cystitis causes symptoms ver>' similar to
those produced by inflammation from gonorrhea and the irri-
tation of calculi. Hematuria is a symptom in all varieties,
but differs in tuberculosis. It appears early in the disease,
and the blood is generally mixed with the last drops of urine.
The bleeding ceases as the disease advances. In common
, with other vesical inflammations, pain, urethral spasm, and
\ letention and incontinence of urine are marked.
■■^121. Diagnosis of Cystitis. — Cystitis is not difficult to recog-
n
364 GYNECOLOGY.
•
nize. The frequent micturition, pain, alkaline reaction of the .
urine, large quantity of sediment, and mucopurulent appear- \
ance are ample evidence. In cystalgia and functional dis- j
eases of the bladder the urine will be fotmd clear. Probably
the greatest difficulty will be experienced in differentiating
pyelonephrosis. Indeed, the infection from the kidney may
lead to disease of the bladder and ince versd. The prognosb
and method of treatment must depend upon the accurate
determination of the structures involved.
The existence of pyelonephrosis is recognized by finding
the urine unaltered after irrigation of the bladder, while in
cystitis it becomes clear. The condition of the urine from
each kidney is recognized by securing the urine separately
through catheterization of the lu'eters or by the employment
of the Harris segregator.
The careful investigation of the urine will often be sufficient
to determine the diagnosis. Albumin is contained in the urine
in either cystitis or pyelitis, but in very slight amount in the
former, while it is present in quite large proportions in the latter.
The presence of a proportionately great abundance of albu-
min in the urine, associated with pus, should be considered
as indicating the presence of renal disease. The most frequent
cause is tuberculosis. Tlie diagnosis of tuberculosis of the
urinary tract is determined by the presence of the tubercle
bacillus in the urine. Dr. Joseph Walsh, of Philadelphia, asso-
ciated with Dr. Flick in his investigations in tuberculosis,
however, informs me that the tubercle bacillus is found much
more frequently in the urine of the tubercular patients than
is generally supposed. The great majority of these patients
will be found not to have a tuberculous kidney, though they
will show a catarrhal condition of the kidneys, which is mani-
fested by pains or aching in the bones, and by the presence
in the urine of epithelial or granular casts, pus, and sometimes
albumin. The bacilli may be found in the urine without any
inflammatory symptoms. In sixty nonselected tuberculous
patients whose urine Dr. Walsh examined, the bacilli were
recognized in forty-four ; in thirty of these the disease was in an
advanced stage; in ten it was considered marked, and in four,
was only incipient. In patients in the advanced stages of
the disease it is rarely that the bacilli will not be found in the
urine. In five of the forty-four cases above cited tubercle
bacilli were found in the urine, but not in the sputtun, though
the |)resence of a pulmonary lesion was recognizable. I have
quoted Dr. Walsh fully, because his investigations seem to
clemonstrate that the presence of tubercle bacilli in the urine
can not be accepted as evidence of the existence of a true renal
:nflammations. 366
lesion. The usually recognized difficulty of finding the bacilli
in the urine is my justification for quoting here Dr. Walsh's
niethod of examination : ' ' Six fluidounces of urine are cen-
trifugated in a water motor centrifuge ; the sediment is then
poured on one or two cover-glasses and allowed to dry thoroughly
(twenty-four to forty-eight hours). The process is complicated
by an excess of the crystalline sediment, which may render it
impossible to find the micro-organism. In such cases, there-
fore, the sediment secured by centrifugation should be dis-
solved in water, a weak nitric acid, or a caustic potash solution.
and again subjected to the centrifuge. In rare cases the sedi-
ment may resist any one or all of these solutions. After dry-
ing, it is fixed to the cover-glass by passing the latter through
a flame two or three times, repeating this procedure twice,
at intervals of a minute or two. The procedure for determina-
tion of the bacillus in urine requires more heat than tlie corre-
sponding examination of the sputum. Even after the pro-
cedure for fixing given, the sediment will occasionally be washed
off by the running water and the specimen thus destroyed.
' ' The specimen is stained with carbol-fuchsin for three to
five minutes or longer, washed in turn with 95 per cent, and
absolute alcohol for one to three minutes, decolorized, and
counterstained with Gabbet's solution. The greater number
of foreign elements in the urine, some of which hold the fuchsin,
makes a larger experience necessary for the recognition of the
bacilli than is requisite in sputum.
■ ' The organisms must be absolutely typical to render the
diagnosis certain,"
In examining over the abdomen of a patient sulTering from
tuberculous cystitis, greater pain is experienced by suddenly
withdrawing the hand pressure than is produced by deep pal-
pation. A cystoscopic exploration of the bladder will reveal
the extent of involvement and amount of tissue destruction.
Tuberculous cystitis may supervene upon the gonorrheal,
without cessation of the latter.
Primary vesical tuberculosis is manifested by a very ir-
ritable bladder, frequent and painful micturition, followed by
the passage of a few drops of blood. Such symptoms may
subside, to be followed by an aggravated attack. The pres-
ence of pus in the urine indicates preexisting disease, which
may have been unsuspected. The progress of the disease is
more rapid when complicated by the discharge of pus, the
presence of a fistula, or the existence of pyelonephritis. The
last compUcation should be suspected when the urine shows
tbe presence of a large pus sediment, inordinate quantities of
albumin, and if the patient gives a history of incontinence of
366 GYNECOLOGY.
urine and repeated exacerbations of high temperatiire. Poljniiia
is a most constant symptom of iirinary tuberculosis.
Gonorrheal cystitis is associated with evidences of infectioa
of other portions of the genito-urinary tract, particularly the,
urethra, glands of Bartholin, cervix, and pelvic organs, whidi
have preceded the vesical disease. The gonococcus can generally
be foimd.
A form of inflammation of the bladder, known as mem-
branous cystitis, is a condition in which there is more or less
extensive exfoUation of the bladder-wall, as in pseudo-
membranous, gangrenous, croupous, or diphtheric inflammar
tion. It is always secondary to overdistention of the bladder
from retention of urine. The mucous membrane is anemic
during distention, but upon the removal of the bladder contents
it becomes acutely congested and engorged with blood. It
may be produced by any obstruction of the urethra. The
most frequent causes are incarceration of a retroflexed gravid
uterus, unilateral hematometra, fibroid and ovarian tumors
deeply seated in the pelvis, and loss of muscle power in low
fevers and in septic conditions.
The nurse or attendant may be led by the incontinence
to overlook the occasionally enormous distention. The en-
largement is gradual, extending above the navel, in the fonn
of a tumor, which may very readily be mistaken for an ovarian
cyst. The distention reaches its maximum when the reservoir
can retain no more, and the abdominal pressure produces an
involimtary discharge of the overflow, a condition which has
been spoken of as incontinence of retention.
Even though the bedding is constantly soaked with urine,
the bladder is never completely emptied. The continuous
pain, involuntary discharge of urine, a suddenly formed, gradu-
ally increasing tumor, percussion dulness over its site, absence
of the uterus above the symphysis, and the projection backward
of the anterior vaginal wall, should make plain the diagnosis.
Constant dribbling of urine should always awaken suspicion of
such a condition.
Catheterization of such a patient by an ignorant midwife
may cause the formation of a false passage, or negligence in
the previous cleansing of the vulva will favor the entrance
of infective agents into the bladder. No more favorable con-
ditions for the extension of the sepsis could be imagined.
Even if cystitis did not exist, hyperemia, infection, and
traumatism, as a result of retention, would not be surprising-
The enormous distention of the bladder causes anemia of its
mucous membrane, thus producing disturbance of nutrition
and superficial necrosis. Deep necrosis is caused by bacterid
INFLAMMATIONS.
action. All such processes favor destruction of the mu(
membrane. The inner wall of the bladder may become partially
or completely detaehed, covered with phosphates of ammo-
nium and magnesium, and penetrated with putrescent bacteria.
The surface of the membrane is black or gray, contains numerous
excavations, and sometimes homy concretions. The mucous
membrane may come away in pieces or as a complete cast of
the bladder.
A portion of the membrane or the entire structure may
lodge in front of the urethral orifice and completely obstruct
the evacuation of urine. A small quantity of pus only may
reward the introduction of the catheter. This pus has accu-
mulated at the lower portion of the bladder, but a more forcible
pressure of the catheter may cause it to penetrate the mem-
brane and permit the evacuation of the decomposing urine-
Violent tenesmus is a frequent symptom of such conditions.
The urethra, dilated, wUl often permit the expulsion of the
entire sac as a black, putrid mass. Cases have been reported
in which complete exfoliation has taken place and the patient
subsequently recovered good health without disturbance of the
vesical functions. Neoplasms are differentiated from cystitis
by the early appearance of hematuria, with absence of pain,
tenesmus, or frequent micturition.
The quantity of blood increases near the close of micturition ;
it may continue for days or weeks, and may suddenly cease.
Sometimes fragments of the growth may be discharged. Hema-
ttuia dependent upon tumors varies with their character. If
the growth is benign, its progress is slow, unless the pelvis of
the iadney and lu-eters are involved.
Cystitis due to the presence of foreign bodies, such as calculi,
is characterized by severe pain, frequent micturition, violent
expulsive efforts, and hematuria, after active exercise. In
am%"ing at a correct diagnosis it must not be overlooked that
ver>' marked disturbance of the bladder may arise from the
administration of various drugs, from the apphcation of vesi-
cants, especially cantharides. In such cases micturition is
frequent and very painful, while tenesmus is marked. The
withdrawal of the irritating cause is followed by prompt rehef.
422. The prognosis of cystitis is necessarily uncertain, and
must depend upon the duration and character of the disease,
extent of involvement, comphcations, and carefulness of treat-
ment. When the disease has existed for a long time, the in-
flammation has extended through the mucous siuface, more
or less involving the muscular coat and causing contraction
and distortion of the organ. It can readily be understood.
368 GYNECOLOGY.
therefore, that no treatment will restore the functionatinj
power of the organ.
The prognosis is especially unfavorable when the disease
has extended to the ureter, and especially to the pelvis of the
kidney. Tubercular disease of the bladder also presents
an unfavorable prospect for ultimate recovery, although I
have seen most gratifying results when the tuberculosis wa»
secondary to disease in one kidney and ureter after the removal
of the offending organs. The favorable results in all cases
will largely depend upon the carefulness of the treatment and
the degree of cooperation the physician can secure from his
patient.
423. Treatment. — In the treatment of inflammation of the
bladder the aim should be, first, to remove or lessen its cause;
second, to afford relief to pain; third, to improve the general !
condition of the patient. i
Prophylaxis. — The first indication is met most completely 1
by prophylaxis, which, in all conditions dependent upon microbn:
invasion, should be the first consideration. Disinfection of
the body, of the surroundings, of the hands, and of the instru-
ments is necessary. The old procedure of introducing the
catheter by touch is reprehensible. In the puerperal woman
artificial light may be necessary. The legs should be flexed
strongly, the better to bring the vulva into view. A small
vessel is placed between the limbs, or the patient may be placed
upon a bed-pan, and a warm disinfectant fluid poured over
the vulva, which may enable her to void the urine spontaneously.
If unsuccessful, the vulva is sponged with a cotton tampon
and an irrigation stream is directed upon the urethral orifice.
Then the catheter is taken from a disinfecting fluid and care-
fully introduced, to avoid pain. Occasionally there is resist-
ance at the internal end of the urethra, which is not over-
come without pain. Care should be exercised in the with-
drawal of the instrument, as the mucous membrane maybe
sucked into the eyelet of the catheter. Pushing up the instni-
ment before its withdrawal will loosen it, when it can be re-
moved without vesical injury. Whenever possible, the use
of the catheter should be avoided, as, notwithstanding all pre-
cautions, the mucous membrane of the urethra will be irritated
by its frequent introduction, thus affording an opportunity
for infection.
Medical treatment to a limited degree meets all the indications
we have assigned for the treatment of cystitis. The acidity
and tendency of the urine toward decomposition are combated
by the use of diuretics and by the administration of larg^
quantities of tlie alkaline waters, such as Saratoga, Vichy.
INFLAMMATIONS.
mpanying hyperplasia of the connective tissue may ]
E or less constriction of the gland-ducts, and in certain I
6ey may be completely closed, thus resulting in the I
distention of the glands and the formation of cysts. These cysts I
are known as retention cysts or ovules of Naboth. {Figs. 294 and f
395.) They form nodular projections around the external <_
"an project deeply into the cervical tissue, becoming prominent '
;. — Extensive Cj'
IfM. Gland* dilated with secretion, b. Lari
glands and distended with fluid.
of the Cervix,
nodule formed by union of many
Upon the vaginal surface at quite a distance from the external os.
As the vaginal portion in the normal condition possesses no glands,
it is evident these have been either extruded from the os with
the hypertrophied mucous membrane, or have pushed through
the structure of the cervix in the manner already described,
and may lead to an extensive cystic degeneration of its structure.
in one jKitient recently under obsen.'ation change in the struc-
: of the cervix was so marked as to lead to the diagnosis of
370 GYNECOLOGY.
of membrane and casts of the bladder shoiild be early separated
and evacuated.
Gonorrheal and acute cystitis are considered as requiring
diuretics, such as the alkaline salts, alone or in combinatioa
with oil of birch, buchu, or triticum repens. The following
prescription is often serviceable:
H . Ammon. benzoat., 3 iij^-or
Tinct. hyoscyami, f z j-ij
Ext. buchu vel tritici repens, ad f X ij* M.
SiG. — A teaspoonful in an ounce of water four times daily.
Marsh directs:
B . Acid, oxalic, ct. xvj
Syr. aurant. cort., f^ j
Aq. pluv., ad f 31V. M.
SiG. — A teaspoonful every four hours.
Benzoic acid, gr. x, in capsules may be given three or four
times daily, directing the patient to take large draughts of some
bland water. Benzoic acid, gr. x, or camphoric acid, gr. xv, may
be given three or four times daily with great relief.
The bromid salts are often of value.
Free evacuation of the bowels by salines should be secured
After the severe distress and pain have subsided in acute cases
and in all chronic inflammations advantage may be secured
from intravesical medication.
The bladder is irrigated through a return-current catheter
by means of a fountain syringe: the fluid may be permitted
to flow in until the discomfort is marked, when the tube is
pinched and the fluid evacuated. (Fig. 292.) In the absence
of a double catheter a single instrument may be used ; the bladder
is filled and the fluid is allowed to flow out, and the process is re-
peated until the bladder has been filled and emptied a number of
times. This procedure, practised once or twice daily, gradually
distends a contracted bladder and diminishes its irritability.
The irrigation fluid may be hot normal salt solution ; boric acid,
3ij-iv, to water, Oij; or methyl-blue (pyoktanin), gr. xv, to
water, Oiss, night and morning. If the urine contains pus,
employ a 2 per cent, solution of ichthyol five or six times daily;
the strength may be gradually increased to five per cent, after
subsidence of acute symptoms. The strength of the solution
at the beginning should not exceed one-half of one per cent.
S. D. Powell advocates irrigation of the bladder with a solution
of carbolic acid i : 30, followed by irrigation with alcohol;
subsequently a 2 per cent, solution of the carbolic acid is em-
ployed. Protargol i to 10 per cent., mercurol 2 per cent,
(zinc acetate and aluminol 1:4), are also highly extolled.
INFLAMMATIONS. 371
utaud advocates throwing into the bladder, after irrigation
tth a boric-acid solution, foiir ounces of tepid water, to which
added a teaspoonful of the following emulsion:
B . Iodoform., 3 J
Glycerin 3 x
Aq. destil., 3 v
Tragacanth., gr. iv. M.
This preparation should be introduced and permitted to
tnain. In necrotic and suppurative cases cleanliness is of
ime importance. The bladder should be frequently irrigated.
le frequent ichthyol irrigation is rapidly curative. Irrigation
th 3 to 5 per cent, solutions of resorcin or with silver citrate
: 8ooo to I : 4000) have been advocated. I have found great
iprovement following the injection of one to two drams of the
► to 20 per cent, solution of argyrol into the bladder and allow
to remain. In tuberculosis and chronic cystitis the daily in-
ction of 15-25 minims of 5 to 20 percent, solutions of guaiacol
sterile olive oil has been advised. The cavity of the bladder
ay be explored by dilating the urethra and introducing one
Fig. 292. — Double-current Catheter.
i the vesical tubular specula used by Kelly. With a good light
he cavity can be carefully inspected and applications, such as
flver nitrate, gr. x-xxx, to aq. destillat., f 5j, made directly to
he affected area. In the use of these stronger applications
ouching the affected or ulcerated points with a solution should
3e followed by irrigation with a salt solution.
In subacute and chronic cystitis Clark introduces a vesical
l»Doon of thin rubber. This balloon is connected with a thicker
rubber tube, provided with a cut-off valve. Before using,
it is boiled in a boric-acid solution, and its surface is coated over
with a mixture of gelatin and ichthyol, 10 per cent., or bis-
nwith and zinc, salicylic acid, or weak bichlorid. The mix-
tee is melted and poured over the bag, which has been rolled
w the shape of a suppository. With a slender pair of forceps
the balloon is introduced through the speculum. It is then
n^ted by a bulb syringe, the number of bulb pressures re-
quired to fill it having been previously determined. The balloon
'^inains in situ twenty minutes.
372 GYNECOLOGY.
Guyon, in bad cases, advises that the bladder should be
irrigated under anesthesia vi4th a solution of boric acid or sub-
limate (i : 10,000) and cureted with a medium-sized curet.
The finger in the vagina as a guide enables him to go over the
base and sides, while the hand over the abdomen aids in reach-
ing the anterior surface; lastly, the urethra is scraped, the
irrigation is repeated, and a self-retaining catheter is intro-
duced and retained some fifteen or twenty days.
Camero reports twenty-nine cases thus treated, of which
nineteen were successful. Le Clerc-Dauday follows cureting
by irrigation with a solution of chlorid of iron, and later by
instillation of a 1 per cent, solution of silver nitrate. In serious
tubercular cases in which pain and tenesmus are verj' marked
cystotomy may be employed. It places the bladder absolutely
at rest. A sound or bougie is passed through the urethra and
used to depress the anterior vaginal wall, while an incision is
made through the septum. The vaginal and vesical surfaces
are united by sutures to prevent the opening from closing.
This procedure deprives the patient of control of the bladder
contents, and requires the provision of an apparatus or receptacle
for the urine.
In septic conditions, where a large portion of the vesical
mucosa has become necrotic, the removal of the gangrenous mass
should be followed by irrigation of the bladder with a. boric-acid
solution {4 : 100} or a formalin solution (i : 5000). A gmduated
irrigator is preferably employed, and not more than three or four
ounces should be injected at one time. This may be pressed out,
and the fluid again allowed to flow in, repeating this twenty times.
The irrigation should be performed four times daily. It is sur-
prising in these cases of extensive septic inflammation to note
the subsequent power to retain the urine.
424. TTreteritis is inflammation of the ureter, and may be
acute or chronic. It generally begins in the mucous mem-
brane, extending through the wall of the canal, so that the
ureter presents the palpable sensation of a thick, rigid cord.
Causes.— The disease, according to Mann, is produced by
a number of causes: first, injuries during parturition; second,
from previous disease of the bladder; third, gonorrhea; fourth,
suppuration in the pelvis of the kidney; fifth, pelvic disease,
such as pelvic peritonitis, cellulitis, and tumors; sixth, abnormal
conditions of the urine; seventh, tuberculosis, to which may
be added an eighth — the passage of calculi.
425. Acute ureteritis is often mistaken for intestinal colic,
pain from renal strain, catarrhal appendicitis, or acute catarrhal
salpingitis. The patient has a sudden attack of abdominal
pain in which the distress is limited to, or more pronounced
INFLAMMATIONS.
upon, one side, or but slight upon the other. The pain is in-
termittent, with not infrequently severe paroxysms. General
abdominal tenderness is probably absent, while there is notice-
able tenderness upon deep palpation upon the affected side, I
which in the beginning is more marked near the pelvis of the ]
kidney. The site of most marked tenderness may be situated
at McBurney's point. As the inflammation subsides the pain
disappears, and may be recognized at a point an inch above
Poupart's ligament. Originating in the back, it can not be
differentiated in the early stage from colic occasioned by renal
strain. When complicated by intestinal disorder, it may be
recognized by its characteristic progress from above down-
ward, the appearance of vesicoureteral tenderness, and the
urinary disturbance. When occurring upon the right side, its
sv-mptoms are sometimes attributed to appendicitis. The con-
dition may terminate in recovery or may result in the chronic
form.
426. Chronic ureteritis is characterized by frequent desire
to urinate, which is more marked while erect, especially when
standing, and is not wholly relieved by retaining the recumbent
position. The patient is obliged to arise from one to many
limes a night; the discharge may or may not be painful, Fre-
quentiy, the desire to evacuate the urine will be imperative,
and the urine will gush forth before she can secure privacy.
In some cases she complains of bearing down, greatly increased
by standing, which disappears after a few hours' rest in bed.
Palpation may afford no sign, except a slightly thickened cord,
or a rigid mass almost the size of the finger, pressure along
which will cause a discharge of urine with such power as to
drive it some distance from the urethral orifice. The necessity
for a cystoscopic examination of the bladder will depend upon
the severity of the attack; when attended with much pain,
it should be made. An alteration of the vesical mucous mem-
brane in and about the orifice of the ureter will be recognized.
This alteration may vary from a slight eversion and gaping
of the orifice to one in which the orifice is an oval opening upon
the summit of a mound of angry-looking mucous membrane.
The mucous membrane in the immediate vicinity may be normal,
but is generally red and injected, even roughened and eroded.
The urea is said to be decreased upon the affected side.
The urine may be secured for examination by catheterizing
the ureters or by the introduction of the Harris double catheter.
Treatment.— -General treatment consists in the careful regu-
lation of the diet, from which should be excluded strawberries,
asparagus, and stimulants; tomatoes, onions, and cabbage should
be used sparingly and with caution. The food should^^^edy
374 GYNECOLOGY.
albuminous, of which skimmed milk may often with advantage
form its base. Large quantities of water, alkaline diuretici,
or the alkaline waters are useful. In acute and subacute coo-
ditions the patient is best in bed. The nutrition should be
maintained by general massage.
Local applications 3x^ advantageously made to the inflamed
orifice of the ureter and to the eroded surface about it. A
solution of silver nitrate (gr. x-xxx to fSj) produces good
results. It should be applied through a specultmi directly to
the affected surface, after which the bladder should be irrigated
with a normal salt solution.
When the inflammation of the canal is extensive, the dis-
ease may be treated by irrigation through a ureteral catheter.
In tuberculous disease, which is generally secondary to
disease of the kidney, the affected kidney (the other having
been demonstrated to be healthy) should be extirpated, and
with it the ureter.
INFLAMMATION OF THE CERVIX AND BODY OF THE UTERUS.
427. Classification. — The classification of uterine inflamma-
tion has been and still is a difficult and perplexing problem.
Various views have been presented. The existence of in-
flammation of the endometrium, except in acute conditions,
has been denied. The so-called chronic inflammation is de-
nominated catarrh and uterine congestion, and is frequently
attributed to peri-uterine inflammation. This statement would
seem a distinction without a difference, and results from failure
to appreciate the varying character of inflammatory changes
in different tissues. The continuous mucous membrane is
exceedingly vulnerable to the possibilities of infection. The irri-
tation thus produced results in the production of inflammation.
Its violence and extent will depend upon the virulence of the
poison and upon the resistance of the patient. It may vary from
a slight inflammation which involves the cervix only to one which
extends to the entire uterine cavity with infiltration of the sub-
mucous structures ; may become interstitial or parenchymatous,
and not infrequently in virulent attacks passes through the
wall to its surface and causes perimetritis. In our early classi-
fication we spoke of metritis, in a sense of inflammation of the
entire organ ; when it predominates in the lining membrane, it
is called endometritis. When involvement of the deeper stnic-
tures occurs, it is known as parenchymatous or interstitial
metritis, and as perimetritis if the peritoneum becomes involvad-
The latter condition is generally described as pelvic peritonitis,
because, although inflammation can reach the peritoneum
INFLAMMATIONS.
as described, it more frequently does so by the progress of
the inflammation through the tubes, and the inflammation ex-
tends to other structures than those immediately enveloping the
uterus.
The anatomical arrangement of the cervical mucous mem-
brane makes it evident why inflammation can be confined to the
cervix, although in puerperal women it is very prone to extend
to the body.
The various classifications are based upon clinical phe-
nomena, pathologic changes, and causal relations. The ideal
classification is that of Doderlein, into two divisions: first,
inflammation produced through the influence of micro-organisms ;
second, inflammation independent of their influence. The
former is subdivided into : (a) septic and saprophytic ; (b) gon-
orrheal; (c) tubercular; (d) syphilitic; (e) diphtheric. The
brevity of our knowledge of the influence of micro-organisms
makes a careful differentiation difficult, but we are scarcely
in a position to assert that there is any inflammation that is
absolutely independent of bacterial production. My experience
as a teacher has led me to discard the classification based upon
the chnical phenomena, because it is difficult to associate there-
with the pathologic relations. For this reason I propose to
present the simpler and more frequently employed classification
into acute and chronic, the latter subdivided into cervical
catarrh, or endocervicitis, endometritis, and metritis. Acute
endometritis affects both body and cervix. The chronic in-
flammation can be localized in the cervical mucous membrane.
The classification of uterine diseases is still further complicated
by the physiologic changes which occur in the uterus as a
result of menstruation. Thus, the uterine mucosa undergoes
a periodic hypertrophy and degeneration, and it is often difficult
to differentiate between the physiologic condition and early
pathologic processes.
428. Endocervicitis —Chronic Cervical Catarrh. — Cervical en-
dometritis is an inflammatory process which affects not only
the cervical canal, but the entire cer\-ix. The symptoms and
appearance of the disease differ greatly in the unmarried or
nulliparous and the multiparous woman, and it manifests itself
as inflammation of the portio vaginalis or of the cervical canal.
In the former, the connective tissue of the vaginal portion of
the cervix shows decided small-cell infiltration ; the blood-vessels,
especially the capillaries, become dilated and turgid with blood.
Sometimes they become so distended as to form varicosities
resembling hemorrhoids. Immediately beneath the epithelium
the connective tissue is found rich in cells, which later become
inverted into granular tissue. The squamous epithehum of
3/6 GYNECOLOGY.
the surface is in many places infiltrated mth Ieuk0c5i.es, and
it undergoes hypertrophic changes from the increased blood-
supply. Numerous papillas are formed and become covered with
a single layer of epithelium which permits the red color to shor
through and the surface to present the appearance of an erosion.
(Fig. 293.) Such a condition is generally recognized as simjde
erosion, and it generally involves the squamous epithelium of the
vaginal portion of the cervix. When the external os has been
lacerated, the lips will often be widely separated and gapii^.
The mucous membrane is everted and presents irregular granular
patches which protrude beyond the os. Such a condition was
formerly regarded as ulceration, The microscopic examination
IH
of such a surface revetils the apparently denuded portion covered
with epithelium. The increase<l blood-supply and the iniiltra-
tion of the tissue with Iymph<.>id cell cause the cer\-ical lining
to become everted and project from the os like a fungus. Such a
reddeneJ, everted surface is sometimes known as granular or pap-
illary ertision. At first the glandular structure is not involved,
but eventually hyperplasia of the glandular epithelium results
and there is an increase in the number and size of the glands.
(Fig. 294.) The latter condition ts more limited to the super-
ficial structure, which seems to be taken up with glandular tissue,
to the almost complete exclusion of the connective. In the
former, the glands enlarge and project through the structure
of the cervix, Sf)metimes even hfting up the squamous layer.
INFLAMMATIONS. 377
"he accompanying hyperplasia of the connective tissue may
atise more or less constrietion of the gland-ducts, and in certain
laces they may be completely closed, tlius resulting in the
istention of the glands and the formation of cysts. These cysts
re kno-wTi as retention cysts or ovules of Naboth. {Figs. 294 and
JS.) They form nodular projections around the external os or
m project deeply into the cer\'ical tissue, becoming prominent
Fig. 395.— Extensive Cystic Disease of the Cervix.
"■ Glands dilated with secretion. 6. Large nodule formed by u
glands and distended with fluid.
ipon the vaginal surface at quite a distance from the external os.
:'^lhe vaginal portion in the normal condition possesses no glands,
" is evident these have been either extruded from the os with
the hypertrophied mucous membrane, or have pushed through
"IS structure of the cervix in the manner already described,
and may lead to an extensive cystic degeneration of its structure,
linne patient recently under observation change in the struc-
ture of the cer\'ix was so marked as to lead to the diagnosis of
378 GYNECOLOGV.
sarcoma by myself and others, but the subsequent investigatiat I
disclosed that the condition was benign, though the cervix was 1
entirely taken up with the cystic chfttigft, Infection may te- I
suit in the formation of abscesses, or the gradual distentioB I
may lead to a rupture of the cyst, producing what is known
as follicular erosion, in which the greater portion of or the entile
cervix may be involved. The increased glandular secretion,
mixed with the transudation from the eroded surface, producei
a very profuse leukorrheal discharge. The protruding struc-
ture often is so extensive as to render its origin uncertaio, but
it evidently is produced by proliferation of the epithelial liniuj
Fig 296— CI rone Endoc rvicitis
a. Dilated gland forming cyst of Naboth b Detachment of glandular ep"
thelium after absorption of fluid
of the cervical glands. Chronic inflammation of the connec-
tive tissue occasionally causes such hyperplasia as greatly to
increase the size of the cervix. In the nulliparous the cen-ix
forms either a rounded mass, which increases the size of the
cen,'ix in all directions, or the latter may become so elongated
as to produce a condition resembUng prolapsus, and hence
known as pseudoprolapsus. In previous laceration of the cer-
\-ix only one lip may have undergone this hyperplasia, or both
lips may be involved, when they will be widely everted and
turned outward and backward, reminding one of the top of
a celery stalk. The glands over such a surface are likely to
INFLAMMATIONS.
become obstructed and produce retention cysts, which are ]
recognized as firm, pea-like masses beneath the finger. Occa-
sionally such cysts form abscesses or rupture, and with the
proliferating epithelium present an extensive raw surface which
can be mistaken for carcinoma. A number of cysts in close
appro.\.imation may become united through the absorption
and breaking-down of the intervening septa and thus form '
one large cyst. Puncture of the cyst permits the escape of a
large quantity of viscid fluid rich in corpuscles, with subse-
quent contraction and obliteration of the cavity.
From the discussion it can be readily inferred that the
inflammation involves all the structures of the cervix, the epithe-
lium, the glands, and the connective tissue, and thus varies in its
form and manifestations according to the predominance of the
structure involved. When the glands are extensively involved,
the cervix presents what is known as cystic degeneration. The
increase of connective tissue results in what Thomas has so aptly
described as areolar hyperplasia or cervical sclerosis.
429. Causes. — Inflammation of the cervix arises from exten-
sion of inflammation from the body of the uterus, the vagina,
and the vulva, as a result of excessive coition, laceration, in-
juries during instrumental and digital examination and manipu-
lation, and from puerperal and gonorrheal infection. The
cylindrical lining of the cervix is particularly vulnerable to
infection, especially after laceration, when exposed to friction
against the walls of the vagina, and to injury during the act
of coition or examination. It is rare to have inflammation
of the body of the uterus without involvement of the cervix.
The latter is prone to occur because the uterine discharges
flow over the cervical mucous membrane and irritate it. Endo-
cervicitis is particularly hkely to be produced by congestion
of the uterus in association with flexions, and especially retro-
flexion. In retrodisplacements and in anteflexion separation of
the lacerated surfaces is favored, and the delicate cer\'ical mucous
membrane is to a greater degree exposed.
430. Symptoms. — The principal syinptoms of cervical in-
flammation are leukorrhea, pain in the back and loins, ag-
gravated by exercise or standing, irregular menstruation, and
sterility. Leukorrhea is the most important symptom. The
normal secretion from these parts is insulScient to attract
attention. When it is excessive, it becomes known as leu-
korrhea, or. in popular language, the whites. A temporary
discharge — a transparent leukorrhea, like white of egg— not
infrequently occurs preceding and following the menstruation,
due to temporary congestion. The secretion from the cervical
glands is clear and viscid, resembling white of egg.
?g. I^^
380 GYNECOLOGY. |
comes white when mixed with mucus-corpuscles, and yellowish
when pus-corpuscles are present. Not infrequently it is tinged
with blood, which escapes from the delicate vessels of the newly
formed vascular tissue. Pain is aggravated by walking, stand-
ing, riding, or anything which increases the friction between
the cervix and the vaginal walls. Menstruation is irregular
and there is generally an increase in the quantity of the flow,
probably produced by an extension of the inflammation to
the endometrium. Sterility is often present. In the nuUip-
arous woman suffering from endometritis the cer\ncal canal
is filled by a plug of mucus, which may afford a bar to con-
ception. In the muciparous woman the presence of cervical
inflammation may render the woman less susceptible to preg-
nancy, but it is not, however, considered an absolute obstacle
to conception.
431. Physical Signs. — The appearance and outline of the
cervix differ in the nuUiparous and in the multiparous woman.
In the former it is puffy and large, the os being soft and velvety.
The patient will complain of pain when the cervix is moved
or pressed. In the multipara the cervix is generally lacerated;
its margins are soft, velvety, and eroded, or hard, presenting pea-
like nodules, polypoid projections, cystic masses; or the osmay
be gaping, so as to permit the introduction of the finger nearly
to the internal os. The one lip may have undergone involu-
tion, while the other is enlarged and elongated. The mucous
membrane is irregular, not infrequently presenting longitudinal
ridges. Digital examination affords an idea as to the position
and relaticni of the cervix, and as to its condition, whether lace-
rated or otherwise. The digital examination should be supple-
mented by the use of the speculum, the latter being used to con-
firm suspicions which have been engendered by the digital exami-
nation. The Sims speculum is preferable, as it affords less dis-
placement to the parts and permits more thorough and complete
inspection. In the nullipara the os will be filled with a plug of
tenacious mucus surrounded by a patch of excoriated tissue, par-
ticularly upon the posterior lip, from which the outer layers of the
epithelium have been desquamated. In the multipara a lacera-
tion will probably be seen. Its presence is often overlooked, be-
cause the fissures are filled up with indurated cicatricial tissue.
The use of tenacula to turn in the surfaces demonstrates its
existence. The bluish-red ovula Nabothi may be readily seen
as nodular projections upon the surface.
432. Diagnosis. — Cervical catarrh is readily determined from
vaginal inflammation by the use of the speculum. In the
former a plug of mucus will fill up the cervical canal and prO"
ject from it, being so viscid and tenacious that its removal
INFLAMMATIONS.
is accomplished only with difficulty. To thoroughly remove the
mucus from the surface it may be necessary to use a curet. The
mucus in the interior of the dilated glands should be removed
by puncture and digital press\u-e. When the cervical dis-
charge is insufficient to render it visible, Schultze's method
may be employed, He gives the patient a vaginal douche,
introduces a speculum, thoroughly cleanses the surface, and
places a tampon soaked with a solution of tannin against the
external os. This applied at night and removed 'through a
speculum the following morning, the character and quantity
of the discharge from the cervix can be noted. The differen-
tiation between endocervicitis and endometritis is still more
difficult. In many cases, indeed, we may not be abie to say
definitely that a cervical catarrh is not associated with more
or less inflammation of the endometrium. The enlargement
and thickening of the cervix demonstrate that it is the seat of
inflammation. It is sometimes difficult to differentiate be-
tween inflammation and malignant disease of the cer\'ix. In
the former the hypertrophy is more general and uniform, the
tissues are more or less firm, but not hard, and show no in-
clination to friability. In malignant disease the cer\-ix may
at points be hard and indurated from the presence of an in-
filtrate which is more or less localized. An excavated ulcer
may be present, covered with friable, easily broken-down tissue,
which will crumble and become detached under the finger, while
the base is hard and resisting. Hemorrhage and a profuse, foul-
smelling discharge are prominent symptoms. When the condition
is such as to leave one in doubt, a test excision should be made
and the excised tissue subjected to microscopic investigation.
433. Prognosis. — Tiie curability of endocervicitis is de-
pendent upon the general health of the patient, the duration
of the disease, and the extent of involvement. Not infre-
quently it will be found that these patients have passed through
the hands of a number of physicians, and, therefore, extreme
care must be exercised as to .the prognosis. The result is less
favorable when there is a large amount of secretion and ap-
parently but little glandular degeneration.
434. Treatment. — First, constitutional: The patient should
be encouraged to take outdoor exercise, and not infrequently
change of air will prove of decided value. Tonics, such as
quinin, iron, strychnin, arsenic, and the bitter tonics, will be
of advantage. Indigestion should be corrected, regular action
of the bowels sec'ured, and sexual rest advised.
Second, local treatment: In the nullipara it is advisable
to give hot vaginal douches through a fountain syringe under
moderate pressure for ten to fifteen minutes each night, ha^-ing
382 GYNECOLOGY.
the patient preferably in the recumbent position. Doubt-
less in some cases the hot water thrown with force from a bulb
syringe against the cervix will have a more marked modifv^ing
influence upon the hy-
perplastic process and,
therefore, it should sup-
plant the fountain syr-
inge. The temperature
of the water should be
from iio° to 115" P.,
and the patient should
be advised to remain
in bed following the
douche. Astringents
can be added, such as
a solution of zinc sul-
phate ( 5 j-ij-water Oij},
powdered alum (oj-
Oij), lead acetate (oj-
ij-Oij), or the latter
and zinc sulphate may
be combined. Mild so-
lutions of antiseptics may be substituted for the astringent, as
hydrargyri bichlorid (1:4000), formalin {1:2000), but these
agents present no special advantage over the douche of sodium
chlorid , 5 j , water O i j .
The OS, when narrow
and contracted so that
drainage is ineffective,
should be notched bilat-
erally with scissors, to
permit the escape of the
mucus. The hps should
be trimmed, making
funnel-shaped opening.
(Figs. 297 and 298.)
When the secretion con-
tinues, local applications,
such as tincture of iodin
or carbolic acid, a satu-
rated solution of iodin
crystals in carbolic acid,
95 per cent., can be em-
ployed ; the former in
mild , the latter in more severe, cases. Heywood Smith ad\'isesacid
nitrate of mercury; De Sinety, chromium trioxid. Better results
INFLAMMATIONS.
are secured from the employment of the milder agents, as zinc sul-
phate or chlorid gr. X, aqua f3j, silver nitrate gr, x-xv-3j, or so \
iution of argyrol (20-40 per cent.)- In making an application,
the mucus should first be removed from the canal with a cotton-
wrapped applicator or a blunt curet. When the mucus is very
tenacious, its removal is greatly facilitated by throwing in a few
drops of hydrogen dioxid by means of a pipet, after which
it is more readily removed with the blunt ciu^et. This step is im-
portant to prevent the application being coagulated by the
mucus without reaching the affected surface. After the ap-
plication any surplus fluid should be removed, and a tampon
of cotton or of gauze saturated with glycerin should be placed
beneath the cervix. A 25 per cent, solution of ichthyol in
glycerin, or ichthyol in lanolin, of the same strength, may
be applied to the cervical canal with a cotton-wrapped probe,
or a small pledget of gauze or cotton anointed with it may
be carried into the dilated cervix, or a tampon medicated with
it may be applied to the eroded cervix. Ichthyol is advisable
because of its germicidal action. The application of such a
tampon will not infrequently result in the desquamation of
an epithelial cast, followed by a regeneration of the epithelium
and restoration of a healthy appearance of the cervix. The
application of a saturated solution of iodoform in ether is ad-
vised. Ether stimulates contraction of the glands and forces
out the secretion, while the iodoform remaining acts as an
antiseptic. In the multipara endocervicitis is not infrequently
complicated by retroflexion, subinvolution, or laceration of
the cervix. The first consideration should be to relieve conges-
tion by scarification of the surface, punctiu^ of retention cysts,
employment of hot astringents or antiseptic douches, and the use
of medicated tampons. Some form of glycerin medication upon
the tampon is especially efficacious in causing profuse depletion.
The displacement should be corrected and the organ should be
maintained in a proper position by a tampon or by the use of
the pessary. Wlien the cervical mucous membrane is much
everted and the lips are widely separated by laceration of the
cervix, the relief of the engorgement and congestion can be over-
come by the employment of Emmet's operation. The uterine
congestion may be greatly decreased by local depletion through
scarifying or puncturing the cervix. Such depletion is of special
value where a number of glands of Naboth have become obstructed
and have formed retention cysts. Evacuation of the cysts
and the introduction of tincture of iodin or carbolic acid into
their cavities produce a sufficient amount of inflammation to
obliterate them and relieve the pressure. In very obstinately
chronic cases destruction or removal of the diseased glandular
384 GYNECOLOGY.
tissue is imperative. It may be accomplished by the use of
the Paquelin thermocautery or by various caustics. Skoldberg
recommends zinc -alum sticks, which are made by running ,
together into molds equal parts of zinc sulphate and alum,
forming a small stick, which is carried into the cervLx and
retained by a plug of gauze in the vagina, which also re-
ceives the discharge. Silver nitrate in solid stick was formerly
much used for this purpose. The latter method of treatment
is required only in exceedingly severe cases, and its application
should be extremely limited. It cures by destruction of the
mucous membrane and glandular structure, substituting for
them cicatricial tissue. It should not be used where there
is danger of the cervical canal becoming so contracted as to
interfere with drainage from the uterine cavity. Colpe, finding
that an inflammation of the cervix did not yield to the use (rf
astringents and caustics, examined the secretion and found
present mycotic spores, after which he used lactic and salicylic
acids, with immediate relief.
Electricity has its advocates — the negative pole is introduced
into the cervix, while the positive pole is placed upon the abdo-
men. It is questionable, however, whether this plan of treat-
ment has any advantage over other caustic measures. The use
of the sharp curet not only removes the glands from the cervical
canal, but, as advocated by Thomas, scrapes away the arbor vita
from the internal to the external os. This measure not infre-
quently has to be repeated a second or even a third time before
relief is complete. When there is very marked eversion or an
eroded, deeply fissured surface, Schroder's operation should be
performed. This consists in the formation of a single flap in
each lip. The method of procedure has been described. (Sec-
tion 336.) Martin removes a larger amount of the cervix, and
combines amputation with excision. He splits the cervTX into
two lips, cuts through the cervical mucous membrane on the
posterior lip above the diseased portion, then removes as much
of the lip as is necessary, and stitches it. The anterior lip is
treated in the same wav.
435. Acute Metritis and Endometritis. — In acute inflamma-
tion tlic pathologic changes arc not confined to the endometrium,
but rapidly involve the entire organ. In the nonpuerperal
uterus they arc excited by infection from gonorrhea, or follow
trauma, induced by exploratory operative procedures, or result
from exacerbations of the chronic state. The nonpuerperal
cases are rare and scarcely ever fatal or sufficiently threatening
to require liystercctomy. Such an inflammation is generally
broui^lit Ky\\ by an infccti(.)n wliich has occurred during parturition
or abortion, and, consequently, is more an obstetric than a
gynecologic condition.
INFLAMMATIONS. 385
Infection is favored :
1. By protracted labor during which the tissues have been
subjected to bruising or laceration.
2. Through want of skill or of cleanliness in the practice of
manual or instrumental procedures.
3. From the retention of clots or of portions of placenta or
decidua after labor or abortion.
4. By the presence of septic germs in the genital canal prior
to the occurrence of gestation, by their introduction during the
process of delivery or in the subsequent convalescence.
436. Pathologic Alterations. — The infection is originally im-
planted in the degenerated mucous membrane, the blood-clots
of the uterine sinuses, the site of the placenta, or in retained
portions of the placenta or decidua. Intense hyperemia results,
with alterations in all the tissue elements. The gland lumina
are dilated by the increased secretion and proliferation of the
glandular epithelium. Inflammatory infiltmtion takes place
into the tissues, with subsequent degeneration and destruction
of the cellular elements. The mucous membrane becomes
greatly swollen and edematous. The epithelium is found
granular and desquamating. The blood-vessels become engorged
and thrombosed. Inflammatory material is poured into the
cellular tissue, which may terminate in abscess formation, either
in the wall or sinuses or both.
These pus-pockets, at first small and localized, increase in
size, the intervening walls bre^k down, and an abscess of con-
siderable size may form, wliich may ruptiu-e into the uterine
cavity and thus terminate favorably, or a large portion of the
uterus may become gangrenous, causing serious detriment to
the health, and even loss of life. In an autopsy upon a patient
who died under my care in the Philadelphia Hospital the entire
fundus was found to have been completely destroyed.
437. Varieties and their Source.^The symptoms will be
found to depend upon the character of the infection, and this
can be divided into sapremic and septicemic. Sapremic infec-
tion is induced by the action of the saprophytes upon retained
blood-clots and portions of the decidua or placenta, which
cause decomposition of the retained tissue, with the subsequent
absorption of the decomposing products. Decomposed material,
when undisturbed, presents a soil favorable for the implantation
of septic infection. Septicemia, however, occurs much more
frequently as a primary disorder induced by the entrance of
pathogenic germs through fractures of the mucous membrane
of the uterine boily, cervix, vagina, or vulva. We have already
asserted that inert pathogenic germs which inhabit the vagina
can. by changed conditions, be stimulated into activity, but
386 GYNECOLOGY.
they are, however, more frequently introduced from \\4thout,
through failure of the physician or nurse to obser\'e proper
antiseptic or aseptic precautions.
438. Symptoms. — Sapremia occurs in from three or four to
ten days subsequent to delivery. The onset of the trouble is
rather sudden, and is manifested by elevated temperature and
repeated rigors. The patient may have severe chills, and daily
temperature varying from 102° to 105° F. The lochial dis-
charge may be absent, or, if present, is exceedingly foul. The
patient generally manifests but little tenderness upon pressure.
Manipulation over the uterus may be followed by contraction
and the expulsion of a large offensive mass, after which the
patient will improve, or she may have quite profuse bleeding.
Digital examination discloses the presence of retained masses
and affords evidence of their decomposition. The onset of
septicemia is more insidious, but the symptoms occur earlier.
The reaction induced by septicemia will depend upon the condi-
tion of the patient, the time of the infection, and the virulence
of the infective poison. As early as the second or third day, 1
not infrequently upon the first, the patient will exhibit an j
elevation of temperature, which gradually increases. She *
suffers from pain or tenderness in the lower abdomen, whidi
may be so marked as to confine her to the dorsal decubitus, !
with her limbs flexed and unable to exercise the slightest muscular
action, because of pain. Not infrequently the bladder becomes ;
greatly distended; the pulse is rapid, varying from no to 140^ 1
respirations frequent, and the temperature displays a range
from 101° to 107^ F. The lochial discharge is arrested or free,
and may be mucous, mucopurulent, ichorous, or sanguinolent
It may have a stale, sickening smell or be almost free from odor.
The cervix and vagina, upon inspection, may appear normal
or highly inflamed, swollen, and covered with glairy mucus,
or exhibit patches of diphtheric exudate. The uterus is likely
to be smooth, swollen, and exceedingly tender to pressure.
The cervix will appear lacerated and boggy. The entire organ
will be found enlarged, edematous, and flabby. When the
inflammation is confined to the uterus, the organ will be tender
and enlarged, but not so sensitive as to preclude palpation.
If, however, the peritoneal coat is involved, the pain and tender-
ness will be very acute ; the limbs are drawn up to protect the
abd(-)mcn from pressure of the clothing and to relieve the traction
upon tlie abdominal wall. The progress of the disease ^n"!"
de]:)end upon tlie virulence of the poison and the resistaiice
of the ])atient. In the sapremic condition the source of origin
of tlie disease may be expelled and the patiently rapidly pro-
gress toward recoxery. A patient suffering from septicemia
INFLAMMATIONS. 387 1
may be so fortunate as to secure immunity against its further
progress and slowly recover. The disease may become localized
and a pus-collection be spontaneously or artificially evacuated,
or the general system may become so infected that, notTAith-
standing every therapeutic procedure, the patient succumbs.
An unfavorable prognosis is indicated by a persistent high
temperature, a pulse-rate continuously above 130, and the
absence of localized foci. If the serious symptoms subside
and the general condition of the patient improves, but a rapid
pulse-rate continues, associated with an evening temperature
of 100" F. or over, the patient should not be regarded as out
of danger. This disorder was formerly known as puerperal
fever and supposed to be due to some obscure poison charac-
teristic of the condition. The investigations of Semmelweis
and others demonstrated that it was analogous to surgical
fever and due to a similar cause. The disorder is hydra-headed
in its manifestations, and makes its invasion by one of three
routes: through the continuous mucous membrane of the
body of the uterus and Fallopian tubes to the peritoneum;
through the blood-vessels or the lymphatics. Thus we may have
inflammation of the structure of the uterus, the Fallopian
tubes, the ovaries, the pelvic cellular tissue, or the pelvic perito-
neum, or even all combined. Any of the veins of the body
may become involved in the septic phlebitis, but the condition
occurs most frequently in those of the lower extremities, caus-
ing the condition formerly knc^Ti as milk-leg, which we now
recognize to be an infective phlebitis. It may manifest itself
also by a severe lymphangitis. The disease may rapidly in-
volve the general system, giving rise to profound symptoms
of septicemia without any special localization.
439. Diagnosis.— The early differentiation between sap-
remia and septicemia is very important. The former, being
associated with retained decomposing products, manifests
itself several days after deliver^'. Symptoms develop suddenly
in a patient who seemed to be undergoing a normal convales-
cence. The lochial discharge, where present, is exceedingly
offensive. A digital examination discloses a clot, a portion
of placenta, or a portion of decomposing membrane within
the uterine cavity. These products, when removed, have a
verj' offensive odor, and with their disappearance the symptoms
rapidly subside. In septicemia the symptoms occur more
inadiously, and at an earlier date following deHvery. unless,
however, the infection should have been implanted late. The
occurrence of elevation of temperature following a delivery
should be regarded as a danger-signal, which should cause
the attendant to make a careful investigation of the history
388 GYNECOLOGY.
of the case, together with a judicious interrogation of the phy-
sical signs. The condition of the breasts should be ascertained,
for not infrequently women have a high temperature con-
comitant with the establishment of lactation. The breasts
become greatly distended, caked, and hard. The temperature
of the patient reaches 105° F. or over. Not infrequently
the nipples may be the source of infection, which may lead to
the occurrence of a mammary abscess. Typhoid fever and
malaria are frequently mistaken for sepsis and vice versd. The
possibility of these conditions should be excluded by a careful
examination of the blood; finding in malaria the Plasmodium
and in typhoid fever the securing of a positive Widal reaction
and the examination of the urine are considered suflBcient
evidence to establish the diagnosis. Ftirthermore, the typhoid
bacillus may be fotmd in the urine and also occasionaUy in
the blood. A digital examination excludes sapremia when
it reveals the walls of the uterine cavity smooth and free from
any decomposing products. Intoxication from morbid prod-
ucts in the intestinal tract may sometimes closely simulate
septicemia. It was quite recently my privilege to see,
with two young doctors, a yoimg woman who was suffering
from a very high temperatiu"e with some abdominal distention,
in whom there were no signs of any localization of sepsis. The
patient had been delivered a week prior to the manifestation
of symptoms. Examination disclosed the uterine cavity free
from any decomposing material, and absence of tenderness
over the uterus. The woman had had some fifteen foul-smelling
stools during the preceding twenty-four hotu^. It was her first
confinement, and there was a history of her having imdergonea
curetment some three years before. She had been very care-
fully managed during her confinement, with every aseptic
precaution, and had been cared for by a well-trained nurse.
The inference of the attendants was that she had had some
local accumulation in a tube prior to her delivery, from
which this infection had developed. But as I fotmd the uterus
free from any tenderness or undue enlargement, no sign of in-
fection in the vagina, and she had what seemed to me no tender-
ness or swelling about either tube or ovary, I reasoned, there-
fore, that if such local cause had existed, it should still show
evidence of its presence, and in view of the very evident in-
testinal disturbance, I ascribed the symptoms to an intestinal
infection, and suggested measures for its correction. The
rapid subsidence of the symptoms and recovery of the patient
confirmed the diagnosis.
Having reached a diagnosis in septicemia, by exclusiofl'
it is then desirable to recognize and treat the local manifes-
INFLAMMATIONS. 389
tations promptly. These we determine by the size and e\'idence
di laceration of the uterus, the existence of patches of diphtheric
exudation in the vagina or uterus, and the possible form and prog-
ress of the infection. Metritis will be indicated by a large,
swollen, more or less tender and boggy uterus; perimetritis or
pelvic peritonitis by extreme tenderness in the lower portion
of the abdomen, pain and anxiety of the patient, with a fre-
cpient, rapid, wiry pulse, and high, sometimes low, and even
subnormal, temperature; the latter symptoms, moreover, rather
increasing the danger. Phlebitis will be recognized by tender-
ness over the femoral and saphenous veins, as these are the
ones in which the disease most frequently manifests itself.
Lymphangitis is often indicated by the existence of inflammation
of the cellular tissue and by pain and tenderness over the lumbar
or inguinal regions.
440. Prognosis. — Sapremia is a condition which usually
temiinates favorably. The removal of the putrid products
soon results in the subsidence of the constitutional intoxication.
It should not be forgotten, however, that the putrid material
affords a favorable soil for the development and propagation
of septic germs, so that when a patient comes under obser-
vation she may have been subjected to mixed infection. Under
proper management this condition generally terminates in
recovery. Septicemia is an exceedingly dangerous disease;
its manifestations are so various that often when the patient
survives she may be in a condition which cripples her for life
and at the expense of serious sacrifice of important organs.
The condition demands the most careful scrutiny of the prog-
ress of the disease, with the resort to radical procedure when
it is manifest that local foci are continuing its propagation.
441. Treatment. — Prophylaxis is the most important treat-
ment, but is so closely associated with the work of the obstet-
rician that we will not consider it. A woman who develops
symptoms leading one to suspect the occurrence of a septic
process should at once be subjected to careful investigation.
This careful scrutiny is advised in order to eliminate the possi-
Wity of other conditions being confounded with sepsis. Finally,
a pelvic exploration should be made, and all decomposing
products, such as blood-clots, portions of placenta, or remnants
ofdecidua should be removed. The patient should be placed
^oss the bed ; if the abdomen is tender, an anesthetic should
be given, and two fingers introduced into the uterus, which,
^th the hand over the abdomen, will permit the entire uterine
cavity and wall to be thoroughly explored and all products
and debris removed. The procedure not only removes the
d6bris and contents of the uterus, but favors the pressing out
390 GYNECOLOGY.
of infected clots from the blood-vessels and uterine sinuses.
This manipulation should be followed by intra-uterine douches
of sterile normal salt solution, or, better still, a i per cent,
saline solution, made up of 2 ^ grains sodium bicarbonate tO'
7i grains of sodium chlorid to the 1000, or formalin solution
1 : 1500-1000, or sublimate solution i : 3000. When the uterine
cavity is clear of decomposing masses and other causes are
excluded, we are justified in accepting the diagnosis of
septic infection, as distinguished from putrid intoxication.
In septicemia, intra-uterine manipulation often will be unpro-
ductive of any favorable result. The micro-organisms have
already penetrated beyond the reach of any local measures. 1
Curetment, by affording fresh avenues for infection, is hann- ^
ful. The uterine cavity should be irrigated through a double-
current tube three, four, or more times daily with a hot i per
cent, saline solution or solutions of formalin or bichlorid. The
latter solution (i : 3000) should be followed with normal salt
solution to avoid the danger of mercuric poisoning.
The removal of decomposing products, irrigation of the
uterus, and the internal administration of salines in sapremia,
or putrid intoxication, usually establishes early convalescence.
Not infrequently, however, there will be a marked rise of tem-
perature after such a procedure, but it soon subsides. Sepsis,
on the other hand, is caused by micro-organisms which have
entered the blood, and kill, not so much by their presence, as
by the toxins or poisons which they generate. Researches
have seemed to demonstrate that these toxins, obtained from
pure cultures of the organisms and injected into the circulation
of some of the lower animals, soon generate an antitoxin which
acts as an antidote to the original poison. My early experience
in the treatment of sepsis by the administration of the anti-
streptococcic serum was such as to lead me to place greater
reliance upon its efficacy in affording prompt immunity than
the later experience of myself and colleagues would seem to
justify. In severe cases as much as ten cubic centimeters
(two and a half drams) in twenty-four hours should be employed-
In less severe cases smaller doses, three to six cubic centimeterSi
can be employed. The dose should be administered daily
until the abnormal symptoms subside. The advocates of tb^
employment of serum-therapy in the treatment of puerper^-l
sepsis are doubtless correct in their demand that the senrm
must be fresh. The want of success may have been due t.<^
this cause, as many have employed the imported serum <^^
Marmorek. A requisite to accuracy is the careful bacterid*
investigation of the secretions, for it would not be reasonat>l;^
to expect a satisfactory result by the employment of ant:^^''
INFLAMMATIONS. 391
Streptococcic serum in a staphylococcic infection. To be most
effective, it is most important that the serum should be ad-
ministered early and in good dose. The strength of the patient,
and her consequent ability to fight the disease, should be main-
tained by the administration of supporting remedies, by a
nutritious, easily digested diet, and by the judicious use of
stimulants.
Quinin may be given in suppository (gr. v-x) three or
four times daily ; strychnin, atropin, tincture of digitalis, digitalin
or adrenalin chlorid solution (i : looo) should be administered
hypodermically, as the indications demand. Action of the
bowels should be secured by the proper use of salines, which
facilitates the elimination of the infective products, though
care should be exercised to avoid undue depletion.
Intravenous Injections. — The intravenous injection of normal
salt solution has been of great service to the surgeon in over-
coming shock and in carrying patients over a critical condition.
It has been demonstrated, also, that this procedure is service-
able in low septic conditions by increasing the voltmie of the
blood, thus diluting toxic material, promoting secretion, and
the consequent elimination of poisonous products. The com-
bination of chlorid of sodium with bicarbonate of sodium,
making a i per cent, saline solution which should be in the
proportion of yj parts of the chlorid of sodium to 2^ parts of
bicarbonate of sodium, has proved especially efficacious in
septic conditions, as it increased the phagocytes and the con-
sequent ability of the patient to resist the progress of the in-
fection.
The brilliant results achieved by Professor Baccelli, in
1889, in the treatment of pernicious malaria, by the intra-
venous injection of hydrochlorid of quinin, has directed the
attention of the profession to the intravenous injection of
gennicides. Baccelli later instituted the intravenous injection
of corrosive sublimate in the treatment of syphilis, after the
administration of mercury by other methods had failed. His
experiments on the lower animals demonstrated the fact that
albuminate of mercury, which was first formed, was redissolved'
in an excess of albumin.
As it is known that the micro-organisms enter the blood,
the introduction of germicidal agents into this fluid to render
it an unfavorable soil for their multiplication is a plan
which naturally appeals to the scientific mind. The difficulty
has been to secure some agent which shall prove destructive
to the specific germ in the hemal circulation, without inducing
degenerative changes in the circulatory fluid. Carbolic acid,
subUmate, and formalin have all been recommended as suit-
392 GYNECOLOGY.
able agents for this purpose. In a recent case in which
the conditions were such as to make it evident that death
was imminent unless the poison could be arrested, I injected
J of a grain of sublimate in 500 centimeters of normal salt
solution. The patient the following day developed an in-
farct which cut off the circulation in the end of the nose, and
she died at the end of forty-eight hours. As air, however,
had entered, due to the faulty apparatus employed, it is not
justifiable to condemn the bichlorid as the cause. Formalin
has been especially commended of late, particularly by Barrows,
of New York, and Maguire, of London. The latter, in his
experiments, has injected solutions as strong as i : 500 into
himself. This was followed by hematuria, albuminuria, cramp-
like pains, and faintness. I have applied gauze, wet with
formalin solution (i : 1500-2000), to the peritoneum, with com-
plete destruction of the endothelial covering of the involved
surface, so that I should regard the injections of solutions of
formalin, therefore, under i : 5000, as extremely dangerous,
and as it has been claimed that it is germicidal in solutions
of I : 200,000, a weaker solution still would seem preferable.
As the simple injection of water into the blood-vessels causes
degenerative changes in the blood-corpuscles, it would seem
much wiser that these injections should be made in combina-
tion with normal salt solution. In cases, then, in which it is
evident that the patient will succumb to the disease unless
it can be arrested, we should feel justified in proceeding to
extreme measures with the hope of affording reUef ; and with
our present knowledge of conditions, I should favor the formalin
in combination with a normal salt solution as being the least
deleterious of tlie agents we can employ. I would advise against
it being given in greater strength than i : 10,000. The beneficial
results from the intravenous employment of this drug have
not been sufiiciently brilliant to compensate for its well-recog-
nized disadvantages.
Localization of infection may result in abscess formation
in the uterine wall, in the pelvic cellular tissue, in the tube,
in the ovaries, or in multiple abscesses in various portions
of the body. The manifestation of such a local collection
should be deemed an indication for prompt surgical inter-
ference. The treatment necessarily must depend upon the
site and extent of the lesion. If an exudate or inflammatory
collection can be reached by a vaginal incision, through which
the contents of the cavity can be evacuated, its sac enucleated
and removed, or the cellular tissue opened up and drained,
more serious destruction of tissue can often be avoided. Where
the uterus remains large and extremely tender, or presents
INFLAMMATIONS. 303
ications of localized peritonitis or localized abscess formation,
i the condition of the patient will permit, the abdomen can
opened and hysterectomy performed. It should be capable
demonstration that the uterus is the seat of irreparable dam-
! or a focus for the continued distribution of infection before
is removed, because I have been consulted as to its removal
women who have recovered without operation, and even
bsequently given birth to children. In doubtful cases the
erus can be explored by an incision through the posterior
S^l fornix, and in many cases the opportunity thus granted
r peritoneal drainage will afford the required relief. The ex-
:s&
Fig. 399. — Interstitial Endometritis,
■■ Fne uterine surface, b, b. b. Hyperplasia o£ conni-ctive tissue, c. c, c. c.
Ohliieration of glands, d. Choking of gland from increase of fibrous tis-
""■ f, e. Glands occluded and somewhat dilated.
Osiffli of a section of an infected vein has been successfully per-
■oniied, but one must be satisfied that the condition is not dif-
™se before resorting to such a procedure.
When the temperature is elevated, the skin hot and dry,
associated with tympanites and repeated vomiting, the most
™ective plan of treatment is to irrigate the stomach with hot
*™ial salt solution, followed by intercolonic irrigation. The
fitter should be continued over several hours, or a quart of
"^"lal salt solution should be injected into the bowel every
^w. The better plan is to elevate the foot of the bed and
™wigh a double rectal tube subject the rectum to more or less
394 GYNECOLOGY.
continuous irrigation with a one per cent, salt solution,
administration of large quantities of salt solution promotes
ination. The tongue and skin become moist, the secretin
urine increased, the pulse increases in volume, and the tem
ture becomes reduced.
442. Chronic endometritis is an inflammation of the mi
membrane of the body of the uterus. It rarely, if evi
the consequence of acute endometritis, but more frequ>
follows subacute processes and long-continued hypen
It is divided by Ruge into glandular, interstitial, and m
according to the structure of the mucous membrane
extensively involved. In all varieties of inflammation
Fig. 300.— Ihpcrtrophic Glandular Endometntis showing Increase:
and Numbers of Glands
a. a. Glands dilated and containing secretion b Infiltration of leuko
entire structure of the membrane is necessarily more 0
affected. With thickening of the mucous membrane the g
become elongated, dilated, bent, and tortuous. Cells hi
swollen and proliferated, resembling those of the dc
The vessels of the deeper portion of the mucosa are d
and in a state of congestion. The mucous membrane i
infrequently several times its normal thickness, soft, sp
and easily scraped away. The surface presents veget
or growths, which, according to De Sinety, are of three 1
In one, the tissue consists of dilated blood-vessels ; in the s(
of dilated, hypertrophied glands (Fig. 301); in tlie thb
INFLAMMATIONS.
onic tissue containing but few blood-vessels and only
of glands. With these conditions are associated three
of discharge — sanguinolent, leukorrheal, and mucopuru-
As a result of the changes in the mucous membrane.
ioi.— Hypertrophic GKiiduUr Lndt nic tnt s Vertical Section through
the Mucous MLmbrane
od-vessel distended with blood cells 6 Gland penetrating muscular wall.
nfrequently portions project as polypoid masses, which
it of either glandular or vascular structure. (Fig. 302.)
is condition the mucous membrane is thickened and granu-
1 appearance, and the state has been called villous de-
396 GYNECOLOGY.
generation, or endometritis fungosa. With cell-proiiteratiJ
in its connective tissue and the subsequent contraction of IJ
gland its structure is compressed and obliterated, so t
the surface is almost free from glands. Or, again, the orffico'l
of the glands' ducts in places become occluded and cvsis result 1
The hypeq>Iasia of the uterine mucosa in some cises results j
in the desquamation of the epithelial layers at each menstroal |
period. This desquamation may take place in t]ie formation I
of shreds or in a complete cast of the uterus, in vliich the onfices I
of the Fallopian tubes and the internal os are recognized. This!
condition is known as exfoliative endometritis, membranous dy^■
menorrhea, or. probably better, menstrual decidua. (Fig. 303.) I
.^>.^^
F g 30a — Po ypo d Mass s Assoc ated n th Chron c Endometritis
I G ands e atly d ated w th destruct on of the interve ng septum.
443. Symptoms. — The disease arises after abortion or labor,
as a result of an attack of uterine inflammation, or an attack
of gonorrhea. Occasionally, it may begin insidiously and
without any sign of a cause. It occurs more frequently in
the multiparous, and is more common in the later menstrual
life. NuUiparse are not exempt; even virgins are sometimes
affected — a condition known as virginal endometritis. This
especially occurs in narrowing or stenosis of the external os.
A form of the disease occurs subsequent to the climactfiriCi
when it is known as senile endometritis. Endometritis is
characterized by the following symptoms : leukorrhea and
menorrhagia. The discharge from the body of the utems
: viscid than that from tiie cervix. It may be clear, but
more generally is mucopurulent ; occasionally it is tinged with
blood, so that the patient imagines herself continuously un-
well. The discharge flows freely or there is an apparent ac-
cumulation. Retention of the discharge and its evacuation
in considerable quantity occur when endometritis is complicated
by retrodisplacements or when the os is small. The discharge
may have an offensive odor and be so irritating as to give rise
to extensive excoriation of the vulva. Excessive menstrual
flow, or menorrhagia, may or may not be present. Occasionally,
it will be so profuse as to occasion a suspicion of malignant
disease and cause a profound anemia. The resulting loss of
^S^^
'-K^.
Fig. 303. — Membranous Dy amenorrhea.
vasomotor tonus results in increased tendency to hemorrhage.
Dysmenorrhea, or painful menstruation, is not so common
as in disease of the appendages or in chronic metritis. It is
especially marked when accompanied by the discharge of a
menstrual decidua. The influence of endometritis upon con-
ception is not fully determined, but the increased frequency
with which women become pregnant subsequent to a curet-
ment renders it evident that it has a restraining influence upon
the occurrence of conception. Endometritis is a prolific cause
of abortion.
444. Diagnosis. — The existence of leukorrhea or of irregular
398 GYNECOLOGY.
and profuse menstruation, associated with enlargement of the
uterus for which no explanation external to the uterus can be
found, justifies the suspicion of endometritis. The history ot
abortion, or prolonged convalescence subsequent to labor, con-
firms the suspicion. The use of the curet is of incalculaUe
advantage in determining the diagnosis. Portions removed
with the curet will show small-cell infiltration of the entire
glandular tissue, without glandular hyperplasia, or marked
hyperplasia of glands with proliferation of the glandular epithe-
lium. The epithelial cells become enlarged and granular, lose
their cylindrical shape, and resemble the decidual cell. Endo-
metritis, when uninterrupted, extends to the deeper structures,
producing metritis. It predisposes to malignant change. When
permitted to pursue an undisturbed course, it may involve the
peri-uterine covering. Deposits occur in the cellular tissue
about the ovary or around the orifice of the Fallopian tube, or
the disease involves the pelvic peritoneum. Neglected cases
result in cellulitis, salpingitis, ovaritis, peritonitis, the for-
mation of abscesses, the destruction of tissue in the organs,
and not infrequently, alas! in loss of life. Senile endometritis
is associated with retention of secretion which decomposes,
producing an exceedingly offensive odor, and arouses the sus-
picion of malignant disease (Dunning). The examination of
such a uterus reveals its walls thinned; the mucous membrane
consisting of a thin layer of connective tissue cov^ered with a
single layer of flattened epithelial cells.
445. Treatment. — Constitutional treatment is of marked
value, and will be discussed with chronic metritis. Prophylaxis
will require rigid asepsis during labor or abortion, as well as
in making gynecologic examinations. A rise of temperature or
the suspicion of the retention of a portion of placental debris
should be considered as indicating the necessity for thorough
use of the curet, free irrigation, and, in many cases, gauze pack-
ing. Laceration of the cervix or of the pelvic floor should
have early repair. All suspicious discharges must be removed
by treating the cause. Before the third or fourth day an en-
dometritis of gonorrheal origin is best treated by frequent
irrigation with antiseptic solution, such as permanganate of
potash (i : 3000-2000), mercurol (i to 2 per cent.), protargol (0.5
to I per cent.). If the acute symptoms have subsided, paint the
cervix, and where the os is patulous, the cervical canal, vnX^
50 per cent, solution of ichthyol in water, or glycerin, and later,
if the condition persists, curet and pack with iodoform gauze-
Careful antiseptic or aseptic cureting is the proper form of treat-
ment in all forms of endometritis, whether complicated or utV'
complicated. In serious cervical lesions, with much eversi^^
INFLAMMATIONS.
and thickening of the mucous membrane, cureting should be
associated with Schroder's operation upon the cervix. Drainage
is of incalculable advantage in endometritis when complicated
with slight catarrhal salpingitis. It will also pn^ve serviceable
in mild forms of peri-uterine inflammation, Cureting should be
considered contraindicated in well-established pathologic changes
in the adnexa and in chronic peri-uterine inflammation unless
immediately followed during the anesthesia by an abdominal
incision for the correction of the pelvic lesions. In addition
to curetment, intra-uterine treatment consists in the employ-
ment of antiseptics and caustics. Free drainage should be con-
sidered as a prerequisite to all intra-uterinc treatment. The
inflamed uterine canal is similar to a sinus. Unless the pent-up
discharges have free vent, the irritation is aggravated. When
the canal is patulous, large injections of a feeble antiseptic
solution such as formalin (i : 2000), normal salt solution, or a
two per cent, solution of bicarbonate of soda through a re-
turn-current catheter can be employed. The latter solutions,
when used, are as salutary as the more distinctly defined
germicidal agents. If the cervical canal is insufficiently large,
it should be dilated with laminaria tents, after which irri-
gation should be practised. In mild cases the canal may be
swabbed, by means of a cotton-wrapped applicator, with tinc-
ture of iodin; in more severe cases, with carbolic acid. When
the mucous membrane is thickened and tends to bleed or to
furnish a profuse discharge, more active agents may be em-
ployed: silver nitrate, gr. xxx, to aq. destil., Sss-j; zinc chlorid,
3j-iv to fSj : chromium trioxid, gr. x-xxx, to fSj ; fuming nitric
acid, acid nitrate of mercury, tincture of chlorid of iron, pencils
of silver nitrate, zinc chlorid, zinc sulphate, copper sulphate,
or formalin. When strong caustics are used, precautions
must be practised to protect the healthy vagina from con-
tact with the solution. Indeed, in my judgment the employment
of the strong caustics is very infrequently required. Much more
is to be gained where a strong effect is desired by the use of the
curet and the subsequent applications of the milder agents, as
argyrol (10 to 50 per cent.), protargol (5 to 10 per cent.), or the
ordinary tincture of iodin. A mass of absorbent cotton should
be placed beneath the cervix prior to the application, and
the superfluous caustic should be removed by sponging before
the pledget is withdrawn. Pencils are objectionable in that
they produce sloughing of the cervical mucous membrane
and cause the development of atresia.
Tampons. — Intra-uterine treatment should be supplemented
by placing beneath the cervix a tampon, preferably saturated
'1 a preparation of glycerin, a 50 per cent, solution
emented 1
aturated M
of boro- fl
400 GYNECOLOGY.
glycerid in glycerin, a lo to 15 per cent, solution of ichtliyol
in glycerin, or a 25 per cent, ointment of ichthyol in lanolin.
The following prescription is an excellent astringent and anti-
septic:
B. Pulv. a!um..^ fjj _
Acid, carbolic ;^ vj
Glycerin., Oj.
Various ointments, either astringent or alterative, with
lanolin as a base, may be used upon the tampon. A tampon
improves the circulation by raising and maintaining the uterus
at a higher level. The antiseptic tampon may be retained from
twenty-four to seventy-two hours, according to its character.
When the tampon is not used, or after its removal, a vaginal
douche of two or three quarts of hot salt water (i 10° to 120° F.)
should be used twice daily, with the patient in the recumbent
position. When using very hot injections cover the vulva
and perineum with vaselin. to prevent burning. The employ-
ment of rock-salt, an ounce to the quart, in a douche,
promotes its efficiency. Scarification under continuous irri-
gation will often prove of advantage, and is more effective
than leeches. An iodoform gauze tampon should follow. Intra-
uterine injections have been employed for endometritis, but
should never be used unless the canal is sufficiently patulous
to permit the escape of the superfluous fluid. The preferable
plan is to employ a pipet or syringe by which one, two, or three
drops may be introduced. Occasionally, even this small quan-
tity will cause violent uterine colic. These attacks are not
necessarily dangerous, but they are not calculated to encourage
the continuation of treatment.
The treatment par excellence in chronic endometritis is
the use of the curet. In senile endometritis the important
consideration is drainage; to insure this, it may sometimes
be necessary to employ a tube. The cavity should be frequently
irrigated with an antiseptic solution,
446. Chronic Metritis. — Chronic metritis is an inflammation
in the muscle-wall of the uterus, leading, when long continued,
to increased connective-tissue formation. The term metritis
is used in a comprehensive sense, and comprises conditions
which have been described by different writers under such
terms as chronic parenchymatous inflammation (Scanzoni);
subinvolution (Simpson); diffuse proliferation of connective
tissue (Klob) ; infarction (Kiwisch) ; hyperplasia of flbromuscular
tissue, similar to fibroid tumors (Virchow); diffuse interstitial
metritis (Noeggerath) ; irritable uterus {Gooch). The term
may be criticized from a pathologic standpoint, as there is
INFLAMMATIONS. 401
Hd chronic inflammation of the muscle-fiber of the uterus,
IjBt an increased amoimt of connective tissue, out of proportion
ttt that of the muscle-fiber. Clinically it is satisfactory, as
it enables us to comprise under one term a variety of conditions
"Which may be developed from different causes but produce
I similar group of symptoms. It has been objected to this
term that, by inference, there lias been a profuse acute inflam-
mation, which is not the case, as chronic inflammation of the
Bterus does not follow the acute. It is more correctly described
IS an increased tissue formation, dependent on long-continued
soogestion. The term chronic is applied to analogous forms
tf inflammation in other organs and structures of the body,
IS cirrhosis of the liver, which describes a condition similar
bo that which is foimd in the uterus. Subinvolution is, in
nme English books, described separately, though it is due to
lie same catise.
The differential diagnosis between subinvolution and chronic
netritis is impossible, and the treatment of the two conditions
ioes not differ. The altered condition of the uterus will vary
nxth the period at which the patient comes under observation.
In the early stages the organ is enlarged, hyperemic, and soft.
Later, it may decrease in size, though it is still large, and then
becomes hard, indurated, and anemic. The enlargement of
tbe organ is uniform, so the shape is not altered. Upon open-
ing the abdomen of such a patient the peritoneal surface will
present a normal color, or patches of extravasated blood may
be present. On section, in the early stages the tissues will
be soft, hyperemic, easily incised; later, firm, cartilaginous,
presenting a whitish color, the walls thickened, and the cavity
of the uterus enlarged. Not infrequently the organ will be
found as firm and dense as a mature fibroid growth. During
the first period, De Sinety says, the dominant lesion is the
presence of a large number of embryonic elements through-
out the thickness of the muscular wall. These are more par-
ticularly situated around the blood-vessels, or they may form
Wands more or less separated from one another. The second
period is characterized by two changes : first, marked dilatation
of the lymphatic spaces ; second, localized hyperplasia around
the blood-vessels. We may find it difficult to determine whether
the muscular tissue remains normal, or is present in decreased
quantity. Fritsch examined uteri removed for cancer, and
found associated evidences of chronic metritis, in which the
/oDowing pathologic changes were noticed: The arrangement
of the muscular fiber and connective tissue is less regular than
in the normal, and the latter is greatly increased in quantity.
?iood-vessels are more numerous and tortuous. The vessel
26
402 GYNECOLOGY.
lumen is contracted, its tunica media is thickened, and the
contour of the vessel is masked by the degeneration of the con-
nective tissue in its wall. The lymphatic spaces, instead of
being narrow clefts, are gaping; the peritoneum is thickened
Both Comeuil and Snow- Beck described an increased num- .
ber of round and oval globules with amorphous tissue in the
uterine walls. The increase in the size of the organ is due to
the presence of this rather than to the increase of muscle-fiber.
447. Etiology. — The causes of chronic metritis are di\'idcd
into two classes : the predisposing and the exciting. The former
may be divided into: (a) Those which operate by interference
with the normal involution of the puerperal uterus; (6) those
which are due to the production of repeated or protracted
congestion. The first class comprises: first, retentions within <
the uterus of portions of placenta, membranes, or blood-clots; j
second, cervical lacerations; third, pelvic inflammations subse- j
quent to labor; fourth, too short convalescence follo^^'ing de- *
livery; fifth, nonlactation ; sixth, repeated miscarriages. Two
factors are essential to the accomplishment of involution:,
first, fatty degeneration of the muscle-fiber; second, removal
of the products of degeneration. Now, subinvolution or failure
of the uterus to undergo complete involution is due not to want
of degeneration of muscle-fiber, but to substitution of con-
nective tissue for the products of this degeneration. Metritis,
then, is generally found in women who have borne children,
and it has been asserted that involution is retarded by the
removal of the ovaries, although a patient of mine who
completed her gestation after the removal of both ovaries
did not manifest any failure in the process of involution. Any
irritation in or about the uterus will cause a chronic metritis,
and this explains the effect of retention of portions of the placenta
or membranes, of lacerations of the cer\dx, and of the existence
of peritonitis or cellulitis, as these cortditions interfere with
the circulation, which is also affected by premature getting
up following labor. The organ is heavy, and the increased
weight leads to its being displaced to a lower level, producing
passive congestion. Passive congestion is decreased by any
cause which increases uterine contractions; the physiologic
stimulus of nursing excites contraction reflexly through the
mammcX and favors involution. Abortions are especially in-
strumental, for the reason that the patients do not take so much
care of themselves as they would subsequent to a labor, and
the stimulus of lactation is absent. After an abortion con-
ception is likely to occur before the process of involution is
com|)lete. and this favors the recurrence of abortion.
The second class of cases, which operate through production
INFLAMMATIONS. 403
f repeated or protracted congestion, includes displacements
I the uterus, the presence of tumors in or near it, and causes
hat produce increased flow of blood to the uterus, such as
ndometritis and the free use of caustics. To this class also
lelong malformation, incomplete development, congenital ante-
kxion, conic cervix, stenosis of os, improper clothing, expo-
nre to cold, and masturbation. Metritis is favored at each
menstrual period, by exposure to cold, especially when the
Bterus is displaced or the cervix is contracted or lacerated, by
Bcessive copulation or its practice during menstruation, and
by gonorrheal infection from an incompletely cured husband.
Chronic contusions from the use of a pessary may engender
the inflammation. The intra-uterine stem-pessary is capable
of doing the most injury.
448. Symptoms. — In the large majority of cases the patient
will date her trouble from a confinement. Not infrequently
die will report repeated abortions, and that she subsequently
regained her health very slowly.
The symptoms are not characteristic, but are similar to
(hose foimd in cancer, fibroma, displacements, and other local
disorders. They are: weakness; pain or aching over the lower
hnnbar and sacral regions; a sensation of weight and bear-
ing down, as if the pelvic organs were to be extruded; an ap-
parent loss of power in the limbs; points of anesthesia over
the anterior surface of one or both thighs ; painful contractions
of the uterus ; irritable bladder ; constipation ; loss of all plea-
wrable sensation during the sexual relation; pricking pain
in the eyes and weak sight; photophobia; occipital pain, but
more frequently pain over the coronal suture ; and disturbances
of menstruation, as dysmenorrhea, abnormal bleeding, menor-
Aagia, or metrorrhagia. In weak patients are found amen-
orrhea, leukorrhea, hydrorrhea, hydrorrhoea gravidarum, puer-
peral hydrorrhea associated with retention of portions of placenta
and clots. Not infrequently there are loss of appetite, nausea,
dyspepsia, and enfeebled assimilation. The patient is pale,
anemic, and exceedingly weak, with dark circles beneath her
eyes. She suffers from palpitation and a sense of oppression,
and is exceedingly despondent and profoundly melancholic.
Acute mania, epilepsy, hysteria, and neurasthenia are occasion-
ally induced, and are always aggravated by the existence of
chronic metritis. The diseased condition under discussion is
responsible for the majority of cases of semi-invalidism. The
patient is continuously conscious that she has a uterus; the
distress is increased by exercise and lessened by rest. The
constipation and digestive disturbances are aggravated and
increased by dread of pain and by her sedentary habits. The
404 GYNECOLOGY.
patient can suffer from acute exacerbations, with diarrhea and
rectal tenesmus, as a result of extension of the inflammation to
the rectum.
Menstrual disturbances are common, largely induced by
the accompanying endometritis, called, from the bleedings
hemorrhagic endometritis.
The hemorrhage is probably quite as often due to the dimia-
ished contractile power of the organ as to the substitution
of connective tissue for the muscle-fiber. The associated
disease of the mucous membrane adds to the dysmenorrhea,
which may precede, be simultaneous with, or follow the period.
It is generally continuous with the period, in the form of in-
creased backache, pressure, and pelvic discomfort.
Leukorrhea is produced by alterations of the uterine mucoas
membrane. In the aged not infrequently a hydrorrhea de-
velops, with a periodic discharge so offensive as to lead to the
suspicion of the development of maUgnant disease.
Sterility is a natural consequence of the prolonged existence
of chronic inflammation, not only from alterations in the stnic- |
ture of the wall and mucosa, but probably much more fro©
the superadded changes in the pelvic peritonetmi, affecting
the tube and ovaries. The escape of the ovimi may be pre-
vented by extensive adhesions fixing the ovary, or through
thickening of the ovarian tunica albuginea, which prevents
its exit from the maturing Graafian follicle. The Fallopian
tube may furnish the obstacle, through closure of its abdom-
inal or uterine end, or by stricture along its course.
In the earlier stages of the inflammation the susceptibility
to pregnancy may be engendered by the conditions, while
the existing changes unfit the internal uterine surface for the
complete nutrition of the developing embryo, and abortion
or premature discharge of the contents follows. The sub-
stitution of connective for the muscular tissue, through the
consequent uterine inertia, when gestation is completed, renders
deUvery tedious and increases the danger of postpartum bleed-
ing.
Chronic metritis is responsible for a large proportion of
the sofa and bath-chair population — ^the nervous, debilitated,
dyspeptic women who wander from physician to physician
or crowd the watering-places during the summer. The con-
dition is frequently unrecognized and untreated, and the patient
is condemned to suffer deeper and deeper wretchedness.
449. Physical Signs and Diagnosis. — ^The uterus is large,
without a change in shape. The walls are firm and rigid— in
later stages almost as resistant as a fibroid ttunor.
The organ may have a normal position, may be situated
INFLAMMATIONS.
405
at a lower level, or may be displaced. It may be freely movable
or more or less fixed; readily outlined or fixed in a mass of
pelvic exudate. The organ is sensitive to pressure.
Differential Diagnosis. — Pregnancy in the early stages pre-
sents a history of cessation of menstruation and of increased
discharge. The uterus is enlarged, the cervix soft, while the
body bulges like a jug and is not resistant. Cancer usually
involves the cervix, though the body may be the site of origin.
In the latter the bimanual examination will disclose points of
increased resistance. Bleeding results from severe manipu-
lation, and an offensive, thin, and serous discharge will prob-
ably be present. Pain is a frequent symptom, and occurs
most severely toward evening. The use of the curet or digital
exploration after dilatation with tents may be required to
confirm the diagnosis. The cureted tissue in cancer will be
friable from infiltration, exhibiting under the microscope the
characteristic cellular structure.
Small fibroids are frequently difficult to recognize, especially
when interstitial or submucous. The irregular enlargement.
well-defined points of resistance, and frequently intermittent
pain are diagnostic. Digital exploration of the uterine cavity
determines the presence, size, and situation of the growth.
Salpingitis is often associated with metritis, when it may be
difficult to determine which predominates. A small ovarian
tumor may be the cause of hemorrhage.
Rectal disease may produce symptoms simulating chronic
metritis. The general health may be so affected as to cause
the local manifestations to be overlooked. Thus, the patient
may complain of persistent cough, difficult breathing, or pro-
gressive emaciation, or the stomach may be the source of trouble,
causing loss of appetite, flatulence, and gurgling, and present-
ing evidences of dilatation. She may have precordial anxiety,
palpitation, or cardiac and vascular murmurs.
It is a good rule to make a careful uterine examination
in all cases of chronic disease.
450. Course and Prognosis-^Metritis in all forms is obsti-
nate and rebellious. The mucous membrane, muscidar wall,
and serous covering in turn are affected, followed by uterine
sclerosis, cyst formation, and, finally, chronic metritis. In
alterations of structure we can not hope to cure in the sense of
restoration of altered tissues; we can hope only for arrest of
the process, relief of congestion, and amelioration of unpleasant
symptoms.
451. Treatment. — The best treatment is preventive. It
consists in thoroughly emptying the cavity of the uterus after
labor; in early repair of lacerations; in the relief of inflam-
400 GYNECOLOGY.
matory conditions existing about the uterus; in stimulatiii|
involution of the organ by hot vaginal douches; in the ad-
ministration of ergot and of remedies that will facilitate the
contraction of its muscle-fibers ; in the exercise of such measures
as will diminish congestion; in preventing the patient from
rising too early from bed after pregnancy or abortion, and,
when the condition subsequently exists, obliging her to remain
in bed several hours daily, and to avoid sedentary occupations
and long standing. While it is important that the patient
should have sufficient rest, it is equally desirable that this
should not be excessive. A certain amoimt of exercise in the
open air is as desirable as rest. Tight clothing should be ex-
cluded. If the abdominal muscles, however, are very much
relaxed, a snugly fitting abdominal binder affords great com-
fort and relief. This relaxation of the abdominal muscles is
not infrequently associated with relaxation of the vaginal
walls, when the use of a ring-pessary gives comfort. The
circulation of the pelvis shotdd be stimulated by vaginal douches
of either hot or cold water. The latter are more stimulating,
but few patients can employ them. Patients should tate
a hot douche containing rock-salt, at a temperature of from
103° F. to 120° F., for ten or fifteen minutes before retiring.
These douches are more effective when the patient is in the
rectunbent position. She can lie across the bed with her pelvis
upon a basin or rubber pad, which should drain into a pail
below, while her feet rest upon chairs. A douche bag, con-
taining at least three pints, should be placed three feet abo\'e
the level of the patient. Prior to its use the vulva and peri-
neum should be coated with vaselin, to protect from the heat.
The tube should be introduced to the cervix, and from three
to ten pints of fluid should be used with each douche. Occa-
sionally, warm baths should be used simultaneously with the
vaginal douche. A cold hip-bath in the morning will be of
great service. Medicated baths and waters are often of value.
A course in hydrotherapy will frequently be serviceable. In
catarrh or in scrofulous and chlorotic patients iron waters are
beneficial. In nervous patients the character of the water
is unimportant, but the patient should be encouraged to take
large quantities. With dyspeptics, alkaline waters are desir-
able. In the lymphatic and scrofulous cases waters impreg-
nated with chlorid of sodium are very efficient. These are
also of value in some forms of chronic metritis where engorge-
ment of the uterine body predominates. Patients not infre
quently derive great advantage from change of air or sceii^
new surroundings, new relations, or a visit to the seashoi
or country. Constipation should be combated, preferat>
INFLAMMATIONS. 407
with foods, such as vegetables, Graham bread, and prunes;
often effectively wth other agents, as a teaspoonful of white
mustard in water at meals ; enemas to which glycerin is added ;
the administration of mineral waters — the Friedrichshall water,
Carlsbad salts, or Hunyadi Jdnos. The Carlsbad salts are of
particular value in bilious patients. A teaspoonful should be
dissolved in a glass of water and drunk in repeated sips during
fhe morning. Friedrichshall and Hunyadi act best when
mixed with equal quantities of hot water. A good mixture is
a tablespoonful of the following preparation :
R . Ma^esii sulph., 3 vj
Qmnin. sulph gr. xxiv
Acid, sulphuric, dilut.,
Tinct. capsici aa f zj
Aqua, ad f 3 vj. M.
SiG. — ^Tablespoonful three times daily.
Contraction of the uterine muscles may be increased by
the administration of ergot, which should be given in doses
of gtt. XX to f 5] of the fluidextract t. d. When the condition
is complicated with menorrhagia, extract of hydrastis canadensis
may be combined. An effective prescription would be a mixture
of ergot and hamamelis. (Section 224.) Potash salts are
especially beneficial in chronic inflammation of the uterus.
Chlorate of potash is highly recommended by Tait. lodid
of potash, however, is equally effective, and, when the patient
isner\^ous and restless, may be combined with a bromid, giving
of the iodid, gr. v, with bromid, gr. x, largely diluted with water,
three times daily. Potash salts may be administered in the
bitter tonics, as in compound tincture of cinchona or compound
tincture of gentian. In the anemic and debilitated, iron,
strychnin, quinin, arsenic, cod-liver oil, and malt extracts
will prove beneficial. The general health should be carefully
watched and any deranged condition of the various organs
should be corrected. During the menstrual period patients
should be confined to the sofa. When the pelvic distress is
marked, or when the metritis is complicated by inflammation
in the. surrounding structures, benefit will be derived from
the use of counterirritants, in the form of small blisters over
the inguinal region, or the use of iodin or of croton oil. A
good mixture is croton oil, one part; tincture of iodin, two parts;
sulphuric ether, five parts, which can be painted over the hypo-
gastric and iliac regions until a crop of pustules arises. The
application should then be discontinued until they have healed.
Exercise care not to allow the application to be made in tlie
poin. Blistering fluid may be a])plied to the cervix and to
the vault of the vagina, or tincture of iodin, or a combinatio:\
408 GYNECOLOGY.
of tincture of iodin and glycerin, may be thus used. Scanzoni
advocated this application:
B . Potass, iodid gr. iv
Glycerin., ir^xxx.
When cervical catarrh complicates the condition, punctur-
ing or scarifying ' the cervix, tmder an antiseptic stream, wiD
be beneficial. Considerable depletion can thus be effected
and the patients relieved. After the bleeding has stopped, a
tampon of cotton and gauze, saturated with one of the prep-
arations of glycerin, will prolong the depletion. A tampon
raises the uterus to a higher level and improves its circulation,
while, medicated with glycerin, it has a depletive or cholagoguc
effect upon the vessels of the cervix, causing a profuse watery
discharge. The patient may be instructed how to introduce
these tampons, and may use them daily. A tampon saturated
with a 50 per cent, solution of boroglycerid in glycerin, a 10
to 20 per cent, solution of ichthyol in glycerin, or carbolic add
(i : 16) may be kept in place for one to two days. A tampon
anointed with one part of ichthyol to four of lanolin is valuiLbie
when more or less irritation of the vagina is associated nith
the uterine lesion. In laceration of the cervix, where it btt
subsequently become hypertrophied, Emmet's operation is of
service in relieving the congestion and promoting involotion
of the organ. If the cervical mucous membrane is much everted,
with papillary projections and eroded surfaces, amputation
of the cervix by the single-flap method advocated by Schidder
(Section 336) will be more efl^ective. Any disturbances of
menstruation, such as dysmenorrhea and menorrhagia, should
receive treatment suitable for endometritis. (Section 434.)
For this condition, as well as for the chronic metritis, dilatation
and curetage of the uterus are of value. The dilatation is pref-
erably done with Pratt's dilators, as these instruments gradually
stretch the uterine canal without danger of tearing, unless
the dilatation is excessive, which may occur in the use of the
parallel-bar dilators.
After preparation of the patient (Section 181) she is placed
upon her back, the uterus is exposed by the Edebohls speculum,
the cervix is seized and fixed with a double tenaculum, prefer-
ably with two, when there will be no tearing out tmder the strain
of dilatation, and the bougies are introduced, thus gradually
dilating the cervical canal. The dilatation is followed by the
use of the curet. This instrument may be blunt or sharp;
the latter is preferable, if carefully used. The handle of the in-
strument should be perforated, so that the siu^faces can be irri-
gated as the cureting is done. The instrument is held lightly
INFLAMMATIONS. 409
thiunb and finger, and is passed into the uterus and
on all sides of the organ in long sweeps, paying par-
.tion to the angles of the body and to the orifices of
n tubes. The use of the curet in this manner does
the entire mucous membrane; even though it did,
membrane would be regenerated from the portion of
IT structure which penetrates the muscular wall.
; may be followed by swabbing out the cavity of the
tincture of iodin, with a combination of tincture
d carbolic acid, perchlorid of iron, or preferably
solution of iodoform in ether. When any of these
pt the last, are used, the irrigator should be in-
gain washing out the cavity of the organ, thus
g. 304. — Uterus Dilated with Graduated Bougies.
ly clots and superfluous medicine. If the discharge
slight, the uterine cavity need not be packed. If
siderable discharge, it should preferably be packed
tn gauze. Gauze packing is serviceable in that it
1 a tampon, decreasing the danger of bleeding or
ation of a clot of blood, which might become in-
^ve rise to extension of inflammation to surround-
•es. Second, by its pressure upon the surface it
throwing-out of exudation and shuts off the en-
sptic material into the uterine sinuses; third, by
' action it affords a hmited amount of drainage;
ts presence as a foreign body it stimulates uterine
and facilitates the prcKcss of involution. The
410 GYNECOLOGY.
vagina is carefully cleansed and a gauze pad is placed within
it, thus raising up the uterus. This gauze dressing may be per-
mitted to remain two or three days. After its removal the
vagina should be irrigated once or ivnce daily with a bichlMid
or formalin solution. When the uterine cavity has been the
seat of e.xtensive inflammation, with a predisposition to hem-
orrhage, the removal of the gauze may be subsequently fol-
lowed by uterine irrigation through a double-current catheter.
In hydrorrhea or pyometra in the aged it is very important
to make sure that drainage is complete. The accumulation
of fluid within the uterine cavity results in the formation of
a sac of this organ, the contents of which may become infected
and produce an occasional profuse discharge, which may cause
the greatest alarm on the part of the patient. Drainage in 1
such cases should be insured— when necessary, by the intro-
duction of a drainage-tube, through which the cavity is «ell
irrigated and cleansed. Remedies should be applied to the
uterine cavity which will establish a healthy inflammation
and arrest the abuormal accumulation. When the uterus
is dis]ilaccd, associated with hydrometra or pyometra which
a ])fssary fails to correct, the advisability of extirpation ot
the uterus should be considered, particularly if the woman
has passed the climacteric. Uterine adhesions or peri-uterine
INFLAMMATIONS. 411
inflammation need not necessarily contraindicate curetage,
is not infrequently the increased drainage thus secured will
result in the relief of the peri-uterine disease. In patients
ifho have suffered for a great length of time, who have become
exceedingly nervous, hysteric, with general health destroyed,
ttffering from delusions or illusions, exceedingly irritable tem-
per, a source of worry and distress to the family and to them-
wAves, no better plan of treatment can be instituted than that
advocated by Weir Mitchell as proper for neurasthenic patients.
This treatment consists in placing the patient in bed; at first
upon a distinct milk diet, with careful regulation of the bowels,
correction of disordered condition of the alimentary canal;
and, later, forced feeding, with as large a quantity of food
as the patient can properly digest. She is under the control
of a discreet, careful niu^se, who allows her to take no exercise —
nor even to move without assistance. In place of exercise
«he is given, once daily, thorough massage, thus carrying for-
ward the blood-current, stimulating the absorption of waste
material, and causing the introduction into the uttermost
parts of the body of blood containing oxygen. The anemia
which characterizes such patients is thus rapidly overcome,
the number of red blood-corpuscles greatly increases, while
the elimination of waste material is promoted. Once a day
she is given an application of the faradic current — general
faradization. She is isolated from the members of her family,
and during this period of isolation is brought under careful
mental discipline, which aims to stimulate her ambition, to over-
come the condition to which she has become subjected, so
that by the end of six weeks or two months the patient tmder-
goes a complete physical and mental change.
452. Inflammation of the Fallopian Tube. — Inflammation
of the tubes is a frequent result of infection, and the gravity
of the physical changes is directly in proportion to the viru-
lence of the poison. Gonorrhea and sepsis are the most fre-
quent forms of infection which invade these organs. The
invasion may occur through the uterus by the continuous
mucous membrane, or through the blood-vessels or lymphatics,
the former being the more frequent. The inflammation may
involve the mucous membrane, the muscular wall, and even
the peritoneum. It may be catarrhal or suppurative. Gon-
orrheal infection most frequently reaches the tube by the
continuous mucous membrane of the uterine body, and is more
prone to involve the tubal mucosa, resulting in either catarrhal
or suppurative salpingitis. It may, however, pass rapidly
over the surface epithelium into the decj)er structures of the
luf)e, and causes profound destruction. Otlicr avenues for the
412 GYNECOLOGY.
entrance of infection are an inflamed or diseased appendix, es-
pecially upon the right side, through adhesions to a knuckle of
intestine, especially where the tube contains a collection of
blood, and, finally, through the peritoneum, in which case, how-
ever, the infection is generally tubercular. The entrance of
infection into the tube is followed sooner or later by evidences
of inflammation. The epithelium becomes swollen, edematous,
and granular, with the infiltration of inflammatory materials
into the deeper layers. Serous effusion takes place into the tubal
canal. (Fig. 306.) Loss of the cilia from the epitheHmn also
Fig. 306. — Acute Salpingitis.
a. Swollen and edematous fold. b. Inflammatory exudate. ■;. Dilated blotKr
vessel, d. Desquamation of epithelium, e. Infiltration o£ leukocytes- r
Disintegration of longitudinal fold.
occurs, especially upon the free surface, while they may be re-
tained upon that portion between the folds. The epitheliuit
will be found well preserved upon the surface of the tubal mucoo:
membrane even when suppurative processes exist. (Fig. 30J-
The irritating discharge from the tube early leads to irritation o
the peritoneum and agglutination at the abdominal end c
the tube, while the swollen structures obstruct the uteris
orifice. The exudate which collects in the tube may be sero""
or purulent, according to the virulency of the infection a-'
the resistive force of the patient. In either case the exudati
is likely to increase, forming a clear serous collection in "*
INFLAMMATIONS.
J, which is known as hydrosalpinx or sactosalpinx,
e more virulent process (Fig. 308), which results in a
less extensive pus-collection, is called a pyosalpinx.
. 307. — Chronic Salpingitis showing Agglutination of Folds.
if folds forming gland-like areas, b. Thickened and retracted fold'
)eaquaination of epithelium, d. Hyperplasia of tubal wall.
«. 30S. — Extensive Pus-colli
with General Adhesions.
414
GYNECOLOGY.
(Fig. 309.) Occasionally the excessive hyperemia or a partial!
twisting of the base may cause rupture of the blood-vessels I
with an intratubular accumulation of blood. This condition 1
is denominated hematosalpinx. The latter condition, how- '
ever, is more frequently associated with the retrogressive pro ■
cesses of ectopic gestation. As a resiUt of the inflammatory
process the tube may assume the form of a simple sac, whidij
gradually becomes distended until it attains a large size, .
presents as a thin-v
cystic tumor. If the i
toneal wall has not I
involved, the tumor na^* ]
remain freely movabli- j
whether it contain senui'
or pus. Such a sac may, oc-
casionally, become twisted
upon itself until the veoots ,
circulation is partially or
completely obstructed, and
then rapid increase in SK
results from the hemor-
rhage, which takes {dace
not only into the sac, but
also, occasionally, into the
peritoneal cavity. A young
girl recently came undermy
observation in whom there
had been an apparent acute
exacerbation. Examina-
tion revealed a large mass
upon either side, that on
the left side being situated
above the uterus, and that
on the right posterior to and
below the fundus. An op-
eration was advised and {
subsequently performed.
This revealed so much blood
as soon as the abdomen was opened as to arouse the suspicion
of an ectopic gestation. The hemorrhage in this patient came
from the tumor of tlie left tube, the neck of which was twisted
near the uterus. Tlic tubal sac was dark (Fig. 312), and covered
with clotted blood, which also filled that side of the pehis.
The right sac was clear and free from blood. Both sacs were
found to contain pus, the left being mixed with blood. Both
tubes WLTc free from adhesions. Sometimes the distention ct
Fig, 309.-
INFLAMMATIONS. 415
■bal sac overcomes the swelling of the mucous membrane
uterine end, and, therefore, its opening remains patulous
and permits its
contents to es-
cape, after which
the sac attains
a favorable posi-
tion. Such a con-
dition may lead
to occasional dis-
charges of a
considerable
quantity of fluid
through the uter-
us, giving rise to
the phenomenon
known as hy-
drops tubje pro
fluens or nter
mittent hydro
salp nx Inflim
3 — S ntic Fold
from Wa 1 of Pus-
t be enWrgcd L tie
through uppir por-
Folds matted together form ng i,land I kc
cea. b, b. Folds undergoing d >: olut n
IW9 complete desquamation of ep th 1 um
ering folds, d, d. Blood-vessels d stend d
b blood -cells, i: Leukocytic nf 1 rat on
I of the tube involving its muscular wall causes a shortening
longituilin.-il muscular fibers, \vliicli, owing to the mnbiiity
subscri)s;i, permits the fimliria tn be ilrawn into the
416
GYNECOLOGY.
tube and the peritoneum to be pushed over it like the
puce over the glans penis in phimosis. (Fig. 313.) The
toneal edges coming in contact are agglutinated, and the ti
sealed up. If the fimbriae are not completely withdrawi
protruding fimbriae may serve as an avenue for leakage in
sequent distention of the sac and thus cause recurring at
of localized petite
(Fig. 3M-)
The tubal in
mation, insteac
forming the (
tumor already
cribed, may resu
extensive small-a
filtration and thi
ing of the longitu
folds, which nw
rily decreases the
ber of the tube.
thermore, in plaa
edges of the fold
their epithelium
come more or
adherent, and
microscopic sec
present theappea;
of distended gl
Such a conditior
been called salpii
cysto-adenosa, bu
term, like salpii
foUicularis, pach
pingitis. and 1
designations, is ai
necessary distine
The inflammator
filtration frequ'
involves the folds
wall of the tube,
ducing such hyperplasia of these structures as almost to oblit
the tubal canal and to form a large sclerosed mass. Thecoi
tion of the circular fibers may cause the formation of a sei
small sacs, each one of which is independent of the otha
for which the only relief is afforded by the extirpation of the
In the more virulent forms of infection the peritoneal s
of the tube becomes in\-oh-ed by an extension through i
Fig. 313. — Distended Pus-tubes Removed from
Young Girl.
A. Tube whose pedicle was twisted. Sac filled
with blood and pus. B. Right tube filled
with pus.
^\r
INFLAMMATIONS. 417
linal end or through its walls, and extensive adhesions unite
organ to coils of the intestine, the uterus, the ovary, or the
ic peritoneum. The enlarged and swollen tube drops down
the retro-uterine culde-
and generally becomes
erent to the sigmoid
nre or side of the rec-
L As the sac becomes
■e and more distended
union thus formed may
nit the establishment
1 communication with
lumen of the bowel,
mgh which the tubal
:ess drains. The tube
sne side, dropping into
pelvis, may become
erent to the extremity
the other and form a
imon pus cavity, which may attain a large size. (Fig. 315.)
a rupture of the tube, infection of Douglas' pouch may occur,
s filhng the entire pelvis with a walled-ofE abscess. '^The
mate association of the abdominal orifice of the tube with the
e:m
try causes frequent adhesions between these organs, result-
in intimate fusion of the involved structures, ami rendering
ometimes difficult to differentiate between the two organs.
418
GYNECOLOGY.
Occasionally they appear as a tubo-ovarian tumor or a lusidl
inflammatory mass, which may contain serous fluid or pus.
453. Symptoms. — Tubal inflammation has no charaderi
symptoms. If a patient has had an acute pelvic inflairima6i*»i
characterized by extreme tenderness in either pel\-ic regiift 1
and aggravated by motion, it is justifiable to conclude tW-
the possible pelvic peritonitis has had its origin in a tubal in-
flammation. When each menstrual period is followed bj
Fig-S'S- — Double Tubo-ovarian Collection.
pain and tenderness in the inguinal regions, tubal inflammatio
is very probable. A normal tube is not usually palpable. I
diseased conditions, however, especially when the tube hs
become thickened by salpingitis or parenchymatous inflait
mation, it may be recognized as a more or less thickened cor
which slips under the finger and is quite sensitive. \Vhe
hyperplasia of its connective tissue occurs, the tube is felt as
INFLAMMATIONS. 419
acted, distorted, nodular mass, closely associated with
terus and frequently firmly fixed in the pelvis. When the
ninat end is closed, it may present an enlargement increas-
■om the uterus outward, something like a bell-retort or
in shape, or resembling a sweet potato or sausage or
ne-like links.
\, Diagnosis. — When the uterus is bound down, with evi-
jf extensive peritoneal inflammation upon either side of the
in the majority of cases the tubes will be found to have
he source through which the infection has reached the
leura. In a normal condition, unless the patient is
tiin, the tubes are not palpable. Inflammatory change,
•r, which renders the tubes resistant and causes them to
sned, leads to their recognition, so the determination of a
te structure running out from the side of the uterus is evi-
)f tubal inflammation. Where the tubes become occluded
r abdominal ends and filled with secretion, they become
ind more retort-
, being larger at
nual portion and
ii^ toward the
A tumor pre-
Buch a shape as
id quite movable,
, firaquently a hy-
Jax. (Fig. 316.)
oe that pus-tubes
times be free from Fig. 316.— Hydrosalpinx,
PDi, but in the
y of cases the infection which is so virulent as to lead
formation of pus causes a perisalpingitis, which leads
lutmation of the surrounding structures, and not infre-
r to absolute fixation of the pelvic structures. Where
le is free from adhesions, it is likely to drop into Douglas'
Here the change in the circulation not infrequently
o it becoming adherent to the posterior surface of the
the sides of the rectum, or the ovary and tube of the
X side, forming a large mass filling up the pelvis. (Fig.
These conditions are readily reco^ized by bimanual
.on. In practising this procedure, however, it is very
ant that it should be done with great precaution, re-
aing that not infrequently these sacs may be so thinned
3due pressure may lead to their rupture with the escape
r contents into the peritoneal cavity, causing a general
m, to be followed subsequently by j)eritonitis. The
tion of the ovary in a mass of this kind, forming a tubo-
420 GYNECOLOGY.
ovarian abscess, is not always readily recognized. A tubiy \
ovarian cyst is more readily determined by the increase in '
size, by the greater spherical character of the external end d
the sac, associated u-ith a bell or retort-like shape as we ap-
proach' the uterus.
455. Prognosis. — Tubal inflammation should always be con-
sidered a source of danger. Even its mildest forms should
necessitate resort to treatment, in order, if possible, to am*
Fig. ji ;. — UouUt- Pyosalpii
tlie progress and limit the extension of the inflammation. WJ
associated with jK-lvic peritonitis, the extensi\'e infecti'
especially the streptoc(>ccic form, is one of the most dangen
lesions with which we have to deal. When associated w
disease of the ovaries and extensive suppuration of the tn
the cure of the patient, in the sense of restoration of her fu
tions, is absolutely impossible. While the patient may recc
her health and cnnifort, she is subsequently crippled for
l>ocause her powers of procreation are destroyed.
INFLAMMATIONS.
421
Treatment. — (See Section 459,)
456. Inflammation of the Ovary. — Inflammation of the
ovary occurs in two forms: oophoritis, inflammation of the
structure of the organ ; peri-oophoritis, where the inflammation
is confined to its surface. A hyperemia or congestion of the
ovary may arise as a result of infection. This may be so ag-
gravated as to lead to rupture of vessels. The occurrence of
hemorrhage into the structure of the ovary produces small
collections of blood-clots in the organ, known as ovarian apo-
plexy, or a large collection of blood, an ovarian hema-
toma. The latter may destroy the ovary and even rupture
its coat, and result in a serious internal hemorrhage. Oopho-
ritis is an interstitial inflammation of the ovary, which may
be either acute or chronic, septic or gonorrheal. It is char-
acterized by all the signs of inflammation, hj-peremia, swell-
ing, increase in size of the vessels, extravasation of blood, and
later pus-formation. The latter may involve only a small
portion of the ovary or the entire organ may become the seat
of an abscess. The origin of the infection not infrequently
arises in a corpus luteum, so we have what are known as corpus
luteum abscesses. In these cases the walls of the abscess may
be recognized by the wa\-y elevations of the inner wall on micro-
scopic section. The acute form of the disease is most frequently
the result of infection ; the latter gains admission through lesions
of the vagina, of the uterus subsequent to labor or abortion, sur-
gical operations, or an accidental injury. Infection may reach
the ovary through the continuous mucous membrane of the
tube or by way of the lymphatics or blood-vessels. In fatal
cases the ovary will often be found very much enlarged, soft,
and sloughing, and containing small extravasations of blood
or pus, or small collections of pus will be found in the con-
nective tissue and structure of the ovary, or a single large abscess
may exist, equal in size to a hen's egg or even larger. The
larger abscesses may be produced by suppuration of an ovarian
cyst. Suppurating ovaries generally become adherent to the
neighboring structure, and, if the walls are thick, the pus may
remain quiescent, thus being the cause of a chronic state of ill
health. However, the pus may escape by rupturing into the
bowel, bladder, or vagina. The cavity thus emptied may
shrink and ultimately disappear, while a state of chronic ill
health will still continue. An inflamed or cystic ovary, ad-
herent to the inflamed tube, frequently loses the intervening
wall and forms a concavity, which is known as a tubo-ovarian
cyst or tubo-ovarian abscess. Coalescence of both
and tubes in such a sac may result in the formation of a tumor
which fills up the pelvis. The formation of an abscess in the
'\'j:2 gynecology.
1 1\ .11 V ir>> ii'ii. .'ilways asv/.iate'': with x.ieri-C'Ophoritis. Some years
ii^v I -^'iw a p.'itiriii in o'^nsultation. and subsequently operated
ii|iMii Im'i. ill wlioni, some three weeks follo^^"ing her delivery,
luj iriii|M r.iliin* ros<; V) 104*^ F. Careful examination failed
(.1 ummI iiiiy iinrrasc in the size of the uterus or anything to
milifiili- lliiit iIm* uterus was the seat of disease. Some en-
l.iij'i imiil lit llif ovary ujnm the left side, which, however, was
hii' hiHii .tillirsiuiis, M me to open the abdomen. After enter-
lui' I III' iilulMmiiial cavity the left ovary was found the size of
.» r,m.»ll .HiHi^M'. ii was free from any adhesions, but had a small
il.iUi- .>( iMMpli Mil one side, which corresponded to a similar
\\aIx' \\\ ilu- niiliif «»1" llie tube. The tube itself was not enlarged
u»M ill. I »i jilu»\v aiiv si^ns of an inflammatory condition. The
,»\.n\ w.i^ .ilh'iwanl removed and, when opened, contained
nnwImu .1 ilun j.lii'll suine ihiek, j^reenish pus. The subsequent
. .M\\.»K '.I *'»»!*• t'l llu* patient was uninterrupted. In chronic
,-,'.':..>ni»*. ilu'ii* ir» a jMTat increase in the connective tissue,
N\:,, !'. u-.nll*. \\\ ronirai'tion and thus causes destruction of
\-., .,:!»iU-. .mil ii»inpressioi\ and arrest of development of the
^ \\!\iK' \\\s' *'|Miheh\nn o!" the free surface is the longest
»s ,.\x,'. V\\v. \\\A\ present extensive fissures, the residt
.-, , .'.\'.!.;i M«Mi lt\ *'ln\M\iv* inilammation the tunica albu-
. . -^..-vx- i".i.;il\ ilMx'kvM'.eil. si^ it J.vvs not readily rup-
, , ^^ , ■ .*» .\ \*'*..M»i'.u'.'.' V*'. il*o ^.ir.i.itu:! idlicle. The con-
•/•»• ■.,*!!\x \' •.•*A"A\;ses v.\ s:/o. and such an ovar\'
X , . . . .« w.\r\\\'\ r[ v\>'.s yv.\:v.c:r.g: the condition
\* -...rv. Another form
■. .• .'\.:-\ '-.:> Vocr. denominated
. \ ••'.■.■•. ".rMVl^n is chronic
■ . .' ■■'..' r,:;.* 0: cases it is
.-.. . ><-,:;.:el c: fevers,
NX ■ x .■•!.:: rr.:iy follow
■.s Vcv/rr.e swollen,
-^ • Ir. Advanced
X ,irjA aln^.ost
: .:;*■ ;cl::erdted.
-. ^-."j^ cringes
-0'"- -wTere rro-
- •-• ^-cr-er^'Vise
. .■■■■■Ill* » •••
x"i
- .:e
INFLAMMATIONS. 423
Mf a true oophoritis. This condition, like simple odphoritis,
T frequently a part of a widely extended inflammatory process,
"^ h may involve uterus, oviducts, ovaries, pelvic peritoneum,
d cellular tissue. (Fig. 318.) It is generally consequent upon
1 extension of infection from the tubal orifice to the pelvic
ffttitoneum. although it may follow an abscess of the ovary.
|«leend of the tube is usually associated" with the ovary in
1(is fomi of inflammation, and it may be the forerunner of a
frtnbo-ovarian abscess. The inflammation varies from a few
'"•nds of adhesions which bind down the ovary and tubal orifice,
•possibly occluding the latter, to a mass of exudation which
Fig, 318. — Peri-oOphoritis. Tube and Ovary Encysted.
completely obscures both and forms so intimate a fusion as to
render difficult the line of demarcation between these organs.
The chief function of the ovary, apart from any supposed
internal secretion, is to provide a site for the perfect develop-
ment and maintenance of healthy ova, and to permit them,
under circumstances as yet undetermined, to pass into the
mouth of the oviduct. Peri-oophoritis necessarily interferes
with this process, by the presence of adhesions about the ovary
or the consequent induration of its tunic. An ovum escap-
ing from a matured Graafian follicle will be barred from en-
trance into the oWduct by adhesions which fix the fimbriated
orifice or so envelop the ovary as to prevent it reaching the
oviduct. Such adhesions are a cause of severe suffering, espe-
cially when they limit the free mobility of the ovary and fix it
% *'/// ♦, Vy ;>:':v/jr';. as ^j^ttArA the uterus or over the rectum, or
//;.'?<; ,;,V'A;,va1 aMh':-:iorjs subject it cor^stantiy to dragging and
♦-/r»i'..'/ri •/•/ jriV:MinaI j^rristalsis. An ovar\- fixed in the retro-
\iUu}J: iy/'ir}i, v/ith an overlying retro verted uterus, is a con-
i;t.;»fit '/f'lrr': of distress. Its position, independent of the ad-
Ji<:MOfr,, ' aij'/:'v ^:on;^estion from the obstructed circulation, while
til' \ftt.'/,Mrt: of U'/jt-i and the impinging male organ during coi-
t,iori aijj^ffj'Tnt iJie (hHCfjmlfjTt.
457* Symptoms. - Oophoritis exhibits no characteristic symp-
Iniii', ly/t'ti in cas^;s of acute septic poisoning no symptoms
will h<! \iri"j'.ul which can 1x5 said to be absolute indications
o/ ;tn ov;irian hision. In the less severe form of inflammation
w fiii'iy ri'f'i}y^umt symptoms which we could justly attribute
III ov;iiiafi discaw;, but they are so intimately associated with
Uio'n- I iiw.j'A liy (iis<jase of the oviducts that it becomes difficult
III iWlit'vrwiiiiUi tlicm. Pain is the only constant symptom
III ;ill v;irirti<!S of jxjlvic inflammation, and the site to which
It. ill irlnrrd Ixturs no constant relation to the affected organ.
Thr rutin* privic rcj^Mon may be the seat of pain, but we are,
liciwrvc'!', niiablc^ definitely to distinguish the exact origin of
piiiii ;i!hI say wlirlluT it is due to affections of the tube, ovary,
priii«»tiiMiin, l)PK»cl li^amtMit, body of the uterus, cervix, or in-
ilipriHlrut. of clisnnlrr inany of them. We can readily appreciate
t lii'i wliiMj \vr rrnuMiihor Ihat the nervous distribution of the vari-
nii'i «»iy..mr; is (U'Hvi'd from a common sympathetic center. As
in .inN' inllnuinatory ronililion, pain is aggravated by pressure,
■.M in inll.nninatory i>nKVSSos of the pelvic structures pain is
m.if.inlu'il \^\■ prrssun* and motion. The pain is distinguished
li»»in that i»l iiniMlvsnuMiorrhoa by the fact that it is an exagger-
ation »»l tluMlistrossand is toll hot ween the periods, while true dys-
inrn«»i i Ium is pnrclv a inonslnial \\\\n. Not infrequently patients
will aNMiir ns that tl\c only linio ihey are free from discomfort is
Mmiin* thr menstrual \\o\\. Pain may jx^rsist subsequent to coi-
ii.Mi a*, a M'Nvili oi roni:i\siivo lonsivMi. When produced by intra-
al'J»Mn\nal pivssuro auvl inoroasovl by standing, pain is greatly
ixMh-NTxl b\ aNsnntiUi: tlio iwuinlvnt ]vsition. Ovarian pain is
*lnv\ tl\ a':*Ma\aiv\i hv pivssinv over tr.o organs through the va-
I'ma oi iv'.wun. as vliirnvc ».\Mtus. .1:1 oXsvir.ination, or the passage
oi \a\\w ixwi! '.r.r^'^v^s I'V.o x.iriv^us syiv.ptoms of peh*ic disease,
-aix !', a. ;*'rv"-..^: •. '\ ,-.. !r.v^-/.v^vr;\.ii::.i. x^r 'oukorrhoa. are not char-
u^'*.i.',\ ^v .\^'/'.^- ••..s :\^-/*. vV"i^*.^r.:i> vMuses pain which is
\\^",' x'- \- . . .■•■.. -wx ; \\"- v^ ". ..'. :"'o w/.-.c' ^ri::i. and extends
< «
W '
. \' .. \\ ..\'. >-..-.o N\^: infrequently pain
x'\\'--, \x • ■ ■ \* / ^- .'- ' ■" ;-'c >•■:.".>: The inflammation
•.\ . \ , ■ ■ • . - . / . ■.'.• ■ ..:"v :r.::^ its substance
>.' . . . - - ■■ ■>■. ;.-.:> rr'.lisTles. or hem-
INFLAMMATIONS.
42S
orrhage, producing a condition, in tlie one case, known as cystic
degeneration of the ovary, and, in the other, as ovarian hema-
toma or ovarian apoplexy. The wide distribution of neurotic
symptoms must not be overlooked. The local pelvic lesion
may be a minor one. To oophoritis or uterine displacement
are often attributed symptoms wliich are the result of fissiires
of the cervix, mobility of the kidney, enteroptosis, gastroptosis,
or even central lesions of the nervous system, which will per-
sist after the supposed local lesion has been cured or removed.
Such experiences are a source of great disappointment to the
medical practitioner. At times rehef is obtained, at others
pain and distress continue or are even aggravated.
458. Diagnosis. — Inflammatory processes of the ovary do not
present a constant characteristic clinical picture. The infection
rarely confines itself to the ovary, consequently the sympto-
matic phenomena are modified by the circumjacent inflamma-
tory changes. The recognition of a tender body, somewhat
enlarged, yet retaining the shape of the ovary, by vaginal or rec-
tal palpation, adds certainty to the diagnosis. The presence of
adhesions or exudate will render its determination difficult
and make it doubtful how much the swelling is due to the
ovary, the tube, or the exudate. In acute conditions or in
hyperesthetic patients an anesthetic will prove of value.
Where the obscurity of the condition can not be overcome, a
preliminary vaginal or abdominal incision may be necessary in
order to determine the proper operative procedure.
459. Treatment of Inflammation of the Appendages. — In
the great majority of chronic inflammations of the uterine
appendages the treatment of diseased conditions of the tubes
is similar to that of diseases of tiie ovaries, or, in other words,
the two conditions are so closely related that I deem it better to
consider their treatment under the one section. The first aim in
the treatment should be the preservation of the function of the
affected organs. The second, the restoration of health to the
patient. Treatment may be either medical or surgical. The
medical or nonoperative treatment consists in rest in bed and
in keeping the patient absolutely quiet. Free purgation shotild
be established by the use of salines in order to make the in-
testines drain the peritoneal cavity and relieve the congestion.
The diet should be restricted and cold should be applied to
the external surface. In the acute stage the application of
cold in the form of the ice-bag is of value, and this should be
kept more or less continuously applied. The ice-bag decreases
the congestion, limits the exudation, lessens the danger of
suppuration, and promotes absorption. After the more acute
symptoms have subsided the treatment may still further be
424 GYNECOLOGY.
subject to pressure, as behind the uterus or over the rectum, ■
where intestinal adhesions subject it constantly to dragging a
tension by intestinal peristalsis. An ovary fixed in the retrc
uterine pouch, with an overlying retroverted uterus, is a i
stant source of distress. Its position, independent of the ;
hesions, causes congestion from the obstructed circulation, ■
the pressure of feces and the impinging male organ during coi^J
tion augment the discomfort.
457- Symptoms. — Oophoritis exhibits no characteristic symp-^
toms. Even in cases of acute septic poisoning no symptoms
will be present which can be said to be absolute indications
of an ovarian lesion. In the less severe form of inflammation
we may recognize symptoms which we could justly attribute
to ovarian disease, but they are so intimately associated with
those caused by disease of the oviducts that it becomes difficult
to differentiate them. Pain is the only constant sj'mptom
in all varieties of pelvic inflammation, and the site to which J
it is referred bears no constant relation to the affected orgaiL.!
The entire pelvic region may be the seat of pain, but we ^16,-4
however, unable definitely to distinguish the exact origin of "
pain and say whether it is due to affections of the tube, ovary,
peritoneum, broad hgament, body of the uterus, cervix, or in-
dependent of disorder in any of them. We can readily appreciate
this when we remember that the nervous distribution of the vari-
ous organs is derived from a common sympathetic center. As
in any infiammatory condition, pain is aggravated by pressure,
so in inflammatory processes of the pelvic structures pain is
magnified by pressure and motion. The pain is distinguished
from that of true dysmenorrhea by the fact that it is an exagger-
ation of the distress and is felt between the periods, while true dys-
menorrhea is purely a menstrual pain. Not infrequently patients
will assure us that the only time they are free from discomfort is
during the menstrual flow. Pain may persist subsequent to coi-
tion as a result o£ congestive tension. When produced by intra-
abdominal pressure and increased by standing, pain is greatly
reUeved by assuming the recumbent position. Ovarian pain is
directly aggravated by pressure over the organs through the va-
gina or rectum, as during coitus, an examination, or the passage
of large fecal masses. The various symptoms of pelvic disease,
such as amenorrhea, menorrhagia, or leukorrhea, are not char-
acteristic of oophoritis, Peri-oophoritis causes pain which is
more or less distinctly localized at the pelvic brim, and extends
down the thigh of the affected side. Not infrequently pain
is experienced in the corresponding breast. The inflammation
may extend from the surface of the ovary into its substance
and cause changes in its stroma, dropsy of its follicles, or hem-
INFLAMMATIONS. 426
orrhage, producing a condition, in the one case, knoviti as cystic
degeneration of the ovary, and, in the other, as ovarian hema-
toma or ovarian apoplexy. The wide distribution of neurotic
symptoms must not be overlooked. The local pelvic lesion
may be a minor one. To oophoritis or uterine displacement
are often attributed symptoms which are the result of fissures
of the cervix, mobility of the kidney, enteroptosis, gastroptosis,
or even central lesions of the nervous system, which will per-
sist after the supposed local lesion has been ciu^ed or removed.
Such experiences are a source of great disappointment to the
• medical practitioner. At times rehef is obtained, at others
pain and distress continue or are even aggravated.
458. Diagnosis. — Inflammatory processes of the ovary do not
present a constant characteristic clinical picture. The infection
rarely confines itself to the ovary, consequently the sympto-
matic phenomena are modified by the circumjacent inflanmia-
tory changes. The recognition of a tender body, somewhat
enlarged, yet retaining the shape of the ovary, by vaginal or rec-
tal palpation, adds certainty to the diagnosis. The presence of
adhesions or exudate will render its determination difficult
and make it doubtful how much the swelling is due to the
ovary, the tube, or the exudate. In acute conditions or in
hyperesthetic patients an anesthetic will prove of value.
Where the obscurity of the condition can not be overcome, a
preliminary vaginal or abdominal incision may be necessary in
order to determine the proper operative procedure.
459. Treatment of Inflammation of the Appendages. — In
the great majority of chronic inflammations of the uterine
appendages the treatment of diseased conditions of the tubes
is similar to that of diseases of the o\-aries, or, in other words,
the two conditions are so closely related that I deem it better to
consider their treatment under the one section. The first aim in
the treatment should be the presen-ation of the function of the
affected organs. The second, the restoration of health to the
patient. Treatment may be either medical or surgical. The
medical or nonoperative treatment consists in rest in bed and
in keeping the patient absolutely quiet. Free purgation should
be established by the use of salines in order to make the in-
testines drain the peritoneal cavity and relieve the congestion.
The diet should be restricted and cold should be applied to
the external surface. In the acute stage the appHcation of
cold in the form of the ice-bag is of value, and this should be
(kept more or less continuously applied. The ice-bag decreases ^^
the congestion, hmits the exudation, lessens the danger of ^^H
suppuration, and promotes absi^rption. After the more acute ^^^|
symptoms have subsided the treatment may still further be ^^^|
424 GYNECOLOGY.
subject to pressure, as behind the uterus or over the rectum, or \
where intestinal adhesions subject it constantly to dragging and
tension by intestinal peristalsis. An ovary fixed in the retro-
uterine pouch, with an overlying retro verted uterus, is a con-
stant source of distress. Its position, independent of the ad-
hesions, causes congestion from the obstructed circulation, while i
the pressure of feces and the impinging male organ during ca-
tion augment the discomfort.
457. Symptoms. — Oophoritis exhibits no characteristic symp-
toms. Even in cases of acute septic poisoning no symptomi
will be present which can be said to be absolute indicatiom
of an ovarian lesion. In the less severe form of inflammation
we may recognize symptoms which we could justly attribute
to ovarian disease, but they are so intimately associated with
those caused by disease of the oviducts that it becomes diflScult
to differentiate them. Pain is the only constant symptom
in all varieties of pelvic inflammation, and the site to which
it is referred bears no constant relation to the affected organ.
The entire pelvic region may be the seat of pain, but we are,
however, unable definitely to distinguish the exact origin of
pain and say whether it is due to affections of the tube, ovary,
peritonetun, broad ligament, body of the uterus, cervix, or in-
dependent of disorder in any of them. We can readily appreciate
this when we remember that the nervous distribution of the vari-
ous organs is derived from a common sympathetic center. As
in any inflammatory condition, pain is aggravated by pressure,
so in inflammatory processes of the pelvic structures pain is
magnified by pressure and motion. The pain is distinguished
from that of true dysmenorrhea by the fact that it is an exagger-
ation of the distress and is felt between the periods, while true dys-
menorrhea is purely a menstrual pain. Not infrequently patients
will assure us that the only time they are free from discomfort is
dining the menstrual flow. Pain may persist subsequent to coi-
tion as a result of congestive tension. When produced by intra-
abdominal pressure and increased by standing, pain is greatly
relieved by assuming the recumbent position. Ovarian pain is
directly aggrav^ated by pressure over the organs through the^'a•
gina or rectum, as diuing coitus, an examination, or the passage
of large fecal masses. The various symptoms of pelvic disease,
such as amenorrhea, monorrhagia, or leukorrhea, are not char-
acteristic of oophoritis. Peri-oophoritis causes pain which is
more or less distinctly localized at the pelvic brim, and extends
down the thigh of the affected side. Not infrequently paifl
is experienced in the corresponding breast. The inflammation
may extend from the surface of the ovary into its substance
and cause changes in its stroma, dropsy of its folHcles, or hem-
INFLAMMATIONS. 425
orrhage. producing a condition, in the one case, known as cystic
degeneration of the ovary, and, in the other, as ovarian hema-
toma or ovarian apoplexy. The wide distribution of neurotic
symptoms must not be overlooked. The local pelvic lesion
may be a minor one. To oophoritis or uterine displacement
are often attributed symptoms which are the result of fissures
of the cervix, mobility of the kidney, enteroptosis, gastroptosis,
or even central lesions of the nervous system, which will per-
sist after the supposed local lesion has been cured or removed.
Such experiences are a source of great disappointment to the
* medical practitioner. At times relief is obtained, at others
pain and distress continue or are even aggravated.
458. Diagnosis. — Inflammatory processes of the ovary do not
present a constant characteristic clinical picture. The infection
rarely confines itself to the ovary, consequently the sympto-
matic phenomena are modified by the circumjacent inflanmia-
tory changes. The recognition of a tender body, somewhat
enlarged, yet retaining the shape of the ovary, by vaginal or rec-
tal palpation, adds certainty to the diagnosis. The presence of
adhesions or exudate will render its determination difficult
and make it doubtful how much the swelling is due to the
ovary, the tube, or the exudate. In acute conditions or in
hyperesthetic patients an anesthetic will prove of value.
Where the obscurity of the condition can not be overcome, a
preliminary vaginal or abdominal incision may be necessary in
order to determine the proper operative procedure.
459. Treatment of Inflammation of the Appendages. — In
the great majority of chronic inflammations of the uterine
appendages the treatment of diseased conditions of the tubes
is similar to that of diseases of the ovaries, or, in other words,
the two conditions are so closely related that I deem it better to
consider their treatment under the one section. The first aim in
the treatment should be the preservation of the function of the
affected organs. The second, the restoration of health to the
patient. Treatment may be either medical or surgical. The
medical or nonoperative treatment consists in rest in bed and
in keeping the patient absolutely quiet. Free purgation should
be established by the use of salines in order to make the in-
testines drain the peritoneal cavity and relieve the congestion.
The diet should be restricted and cold should be applied to
the external surface. In the acute stage the application of
cold in the form of the ice-bag is of value, and this should be
Lkept more or less continuously applied. The ice-bag decreases
the congestion, limits the exudation, lessens the danger of
supptu"ation, and promotes absorption. After the more acute
symptoms have subsided the treatment may still further be
426 GYNECOLOGY.
promoted by the application of pressure, using three to five
pounds of shot in a bag, which is applied over the inflamed,
indurated tissues; the pressure is increased and its position
changed as the condition may demand. Unless suppuratioB
has occurred, resolution will probably be accomplished. The
absorption may be still further promoted by the use of counter-
irritants, such as small blisters, painting with iodin, the vat I
of croton oil, or inunctions of dilute ointment of the iodid of"!
mercury or a dram of the official ointment to an ounce of lanolin. !
Occasionally ice w411 be very uncomfortable to the patient, whik
heat will be more grateful. A flaxseed poultice may be ap- 1
plied, or, what is probably much more agreeable to the patient '
and more easily applied, would be to take a piece of spongio-
pilin, wring it out of hot water, and place it over the abdomen,
and over this a dry cloth. This should be changed as frequently
as may be necessary. The changing may be made less frequent,
however, by the application over it of a hot-water bottle. Ich-
thyol in lanolin, one or two drams to the ounce, may be rubbed
into the lower part of the abdomen, and this supplemented
by the pressure already suggested. Hot vaginal douches
should be employed, and benefit will frequently be obtained
from the use of hot rectal enemas, using a pint to a quart of hot
water and directing the patient to retain it as long as possible.
This is more effective than hot vaginal douches, for the reason
that the heat comes more nearly in contact with the inflamed
surfaces and can be retained for a greater length of time. In-
ternal medication during this time, aside from the application
mentioned, should be largely supporting. The patient should
be carefully protected from any possibility of exposure or
overfatigue. During the menstrual period it is preferable
that the patient should be confined to bed. The more acute
stages having subsided, in addition to the douches and enemas
recommended the patient may take a hot sitz-bath for fifteen
to thirty minutes daily. With the further subsidence of the
acute symptoms and in those cases in which it is evident that
suppuration has not occurred, the adhesions binding down
the ovaries and tubes may be overcome by the employment
of pelvic massage. The structures are lifted up with one or
two fingers within the vagina and manipulation over the ab-
domen employed, gradually pressing the fingers in so as to
follow lines of cleavage and to lengthen the bands of adhesions
or promote their absorption by stretching and irritation. The
congestion and pain in chronic inflammation of the ovary may
frequently be very greatly lessened by the administration
of fluidextract of gelsemium, giving five drops three times
daily. In these conditions great prudence must be exercised
INFLAMMATIONS. 427
I the administration of anodynes. A patient suffering from
elvic pain as a result of attacks of peritonitis, with binding
(own of the pelvic viscera, may very easily be led into the
labit of taking morphin or opium until, instead of it simply
CKing a servant, it attains the position of master, and the patient
Ends herself enslaved to a drug from which emancipation is
very difficult. While it may be necessary, in an acute attack,
to administer a dose of morphin in order to allay the violent
pain, yet, in the majority of cases, the early and continuous
administration of salines, associated with the application of
the ice-bag, will be effective in arresting the severe pain, or
at least in making it endtirable. The measures which we have
alreadv discussed are in the line of what we have denominated
the first aim in the treatment of lesions of the uterine appen-
dages— that is, to maintain the functions of these organs.
Surgical Treatment: — The surgical treatment does not neces-
sarily exclude the object which we have considered as the first
aim in treatment, but may, indeed, assure its accomplishment,
especially when early and efficiently established. Delay, how-
ever, would almost certainly favor the development of conditions
which would necessitate more serious procedures. Operative
treatment, with a view to maintenance or restoration of func-
tion, is known as conser\"ative treatment. Where the sacrifice
of the appendages is considered necessary, in order to save
* life or insure good health, the procedure is known as a radical
one. Conser\'ative treatment may consist in the breaking
up of adhesions, the reopening of the orifice of the tube, sal-
pingostomy, or the partial resection of the tube itself, thus
shortening it and permitting the removal of those portions
which are prejudicial to health. (Figs. 319 and 320.) This
procedure also comprises the resection and removal of any
diseased portion of the ovary, with the endeavor to retain a
sufficient portion of the organ to insure the continuance of
ovulation and menstruation. In chronic oophoritis with marked
thickening of the tunica albuginea and the development of
small cysts in the ovary, a resection of the ovary or removal
of the more diseased portion will frequently result in such
metabolism as to restore the remaining portion of the ovary
to a more normal condition. Wherever conditions wdll permit,
? portion of the ovary should be retained ; its retention will
insure the continuation of menstruation and ovulation and
have a marked influence upon the general morale and nervous
condition of the patient. The retention of the whole or a
part of the ovary is desirable even though it may be necessary
to remove both tubes, because it insures the continuation of
ovulation and menstruation. This has a marked influence
GYNECOLOGY.
Upon the nervous system of the patient. In surgical opera-
tions we are obliged to be governed by the physical condition
of the organs under consideration. The abdomen should not
be opened unless palpable disease of the uterine appendaga
by physical examination can be determined. Operations for
of Tub« Completed.
pain in the region of the ovary, without ovarian enlargement-
will most frequently be attended with no favorable result.
Where the disease is extensive and ovaries and tubes ha^"^
undergone destruction, the removal of these organs will otWt»-
times be the only procedtore that will afford any hope for res-
toration of the comfort and health of the patient. In suV
INFLAMMATIONS.
purative conditions where the ovary is also involved in the
inflammatory process the better plan of procedure will be
the removal of the ovary and tube complete. In a patient
upon whom I recently had to operate the left ovary and tube
were so extensively involved that their removal was indicated.
The right tube was considerably enlarged, its wall was several
times its ordinary thickness, and the cavity of the tube contained
pus. In this case, the left tube and ovary having been re-
moved, the right tube was dissected out from tlie comua of
the uterus and the opening in the broad ligament was closed
■n-ith a continuous catgut suture, thus controlling hemorrhage.
The ovary, as it presented no marked abnormal change, was
permitted to remain. In these cases the operation is some-
times exceedingly diflictilt, as on opening the abdomen we
will find the tube and ovary, with the fundus of the uterus,
matted down in the pelvis in close association with coils of
intestine, the omentum, and the parietal peritoneimi. Where
the condition is one of recent sepsis, it may sometimes be neces-
sary to consider the advisability of removal of the uterus as
well as of the appendages. When there is occasion to open
the abdomen, the structure should be carefully inspected and
examined by touch. The adhesions shotild be broken up and
proper care be exercised to insure control of hemorrhage. In
some patients the broad ligament will be so contracted from
the inflammatory changes that we will be unable to lift the
ovary and tube out of the wound. In such cases the broad
ligament should be resected with the ovary and tube. This
may be accomplished without the apphcation of ligature, seiz-
ing the bleeding vessels as we proceed, and holding them with
hemostatic forceps, after which the wound in the broad hga-
ment can be closed with a continuous catgut suture, so intro-
duced that each turn or second turn shall lock the preceding
stitch, and thus secure against hemorrhage and prevent the
broad ligament from being distorted. After operations in some
of these more critical cases, and sometimes prior to operation,
the patient may be very greatly benefited by the employment
of the rest treatment — the plan of treatment introduced by
S. Weir Mitchell. It consists in the isolation of the patient,
careful study of her condition, and the improvement of her
general nutrition. The patient should be kept absolutely in
bed ; she should have her secretions made normal and her diet
restricted, possibly at first to milk, and, later, feeding should be
forced. Graduated exercise should be advised, supplemented
by the employment of massage and electricity. By these
means the elements of the blood are restored and the patient
gradually regains her strength and health.
430 GYNECOLOGY.
460. Pelvic Inflammation. — The term pelvic inflammation
is a comprehensive one. It is necessary, at the outset, to
limit it to the conditions which we intend it shall include. In-
flammation of the individual pelvic viscera has been discussed,
so this term will be confined to inflammation which involves the
cellular tissue and the peritoneum. It consequently includes those
affections described as pelvic cellulitis and pelvic peritonitis.
These conditions have been designated as peri-uterine
inflammation; by some WTiters of distinction, notably Virchow
and Matthews-Duncan, the terms parametritis and perimetritis
have been used — the former to indicate inflammation of the
cellular tissue ; the latter, of the peritoneum. These terms are
objectionable for the following reasons: First, they are so nearly
alike in sound that it is difficult for the student to avoid confusion
in their use, and the subject is rendered more difficult of com-
prehension. Second, a difference in the anatomic relations
of the peritoneum and cellular tissue to the uterus is implied
which does not exist. The pelvic connective tissue and the
pelvic peritoneum are in equally close contact with the utenis.
It is distinctly objectionable, therefore, to consider one as an
inflammation around the uterus and the other as an inflamma-
tion near it. Third, the conditions are described as associated
with the uterus, while they may exist in all the tissues of the
pelvis, and are not necessarily uterine in their origin.
Careful investigation of the pathology of these conditions
by autopsy, and their more extended study during abdominal
procedures while in active stages of disease, have demonstrated
how easily such erroneous views could arise.
Bemutz and Aran, of France, many years ago demonstrated
the true nature of pelvic inflammation, which has been abun-
dantly confirmed in the practice of abdominal surgerj% where
the opportunity has been afforded for comparing physical
signs with the actual existing pathologic changes.
461. Varieties. — Pelvic inflammation, as we have described
it, is properly divided into inflammation of the cellular tissue
(pelvic cellulitis) and inflammation of the peritoneum (pelvic
peritonitis). It must not be understood in these definitions
that the demarcation between these affections is sharply de-
fined, for, in practice, we do not find inflammation confined
to the single or specific structure. Their use indicates simply
that the inflammation predominates in the structiire named.
462. Pelvic cellulitis, parametritis, or peri-uterine phlegmon
is an inflammation of the pelvic cellular tissue. It may be
either primary or secondary: i. e., it may have originated in
the cellular tissue or may have reached it by extension from
the neighboring structures. The primary inflammation is an
INFLAMMATIONS. 431
lite infective disease which differs in no respect from acute
Bammation of the connective tissue in any other portion
the body. Chronic pelvic cellulitis is always a secondary
EEection, and may or may not have been preceded by an acute
ttack. The pelvic connective tissue is not a special structure,
nxt a portion of that wide system of mesoblastic connective tis-
.tie which surrounds the great vessels of the trunk and accom-
xuoies their branches from origin to termination. It is foimd
n the pelvis, partly in the form of a loose areolar network, partly
in the more condensed form of fascia. It surrounds all the blood-
vessels, nerves, and lymphatics, as well as the uterus, and serves
as investing sheaths for them outside the pelvic cavity. It is
dosed off from the perineum and ischiorectal fossa by the
pelvic fascia, a strong aponeurosis, which is attached to the
pelvic wall between the pubic bones and bodies of the ischia,
and along that thickening of the obturator fascia known as
the white line. It passes as a continuous layer over the levator
ani and coccygeus muscles to the vagina in front, and to the
rectum and coccyx behind. It closely blends with the vaginal
orifice, behind the pubic symphysis, as the triangular liga-
taait. Inflammatory exudations of the female genital organs
above the vulva are situated above this strong fascia. The
cellular area with such a boundary below has the peritoneum
for its superior limitation. This boundary, however, is less
abrupt, as it is continuous with the subserous connective tissue
of the parietal peritoneum of the abdomen. With the ex-
ception of the fundus of the uterus, it forms a layer beneath
the entire pelvic peritonetmi — both parietal and visceral. The
soKialled uterine ligaments contain more or less of it between
their peritoneal folds, and in certain situations it is abundant ;
for instance, around the supravaginal portion of the cervix,
and along the base of the broad hgaments and between the
bladder and symphysis pubis. In the latter situation it con-
tains a varying quantity of fat in its meshes.
Its office in the pelvis, as elsewhere, is to protect and sup-
port the other tissues, performing a passive mechanical function.
It affords a cushion which prevents injury of the viscera (Schae-
fcr). The connective-tissue layer, between the vagina and
peritoneum posterior to the uterus, generally does not measure
more than J of an inch in thickness, but in pregnancy its thick-
ness is greatly increased. During the progress of develop-
ment of a pregnant uterus the broad ligaments are gradually
drawn upward, imtil at the completion of the pregnancy they
Ue in the iliac fossa, above the brim of the pelvis, while no peri-
toneum dips into the lateral parts of the pelvis. The space
thus vacated is filled with connective tissue, which during
432 GYNECOLOGY.
the later months of pregnancy is enormously increased. Freund \
describes a form of cellulitis which affects more particular^
the fat less connective tissue, or fascia, which he calls paia-
metritis chronica atrophicans circumscriptum et diffusunL;
Cellulitis is a very common complication of pelvic peritonitil
involving particularly the uterosacral ligaments and peritoneal,
folds. Schultze calls this parametritis posterior: uterosacnl
cellulitis is more accurate. Cicatrization of the ligaments foDow-
ing such inflammation causes traction upon the upper part of
the cervix, and is a very common cause of dysmenorrhea and ster-
ility. As a result of the contraction of -the tissues the uterai ;
may be anteflexed and drawn to one side or backward, thus pro-
ducing a pathologic anteflexion. By compression of the ve^eb
and nerves the uterus and ovaries may become atrophied
Cellulitis may exist with or without suppuration. When sup-
puration does not occur, an exudation results in the connec-
tive tissue, which becomes edematous, and subsequently more
or less organized, firm, and hard, causing pressiu'e upon the
vessels and nerves which pass through it. The changes in
this structure are similar to those which take place in cirrhosis
of the liver or of the kidney.
463. Etiology. — Primary pelvic cellulitis is always a re-
sult of sepsis. Ready entrance for septic material is afforded
through lacerations of the cervix uteri. These injuries may
be caused by the use of forceps, and, if kept aseptic, readily
heal. In the nullipara cellulitis may arise from the same causes
as pelvic peritonitis, such as exposure to cold during men-
struation, being then generally associated with pelvic peri-
tonitis, and from surgical operations which open the connecti^'e
tissue, as in the removal of large uterine polypi, affording an
opportunity for cellulitic infection. The danger is especially
great when the growths are expelled or removed while in a
state of necrosis. A certain amount of lymphangitis is then
associated, with which the lymphatic glands may be implicateA
Cellulitis may develop from disease in the bladder. As a re-
sult of such irritation thickening occurs in the connective tissue
outside the bladder, which thickening passes outward and for-
ward, and in ultimate atrophy may cause uterine displace-
ment in the opposite direction. From the rectum, the causative
irritation may be dysenteric. A pelvic cellulitic abscess is
not infrequently so situated as to render it more than probable
that the hypogastric glands are involved. Inflammation occiflS
much more rarely in the cellular tissue than in the pehHc peri-
toneum. With the advent of suppuration an abscess follows,
which is generally of large dimensions, although occasionally
several abscesses may be found in close apposition.
INFLAMMATIONS, 433
464. Symptoms. — In puerperal cases the cellulitis is gener-
ally ushered in about the second or third day, with a rigor or
chill, although it may occasionally occur later. In nonpuer-
peral cases the interval between infection and the first mani-
festation of symptoms is rarely more than one or two days.
The occurrence of the chill has produced the belief that the
inflammation arises from exposure to cold ; simultaneously with
the chill occurs an elevation of temperature, a rapid pulse, but
rarely pain, unless the peritoneum is involved. When suppu-
ration occurs, the most marked symptom is the progressive
emaciation associated with pallor or earthy sallowness of the
skin. The skin is harsh, dry, and covered with branny scales
from the fine desquamation. Peritonitis may complicate the
condition and will be indicated by the frequent vomiting of
a dark-green fluid. Vomiting will be excited by the ingestion
of the smallest quantity of anything, even liquids. The patient
looks ill, loses her appetite, and suffers from marked debility and
severe mental depression. She becomes very irritable. If the
exudation extends to the fascia over the iliacus and psoas
muscles, and particularly if the connective-tissue elements
between these muscles are involved, the patient will lie upon
her back with the leg of the af?ected side flexed and the thigh
bent upon the trunk. The symptoms are those of a subacute
form of septicemia. Pain and local signs may be so slightly
marked as to lead to the condition being unsuspected or over-
looked.
465. Physical Signs. — In the early stages of an acute attack
the physical signs are but slightly marked. AH that will be
noticed by digital examination is that the vagina is hot and its
vessels are pulsating. In a few hours there are indications
of an inflammatory exudate. There is a doughy sensation and
fullness on one side of the uterus and in the iliac fossa. This
may extend partly around the cervix, and subsequently become
hard and indurated. If the poison has entered through a
wound in the cervix, the latter becomes less movable. The
supravaginal tissues on the aflected side are tender, more or
less hard, and unyielding. There is a bulging at the side of
the uterus, and the lateral fornix on that side is apparently
obliterated. {Fig. 321.) We rarely find both sides of the
uterus affected at the same time, but occasionally the whole
supravaginal portion of the cervix may be embedded in a thick
collar of indurated tissue, which more or less completely sur-
rounds it. Generally the disease spreads laterally along the
base of the broad ligament to the tissue beneath the reflection
of the peritoneum on the anterior abdominal wall. When this
occurs, a uniform hardness or resistance is felt in the abdominal
434
GYNECOLOGY.
wall beneath the muscles. This may assume the form oi tl
broad band, from J of an inch to a inches or more in wiHj
which hes along the upper border of Poupart's ligament.
sionally the exudation spreads upward and outward from above 1
Poupart's ligament into the iliac fossa. This exudation nayl
extend in one of two ways : (a) it follows the course of thelynph-l
atics which run from the uterus outward beneath andlfrl
tween the layers of the broad ligament to the glands and lumbwl
region; (b) by lines of cleavage in the cellular tissue of the pdnil
In the latter form it not infrequently passes backward, pro-l
ducing an exudation in the tissue of one or both uterosacnll
ligaments in the tissue surrounding the rectum, and lines tbe 1
posterior pelvic wall beneath the peritoneum. In these c
Fig, 331. — Exudation in Broad Ligament from Pelvic Celluliti*.
the rectum will be felt wholly or partly surrounded by a belt d
exudation, which forms a bridge or an arch. If suppuratioii
does not occur, the exudation becomes absorbed, and in un-
complicated cases the hardness may so far disappear as to
leave no subsequent trace. In not a few cases pelvic cellulitis
results in the formation of an abscess. The situation of th*
abscess and the direction in which it may be expected to extend
depend upon the situation and the extent of the infiammaton
exudation. If the inflammation is seated in the base of the
broad ligament and passes forward beneath the peritoneuin.
where it is reflected on to the anterior abdominal wall, an area
of induration may be noticed above Poupart's ligament. Sup-
puration can be recognized by the occurrence, over the indurated
INFLAMMATIONS.
435
ma in the skin, which pits on pressure; by deep-
uation, especially recognized by bimanual examina-
f the eventual pointing of the abscess a little above
gament. The pus can often be detected before it
siirface by passing the tip of the finger carefully over
ion, when a softened point will be recognized in the
hardness. As we have already noticed, pelvic cellu-
afortunately extend backward instead of forward,
)puration follows, an abscess forms beneath the peri-
ering the back of the pelvis. Such an abscess has
cess to the free surface, relief is much longer delayed,
ve burrowing follows. It can extend into the iliac
he loin, particularly when the posterior wall is the
abscess. It
at the iliac
ly sometimes
•elvis by the
h and follow
)f the sciatic
ssels. Again,
in Scarpa's
ving followed
the femoral
ly whatever
bscess leaves
.t will follow
ation of the
tissue upon
essels or the
er than that
s or tendons.
ter burrows
■soas muscle, it comes, not from cellulitic i
iad bone, and this is an important fact to keep in
th the late Dr. Kappes a patient who had been con-
six weeks previously, and she was suffering from
apparently a subacute attack of septicemia. She
■ith her limbs drawn up. complaining of severe pain
jmen, extending into the groin. On examination.
ixjuld be recognized extending from the left lumbar
' the groin. Vaginal examination disclosed the
y movable, with no induration about it nor in the
I the finger was passed well above the brim, when
ed psoas muscle was rccngnized. On investigating
of this patient it was fuund that she had suffered
Fig, 32 3
—Exudation of Cellulitis over Rec-
436 GYNECOLOGY.
from a fall about the third month of pregnancy. She i^as
walking on stilts in her back yard to amuse her children, whca
she tripped and fell in a sitting position. She suffered more
or less discomfort during the entire remainder of the pregnancy.
An incision was made on the left side over the crest of the ilium-
and the peritoneum was pushed forward, when the tissue of the
psoas muscle was found infiltrated with purulent material. It
was hoped that the vent thus afforded would give the patient
relief. She improved for a few days, when pain occurred upott
the opposite side, where a similar condition was foimd.
We not infrequently hear of cellulitic abscesses opening
into the rectum, vagina, or bladder, but these cases, when
considered in the light of the pathology of pelvic inflamma-
tion, are doubtful, and are more than likely cases of intra-
peritoneal suppuration which has originated either in dis-
ease of the Fallopian tubes or of the ovaries. An abscess will
usually point between the seventh and twelfth weeks.
In discussing pelvic disease we should not overlook a peculiar
malignant form of inflammation, mostly occurring in puer-
peral women, in which, associated with other lesions significant
of the virulence of the infection, multiple abscesses in the con-
nective tissue are found. Many of these abscesses are so small
as easily to elude detection. The condition is knowTi as diflFuse
pelvic suppuration, and has all the characteristics of phleg-
monous erysipelas. The tissues become edematous and of
a livid hue. Suppurating thrombi are found in the veins and
the lymphatics are acutely inflamed. Occasionally, the ovdhes
may be found in a state of suppuration. Associated ^ith
this condition are all the symptoms of acute infection in its
most virulent form.
466. Diagnosis. — The absence of pain not infrequently
permits considerable progress before the existence of the con-
dition is suspected. Puerperal women, because of the tender-
ness of the external genitals and the presence of the lochia!
discharge, are very averse to vaginal examination. If the
puerperium pursues a normal course, this aversion should be
respected, but it can not be too strongly asserted that examina-
tion sliould be made whenever symptoms of pyrexia supervene
and the ordinary course of convalescence is interrupted. A
temporary disturbance of temperature and of pulse-rate may
result from such causes as constipation, excitement, and mam-
mary engorgement. Unless such conditions can be recognized
as provocative of the disturbance, or if the abnormal symp-
toms are persistent, and especially if the lochia is offensive, a
thorough examination not only of the vagina, but of the in-
terior of tlie uterus, should be made. During the first ten
i
INFLAMMATIONS. 437
days subsequent to delivery the uterus can be readily explored
without artificial dilatation. If a portion of placental tissue
or a decomposing blood-clot is found, it should be removed,
and the uterine cavity should be cleansed and disinfected.
Ordinarily the symptoms will be promptly relieved. If they
are not, the examination will have revealed the probable cause
of the disorder, and simultaneously will permit any sweUing
or other morbid condition of the pelvic tissues to be detected.
A few days after the onset of the attack the physical signs
of cellulitis will be so marked as to render the diagnosis cer-
tain, and a laceration of the cervix or of the vagina will be
disclosed as the probable gateway for the entrance of the in-
fection. Occasionally the first indication of cellulitis will be
an impaired mobility of the cervix upon one side, on which
tenderness and swelling will be marked. Later, this inflamed
structure becomes stiff, and passes to well-defined hardness.
The cellulitis may be situated to one side of the cervix or may
extend along the base of the broad hgament of the affected
side. The lateral fornix of the vagina vnW be completely ob-
literated. When the inflammation extends backward, vaginal
examinations of the posterior wall will reveal a diffuse fullness
and hardness on the affected side, which is still further dem-
onstrated by rectal examination. In the rare cases in which
the broad ligament itself is affected the diagnosis is determined
by finding the mobihty of the body of the uterus impaired,
and a more or less flattened mass of induration upon one side,
which is continuous with the uterus. Excepting the plane
of tissue between the cervix uteri and the bladder, the cellular
area of one side of the pelvis is practically shut off from that
of the other. Hence, we find pelvic cellulitis is, for the most
part, unilateral. The differential diagnosis of pelvic peritonitis
will be discussed later. (See Peritonitis.) The only other
conditions with which cellulitis can be confounded are hematoma
of the broad ligament and myoma of the uterus. In hematoma
there is an effusion of blood into the connective tissue, which
forms a slightly movable, somewhat flattened tumor along-
side of and continuous with the uterus. The history of the
case and the absence of symptoms of severe illness will generally
ser\-e to distinguish it. It occurs suddenly, from rupture
of a pregnant tube or of a varicose vein in the broad ligament.
In either case the onset is marked by violent pain, faintness.
syncope, and usually vomiting. In pregnancy of the tube
one or two menstrual periods will have been passed, and the
pain will be situated in the lower part of the abdomen, generally
on one side, with irreguJar uterine bleeding. The effect of
such an outpouring of blood upon the temperatiu^e and pulse
438 GYNECOLOGY.
is transient. The temperature is not elevated. If infectioB
occurs, suppuration results, and the symptoms then are similar!
to those of pelvic abscess from cellulitis. Myoma can rardy
be mistaken ifor cellulitis. Only in those rare cases in which
the myoma develops laterally between the layers of the broad
ligament and forms a more or less hard tumor directly con-
tinuous with it is error possible. Should the myoma be com-
plicated by a localized peritonitis, or the tumor become in-
flamed or gangrenous, the diagnosis may be difficult. In the
posterior wall error is scarcely probable, for large inflammatory
exudations into the connective tissue behind the uterus axe
extremely rare. In the anterior wall the signs of celluHtic
exudation between the bladder and the upper part of the cervix
are well marked and characteristic.
467. Prognosis. — The disease usually terminates in recovery,
except in the very diffuse variety, in which it is a part of a
general septic process. With the subsidence of the fever the
exudation is gradually absorbed, and under favorable circum-
stances entirely disappears in a few weeks. Cellulitis un-
complicated by peritonitis leaves no unpleasant results, no
adhesions nor displacements. Its existence, consequently, is ]
no bar to subsequent pregnancy. If fever continues longer 1
than five or six weeks, suppuration has probably resulted i
The duration and progress of the illness will largely depend
upon the direction the pus takes. Grenerally it points above
Poupart's ligament, where it can be easily and satisfactorily
opened. Such cases invariably do well. In the rare cases
when it occurs at the back of the pelvis, pus is longer in reach-
ing the surface, and may burrow in different directions. Such
cases often last a long time, and are likely to be complicated
by extension to the peritoneum. When resolution and the
absorption of the inflammatory processes are slow, the exudate
will become organized, and cause cicatricial contraction and
resulting displacement of the uterus. Such contractions also
lead to atrophy of the uterus and ovaries. The obstruction
of the circulation produces localized congestion and even
inflammation, and causes disturbances of menstruation, such
as menorrhagia, dysmenorrhea, and sterility. It is neces-
sary, then, to be guarded in our promises of complete recovery.
468. Treatment. — A description of the disease and of its
causes emi:)hasizes the importance of preventive treatment.
This consists in careful attention to the principles of asepas
or surgical cleanliness in all midwifery cases and in surgical
manipulations. If freedom from infection could be insured,
y)eh'ic cellulitis would disappear. When the disease is once
developed, medication, either internal or external, has but
INFLAMMATIONS. 439
fittle influence. The most important indication is to avoid
doing the patient harm. Particular care should be exercised
Id the administration of opiimi and antipyretics. The former
■igent is generally given as a matter of routine. Opium adds
Co the disturbance of the already obstructed digestive functions
amd aggravates one of the difficulties which it is important
to obviate — viz., constipation. Opium or morphin should
"ht given only in cases complicated by peritonitis, in which it is
Hbsolutely necessary to afford relief. Similarly, antipyretics
flbould be reserved for the rare occasions when the temperature
3i so high as to constitute in itself a source of danger. A simple
siline mixture, potassium citrate, or small, frequently repeated
of magnesium sulphate should be given until the bowels
freely evacuated. Care should be exercised to avoid fecal
accumulation. The question of feeding is of equal impor-
tance: farinaceous diet in the acute stages, with meat, eggs,
and easily digested food in the later period of the disease. The
tendency to emaciation calls for generous feeding. In the
eaiiy stages of the inflammation an ice-bag over the abdomen
irill limit the congestion and the amoimt of inflammatory
exudate. When the ice-bag is uncomfortable or causes dis-
tress, hot fomentations should be applied. Hot vaginal douches,
at a temperature of from iio° F. to 115° F., are advocated
by Emmet, although the influence they exert is doubtful. When
pus forms, the case should be dealt with according to recog-
nized surgical principles. The abscess should be opened as
soon as fluctuation is detected or there is the faintest indication
of pointing, and drainage should be instituted for a few days.
If the abscess points in the vagina, it must be opened there.
Most of the fluctuating swellings felt through the vaginal roof
are not cellulitic abscesses, but come from an entirely different
direction. While it is not generally recognized as the proper
plan of treatment, yet, without question, the course of an abscess
can be shortened or suppuration prevented by making an incision
into the infected cellular tissue through the vagina as soon as the
swelling about the uterus can be recognized. The infected area
should be broken into with the finger, and a gauze drain inserted
which will afford vent for the discharge. The drainage thus se-
cured will frequently obviate the occurrence and danger of sup-
puration and prevent the extension of inflammation to the pelvic
peritoneum. If the patient lies with the thigh flexed on the
body, the hmb should be exercised by lifting the foot with
the hand under the heel two or three times a day sufficiently
to straighten the knee. This will prevent permanent contrac-
tion and stiffening of the joint.
Chronic pelvic cellulitis, as already asserted, does not exist
440 GYNECOLOGY.
as an independent affection. It not infrequently follow'^ puni-
lent salpingitis or other intrapelvic suppiirative inflammation,
and involves only the parts immediately contiguous to the inr
flamed structures. The induration which it causes, for a time,
of course, introduces an element of obscurity into the diagnosis
of deep-seated inflammatory lesions of the pelvis. It is randy
attended with cellulitic abscess, and is characterized chiefly 1^
edema and small-cell infiltration of the connective tissue. Ite
absorption and the mobility of the uterus may be promoted by
the practice of pelvic massage. (Section 231.) When celltditis
has existed sufficiently long to result in atrophy of the uterus or
ovary, treatment exerts but little effect.
469. Pelvic peritonitis^ perimetritis^ perisalpingitis^ or peri-
oophoritis is an inflammation of the peritoneum situated with-
in the pelvis. It occurs much more frequently than pehic
cellulitis; indeed, more frequently than any other form of in-
flammatory disease within the pelvis. In the great majority
of cases it is an infective process, due either to the presence
of micro-organisms or to the effect of their chemic products.
In the main its action may be regarded as beneficial, it being
one of nature's eft'orts to resist or to do battle with the invad-
ing foe by erecting barriers around the diseased area. These
barriers serve to narrow or to confine the field of invasion, and
shield the neighboring structures from damage. Treves asserts
that the purpose of peritonitis is to save and not to destroy
life. Unfortunately, the poison may be so virulent, exist in so
large a quantity, or the resistive powers of the patient be so en-
feebled that we are neither able to limit nor to guide the inflam-
matory process to a successful issue.
470. Etiology. — Pelvic peritonitis probably never occurs
as a primary disease, but always as a complication of a pre-
existing disorder. Occasionally, however, it is the first recog-
nized expression of such disease. The symptoms of peritonitis
are so severe that attention is at once aroused, while the con-
dition from which it originated may have been so insidious
as to have been overlooked. From want of knowledge, then,
of the previous condition we are often compelled to ignore the
exciting condition, and to say that the patient suffers from
pelvic peritonitis. Is it surprising that the original condition
was formerly unrecognized and the disease denominated idio-
pathic peritonitis, the result of a slight injury or of exposure
to cold? It is true there are still cases in which we are un
able to discover the preexisting disease, but the number o
such cases has become less and less frequent, and failure t<
determine the cause of pelvic peritonitis is the result of de
fective observation and of want of knowledge.
INFLAMMATIONS. 441
The most frequent cause is sepsis; next, gonorrheal infection.
he micro-organisms principally concerned in the develop-
lent of infection are the streptococcus, the staphylococcus,
be gonococcus, the bacillus coli communis, and the bacillus
ttberculosis. The propagation of these infectious micro-organ-
sms is favored by parturition, abortion, instrumental ex-
onination, and surgical interference. Other causes are in-
kmmations of the appendix, intestinal perforations, abdominal
eaons, rupture of an ectopic gestation, hematocele, ovarian
ibscess or hematoma, and malignant disease.
Infection generally reaches the peritoneum in one of three
ways: first, by the continuous mucous membrane through
the uterine cavity and tubes; second, by the blood-vessels;
third, by the lymphatics.
Tubal disease is the most common cause of pelvic peri-
tonitis, and should receive first consideration. The mucous
membrane of the Fallopian tube is continuous with that of
the uterus, and at its abdominal end opens into the peritoneal
cavitv.
The continuity of the tubal mucous membrane with that of
the uterus and vagina subjects it to continual danger of in-
fection. The tendency of every acute infective endometritis,
whether septic, gonorrheal, or tubercular, is to extend to and
involve the tube. The relation of the tubal mucous mem-
brane to the peritoneum, in infection of the former, favors
its extension to the latter. This risk is further aggravated
by the anatomic position of the tube in woman. No other
mucous membrane is similarly situated. The uterine cavity,
when inflamed, naturally drains into the vagina through the
external os; but the tube has its most constricted portion
toward the uterus, where the lumen of the canal is but large
enough to permit the passage of a bristle. A very slight amount
of s^-elling will be sufficient to close the uterine end, when
the only outlet of the tube is into the peritoneum. The ab-
sence of a suitable outlet for morbid secretions of the tube
and the continuity of its mucous membrane with the perito-
neum render inflammatory affections of the canal of especial
importance and make pelvic peritonitis so frequent a conse-
quence of salpingitis.
A prompt result of peritonitis from tubal infection is closure
^ the abdominal ostium of the tube by adhesions or by in-
flammatory changes in the fimbriae. Tlie tube then becomes
fiUed with retained secretion, and is the center for an inflamma-
^ process which extends through the wall to the neighboring
pssues, especially the peritoneum. If this extension is not an
miinediate occurrence, the tube is subject to frequently recurring
442 GYNECOLOGY,
inflammatory attacks from slight causes. When the retained
secretion consists of pus, the liability to recurring attacks of
pelvic peritonitis is much greater than when the accumulation it
serous or mucopurulent, to which liability is added the danger of
ulceration and thinning of the tube-wall and the possibility of pus
escaping into the peritoneal cavity by perforation or rupture.
Frequently the ovsLvy becomes infected from the tube, suppurates,
and affords a fresh source of danger. Both inflamed tube and
ovary may act as further sources of peritonitis, but sometimes the
tube, after infecting the ovary, recovers and is no longer a focus
for infection. Infection of the ovary is very prone to occur when
the latter has been the site of cystic disease or when a Graafian
follicle has recently ruptured. The most frequent mode of in-
fection is through a cyst -wall which has become adherent to a
diseased tube. Sometimes the infection occurs through an ul-
cerative process which permits the tubal contents to enter the
cyst suddenly by perforation of the cyst-wall. Tubo-oVarian
abscess is thus explained. Such an infection may produce an
attack of peritonitis more violent than any preceding.
A more alarming attack of peritonitis is engendered by the
escape, through ulceration, of the contents of a suppurating
tube or ovary into the peritoneal cavity. Fortimately, such an
occurrence is rare. The thinned wall of such a collection is a
menace which places nature upon her guard and stimulates
her to form adhesive barriers which will limit the space into
which the rupture occurs and favors the formation of an intra-
peritoneal abscess. Such an abscess may rapidly enlarge,
and, if the patient survives, may burst into one of the neighbor-
ing viscera, into the peritoneal cavity, or externally, accord-
ing to its situation. Suppuration of an ovarian cyst may be
independent of infection through the tube; occasionally, it
more than probably occurs from the proximity of an inflamed
growth to the rectum or intestine. The cyst is more \iihier-
able to such infection when it has been exposed to injur}' or
subjected to bruising, as in labor.
Peritonitis may be favored by twisting of the pedicle of
an ovarian cyst. This accident can result in strangulation,
intracystic hemorrhage, inflammation, or necrosis of the growth,
according to the amount of strangulation. The accident is
particularly prone to occur during parturition.
The presence of puerperal sepsis should be regarded as de-
manding careful investigation. New pelvic growths, by their
mere presence, may engender peritonitis. This is common
in ovarian tumor. The tumor varies greatly in the prob-
ability of its producing peritonitis. Uterine fibromata may
attain a large size without adhesions unless degenerative proc-
INFLAMMATIONS. 443
set in, while a papilloma of the ovary or tube, dermoids,
id malignant diseases are usually associated with extensive
sritonitis.
Severe septicemia may follow abortion, parturition, or sur-
cal manipulations, and, instead of being confined to the uterine
nicous membrane, can at once be carried by blood-vessels
r lymphatics to the peritoneum, and generate a diffuse septic
ifection in the pelvis. Such a peritonitis may become localized
1 the pelvis or may rapidly prove fatal by its extension to
he general peritoneum.
Clinical experience has demonstrated that injury alone
irin cause peritonitis only when the hand or instrument in-
Kcting the injury is surgically unclean. The truth of this
issertion is illustrated by the infrequency with which exten-
ave operative manipulation within the peritoneal cavity is
followed by inflammation, and by the frequent attacks of
vinilent and fatal peritonitis following slight injuries in efforts
to produce abortion. It is, without question, a mere prob-
lem of infection. The operator in the latter is usually ignorant
or reckless.
Complications during parturition may cause peritonitis.
The shape and size of the normal pelvis is adapted to the pas-
sage of the normally constructed child at full term, and is with-
out extra accommodation. Any encroachment upon the pelvis
by tiunor, gro'wth, or malformation affords an obstacle which
tenders passage through the canal possible only at the expense
of injury or bruising, which may result in loss of vitality of
tissue or growth, and thus render the structures more suscep-
tible to the influence of pathogenic micro-organisms.
Pelvic cellulitis, it has been said, is generally secondary,
but still it may precede the peritonitis. This is particularly
true of suppuration.
Peh'ic hematocele is a source of peritoneal inflammation.
The irritation induced by the blood diffused into the perito-
neal ca\'ity causes exudation and adhesive peritonitis. The
blood-serum may be roofed in beneath adherent omentum
and coils of intestine, when the peritonitis limits effusion and
promotes its subsequent absorption.
Inflammation of the vermiform appendix, or appendicitis,
^ a not infrequent cause of pelvic peritonitis. Its normal
situation is in the right inguinal region, just above the brim
of the pelvis, but instances have occurred in which it was found
lying within the peh^s. In right-sided inflammation of the
P^Wc peritoneum an inflamed a])pendix should always be
J^garded as a possible source of the infection. An aVjscess
'ormation may follow, which will fill up Douglas' pouch. In
444 GYNECOLOGY.
many cases it is difficult to determine whether the appendix
or the right tube is the original source of infection.
471. Pathologic Anatomy. — Inflammation of the peritoneum
may be serous, adhesive, or suppurative, and acute or chronic. ,
As it most frequently originates from infection through the j
tubes, the tubes and ovaries are, therefore, implicated. It
begins as a congestion or hyperemia of the serous surface,
with cloudy swelling of the endothelium. The membrane,
instead of being smooth and glistening, becomes dull, dry,
clouded, and slightly roughened with plastic lymph, whidi
is poured out between its adjacent surfaces. The adhesions
thus produced are its most characteristic feature. In recur-
rent attacks we find additional adhesions. Serum exudation
becomes encapsulated, is found in the meshes of the connective
tissue, may fill the culdesac or pelvis, posterior to the uterus,
or it may be encysted to one side. Such collections may simu-
late a cyst. When the exudation thrown out is considerable,
it may form a distinct coating, which may be peeled from the
surface of the peritoneum. These lymph coagula are also
found floating in the serum, and, as the fluid becomes absorbed,
this coating stiffens the peritoneum, and. with the induration
in the subjacent cellular tissue, causes the hardness which is
one of the striking characteristics of chronic pelvic peritonitis.
These indications of inflammation are usually most strongly
marked about the fimbriated ends of the Fallopian tube, and
diminish as they pass from it. When the inflammation has
originated from some other cause, such as an inflamed appen-
dix, the alteration and adhesions are most dense at the seat
of origin. Thus, a Fallopian tube, when it becomes inflamed
and increases in weight, drops from its original position, so
that it is found upon the floor of the lateral fossa of the pelvis,
in the pouch of Douglas, or adherent by its fimbriated end
to the ovary or to the side of the pelvis. Occasionally the
two tubes meet, and the distal ends become adherent to each
other behind the uterus. At other points the direction of the
tube may differ in two sides of the body. One side is bent
like a horseshoe, while the other terminates against the lateral
wall of the pelvis, to which it is adherent by its abdominal
end. If the uterus is lifted out of the pelvis by pregnancy,
the tube may be found situated above the brim, close to the
border of the psoas muscle. The ovary is generally found
implicated in the mass of inflammation which has extended
from the tube. When this inflammation has existed for some
time, wc generally find the ovary in a cystic state, and con-
siderably enlarged. These changes result from the effect of
the surrounding peritonitis.
INFLAMMATIONS.
445 ,
In chronic cases the peritoneum, in places, is Ufted up by
circumscribed collections of serous fluid in its meshes. These
swellings vary in size from a pea to a large orange. They
possess no pathologic importance, but often increase the diffi-
culty in arriving at an accurate diagnosis. A mass formed
by an inflamed tube, ovary, and broad ligament not infre-
quently is found adherent to tlie posterior pelvic wall and rectum.
Sometimes a coil of intestine or a portion of omentum may
intervene, when the parts are so entangled in an extensive
mass of exudation as to cause great difhculty in outlining and
determining their relations. The body of the uterus is envel-
oped in a mass of adhesions or is completely free. When
the lesion from which the peritonitis has originated is puru-
lent, peritonitis is also apt to be piuiilent, and, instead of an
accumulation of serum, pus or intrapelvic abscesses are foimd.
Occasionally, suppurative peritonitis exists. The latter occurs
only in cases of exceptional virulence, or from sudden bursting
into the peritoneal cavity of a pus-collection which was situated
in an ovary or tube. Intraperitoneal abscesses may be single
or multiple. They generally originate by the rupture of a
suppurating Fallopian tube or by the discharge through its
abdominal ostium of pus into Douglas' pouch or into a space
bounded by adliesions. Both tubes may thus discharge into
a common receptacle, which is most generally Douglas' pouch.
A tense, fluctuating swelling is formed, easily felt through
the depressed vaginal roof, which, by pressure against the
intestine, causes more or less obstruction. Purulent inflam-
mation of the tube leads early to closure of the abdominal
ostium, when the pus is confined witlun the tube, and forms
what is known as a pyosalpinx. An intraperitoneal abscess
or general peritoneal infection may then be induced by in-
fection through the tubal wall, or by the bursting of the pyo-
salpinx from ulceration within, or by the spread of infective
processes to the ovary, causing it to suppurate.
An intraperitoneal abscess walled in by adherent viscera
may run an acute course or may be retained for a long time,
causing few, if any, indications of its presence. One of two
things is likely to occur, however: either the abscess gradually
dries up and disappears, or its walls undergo ulceration and
its contents escape into the bowel— usually the rectum, sig-
moid flexure, or colon — or into the vagina, the bladder, the
general cavity of the peritoneum, or some part of the abdom-
inal wall. The most frequent exit is through the intestine.
The other routes are exceptional. Such abscesses differ very
markedly from cellulitic abscesses, and will quickly disappear
when they have once found an outlet. The latter discharge
ter very j
isappear M
ischarge I
446 GYNECOLOGY.
their contents imperfectly. A troublesome sinus remains for
years, producing serious ill health. Among the secondaiy
changes resulting when salpingitis is tmilateral is an exten-
sion of the peritonitis to the other side of the pelvis, involv-
ing the healthy uterine appendages in a mass of adhesiom
which complicate the fimction of both tube and ovary. Such
a condition may be followed by hydrosalpinx.
Hydrosalpinx may result as a sequel of salpingitis, but
is less frequent than pyosalpinx.
Effusion of blood within the tube (hematosalpinx) often
arises as a consequence of tubal gestation, but occasionally may
be independent of the latter.
472. Symptoms. — The first characteristic of acute pelvic
peritonitis is pain in the lower part of the abdomen, which
is sudden in its onset. For a few hours it is extremely severe,
associated with fever, with increased rapidity of pulse, and
often with vomiting. An early symptom is more or less intes- ^
tinal distention, which may be general or localized. Follow- i
ing the acute pain, movement is attended with great suffering,
because of the tender, inflamed parts, and the patient is gen-
erally obliged to remain in bed for a length of time dependent
upon the severity of the attack. Rigors are infrequent, unless the
condition is part of a diffuse septic inflammation or the re-
sult of intraperitoneal rupture of a pyosalpinx or a suppu-
rating ovary. Constipation is usual. Pain precedes defecation
and micturition, owing to the contiguity of the inflamed part
to the rectum or bladder. Not infrequently the pain is greater
at the completion of micturition. The patient generally assumes
the recumbent posture, with the limbs flexed, and guards
the abdomen against the pressure of clothing or contact with
the hand. In subacute or chronic cases pain in the back
and inability to undergo physical exertion are experienced.
Menstruation is more profuse than normal, often painful.
Very trifling causes will result in recurrence of the attacks.
This is particularly true when the chronic pelvic perito-
nitis is maintained by the presence of pehdc suppura-
tion. Recurrence of pain and abdominal tenderness are more
reliable indications of the presence of pus than is ele\'ation
of temperature. Not infrequently a large quantity of pus
may be found in the pelvis of the patient who has either a
normal or a subnormal temperature. Patients in whom ex-
tensive suppuration exists are foimd emaciated and incapac-
itated for work or exercise. In the worst cases the patient
will be bedridden. The amount of suffering depends upon
the nature and extent of the disease and upon the social poa-
tion of the patient; in other words, upon the demands that
INFLAMMATIONS. 447
made upon her activity. In an acute attack the abdominal
are kept rigid over the aflfected parts. This rigidity
il due to muscular contraction, and is beyond the control of
Ibe patient. Occasionally, by abdominal palpation a definite
nvelling can be recognized. This is particularly true when
^le mass is situated above the brim of the pelvis, has attained
A large size, or presents an encysted exudation of serum or
'pos in front of the uterus or against the pelvic wall. Occasion-
^y the abdominal enlargement will be due to the presence
Ai serous fluid. When depression of the vaginal roof occtirs,
it will not be lateral, but central, because the accumulation
4d effusion, serous or purulent, is in Douglas' pouch. Upon
'Vaginal examination the parts may be very tender, with a
lense of resistance, or the uterus is pushed forward. After
•ttbsidence of the acute symptoms a careful bimanual examina-
tion, for which an anesthetic may be required, will often re-
veal in the posterior fossa of the pelvis the presence of a fixed,
irregular, tender swelling. This begins at the uterine comu
as a cylindric body, equal in thickness to a lead-pencil ; it may
be rolled between the fingers, but may suddenly become thicker
a short distance externally; it curves itself, may completely
reverse its direction, and finally ends behind the cervix uteri
in the pouch of Douglas. A Fallopian tube can be adherent
to the ovary, which is embraced within the concavity of its
curve, and surrounded on all sides by a thickened, adherent
peritoneum. The uterus is not always displaced, but is often
found retro verted or retroflexed, and adherent in its abnormal
position. Again, it may be pushed forward by a mass of effusion
m Douglas* pouch. The shape and consistence of the swelling
vary in different cases, as the tube may be soft, sausage-shaped,
particularly when its abdominal ostium is occluded, or it may
be distended mostly at the outer end, which gives it the shape
of a retort. Occasionally it is irregular, distended from sac-
culation, thrown into knuckles or prominences, bent upon
itself with sausage-like convolutions produced by intervening
constrictions. Its consistence depends upon the extent to
which the walls of the tubes have become thickened and upon
the induration of the surrounding peritoneum.
473. Diagnosis. — Peritonitis may be confounded with hema-
tocele and cellulitis. Pelvic hematocele is readily distinguished
by its clinical history, slight febrile disturbance, history of
a possible tubal gestation, severe pain attending the rupture
of the latter, and the subsequent bloody discharge from the
uterus. The distinguishing features between peritonitis and
cellulitis are as follows:
448
GYNECOLOGY.
Peritonitis.
Cellulitis.
1. Inflammation is chiefly confined to i. Inflammation principally afiectt
the pelvic peritoneum. the pelvic cellular tissue.
2. Inflammation is bilateral. 2. Inflammation is unilateral.
Differential Diagnosis. —
Peritonitis.
1. Its onset is sudden, with severe
pain.
2. Both legs are drawn up.
3. A firm, flat effusion surrounds the
uterus or a mesial bulging is pro-
duced by serous effusion in
Douglas* pouch; the vaginal por-
tion of the cervix is of normal
len^h.
4. The mflammation does not extend
along the round ligament and
iliac fossa, but it may affect the
entire peritoneum.
5. The uterus is displaced forward or
backward.
6. Vomiting is frequent.
Cellulitis.
1. Its onset is insidious, pain not
marked.
2. One leg is drawn up.
3. A firm effusion bulges usually mto
the fornix of the one side; the
cervix is apparently shortened 00
the affected side.
4. Exudation, or pus. spreads in
definite directions, and is usually
localized.
5. The uterus is displaced to one
side.
6. Vomiting is infrequent.
474. Prognosis. — The mortality of peritonitis is much higher
than that of celluhtis. Even when the patient recovers, the
after-effects are more troublesome, and not infrequently the
sequels are sufficiently serious to entail a life of chronic in-
validism. The disease from which the peritonitis originates
remains after the subsidence of the acute attack, and con-
stitutes a focus from which subsequent attacks are likely to
result, either from changes in the diseased tissues or from ex-
ternal agencies. Recurring attacks of peritonitis are mudi
more likely to occur when associated with the presence of pus,
either in the form of pyosalpinx, suppurating ovary, or intra-
peritoneal abscess. The damage done to the uterus, ovaries,
and Fallopian tubes, particularly to the latter, by the obstruc-
tion of the abdominal ostium, necessarily causes sterility. If
the gradual absorption of the morbid products permits the
occurrence of conception, the continuation of pregnancy to
full term may be rendered impossible by the inability of the
organ, from extensive adhesions, to become enlarged. It
is not possible, however, to say that pregnancy can not
occur, for experience has demonstrated that even after the
most virulent peritonitis the parts may so recover themselves
as to permit of a subsequent conception. The discreet prac-
titioner will consequently hesitate positively to assert that
the patient can not give birth to children. Another effect of
pelvic peritonitis is interference with the normal action of the
intestinal canal.
INFLAMMATIONS. 4^
The termination must depend upon the condition of the
dividual patient.
475. Treatment. — The first and most important aim of treat-
ent is prevention. The large majority of nonpuerperal cases
; pelvic peritonitis originate from a preexisting gonorrheal
il^gitis; consequently the treatment should consist in the
rrest of the infection before it has extended beyond the reach
f local application. Unfortunately, gonorrhea is very frequently
e^irded as an imimportant affection, although it probably
iKtroys the health of a larger number of women than does the
Dnch more dreaded poison of syphilis. The earlier symptoms
if the disease usuaUy
It"
xss unregarded. They
ire attended with but
Itttte pain — often none,
if the urethra is not in-
volved— and the signifi-
once of the puralent
discharge is not realized.
Medical advice, conse-
qnently, is unsought
QDtil the infection has
poduced serious results
or has inflicted life-long
damage. Even when
advice is obtained, the
disease is seldom re-
garded seriously, and
ligorous treatment is
not employed. A puru-
lent vaginal discharge
in a recently married
WMnan shoiild always
be redded with grave
■Qspicion, and its
treatment should be undertaken with a due sense of responsi-
Mity.
The object of treatment should be to prevent the extension
of disease to the tube and the development of septic salpingitis.
Its occurrence means a focus for the continuous distribution of
fflftction and a cause for frequently recurring attacks of peri-
toneal inflammation. Such invasion, as would naturally be
ofened, is a frequent consequence of gonorrhea, but its avoid-
■nce requires rigid adherence to the rules of aseptic surgery
•od midwifery in the management of abortion, parturition,
•"d surgical manipulation. Care should be exercised in the
y * ■"
-:^
Fig 313 — Induration from Pentonitis
450 ! - GYNECOLOGY.
examinatioii of patients, and particularly when such investigatkv
is to be intra-uterine.
When the patient has once been the victim of pelvic pai
tonitis, it is extremely important that all causes likely to pro
voke a relapse should be avoided. She should be careful ii
her dress, should not be exposed to cold or damp, espedaHj
during her menstrual period, and exhausting exercise or ovtf-
fatigue should be guarded against. Prolonged standing i>
as disastrous as excessive exercise. She shotild be advised
to secure sufficient rest, and the state of her bowels should Ix
carefully watched. Intestinal adhesions naturally increase th<
tendency to habitual constipation. The fecal accumulation
favors the development and migration through the coats d
the intestines of pathogenic micro-organisms, so the tendency
to constipation should be oT*ercome by suitable aperients, or
by enemas of glycerin or of soap and water. TTie medial
treatment is very similar to that employed in pelvic cellulitis^
with the exception that opium and its derivatives may be noes-
Fig. 324, — -Induration from Pelvic Cellulitis.
sary in some cases of peritonitis. Their administration, how-
ever, should be regarded as an unavoidable evil, and only small
doses should be given, and these discontinued as early as pos-
sible. Constipation should be prevented by appropriate aperi-
ents or enemas, or both. Accumulation of scybala is nioie
harmful than active purgation. Dining an acute attack the
patient should rest in bed, and the diet should be restricted
to liquid or easily digested food at regular intervals, Tix
pain should be relieved by the application of the ice-bag, or,
if this is uncomfortable, by hot fomentations. Intestinal dis-
tention is relieved by the use of enemas. The patient wiU
probably be tormented by thirst and by the desire for ice or
to drink effervescent waters. She will find much greater re-
lief from frequent sipping of hot water. Ice should be avoided,
as, when once employed, it increases the thirst, and the patiait
will be constantly demanding it, with the result, if grantwii
that the mouth and tongue will soon suffer from a severe attadt
of glossitis. If the enemas fail to give relief, an aperient
INFLAMMATIONS. • 451
should be administered^-doses of calomel, castor oil, or, what
is more efficient, sulphate of magnesium. The last may be
given in one- to two-dram doses, dissolved in syrup of ginger
and cinnamon-water, every two or three hours until the bowels
are freely evacuated; subsequently tliree or four times a day,
as the condition may demand. The state of the pulse is a more
correct guide to the condition of the patient than the temperature,
and will indicate the need for stimulants. If the pulse shows
signs of flagging, becomes thin, feeble, and intermittent, brandy
or whisky should be given in regular doses, diluted with five or
six times the quantity of water, its effect being carefully watched,
the dose to be increased or diminished according to its influence.
Stimulants should not be allowed to take the place of food. The
indications of collapse— coldness of the extremities, sunken
feattu"es, flagging pulse, subnormal temperature — should be
further combated by the application of external heat and by the
hypodermatic injection of strychnin and atropin ordigitalin. The
intensely depressing effect of intestinal distention should be kept
in mind, and this condition should be reHeved by the use of ene-
mas or by the introduction of a soft-rubber rectal tube with the
patient turned upon the side. Not infrequently, as suggested
by Keith, an injection of quinin, gr. vj, whisky, fSss, and water,
fSij, repeated every hour until three doses have been given,
stimulates the nerve-centers and increases peristalsis. The
most effective enema is an ounce of powdered alimi dissolved
in a quart of hot water. This is best given with the patient
lying either upon one side or upon her back, with the hips elevated.
This enema promotes peristalsis, and, consequently, is of service
in tympanites. Where peritonitis is estabhshed and the patient is
ejecting a dark-green fluid from the stomach and is unable to re-
tain even Uqmds, the stomach should be irrigated through the
stomach-tube with a normal salt solution. This should be re-
peated if the vomiting returns. No food, not even water, should
be allowed to enter the stomach. Peristalsis should be quieted
by injection of gr. J -J morphin hypodermatically, followed by gr.
i^g I'a of the same agent every three hours. The nutrition should
be maintained by rectal feeding, administering normal salt solu-
tion three ounces, bo\'inine one ounce, every three or four hours,
and, where necessary, hypodermoclysis or intravenous injections
normal solt solution may be employed.
The occurrence of peritonitis should lead to a careful examina-
tion of the pelvis, and any indication of tenseness in Douglas'
pouch or about the cervix should be considered an indication
for immediate vaginal incision to break up the tissue and per-
mit the fluid to escape. The opening should be kept patulous
by the introduction of a gauze drain. Such a course will not
452 GYNECOLOGY.
infrequently arrest or limit the progress of the inflammation.
The mere removal of the tension affords great relief. If an
intraperitoneal abscess exists, such interference not only affords
relief, but may anticipate its bursting into the rectum and
establishing a troublesome sinus. Unless such conditions can
be determined, however, it is wiser to defer surgical inter-
vention until the acute symptoms have subsided. If the
attack is the first the patient has had, and the swelling is so
slight as to indicate a possibiUty of a probable nonpurulent
inflammation, operative interference should not be advised.
If the patient has repeatedly had similar attacks, and swell-
ing of such a size is found as to render it probable that in its
midst there is an occluded, distended Fallopian tube or an
enlarged, cystic ovary, operation should be .tirged. Such a
mass, with the recurring attacks, almost positively indicates
the presence of pus; and where pus is present, surgery is ab-
solutely indicated. It is impossible, of course, to lay down
positive rules: every case must be personally decided. A
woman from the laboring-class can not afford to spend as
much time in invalidism as a woman in better circtmistances.
When operation has been decided upon as necessary, the
method of procedure still remains undetermined. Abdominal
section being the older and more generally adopted procedure,
it will be first described. (For the preparation of the patient
see Section 187.) The patient is placed upon the operating
table, preferably one by which the Trendelenburg posture
can be secured, and an incision from 2^ to 3 inches long is made
in the median line, beginning an inch above the sjTnphysis pubis.
The operator must remember the possibility of adhesions be-
tween the intestines, the omenttun, and the anterior abdominal
parietes, and should proceed carefully as he approaches the
peritoneal cavity. Generally the omentum is adherent to the
mass in the pelvis, over the surface of the uterus, the tubes,
or the ovaries. The first step is to separate these adhesions
and to free the omentum and any coil of intestine which may
be adherent. The omentum and intestines are drawn upward
to expose the matted contents of the pelvis beneath them. When
the patient is lying flat, we have to be guided almost entirely
by the sense of touch. In the Trendelenburg posttire we are
aided in our manipulations by sight. Following the fundus
of the uterus as a guide, the operator endeavors, with the tips
of the first two fingers, to enucleate the diseased uterine appen-
dages from their adherent surroundings. The ftmdus of the
uterus may be free or impHcated in the adherent mass, b
the latter case its identification may be exceedingly difficult,
rendering it necessary for an assistant to pass one or two fingers
INFLAMMATIONS.
453 '
into the vagina to elevate the uterus by pressure against the
cervix. The fundus is thus identified. The affected tube,
on one side, is traced out from the uterine comu and made
to serve as a guide when searching for planes of cleavage. If
it turns backward and becomes lost in the adherent mass,
the safest way is to keep the fingers close to the posterior sur-
face of the uterus, and to trace the adherent mass downward
to Douglas' pouch. In breaking up the adhesions it is neces-
sary to separate the mass from the walls of the bowel, includ-
ing the anterior wall of the rectum. It is often advisable to
have an assistant pass his forefinger into the rectum, partly
to facihtate the separation by steadying the bowel, partly to
ascertain where the bowel is and whether the manipulation is
in dangerous proximity to it. The separation of these adhesions
in Douglas' pouch is generally the most difficult part of the
operation. Indeed, I know of no operation more difficult than
to have to break up adhesions which have existed for a long
time between knuckles of intestine and the fundus of the uterus
or the ovaries and tubes. The separation is to be continued
posteriorly from below upward. When the mass has been
cleared from its posterior and inferior attachments to the uterus
and to the uterine appendages of the opposite side, there still
remain adhesions to the back of the broad ligament, which
has become more or less folded over the diseased parts, and
forms a deep, concave surface on its posterior aspect. This
concave surface has to be unfolded in order to permit the mass
to be brought into view and the broad ligament below it to be
transfixed. This separation can be accomplished by working
from below upward, and should be continued until the ovary
and tube remain attached to the uterus and broad hgament
by their anatomic connections only. The pedicle is then tied
in the same manner as in the removal of the normal ovary and
tube for the relief of myoma. The appendages on the opposite
side are examined, and are removed or left, according to their
condition. If merely adherent, the operator may content
himself by simply separating the adhesions.
During such manipulation it is not infrequent to find an
escape of pus, which may be independent of any fault of the
operator. It is often difficult to accomplish without ruptiu'e
the separation of adhesions around the ostium of a suppurating
tube or the enucleation of a suppurating and adlierent ovary
the wall of which is thinned and nearly ready to burst. For-
tunately, unless the pus is unusually virulent, no serious harm
results. However, we should always exercise care, in such
cases, to wall off the general peritoneum and intestine with
several layers of gauze pads, to prevent their being soiled.
M
45i
GYNECOLOGY.
(Pig. 325.) Occasionally, in severe cases, when the patient
is much depressed, the persistence required for the separation
of extensive adhesions would so prolong the operation as to
endanger the life of the patient. It may be necessary then to
content ourselves with mere emptying and draining of the
suppurating cavity. The greater the experience of the operator,
however, the less frequent will be the incomplete operation.
Separation of adhesions between different parts of the intestinal
canal other than the rectum should be made as much as possibfe
under the eye, and any injuries to these structures should be
Pig. 395. — Intestines Held Back by Gauae.
Trendelenburg P
immediately repaired. The inexperienced operator should be
careful not to mistake a thickened and adherent intestine for
an inflamed Fallopian tube. This mistake may be avoided by
following the tube toward the uterus before an effort is made
toward its separation.
During the performance of these operations the general
peritoneum should be carefully protected by drawing back the
intestines and omentum, and retaining them with gauze or gauze
sponges, so that they shall not be soiled by rupture of an absc«s
cavity. When the operator and his assistants have been unable
INFLAMMATIONS.
4S5
to protect the intestines from the contact with the contents of
the abscess, I think it better to irrigate the abdomen with hot
normal solution, 105" to 112° F., and thus complete the peritoneal
toilet rather than to attempt to accomplish it by dry sponging.
In such cases the belly cavity may be left filled with the salt
solution. Drainage must be decided by the indications of the
individual case. The larger the experience of the operator, un-
less he is particularly prejudiced, the less frequently will he be
likely to use drainage. Even in the most virulent cases, with ex-
tensive adhesions, irrigation of the cavity with a large quantity
of normal salt solution, repeating it before the cavity is closed
and leaving a considerable quantity of fluid within the abdomen,
dilutes any poison that may remain and renders it less active and
less Hkely to produce deleterious effects. In this way drainage
may be avoided. In suppurative peritonitis McCosh suggests
intra-intestinal injections of sahne cathartic. He cleanses the
peritoneal cavity thoroughly with irrigation instead of sponging.
Through a hollow needle between one and two ounces of a
saturated solution of magnesium sulphate is introduced into
the small intestine at a point as high as possible in the jejunum
or ileum. The needle-puncture is closed by a Lembert suture.
The action of the saline produces free watery discharges, and
thus makes the intestine act as a drainage-tube for the peri-
toneal cavity. When drainage is used in suppurative cases,
the gauze or wick drain, in which a number of strands are in-
troduced into different parts of the abdominal cavity, is the
preferable method of drainage. If the ends are carried well
around the side of the body and are surrounded by cotton and
gatoze at a point below the level of the internal ends, we then
secure a siphon-like action, which more effectually drains the
cavity.
Postural drainage was suggested by Clark, who thus utiUzed
the healthy and unirritated portion of the peritoneum for ab-
sorption. He recognized that, in the ordinary positions of the
body, fluids, serum, and blood were likely to accumulate on those
portions of the peritoneum which have been injured and con-
sequently was less able to take care of them, and in which there
were possibly still remaining tissues impregnated with pathogenic
germs and the culture fluid was thus maintained in contact with
the germs at a most favorable temperature. Such a misfortune
can be avoided by elevating the foot of the bed thirty-six inches.
The patient could be occasionally turned from one side to the
other, so that no fluid would accumulate in the pelvis, but be
thrown upward upon the healthy peritoneum, which was better
able to take care of it. Other advantages for this posture were
that a decreased amount of blood was sent to the injured part,
456 GYNECOLOGY.
lessening the amotint of pain from which the patient suffered
subsequent to the operation ; that it permitted immediate closmt
of the wound and greatly decreased the danger of a weak ventrum
and a consequent hernia. The procedure suggested by Fowler,
to elevate the body of the patient so that the drainage may ao
cumulate in the most dependent portion of the abdomen,
whence it can be siphoned by a gauze wick emerging from the
lower angle of the wound or into the vagina, has appealed to the
profession as the more satisfactory procedure. In closure of the
wound we must endeavor to utilize measures that will bring to-
gether and hold in apposition the tissues, so that firm union may
be secured and the risk of hernia lessened. Various methods of
procedure have been employed to accomplish the purpose— the in-
troduction of a double row of sutures or of a series of sutures, one
in the peritoneum, another in the aponeurosis, and another in the
skin. The difficulty in the introduction of rows of sutures, how-
ever, is that not infrequently there are left dead spaces, in which
Fig. 326. — Three-pronged Vulselltim.
an accumulation of fluid occurs. This later becomes infected
and results in the formation of an abscess, which necessarily
weakens the wall. I endeavored to obviate this difficulty by
the employment of the figure-of-8. suture. The suture was
made to cross just in front of the aponetirosis or that portion of
the abdominal wall which it is most important shotild be main-
tained in apposition. The figure-of-8 suture was designed to
accomplish the same purpose as a double row of sutures, but
affording the advantage that the suture could be removed. It
was found to have the disadvantage, however, that in order to
secure apposition of the tissues, the suture was likely to be drawn
so firmly as to result in a slough, which produced a stitch abscess.
I have experienced the greatest satisfaction by a com-
bination of continuous chromic catgut suture with interrupted
silkworm-gut sutures. Beginning at either angle of the wound,
the catgut suture is introduced external to the aponeurosis upon
one side of the wound, brought out in the peritoneum and fascia
of the opposite side, and then through the edges of the peritoneal
wound until the other angle of the wound has been reached,
INFLAMMATIONS.
457
rhen it is brought out above the aponeurosis. The silkworm-
at sutures are now introduced, including all the tissues above
be peritoneum, the wound is cleansed, and the catgut suture
ontinued, uniting the edges of the aponeurosis, when the
round is carefully dried before the introduction of the last
om and the tying of the knot. Again drying the wound, the
ilkworni-gut sutures are tied. This procedure gives secure
Fig. 327. — Vaginal Incision for Pus-collection in the Broad Ligament.
union of the peritoneum, aponeurosis, and skin with but one
buried knot. When twenty-day catgut is used, the wound
sliouJd be firmly secured against subsequent weakness.
The silkworm-gut sutures serve as supports to the wound,
toi should be tied only closely enough to hold the surfaces
"1 apposition. The after-treatment is similar to that of other
abdominal operations. (Section 206.) The combined crescent
458 GYNBCOLOST.
and vertical incision (see Fig. 79), where lai^e masses do nodhaw
to be removed, has given me great satisfaction and greatly lessen
the danger of hernia, while it affords an opportunity to concealaa
unsightly scar beneath the pubic hair.
Vaginal Section and Uterine Castration. — Many clinical
observers have appreciated that the infected uterus, km
which the disease had been transmitted to the peritoneum
and appendages, has continued to be a cause for discomfort
and ill health after the secondary foci of infection — the ap-
pendages— have been removed,
P6an, in 1886, to insure relief in such cases, advocated
the removal of the uterus through the vagina as a routine pro-
cedure in all cases in which that organ had been involved m
an infectious process. This operation he designated as uterine
INFLAMMATIONS.
459
tration. The procedure was subsequently popularized by
advocacy of Segond and Jacobs. The diseased appendages
f or may not accompany the uterus in its removal. In
paring for this operation the following instruments shotild
sterilized: Three double tenacula; fotir vaginal retractors;
nife; one pair of straight scissors and one pair curved on
flat; fotir large and twelve small pressure forceps; an
iotribe; Deschamps ligature-carrier; needle-holder; needles,
xaded with silk loops; chromic catgut, sizes o and 2. The
Fig. 329. — Clamp Forceps for Securing the Broad Ligament.
itor may also have at hand the thermocautery and a large
ber of sterile gauze sponges. The steps of the operation
amilar to those in the performance of the ordinary opera-
oi vaginal hysterectomy. The patient is prepared as directed
action 182. She is placed in the lithotomy position, and
uterus is exposed by the vaginal retractors, one anterior,
cond posterior, and one on each side. These retractors
held by two assistants. The cervix is seized by a vul-
Fig. 330. — Deschamps Needle Ligature Carrier.
im or double tenaculum, dragged down, and a circular
don made through the vaginal walls, which will be nearer
OS externum anteriorly than posteriorly. Behind, the
don extends for half an inch or more above the os, and,
jquired, additional room can be secured in the vagina by
•al incisions in the vaginal wall which extend for half an
outward from the circular incision, and parallel with the
id ligament. The incision about the uterus is often made
460
GYNECOLOGY.
with the thermocautery, which has the advantage that, i
addition to decreased bleeding, the bum prevents the s
from immediate union and affords better opportunity for di
age. After cutting through the vagina the tissues are p
away from the cervix with the finger, the separation h
the bladder and the cervix is accomplished by blunt diss
with the finger or some blunt instrument, or by s
snips of the scissors. The late Joseph Eastman inserted tl
scissors, closed, near to the cervix and then separated the blades,
which facilitated the dissection. The dissection can be more
rapidly accomplished posteriorly, as there is but little danger
of injuring the rectum. The dissection is completed front
and back by opening the peritoneal cavity when the utens
is held by the broad ligaments, through which pass the uterine
and ovarian arteries. The tissues upon each side are divided
with successive snips of the scissors, and the uterine artery
is seized with forceps as soon as exposed, or immediately when
INFLAMMATIONS.
461
■ fundus of the uterus can then be tilted forward
;he anterior fornix of the vagina. This permits the
be carried upward. With the fingers passed over
s of the uterus the ovary and tube are followed upon
surface of the broad ligament and dragged down,
air of clamp forceps can be placed upon the broad
to secure it. This is usually done first upon the left
which the
ment is cut
the uterus
forceps,
nits more
ess to the
ube and
as the
: the uter-
imed out
-ay. This
ovary are
down in
* manner,
I ligament
external to
i the mass
. We have
bleeding
soured by
jstue for-
the condi-
he patient
s to make
itious op-
esirable, it
completed
y packing
;ina with
ween these
irrying the
II over the
le forceps in order that the intestine shall not impinge
hem and become injured. The forceps and vulva
ed with a sterile dressing and the patient put to bed.
!ps should be allowed to remain for forty-eight hours,
e for four or five days. The clamp method, while
us, has the disadvantage, however, that the tissue
in the grasp of the forceps undergoes necrosis and
462 GYNECOLOGY.
causes a disagreeable odor for two or three weeks subsequat , '[.j^
to the operation. This condition is a worry to the patitnt, ■ ' 7 ■
nurse, and physician. There is always a possibility of th('- ■^;
infection of the structures and of the peritoneal cavity, so tW ■ ";" ^..;
the majority of operators prefer to employ the ligature. Tin ^,:-_'.
upper part of the broad ligament, that in the grasp of iheupjiB ^;'
clamp, may be crushed with the angiotribe and ligated w '^^- -
chromic catgut in the groove. The angiotribe, however, slioiild \i'_
not be employed if the tissue has undergone inflammatico \ '
,13- — Ligation of the Broad Ligament in Vaginal Hysterectomy.
and contains more or less exudate. The angiotribe crushes
this tissue, indeed, almost bites it off, and, therefore, does not
preclude tlic possibihty of bleeding. Care must be employed
in the use of the ligature to make sure that it is firmly tied
and that it docs not sHp. The uterine arteries, if they are
in the ^x^i\^ of the small forceps, may be ligated wth catgut.
These, if they have been picked up separately, do not require
a large mass witliin the ligature. In the employment of liga-
INFLAMMATIONS. 483
le pelvis, the catgut should be preferred, although
disadvantage of being more likely to slip. The liga-
is very likely to become infected, consequently, if
ligature, it leads to a profuse discharge, to the for-
extensive granulations, and to a condition which is
.ble to the patient and a source of worry to the
Therefore, the chromic catgut should be employed
ce to the silk, which is almost certain to become
The ideal
avity has been opened and disturbed. Gauze may be
) the pelvis temporarily during the remaining steps
ation. In some cases the uterus is so bound down
atory exudate that the dissection through the ante-
of the vagina is somewhat difficult. In these cases
on may be expedited by splitting through the an-
if the uterus, holding each side of the organ with
464 GYNECOLOGY.
the double tenaculum, and drawing it down while the eervii
is being split. This affords a better opportunity to obsem
the relation of the bladder and the uterus, and to keep withk
the layer of connective tissue in the septum. Splitting the
cervix and making traction upon its sides enable us to seethe
relation of the bladder and, consequently, to avoid icjuiinj
it. Another modification is the amputation of the cerva
after the lower part of the broad ligament has been cut thiou^
This permits the more ready rotation downward of the fundus
through the anterior fornix, as it has a shorter arc throi^
which to rotate. The fundus of the uterus may be rotated
through the posterior fornix, but the anterior is preferable,
Fig. 335, — The Introduction of Gauze after Removal of the Uterus.
for the reason that it puts the broad ligament more readily
upon the stretch and enables us the better to find the lines of
cleavage between the tube and ovary and the other adherent
viscera. If the ovary and tube are not readily brought down,
or if the patient is suffering from chronic hyperplasia of the
tubal and ovarian structures, by which these oi^ns are often
largely obliterated, we may apply the clamp on either side of
the uterus prior to its removal. After the removal of the
uterus we can then proceed in our effort to remove the ap-
pendages upon each side ; but should we fail in this or if the
adhesions are very firm, these structures may be permitted
to remain, taking care, of course, that all pus-pockets have
INFLAMMATIONS.
465
■oroughly broken up and packed with iodofonn gauze.
»t majority of these cases have been infected. It is
y preferable to keep the wound open by packing it
ioform gauze rather than to close the vagina and peri-
surfaces. Landau advocates and practises the bifur-
jf the uterus through the anteroposterior line as a pre-
y. One half of the organ is pushed upward, the other
■n down. This procedure affords much more room for
Fig. $36. — Closure of the Vaginal Wound by Sutures.
lipulation necessary in the application of forceps, the
the ligature, or in crushing with the angiotribe. It
better opportunity, also, for dealing with the infected
d ovary. As a preliminary, the peritoneum can be
d by packing with sterile gauze before we proceed to
e or separate the ovary and tube. In the employment
1 of gauze it is very important, however, that the end
466 GYNECOLOGY.
of the gauze shoidd be fixed with a pair of hemostati)
as the gauze is very readily worked upward into the i
cavity by intestinal peristalsis, and may readily get be
reach of the surgeon. Nothing is more annoying th;
peditiously perform an operation and subsequently
lose valuable time in hunting sponges. The nurse
penses the sponges should do nothing else, and sho
an accurate account of the number of sponges she I
out. These should be accounted for before the ope
considered completed.
DISPLACEMENTS OF THE PELVIC ORGAHS
476. Changed Relations of Structures of Vulva.—
lations of the structures of the vulva are modified
torted by hypertrophy, by varicose veins, by infla'
exudates and deposits, by edema, and by hernia and
but they are, however, so intimately connected with tl
DISPLACEMENTS OF THE PELVIC ORGANS.
467
*ructiires that they are not subject to anything like displace-
«aent. All the other pelvic structures are capable of more
w less marked displacement ; still all are so closely related to
■tad. dependent upon uterine deviations that we will proceed
'to the consideration of the uterus and its displacement as a
primary subject.
477. Physiologic Movements of the Uterus and the Forces
^ WUch It Is Sustained.— The uterus is a freely movable
^ipUL It is suspended in the pelvis, with its fundus at or a
itUB above the level of the brim of the pelvis, by the action
Pig. 338,— Utems Displaced by Distended Bladder.
l( the uterosacral, the uterovesical, and the inferior portion
<i tiie broad ligaments, and occupies the axis of the pelvis,
*ith its cervix directed toward the last sacral vertebra. The
Supports of the uterus are not ligaments in the ordinary sense,
but consist of connective tissue, into and through which run
ptolongations from the uterine muscular structiu-e, so that
the organ is virtually sustained by muscular action. That
tie uterus is supported by muscular action is evident from
fte fact that the organ moves upward and downward with
wny respiratory excursion, changes its position with that of
tte body, and is influenced by the distention and condition
468 GYNECOLOGV.
of the surrounding viscera. In the nonnal position the utenit
rests forward upon the bladder, in a position of slight ante-
fiexioD, while the cervix is directed ahnost at a right ao^
to the axis of the vagina. Such a position is markedly changai
by the distention of the bladder, which raises the fundus ami
decreases the angle between the uterus and the vagina uEtl
it becomes exceedingly obtuse (Fig. 338), and in marked dil-
tention, indeed, the uterine axis becomes nearly parallel lidi
that of the vagina. The cervix is pushed forward by distto-
tion of the rectum. (Pig. 339-) When the rectum and tta
bladder are both distended, the organ is elevated, and noloi^
Fig. 339. — Uterus Displaced by Impacted Rectum.
finds room between these two viscera. It will be seen tbst
the muscles, arranged as just mentioned, support the cervfl-
The movements of the body of the organ are influenced W
the broad ligaments on each side, which prevent it from un-
dergoing lateral change of position, and by the round ligaments,
which act as stays to prevent it from falling backward, or to drs*
it forward, when the bladder is emptied. The round liganienB
are, of course, an insignificant force, but it must be reman-
bered that the uterus weighs less than an ounce, and we can
understand, therefore, how they serve to maintain the utenB
far enough forward to permit the intra-abdominal pressui*
DISPLACEMENTS OF THE PELVIC ORGANS. 469
to be directed against its posterior surface. So long as the
intra-abdominal pressure continues upon the posterior surface
of the uterus, it is held forward against the bladder. It is
also important for the maintenance of the uterus in its normal
place that the muscular structure of the pelvic floor shall re-
main in normal condition. Relaxation of the vaginal walls
and of the muscular structure, occasioned by injury to the
pelvic floor in which the perineal muscles are torn through, —
and, particularly, the levator ani, — withdraws a support, which
sooner or later favors displacement. The normal condition
of the peritoneum is a factor. This structure is certain to be
Fig. 340. — Scheme of Dislocated Uteri. — (Dudley.)
affected by loss of muscular tone and of muscular support. It
is not one factor, then, but several, which combine to maintain
the uterus in its normal relations.
478. Pathologic Changes and What Constitute Them. —
From what has been said of the physiologic changes of position
in the situation of the uterus it can readily be perceived how
difficult it is to draw the line of demarcation between physi-
ologic and pathologic changes. It may be said that when the
uterus undergoes such changes in its structure or in its envelopes
that it becomes stable in a position which is at times regarded
(
470 GYNECOLOGY.
as physiologic, it becomes pathologic and is known as <
ment. Thus, the uterus may be pushed forward by a <3
bladder, which will increase the angle between its axis •
of the latter; but if it does not follow the bladder forwa
that organ is emptied, the position becomes abnormal
These changes may result from:
I. Neglect of hygiene on the part of an individua
in permitting the bladder to become habitually overd
or the rectum to be loaded with fecal matter until th'
is so driven back that the intra-abdominal pressure is n
directed upon its posterior, but falls upon its funduE
Fig. 341.— Uterus Pushed up by Tumor in Douglas' Pouch.
terior surface, which will lead to changes productivf
abnormal fixation.
2. Inflammatory changes in the uterus, leading to ii
weight of the organ, straightening of the body, loss of its
curvature, and, by the weight, displacement of the orj
ward, by which pressure is exerted against the ftmdu!
bladder; or, again, the increased weight produced by
matory conditions causes relaxation of the pelvic lij
and consequent displacement of the uterus downwa
backward, while the body is bent upon the cervix. Th
ing may take place forward, backward, or laterally.
3. The presence of inflammatory material in the
tissue and in the structures surrotmding the uterus
DISPLACBMBNTS OP THE PELVIC ORGANS. 471
splacement by the volume of exudation, and subsequent
cement in the opposite direction takes place by the re-
g inflammatory contraction. The uterus may be dis-
1 as a whole, while its axis still remains parallel to what
I before, causing a change of location ; or, again, it may
ned. upon its axis forward, backward, or laterally; may
It upon its own axis; may be depressed downwsird; and
ittdergo torsion.
The presence of growths, either of uterine or external
9- Clasufication of Displacements. — As may readily be in-
Fig. .14*. — Uterovaginal Prolapse.
!d from what has been stated in the previous section, the
"US is capable of displacement upward, downward, back-
d, forward, and laterally, and of being twisted upon its
. Upward displacement is known as ascent; downward,
ilescensus or prolapsus uteri. (Fig. 340.) The location
he uterus is subject to change: thus, when it is situated
ird the back part of the pelvis, hugging closely the hollow
he sacrum, it is known as a retrolocation ; close to the sym-
sis pubis, as an antelocation ; and toward one or the other
of the pelvis, as a dextro- or sinistro-location, according to
nde on which it is situated. When the direction of the axis
472 GYNECOLOGY.
of the organ is changed, it is known as a version; with thel
well forward, it is an anteversion; the fundus turned
ward, a retroversion; and toward either one or the othe
a dextro- or sinistro-version. The organ may be bent
its axis, in which event the cervix and fundus approac
other. This bending may take place forward, backws
laterally, giving rise to the terms anteflexion, retrot
and dextro- and sinistro-flexion. Finally, it may be l
upon itself, producing a torsion.
480. Ascent is the least frequent form of displac
Those conditions which increase the weight of the oi^an
rally, by force of gravity, depress it. It is only when th
has attained a size so great that it is no longer accomn
within the pelvis that ascent occurs. This is recognia
physiologic ascent in pregnancy, and occurs after the
month, when the uterus becomes so large that it can nc
be retained within the pelvis, and rests upon the bi
similar state develops when fibroid growths are situ;
the organ and become large. (Fig. 341.) The uterus is
or pushed up by growths which may have developed
DISPLACEMENTS OF THE PELVIC ORGANS. 473
and become adherent to it. As they increase in size and
out of the pelvis, they drag or ptish the uterus up with
Ovarian tumors, extra-uterine pregnancy, extensive pel-
W exudation, hematocele, and retro-uterine growths may bring
^about an elevation of the uterus.
481. Diagnosis. — ^The elevation of the uterus is readily de-
IniniDed by digital examination. The cervix is absent from
ia usual position in the vagina ; frequently so elevated as to
be with difficulty reached behind or even above the symphy-
sis; often a growth or mass fills the pelvis, over which the
*■ 344- — Vagino-uterine Prolapsus with Hypertrophic Elongation of the
Wnix can not be reached. Greater difficulty is sometimes
experienced in determining the condition which has caused
the displacement, and this is more important than the treat-
"■nt, for the latter is entirely dependent upon the cause pro-
ducing the displacement.
463. Descent, or Prolapsus. — Descent or prolapsus of the
irterus varies in degree. By this term is understood a down-
*ini displacement of the organ, which is generally associated
'ith retroversion, so that retroversion is often considered
« the first degree of prolapsus. The uterus is situated at a
474 GYNECOLOGY.
lower level, with the os directed in the axis of the vagina. T^l
second degree of prolapsus is when a portion o£ the orgin P
trudes through the vulvar orifice, and the third degree ^
the entire uterus is outside of the vulva. This term iacl
a partial or complete prolapsus or inversion of the vagina.
lapsus is also divided into complete and incomplete, accc
to the situation of the uterus. When the organ is still atuafi
within the vagina or only a portion protrudes from the vulvfcj
it is known as incomplete prolapsus, but when the entire utenw
is external to the vulva, it is called a complete prolapsus. TteJ
term procidentia is also applied to prolapsus, but only when tl»|
entire uterus is external. Prolapsus is further divided into thi** 1
Pig. 34S. — uterus Detached, Showing Hypertrophic Elongation of theCenS-
varieties, according to the relation of the uterus to the vagina-
Thus, it is called uterovaginal prolapsus (Pig. 34a). whe"
the prolapsus begins in the uterus, which is extruded through
the vagina with only partial inversion of the latter; (a) vagino-
uterine prolapsus, when the prolapsus begins in the vagmal waBs
and more or less extensive protrusion of the vagina precedes
the prolapse of the uterus (Figs. 343 and 346). In such cases
the prolapsus of the uterus may be incomplete, while the vagin*
is inverted, and a hypertrophic elongation of the cervix cnsB
(Figs. 344 and 345). The third variety is pseudo-prolapsus-
DISPLACEMENTS OF THE PELVIC ORGANS.
475
In this condition a large portion of the cervix projects into or
through the vulva, while the fundus retains its normal position
and the vaginal walls are unaffected (Figs. 347 and 348). In
the latter case the hypertrophic elongation takes place in the
vaginal portion of the cervix.
483. Etiology. — The causes of prolapsus may be classified
under three heads: first, decreased support; second, increased
weight; third, increased intra-abdominal pressure. These con-
ditions can exert their influence separately, but they usually act
in conjunction. Decreased support is characteristic of individ-
uals who have given birth
to one or more children,
and in whom the pelvic
structures have been in-
jured during the process
of parturition. Lacera-
tion of the perineum or
removal of the support
of the posterior segment
of the pelvic floor per-
mits a protrusion of the
anterior wall of the
vagina and the bladder
during the distention of
the latter organ. This
protrusion of the ante-
rior segment of the pelvic
floor, because of the close
attachment of the blad-
der to the cervix, drags
upon the latter, and,
unless the uterus is fixed
by firm ligaments or
inflammatory adhesions,
the entire organ is gradu-
ally brought into the
axis of the vagina, with
its fundus thrown backward, and the intra-abdominal pres-
sure win subsequently be directed upon it or its anterior
surface. The decreased support to the posterior wall of the
vagina permits protrusion of tliis segment -with the rectum, and
the cervix is drawn upon by both the anterior and posterior
vaginal walls. Decreased support may exist in women who have
not given birth to children, where, o\ving to want of normal
muscular development, to ill health, or to tbo straight a sacrum,
the support is lessened and the muscles of the pelvic floor are
476 GYNECOLOGY.
greatly relaxed. If, in such cases, intra-abdominal pn
increased, extensive displacement results. Prolapsus rt
be produced in the unmarried. In marked relaxation a
of pelvic support, which have resulted from lesions of pai
the tendency to prolapse is increased by enlargemenl
uterus or by failure to complete the process of involutic
uterus remains heavy, so that these two forces, decreased
and increased weight, acting in conjimction, lead to desc
is true, we may have prolapsus when the uterus is sma
in cases in which, subsequent to the climacteric, the patii
Pig. 347. — Pseudoprolapsua. Cervix Within the V^na.
flesh, the absorption of the fatty cushion decreases the
of support, and, with enfeebled muscular action, permit
uterus to be driven through the pelvis. This is a caus
lapsus in the aged. Increased intra-abdominal press
arise from want of hygiene in clothing, where t^ht ca
heavy skirts fastened about the waist afford insi^cienl
the abdomen for the viscera, which are driven downv
the pelvis. Neglect of the evacuation of the bowels ai
bladder increases the tendency to displacements. Pre
DISPLACEMENTS OP THE PELVIC ORGANS. 477
Avored by straining at stool, by lifting and carrying heavy
lights. Not infrequently a patient will give a history of having
ttd a weight or of violent straining, after which a protrusion
isnoticed at the vulvar orifice. In such cases the condition has
^_ —isted for some time, and in the majority has been aggravated
I ; cnly at the time of the extra effort. The presence of growths
wiliiii the abdominal cavity — fibroid tumors, ovarian cysts —
■lAich press upon the uterus may force it down. In relaxation
' <rf the pelvic floor it is not unusual to observe a prolapsus of the
■tenis, which has been produced by the increased intra-abdominal
pressure incident to the presence of a new-growth.
Pig. 348. — Pseudoprolapsus. Cervix Protruding from Vulva.
484, Symptoms. — In the early stages of prolapsus of the
Jjj*nis there are no symptoms characteristic of the condition.
The patient complains of a sensation of weight, pressure, dis-
Wmfort in the bladder, a feeling of burning in the rectum, and
''fagging sensation while walking or standing — all of which may
l* associated with other conditions. As the prolapsus pro-
tKsses, the patient will notice a protrusion from the vulvar
orifice, which is increased by straining and lifting. As this pro-
tnision increases, the close association of the bladder with the
cervical wall causes the uterus to be dragged down. The bladder.
478
GYNECOLOGY.
with exceedingly rare exceptions, accompanies the displacement
Occasionally, however, the peritoneal fold may be driven down
between the bladder and the uterus, and a prolapsus thus occur
without the bladder being associated with it. With the continu-
ation uf the prolapse the anterior wall becomes more and mow
everted, and, not infrequently, forms a considerable-sized tumor,
which projects anteriorly, is increased by straining, and forms a
tumor with a smooth, globular surface. This protrusion of the
anterior wall of the vagina
and bladder is known as a
cystocele, (Fig, 349.) The
posterior wall of the v-agina
may be likewise protruded,
though less frequently than
the anterior. In cases of
inversion of the vagina the
posterior ^vall is generally
associated, although evm
then not to the same degree
as the anterior. (Fig. 349.)
The posterior protrusion is
known as a rectocele. The
uterus is separated from
the rectum by a prolon-
gation of the peritoneuBi
which extends below the
rectum on the posterior
wall of the vagina. In the
inversion of the posterior
wall of the vagina to form
a rectocele, the intestine
may or may not be assoa-
ated with it. Occaaonally,
the want of support of the
anterior rectal wall permits
it to be pushed downward,
and form a diverticulum
considerably below the
anus, which renders the evacuation of the bowel difficiilt, and
at limes impossible, unless it is pushed up with the hand, when
the sc\-b:ik)us m;isses situated in the pouch can be extruded.
In cumplctu pn">lapsus of the vagina with the formation of
an extensive cystt.'cele a portion of the bladder is situated
boluw tlie level oi the internal orifice of the urethra, and ss
this ])rMtrusii.in extends, the bladder is incompletely evacuated,
tlie retained urine with mucus in this reservoir undergoes
Fig. 345. ■
iml PostfriorColpocele.
DISPLACEMENTS OF THE PELVIC ORGANS.
479
ion, forming an ammoniacal urine, which irritates
{ membrane of the bladder and produces a cystitis.
/ertictalum, with a plug of mucus as a nucletis, a
'. considerable size can form; indeed, one weighing
a.s been found in such a sulcus. With the protru-
stress of the patient is greatly increased, because of
Fig. 350. — Cystocele.
r irritation and the friction of the protruding tumor
J clothing and limbs of the patient. The urethra,
passing upward and backward as in the normal
passes backward and even downward. The pro-
ina in a complete prolapsus may form a large tumor
half-way to the knees, in which tumor is situated a
480
GYNECOLOGY.
portion of the bladder, the uterus, ovaries, tubes, and prol
intestines — an extensive hernia (Fig. 352). The mucous
brane of the vagina loses its moistened, reddish appea
and instead becomes pale, thickened, and covered with fia
epithelium, and resembles the appearance of the skin. I
with urine and fecal matter, irritated by the clothing a
friction against the limbs, and congested from the deci
ulceration is produced upon the external os and upon thi
^Prolapsus with both Rectocele and Cystocele,
of the tumor, which, at times, causes extensive loss of structi
adds greatly to the discomfort of the patient. In the earl;
of the displacement the menses are increased, possibly irr
and occur at shorter intervals. Leukorrheal discharge is p
often profuse, as a result of the congestion of the organ.
prolapsus becomes still more extensive and approaches
to complete prolapsus, menstruation is likely to be decreas
the leukorrheal discharge disappears. The displacemen
DISPLACEMENTS OF THE PELVIC ORGANS. 481
:essarily interfere with conception, as pregnancy has often
si with complete prolapsus; but in the later stages the
t is more likely to be sterile.
;. Diagnosis. — The patient considers every protrusion
lie vulva to be a prolapsus or falling of the womb. The
m would seem self-evident, but it must be conceded
lot every such protrusion is necessarily a prolapse of the
i, and it is important to determine the degree, the form
■olapsus, and the structures involved. This knowl-
is obtained by insfjection, while the patient is directed
-Tease the displacement by straining and bearing down,
s further confirmed by touch. A protrusion from the
JT part of the vulva, which, on separating the labia, is
to be continuous with the urethra and anterior wall, is a
ele. It is the most frequent protrusion from the vulva,
lay be accompanied in part or wholly by the uterus,
ele is recognized by the finger entering the vagina be-
Jie protruding mass, which can generally be replaced
ase. The cervix, when accompanying it, will be situated
posterior surface. A protrusion of the posterior wall
vagina is recognized by its continuity with the peri-
and the finger enters the vagina in front of it. Con-
)Ie protrusion of the vaginal walls may occur without much,
, displacement of the uterus. The degree of displace-
482
GYNBCOLOGY.
ment of the anterior and posterior walls of the vagina is
nized by the introduction of the finger around the utenis.
the cervix may protrude from the vulva without then
any shortening of the posterior, and but slight shorte
the anterior, wall of the vagina. With inversion, c
plete prolapse of the vagina (Fig. 351), the siimmit of l
trusion is occupied by the cervix, which may appeal
normal-sized ope
external os; 01
laceration of tb
has occurred, '
may be widely
and show an
cervical mucou
brane. When i
is complete, the
situated in the
external to th(
generally in the
of retroversion
flexion ; rarely i)
flexed. Theutei
form of prolaps
termined fromth
uterine variety
lessened involve
association of tl
with the protru;
the uterovagin
(Fig- 353) th.
is driven thro
vagina, drags
the upper pa
finally residts i
inversion of t\
When the pro
complete, the 1
likely to be si
its cavity short. In the vagino-uterine variety the
begins at the lower segment of the vagina by a rolling
of the anterior and posterior walls. The thickened an(
vaginal walls drag upon the cer\'ix, and lead to disp
of the uterus; or, where the fundus is fixed by the 1
of its ligaments or by inflammatory disorders, the
drawn out. an<i causes a very marked elongation of th
This condition is determined by placing the fingers of <
ithout Protrusion of
il Walls.
DISPLACBUBNTS OP THB PBLVIC ORGANS. 483
Dat of, and those of the other hand behind, the protruding
. when we detennine the situation of the fundus of the
IS. (Pig. 354.) The protruding tumor can be grasped
eea the thumb and fingers of one hand, when the fingers
distinguish the uterus outside the vulva, or the cord-like
X protruding into the vagina, when hypertrophic elon-
n of the cervix exists {Fig. 355)- The situation of the
OS can still further be recognized by the introduction of
inger into the rectum. By dragging upon the cervix with
laculiun while passing the finger into the rectum the at-
lal Palpation.
-tion of the neck is determined, and the situation of the
ts is recognized (Fig. 356). In pseudoprolapsus the fundus
t little displaced from its normal situation. There is a
oding mass from the vulvar orifice, and the introduction
e finger into the vagina shows that the vaginal walls are
lisplaced; this elongation has taken place in that portion
e cervix which is situated below the vaginal attachments.
nerally results from enlargement and increased weight
e cervix. The anterior segment of the vagina is attached
e cervix at a lower level than the posterior. Occasionally,
484
GYNECOLOGY.
we find a protrusion of the anterior wall of the vagina, sad
at its posterior surface the cer\ix, while the introduction d
the finger into the vagina shows that the posterior vaginal
wall is not displaced. (Fig. 357.) In other words, the elonga-
tion has occurred in that portion of the cervix situated l«-
tween the attachment of the anterior and the posterior ^-agiral
walls.
In considering the differential diagnosis ^"e must concede
the possibility of the protrusion having arisen from a cj^a
in the anterior wall of the vagina, a hernial protrusion through
the posterior fornix, a fibroid pcjiypus, and an inversion of the
uterus, assfxriatcd with inversion of the vagina. Cyst cf the
with Thumb and Fingers of One Ha^'
vagin:! is recognized by bimanual palpation. A catheter or
siiund intnxhK-cd into the bladder, and a finger into the vagina,
will revi-al an almormal thickness of the anterior wall, and tlie
character of the condition will be readily disclosec!. The bi-
manual examination ean reveal a fibroid polypus protniding
from the orifice of the cervix by a more or less distinct pedicle.
Traetii>n u]H'n the lumor and the introduction of a finger into the
reetum will disclose the position of the uterus. Displacement «
the reetum is not generally associated with pnilapsus ^
the vagina] walls, and, when so, is less intimately coniieclf>i-
DISPLACEMENTS OF THE PELVIC ORGANS.
485
m of the uterus is recognized by a protruding tumor,
.oes not present an external os, is more sensitive, under
examination shows the orifices of the Fallopian tubes,
i globular, well-shaped tumor, which can, still further,
an inversion of the vagina in which the relation of the
o the tumor and the vagina is readily determined.
atwele, or hernia through the posterior fornix of the
is a rare condition, although I have seen two such cases
h the hernia extended to the vulva. (Fig. 358.) The
56. — Diagni
'rine Body by Rectal Touch.
s generally more elastic and is greatly distended. The
of the uterus, in association with it, is 'recognized,
.ction of the hernia the opening into the posterior fornix,
which it had passed, is readily recognized.
Prognosis. — The results of treatment must generally
upon the stage of development, the existing compli-
and the manner of life the patient is required to live.
rlier the displacement comes under obser\'ation, the
ical will be the means required to maintain the organ
•eplaced position. When both uterus and vagina are
486
GYNECOLOGY.
\
prolapsed, changes have taken place which are beyond ott |^
skill to restore to the previous condition. While much cant«
done for the comfort of the patient in all cases, still ii
however, it may be necessary to sacrifice the uterus and part
of the vagina. The irritation to which the vagina is subjected
will sometimes lead to the development of an epitheEoniL
(Fig. 3S9.) Not infrequently we will find gravity sores' and
extensive ulcerations as a result of friction and the interfercMi
with the circulation. The restoration and maintenance rf
the pelvic organs in their proper place will depend upoa the
complications which may be associated with the displacements.
The most frequent complication is the sequel of inflammatory
changes, in which the displaced organs are more or less fixed
by extensive exudation and adhesions. In procidentia the
protruding sac or hernia, in addition to the uterus and part
of the bladder, is likely to contain the ovaries and tubes, and
even a large portion of the large and small intestines. In-
flammatory changes in such a condition may lead to an ir-
reducible hernia, which must necessarily add very much to
the distress and discomfort of the patient. Such a patient
can neither sit nor stand with comfort. In one patient (see
DISPLACBMBNTS OF THE PELVIC ORGANS. 487
Kg. 352) a large faxitruding sac contained the uterus, ovaries,
M tubes, the latter having become infected, and resulted
■ the formation of a quite considerable-sized abscess. For-
hmately, the condition was irreducible, for otherwise the re-
daction of such a mass into the abdominal cavity might readily
itm resulted in rupture of the tube and general infection of
Bm peritoneum. In one instance I was obliged to remove
it uterus because of a partial necrosis of its structure, Or-
finarily, hysterectomy would not be the operation of election,
H the removal of the uterus leaves an open space, which it is
lifficult thoroughly to close, and favors the subsequent develop-
Wnt of a va^nal hernia, which is difficult to remedy. With
Pig 358 — Enterocele through the Postenor Vaginal Fornix.
K retention of the uterus and its proper anchorage in the
sivis it serves as a plug and obstruction to the redevelopment
s hernia. It is self-evident that the patient who is enabled
I Hve a luxurious life need not be subjected to the same treat-
eat as the woman who must maintain herself, and, possibly,
I members of her family, by laborious industry. The former,
' rest and proper hygiene, may be able to prevent the develop-
Olt of the prolapsus, consequently an operative procedure
ay be delayed or mechanical means employed to overcome
econdition, while the woman who must earn her hving at the
uhtub or by continuous maintenance of the upright position
in be required to subject herself to operative interference in
"derto prevent a more extensive displacement.
488 GYNECOLOGY.
487. Treatment. — The treatment of prolapsus uteri
necessarily depend upon the extent of the cUsplacemest
involvement of the vagina, the distention of the vaginal 0
and the age and physical condition of the patient. The
important treatment is prophylaxis. This consists in the
ful management of the woman during labor and the puerpe
the early repair of lacerations of the cervix and peril
the examination of the patient subsequent to her de
to determine the condition and situation of the uterus,
advent of inflammatory conditions should be follow*
judicious treatment, such as the employment of hot v
douches; cold applications over the abdomen; rest in
depletion of the uterus; and, where endometritis exists, tl
of the curet. A heavy uterus should be sustained by tai
Fig- 359-— Vagi
Prolapse Complicated by Proliferating Epit
or a pessary, until the process of involution has beer
pleted. The treatment of prolapsus may be di'vided in
gienic, mechanical, and operative. Hygienic treatmen'
prises the wearing of proper clothing. A woman with
dency to prolapsus of the uterus should not wear tight cl
The increase of the intra-abdominal pressure necessar
gravates the displacement: consequently, the clothing
be loose. Skirts should be suspended from the shoulders
than from the waist; the bowels should be kept regul
all straining at stool avoided ; lifting and carrying heavy '
should not be undertaken ; the patient should frequently
the knee-chest position, and, while in this attitude, 9
the vulva in order that the air may enter and magnify
fluence of gravity in restoring the displaced organs
position should be particularly assumed for several i
DISPLACEMENTS OP THE PELVIC ORGANS.
4S9
I
as a last act before retiring, and patients should assume the
lateral or prone position rather than the recumbent.
Mechanical treatment of prolapsus consists : (i) in the reduc-
tion of the displaced uterus or its return to a normal position; (2)
in the employment of means to insure that this position will be
maintained. The first step, then, in treatment is to replace the
displaced organs. Ordinarily this is not difficult, as the increased
size of the vaginal canal readily permits the organ to be carried
upward to its proper place. \Vhere the displacement, however.
is complicated by inflammation with extensive exudation into
the pelvis, it may result in matting together the uterus, ovaries,
and tubes with knuckles of intestine and portions of omentum.
Such a condition will render the restoration of the organs ex-
ceedingly difficult, if not impossible, -without resort to operative
interference. Sometimes the displaced uterus, from passive
congestion or edema, will become so large and engorged that
it can not be replaced through the pelvic canal. This is par-
ticularly prone to occur in those cases in which the prolapse
is complete and the uterus and vagina have been subjected
to friction against the clothing, causing the formation of gra\4ty
sores, and swelling to such an extent that the mass is rendered
too large to be returned through the pelvis. Such a tumor
may sometimes be reduced in size by the application of an
elastic bandage, or by keeping the patient perfectly quiet in
bed, with the pelvis somewhat elevated, and cold applications
applied to the swollen structures. Cloths wet with lead-water
and laudanum and covered with oiled silk, over which an ice-
bag is applied, will frequently be effective in relieving the en-
gorgement, and after a few days' treatment will result in such
a decrease in size as to permit the parts to be reduced. The
organ can be replaced with much greater ease by placing the
patient in the genupectoral position. While the patient is
in this position the tumor can be lirawn down, compressed
with the fingers, and gradually pushed up to its normal site
within the pelvis. A mass too large to permit of its replace-
ment with the patient in the dorsal position can generally
be returned while in the knee-chest posture. When the uterus
is fixed by inflammatory exudate, the patient should be put
to bed, the parts subjected to pelvic massage, and in the in-
tervals the uterus supported as high as possible by tampons
of cotton and gauze, or, probably still better, lamb's wool
saturated with medicinal agents, in which glycerin shall form
an essential part. This treatment should be alternated with
hot vaginal douches. Inflammatory adhesions may also be
overcome by the employment of continuous weight or pressure.
This is rather diffictilt to apply within the pelvis, because of
490
GYNECOLOGY.
its being the most dependent portion of the trunk. The patknt
can be placed upon her side, with the pelvis somewhat elevatai
Pressure is then obtained by introducing a small rubber ba^
containing mercury, into tiie vagina. The continued pin-
stu-e thus directed upon the surface will promote the absorp-
tion o£ the exudation, and, by change of position, the uteni
can be gradually worked free from the exudate. Thus, tampons.
Fig. 360. — Ring Pessary.
Fig. 361, — Disc Pessary.
douches, massage, and pressure should be employed until
the uterus becomes freely movable and its reposition is accom-
plished. This, of course, is desirable as a preliminary' to the
employment of such a mechanical support as the pessaiy.
In cases of prolapsus the pessary acts by so distending the
upper part of the vagina that the levator ani and the muscles
of the pelvic floor form a support for the instrument, and thus
prevent the displacement. Consequently it is necessary that
Fig. 36a.-^Smith-Hodge Pessary.
Fig. 363. — Munde Pessuy.
the pessary shall be of sufficient size to accomplish this dis-
tention. The pessaries most frequently employed are the
ring (Fig. 360). the bulb, the disc (Fig. 361), the Smith-Hodge
(Fig. 362), or Thomas or Munde (Fig. 363) modification <rf
the latter. Numerous other pessaries are employed, such
as the soft-rubber pessaries (Fig. 364), the Zwaak or bat-like
pessary (Fig. 36.O. the Gehrung (Fig. 366), the double carved
pessary, the saddle or Graily Hewitt (Fig. 367), according
DISPLACEMENTS OF THE PELVIC ORGANS.
491
> the purposes intended to be accomplished by their designers.
t the employment of many of these pessaries, however, it is
JBolutely necessary that the pelvic floor shall afford a point
: resistance to the intra-abdominal pressure. In cases in
Inch the pelvic floor has been lost, or where the prolapsus
of the vagino-uterine variety, the pessary, having no point
t -resistance, is at once extruded when the patient makes a
T
P'l- 364- — Hoffman Soft-rubber
Pessaiy.
Fig. 365. — Zwank
training effort, or even upon standing. In such cases a pessary
nay be employed with an external support. This is in the
onn of a cup with a stem attached to straps which are fastened
0 a belt around the waist. Such an instrument, however,
t exceedingly uncomfortable ; the stem and straps are irritating
othe delicate external surfaces. The cup may cause ulceration
ind abrasion of the cervix and vagina. The employment
Pig. 366. — Gehrung Pessary.
F'g. 3*^7' — Hewitt Cradle Pessary.
i i. pessary in prolapsus can only be palUative ; it has no power
to restore function to the part. However, a patient came
under my observation who had worn a pessary for twenty-
tt years. This had produced such marked abrasion and
irritation of the vagina that granulations had sprung up which
Wveloped the greater part of the instrument with new tissue.
The pessary was cut with bone-pUers, and each half removed
492 GYNECOLOGY.
separately, leaving undisturbed the mass of cicatricial tissue
by which the uterus was subsequently supported. I have
seen, in several instances, the bulb or glass-ball pessary worn |
for a long period of time, until it resulted in cicatricial changes ,
in the vagina, which formed the support for the atrophied utenis.
The maintenance of the uterus by the establishment of cicatricial
tissue has been attempted by the injection of quinin and other
irritating materials into the broad ligaments. This was done
in order to establish a cellular inflammation, which should
cause such contraction of the connective tissue as to retain
the uterus in position. Such a plan of treatment, however,
is attended with too much danger to justify its employment.
The operative treatment affords the only means which can
be considered radical, or as giving hope for the restoration
of the structures and their maintenance in normal position.
In the employment of such measures I wish to direct your
attention to the three causes which have been assigned for
the development of prolapsus. These are, increased weight
of the uterus, decreased pelvic support, and increased intra-
abdominal pressure. The malposed uterus is rendered heav?
by a condition of subinvolution or chronic inflammation, which
has in part resulted from obstruction to its circulation. Not
infrequently will we find that the cervix has tindergone hyper-
trophic elongation, and that the vaginal walls are dragging
upon this elongated portion of the organ. The first step, then,
in the restorative process, should be the amputation of the
cer\- ix. This decreases the size of the uterus, not only by the
amount of the cervix removed, but by the favorable metabolism
thus engendered. The amputation may be free or the double-
flap or single-flap method can be employed (see Amputation
of Cervix, § 336), according to the particular pathologic con-
dition present. In i)erforming this operation we would suggest
that the cervix be sutured with chromic catgut, as such sutures
can be allowed to remain; moreover, the stretching of the
newly united surfaces consequent upon the removal of
sutures is thus avoided. The second indication is met bv
narrowing the vaginal canal and reconstructing the poh'ic
floor. Early in the history of gynecology various operations
were devised to secure this object. Sims did a triangular
denudation upon the anterior wall, the surfaces of which were
united and the canal thus reconstructed. The method of
freshening the surface will largely depend upon the character
and form of the prolai)sus. The protrusion of the anterior
wall of the vagina, for which these procedures are considered,
is known as cystocele. Furthermore, the maintenance of the
uterus in position by narrowing the vagina wall be especially
DISPLACEMENTS OP THE PELVIC ORGANS. 493
■pplicable to the correction of the cystocele. In cystocele we
Mve to deal not only with the protrusion of the vaginal wall,
bat also with an accompanying prolapse of the bladder; a. por-
tkm of the bladder is consequently oftentimes below the level
of the internal orifice of the urethra. The portion thus dis-
placed, as we have seen, affords an opportunity for ammoniacal
iBrinentation and decomposition of the urine. In the sulcus
or depression thus formed, not infrequently calculi are devel-
Fig. 36S. — Anterior Colporrhaphy. Anterior Vaginal Wall Removed.
oped, which further aggravate and add to the distress of the
patient. Any operative procedure, then, should comprise
not only the contraction of the anterior vaginal wall, but the
elevation of the bladder to a higher level. This change of
the bladder position is accomplished by an incision through
"le anterior \'aginal wall into the connective tissue between
the vaginal and vesical surfaces. The edges of this incision
are held with forceps, while, by blunt dissection or with sue-
494
GYNECOLOGY.
cessive snips of the scissors, the vesical surface is dis
this dissection is extended upon either side to a degre«
to permit the removal of the relaxed tissue of th
vaginal wall. The bladder should then be pushed i
the cervix, up to or even through the peritoneum.
This dissection is followed by tucking the bladda
below, and stitching it fast to the cervix at a higher k
method renders the posterior surface of the bladder n
Some oper.
advocated
ing the t
the anteri(
through a
nalinciaoi
a procedu
Th
upon the b
its fixatio
anterior su:
uterus wil
the' pressu
the*recon
vaginal w:
vaginal
should be u
near the c
the suturh
outward, 1
being pus!
pnx^ed, Ii
nera stror
segment of
floor is e
(Fig. 369)
turing shot
in a vertica
a continuoi
catgut suture, which should be locked at every se<
in order to prevent puckering of the wound. Tl
the operator should be to make a long anterior wa
the cervix backward, and, consequently, tilt the fu
forward. In greatly relaxed vaginal walls the exc
be'.imade circular, and the \\-ound closed with the StoJ
(Fig. 370.) This, however, contracts the vagina
direction and, therefore, is less favorable in the n
Fig, 369. — Wound
DISPLACEMENTS OF THE PELVIC ORGANS. 495
» than the method of anterior colporrhaphy already de-
hed. The ordinary method of performing the operation,
wn as anterior colporrhaphy, consists in making a denuda-
B which does not penetrate the entire vaginal wall. When
aied, such a denudation forms a wall of connective tissue,
ich is not so durable as the method we have described. The
aation upon the anterior vaginal wall should be supplemented
one upon the posterior. This may be slight or extensive.
Fig. 370. — Stoli's Purso-string Suture.
rding to the amount of relaxation. The restoration of
posterior segment may be accomplished by performing
Operation known as the modified Garrigues-Hegar, or the
ation designed by Emmet. For a description of the method
erforming these operations see Section 372. The decrease
he size of the uterus, the restoration of the pelvic floor,
*scribed, will, in some cases, prove effective in maintain-
the uterus in its proper position. In others, however.
I
496 GYNECOLOGY.
in which the uterus is large and does not maintain its proper
axis, but drops backward, the intra-abdominal pressure will
tend to drive it through the newly united canal and reestablish
the hernia. It is consequently important that the uterus
should be anchored within the abdomen, to prevent such an
occurrence. This anchoring of the uterus may be accomplished
by the operation known as ventrosuspension, or, still better,
ventrofixation. For the description of this operation and
its indications and contraindications see page 541. The same
purpose can be effected by one of the operative procedures
which utilize the round ligaments, as in the Alexander, the Gil-
liam- Ferguson, the Ries, or other modifications, which will
be described later. The aim, of course, of the ojjerative pro-
cedure is to maintain the fundus of the uterus forward. This
can be accomplished by vagino-uterine fixation or by shortening
the round ligaments through the vagina. These operations
can readily be done in association with those upon the anterior
wall of the vagina, as in the procedure we have already described.
When the bladder is pushed away from the cervix, it is very
easy to enter the peritoneal cavity through an anterior colpotomy
and employ the opportunity thus afforded to break up adhesions,
to treat ovarian and tubal disease, and to restore the uterus
to its normal position. The incision through the posterior
vaginal fornix is also employed for shortening the uterosacral
ligaments. It will readily be understood that if the cervix
is carried upward and backward, the fundus will necessarily
fall forward. The contraction of the uterosacral ligaments,
or the tissue in which they are usually situated, is of special
value in marked prolapsus, for if the ventrosuspension or fixa-
tion, or one of the operations upon the round ligaments alone,
is done, we would have the uterus hanging and dragging upon
its anchorage. Shortening the uterosacral ligaments, however,
lifts up the cer\'ix and, consequently, throws forward the fundus,
thus making the uterus ser\^e as a plug to obstruct the egress
through the pelvis. Where the utero-sacral hgaments are short;-
ened as a part of the general procedure, they should be exposed
before the sutures are tied in the operation upon the anterior
vaginal wall. Bovee advises that the ligaments be exposed by
a vertical incision from the posterior surface back toward the
rectum, which shall extend to but not throi;^h the peritoneum.
The latter is pushed off on either side until the thickening in-
dicating the position of the ligament can be determined. Each
ligament should be seized with a hemostat about its middle and
drawn downward, while traction upon the cervix is discontinued.
Each loop should be transfixed by a suture which is tied and the
end of the doubled ligament secured just behind the cervix, near
DISPLACEMENTS OF THE PELVIC ORGANS.
497
lonnal attachment of the ligament. This course applied
>th ligaments results in holding the cervix at a higher level
may in many cases obviate the necessity for opening the ab-
m. The sutures for closing the wound in anterior colpor-
hy should have been introduced and secured by hemostats
■e the incision to expose the uterosacral ligaments, and after
latter are secured,
re have indicated
«,the formershould
;ied and by this
se no traction is
e upon sutures after
have been secured,
e measures may
rther supplemented
he retraction of the
srior vaginal wall or
ic floor. When the
nents have been se-
d, the vaginal inci-
for their exposure
lid be united by con-
ous catgut suture,
ing a vent through
;h gauze drainage
be employed.
ind ad\'ised in aged
len, in whom the
apsus was marked
the condition of
patient unfavorable
I radical operation,
silver wire sutures
lid be passed so as
)rm successive rings
ath the uterus,
introduction of the
ires should begin im-
iately beneath the
TX, so as to push up
maintain the organ at a higher level. He directed that they
rawn moderately tight and fixed by twisting ; the ends are then
off and pushed into the vesicovaginal septum. The silver wire
■ secured forms successive bands or hoops around the restored
ina, which it was thought would maintain the uterus in place,
own experience, however, is that upon very slight exertion
of the Vaginal Walls for Pro-
498
GYNECOLOGY.
the entire condition is reestablished. Moreover, the silve
sutures are likely to cause irritation and possibly the forn
of abscess, which will ultimately require their removal. Att
have been made to maintain the uterus within the pelvis I
flammatory changes in the broad ligaments. Injections of <
hypodermatically have been employed for this purpose, bu
procedures must be futile, inasmuch as they meet but a p
the required indications. Wiggins endeavored to accor
the same by an intraperitoneal purse-string suture in each
ligament. In prolapsxos of lai^e uteri, complicated by infla
tion of the tube
ovaries, with ba
adhesion fixing <
tiun or coils of
tine to the uten
bladder and wit
subsequent cicai
changes, the p
able plain of pi
ure, in my jucfe
is the partial or
plete removal c
organ. Even bo
cal a procedure s
be supplement*
a pU^tic opa
upon the vagii
order to nairo^
canal and i
better support t
abdominal visi
Such patients,
though old, bea
eration fairly
Where the com
of the uterus will permit of its retention, the organ should t
sacrificed. We have already cited reasons why hysterec
should not be the operation of election. In hypertrophic el
tion of the cervix it may be difficult, by simple amputat
the cervix and fixation of the uterus, to sufficiently elongal
vagina to prevent recurrence of the hernia. In such ■
especially where the woman has passed the climacteric
supravaginal amputation of the fundus uteri, through an ab
inal incision, followed by suturing the stump, covered with
toneum, to the broad ligaments upon each side, as advo
by Baldy, will be effective, or, when the vagina is very :
Fig. 3T-
I. Showing Denuda-
DISPI^CBHBNTS OP THE PELVIC ORGANS.
, we may sew the stump of the cervix directly to the
bdominal parietes, as advocated by Noble. E. C. Dudley
sserts that the part of the vagina most resistant to displace-
aent is its lateral surface, and that, instead of narrowing the
•^lina on the anterior and posterior walls, the preferable plan
if procedure would be to denude an elliptical surface upon either
ftteral fornix, with the long diameter anteroposterior. The edges
i newly made surfaces are apposed and secured with sutures
lirough the long diameter. From this a lateral denudation is
nade upon either side, in which the sutures are introduced from
xhind forward and from above downward, in such a way as
to lift up the anterior wall of the vagina. (Figs. 371 and 372.)
Bven in marked cases of prolapsus sutures may be introduced so
as to in some degree serve
to anchor the lateral sur-
faces of the vagina.
488. Urethrocele.—
Tte urethra, in extensive
cystocele, is generally
more or less involved.
As has already been rec-
ognized, the intimate
connection of the bladder
and urethra with the
anterior vaginal wall
aecessitated their associ-
ation in any prolapsus
(rf the latter structiire.
When a segment of the
bladder is situated below
the internal orifice of the
iircthra, the upper part
(rfthe urethra, as a consequence, becomes prolapsed. The lower
Mpnent of the urethra, however, generally retains its normal
otuation. Occasionally we may have a protrusion from the
central portion of the urethra, which forms a sac-hke projec-
tion (Fig. 373) at the lower portion of the anterior wall of
the vagina. This latter condition is independent of any uterine
OT vaginal displacement. This projection, on the introduc-
tiM of a catheter, is found to be a part of the urethra. It is
at times so large as to form a kind of diverticulum, over which
tbe urine flows, without entering it, or enters it only to a limited
Went. Pressure over the urethrocele causes a discharge of
quite profuse purulent material, although pus has not previously
'ten found in the urine. The treatment consists in dissecting
ont the sac, a catheter having been previously introduced as a
Fig. 373. — Urethrocele.
500 GYNECOLOGY.
g^ide. The opening in the urethra is closed while the catheter
is in place. The vaginal wall is then sutured over this wound,
and the urine is subsequently evacuated through a permanent
catheter for two or three days.
489. Dislocation of the uterus is a displacement in which
there is but slight change in its axis. These dislocations may
be forward, backward, or lateral. The organ is more or ]es&
fixed in the abnormal position by inflammatory changes, fre-
quently in the form of inflammation of the cellular tissue. In
anteposition the uterus is situated close to the symphysis, gener-
ally above it, and the condition is produced by growths or by
accumulations in the pelvis which push up the uterus. The
organ, once fixed in the abnormal position, remains. In retro-
position the uterus is situated at a lower level, and close to the
hollow of the sacrum. It results from inflammatory changes
which contract and fix the organ ; thus, a hematocele in its
earlier stages may push the uterus forward into a state of
anteposition, but later, as the collection becomes absorbed and
organized, contractions occur which draw the organ back-
ward. When the contraction involves the region of the folds
of Douglas or the uterosacral ligaments, the ftmdus of the
organ will be pushed forward, and an anteflexion will be es-
tablished. It is only when the organ has previously been
the seat of metritis and has become so rigid that it resists the
tendency to flexion that it retains the retroposed position.
Lateral position, either right or left, is generally due to
inflammation in the cellular tissue of the broad ligament. In
the acute stage of inflammation the organ may be pushed to
the side opposite to that on which the exudation occurs. As
the condition becomes chronic, the inflammatory material con-
tracts, and the uterus is drawn to the affected side. These
displacements cause no special symptoms. The syinptoms,
when present, are due to the complications or conditions which
have produced the displacement and are a consequence of the
displacement.
490. Diagnosis. — The situation of the displaced organ is
recognized by bimanual examination. The fixed position and
situation are usually sufficient to establish the diagnosis. In
lateral displacement the organ is not in a median position,
and on manipulation moves more readily toward the affected
side. In a woman whose abdomen is very fat or the abdominal
wall quite ri^id, the posterior dislocation is often difficult to
differentiate from retroversion. The introduction of the sound
would afford information, but the advantage derived from
determining the position is insufficient to compensate for the
danger from its use. An assistant dragging upon the cervix
DISPLACEMENTS OP THE PELVIC ORGANS. 501
with a tenaculum or vulsellum, while either the vaginal or rectal
timaniial is practised, will generally afford a definite deter-
mination as to the character of the malposition.
491. Torsion. — Torsion is generally associated with either
a retroposition or a lateral position, and is due to an irregular
contraction of the portion of the broad ligament which has
been subject to cellular inflammation. This contraction twists
the uterus upon its axis, so that the comua may be turned
anteroposterior instead of being situated laterally. The entire
oterus can be thus twisted, so that, upon inspection, the os,
Pig- 374. — Anteversion of the Uterus,
instead of being transverse, will present an oblique or nearly
Mteroposterior line. Torsion also results from the presence
of growths in one or the other broad ligament or of an ovarian
t'wior to which the tube is adherent. As the tumor enlarges
It drags upon the uterus and twists it. This lesion is frequently
overlooked, and presents no symptoms of special importance.
(Treatment, see page 547.)
_ 493. Anteversion. — In anteversion, the uterus is found
•ith its fundus forward and the cervix directed backward or
Jipward and backward. (Fig. 374.) The organ may be fixed
•D the abnormal position by complications, such as inflamma-
502 GYNECOLOGY.
tion, which may cause adhesions between the fundus and an-
terior parietal peritoneum, or more frequently in the cellular
tissues about the uterus, the cervix, or in the uterosacral liga-
ments. An inflammatory process of the uterosacral ligaments
with a normal uterus will produce flexion, but when the latter
organ is stiffened by long-continued inflammation, it causes
anteversion. The uterus is considerably increased ih size; its
walls are thickened and often rigid and firm. The normal
flexion has disappeared, and the canal is perfectly straight.
This position of the uterus is caused by increase of weight,
and in severe versions the fundus will lie forward upon the
bladder or against the symphysis, while the cervix may be
directed upward and backward.
493. Etiology.— Any disorder which increases the weight
of the uterus increases the tendency to an antedispiacement.
When the uterus has been the site of previous inflammation,
particularly a metritis, this displacement is necessarily an
anteversion. Metritis, subinvolution of the uterus, pelvic cellu-
litis, occurring in the posterior portion and in the utero-sacral
ligaments; fibroid growths in the fundus; ovarian growths — all
may cause this form of displacement.
494. Symptoms. — Anteversion presents no characteristic
symptoms. The symptoms are those which are associated with
the compHcation by which it is produced. The patient may
complain of a sensation of distress, from pressure upon the
bladder, of frequent micturition, and of pain or a dull ache over
the region of the symphysis.
495. Diagnosis. — Anteversion is readily determined by bi-
manual palpation. The cervix is situated high posteriorly,
and often reached TJiith some difficulty, while the uterine body
can be traced forward and is found to rest upon the bladder.
Not infrequently the fundus lies well against the symphysis.
The situation of the fundus in the anterior portion of the ab-
domen, the absence of any angle in the uterus, and its size,
weight, and more or less immobility, definitely differentiate it.
496. Treatment.— As we have already seen, anteversion is a
symptom or sign rather than an actual disease. It is a develop-
ment that arises as a natural consequence of increased weight of
the uterus, and the treatment must necessarily be that which is
apphcable to the existing complication. The most common
complication is inflammation, causing hypertrophy or hyper-
plasia of the uterus, an irritative infiltration and proliferation
of the tissue element. The inflammatory condition may exist
with or without adhesions. The treatment of the condition,
then, in the great majority of cases, is that of existing inflam-
mation— hot vaginal douches, tampons medicated with agents
DISPLACEMENTS OP THE PELVIC ORGANS.
503
which are expected to exert an influence in decreasing the
size of the uterus. This decrease can frequently be accom-
plished, to a considerable degree, by thoroughly dilating the
uterine cavity with laminaria tents, and after their removal,
swabbing the interior of the organ with tincture of iodin, a sat-
urated solution of iodin crystals in 95 per cent, carbolic acid,
or a saturated solution of iodoform in ether. Following such
■ an application the decrease in size of the uterus may still further
be promoted by packing
the organ with iodoform
gauze and by placing a
tampon of iodoform gauze
beneath it. This raises the
organ to a higher level and
promotes its circulation.
Furthermore, the uterus
can be dilated with gradu-
ated bougies, its cavity
cureted, and applications
made as suggested. Where
the uterus is free from ad-
hesions, it may be sup-
ported by a pessary. The
pessaries which were de-
vised for the purpose of
elevating the fundus have
not proved satisfactory.
The retroversion pessar>'
in some cases of heavj'
uteri is particularly ser-
viceable, although it may
seem a paradoxical instru-
ment to employ in ante-
version, but it does, how-
ever, afford relief by hold-
ing the uterus at a higher
level. Pelvic massage em-
ployed daily is of special
value in promoting drainage, in facilitating metabolism, and
in decreasing the size of the uterus. Operations upon the
cervix, amputation, or the repair of a laceration of the cervix
win establish a process of metabolism which will decrease the
size of the uterus. When the uterosacral Hgaments have not
become shortened through inflammatory processes and thj"'^
caused an irremediable displacement, the operation devised!
Sims may be practised. This consists in making a transvT
Fig. 375--
i' Operation for Anteversion.
502 GYNECOLOGY.
tion, which may cause adhesions between the fundus and an-
terior parietal peritoneum, or more frequently in the cellular
tissues about the uterus, the cervix, or in the uterosacral liga-
ments. An infiammatory process of the uterosacral ligaments
with a normal uterus will produce flexjon, but when the latter
organ is stiffened by long-continued inflammation, it causes
anteversion. The uterus is considerably increased ih size; its
walls are thickened and often rigid and firm. The normal
flexion has disappeared, and the canal is perfectly straight,
This position of the uterus is caused by increase of weight,
and in severe versions the fundus will lie forward upon the
bladder or against the symphysis, while the cervix may be
directed upward and backward.
493. Etiology.— Any disorder which increases the weight
of the uterus increases the tendency to an antedisplacement.
When the uterus has been the site of previous inflammation,
particularly a metritis, this displacement is necessarily an
anteversion. Metritis, subinvolution of the uterus, pelvic cellu-
litis, occurring in the posterior portion and in the utero-sacral
ligaments; fibroid growths in the fundus; ovarian growths — all
may cause this form of displacement.
494. Symptoms,— Anteversion presents no characteristic
symptoms. The symptoms are those which are associated with
the complication by which it is produced. The patient may
complain of a sensation of distress, from pressure upon the
bladder, of frequent micturition, and of pain or a dull ache over
the region of the symphysis.
495. Diagnosis. — Anteversion is readily determined by bi-
manual palpation. The cervix is situated high posteriorly,
and often reached with some difficulty, while the uterine body
can be traced forward and is found to rest upon the bladder.
Not infrequently the fundus lies well against the symphysis.
The situation of the fundus in the anterior portion of the ab-
domen, the absence of any angle in the uterus, and its size,
weight, and more or less immobility, definitely differentiate it.
496. Treatment.- — As we have already seen, anteversion is a
symptom or sign rather than an actual disease. It is a develop-
ment that arises as a natural consequence of increased weight of
the uterus, and the treatment must necessarily be that which is
appHcable to the existing complication. The most common
complication is inflammation, causing hypertrophy or hyper-
plasia of the uterus, an irritative infiltration and proliferation
of the tissue element. The inflammatory condition may exist
with or without adhesions. The treatment of the condition,
then, in the great majority of cases, is that of existing inflam-
mation— hot vaginal douches, tampons medicated with agents
DISPLACBMBNTS 07 THE PELVIC ORGANS. o03
bich are expected to exert an influence in decreasing the
K of the uterus. This decrease can frequently be accom-
ished, to a considerable degree, by thoroughly dilating the
xrine cavity with laminaria tents, and after their removal,
fobbing the interior of the organ with tincture of iodin, a sat-
ated solution of iodin crystak in 95 per cent, carbolic acid,
: a satiirated solution of iodoform in ether. Following such
1 application the decrease in size of the uterus may still ftuther
B ^moted by packing
le organ with iodoform
uue and by placing a
unpon of iodoform gauze
eneath it. This raises the
i;^ to a higher level and
somotes its circulation.
?Brthermore, the uterus
so be dilated with gradu-
ited bougies, its cavity
meted, and applications
made as suggested. Where
the uterus is free from ad-
heaons, it may be sup-
ported by a pessary. The
pessaries which were de-
vised for the purpose of
derating the fundus have
not proved satisfactory.
Tie retroversion pessarj'
in some cases of heav>'
uteri is particularly ser-
viceable, although it may
Mm a paradoxical instru-
OKnt to employ in ante-
wisioii, but it does, how-
ever, afford relief by hold-
ing the uterus at a higher
level. Pelvic massage em- Fig. 375.— Sims' Opera
ployed daily is of special
value in promoting drainage, in facilitating metabolism, and
in (decreasing the size of the uterus. Operations upon the
cervix, amputation, or the repair of a laceration of the cervix
'[ifl establish a process of metabolism which will decrease the
Me of the uterus. When the uterosacral ligaments have not
Ijttome shortened through inflammatory processes and thus
Mused an irremediable displacement, the operation devised by
Sms may be practised. This consists in making a transverse
for Anteversion.
504 GYNECOLOGY.
denudation upon the anterior lip, another upon the anterior
vaginal wall at a suitable distance from it, and uniting these two
surfaces by sutures (see Fig. 375). As a result of this operation
the cervix is drawn toward the vulvar outlet, the fundus is
tilted upward, and a more correct position is secured. When
the uterus is fixed by adhesions, in addition to the treatment
already suggested, pelvic massage will prove beneficial. Two
fingers in the vagina are hooked behind the cervix and press
the fundus of the organ upward; while the external hand is
rotated over the fundus, the fingers pressing down along its sida
and in front of it, push the fundus backward. While the fundus
is pushed backward with the fingers of the external hand and
drawn forward with the fingers in the vagina, bands of adhesion
are put upon the stretch and are manipulated to such an extent
that their absorption is promoted. The manipulation of the
uterus promotes absorption of inflammatory exudate within its
walls, and thus assists in decreasing its size, so that by the
time the adhesions are
Fig. 376.— Abdominal Belt. will support the abdomi-
nal viscera and relieve the
intra-abdominal pressure to such a degree that the ache or dis-
comfort will disappear.
497. Retroversion. — In retroversion the uterus is turned mth
the fundus backward. (Fig. 377.) The cervix is directed forward
against the posterior wall of the bladder. This displacement
varies in degree according to the relations of the cervix and uterus
to the axis of the vagina. The maximum degree is a backward
displacement in which the fundus lies low in the hollow of the
sacrum, with the cervix directed upward. Retroversion is recog-
nized as an early stage of prolapsus. With this displacement
the intra-abdominal pressure is directed upon the fundus or upon
the anterior wall of the uterus, which favors downward displaw-
ment, so that we usually find retroversion associated with a
certain amount of descent of the uterus.
498. Etiology.— The most frequent cause of retroversion
is a lesion of pregnancy. Retroversion occurs in the unmarried
or sterile woman, but much less frequently. It is produced
by decreased support of the ligaments, particularly of the
DISPLACEMENTS OP THE PELVIC ORGANS. 505
acral, which permits the uterus to sag downward and
rotated backward; the latter action is occasioned by a
ded bladder, until finally the ligaments lose their mus-
tone and the organ does not regain its normal position,
version can be produced by traumatism, as when the
1 falls from a height and strikes upon the feet or, par-
rly, upon the buttocks, and by the presence of growths
uterus or in the ovaries.
0. Symptoms. — Retroversion causes few symptoms. The
nfort in the majority of cases arises from complications.
its may have marked retroversion without experiencing
F'S- 377' — Retroversion.
aconvenience or being aware of the condition until it is
ht to their knowledge. Inflammatory complications pro-
a sensation of weight or dragging, as if everything were
to protrude when the patient stands or walks. The
:rual flow is increased, producing menorrhagia; occasion-
here is an irregular, bloody discharge, or the intermen-
inter\-als are shortened, or, as a result of the coexisting
•h, the patient will have a profuse leukorrhea. The pro-
n backward of the fundus and pressure of the cervix
St the bladder cause a more or less frequent desire to
506 GYNECOLOGY.
urinate. Not infrequently there is an extension of the inflam-
mation to the vesical mucous membrane, which produces cystitk
Pressure of the uterus upon the rectum increases the tendency
to constipation, interferes with the rectal circulation, and
develops hemorrhoids and fissure of the anus. An injury
of the anus or rectum under these circtmistances is slow to re-
cover, which makes it important, in cases of rectal disease,
to ascertain the condition of the uterus before we resort to
any operative interference.
$00. Diagnosis. — Digital examination discloses the cervix
uteri in the axis of the vagina, or looking forward and sometimeB
upward. Through the posterior vaginal fornix the examining
finger recognizes a mass which is continuous on a straight line
with the cervix. The bimanual examination discloses the
absence of the fundus from the anterior fornix. The rectal
bimanual affords an opportunity to explore the ftmdus and
even the anterior surface of the uterus. (For treatment sec
Retroflexion, Section 571.)
501. Lateral Version. — Lateral version is a form of dis-
placement in which the fundus is situated to one side of the
pelvis, while the cervix is directed toward the other. This
condition is produced by cellulitis in the broad ligament and
by intraligamentary growths, either fibroid or ovarian; in
marked cases of inflammation contraction can occur in the
base of one broad ligament and in its upper part on the op-
posite side. This produces a fixation of the uterus directly
transverse to the pelvis, not unusually with a certain amount
of torsion. The lateral version causes no special S3rmptonis,
and is readily recognized by a bimanual palpation.
502. Anteflexion. — In anteflexion the uterus is bent upon
its axis, with the ftmdus forward, while the cervix lies more
or less in the axis of the vagina. The flexion may be slight
(Fig. 378), but httle more than normal; indeed, any flejdon
which is fixed is an abnormal one, even though it may not be
greater than the ordinary bending of the uterus. From a slight
flexion we may have a very acute one (Fig. 379), in which the
fimdus and cervix seem to he upon each other at a very acute
angle. The anterior wall of the uterus, at the point of flexion,
undergoes a change in which there is a substitution of fibrous
tissue for the muscle-wall. The posterior surface becomes
exceedingly thinned where it bends over the anterior. (Fig.
382.) The anteflexion may be mobile or immobile. The former
results from a heavy fundus when the cervix is in a more or less
fixed position. Raising the fundus, we can tilt it backward, and
leave the uterus in a position of retroflexion, so that at times
the organ is anteflexed; at others, retroflexed. Not isbt-
DISPLACBHBNTS OP THE PELVIC ORGANS. 607
Fi*- 379- — Acute Anteflexion.
508 GYNECOLOGY.
quently a diagnosis of anteflexion will be made, and at ftj
subsequent examination by another person the uterus is fc
retroflexed. If the fact that the organ is mobile is not
bered, an error in diagnosis will be attributed to the first invesfirl
gator. In the immobile uterus the flexion is fixed. Anteflexion,^
again, may be regarded as physiologic, pathologic, and indifiercnLl
A physiologic anteflexion is one which corresponds to the noi
condition of the uterus; a pathologic, one in which the flexion ill
more or less fixed or is greater than normal; while in an indH-
ferent anteflexion the bending causes no symptoms.
503. Etiology. — Anteflexion is probably next to the moSl
frequent form of uterine displacement, and it occurs less fre- '
quently in the married than do the retrodisplacements. It
occurs with greater frequency in the unmarried or nulliparous
woman, and is a result of congenital conditions, or, rather,
those which are associated with the earlier development of
the uterus. Anteflexion may be ascribed, first, to the long
cervix of the puerile organ, the situation of which, in the vagina,
necessitates the fundus bending forward over it. Second,
inflammation in the uterosacral ligament or in the cellular,
tissue posterior to the uterus, which draws the cer\''ix upward
(Fig. 383), promotes, in a flexible body, its falling forward,
and the angle between the body and the cervix is increased.
Third, the displacement arises from localized inflammation
at the site of the placenta, when situated upon the posterior
uterine wall. Involution is more rapid in the anterior, and
the shorter wall becomes the string of the bow which bends
the uterus forward. Fourth, anteflexion is produced by growths
in the fundus of the uterus.
504. Symptoms. — The symptoms most frequently attributed
to anteflexion are sterility and dysmenorrhea ; but when un-
complicated by inflammation, neither of these symptoms is
necessarily present. The patient with marked anteflexion
generally suffers from chronic vesical distress. Pain occurs
when the bladder is moderately distended, micturition is fre-
quent, and generally there is a sensation of distress and annoy-
ance which follows the evacuation. These symptoms, how-
ever, are not infrequently produced by inflammation in the
bladder, so that, as a rule, the urine should always be carefully
examined. Dysmenorrhea has been attributed to an obstruc-
tion of the canal from which there is an accumulation of material
within tlie uterine cavity, and the organ has to go into labor
to expel it. As flexion does not cause dysmenorrhea when
the lesion is uncomplicated by inflammation, it is e\4dent that
the latter is the cause of the symptom, and that the hyperemia
prior to and coincident with menstruation produces pain during
DISPLACEMENTS OF THE PELVIC ORGANS, 509
the distention of the inflamed surfaces rather than an obstruc-
tion of the canal. Even in the congenital conditions the dys-
raenorrhea does not occur with the first menstruation, but
later, when there is distinct evidence of the development of in-
flammatory trouble,
505. Diagnosis. — Anteflexion is recognized by digital and
bimanual palpation. The cervix is situated in the axis of
the vagina, and, by carrying the finger in front of it, a body
is felt in the anterior fornix of the vagina, between which and
the cervix a distinct angle is recognized. During bimanual
palpation this angle can to some degree be straightened, and
the relation of the flexion to the cervix and body is more
distinctly recognized. The flexion is particularly determined
by passing the index-finger into the lateral fornix, first upon
one side and then upon the other; by pressing from above
we are able to recognize the lateral borders of the uterus and ■
the absence of any growth. We can be in doubt as to whether
the mass found in front is the fundus uteri or a fibroid growth
attached to the anterior wall. Each condition may afford
an equal-sized angle. The method we have already described,
of passing the finger along the lateral aspect of the uterus,
\viU enable us to differentiate them. By changing the position
of the organ and pressing it well forward with the hand over
the abdomen, we can outline the posterior surface of the fundus,
and determine that its size and relations correspond to those
of the cervix to the fundus, rather than to a growth. When
the uterus is fi.\ed. bimanual palpation is difficult. The posi-
tion of the organ can be determined by the introduction of a
uterine sound into tlie canal. The use of the sound, however,
under these or any other circumstances, is fraught with so
much danger that it is preferable to administer, if necessary,
an anesthetic for the further practice of the bimanual, rather
than to make an intra-uterine exploration.
Rectal palpation with the digital finger, while the thumb
of the same hand is placed in the vagina against the cervix,
and the other hand over the abdomen, enables us to bring
the uterus definitely under observation.
506. Treatment.— Anteflexion requires treatment only when
it is associated ^vith symptoms, and these are usually the re-
sult of comphcations. The symptoms may be caused by com-
plications incident to changes in the structure of the uterus
itself, as inflammation either in the wall of the organ or in the
suiToimding structures. It may be incident to the various a
constitutional conditions, as a rheumatic or gouty diathesisj^
the eifect of neurasthenia, but in such cases the treatment
may be constitutional or a combination both of constitutionaT
510 GTNECOLOGY.
and local measures. The most frequent symptoms i
with this displacement are those of dysmenorrhea or \
menstruation, and sterility. That these symptoms, hoi
are not necessarily the result of anteflexion alone is evide
from the many cases in which the patients with marked ai
flexion have both menstruated pamlessly and given biith t
children. Patients suffering from dysmenorrhea assodatif
with anteflexion should be encouraged to live an outdoor liffc
Hygienic measures are particularly important. The cloUmif
should be suitable, and the extremities be warmly clad. Vfliy
frequently women who suffer from dysmenorrhea while it
oiu- northern climates, will be absolutely free from this symptom
when residing in the South or in the Bermuda Islands. Meai-
ures should be instituted to improve the general nutrition,
to obviate the sluggish circulation, to regulate the bowdL
Such patients are often improved by bicycle-riding, playing
golf, and anything which leads to an outdoor life. Pelvic
Fig. 381. — Stem-pessary.
or uterine congestion should be decreased by the administration
of iodids and bromids, the employment, particularly, a few
days to a week before the menstrual period, of gelsemium or
Pulsatilla, taking five drops of the fluidextract of gelsoniuin
or ten drops of tincture of Pulsatilla, three or four times in the
twenty-four hours, until the patient exhibits signs of its phya-
ologic action. Thyroid extract has proved of value in these
cases, when the drug is given in doses of three to five grains
two or three times in the twenty-four hours. Douches, tam-
pons, painting the vault of the vagina with tincture of iodia
gauze packing, and pelvic massage are all of service. The
pessary, particularly the Graily-Hewitt (Fig. 367) or the Thomas
anteflexion pessary (Fig. 380), which tilts up the fundus of the
uterus, have had their advocates. Their efficacy, however,
is somewhat doubtful. Pelvic massage is of spec^ value in
these cases, as the manipulation of the uterus serves to straighten
the organ and promote a healthy condition of its circulation.
DISPLACEMENTS OF THE PELVIC ORGANS.
511
■hen the patient is not improved by douches tampons or
pnstitutional measures, the uterus may be dilated by the m
■oduction of a laminaria tent. This procedure should be done
■rtrr most thorough aseptic
Mcautions, with the vagina
ptHDughly cleansed, the cervi-
Ml caiial rendered as aseptic as
Cible, and the tent itself ster-
i, preferably by dry heat.
Bowever, the tent may be
phced for several minutes in a
totntion of iodoform and ether,
is equal parts of alcohol and car-
bolic acid, or, better, in iodin
IJDCture prior to its introduction.
The cervix should be seized with
■ double tenaculum, sponged
nith a solution of formalin, and
by traction straightened so that the tent can be the more'readily
intioduced. As large a tent as the caliber of the cervical canal
Flexion.
Kg. jlj. — Anteflcidon Associated with Contraction of Uterosacral Ligaments.
'ill allow should be employed. The tent is removed in from
twelve to fourteen bom's, after which the uterine cavity is irri-
512 GYNECOLOGY.
gated, if necessary ctireted, swabbed with a saturated solutwal^^
of iodin in carbolic acid or of iodoform in ether. The canaliMjls^
or may not be packed with iodoform gauze. The dilatatktt*^ -
with tents may be repeated at intervals until the tendency
to displacement appears to be overcome and the complicatiiip^
involvement of the uterus has subsided. Inflanrmiation in tlie
cellular tissue about the uterus, or in the tubes and ov^es,
as evidenced by their being enlarged and fixed in the pelvis,
should be considered a contra-indication to the employment
of tents. The dilatation can be accomplished by graduated
bougies and their employment followed by curetment. Twenty-
five years ago the employment of the stem-pessary was a favorite
method of overcoming an anteflexion. The stem was one-
eighth of an inch shorter than the uterine cavity; the patient
was required to wear it for a considerable length of time, (Fig.
381.) The objection to the stem-pessary is that it is a source
of irritation, affords constant danger of infection to the uterine
mucosa, and may lead to the development of more serious
trouble. W. Gill Wyhe advocated the employment of a grooved
stem of hard rubber or glass which should serve as a drainage-
tube. He and others still practise this method of overcoming
the dysmenorrhea incident to acute anteflexion and claim
marked improvement in many cases. The favorite treatment of
Sims was a bilateral incision — occasionally one through the
posterior lip. Unless precautions are taken to prevent union,
the parts are reunited. Even when precautions are employed,
cicatricial tissue forms, which subsequently causes distress, some-
times greater even than the preexisting condition. The pos-
terior lip can be split up to the angle of flexion and its cenical
and vaginal lining membranes united by sutures, to prevent re-
union. Occasionally, after such an operation, the cer\'ix spreads
out, owing to the intra-abdominal pressure, and the more delicate
cervical mucous membrane is thus exposed to pressure and
irritation, resulting in endometritis and formation of cysts
of Naboth, which w^U require continuous treatment. Splitting
the anterior lip has been advocated. This is performed by
dissecting the bladder from the anterior wall of the cer\ix to
the level of or above the point of flexion. A grooved director
is then introduced into the uterus and the cervix is incised.
As the incision approaches the os it is carried around to the
side of the cervix. The cervical mucous membrane is united
to that of the vaginal wall. This enlarges the opening from
the front and prevents obstruction, but is subject to the same
objection made to the posterior operation, in that it exposes
delicate surfaces to irritation and subsequent inflammation.
E. C. Dudley has devised an ingenious operation, in which he
DISPLACEMENTS OP THE PELVIC ORGANS.
513
M posterior lip beyond the vaginal attachment; the
are held apart by tenacula and the incision is deepened
e cervical side with a knife, A wedge-shaped piece is
: from each side, and the sutures are so introduced
lite the edge or apex of the incision on each side with
i. By this method eversion of the cervical mucous
ne is prevented. (See Fig. 384.) The anterior lip
-Dudley's Operatior
ervix is then amputated, and the wound closed with
se sutures, which push back the cervical orifice and
31 the canal. (See Fig. 385.) Nourse, recognizing
flexion corresponded to the shorter wall, made a bi-
ncision to the level of or a httle above the angle of
Traction is then made upon the posterior Up, which
I straightening the canal. The new surfaces are apposed
red with sutures, leaving the posterior lip longer. When
514
GYNECOLOGY.
the latter is half an inch or more in length, it is amputated by'
the flap metliod, thus making it the same length as the anterior
lip, The raw surfaces are united by suture. (Figs. 386 and
387.) When the elongation is short, it is left to contract.
C. A. L. Reed advocated opening the abdomen and removing
a wedge-sliaped piece from the posterior wail of the uterus
opposite the angle of flexion. This surface is closed by vertical
Denudation and
sutures and restores the organ to normal position. Burrage
advises, in proper cases, incision of the uterosacral ligaments
and the performance of a ventrosuspension, thus raising the
fundus of the organ upward.
507. Retroflexion, — In retroflexion the fundus is bent back-
ward upon the uterine axis, and, according to its degree, lies
toward the rectum (Fig. 388) or is forced well down into Douglas'
DISPLACEMENTS OF THE PELVIC ORGANS.
ch. (Fig. 389.) The cervix is in the axis of the vagina. The
oflexion may be mobile or immobile, may be pathologic
indifferent, but can never be saiil tci lie physiologic. This
■m of displacement is very 1'ri.Tjiienlly a sequel of version,
le uterus l>ecomes retroveriecl ami the abdnminiil pressure
516
GTNECOLOGT.
then drives the fundus downward, bending it upon its
forcing it into Douglas' pouch. (Fig. 390.)
508. Etiology. — Retroflexion is produced by metritis
involution; inflammation of the placental site, in the ar
wall of the organ; fibroid growths in the fimdus or ai
uterine wall (Fig. 391), parametric inilainmation, or cellul
the anterior segment of the pelvic floor, which draws the 1
forward; localized peritonitis; or contraction following he
Fig, 388.— Retroflexion of Slight Degree.
cele (Fig. 392), by which the fundus of the organ is drawn
ward.
509. Symptoms. — Retroflexion, like the other forms (
placement, when uncomplicated presents no special sym]
It produces a sensation of weight and pressure, not
quently pain in the region of the anus, an uncomfortabl
sation down the posterior surface of the lower extrei
points of anesthesia over the thighs, congestion, partii
struction of the rectum, obstinate constipation, and not
quently a sensation that the intestine is so obstructed th
DISPLACEMENTS OP THE PELVIC ORGANS. 517 I
518
GYNECOLOGY.
bowel can not be evacuated. Development of hemorrh-
anal fissures, and more or less prolapse of the rectal mi;
membrane not unusually follow. Menstruation is irregulai
profuse, or the menstrual intervals are shortened, and le
rhea is quite profuse.
$10. Diagnosis. — Digital examination discloses the ■
Fig- 392. — Retroflexion the Sequel of Inflammatory Adhesions.
situated at a lower level in the pelvis, occupying the ai
the vagina or directed a little anteriorly; the finger in the
terior fornix recognizes a body slightly above, or even be
the cervix, which is rounded, may be movable or fixed,
somewhat larger than the normal fimdus. Between it and
I DISPLACEMENTS OF THE PELVIC ORGANS. OlW
I oervix is a distinct angle, though the structures can be traced
[ ftmi one to the other. The finger in the anterior vaginal fornix
S. 393. — Retroflexion Simulated by Posterior Uterine Myoma.
% 394— Retroflexion Simulated by Small Ovarian Cyst in Posterior Culdesac.
"Id the Other hand over the abdomen discloses the absence
"f the fundus uteri ifrom its normal position. The flexion is
620 GYNECOLOGY.
apparently increased by pressure upon the cervix, and tb
is driven more deeply into the oUdesac. By prea
finger upward on either side of the uterus and cervix th
margins can be determined. Digital examination
the rectum enables us to pass directly over the fun
to feel to some degree its anterior surface, which now
posterior. Retroflexion of the uterus can be confount
fibroid growths (Fig. 393) situated in the posterior utet
adherent ovarian growths (Fig. 394), and pelvic infiai
exudation. (Fig. 395.) The introduction of the soi
the uterine canal, and its passage backward into tl
would be definite evidence that a retroflexion exists;
Fig. 395. — Anteflexion and Retroflexion Simulated by Pelvic Ex
in other uterine conditions, this procedure is fraught
much danger that it is preferable to make the diagnc
out it, and, if necessary, even to leave it uncertaii
a careful bimanual examination, as has been advised
rectum, the vagina, or both, we are generally able 1
mine the relations of the uterus to the surrounding ■pi
absolutely to fix the diagnosis. When the existence 1
exudate or immobility of the uterus and a resistant
abdomen prevent its accomplishment, the patient si
given an anesthetic.
511. Treatment of Retroversion and Retroflezioa. — j
flexion is simply a bending of a version, we will, theref
DISPLACEMENTS OF THE PELVIC ORGANS.
521
sider the treatment of these two conditions together. As
the majority of the other displacements are not characterized
by symptoms, unless complications are present, so, in these
conditions, symptoms are not manifest without the existence
of complications. The organ, however, in maintaining a retro-
position, interferes with its circulation, which results in con-
gestion and subsequently in more or less inflammation. There-
fore the treatment of the complications is ineffective so long
as the displacement remains. The relief of the inflammatory
condition is expedited by maintaining the uterus in a correct
position. Treatment largely depends upon the duration of
the displacement, the changes which the structures have under-
Pig, 396. — The Retroverted Uterus Replaced; Patient in Dorsal Position.
gone, and the ability of one to replace and maintain the organ
in proper position. No means for maintaining the uterus in
position are effective until it has first been accurately replaced,
after which it can be supported with relief of many of the dis-
tressing symptoms. Three methods are generally recognized
as proper for replacing the organ. These are: (i) The bimanual.
The patient is placed in the dorsal position with her limbs
flexed. Two fingers are introduced into the vagina, while the
fingers of the other hand are placed over the abdomen (Fig,
396). The middle or long finger is passed into the posterior
fornix of the vagina to press up the fundus, while the index-
finger is carried in front of the cervix to pi;sh it backward.
522 GYNECOLOOy.
The pressure against the lower end of the lever carries tbe
opposite end, the fundus, forward, until it can be grasped \ij
the external hand and brought into a position of ante\traon.
In some cases the fundus of the uterus is caught beneath tie
promontory of the sacrum and can not readily be dislodged
If the cervix, however, is grasped with a double tetiacijum
or vulsellum, and drawn down, while the fundus is pushed if
with the finger in the vagina or rectum, the fundus uteri it
readily displaced from beneath the promontory and the cervii
can then be carried back\vard. The second procedure con-
sists in placing the patient in the genupectoral position and
the employment of the Sims speculum to open the vapa
The atmospheric pressure balloons the vagina and the uterus is
Fig. 357.— Schultzi;"s Muthod of Replacing an Adherent Retro\-erted Vwftt'
carried to the upper part of the canal. This procedure, how-
ever, does not of itself correct the position, as the uterus, though
elevated, may still be retroflexed or retroverted. The posi-
tion, when uncomplicated, may be readily corrected by seiring
the cer\'ix with a tenaculum or vulsellum, and drawing it to-
ward the vaginal orifice, and then carrying it backward and
upward. The fundus is thus dislodged and the position corrected.
A third procedure consists in the employment of the uterine
sound. With the patient in the dorsal position, two fingers an
introduced into the vagina and the sound, carried between
them, enters the os and is introduced to the fundus and then
rotated. The external end of the sound is carried through
;i wide arc so as to do as little injury to the internal mucous
membrane as possible, while the handle of the sound is de-
DISPLACEMENTS OP THE PELVIC ORGANS.
523
I and the finger in the posterior fornix pushes the fundus
L This combined movement carries the fundus for-
antil it can be controlled with the external hand. In
f the most careful precautions, the uterine mucous mem-
will be injured by this method of procedure. It is ex-
;ly difficult to avoid the danger of the introduction of
JUS material into the uterus, which necessarily favors
ivelopment of further complications. For such reasons,
and should not be employed, especially as every purpose
^ by its use can be readily accomplished by the employ-
of the dorsal manipulation or with the patient in the
xtoral position. Various jointed sounds have been
Replacing Uterus by Schultze's Operatiot
for the purpose of replacement of retrodisplaced uteri,
se instruments are open to the same objections offered
use of the ordinary sound.
idherent uteri none of these methods of procedure \vill
lish the restoration of the displaced organ. When
lesions exist between the posterior uterine surface and
erior rectal wall, the intestine may be dragged up with
rus and apparently permit it to assume its normal posi-
tt as soon as the supporting force is removed, the uterus
a back and, if mechanical efforts are employed to main-
in position, the fundus is bent backward and the retro-
is greatly increased. If adhesions are present and they
524 GYNECOLOGY.
are not too firm and of too long duration, pelvic massage affords
a valuable method for overcoming their baneful influence and
promoting their absorption. The massage should be supple-
mented by the use of tampons. In some cases the pressure
of an air pessary within the vagina stretches the bands of ad-
hesions, promotes their absorption, and supports the uterus.
Schultze advocated a procedure which is very effecti\-e in over-
coming recent adhesions. The patient is placed in the dorsal
position, with the muscles well relaxed by an anesthetic. Two
fingers are introduced into the rectum, while the thumb in the
vagina against the cervix steadies the uterus until the rectal
fingers, one on either side of the fundus, can invert and draw
down the bowel and separate it from the uterine surface (Figs.
397 and 398). As the adhesions are separated and the uterus
is set free, the external hand grasps the fundus and draws it
forward, after which the remaining bands of adhesion are broken
up. Care must be exercised in carrjang out this procedure
not to employ too much force, otherwise the intestine may
very readily be injured. There is more danger, however, of
injuring the tubes or ovaries, when these organs are adherent,
An adherent tube may be torn and liberate poison at the seat
of inflammatory trouble, which, particularly if of a purulent
character, would be followed by a violent attack of pelvic or
possibly general peritonitis. With purulent inflammation or
pus collections in the tube excluded, the absorption and loosen-
ing of the adhesions of the ovary, tube, and uterus can be
effected by pelvic massage. If the adhesions are extensive and
the vagina tender, especially when its posterior fornix is more
or less obliterated by the long duration of the displacement,
the uterus can be temporarily supported by the employment
of vaginal tampons, medicated or not, as the conditions require.
The employment of continual pressure over the abdomen or
within the vagina may be effected by shot-bags or the employ-
ment of rubber bags containing mercury. Three to five pounds
or more of shot may be applied over the abdomen to make
pressure over a mass of exudate and thus promote its absorp-
tion and the setting free of an adherent uterus. The absorp-
tion of the vaginal exudate may be expedited by the use of
mercury, applied in a rubber bag. Such a weight introduced
into the vagina, with the position of the patient changed from
time to time in order to subject different portions of the exudate
to the weight, promotes its absorption and the consequent loosen-
ing of the uterus and pelvic structures.
When the uterus is free from adhesions and, consequently,
can be readily replaced, we can at once resort to the use of a
pessary. Some of the more prominent retrodisplacement pes-
J
DISPLACEMENTS OF THE PELVIC ORGANS.
525
re the Hodg^ (Fig. 362), Thomas, Mirnde (Fig. 363),
Schultze (Fig. 399) instruments. The various modi-
of the Hodge pessary consist of a posterior bar with
i^ side bars which are united
Iter bar anteriorly. Laterally,
iry has the shape of a letter S-
xdoT bar is carried behind the
nto the posterior fornix. In
lification by Thomas and
the posterior bar is thick-
lich makes a latter mass in
lix. The pessary does not
the body of the uterus on
rior bar, but it so drags upon
erior vaginal fornix as to pull
the cervix and lift it up, until the other end of the
he fundus — is held so far forward that the intra-
lal pressure is directed upon the posterior uterine sur-
Fig. 399. — Schultse Pessary.
■Proper Position of the Pessary,
rhis puUey-hke action of the pessary is readily seen
400, which shows the proper position of the pessary
ion to the uterus and vagina. It has already been
zed that the pessary does not support the body of the
526 GYNECOLOGY.
uterus, and that the position of the organ must be corrate
before the introduction of the instrument. The result of
attempt to employ the pessary to correct the position of &
uterus can be seen in Fig. 401. It is very important that '
pessary should not be unduly long. When too much pressm
produced, ulceration of the vagina occurs, rendering the
tient unable to retain it, or, if the instrument is too long,
may project from the vulva and cause irritation about the
or neck of the bladder, and much discomfort in sitting. Tta|
proper length of the pessary is readily determined by the '
duction of two fingers into the vagina to measure the distance]
Fig, 401. ^Faulty Position of the Pessary.
between the distended posterior vaginal fornix and the intenul
margin of the symphysis. The proper i^-idth of the pessary
is appreciated by determining the extent to which the fingH'
can be separated without undue lateral pressure in the va^
The proper size of the instrument to be employed is thussS"
certained. While a pessary too long produces the conditioiB
we have already mentioned, one too short allows- the fundus
of the uterus to fall backward over its posterior bar and iH'
creases the retroflexion and adds to the distress of the patiait-
It is difficult to maintain the pessary in place where the vagin*
is much relaxed. If the uterosacral ligaments are much dw*-
DISPLACEMENTS OF THE PELVIC ORGANS. 527
d, and the posterior fornix distensible, the pessary will
to maintain the uterus in its normal position, and, more-
•, it will permit the organ to drop back and rest upon the
rument. (Fig. 401.) Schultze designed the pessary known
he figure-of-8, which is very effective for such cases. This
ary laterally is similar in shape to the Hodge instrument,
ning a letter S. The lateral bars of this pessary are twisted
Fomi a figure-of-8, the upper loop of which surrounds the
k of the cervix and carries it upward, while the inferior loop
0 broad that it receives support from the vagina and does
incline to prolapse. Shoiild the figure-of-8 prove im-
sfactory, the sledge pessary of Schultze may be efficient.
J. 402.) Its posterior end has a bar curved forward, which
s in front against the cervix and holds it back, while at
same time traction is made upon the cervix through the dis-
ion of the posterior fornix by the upper part of the instru-
it. The pessary should be sufficiently broad to impinge
inst the side walls of the vagina to
rent it being displaced downward,
istends the vagina in three direc-
s — in length, laterally, and in
anteroposterior direction. When
esions are present, the pessary is
ly borne and is harmful. It is at
imes a foreign body and produces
Ttain amount of irritation in the
ina, which, to many patients, is Fig. 402.— Schultze's Sledge
mrce of much discomfort ; besides, Pessary,
i not always efficient in maintain-
the uterus. It must be worn for months or even years to
ire sufficient contraction to maintain the organ, consequently
ly patients prefer to submit to operative interference.
The pessary may be employed in retroversions due to sub-
)lution of the uterus subsequent to a recent delivery. In
\i cases the pessary will maintain the uterus at a higher
il, promote the process of involution, and thus favor the
ntenance of the organ in a replaced position after it has
ihed its normal size. It may be employed after adhesions
e been broken up, by the Schultze method, or when we
e been able to accomplish the loosening of the uterus by
nc massage. Where retrodisplacement has existed for
letime, the posterior fornix of the vagina may be so shortened
t the pessary can not be worn. Such a condition will re-
t treatment by douches and tampans until the posterior
inal fornix is stretched. They are also of little value in those
^ in which the vaginal portion of the cervix has been des-
528
GYNECOLOGY.
troyed by amputation or as a result of repeated labor*- 1*1
the pessary is a foreign body, it is therefore impoitanC- ™'
explicit directions should be given regarding its manag^^Jort
before this subject is dismissed. Directions have been jt^
for the determination of a suitably sized instrument, »— "dl
would again emphasize the fact that the instrument sfc^O^iM
be neither too large nor too small. The former will daw
pressure upon the surrounding parts, producing irritaB- "txn,
ulceration, loss of structxare, and open avenues for the entc-aace
of infection. A smaller instrument is easily dislodged ^taa
its position, does not serve any useful purpose, and may on/^
serve to aggravate the condition. The patient should be directed
isfl^i
1^1
w^M^
91
ROUND J
^PRlNALN. ■
IIGKT. J
J
I
1
Fig. 403. — Alexander Operation; Round Ligament Exposed.
to remove or have the instrument removed if it gives rise w
increased discomfort, and return to the physician within a
week at least after its introduction. He can then determine
definitely whether the instrument is serving its proper purpose
or causing any irritation. In neurotic patients too much at-
tention must not be given to the instrument, otherwise tbs
patient will manufacture a long train of distressing symptoms
and attribute them to its presence. The instrument is likely
to increase the vaginal discharge, and for this reason it is im-
DISPLACEMENTS OF THU PELVIC ORGANS. 529
that it should be kept clean. It is undesirable, how-
o employ mineral astringents in the douche for this
s, as they are likely to become deposited upon the sur-
the pessary, thus rendering it rough and, therefore,
kely to serve as an irritant. A properly fitting instru-
an be worn by the patient without her being aware of
ence, but even though it causes no annoyance, the patient
be advised of the importance of having it removed at
Fig. 404-— Round Li(j:
intervals, not exceeding three months, for cleanliness,
I make sure that it is producing no irrit;ition. These
ipply to the hard-rubber itistrumcnt. Wliere the in-
nt is of the soft-rubber variety, it should he removed much
requently, as the discharges to some dt;gree enter into
bber, decomposition takes pl:n.-c, ami a foul odor arises
is very annoying to the putieiil. ami to those with whom
530 GYNECOLOGY.
she is associated; moreover, it may give rise to systenric
infection.
The operative procedures for the correction of retrodisplaa-
ments of the uterus consist of the extraperitoneal and intra-
peritoneal shortening of the round ligaments, by abdoininJ
or vaginal incision, and the construction of artificial ligaments,
as in such operations as ventrofixation or ventrosuspension.
Rijund Ligament Sutured.
Besides these, there are also numerous vaginal operative methods
fur correcting retmplaced uteri.
Extraperitoneal Sltorlcniiia of the Round Lt'gamenls. ^ShoT^'
inj; of the riMind lij,'.'mients is an operation which ivas perfomec
by Alexander in iJccember, 1881, and two months later b)
Adams, although the latter contributed the first publication-
The operation had, however, been advocated by a Frenchnu"
DISPLACEMENTS OF THE PELVIC ORGANS.
531
imed Alquie, as early as 1840. The operation requires two
idsions, and each consists of four stages: (i) An incision six
mtimeters long, a Uttle inside the pubic spine and above
od parallel to Poupart's ligament, is made through all the
issues to the aponeurosis of the external oblique. (Fig. 403.)
1) Exploration for the round ligament. This is disclosed by
, small ball of fatty tissue which covers its end between the
allars ot the external inguinal ring. Pressure upon the side
auses the mass to pro-
Tude. A hook passed
Deneath this mass en-
ibles the operator to
taise up the ligament.
(Fig. 404.) It is then
detached by a direc-
tor, from the posterior
idherent fibers which
naintain its relation
0 the inferior part of
he canal, after which
t is seized with a pair
>f forceps and drawn
lut. Upon the com-
)letion of the first and
«cond stages, on both
iides, we proceed to
-he third, which con-
iists in shortening and
ixation of the liga-
■nents. The ligaments
Ire drawn upon until
ie fundus is brought
■inder the pubes. This
movement can be facil-
itated and rupture of
the fibrous filaments
ivoided by previously
placing the uterus in
anteflexion, cither by the sound or preferably by the aid <3f the
fingers of an assistant, lite ligaments are drawn out from four to
ten centimeters, according to the resistance. When they become
tense, they are maintained by an assistant, while a needle charged
Wth silk, silkworm-gut, or catgut is made to tra^^erse the external
pilar, the ligament, and next the internal pillar. {Fig. 405 . ) Three
sutures are thus introduced, one centimeter apart. fFigs. 406
and 407.) (4) The wound is closed with silk or silkwnrm-gut
tenial Ol.iliqi
532 GYNECOLOGY.
sutures, dressed with gauze, and the parts are so secured by
bandaging as to prevent the wound from becoming exposed by
the movements of the patient. The employment of a Hodge
pessary for two months following the operation is advisabk,
though some prefer the tampon. Various modifications of tins
operation have been devised. Edebohls spUts the entire length
of the inguinal canal, draws the ligaments out at the internal
ring, and closes the wound as in the Bassini operation, New-
man makes an incision directly over the internal ring, draws
the ligament straight out, and secures it in the wound. FranklBi
Martin and Buret, of Lille, do not use sutures, but pass a pair
of dressing forceps beneath the skin and subcutaneous tissue
from one wound to the other, draw the hgament through, tie
the two ligaments together in a knot, and close the tissues over
DISPLACEMENTS OF THE PELVIC ORGANS.
533
iinion. Cassati joins the lower ends of the lateral wounds
1 a curved incision, in which the crossed ends of the Uga-
its are united by continuous suture. Doleris employs the
le method, uniting the two ligatures with catgut sutures,
T pulling them through, as in the method suggested by
rtin. Goldspohn attempts to extend the usefulness of the
zander operation by stretching the internal ring and open-
through the peritoneum, so that the finger can be passed
) the pelvis and break up adhesions about the uterus, ovaries,
I tubes. By this method a tube or ovary can be withdrawn
i subjected to necessary treatment. The advantages claimed
^^^||^J
408.— Wylie's Operatio
the Alexander operation are: (i) The incisions being super-
il or extraperitoneal, the risk of infection is less; as it is
il, the danger of peritonitis is decreased; (a) the method of
iotaining the uterus forward has less injurious influence upon
rture pregnancy; {3) it imitates the natural support, in that
natural ligaments are employed; and (4) no intraperitoneal
leaons can form. The disadvantages are: (i) That two
isions are required. (2) The operation is limited in its ap-
ation. It is only in those cases in which the uterus is mobile
t we can practise this procedure. Consequently it has the
ther disadvanta^ in that we are not always able to deter-
le definitely the existence of adhesions between the uterus
I the anterior wall of the rectum. Should such adhesions
rt, the uterus drawn forward by the round ligaments is sub-
534 GYNECOLOGY. 1
ject to forces which tend to render the operation nugatwy. '
Tlie procedure of Goldspohn seeks to overcome this objection; i
nevertheless, the objection still remains, for the operation to
break up adhesions and treat the pelvic organs is done through
so small an opening as to render it more or less a blind proce-
dure. Besides, severe injuries may occur and be readily over-
looked. (3) The round ligaments are sometimes so attenuated
as to be of little use in maintaining the organ. In an operatioo
of mine the ligament on one side was apparently entirely absent.
I found no vestige of it in the canal. I therefore apened into
the peritoneal cavity and found that the round Hgament had
disappeared. (4) In cases of infection the infectwl ligament
may slip l>ack and carry infection beneath the peritoneum,
Fig. 409. — Mitnn's Operation for Intra-abdominal Shortening of Round L:?i-
where it will be difficult to reach, and, consequently, render the
operation, as has been proved, not altogether free from danger,
Intrci peritoneal Shortening of Round Ligament.^. — The rouo^^
ligaments are shortened within the peritoneal cavity by making
an incision through the abdomen in the median line. Tbis
procedure jiermits the uterus to be drawn up, the condition of
the appendages examined and treated, if necessary-. Existii^
adhesions can be broken up and the round ligaments shorten^
by folding them. fFig. 408.) VVylie suggests that from two w
four inches of the ligament be doubled up on each side and united
by sutures, so that the shortened ligament draws and holds
forward the fundus, Mann grasps the broad ligament about
the junction of its middle and outer third and folds the ligament
in three parts which are united by sutures. (Fig. 409.) By this
DISPLACEMENTS OF THE PELVIC ORGANS.
535
xi the ligament is well shortened on each side, A. P.
y, of New York, performed an operation which he called
)pycnosis. (Fig. 410.) This is accomplished as follows:
.bdomen opened, an assistant introduces two fingers into
agina and pushes the uterus as high as possible in the
, while the operator brings the organ through the ab-
lal incision. An oval denudation is made upon the ante-
terine wall, making sure that the bladder is not injured;
Complctod.
each round ligament is brought up to the portion of the
meal covering on the inner side, denuderl to correspond
;hat on the uterus, and the three denuded surfaces are then
i with catgut sutures. The sutures must be so adjusted
pass sufficiently deep in the uterine tissue to secure against
536 GYNECOLOGY.
their cutting out before union has occurred. (Pig. 411.) THi
procedure holds the uterus forward in a position of anteveision.
Ries cuts a slit through the anterior surface of the fundus,
through which a loop of the round ligament, drawn out o£ hi
sheath, is carried and fastened on either side, Bissell excises a
portion of the round ligament and imites the cut ends mth cat-
gut sutures. Webster picks up a loop of the round ligamea,
carries it through the broad ligament beneath the Fallopian tube,
and secures it to the posterior surface of the uterus. This jro-
cedure has been modified by Ealdy, who ligates the uterine end
of the round ligaments, incises each ligament external to the liga-
ture, and carries the free end, rather than the loop, through the
broad ligament and fastens it to the posterior surface of the
uterus. All these operative procedures, however, act upon the
strongest part of the ligament, leaving the weakest portion, that
which occupies the inguinal canal, to be stretched out, Gilliao
devised a procedure (Fig. 412) which consists in picking up the
ligament, three or four centimetere from its uterine end, and
carrying a loop of it through a stab wound in the lower part of
the rectus muscle on either side, and there securing it. (Fig. 4iJ-'
This procedure divided the lower part of the abdomen into three
apertures, through two of which coils of intestines were capableof
being pushed and compressed to a greater or less degree. To ob-
viate such danger Ferguson modified the operation by quilting to-
gether the peritoneal surface external to the point transfixed by
|i3-^Round Ligaminl IJrawn through the Abiiominal Wall.
538
GYNECOLOGY.
the loop I if riiund lijiiiment. This hgature, when tied, closes up the
}j;ip in the ]vritone;il favity external tu the \«m\t thrnu^li\vd-b
the loop .,<f the h^'ament is brought out. With these pans stciifd,
the uterus is held forward by a loop of the strongest lurtotthe
round ligament. fFig.414.) Simpson.through a incdiiiii indsiffl
about one iiieh fmm the uterus, i)assed a suture thR>ii};luV,R«-
fourths of the mund ligament, threaded V^jtli ends of thissufjie
inii I a carrier, and through the slit made in the anterior layer ■.!
tliebnud Iii,';iiTK-nt passed it directly forward beneath the jieri-
i'.iu;um of []\i/ \fsieo-uterine pouch to a p'int ujxm the amcrior
abclnniinal w-.,]] ,,nc and one-half inches e.\terna] to the nicifen
liiu', and ciirrird boih ends into the peritoneal cavity, one einl
Ihriailfl iiiio;, sharp curvcil needle and thrust into the niuscuUf
struriure, eiiiiT:.,'rd upon the peritoneum, where it was stvurelb)'
tying with ilir ..ilirr end. I have combined the Simiisim an'!
DISPLACEMENTS OF THE PELVIC ORGANS,
539
m operation as follows: A curved incision, when possible,
n the pubic hair line is made through skin, superficial fascia,
jponeurosis. The aponeurosis is loosened from the pyra-
lis muscles and drawn upward (see Figs. 78 and 79), the
muscles separated, and the peritoneum divided in the ver-
Kne. After freeing adhesions and giving proper attention
e condition of the ovaries and tubes, a suture is passed be-
16.— Second Step, Showing Ligament Fixed with Hemostat while Tem-
ynry Ligature is Carried Beneath Anterior Leaflet of Broad Ligament
ith a Deschamps Needle.
1 each round ligament, one inch and a half external to the
IS. (Fig. 415.) The ends of the suture upon one side are
ded into the eye of a Deschamps needle having a rather long
(Fig. 416.) The round ligament external to the suture is
1 with a hemostat and gi\'en to an assistant with the
tion to keep it taut. An opening is made into the an-
r layer of the broad ligament, just below the insertion of the
«, and through this opening the nee<lle carrying the ends of
540
GYNECOLOGY.
the sutiire is introduceJ and carried outward between the layers-
of the broad ligament until the parietal peritoneum is reached,
when the latter is drawn inward and the point of the instru-
ment plunged through the abdominal parietes, emerging upon
the aponeurosis. The suture ends upon each side, are withdrawn
from the Deschamps needle, and the ends secured by a hemostat.
Seizing the suture upon one side and drawing upon it to make it
tense, a pointed scissors, closed, is thrust alongside the ligature
and the blades separated, when, in the majority of cases, the trac-
tion causes a loop of the hgament to follow the withdrawal of the
scissors. Where it does not at once follow, it can be teased through
by pressing back the tissues as traction is being made. (Fig. 41 7.)
Having thus brought a loop of each ligament through the wall,
the loop is secured to the aponeurosis by catgut sutures. Pre-
vious to securing the protruded loop see that the uterus is in
DISPLACEMENTS OF THE PELVIC ORGANS.
541
pKOper position. If it is not, the portion of ligament next to the
Mterus can be pulled upon to the necessary degree to accomplish
ft* object. The ligaments secured, the wound is closed by a con-
Ip&uous chromic catgut suture in the peritoneum and muscle
This suture should be drawn over firmly enough to hold
■ appcsition the peritoneal surfaces and not strangulate the
^ftiscle structure. A second suture closes the aponeurosis and
^^^iie thinl the skin surfaces. The greatest care must be exercised
"to prevent the accumulation of blood abo\-c or beneath the
^"•■poneurosis, for such an accumulation is readily infected and the
' «Oiinatii.'>n of an abscess will result in a weakened ventnim — pos-
•ibh'in sloughing of the a]X)neurosis. Bleeding vessels should be
Fig. 418. — Suturts Introducvd for Vi
ligated, and where there is a tendency to oozinjf, drainage should
le employed. This methoil of treatment possesses the advan-
tages that: I, it affords ample opportunity for the recognition
and treatment of diseased conditions of the pelvic structures;
3, no opportunity is added by the o]ieration for the formation of
«listurbing pelvic adhesions; 3, the natural condition is more
closely imitated and the uterus maintained in position by liga-
SKDts capiible of evolution and involution.
Veutrajixation and Ventrosns pension. — These terms are ap-
plied to the operation devised by Olshauscn. and moditied by
Kelly, for cstabhshing an artificial ii;;anient fur the purpose o£
maintaining the uterus forward. Tlie uponition consists in an
t542 GYNECOLOGY.
incision in the median line, through which the uterus is expos€
and its fundus sutured to the parietal peritoneum at the low
angle of the wound. Two or three buried sutures of silk, siU
worm-gut, catgut, or silver wire are generally employed. (Fi|
418.) The first suture is passed through the peritoneum aboi
one centimeter from the wound margin, through the fundi
uteri near its center, and brought out through the peritoneui
of the opposite side of the wound. A second suture is similarl
placed about eight millimeters behind the first. To preyer
the peritoneum from being dragged away from the abdomini
wall it is included in the abdominal sutiu"e. Since the fin
edition of this book I have modified my method of performin
this operation by introducing a silkworm-gut suture throug
the fundus of the uterus and the abdominal walls, which is sul
scquently tied externally. A needle, carr\ing a chromic catgi
suture, is intrcnluced through the aponcun^sis of the lower ang
of the right side, through the fundus of the uterus, near the sill
worm-gut suture, and brought out through the peritoneum of tl:
opposite side. Two subsequent turns oi the suture are passe
through the edges of the peritoneum and the fundus of the uteru
after which the peritoneal wound is closed with the remainir
suture. Following the introduction of silkworm-gut sutun
through all the tissues above the peritonetun, this same catgi
suture is carried back through the aponeurosis and tied at tl
lower angle of the wound. Therefore the uterus, peritoneun
and a]M)neurosis are all held by the one suture, and only a sing
buried knot remains in the incision. Silkworm-gut sutures, ii
cludinjj: the one through the fundus uteri, are then tied, whic
wuuld bring in a])jV)sition and secure the skin edges. The sta
(»r lowcT suture of silkworm-gut may be tied over a pledget <
gauzi' to ])revent it cutting the skin, and should be permitted 1
remain for two weeks. Tliis operation establishes a ligamentoi
band between the uterus and ]xirietal ])eritoneum, which is su
iieiently stnmg to maintain the uterus forward and yet not inte
fere witli its nn»bility. Wliere it is i)referable- -as, for instanc
after tlie eliniaeteric, or in ]).'iiienis from whom both ovari
]ia\'t* been reinoxed that the litems should be more firm
lixed t" llu- al'doniinal wall, it is better that the peritoneu
shouM ]»•• i»usli('<l ])ack ^« > that the sutures bring the muse
strueture 'lirecily in C'>ntaet with the fundus of the utert
Such a cairse secures a firmer union and, therefore, the uter
is held m-ire cj. -sely t*. i';e j.arietal wall. The procedure we ha-
describer] |»ern:ii^ t !.■ .p 'U:r:i exp1< t.-ii jmii nf the i)elvic cavit
the se|>ar:iii' -n • >\ :..■ ' lie.^j. )::<. ;..ri,l tlie fixation of the uter
throuirli a -in;.'!'.- i'lei-i-::. T^ie ]>r'.ee<iure has been great
ni"(]i fieri. I5\- .-«.,] I :<•. 1 lie -m: -ir.- -.wr itlaeeil in the anterior uteri:
DISPLACEMENTS OF THE PELVIC ORGANS. 543
The majority of operators insert them in the ftmdus —
5 first suture in the Une of the Fallopian tubes, and the second
little behind it, thus throwing the uterus forward in slight
tflexion. The purpose of the operation of ventrosuspension
establish a ligamentous union, which will permit a certain
mt of uterine mobility. Consequently the uterus is attached
to the peritoneum, rather than to the muscle wall. To
dd the buried sutiure, F. Martin has suggested using the
:hus, and when it is not well defined, a loop of peritoneum
carried from below upward through a buttonhole slit in the
lus and included in the sutures closing the wound. Bov6e
>lo)rs a portion of muscle aponeiu'osis. These modifications,
5ver, have no special advantage. The fixation has been
iplished through a transverse incision above the symphysis,
incision only divides the skin and superficial fascia. A
ical incision is then made through the aponeurosis, muscle
I, and peritoneum. The uterus is brought forward and se-
by two silkworm-gut sutures through the fundus. These
brought out through the muscle wall and segment of integu-
it below the transverse incision. The remaining portion of
vertical wound is closed with catgut and the transverse in-
in the skin with a continuous intercut icular stitch of silk,
suspensory stitches are tied over a gauze roll and permitted
remain two weeks. Ventrosuspension has the advantages
ly suggested, that it permits the inspection of the con-
ion of the peritoneal cavity, the treatment of diseased appen-
;, the separation of adhesions, and the fixation forward of
uterus in a position which is imlikely to give distress. It has
L-the following disadvantages : (i ) That it has been found to inter-
fere to some degree with subsequent gestation and labor, the
patient complaining of more or less pulling and distress during
tte progress of gestation, sometimes so marked as to cause abor-
t • tion or premature labor. When the band of fixation is short, large,
and firm, it may prevent enlargement of the uterus and produce
Running of the posterior wall, which will increase the danger
of rupture and afford obstacles to the normal progress of par-
tarition. A firm band of adhesion, during pregnancy, after the
f. performance of ventrofixation, may cause a condition simulating
I a bifid uterus. I have, in several instances, opened the abdomen
[ during pregnancy and cut the band in order to permit the uterus
• properly to develop. Furthermore, I have seen j)atients in whom
I felt that such a procedure was advisable. In one instance I
i»as called in consultation to see a wr)man who had had a ventro-
suspension performed and who was in labor at full term. Tlie
anterior wall of the uterus and cervix were a])]>arc'ntly doubled u]\
fonning a shelf upon which the fetus rested with an arm j^rotrud-
I
544 GYNECOLOGY.
ing. The attendants, after vigorous efforts to turn the child, had
cut off this arm. The fetus was lying in a transverse positko,^
and a part of the body had engaged. After considerable difficukf ,
I succeeded in passing a cephalotribe upon the body of the chiH,-
with which I crushed the spine and delivered first the lower es*
tremities, and then the trunk and head. (2) That the operatkftj
is not free from danger. I had the misfortune to have ooei
patient in whom a large portion of intestine slipped below thft ■
band of adhesion immediately following the operation. Thil
became strangulated and caused death. Similar cases have beea
reported by Lindfors, Jacobi, Olshausen, and others. ThB
accident in my case occurred almost immediately after tbe
operation, and, although the patient suffered greatly, it was
attributed by her attendants to hysterical excitement following
the anesthetic, and, when recognized, the condition of tbe
patient was such as to preclude any hope of recovery. It would
not require great stress upon the imagination, when one seel
these bands of adhesion, to appreciate the possibility of strangu-
lation occurring at periods more remote from the operation,
and numbers of such instances are recorded. (3) The buried
sutures of silkworm-gut, silk, or silver wire may become a souioe
of irritation, either from immediate infection or later inflamina-
tory changes, and cause a sinus to extend through the abdominal
wall and give rise to an unpleasant discharge. Such a sequence,
of course, annoys both patient and surgeon until the offending
cause — the buried sutures — have been removed or have become
disintegrated. Such a sinus may keep up for months or even
years. The sutures can occasionally be fished up and removei
For this purpose I know of no instrument better adapted than
the hook of the ear-spoon devised by the elder Gross for the
removal of hardened wax from the ear. If this instrument is
ineffective, the surgeon may find himself obliged to reopen the
woimd, and frequently the offending ligature will be found deep
in the pelvis, at the end of the band of adhesion. For the pur-
pose of avoiding this difficulty I have employed the chromic
catgut suture with a single knot. Burrage has advised ventro-
fixation for the treatment of immobile anteflexion. Through
an abdominal incision he divides the uterosacral ligaments close
to the uterus and secures the fundus to the abdominal wafl.
Schmidt, of Cologne, frees the anterior uterine wall from tie
bladder by dissection, excises a wedge-shaped piece with its
point directed toward the cervical canal, and tmites the surfaces
by sutures. This draws the uterus forward in a position of
anteflexion.
Vaginal Operations. — The ease with which the pelvis can
be entered through the vagina has led to the adoption of various
DISPLACEMENTS OF THE PELVIC ORGANS.
545
operative procedures through this canal for the purpose of
maintaining the uterus in proper position. One of the earHest
operations performed through the vagina is that known as the
Schucking. This consists in passing an instrument, curved,
for an acute anteflexion, to the fundus, from which a concealed
needle is driven through the anterior vaginal fornix. This needle
carries back the ligature, which, when tied, fixes the uterus in a
position of anteflexion. Care must be exercised in its employ-
ment to avoid injuring the bladder by pushing this organ to one
side. Injury of the intestine has also occurred. The ligature
is permitted to remain for two or three weeks, when the resultir^
inflammatory changes will maintain the uterus in an anteflexed
position. The procedure is objectionable in that it is a blind
operation, and injury, therefore, may be unavoidable. In-
struments have been devised to push the uterus against the
anterior abdominal wall and thrust needles carrying ligatures
from its cavity, by which the fundus can be fastened ; but these
are open to the objection already assigned — that they are blind
procedures. Vaginal fixation devised by Duhrssen, subse-
quently practised and modified by Mackenrodt, consists in
making a vertical incision through the anterior vaginal wall to
the cervix, when the bladder is pushed off until the peritoneum
is reached. Without opening the latter a suture is introduced,
and by it the uterus is pulled forward. A second suture, placed
higher, near the fundus, is employed to maintain the uterus
forward by bringing its ends through the edges of the vaginal
incision. Mackenrodt modified the operation by opening through
the peritoneum and introducing the sutures at a higher level,
thus securing the fundus or anterior wall to the vaginal incision.
The peritoneal and vaginal wounds were then closed. This
operation for a time was very largely practised, but it was soon
recognized that it was likely to cause much distress and discom-
fort during the progress of gestation. Moreover, it often pro-
duced profound dystocia, which imperiled the lives of both
mother and child. For these reasons the operation is now
rather infrequently practised. Vineberg and Wertheim, through
a similar incision, seize the round ligament some three centi-
meters from the fundus uteri, pass a ligature beneath it, and
bring the ends of this ligature out through the vaginal walls on
either side of the vertical incision. The ligature is then tied.
This holds the round ligament down against the vagina, and,
consequently, fixes the uterus for^\'ard. The round ligaments
have also been shortened through the vagina by performing
the Wylie or Mann operation upon them. I have sutured the
round ligaments to the anterior surface of the uterus through
the vaginal opening. The operation of Ries consists^^
546 GYNECOLOGY.
a loop of the round ligament through a slit in the anterior
of the uterus. This method has been described under abdominall
procedures, but was devised to be performed through the vaginal
incision. Through a posterior colpotomy by a vertical inciaon,
Freimd and Gottschalk shortened the uterosacral ligaments.!
The incision was made from just behind the cervix downward,
toward the recttim. The peritoneal cavity was opened andai
ligatiu'e introduced on each side to separate the surfiaces. Froml
this opening a ligature was carried through the middle of tiie
uterosacral ligament, and one end of it through the posterior
siirface of the cervix. The ligature thus introduced on each side
was tied, which drew the cervix upward and backward. Coo-
sequently the other end of the lever, the fundus, was thrown
forward. A modification of this procedure has been extensively
practised by Bov6e, of Washington, who shortens the ligainent
without opening the peritoneum, and is quite an enthusiastic ad-
vocate of it. Pry or advocated a transverse incision in the pofr
terior fornix of the vagina, through which he broke up adhesions,
carried the uterus forward, and packed gauze into the posterior
culdesac. Then with a tampon he pressed the cervix well up-
ward and backward. The subsequent adhesion of the cervix in
this position leads to correction of the malposition.
512. Lateral Flexion. — Lateral uterine bending may be dex-
troflexion or sinistroflexion. The position of the cervix is more
or less fixed and the fimdus of the uterus is drawn to one side
by cicatricial contraction, or is pushed to the opposite by a large
exudate, an intraligamentary fibroid growth, or an ovarian cy^
No special symptoms characterize the state ; the diagnosis is
readily determined by the methods already cited for the deter-
mination of other forms of displacement.
513. Complications Associated with Displacements. — It has
been noted, in discussing the individual forms of displacement
of the uterus, that they rarely produce symptoms themselves,
and, when it is considered that the organ involved, in its normal
condition, weighs less than an oimce, that its circulation is so
extrinsic that the organ can be bent forward or backward with-
out injury thereto, it is difficult to see why so much stress has
been placed upon these displacements.
The development of a complication, however, by which the
circulation is obstructed, changes the whole aspect of affairs.
The most frequent complications of uterine displacements are:
Endometritis.
Metritis.
Salpingitis.
Oophoritis.
Cellulitis.
DISPLACEMENTS OP THE PELVIC ORGANS. 547
Peritonitis.
Other complications are :
Ectopic gestation.
Ovarian or myomatous tumors.
Ptosis of the abdominal viscera.
These complications are most frequently primary as regards
the production of symptoms, though, as in prolapsus, they may
be secondary in the sense that the displacement lessens the
xcsistance to infection.
514. Prognosis of Displacements. — The prognosis of a dis-
plaiiment will depend upon its degree and the existence of
complications. In the earlier stage of the displacement, when
fbe distress arises from increased weight of the organ, the mere
oorrection of the position and the maintenance of the organ
corrected will bring about a decrease in its size and afford relief
from the displacement. After the displacement has existed for
aome time, it is complicated by chronic inflanmiatory changes,
vfaich will absolutely prevent any procedure from maintaining
fhe organ in its proper position. The symptomatic phenomena,
however, can be relieved and the patient be practically restored
to health.
515. General Treatment. — It will be seen, from a discussion
of the different forms of displacement, that I am disinclined to
bcKeve that uncompUcated displacements are Ukely to produce
symptoms. Of course, I can readily understand that when a
patient has prolapsus, with the uterus protruding from the
Dody, it necessarily produces disturbance and is subject to
tmusual irritation from its abnormal location. The small size
of the uterus, when normal, the manner in which it receives and
discharges its blood-supply, render it difficult to conceive how
the mere displacement of so movable an organ should be pro-
vocative of the serious symptoms which have been frequently
attributed to it. The most frequent compUcations of uterine dis-
I^acement are inflammatory processes and their sequelae, which
cause increase in the size of the organ, its fixation by extensive
adhesions, and interference with the performance of the ftmction
of the adjacent viscera. The treatment, then, must largely
consist in the correction of the existing compUcation. Expe-
rience has disclosed, however, that when such compUcations
exist, their treatment is most effective when associated with
measures directed to maintain the uterus in proper position.
The methods of procedure most effective to accomplish this
purpose are both local and constitutional, such as massage,
electricity, and mechanical procedures. The patient should be
suitably clad, and wear clothing free from undue constrictions
about the waist. Her skirts should be supported from the
in?
GVNEC01.C-GT.
'•^1.
■ ♦r
■4^b*^^» ^h ^
h
nu*-- -L >-i-*
.,^:^ -"c "lie
DISPLACEMENTS OF THE PELVIC ORGANS. 549
"degree constitutional measures for the improvement of the
Serai health, the regulation of the secretions, enforced rest
ing menstruation, with dilatation, curetment, and the estab-
lishment of proper drainage will be means sufficient to establish
4 symptomatic cure. When the anteflexion is acute and dys-
menorrhea is marked, curetment will generally be of only tem-
porary benefit and should be followed by splitting the posterior
^> and suturing the surfaces, as advised by E. C. Dudley. Retro-
version and retroflexion are capable of producing marked influ-
«ce upon the general health, but should not be considered
as indicating the practice of special procedures tmless they are
productive of symptoms. The correction and maintenance of
the uterus in its proper position is indicated as a preliminarj'
treatment of any complication, and retroversion, associated
with subinvolution following a recent parturition, unless com-
plicated by perimetritic adhesions, should be considered an
indication for the use of the pessary, but the previous replace-
ment of the organ must be a sine qua non. In retroflexion, if
the pessary is not well borne and the uterus is freely movable,
the Alexander operation may be employed. The great frequency
with which inflammation and more or less adhesion of the uterus
occurs greatly limits the number of cases to which this operation
IS applicable. Indeed, I would prefer to make the median inci-
sion, for it enables us thoroughly to examine the condition of
the pelvic viscera, to break up existing adhesions, and to treat
diseased conditions of the ovaries and tubes. As already seen,
the great majority of operations for shortening the round liga-
xpents within the abdomen utilize the strongest portion of the
ligament and leave the weakest undisturbed, with the probability
of a redevelopment of the condition. The combination of the
operations of Gilliam and Simpson, which I have employed, seems
tome the most desirable, as it accomplishes all that the Alexander
operation could do. Moreover, it has the advantage over the
operation of ventrosuspension in that it affords no opporttmity
for the formation of adhesions which may serve as a trap by which
a knuckle of intestine may become fixed and obstructed. My
experience leads me to the performance of the operation known
as ventrosuspension or ventrofixation less and less frequently.
Of the vaginal operations, the ones pursued by Vineberg and
Bov6e are the most serviceable. The other vaginal operations
have proved imsatisfactory , for many of the patients thus operated
^pon have experienced trouble during subsequent pregnancy.
ftx)lapsus uteri is a condition which should receive early con-
sideration. The longer the displacement is permitted to remain
^"^antagonized, the greater are the chances that it can not be com-
pletely restored. The first stage of uterovaginal prolapse can be
550 GYNECOLOGY.
corr^ted by the employment of a stdtable pessary. One should
be employed which will maintain the uterus in a position of ante-
flexion or anteversion. The early stage of vagino-uterine prolapse
should be considered an indication for the prompt retraction of
the relaxed vaginal walls and the restoration of the perineum.
The accompanying cystocele should be treated by an excision of
the redundant vaginal portion of the septum. This surface
should be sutured in a transverse direction in preference to the su-
ture that is sometimes advocated, known as the Stolz suture,
which shortens the vagina in every direction. The importance d
having a long anterior vaginal segment is seen in its influence in
maintaining the cervix at a higher level, consequently throwing
the fimdus forward. In the later stages of prolapsus the vaginal
plastic operation should be supplemented by an abdominal pro-
cedure to maintain the organ forward. This may be accom-
plished by shortening of the rotmd ligaments and of the utero-
sacral. After the climacteric, especially when the uterus shows a
marked tendency to descent, fixation of the organ is desirable.
In very extensive prolapsus or in elongation of the supravaginal
cervix the fundus uteri should be amputated, and the stump can
then be secured to the upper part of the broad ligament or to the
anterior abdominal wall. Very frequently the condition will be
complicated by an extensive hernia through Douglas' pouch,
when an extensive vaginal plastic operation, combined with a
ventrofixation, will not necessarily prevent the development of
this condition. The hernia may be obviated, however, by sutur-
ing together the fold of Douglas over the rectum and the remain-
ing part of each fold to the side of the rectum. Enteroptosis may
be still further prevented by fastening the colon to the abdominal
parietes. My experience has led me to condemn the Freund
operation as one of no value.
517. Inversion of the Uterus. — Inversion of the uterus is
that condition in which its inner or mucous stirface is outside
and its internal or peritoneal surface within. Inversion can
be partial or complete, and presents three different degrees:
In a partial inversion the body of the organ is depressed and
inverted until it reaches the cervix, but without dilating the
latter, when it is known as the first degree, or inversion intra-
uterine. (Fig. 419.) Next, the fundus protrudes through the
cervix, the cervix being turned down upon the neck like a cuffi
which is the second degree, or inversion intravaginal, (Fig.
420.) In the third degree the entire uterus is inverted, and
with it, not infrequently, the vagina, the uterus hanging outside
the vulva, and this is known as inversion extravaginal. (Fig.
421.) Now, every degree of this form of alteration of the uterus
can combine itself with a partial or total inversion of the vagina
DISPLACEMENTS OF THE PELVIC ORGANS.
551
so the view that the third degree only is necessarily combined
with prolapsus is a mistake. A trifling degree of inversion or
partial turning in of the uterus is called invagination. This may
be a mere depression, over which the raucous surface becomes
convex, while the peritoneal surface forms a depression or con-
cavity. As this depression continues, the proximity of the tubes
and round ligaments to the ligamentum ovarium draws these
structures into the opening. The ovaries may rest upon the
funnel-shaped depression, while the tube is necessarily, for a
part of its extent, drawn into the cavity. The cavity, with its
Ut«nis, Showing Three Degrees.
enlarged opening in the peritoneal cavity, is called the inversion
funnel. This funnel is usually not quite the depth of the ordinary
length of the uterine cavity. If the inversion continues for
some time, secondary phenomena result, from retrogressive
processes, but the uterus returns to its normal size. The in-
verted mucous membrane is covered with epitheliiun; the neck
of the uterus is small, generally surrounded by a cuff of tissue,
derived from the cervix, which has not been completely inverted
— a cervical ring. The longer the inversion exists, the more consid-
erable is the congestion, with edematous enlargement, and thick-
eningwhich formthemisproportion between the narrow inversion
552
GYNECOLOGY.
funnel and the enveloping cuff of the cervix. We not inf» -
quently find diseases of the adnexa. Tlie orifice of the tnil
situated in the vagina can readily be the avenue for the pas
of infection into the deeper structures. The uterine inner surfao
of the tubal mouths is exposed, the projecting raucous membra
is frequently rubbed and irritated, so this door stands open ict
Fig. 431.— Nonpuerperal InveisiM.
Fibroid Tumor Attached to ita
Fundus Uteri.
the entrance of germs, and infection can take its way through the
tubal raucous raembrane or by the lymphatics to the deeper
tissues, producing endosalpingitis, suppurative processes in tb*
ovary, or purulent pelvioperitonitis by extension of infecliou
from the connective tissue. In ordinary conditions we can liai"e
involvement of the cellular tissue from such infectious processes.
DISPLACEMENTS OP THE PELVIC ORGANS.
553
"ations in the peritoneal covering of the inversion funnel
r, which render the condition more or less fixed.
18. Etiology. — Inversion generally arises from two causes:
from puerperal conditions, relaxation, or partial paralysis
le uterus during the process of labor, especially the third
J of labor; and, second, the nonpuerperal form, in which
items is displaced by the presence of a fibroid tumor at-
«i to the fundus. (Fig- 422-) These two conditions are
much alike in the clinical form of an inversion, but are
It Degree.
■ different in their manner of development. Puerperal
raons are much more frequent than those which arise from
presence of growths. They are in the proportion of nine to
Total inversion is rare. How much more frequently the
jal form occurs is difficult to determine, as not infrequently
;ial inversion resulting from the presence of growths is over-
id. Puerperal inversion, in some cases, is produced by
tion upon the cord in the elTorts to deliver the placenta ; by
ty pressure over the uterus the fundus may be in\-erted, and
he paralyzed condition may be grasped by the deeper struc-
S&l
CT.VECOLOGT.
ttire* and the uiverrion progress until it is completed. A short
cord 11 an occanonal cause for inversion. The traction is made
upon the cord at a time when tlie uterus is relaxed and least resist-
ant. The tTaclioD upon the fundus and the subsequent uterine
c^mtrattion very rapidly complete the displacement. In\-eTsion
rarely occurs spontaneousiN'. The o\'erdist«ition of the cervix by
a larKc fetus frequently causes such relaxation as will permit in-
Pig. 414. — PalpAtion of an Inversion of the Seoood E>egice.
version to occur readily. It will be a matter of interest to know
whether, in the cases in which invereioo has occurred, the plac^ita
has been attached near the fimdus of the uterus.
51{K Symptoms- — In\-ersion causes characteristic symptoms.
The patient generally complains of se\-ere pain, which is con-
tinuous, sometimes for days; sometimes a pulling sensatioa is
fdtin the vagina. Immediat^y following the diskn^taoaa severe
B occurs. This continues in notewartliy a
'M
DISPLACEMENTS OP THE PELVIC ORGANS. 555
yr of the puerperium, and does not completely disappear,
f continue much longer. Later, it appears intermittent,
suspension of discharge rarely corresponds in its duration
ormal intermenstrual interval. During the interval there
ifuse mucous discharge from the genitalia. The profuse
lischai^e may cause the death of the patient from acute
, or later from septic infection. In some cases sponta-
sinversion may take place in the course of the year. The
Ml may be suspected from these phenomena.
Pig. 435, — Appearance of Inversion of the Third Degree.
Diagnosis. — Inversion will be suspected from the severe
;e more or less continuous hemorrhage, and the absence
ondus uteri when the hand is placed upon the abdomen,
examination discloses a globular mass which fills up the
and is encircled by a cuff-like ring at its upper part.
ig is situated at the external os, {Fig. 424.) Placing
1 over the abdomen and making deep pressure, the fxmdus
'll 111
ni'l.
ri'
.■
I'
..nliri
In II
iii
V
■1
,.,
will [.;,
OVS'KCOLOGY.
IS i^, fNun.l to U- absent from its normal situation
I. ;i fiiiiii«;l-Hliaped excavation is recognized which i«
iiillrncnt lo fifctc-rminc the diagnosis (Pi^ ._, f
,iii.' c.n-Iition the uttrus resumes its normal si^
f^lol.iilar or 7rt.'ar-shapcd mass in the vagina im'
Its ii|.i K^r i«trt hy a distinct cuff or ring, and the ^d'
il„ llns tl,o sitme distance on ail sides. Bimanual
I .liM-just-s aliDVc a funnel-shaped depression This
■an In: mm: readily determined bv dramng upon the
ic iilcniK an<l intn,ducing the finger into the rectum
1 iiass Mvcr tlic neck and directly into this funnel*
: F'l'.Tus. .". Fibrdd Poly-
■ up:" Its margin.
r.irr.or is smooth.
; ::* bwer angles
"^tLs a \-agmal
i7.i;:er c: iheas-
'r.r:js::X. ir/.-esii-
.-.--.v. "^^-en the
-- -i r.:: rwcilv
?s ui ": ir:endse
--rV;.iv. kver-
DISPLACEMENTS OF THE PELVIC ORGANS.
557
sion of the uterus is sometimes confounded with fibroid polj^pus
which has been extruded into the vagina. (Fig. 426.) A fibroid
polypus may have a broad-based pedicle and the tumor may
present a shape very similar to that of an inverted uterus. As it
is co\'ered with mucous membrane, the superficial similarity may
be marked. Of course, a fibroid tumor will show no orifice of the
Fallopian tubes, but the latter are not always distinguished.
Sensation in the fibroid is a little less marked than in the inverted
uterus, but is not sufficiently definite to afford a foundation for
diagnosis. The sound carried around the cuff of the inverted
uterus passes on all sides an equal distance. With fibroid tumor
it would pass into the uterine cavity at one side. (Fig. 436, b.)
Occasionally, however, the cav-ity of the uterus may be so stenosed
that the sound will not enter, and the diagnosis may then be
uncertain. (Fig. 426, c.)
If we grasp the mass and draw it down, the finger in the rec-
tum will disclose, in the one case, the cup-shaped depression of the
inverted uterus; and, in the other, the body of the uterus lying
above the neck of the growth. In a partial inversion, associated
with fibroid growth, we may not be able definitely to determine
the condition until we proceed to operation for the removal of
the mass. (Fig. 427.)
521. Treatment.^There is a difference in the treatment of
the two forms of inversion, In the puerperal condition all that
is necessary is to replace the uterus, when it will remain, while
GYNECOLOGY.
in the nonpuerperal form it is necessary to remove the grow
which have occasioned it, Reinversion is comparatively «a!)
recent cases. Pressure against the fundus with the hand
Fig. 419. — Inversion of the Uterus — Extravaginftl.
DISPLACEMENTS OP THE PELVIC ORGANS.
559
"S in the shape of a cone will be frequently sufficient to carry
and directly into the cavity of the uterus and to accomplish
Dmplete reinversion. After the puerperal condition be-
3 chronic we then have to resort to various methods for re-
Dient of the organ. These methods consist in manual
nent — instrumental and operative. In the manual treat-
the fingers exercise a veritable taxis on the inverted organ,
he same as in hernia, and the two hands are necessary for
nent, in which they play an essentially distinct rfile. The
land over the abdomen maintains the uterus, while the
Fig. 430
-Central Taxis.
replaces the inversion. Courty introduces one or two
■s into the rectum and hooks them over the end of the
s, which fixes it more solidly. The other hand is intro-
[ partly or totally into the vagina. The method of taxis
ircised in various directions; thus, it is central, lateral, or
lieral. The taxis is called central when the pressure is made
St the fundus, or median part of the organ {Fig. 430};
J, when it is exercised at the level of one or the other uterine
. (Fig. 431); and peripheral when the pressure is exerted on
rflex i)arts (Fig. 432). The latter is exemphfied when we
560
GYNECOLOGY.
grasp the fundus in the palm of the hand, pass the fingers to the
fundus of the vagina, and spread it out, stretching the funnd
while the fundus is pushed against it. If taxis has been tried
and found inefficient, we can then resort to instrumenul reduc-
tion. A number of instruments for this purpose have been de-
vised. The air pessary of Gariel is introduced and distended. It
exerts a hydrostatic or aerostatic pressure against the fundus, and
pushes it upward, while the vaginal walls, by their traction, pull
apart the cervix. This soft pressure in some cases may be suffi-
cient to accomplish the gradxml reduction of the oi^an. Tbe
pessary can be introduced and the bandage so appBed as to
Fig. 4JI. — Lateral Taxis.
maintain the pressure against the cervix (Fig. 433). A vagina'
tampon of iodoform gauze for twenty-four hours is sometimes
more effective than the pessary. The pressure is sometimes
employed against the fundus by having an instrument with a
cup-shaped end, into which the fundus fits, and a spring upoO
its external surface, by which an elastic pressure is induced-
(Fig. 434.} This procedure is more effective when combined
with Marcy's suggested insertion of two or more Hgatures in the
cervix, by wliich traction can be made upon it, while pressure
is made against the fundus. Thomas advised opening the abdo-
men and dilating the cer\-ix with an instrument similar to a
DISPLACEMENTS OP THE PELVIC ORGANS. 561
Fig. 432. — Peripheral Taxis.
[g. 433. — The Use of the Air Pessary to Reduce an Ii
562 GYNECOLOGY.
glove-stretcher, while pressure is made' against the fui
(Fig. 435.) This procedure was successful in one case and
in another. It has been suggested to introduce the ind^-f
of one hand into the recttim, and that of the other into the'
der, hooking them into the funnel-shaped depression ol
uterus, while the thumbs are pressed against the fundus. 1
ner advocates making a transverse incision through the posi
fornix of the vagina into Douglas' culdesac, through whi
presses the index-finger of the left hand into the inversion fi
and attempts with the thumb of the same hand to press u
fimdus. If the procedure fails, he advises splitting throug
posterior uterine wall, in the median line, by a longitudin
cision, which may extend to within two centimeters of the fu
Fig. 434. — -Reduction of Inversion with White's Apparatus.
from the mucous siu-face to the peritoneal. (Fig. 436.)
renewal of attempts at reinversion under such circumstan
usually successful, for the reason that the resistance is ten
and we are consequently enabled to replace the organ.
the uterus has been reinverted the fundus is turned down thi
the vaginal opening and a number of sutures are introduc
close the incision. Hirst advises a cut through the vagina
tion of the cer\-ix only. Cases have been recorded of spon
ous reduction of the in\-ersion when the vulva has been distt
with the patient in the genupectoral position. If the cond;
DISPLACEMENTS OF THE PELVIC ORGANS. 563
ire unfavorable for an operation of reinversion, we can proceed
x> total extirpation of the uterus or to amputation of the inverted
bndus. When the amputation of the fundus only is made, it is
rery important to guard against reinversion of the stump with a
twulting hemorrhage into the peritoneal cavity. The stump may
be secured by three or four partial ligatures, and then the ampu-
tation may be made below them. When the inversion is pro-
duced by the presence of tumors, we may content ourselves
Fig. 43S- — Intraperitoneal Dii;
ttnply with the removal of the growths and the reinversion of
the organ; or when the organ is very extensi\'ely involved, it
oay be necessary to remove the fundus with the growth. The
possibility of partial inversion should always be kept in mind
in operating upon partial extrusion of gro^rths from the uterine
<*vity. Nimierous cases are recorded in which a fibroid polypus
W growth has been removed by the wire ^craseur, and examina-
tion subsequently disclosed that a portion of the uterine wall was
564
GYNECOLOGY.
removed, causing an opening into the abdominal cavity. With
growths projecting into the vagina, the preferable procedure ii
a careful enucleation of the tumor. The tumor is depressed and
held -while the enucleation is performed under the eye, so that,
even thougli an inversion has occurred, by hugging the tumor
closely we prevent breaking through the wall of the uterus.
522. Displacements of the Appendages. — Displacements d
the ovaries and tubes are \-er\' common with backward uterine
Wall Prtliminary to Ri-duco""
dis]jlacenient. Inflammatory troubles in the tubes cause thflB
to drop clown, from increased weight, and they are found behind
the uterus in Douglas' pouch. {Fig. 437.) Frequently both tubes
may Vie situated in this position, and, united at their abdoroiiul
ends, iovm a single tumor, which contains pus or serum. The
tubes are dislocated by their attachment to growths; ovarian.
DISPLACEMENTS OF THE PELVIC ORGANS.
565
oid, or broad-ligament cysts may draw the tube up into the
lominal cavity and almost double its length. The most fre-
nt dislocation of the ovaries is downward, into Douglas'
lesac. This prolapse can occur as a consequence of retro-
jlacement, or, independent of it, from elongation or rupttire
the infundibulopelvic ligament. The dislocation can be
asioned by enlargement of the ovary, or the hypertrophy
y be secondary to the displacement. The comphcation of
■odisplacement with ovarian prolapse is a source of additional
;ress and annoyance to a patient, as the tender ovarian struc-
es are subject to pressure from the heavy uterus and from
mi of the contents
the bowel. In
s situation they
! also subject to
in and distress
ring the act of
ition, often rend-
ii^ it so painful
it the act is
eaded by the pa-
mt.
523. Symptoms.
■Prolapse of the
fary is generally
isociated with
ironic infiamma-
m, either as a
"imary or second-
y condition. The
fmptoms from Fig. 437.-
hich the patients
iffer are necessar-
/ those which to some degree are occasioned by the chronic
sorder. In addition to this fact, however, the patient suffers
stress during fecal evacuation, during the act of coition, in
iDdng, and on standing. The ache and distress are some-
mes so severe as to render the patient unable to assume or
tain the upright position ; a condition of semi-invalidism from
* influence upon the nervous system is engendered similar to
4t present in chronic ovarian inflammation. There are no
mptoms characteristic of tubal displacement.
514. Diagnosis. — Prolapse of the ovary, when freely movable,
readily determined by bimanual palpation. A mass can be
t posterior to the uterus in Douglas' pouch, which varies from
'/A
— — '*'^=*- ~- ^^'^SCS
•"' " - • i. . 15 €cvc.ipec "With
'*'''■ / •■.'./. .f . ,. . , ;'^" ' • ' • • — - -.- -- TT - - , . TTTf , ^i3 CCTCT—
//.If.' . ,■....'/,;..;;.'.': .r. f-v.*.. :* rr..iy r.'.t "::•= liscovered until
•if" / /,/ .'r'i'/fr.i;.... '.;:./;*./ :. '.:y;r/;.':. Tubal er^rgement with
■i/|n' ,/,»..' ./I fr"| i/r/./ v: ::.:u],w-A vjt as extending around the
■I'l' '•/ »!./ 'i^'MJ. '*ji I^^ ;//,V;rior surface, and the organs are
r.^p* 7 rfmfriiArit. In iriflarnrnatorj' conditions of the tube
Ml '.I /(Ml* III' 'r/,\\\t", \.\\i\ i.n:atTnont is the same as that of the
• l( • '• • 'I ' '.nihicii, ;j-. <|<-.rrit)<:'l in Section 468. Prolapse of the
M 'ii , .1 ■Ml hiinl Willi rlipiiiic ovaritis, in which the ovaries are
1 1 ,' mil' li Miliiij'.*'!, is lirj.l treated by extirpation. When
ilii I iiliiii'i iMi'iil r. f.iiiipiv due to prolapse, causing more or
It (iiiiiii I'lji'tiM, Mm' nrj;;iii should be brought up and fixed
III iIm |iiii|ii«i |iir;iiiiin. P'rcqueiitly shortening the round liga-
Mi'Mix III M'liliiiliNiiiiiiM will brinjj with it the restoration of
lit" iiM'iii.iii III ihr <iv;irirs. WluMi thcsc, however, do not rest
M|«"n iln- iiM'.ii'HHi Mirliuv o{ ihc broad ligament, but drag
tihl.uii.l mill Mi»M|'.!.»?i' poiK'h, Iho infundibulopelvicligaments
.•li.MiM III' ':li.»iii'niMl or llu* i*\tiM-n;il end of the ovary should be
.•iii> 111 .1 I.' ilii' p.".!rn«M- s\irl'.uv of iho broad ligament near its
H|»|M t y\\\ I il»MtN h.i\i* Ihvu ni.ulo to maintain the ovary in
w \^ I. Mill pi«.u\i»M b\ nu\*l*,.i'.nv\d moans, but in my experience
\\u\ H. »» »i illx »n»'tii\ i'.\%* ri'.o vnwrv slips Ix^hind the pessan^
iii.n. u w '■;\» \ \\\wV \\\\\ l\\\^:r.os vv.vr.e.:. and adds to the
A\ M, .' ■.'■1 -^'.'.wMv, l^\\:v.o*.v/.\ ::*.o .'A\vr\' will be caught
Is 'm.».; r , ■ ' . .■ ••.••'. .v.\.\ \'c \\\\'<'\\ \\\\\ be ur.ibie to move
\ y . . w , . .'NX • '•* ;,^ ; \' Sv'\ X
" ;! • ' .",1" ''i5ir:rL ^Urn it
■->
^fsSS- < TV
GENITO-URINARY HEMOBKHAGE.
667
the adjacent cellidar tissue. It can occur at any age, though
it takes place but rarely, except from trauma, prior to puberty.
The significance of hemorrhage is largely dependent upon the age
at which it makes its appearance. The hemorrhage is called
open when the blood escapes from the urethra, vagina, or through
external injuries; concealed, when within the abdominal cavity
or in the cellular tissue. In the latter, also, it may be denomi-
nated as circumscribed. A discharge of blood mixed with urine
is known as heinaturia. An excess of bloody discharge syn-
chronous with the regular menstrual period is named menor-
rhagia; while bleeding of an irregular character is named metror-
rhagia; a collection of blood in the cellular tissue is known as a
hematoma; when in the tissues of the vulva or vagina, it is called
a vulvovaginal thrombus or hematoma; into the cellular tissue
about the uterus, an extraperitoneal hematocele; an accumulation
within the peritoneal ca'vity, which is encysted or closed in by
peritoneal adhesions, is described as an intraperitoneal hemato-
cele; hemorrhage into the structure of the ovary, when small, is
known as an ovarian apoplexy; and when large, or frequently
repeated, so the ovarian stroma is practically destroyed, and
the collection forms a blood cyst, it is called an ovarian hema-
toma. A collection of blood in one of the hollow organs is known,
in the Fallopian tube, as a Iiematosalpinx; in the uterus, as a
hematometra; and in the vagina, as a hematocolpos; or when the
collection is so large as to involve all, it is denominated a hemato-
colpometrosalpinx. Further distinctions are retro-uterine, circum-
uterine, and ante-uterine hematocele, according to the situation
of the blood collection— behind, about, or in front of the uterus.
528. Hematuria and Its Causes. ^Hematuria is blood mixed
with the urine, and is engendered by urethral caruncle, polypi,
vegetations, fissures (the latter situated about the internal
meatus), and malignant disease of the canal. It occurs in acute
and chronic cystitis, associated with more or less vesical ulcera-
tion ; in the aggravation of the disorder occasioned by the pres-
ence of vesical calculi; and malignant growths or villous pro-
jections from the vesical mucous membrane are a prolific source
for the occurrence of blood in the urine. It is often produced by
injury, inflammation, or malignant disease of the ureters or
kidneys. Stone in the pelvis of the kidney frequently causes
bloody urine. Occasionally, blood appears in the urine as a
result of constitutional conditions. So frequently is it associated
with malarial infection as to give rise to the term malarial
hematuria.
529. Symptoms and Diagnosis. — -Tlie blood may be mixed
with the urine, giving it a dark, smoky, often almost black, j
appearance, or may precede or follow the' act of micturition, as a'
i
568 GYNECOLOGY.
few drops of free blood mixed with the iirine or in the form of a
small clot. The clots may be bright and recent, or darkened by
longer retention within the urine. Unmixed blood comes fram
injury or disease of the urethra ; frequently a few drops or a
small clot will follow urination when caused by a fissure of the
meatus. When the bleeding is occasioned by disease or injury
of the bladder, the urine is not constantly bloody. An evacua-
tion may be perfectly clear and the next be bloody.
The cause of the symptom is ascertained by careful exami-
nation. Disorders of the urethral orifice are recognized by in-
spection of the canal, by palpation, and, if necessary, by inspec-
tion through an endoscope or a urethral speculum. A figure'
at the internal urethral orifice causes severe pain upon palpatioQ
of the urethra.
Inflammation of the bladder — cystitis — is recognized by pain-
ful and frequent micturition and attacks of profuse bleeding.
The microscope reveals the cellular elements of the blood and
degenerating epithelium in the urine. In growths or foreign
bodies palpation discloses thickened walls, increased tenderness,
and possibly the mobility of a foreign body or calculus. Micro-
scopic investigation of the fluid evacuated is of great value.
Not infrequently the bladder may be the seat of profuse bleeding,
which becomes coagulated, and the clots interfere with the col-
lection and evacuation of the urine.
Disease of the ureter and pelvis of the kidney may produce
bloody discharge. Irrigation of the bladder permits the char-
acter of the urine from the kidney to be determined. Through
the speculum the ureteric orifice will often be seen as a pouty,
more or less abraded elevation, from which bloody urine is seen
to issue. Catheterization of the ureter will determine the char-
acter of the secretion in the respective kidneys and the existence
of disease in one or both of the organs. Calculi in the renal
pelvis are generally a source of pain in the region of the kidney.
The pain is generally felt along the course of the ureter, not in-
frequently over the distribution of the genitocrural nerve.
530. Treatment. — The treatment of hemorrhage is the same
as that of the condition producing it. Hemorrhage from the
bladder and urethra must be recognized as of importance.
Measures for its relief (Section 409) have been described.
When trouble can not be discovered in the urethra and blad-
der, the treatment should be directed to the disease in the pehis
of the kidney. Before proceeding to internal measures, constitu-
tional conditions should be excluded. If necessar>% the blood
should be examined for the presence of the malarial plasmodium.
The determinaiton of malaria should indicate the use of anti-
malarial remedies. Bleeding may be arrested by the employ-
GEMTO-URINARY HEMORRHAGE.
569
ment of astringents — tannic and gallic acids, hydrastis. and
hamamelis ; cotamin hydn.>chlorate, gr. ss-j every three hours;
ergotin, gr. j-ij four times daily; ol. erigeron, gtt. v-xx every
three hoijrs ; gelatin in lo per cent, jelly by the stomach, or
2 to 3 per cent, solution in salt solution by hypodemnxlysis.
Tyson advises ferri persulph., gr. {-i, as very effective.
Continuation of bleeding associated with renal calculus should
indicate operation for its removal. Operation will be a conserva-
tive course, for the continuance of the disorder necessarily results
in renal degeneration and destruction.
531. Genital Hemorrhage or Bleeding. — This term is em-
ployed to distinguish bleeding which makes its exit externally,
and may arise from any portion of the genital tract. Bleeding
of slight character,— a few drops, — which will occasionally soil
the clothing, will be a source of great anxiety to a nervous patient
and should be considered an indication for a careful investiga-
tion by her physician. Such bleeding may arise from irritation
of the vulva, warty growths, scratching induced by pruritus,
from caruncle of the urethra, papillary growths and granulations
of the vestibule or vaginal mucous membrane, lacerations, abra-
sions or erosions, or beginning malignant diseases of the vagina
or cervix, inflammation of the endometrium, or changes incident
to gestation or parturition. More severe bleeding or hemorrhage
is induced by injuries of the vulva caused by falling and striking
against a sharp object or by kicks or blows ; these injuries cause
very severe hemorrhage when the bulb of the vestibule is in-
jured. Hemorrhage is also incident to malignant disease of the
labia or clitoris, severe injuries of the vagina, or extensive lacera-
tions of the cervix. Interstitial endometritis, fibroid growths
encroaching upon the uterine cavity, and epithelioma, carci-
noma, and sarcoma of the uterus are frequent causes. Hemor-
rhage from the genital tract may also result from disease outside
of the canal which interferes with its circulation, as, inflamma-
tory exudate, cellulitis compressing the vessels of the pelvis and
interfering \vith the return circulation, displacements, extra-
uterine pregnancy, intraligamentary tumors of the ovary or of
the uterus, inflammation of the Fallopian tubes, chronic inflam-
mation of the ovaries, and constitutional conditions (as disease
of the heart, of the kidneys, or of the Hver) which affect the
circulation in the uterus. The circulation is very often tem-
porarily influenced by the development of zymotic diseases.
Severe uterine hemorrhage may occasionally usher in an attack
of typhoid fever. Disturbance of the process of gestation by
hemorrhage may indicate the occurrence of abortion or of pre-
mature labor, or may follow abortion or labor where the secun-
dines or portions of the placenta are retained.
1
570 GYNECOLOGY.
532. Diagnosis. — The determination of the existence of ex-
ternal hemorrhage, of course, presents no difficulty. It is exceed-
ingly important, however, that we should be able to recognize its
etiology and source. This will often be found a difficult ques-
tion. No physician does justice to his patient who permits her
to bleed without subjecting her to a careful examination in
order to ascertain the cause. Not infrequently patients will
object to the necessary examination. Such a patient should be
plainly given to imderstand that the physician can not continue
to treat her unless she affords him an opportunity to know the
existing conditions. He will do himself less injtuy by absolutely
refusing to treat the case than he will if he yields to the patient's
objection and endeavors to palliate an imrecognized disease.
Unfortunately, many patients have an idea that hemorrhage
at or near the climacteric is a condition to be expected, so if free
bleeding occurs at this period, they attribute it to the coming
change of life and continue to endure it. Members of the medical
profession, I find, are often responsible for this misconception,
for frequently they advise the patient that the bleeding is inci-
dent to her period of life, and that, therefore, when this has
passed over, the hemorrhage will cease. Such a statement,
however, only calms the patient and favors a transition from the
existing to another and perhaps more serious state. Moreover,
when the discoverv of the actual condition is made, the time for
radical measures has elapsed. The occurrence of hemorrhage
incident to local or constitutional conditions makes it incumbent
upon us to examine carefully every organ of the body to be
certain of its cause. In every woman who suffers from hemor-
rhage, where we are able to eliminate constitutional conditions,
and where we can discover no disorders in the tissues about the
organ or any disease of the cervix to explain the cause, the
uterine cavity should be thoroughly explored. The previous
histor\'' of the patient will enable us to ascertain whether the
bleedini:^ is due to tlie retention of products of a recent gestation.
Bimanual examination will generally reveal even small growths.
Such a condition will be manifested by localized areas of enlarge-
ment or resistance in the organ. Some of these gro\^i:hs, being
pedunculated, can be moved about in the uterine cavity to a
limited de,c:ree. Combined palpation also alTords information
as to the possibility of malignant disease. The latter occurs
more frequently in the cerv^ix, and when it exists in the body, it
causes more or less hanleninij and sense of resistance from the
presence of infiltration. This, of course, depends somewhat
upon the associated reactionary" inflammation. If the disease
involves only a portion of the lining membrane of the uterus
without the infiltration extending into the wall, the bimanual
GENITO-URINARY HEMORRHAGE. 571
examination will not reveal the induration. Therefore it will
be necessary to explore the uterine cavity, preferably with the
finger. The finger within the uterus and the hand over the
abdomen enables one to outline and definitely determine the
thickness and rigidity of the wall and the extent of induration
as well as the general condition of the uterine mucous membrane.
In the nonpuerperal uterus, however, one can not readily em-
ploy digital exploration of its cavity without a previous dilata-
tion. Dilatation may be accomplished by a variety of methods,
one of which is the employment of mechanical dilators or of
graduated bougies. This procedure affords an excellent oppor-
tunity for the employment of therapeutic measures within the
uterus, but sufficient dilatation of the organ can not thus be
secured to allow the introduction of the finger without tearing
and inflicting serious injury to the structure of the cervix. The
cervix may be spht on either side of the internal os with scissors
or knife, after which the canal can be dilated or stretched enough
to permit the introduction of the finger. Often this method of
procedure is associated with an extensive laceration of the uterine
structure, and, furthermore, incision of the cervix is too radical
an operation for mere exploration. It is only when it is neces-
sary to institute treatment for a threatening condition within the
uterine canity that we would advise cervical incision. Another
method of dilatation is that devised by Vulliet, which consists
in packing the uterine cavity with pieces of gauze until the cervix
becomes gradually dilated, and renewing this gauze packing
until the uterine cavity is so well dilated that the finger can be
readily introduced. This plan is open to the objections, how-
ever, that the gauze is an irritant, requires care that the patient
does not become infected during the progress of the procedure,
and in many cases, particularly when the cervix is the seat of
inflammation and is a httle rigid, the dilatation is ineffectually
accomplished.
The most effective method of dilating the cervix is accom-
plished by the use of tents. The tents may consist of sponge,
laminaria, or tupelo. Sponge tents are objectionable on account
of the difficulty of rendering them sterile and because of the fact
that they readily become impregnated with the discharges,
which quickly decompose and predispose to infection. This
danger has in some degree been obviated by the suggestion that
the tent be covered with a rubber sleeve, but this requires the
employment of special measures to convey the moisture to the
tent. The laminaria tents are exceedingly effective, preferably
those which are perforated. The tent should be carried into
I the uterine cavity without much force, the tent and the canal
having been previously rendered, as far as possible, sterile. As
I
I
0/2 GYNECOLOGY.
large a tent as can be introduced should be employed. When
the cavitv is somewhat dilated or when the first tent is not
sufficiently large, and we wish for more complete dilatation, a
number of tents or a nest can be employed. More rapid dilata-
tion is accomplished by pre\4ously moderately stretching the
canal with bougies. If aseptic precautions are observed, the
danger is not thereby increased. The details of the procedure
and the precautions to be exercised have been given. (Section
85.)
533. Treatment. — The treatment should be directed to the
disorder which has caused the hemorrhage. We may not, how-
ever, be ready, or the patient can not be subjected to radical
treatment, while the hemorrhage is so severe as to necessitate the
exercise of measures to save her life. Various remedies are
advocated for relief of hemorrhage — agents which exercise con-
tractile power upon the involuntary uterine mucous membrane,
of which ergot is one of the most efficient. It not only causes
contraction of the uterine muscle wall, but also decreases the
amount of blood that is sent into the uterus through the con-
traction of the uterine vessels. Thyroid extract and the extract
of mammary gland have been highly extolled. The various
astringents are of benefit, as gallic and tannic acids; dilute sul-
phuric acid ; iron salts, especially the persulphate of iron ; ham-
amelis; hydrastis and its salts, hydrastin and hydrastinin; and
the tincture of cinnamon. The latter may be given with good
effect in combination with either gallic or tannic acid, giving
from ten to thirty grains of the acid with a tablcspoonful of the
li(liii(l. Colarnin hydroclihjrate (stypticin), gr. ss-j every two
or tlircc hours, is frequently very effective in controlling hemor-
rliage. The patient should be kept perfectly quiet in bed; if
hemorrhage is severe, slie should be pre\'ented from rising even
to evacuate the bowels or t(D void the urine. Cold applications
may he macJe to the abdomen, and heat or a mustard-plaster ap-
plied between the shoulders, in carder to divert the current of blood
from tlie pelvis. Local applications of various astringents, such
as alum, zinc sulphate, hyrlrastis, or hamamelis, used in strong
solution or as a douche, may be employed. Douches of hot
water should be given the patient while in the recumbent posi-
tion, using water at from tio° to 115° F., even 120° F. if the
patient can bear it. A]')plications to the uterine canal by in-
jecting a few drops of perchLjrid of iron may be employed, or the
cavity may be swabbdl witli it. The objection to the injection
is that the uterine cavity will contract upon its contents, causing
contraction of the cervix, l)y which the contents are forced from
the uterine cavity into the tubes, and produce inflammation
within them, or, worse, a localized peritonitis. Gersterberg
GEKITO-URINARY HEMORRHAGE.
573
employs a strong solution of formol upon a cotton-wrapped
applicator. A solution of aluminium acetate has been advo-
cated. When hemorrhage is severe, endangering the patient
by its continuance, the uterine cavity sfiould be tamponed, by
packing a good-sized piece of gauze firmly into its cavity. This
prevents the further discharge of blood and facilitates the dilata-
tion of the canal until it can be explored. These measures for
the treatment of hemorrhage are merely palliative. They do
not correct the fault or the trouble which induced it; and the
earlier radical treatment can be instituted, the better it is for
the patient and the more readily is the condition controlled.
Slight bleeding from the vulva and vagina is readily controlled
by making applications of an astringent or a styptic, such as
persulphate of iron, directly to the diseased surface. The cavity
should be packed, in order to secure further improvement through
pressure. When bleeding occurs from an injurj- to the vulva,
the most efficient means is to enlarge the external injury and to
secure the bleeding vessel by ligation. When a large surface
bleeds, the hemorrhage is best controlled by packing with iodo-
form gauze, making firm pressure upon or into the wound.
When the bleeding is the result of incomplete abortion or the ex-
istence of an intra-uterine growth, the offending cause should be
removed. An interstitial endometritis should indicate the em-
ployment of the curet. Atmocausis, or the application of steam
to the uterine ca\'ity by a special apparatus, has had many ad-
vocates, but it would seem desirable to employ more controllable
measures, for it is impossible accurately to regulate the amount
of destruction to which the uterine mucosa will be subjected, and
definitely to equalize its distribution,
534. Vulvar Hematoma or Hematocele. — Vulvar hematoma
or thrombus is a term applied to hemorrhage which takes place
into the tissues of the vulva. It arises as a result of injury
sufficient to cause rupture of a vessel without a break in the in-
tegument. When the injury involves the bulb of the vestibule,
the hemorrhage may be extensive and cause a large-sized tumor,
which involves one or the other large labium. It also occurs
from rupture of \-aricose veins or from compression of vessels
during the progress of labor. The latter is the most frequent
cause. The tumor may attain the size of an orange or even of
the fist, and may be very tense and painful. It usually occurs
suddenly, and is associated with more or less burning and pain in
the region of the swelling while it develops. When the skin is
unbroken and the collection does not become infected, it may be
I completely absorbed.
535. Vaginal Hematoma or Thrombus. — This condition,
L complicated, is of rare occurrence. It is usually associated
ly be ^^H
with ^^^H
4
574 GYNECOLOGY.
hemorrhage into the vulvar tissue, forming a vulvovaginal
thrombus. It usually occurs upon one side of the vagina, and
is most frequently a result of injuries sustained during labor.
The exciting agent is the passage of the presenting part of the
child, which frequently pulls off and stretches the vaginal at-
tachments. This causes rupture of the vessels and severe
bleeding. The tumor may attain a very large size, compress
the vagina and rectum, and cause difficulty in micturition. The
physician may be in doubt, when called to see such a patient,
whether it is an accumulation of blood or a supptirative process.
The better plan of procedure is, of course, to make a careful
examination. With the history of the patient in mind, we may
be able to eliminate the probability of it being inflammatory,
especially when it occurs shortly after a confinement. During
the year 1898 I saw a patient, thirty-four years of age, three
weeks after her first confinement, who had passed through a
normal labor. She had, however, sustained a slight laceration
of the perineum, which was repaired. Two weeks subsequent
to her delivery she developed some elevation of temperature,
with more or less distress in the pelvis, and examination dis-
closed a large swelling which compressed the vagina and recttmi.
The mass thus formed was quite large; the right buttock was
edematous and the mass protruded into the vagina to such a
degree as greatly to obstruct it, as well as to encroach upon the
rectum. Sensation of fluctuation was indistinct. The right
buttock was so much more prominent than the left and the sen-
sation of elasticity, almost fluctuation, so marked that I decided
to incise through it and thus reach the mass, rather than to make
an incision from the vagina. The incision into the buttock,
however, disclosed that the swelling in it was entirely edematous.
Through this incision the levator ani muscle was opened, when
there was at once a discharge of a large quantity of bloody fluid
and clots. By pressure through the vagina the mass was readily
removed, and the patient looked and expressed herself as feeling
greatly improved. A gauze wick was passed through the wotmd
into this cavity with a view to insure drainage and to prevent
its premature closing. The gauze was removed at the end of
tw^enty-four hours, and the subsequent "[)rogress of the patient
was uninterrupted. Another case of this kind came under my
observation in a young woman wlio had been delivered by
forceps. The right side r)f tlic peh'is was apparently occupied
by a large clot, wliich bulged into tlie vagina, protruded into
the labium, and gave rise to suggillatifm of the entire buttock.
This mass was incised froni tlie vagina and it was found to extend
up into the broad ligament of tlie right side. The clot was
thoroughly turned out and tlie cavity packed with a large quan-
GENITO-URINABY HEMORRHAGE. 575
tity of iodoform gauze. The patient recovered. I have ob-
served one case of vaginal hematocele in which labor was com-
plicated by an ovarian dermoid. The union of tMs growth with
the uterus had been destroyed by previous torsion. The tumor
subsequently became engrafted upon the omentum, from which,
by a broad band of adhesion, it evidently received its nutrition.
It was attached below by folds of the peritoneum, which ex-
tended over and to the left of the bladder. In the latter fold,
dipping dovra into the pelvis in front of the bladder and vagina
and to the left of the latter, was an extensive collection of clotted
blood, which had evidently been produced by pressure upon
the inferior attachments of the tumor during the progress of
labor.
536. Diagnosis. — Vulvar hematoma is likely to be confounded
with edema of the labium and with labial tumors. Its devel-
opment, however, is too sudden for the latter condition. Edema
of the labium is generally associated with other disorders. It is
not one-sided. Both labia are involved unless the edema is due
to some special cause, in which there is obstruction of vessels
or lymphatics on one side only. Vulvar and vaginal thrombi
are usually associated, producing the condition already de-
scribed as vulvovaginal thrombus. The condition generally
follows difficult or complicated labors. Pus-collections are
rarely found in the lateral walls of the vagina, but are most fre-
quently pushed into the vagina from the posterior fornix.
Thrombi, on the other hand, are frequently found upon the
lateral surface and rarely affect the posterior vagina! wall.
537. Treatment. — The amoujit of bleeding in these thrombi
is usually limited, for the pressure of the tissues into which bleed-
ing occiu-s naturally controls it. In noninfected cases the
extravasated mass is ultimately absorbed, although in large
collections it may remain for quite a long time. A patient
recently came under my observation in whom an operation
was required for pelvic inflammation. On examination, a
mass was felt posterior to the rectum, in the neighborhood of
the sacrococcygeal articulation, which had an elastic sensation.
Upon inquiry, I found she had undergone her first labor six
months before, with a history of an injury to the coccyx. The
coccygeal injury had, however, disappeared ; the mass remained.
As I had already made an incision through the vagina into the
peritoneal cavity, I did not care, therefore, to attempt to open
into this from the vagina, on accoimt of the dissection required
around the rectum. An incision was made into this sac pos-
terior to the anus, when a teacupful of thick, pasty, reddish
material, evidently the remnants of the clot, was evacuated.
Gauze drainage was instituted, and the cavity gradually closed.
576 GYNECOLOGY.
When the collection is small, it may, without detriment to j
the patient, be left to nature; but when large, the pressure
produces thinning of the enveloping wall and permits the ready
introduction of infecting germs, either from the rectum or
the vagina. In such collections the danger of subsequent ■
infection is decreased by free incision and the evacuation o!
the accumulation. Not only should the clots be removed,
but measiues must be employed to preclude further hemon-hage. \
A large bleeding vessel may be seciu*ed by passing a ligature
beneath or about it with a needle. When ligation is impractic-
able, hemorrhage should be controlled by packing with icKiofonn
gauze. The gauze should be retained for two or three days,
and should be renewed with a smaller amoimt, in order to keep
the external wound open long enough for the cavity to imdergo
thorough contraction.
538. Peri-uterine hemorrhage may be intraperitoneal or
extraperitoneal. Intraperitoneal hemorrhage, tmless preceded
by inflammatory adhesions which form limitations, is free, and
may be large in quantity. Extraperitoneal hemorrhage takes
place into the cellular tissue about the uterus and the broad
ligaments, and is limited by the pressiu*e of the tissue. Hemor-
rhage into the cellular tissue beneath the peritoneimi under-
goes coagulation and forms a bloody ttunor, known as a hemato-
cele. It is analogous to the thrombus which occtirs during
the progress of labor, and which we have described tmder the
term vulvovaginal.
Hemorrhage into the peritoneal cavity will form a coagulum,
and subsequently a tumor, or, when very free, may remain
liquid and the hemorrhage continue imtil the death of the
patient or until surgical intervention is practised.
539. Causes. — The causes may be divided into two classes:
first, hemorrhage that results from extra-uterine pregnancy,
which is more important, because more frequent and more
serious in its restilts; second, hemorrhage of nonpuerperal
origin, which occurs without the existence of fecundation.
The pelvis being the most dependent portion of the abdomen,
hemorrhage from any of the intra-abdominal viscera, or within
any portion of the peritoneal cavity, naturally gravitates into
the pelvis. Thus, we may have intra-abdominal hemorrhage
from traumatic injtuies of the liver or spleen, rupture of an
aneurysm of the aorta or of the celiac axis, rupttu'e of varicose
veins, from the ovar^^ regurgitation from the Fallopian tube of
menstrual blood (particularly when there is obstruction of the
uterine neck), rupture of a uterine or tubal collection, rupture
of bands of adhesion in the pelvic peritoneum, slipping of a
ligature, or the retraction of a cut vessel following an opera-
GENITO-URINABY HEMORRHAGE. 677
Any of these causes may lead to an accumulation of
i in the pelvis or, particularly, in Douglas' pouch, whereby
! intestines containing gas are floated up and the uterus is
ihed forward. Soon or later the coagulated blood causes
ation and leads to the formation of adhesions, by which
i collection may become encysted and form what is known
an intraperitoneal hematocele. (Fig. 438.) The most fre-
nt cause, however, belongs to the division of the puerperal
r «3ttra-uterine.
540. Sjrmptoms, — Intra-abdominal hemorrhage from what-
■ site or cause, unless limited by previous adhesions, will
avitate into the pelvis. The gravity of the symptoms will de-
Fig. 438, — Intraperitoneal Ht-morrhagi
pend upon the size of the vessels injured ani.1 the rapidity of the
nemorrhage. The rupture of the vessel is generally associated
*ith pain in the vicinity of the lesion. This sensation may be
intense cutting or burning. If the hemorrhage is slight, it
*nay be slow and produce little if any constitutional evidence.
When severe, the symptoms of shock are profound and may be
Sonounced by severe, agonizing pain, accompanied by syncope
W repeated attacks of fainting. The skin is pale, covered with
■■cold, clammy perspiration, the pupils are widely dilated, pulse
feble, frequent, or absent in the radius. The mere effort to raise
the head may lead to unconsciousness. The temperature is sub-
"Jonnal. The syncope may be associated with such reduced
578
GYNECOLOGY,
arterial tension that a clot is formed, which obstructs the bleed-]
ing vessel and becomes so firmly fixed that as the patient
the hemorrhage is controlled. The salts of the blood so i
the peritoneum that a mild grade of peritonitis results, wtoAl
leads to the collection becoming encysted. The watery portioM]
of the blood are absorbed and the clot may gradually becowl
organized and result in thickening of the peritoneum and ad«|
hesions as the only traces of its occurrence. More frequentlfl
the condition from which it has originated, or the stagnation fiwi
the imprisoned intestinal coils, leads to infection and the for-
mation or a peine
abscess. Unloi
such a condition t
. - ^IJ ''~\.' ^— ■ promptly evant
/ ' ^^^. ^ ^.^BfliBfl ^teA, general infec-
Z' I V^r *> .^^^I^^H: tion may follow.
— Extraperitoneil
hemorrhage result'
ing in the fonnatkB
of a hematocele may
be produced 1^
puerperal or nofr
puerperal causei
(Fig. 439-) "nj;
former, associated
with ectopic gesU-
tion, are the more
frequent. The
puerperal causes are
the rupture into the
broad ligament rf
varicose veins, and
injury of an artery or its retraction from the stump when the
pedicle is ligated en masse.
542. Symptoms. — Extraperitoneal hematocele in the broad
ligament is limited in its character, and causes symptoms similar
to those which have already been enumerated for the int»-
peritoneal \-ariety, tliough in a much slighter degree. The
indications of shock and collapse are much less marked, aod
hemorrhage, from its limitation, is much less serious in it*
influence. i\s it occupies the broad ligament, it is usual^
situiited upon one side of the pelvis, and pushes the utenc
to the opposite siile. This hemorrhage may be situated either
in the upper part or in the base of the broad ligament, aiw
;. 439. — Extraperitoneal Hi
GENITO-URINARY HEMORRHAGE.
niay produce different physical signs according to its situation.
The hemorrhage, when low in the broad ligament, may dis-
sect forward between the uterus and bladder, or backward
around the uterus beneath the peritoneum, and extend to
the opposite side. In the great majority of cases, however,
extraperitoneal hemorrhage is one-sided.
543. Diagnosis. — Peri-uterine hemorrhage, wliether intra-
peritoneal or extraperitoneal, is determined by the phenom-
ena of internal hemorrhage. It is true that similar symp-
toms— a sharp pain, symptoms o£ collapse — might arise from
rupture of a pyosalpinx or a pelvic abscess. In such accidents,
however, acute agonizing pain is caused, with symptoms of
peritoneal reaction which are more intense than when from
the hematocele, but a tumor does not form. A retroflexed
gravid uterus may be mistaken for hematocele, but the out-
line of the boundaries of the organ are more definite than those
found in hematocele. In the latter the uterus is frequently
inclosed within a mass or pushed forward, while by a careful
examination in a retroflexed gravid uterus the cervix is found
at a higher level, either in the axis of the vagina or looking for-
ward; a distinct angle exists between it and the smooth, definitely
outlined mass filling up the pelvis, which should not be confounded
with hematocele. Ovarian cysts and uterine fibroids imprisoned
within the pelvis possess nothing in common with hematocele.
The manner of appearance and the course of development of
the condition are entirely different. Extra-uterine pregnancy
before rupture does not present similar symptoms, although it
may be a starting-point for the later hemorrhage, and imless
the examination is carefully performed, rupture may result from
the methods used for diagnosis. Extraperitoneal hemorrhage is
determined from intraperitoneal by the situation of the collec-
tion upon one side, which is more definitely localized, its boun-
daries more sharply defined, and the uterus generally pushed to
the opposite side, while in the intraperitoneal hematocele the lat-
ter is surrounded by tlie accumulation or is pushed forward.
The determination of the cause of the hemorrhage is not always
easily accomphshed. Pre\'ious symptoms of pregnancy, amenor-
rhea, with symptoms rapidly ushered in, profound depression.
and very marked anemia, should lead to the suspicion of probable
rupture of a fetal sac. Symptoms of collapse or depression, of
internal hemorrhage, may arise from rupture of internal \'aricose
veins. In hemorrhagic salpingitis the condition is more insidi-
ous, the progress more slight, owing to the gradual effusion of
blood. Should there be any doubt of intraperitoneal hemor-
rhage, the true condition can be surely determined by making
580
GYNECOLOGY.
an exploratory puncture through the posterior vaginal formt
This is a justifiable and commendable procedure.
544, Prognosis. — The affection is always a serious oot
We can not be certain that death may not suddenly leaiJ
from a continiiation of the hemorrhage, or, when hemorrl
has apparently been arrested, that the clot may not be loosenei
and hemorrhage again recur. In large collections the
of the case is exceedingly tedious. Plastic material remaifll
about the uterus for a long time, becomes more or less organized,!
is frequently a source of discomfort, and often a cause of sterility.
That sterility is not invariably caused is evident from the numer
ous cases recorded in which women have suffered from he
cele. in whom the collection is tdtimately absorbed, and
patient again imdergoes an ectopic gestation, and the experienci
is repeated. The presence of a large collection of blood witha
the pelvis is a source of continuous danger, from its close proi-
imity to the vagina and recttmi, through either of which chaih
nels infectious material may enter, to cause pelvic suppuratioiL
Suppuration is particularly likely to occur if the individual hit
had previous tubal disease, from which, doubtless, the infectioft
develops. The extraperitoneal variety is less serious in its in-
fluence, much more likely to imdergo absorption, and leavei
less evidence of its previous existence. Its situation rendcft
it less susceptible to infective changes. When the collectioi
is large, however, and has existed for some time, the patiert
will, without question, have a more favorable prognosis hf
the exercise of measures for its removal.
545. Treatment, — Active interference must depend very mudi
upon the character of the symptoms and the severity of the
attack. WTien the symptoms are such as to indicate escape
of a large quantity of blood into the pelvis, the abdomen shodd
be opened promptly, clots removed, and the bleeding vessd
secured. In profuse internal hemorrhage ligation of the bleed-
ing vessel is just as certainly indicated as in hemorrhage froffl
the radial or femoral artery. When hemorrhage has apparently
been arrested and a reactive peritonitis develops, we are not
absolutely certain that the clot can not be displaced and the
patient suffer from a recurrence of hemorrhage, which tmj
be fatal, or that the collection of fluid about which nature is
forming its barriers may not become infected from the neigh-
boring hollow viscera and cause subsequent changes, necessitat-
ing its evacuation, with increased danger to the patient, b
extraperitoneal hemorrhage the indications for operation are
not so marked. The symptoms are much slighter, the amount
of exudation is less, and the probabilities of infection are dimifl-
ished. In such cases we can afford to wait and trtist to nature
r<
GENITO-URINARY HEMORRHAGE. 581
to absorb the effused fluid. In large collections, however,
much time will be saved by its evacuation. The method of
operative procedure vjill depend upon the time the condition
comes under observation. In an acute attack, and ■with an
evidently bleeding vessel, we should follow the procedure which
affords the most accurate and complete exposure, with the
most ready access to the field of hemorrhage. Abdominal
incision meets every indication, as through it we are enabled
to see and to reach the bleeding vessel. WTien the patient.
however, comes under observation a week or more subsequent
to the hemorrhage, when the peritoneal reactive processes have
resulted in the blood becoming encysted, and vaginal and
abdominal palpation discloses that barriers have been formed
by plastic exudate between the knuckles of intestine over the
surface of the hematocele, the vaginal incision is the preferable
procedure, This procedure is preferable for the reason that
it respects the barriers which nature has constructed to limit
the collection, and affords a free opportunity for the evacuation
of the clots. They are removed by the finger and by irrigation.
With gauze packing and a free vaginal incision the subsequent
progress of the case is much less severe and the length of the
convalescence is decreased. When blood has been effused
into the peritoneal cavity and clots have formed, by neither
the abdominal nor the vaginal method wotild we be able to
remove all the clotted blood. The clotted material remains
adherent to the sides of the sac and pelvis, and is likely in either
procedure to cause a certain elevation of temperature as a result
of the fermentation taking place in the retained fibrin. When
the condition has gone on to suppuration, there should be no
question as to the preferable procedure of reaching the collec-
tion, when accessible, through the vagina, rather than by the
abdominal route. It should be remembered that not all cases
of internal hemorrhage are necessarily fatal nor require opera-
tive procedure. If the patient is unwilling to undergo an
operation, or the conditions do not urgently demand it, the
promotion of absorption should be accomplished by keeping
the patient absolutely at rest in bed, by the use of the catheter
to empty the bladder, and by the evacuation of the bowels
or intestines by enemas. Absolutely interdict the use of
opium, keep the vagina antiseptic by repeated douches, and
when it is supposed that hemorrhage still continues, or that
it is in danger of being renewed, apply an ice-bag o\-er the
abdomen, introduce ice suppositories into the rectum, and thus
bring the ice in close contact with the bleeding vessels. In
extraperitoneal hemorrhage indications for operation are much
I marked. The absorption may be promoted by keeping
582 GYNECOLOGY.
the bowels regular and the patient at rest, and by the applica-
tion of cold over the abdomen or of counterirritants. When
operative interference seems indicated, the preferable procedure
would be to make an incision through the vagina into the broad
ligament, tear with the finger or a blunt instrument through
the tissue of the ligament until the hematocele is reached, then
enlarge the opening, turn out the clots, irrigate the cavity,
and introduce gauze to afford vent for further discharge. When
the collection is very large, it may sometimes be evacuated by an
incision above Poupart's ligament and pushing back the perito-
neum, the collection exposed, opened, and evacuated. After the
cavity is thoroughly emptied, it should be packed with gauze,
as already advised.
EXTRA-UTERINE PREGNANCY.
546, Definition. — When the fecundated ovum does not reach
its normal situation, — the uterine cavity, — but undergoes develop-
ment external to it, the condition is designated ectopic gesta-
tion or extra-uterine pregnancy. Much difference of opinion
exists as to the point at which the union of the spermatozodn
and the ovtmi, and its consequent fecundation, takes place.
Tait very firmly asserted that in the normal condition this
fecundation always occurred in the uterus. Others as em-
phatically believe that fecundation may occur at any point
between the internal os and the exit af the ovum from the
Graafian follicle. The recognition of the fact that in the lower
animals the spermatozoa in normal conditions are foimd in con-
tact with the ovary would seem to afford justification for the
belief that fecundation does not absolutely occur within the
uterine cavity. Fecundation in the majority of cases un-
doubtedly occurs in the tube, but may occur at any point in the
progress of the ovum to the uterus. The changes which follow,
as a result of fecundation, produce alterations in the uterine
mucous membrane which prepare it for the reception of the
fecundated ovum.
547. Causes.— ]\Iuch difference of opinion still exists as to
the causes which lead to the occurrence of a misplaced ges-
tation. Some would deny that inflammation has any part in
its production, and would lead us to believe that the existence
of inflammation in the tube always produces alterations which
preclude the subsequent occurrence of pregnancy. Every ab-
dominal suri^eon of anv experience, however, has seen cases
in which well-marked tubal disease, and frequently of evident
gonorrheal origin, has subsequently recovered, and the pa-
EXTRA-UTERINE PREGNANXY.
583
tients have given birth to children. During the active inflam-
mation of such tubes the abdominal orifices are closed ofE by
exudate, which, during the following resolution, may be reab-
sorbed and afford an entrance to the tube. Those who exclude
inflammatory conditions as a cause attribute the occurrence
of ectopic gestation to congenital conditions. These consist
of long tortuous tubes containing numerous tubal constric-
tions, and, especially, a tubal diverticulum. It is also attributed
to intratubular growths, which limit the caliber of the canal,
or to growths in the tubal wall, or to pressure of growths ex-
ternal to the tube. The hypothesis of the migration of the ovum
from the ovary of one side to the tube of the opposite side
has been well established. As evidence, a history is recorded
in which an intra-uterine pregnancy occurred in a woman who
had lost the tube of one side and the ovary of the opposite
side. It has been supposed that the ovum, having become
fecundated upon its emergence from the Graafian follicle, attains
too great a size before it reaches the tube of the opposite side
to permit of its passage down that canal. The vegetations
upon the ovum, however, which form the chorion, do not develop
until the oi-um has come in contact with the tubal mucous
membrane, hence this cause is of doubtful application. Every-
one familiar with poultry is aware that occasionally an unusually
large egg will be laid. Indeed, I have seen cases in which the
egg was too large to pass through the canal. It is not improb-
able that similar conditions exist in the formation of the ov\im,
and that, occasionally, an oversized fecundated ovum may
lodge on its way to the uterus. Fright and emotional conditions
at the time of conception are ascribed as causes. Were the
latter, however, an important factor, tubal gestation would
be likely to occur much more frequently in illegitimate cases.
The study of the history of ectopic gestation long ago led
to the recognition that a misplaced gestation was frequently
associated with prolonged sterility. It is not unreasonable
to believe that a period of sterility has been one in which in-
flammatory conditions have existed and which have subsequently
improved. Investigations of inflammatory conditions disclose
the fact that loss of the tubal epithelium is of rather rare occur-
rence. The existence of the gestation is due, not so much to
the presence of patches of desquamated epitheUum. as to in-
.flammatory changes which cause the canal to become narrowed,
the folds of the mucous membrane thickened, thus rendering
the passage of the fecundated ovum more tedious than under
normal conditions. The expedition of the ovum to the uterus
is also retarded by the decreased peristalsis resulting from
hyperplasia and loss of activity in the muscular wall. Gon-
584 GYNECOLOGY.
orrheal inflammation seems to have a special influence in 4e
production of ectopic gestation. Thus, Prochownik fcpund
gonorrhea in three out of eight cases, and Ahlfeld, in the fw
cases he has observed, also attributes the condition to goner-
rheal infection. Ekitopic gestation may occur at any penrf
of the reproductive life, as in a first pregnancy or in
who have borne a number of children. Analysis of a laip
number of cases will show that several years of previous steriBtr
will occur in the majority of cases. It may occur inthefirS
pregnancy of a woman who has been married eight, ten, or twenty
years, in a woman who has not given birth to a child for five w
six years; or, again, it may follow immediately after a labor oi
abortion. Furthermore, it may occur in the newly made bride oi
in the urmiarried. Both tubes may be pregnant concumnlly
or one tube may contain a tubal pregnancy or a tubal may com-
plicate a uterine pregnancy. Cases have been reported inwliich
-Tubal Pregnancy.
there occurred a twin pregnancy in the outer portion of the tube,
and an interstitial or single pregnancy in the uterine end, maldoj;
three embryos in the one tube. Dr. Wilmer Knisen has reported
a tubal pregnancy which hadruptured, and in the sac three fetus«
were found .
548. Varieties. — Ectopic gestation is most frequently found
to be of the tubal variety. Some undisputed cases of o\ariaD
pregnancy have been described , but when we consider the fecun-
dated ovum and the conditions necessary' for its nutrition and
development, it is evident that the ovum rarely develops what
not in contact with the Miillerian mucous membrane. It is
quite probable that many of the cases described as o-\-arian prfg-
nancy have been originally tubo-ovarian and have become
separated from their tubal relation. Tubal gestation ocettis
most frequently in the central portion of the tube. (Fig. 44o)
It may be situated toward its abdominal end, and as it <i^
EXTRA-UTERINE PREGNANCY.
585
■Tdops, is extruded or partly extruded and comes in contact with
rfle ovary, when it is known as tubo-ovarian pregnancy. (Fig.
>44i.) When situated within the central portion of the tube
V ampulla, it is known as ampullar or tubal pregnancy. To-
"■ard the uterine end, or that portion which passes through
tte uterine wall, it is known as tubo-uterine or interstitial
lir^naiicy. (Fig. 442.) Rupture of a tube with partial escape
Pregnancy.
«f the ovum, which retains its placental attachment, may sub-
sequently develop, when it becomes an abdominal pregnancy.
Abdominal pregnancy, therefore, is secondary and not primary.
The reimplantation of the ovum upon the peritoneal surface
and its subsequent development have been asserted to be an
impossibility, but when we find the tube having no longer any
Fig. 441.— Tubo-
Interstitial Pregnancy,
Relation or connection with the sac, the placenta situated, as
m the case of Tuholske, upon the liver, and apparently upon
*lie folds above it, it seems impossible to explain its occurrence
"pon any other ground than that of reimplantation,
549- Course and Progress. — The fecundated ovum lodged
^ Uie tube finds a condition different from that of the ovum
within the uterine cavity. In the latter, the mucous membrane
586 GYNECOLOGY-
consists of glandular or lymphoid tissue, which becomes thickened 1
as a preparation for the reception of the fecundated ovum, in |
which the trophoblast cells of the ovum enable it to ank in
and become embedded. The syncytial cells in the choiica
arise from the trophoblast cells, and the uterine epithelium
in no sense plays any part in their production. In the tuhe it
meets with an entirely different condition. There are no glands,
and there is much difference of opinion as to the formaticio
of the decidua. This, in the uterus, consists of a compact and
spongy layer, but in the tube, of a compact layer only. The
decidua cells are found not so much in immediate contact with
the wall of the tube as at either end of the sac. Bandler, in )si
investigations on the development of ectopic gestation, divide
it into three types: (i) The columnar type of tubal gestation;
(2) the intercolumnar ; and (3) the centrifugal, fi) In the
columnar variety, at no point in the tube wall or in the mucosa
Fig, 443. — Tubal Abortion.
is there any decidual change or any condition representing the
trophoblast cells or villi, consequently no decidua or tropho-
spongia develops. The ovum is surrounded by mucous folds
and only an invasion of the tubal capillaries foDows. Abor-
tion in these cases is easy and causes but little danger; bleeding
occurs; the fetus dies, and further hemorrhage expels it. The
tube may subsequently become normal or a hematosalpinx
may follow. (Fig, 443.) (2) In the intercolumnar type one-
half of the tube is normal, the other torn and infiltrated, the
mucous folds are involved down to the muscularis. The ovuin
is situated upon the tube wall, where it compresses and destroys
the folds at the situation known as the serotina. These folds
are united at either side about the ovum, forming a pseudo-
reflexa. Some distance on either side of the serotina, tissue
resembling decidua, with closely grouped cells without capil-
laries or spaces, rests upon and invades the free surfaces. Jbe
EXTRA-UTERINE PREGNANCY. 587
avasion traverses the mucosa in irregular branches or pro-
€ctions about the blood-vessels, invading and infiltrating
'heir muscular walls up to and into the lumen. Trophoblast
seDs are accompanied by syncytitim, but at no point do the
jonnective -tissue cells, the tubal folds, or the delicate sub-
Ducosa, if present, exhibit any evidence of change which re-
embles in the slightest degree those occurring in the uterine
micosa, from which the decidual cells develop. Neither is there
It any point any change of a so-called syncytial character.
rhe ovum rests upon the wall, and the tubal fold immediately
aeneath it will be compressed, but the epithelium may remain
in the depressions. Other folds may form a capsularis, which
consists of mucosa alone. An intervillous space may develop
when the capsularis is formed. The villi at the placental site
enter the wall, and hemorrhage follows, especially upon the
invasion of vessels of the capsularis by fetal cells. The preg-
nancy may terminate in abortion, complete or incomplete,
the latter usually being the rule. If the abdominal end is
closed, a hematosalpinx or tubal mole may follow. (3) The
syncytial type. In this the tissue of the tube is invaded by
villi cell groups — syncytial cells. Here again there is no evi-
dence of a decidua or of any decidual reaction. When unin-
terrupted, the capstdaris unites with the mucosa of the envelop-
ing tube wall in the same way that this process is exemplified
in the uterus. The centrifugal ovum sinks into the wall of
the tube, when invasion of the wall and vessels by the villi
otxjurs. Rupture may take place at the summit or hemorrhage
from invasion of the vessels entering into the intervillous spaces.
Bleeding from the villi penetrates the serosa and rupture at
the placental site may follow, or we may have multiple per-
foration and erosions. The ovum apparently eats up the tube
wall and its destruction is not the result of pressure. In such
cases the perforations may be so minute as only to be revealed
hy a microscope. The death of the ovum may not arrest the
growth of the villi. This form furnishes the majority of cases
of mpture. Very frequently the hemorrhage is due not to
nipture, but to the erosions from the perforating villi. The
presence within the tube of the developing ovum causes the entire
ftructure to become turgid and vascular. There is some tendency
^ the tube to the development and extension of its structure,
l^t to a much less degree than in the uterus. The wall becomes
•tetched, attenuated, and thin. The mucous membrane is
•fetched and its folds effaced. As the tubes vary in length
^ thickness, the rapidity of thinning correspondingly differs.
T^en the ovum is situated in the outer third, changes follow
^ the ostium. In the first four cases the fimbria are swollen,
588 GYNECOLOGY.
tiirgid, and the congestion extends to the adjacent muscular
and serous tissue; the fimbria are gradually retracted, whik
the peritoneal margin of the ostitun forms an irregular ring,
which in four and one-half weeks projects beyond the ends
of the fimbria. It finally contracts, and at the end of the eighth
week is completely contracted and hermetically sealed. The
occlusion, however, is not constant. Occasionally the ostium
dilates. The nearer the ovum is situated to the abdominal
end, the less likely will it be to become closed. As the tube dis-
tends, its vessels rupture and hemorrhage takes place, which fills
up the sac and may cause the extrusion of the ovum. The
more firmly the tubal end becomes occluded, the greater the
danger of tubal rupture. Its situation near the abdominal
ostium favors its extrusion through the opening into the ab-
domen as a tubal abortion. Moles occur in tubal as in uterine
gestation; indeed, they are more frequent in the former. They
vary from one to eight centimeters in diameter and are glob-
ular or ovoid, assuming the latter shape in the larger varieties.
The tubal moles are formed by hemorrhage, which occurs in the
subchorionic diameter, between the chorion and the amnion.
This hemorrhage may be gradual or sudden, and results in
the death and often in the disappearance of the embryo. The
puerperal origin of the condition in the absence of any vestige
of the fetus is recognized by the discovery, with the micro-
scope, of the chorionic villi. The outer investing membrane,
the chorion, is generally shaggy, with villi, which are rendered
more visible by washing the clot im.der a gentle stream of water.
When the amniotic cavity is obliterated, doubt may exist
as to the character of the mass, but section will disclose the
villi in clusters as small circular bodies. Tubal abortion has
been mentioned as one of the terminations of tubal gestation,
when the developing embryo occupies the external third of
the tube. The nearer the fecundated ovum is situated to the
ostium, the greater the danger of its extrusion. As the em-
bryonal sac increases to a size beyond that which the tube is
able to accommodate, it is pushed out through the ftinnel-
shaped cavity and escapes into the abdomen. This accident
is denominated tubal abortion, and is frequently associated
with profuse hemorrhage, which is very similar to that which
occurs in uterine abortion. The mole is discharged vnth copious
hemorrhage into the peritoneal cavity. This displacement is
likely to take place during the first two months of the preg-
nancy. When the ostium is closed, blood escapes from the tube
only after rupture of the sac. The quantity of blood discharged
is sometimes enormous and attended with all the s\'TTiptoms
of internal hemorrhage. This condition is one of the most
EXTRA-UTERINE PREGNANCY. 589*
•
icequent causes of pelvic hematocele. Internal hemorrhage
n such cases has been ascribed to metrorrhagia, to reflex men-
itrual discharge from the uterus, or to hemorrhage from the
Pkllopian tube. The reason why it has been associated with
metrorrhagia is that while the embryo is developing in the tube
I decidua is forming in the uterus. With a tubal abortion,
hemorrhage occurs from the uterus as a result of the separation
lad the expulsion of this decidiia. This not infrequently
happens near the time the patient expects to menstruate, and
iSy consequently, regarded as reflux menstrual fluid. Very
frequently the bloody discharge from the uterus may be derived
from a gravid tube in protracted tubal abortion. If the bleed-
ing occurs at a time not synchronous with the menstrual flow,
it is often attributed to a disorder of the uterus. In all such
cases the affected tube and the bloody discharge should be
carefully examined for the presence of the embryo or the chor-
ionic villi. The abortion may be complete or incomplete-
complete when the embryo and its envelope are discharged;
incomplete when a portion remains attached to the tube. The
latter is the more common. The danger is increased in these
cases, owing to the fact that the bleeding is apt to recur while
the mole is retained. The villi will be disclosed by careful
microscopic examination of the extruded mass and are dis-
covered in sections of the adherent pole of the mass.
A third termination of tubal gestation is that of rupture.
As the embryo develops, the tube becomes more and more
thinned, until it is no longer able to resist the inward pressure,
and rupture results. Rupture of the gestation sac may be
considered under: first, primary rupture; second, secondary
rupture — each of which may be intraperitoneal or extraperi-
toneal. Primary rupture takes place at any time between
the third and tenth weeks after impregnation, and is rarely
deferred beyond the twelfth. Predisposing causes of rupture
are the gradual thinning of the gestation sac by the growth
of the ovum or the undue distention of the membrane by
hemorrhage, especially at the seat of implantation of the chori-
onic villi. The perforation of the tubal wall by the villi
way be excited by violence, as jumping from a train, strain-
ing at stool, jarring of a carriage, vomiting, or sexual congress.
Rupture may occur as a result of efforts to determine the diag-
nosis.
It was my misfortune to see a case of this kind in which
^ examination by myself, and subsequently by the attending
physician, was followed within a few minutes by symptoitis
^ profound collapse, which confirmed the suspicion that an
*^ra-uterine pregnancy was present. As soon as permission
590 GYNECOLOGY.
could be secured the abdomen was opened, to find half a gallon
of liquid blood within it ; and although the vessel was secured,
and every measure taken to restore the patient, she succumbed
to the shock.
The tube is enveloped in two-thirds of its ciraunference
by the peritoneum, which forms a mesosalpinx; as the tube
is enlarged by the developing embryo the mesosalpinx sepa-
rates. This condition is true only of the internal two-thirds
of the tube. The external third is not supplied with the meso-
salpinx. The intraperitoneal rupture is three times as frequent
as the extraperitoneal. In primary intraperitoneal rupture the
embryo and its enveloping membranes, or a mole, are dis-
charged into the abdominal cavity, and a certain amount of
hemorrhage follows. The amount of blood extravasation
will depend upon the period of pregnancy when the rupture
occurs; when early, it may be slight. After the first month,
however, it is copious — frequently sufficient to cause death
in a few hours. I saw one patient who had missed her period
but five days. She was taken with violent pain at night, fainted
several times, and was seen and subjected to operation the
following morning. She was then extremely anemic, and the
abdomen was found filled with a large quantity of blood,
which had escaped from a cyst not larger than a bean in the
left Fallopian tube. The ligation of the bleeding vessel and
the removal of the extravasated blood resulted in her restora-
tion to health. Frequently the hemorrhage may be so great
as to cause a fatal result in a few hours; in some cases even
in half an hour. When a rupture is deferred until the seventh
week, the embryo or mole is not constantly discharged through
the opening. The quantity of blood which escapes may be
very large, and demand immediate attention, or it may be
sUght in character, permitting the patient to escape the im-
mediate dangers incident to the accident with but sHght shock.
The effused blood can undergo absorption and recovery ensue.
When the discharge is not excessive, the blood collects in the
rectovaginal fossa and floats the coils of intestine, forming an
intraperitoneal hematocele, as has been described. Dangers of
the primary intraperitoneal rupture are: first, hemorrhage
so great as to cause immediate death; second, the fatal result
may be occasioned by repeated hemorrhage. In primary
extraperitoneal rupture that portion of the tube not covered
by peritoneum gives way and permits the discharge of the
ovum and the accompanying blood between the layers of the
mesosalpinx. Here the blood is forced into the connective
tissue between the layers of the broad ligament, and, fortu-
nately for the patient, the bleeding is checked by the pressure
EXTRA-UTERINE PREGNANCY. 591
^tom the resisting tissues, and is generally arrested before it
assumes dangerous proportions. This lesion rarely causes
"trouble. Occasionally, the rupture of the tube is slight, the
embryo partly escapes, with its membranes remaining un-
injured, and the pregnancy will continue. Rupture affords
increased space for fiuther development, and, the power of
resistance being decreased, the ovum, as it increases in size,
borrows between the layers of the broad ligament. The rup-
tore may be gradual; the tube does not split suddenly, but
as its walls, through the gradual distention, become thinned,
ihey yield in the part uncovered by peritoneum until an open-
ing forms and the ovum is extruded, accompanied by sudden
hraiorrhage. The extent of collapse and its duration will be
higely dependent upon the amotmt of blood effused. The
artificial opening gradually extends, the embryo and placenta
make their way into the new area, and, unless the hemorrhage
be sufficient to terminate the life of the embryo, the pregnancy
IS continued. This is known as a mesometric or an intraliga-
mentary gestation. In this anomalous development of the
ovum the placenta is liable to many changes which will vitally
influence the life of fetus and mother. The tubal mucous
membrane, as has been mentioned, plays a very insignificant
part in the formation of the placenta. The latter is developed
mainly from the fetal tissues, as the tube does not develop a
decidua. With the fecundation of the ovum there are at once
developed changes in the uterine mucosa in preparation for
its retention and sustenance. When the fecundated ovum
is arrested in its progress and prevented from entering the
uterus, the uterine decidua continues to develop as if it were
normally placed. This decidua, however, is rarely retained
until the completion of gestation, but is thrown off during
the false labor; not infrequently, when the individual suffers
6x)m symptoms of tubal abortion or tubal rupture. The oc-
currence of this profuse bleeding after one or two months' amen-
orrhea, with the discharge of a cast or of shreds of tissue from
the uterus, which may frequently be enveloped in a large clot,
leads the patient and her attendant to believe that a uterine
abortion has occurred. When the individual goes to term,
the uterine decidua is thrown off as a cast or in shreds during
the early months of the pregnancy. When the decidua is
discharged in small fragments, it takes place without unusual
pain; but en masse, the symptoms are similar to those of a
miscarriage. The absence of the uterine decidua at the death
of the oviun from rupture of the cyst, even in the early stages
of pregnancy, is no proof that the membrane has not existed
and been expelled before fetal death. When pregnancy occurs
592
GYNECOLOGY.
in one-half of a bicoraate uterus, the decidua is present in the
unimpregnated comu. Under no circumstances, however, either
in the normal or abnormal pregnancy, is a decidua found in
the Fallopian tubes.
As the destructive
changes of the mucous
membrane of the gen-
ital tract associated
with menstruation are
limited to the uterine
cavity, so the true
decidua is found in the
same portion. It is
sometimes important
to avoid confounding
the decidua of preg-
nancy with the cast
thrown off from the
uterus in membranous
dysmenorrhea. In the
former it consists of
a compact layer of
decidual cells. In the
latter, the cast is more
likely to involve a portion of the glandular structure of the
uterus.
Rupture may be complete or incomplete. Complete rup-
ture is one in which the ovum and its envelopes escape, either
into the peritoneal
cavity or into the
broad ligament, with
more or less profuse
hemorrhage. (Fig.
444.) A partial rup-
ture may result in the
gradual thinning of
the wall until it gives
way in one place ; and
when this takes place
extraperitoneally, it is
reinforced by plastic
exudate, with the oc-
currence of but Httle,
if any. hemorrhage. (Fig. 445.) Successive ruptures or partial
ruptures thus occur unti) finally the envelope becomes sufficiently
distended to permit the fetus to develop as in an intra-abdominal—
Fig. 444,— Complete Ruptu
of Gestation Sac.
EXTKA UTERINE PREGNANCY. 593
pregnancy. At no time during such a rupture has the separation oc-
curred between the placenta and the tube. In the extraperitoneal
variety the embryo and placenta gradually occupy a sac formed
by the expanded tube and separated layers of the broad ligament.
The floor of this space is formed by connective tissue and the leva-
tor ani muscle. The ultimate effects depend to a great extent
upon the original situation of the placenta. When the embryo
is situated above the placenta, the latter is depressed between
the layers of the broad ligament until it is arrested by the pelvic
floor. If the embryo lies below, and the membranes burrow
between the layers of the broad ligament, the placenta is pushed
up until it lies high in the abdomen. As there is no tubal decidua,
the placental villi lie embedded in the decidual cells without
any intervillous system existing. When the placenta is dis-
placed into the tissue of the broad ligament, which occurs
gradually, its structure becomes seriously damaged : the villi
are less perfect in their contour, points of extravasation of blood
are present, and blood-crystals are abundant. Finally, under
the pressure, the placenta becomes gradually reduced to a
mass of compressed villi ; its serotina is destroyed and is replaced
by blood-crystals and by organized blood-clot. While the
consequences to the placenta from its displacement into the
tissue of the broad ligament are thus marked, it is not attended
with nearly so much danger as when the placenta is situated
above the embryo. It is then subject to extreme disorganiza-
tion, forming, as it does, the roof of the gestation sac. The
changes that take place in the placenta, owing to the pressure
of the developing fetus, have a great influence on the sub-
sequent history of the pregnancy, adding to a marked degree
to the peril to the life of the mother, and are, in the majority of
cases, disastrous to the life of the fetus. The constant tension
to which the peritoneum covering the gestation sac is subjected
leads to partial detachment of the placenta and to severe hemor-
rhage, either into the gestation sac or into the peritoneal cavity.
In the later stages of the pregnancy such hemorrhage is al-
most invariably fatal. A woman with an intraligamentary
pregnancy, with a placenta" situated above the fetus, runs a
greater risk of losing her life than she would from placenta
prsevia. A tubal placenta which is situated above the embryo
has its structure so damaged by rupture as to render it an in-
efficient respiratory organ; and the constant results upon the
embryo are very marked. The fetus from such a gestation
is rarely a satisfactory individual. It is very unusual for the
fetus to Ii\-e longer than a few days or weeks subsequent to
its delivery. Not infrequently it is iU formed, suffering
hydrocephalus, club-foot, spina bifida, ectopia of
ffering with A
the viscera, ^
594 GYNECOLOGY.
and other deformities. When normal in shape, it is ex(
ingly defective in size. One case is recorded in whicl]
tubal sac contained two embryos, measuring eleven centiir
in length, which were united by a band in the thoracic n
Dr. M. Price reported a well-formed ectopic fetus which
vived operation and was subsequently healthy. The an
of hemorrhage in an incomplete rupttu^ will depend
upon the situation of the placenta. If the placenta t
tached to the peritoneal surface and rupture takes place
it, the bleeding will be excessive and will possibly result :
death of the patient unless surgical intervention pn
If the placenta is situated on the opposite side to that on
rupture occurs, the envelopes may protrude, but little
ing will follow, and the sac becomes reinforced by plastii
date and adhesions. The sac wall is then formed by the x
the bladder, the parietal or pelvic peritoneum, and the
of intestine.
Secondary Rupture. — The extraperitoneal rupture <
the formation of a secondary broad-ligament gestatioi
which increases in size and may subsequently undergo ru
As has already been indicated, the danger is much inc
when the placenta is situated above the fetus. As the
nancy progresses the peritoneum becomes stretched b
separated from the adjacent parts and from the \'iscera.
sac extends into the abdomen, and strips the peritoneun
the anterior abdominal wall to a greater degree than
an overdistended bladder. When the posterior peritc
is thus raised up, the rectum, as well as the posterior s
of the uterus, may be deprived of serous investment,
placenta is insinuated between these parts, and secc
rupture may result at any time between the twelfth w©
the completion of term. The effects of this secondary
ture are dependent upon the injury to which the place
subjected. After the middle period of pregnancy has i
when it involves the placenta, — as it almost certainl]
situated, as the latter is, above the fetus, — most frightful I
rhage and rapid death will be the consequence. Earlier
course of the pregnancy the hemorrhage is not so sever
may be arrested by prompt surgical interv^ention. 0]
of the sac into the peritoneal cavity is recognized as secc
intraperitoneal rupture. If the fetus occupies the uppe
tion of the sac and the placenta is attached below, the i
may escape among the intestines. Secondary rupture
not always occur. The patient may go to term, spurious
follow, the liquor amnii be absorbed, and the placent
appear. If the extra-uterine pregnancy has not beer
BXTRA-UTBRINB PREGNANCY. 595
^•cted and its course not disturbed, the formation of a mum-
felified fetus, or Kthopedion, results, which may be discovered
Fcars later. Secondary intraperitoneal rupture may occur
It any time between the twelfth week and term. When it
wnirs at or near term, the belief is perpetuated that the fer-
alized ovtmi had timibled into the peritoneal cavity, to in-
^Raft itself upon the serous membrane and there develop. It
hould be tmderstood, however, that there is no primary peri-
oneal pregnancy, but that the condition originally developed
B the FaUopian tube. When the pregnancy develops in the
rtierine end of the tube, particularly that portion which traverses
he uterine wall, it is termed a tubo-uterine pregnancy. This
onnof pregnancy is not frequent, and can readily be confounded
fith pregnancy in one comu of a bicomate uterus. The tubo-
iterine gestation differs in its course, relations, and mode of
ermination from the purely tubal form. Primary rupture
jenerally occurs before the eighth week, and the pregnancy
I rarely continued without rupture beyond the twelfth week.
rhe tubo-uterine gestation sac may rupture in two directions:
nto the peritoneal cavity, causing frightful hemorrhage and
i rapidly fatal result, or, resistance being slighter toward
lie uterine cavity, the fetus and envelopes may be pushed
nto the uterus and terminate as in an intra-uterine conception.
rhe intraperitoneal rupture is much more rapidly fatal than
n the tubal form, and causes more severe hemorrhage, because
lie uterine wall is more vascular and the sac is situated in
loeer apposition to larger vessels. Tubal and tubo-uterine
v^nancy have the following distinctive characteristics: the
nbal pregnancy is very common, the tubo-uterine rare; the
ubal gestation sac is very thin, the tubo-uterine very thick.
The termination can be: (a) Intraperitoneal rupture for
sach, or (b) rupture into the intraligamentary space. In the
wbo-uterine, rupture can occur into the uterine cavity, with
lie discharge of the fetus through the vagina, (c) In the tubal,
ibortion can result, and, as in the primary rupture, date from
che third to the twelfth week. In the tubo-uterine, rupture
xcurs at any time from the fifth to the twentieth week. Ovarian
pregnancy, pure and simple, is extremely rare, and while there
are cases in which careful examination has disclosed ovarian
rtructure in the sac wall, with the tube free and unaffected,
yet we are not prepared to admit that the condition may not
bave originated from the tube, for it is very doubtful whether
the ovum will develop when not attached to the Mullerian
structiu^. The majority of cases of ovarian pregnancy are
luidoubtedly tubo-ovarian, in which the embryo was originally
fttuated in the orifice of the tube and has been partly extruded
596 GYNECOLOGY.
without loss of its vitality. As would be readily inferred,]
the life of the embryo in a tubal pregnancy is necessarily pre-
carious. After rupture, undoubtedly the pregnancy may caa-
tinue until full term. Symptoms of labor set in, during which
the gestation sac may burst into the peritoneal cavity, or,
if this catastrophe is avoided, the fetus dies. The body re-
mains quiescent or produces various forms of disturbance
Thus, the liquor amnii is absorbed; the tissues of the fetus
become mummified or partly calcified, and form a lithopedion.
The softer parts are converted into adipocere or tmdergo other
forms of decomposition. The placental tissue is gradually
absorbed and disappears.
Mummification. — The process of mummification is attended
with absorption of the fluids, while the soft parts are converted
into a dried tissue similar to that which follows when a dead
cat is permitted to remain under an old building, producing
a dried cat. An extra-uterine fetus can be retained in the
.body for a long period of time. Cheston reports a lithopedion
carried for fifty-two years; Barnes, one forty-two. The pos-
sibiUty of the fetus being carried this length of time does not
necessarily indicate that it can not prove a source of danger
to the patient. Pathogenic micro-organisms can find entrance
to the sac through the adjacent hollow viscera, and at any
time produce serious trouble. Suppuration follows, and pos
finds its way through the sac-wall, and penetrates the va-
gina, uterus, bladder, or rectum. Through any of these open-
ings fragments of fetal tissue from time to time escape, caus-
ing frightful distress and necessitating operation for relief.
The existence of a lithopedion or macerated fetal skeleton
does not preclude subsequent pregnancy. One case came
under my observation in which a woman with a good-sized and
distinctly well-defined lithopedion subsequently gave birth to
two children.
550. Symptoms. — The symptoms which should lead one to
suspect the existence of an ectopic gestation are dependent upon
the duration and course of the pregnancy. A history'' will be
obtained of disordered menstruation, the patient having missed
one or more periods. The ordinary sjmiptoms of pregnancy are
present and she has supposed herself pregnant. She may have
experienced a sensation of uneasiness or distress over the region
of the ovary and tube upon one side, associated with frequent
and sudden attacks of colicky pains. These pains may have been
of severe, cutting character, paroxysmal, and occasionally quite
intense. In other cases without any premonition pain of a tear-
ing, cutting character will occur, so severe and lancinating as to
cause the patient to fall and become unconscious. This phenom-
EXTKA-L'TEHINE PREGNANCY. 597
enon may be followed by repeated attacks of syncope in which
the countenance of the patient becomes pale, anxious, covered
with clammy perspiration, lips pale and blanched, respiration
sighing, the sight obscured, sensation of darkness or even blind-
ness, mind frequently wandering, or she may remain unconscious
or pass from one attack of s>'ncope to another. The pulse at the
wTJst becomes exceedingly feeble, faint, and imperceptible. The
temperature is subnormal, and all the indications of approaching
dissolution are present. Generally the symptoms are not so
marked or the patient is weak, debilitated, shows symptoms of
shock or collapse, soon rallies, with recurring attacks of a similar
character, which indicate that the hemorrhage has again recurred
or is slowly continuing. In other cases the progress is insidious.
A smalt aperture exists; the walls have been stretched. Plastic
exudation is thrown out and the pregnancy may progress without
further accident. The tube may rupture either intraperitoneally
or extraperitoneally. The symptoms of the two varieties will
be found entirely different. The gravity of the former is much
the greater, but will depend upon whether the ruptiu^ has been
complete or incomplete, and also upon the situation of the
placenta. When the rupture occurs from the site of the placenta,
even though inctimplete, hemorrhage can be so severe as to cause
the death of the patient if intervention is not instituted. Ac-
cording to the intensity of the hemorrhage, the patient may either
die in the first attack, that is, within half an hour or an hour after
the first s^Tnptoms, or slightly rally and an apparent recurrence
of the hemorrhage follow, with death within less than twenty-
four hours. Should the patient sur\'ive twenty-four hours and
rally, her strength may gradually return and recovery follow, or a
secondary hemorrhage may develop and result in a fatal termina-
tion. When the patient survives the hemorrhage and shock, the
accident is followed by more or less tenderness over the abdomen
and by abdominal distention, which symptoms indicate the oc-
currence of localized peritonitis. In the early stage of hemor-
rhage no physical signs of its existence can be recognized. Pos-
sibly a large quantity of blood in the abdominal cavity of a thin
woman could be recognized by the sensation of fluctuation. In
twenty-four hours the blood will accumulate in the pelvis, and
we then observe a sensation of fluctuation and slight resistance
by vaginal palpation. Change in the position of such a patient per-
mits the collection to flow <iut of the pelvis, when its presence will
no longer be recognized. If the pelvis is again lowered, the accu-
mulation returns. The coagulated blood causes more or less irri-
tation, which results in the exudation of plastic material and the
occurrence of a locaHzed peritonitis. The abdomen becomes tender
to the touch, febrile reaction occurs, the temperature instead of
598 GYNECOLOGY.
being subnormal now rises to loi® F. or even 103® F. The patient-
may experience distress from pressure of the mass on the recttm '
or against the uterus and bladder, which produces freqtwnt
micturition or even incontinence. With the advent of plastic
peritonitis the collection becomes encysted; the patient wiE
often suffer from nausea and abdominal distention. The watery
portions in such a collection become gradually absorbed and the
mass is more apparent and resistant. The uterus may be pushed
upward and forward. The intestines are raised up and forma
part of the wall of the sac. The collected mass varies in its con-
sistence: sometimes it is hard, at others soft, or the same mas
may have several points of softening. The uterus may be envel-
oped by the collection, producing w^hat is known as an enveloping
uterine hematocele ; the fimctions of the rectum and bladder may
be greatly impaired by the compression of the mass against these
organs, which may often cause sjnnptoms of intestinal strangula-
tion and retention of urine. Pressure upon the nerves of the
pelvis frequently gives rise to severe netualgia of the lower ex-
tremities. Even when suppuration does not occur, irregular
attacks of fever are frequently the result of peritoneal reaction.
The course and progress of the disease are essentially chronic, or re-
peated attacks may occur. The congestion which takes place at
the menstrual periods may result in acute symptoms. Sup-
purative change in such a collection is ushered in by an aggrava-
tion of both the local and general symptoms, chills, elevation of
temperature, profuse sweating, increased leukocytosis; the tumor
increases in size and undergoes softening; the mass may sub-
sequently perforate into the rectum, causing the evacuation of
dark, purulent, exceedingly offensive material in the stools,
which may cause more or less irritation of the rectum. These
discharges are followed by cessation of or disappearance of the
tumor. Perforation into the vagina or bladder may occur, though
these are rare. Perforation into the abdominal cavity is for-
tunately infrequent. When it does result, a violent attack of
general peritonitis follows. The occurrence of rupture of the
tubal sac is not infrequently associated with discharge of blood
from the vagina and with severe uterine pain. The uterine pain
or tlie pain from the rupture may cause the victim to believe that
an abortion is impending. This suspicion may be still further
confirmed by the discharge of a cast from the uterus or of shreds
of tissue, associated with clots, which may lead both the patient
and her medical attendant to believe that an abortion has
occurred . When the hemorrhage is slight and the ovum retains its
connection with the tube, the fetus may continue to full devel-
opment, and e\'en reach full term. A pregnancy situated pos-
terior to the uterus may reach full term without causing the
EXTRA-UTERINE PREGNANCY. 599
Mient to stispect that an abnormal condition exists, and it is
WBiy after the beginning of labor, when an examination is made,
Iftt the true state of affairs is recognized. Even then it is not
tfways recognized and the spurious labor may terminate without
lie discharge of the fetus and the sac may tmdergo subsequent
iianges.
551. Diagnosis. — Diagnosis comprises: (i) The recognition
tf extra-uterine pregnancy prior to rupture; (2) the determination
£ rupture or abortion with intraperitoneal or extraperitoneal
lemorrhage and death of the fetus; (3) secondary rupture;
4) continued growth of the embryo after rupture ; (5) peritonitis ;
6) suppuration.
I. Preceding Rupture. — Most frequently the victim of mis-
placed conception does not apply to her physician until the oc-
nrrence of a violent, tearing pain, associated with rupture. The
iistressing symptoms are rarely sufficiently definite prior to this
oocurrence to demand a physical examination. Such an examina-
tion is generally requested in order to ascertain the existence of the
npposed normal pregnancy. The frequent occurrence of ectopic
gestation, however, should lead to the careful investigation of
wwy patient who gives symptoms of being pregnant, where
there is a previous history of more or less extended sterility,
of attacks of pelvic inflammation, and, especially, if the latter
lias originated from gonorrheal infection. Such an examina-
tion is particularly indicated when the patient, having missed
a period, complains of a sensation of uneasiness or distress in
one side of the abdomen, associated with frequent and sudden
attacks of colicky pain. Every such patient should be sub-
jected to a careful examination. Slight enlargement of the
uterus, with some tenderness in the pelvis, more marked upon
one side, associated with a more or less spherical or rounded
distention of the tube, should increase the suspicion of ectopic
pstation. This suspicion would be confirmed by finding
increased vascularity in the broad Kgament, causing marked
pulsation of its vessels. This pulsation is distinctly recogniz-
able upon the affected side, while the pulsation on the opposite
side is not defined. The examination should be made with
tlie utmost gentleness, for rough manipulation or marked pres-
wre in the practice of the bimanual procedure can very readily
mpture a sac which is so thin as to require only a slight amount
of additional pressure. Where the sac is of considerable size,
it is unwise to subject it to much force in the examination, un-
less the operator is prepared for immediate operation should
nipture occur. It has been my unfortunate experience with
a patient in whom the pulsation was as distinct as if the finger
''ere placed over the radial artery, to have the sac ruptured
600 GYNECOLOGY.
by her physician, who was desirous of examining the case.
The patient succumbed to the subsequent operation. Dr.
J. M. Fisher, my assistant, reports two cases, in which he has
observed the rupture of an ectopic gestation during examination.
2. Rupture. — The rupture of an ectopic gestation sac may
be suspected when the patient gives a history of having failed
to menstruate for one or two periods and has exhibited the
ordinary symptoms of pregnancy. She has probably had
more or less discomfort upon one side, with frequent colicky
attacks, when suddenly, without warning, there has been an
attack of most violent, tearing pain, followed by syncope, all
the symptoms of internal hemorrhage, with oncoming collapse.
I have seen such a patient in the space of ten minutes pass
from a condition of apparent good health to one which seemed
to threaten approaching dissolution. The face was blanched,
pale, exceedingly anxious looking, covered with cold, clammy
perspiration; pupils dilated, eyes expressionless, rolling from
side to side; sighing respiration; pulse rapid, feeble, some-
times almost imperceptible; patient complaining of being un-
able to see, and everything appearing dark about her. Some-
times marked nausea and vomiting are present. The slightest
movement, even raising the head of the patient, is followed
by more or less profound syncope. The occurrence of such
a train of symptoms should awaken in the mind of the ob-
server the absolute conviction that an internal hemorrhage
is occurring, and the association of such a group of symptoms
would indicate its origin from an ectopic gestation. A phy-
sical examination affords very little information, for at this
time the tumor is insufficiently large and without the necessar>'
firmness to afTord the sensation of resistance. The physical
signs are consequently indefinite. When the bleeding is ex-
tensive, the abdominal walls thinned and not very resistant,
a sensation of distention may be noted and even fluctuation
recognized. When the hemorrhage is not so profound as to
endanger life, the watery portions of the effused blood are
gradually absorbed and leave a more or less resistant clot,
which can be felt as a firm mass in the pelvis. In the absence
of previous history of recent inflammatory trouble or the pre-
vious existence of a groii\th, it must be recognized as effused
or clotted blood. The accumulation is generally retro-uterine.
A large extravasation may fill the pelvis, push the uterus for-
ward, and raise the intestines above it (Fig. 4,38), In other
cases the uterus may be found in a state of retroversion, while
a mass is situated in front and forms an ante-uterine hemato-
cele; or in very large accumulations the uterus may protrude
through it, producing what is known as a circumuterine hemato-
EXTRA-UTERINE PREGNANCY. 601
cele. Hemorrhage dangerous to life, and productive of the
most profound anemia, may arise without rupture, as in tubal
abortion, or when the vilH have penetrated the wall of the
tubal sac and bleeding occurs from their surfaces. These per-
forations may be so minute as to be unrecognizable by the
naked eye, except for a thrombus projecting from the external
tubal surface. The tubal abortion in its earliest stage causes
no marked physical manifestations outside of those symptoms
which indicate an internal hemorrhage. Later, however, the
blood-clots in the tube, filling up the sac, produce a large, sausage-
shaped mass, which may be firm and resistant. The patients
in whom rupture has occurred may present successive attacks
of shock and syncope. Thus, a patient bleeds until the blood
pressure is greatly reduced, a clot forms, plugs the vessel tem-
porarily, and the circulation is restored. If. however, injudicious
Fig. 446.— Ectopic Gestation Sac Ruptured, Showing Fetus.
efforts are made to revive the patient by Iiypodermatic injections
of strychnin, digitalin, or intravenous injection of salt solution,
the clot is washed or driven out and hemorrhage again recurs,
with a repetition of the former symptoms. Noble has reported
cases in which the rupture and hemorrhage ha\e been associated
with a rather rapid and marked rise of temperature. The
general rule, however, is that where hemorrhage is marked
the patient shows a subnormal temperature, as would be ex-
pected in cases of shock and threatened collapse. The tem-
perature rarely is elevated until some days after the hemor-
rhage, and then is not high. The elevation of temperature
is undoubtedly due to degenerative changes in the collection,
possibly from the fibrin- ferment, or more likely from partial
602 GYNECOLOGY.
infection by organisms from the intestinal canal. At the time
of this elevation of temperattire the peritoneal exudate is thrown
out, which forms barriers and confines the blood accumtilation
within the pelvis. The watery portions of the blood become
absorbed, until a more or less distinct and well-defined mass of
clotted blood is perceived. In extraperitoneal hemorrhage the
symptoms are much less acute. Shock or collapse is less marked,
although we still have symptoms which, to a limited degree,
should lead one to suspect internal hemorrhage. In such a
case examination will disclose on one side of the pelvis a mass
which may fill up and distend the broad ligament. The tumor
may be quite tense and push the uterus to the opposite side.
The condition differs from tubal disease in that the broad liga-
ment is distended by it. There has been an absence of recent
inflammatory trouble, and the patient does not present the
charact^stic symptoms of inflammation. In the intraperi-
toneal variety the irritation of the accumulated blood causes
certain reactive symptoms and sometimes the development
of peritonitis. The temperature becomes elevated, pulse rapid,
the abdomen tender and sensitive to pressure. But the symp-
toms are not so acute and severe as in marked inflammation.
The rupture and internal hemorrhage are usually associated
with a discharge from the uterus of decidual membrane, either
as a complete cast of the cavity or in the form of shreds mixed
with clots. The cast may show the orifice of the Fallopian
tubes and internal os. Inquiry should be made with regard
to this symptom, and, when possible, the discharged material
should be carefully examined. It is important to differentiate
it from the decidua thrown off in some forms of dysmenorrhea.
That of pregnancy is from six to eight millimeters in thick-
ness, while that of menstruation rarely exceeds two or three
centimeters in length and is scarcely two millimeters in thick-
ness, is translucent, is rarely passed entire, and consists of the
compact layer of the epithelium. When the symptoms ha\t
been slight and the woman has considered herself the subject
of an abortion, it is not until the enlarged fetal sac causes a
suspicion of the continuation of the pregnancy that the patient
will present herself for examination, and even then she may
not consult a physician.
3. Secondary Rupture. — Secondary rupture necessarily fol-
lows a primary rupture, which, in the majority of cases, has
taken place in the broad ligament. The rupttire has occurred
in such a way as not to interfere with the vitality of the ovTini.
Retaining its vitality, it enlarges its implantation, and in its
grow1:h spreads out the broad ligament until the latter is no
longer able to retain it, when from pressure the thinned wall
V-UTERINE PREGNANCY.
603
finally ruptures and severe hemorrhage takes place into the
peritoneal cavity. The history of repeated attacks of pain
and distress, of symptoms of internal hemorrhage, of the en-
larging abdomen, and, finally, the cutting, agonizing pain
associated with rupture into the peritoneal cavity should be
sufficient data upon which to base the diagnosis of secondary
rupture. Both in primary and secondary rupture the amount
of hemorrhage will depend upon its relation to the site of the
placenta. Where the rupture takes place over the latter,
the hemorrhage may be very profound and so rapid as to re-
sult in death of the woman before measures can be instituted
for her relief.
4. Continued Growth of the Embryo after Rupture. — As has.
already been seen, this growth may take place into the broad
ligament, spreading it out, or in those cases in which the em-
bryo has become reimplanted upon the surface of the perito-
neum, the ovary, or in a continuation of the tube, the growth
advancing as it would in ordinary pregnancy. The fetal
movements are recognized, the enlargement continues, and
the patient imagines herself normally pregnant. On phy-
sical examination of such a patient the parts are more dis-
tinctly defined by bimanual palpation than if the mass were
situated within the uterus, as there is less structure intervening
between the fetus and the palpating hand. The recognition
of the fetal heart sounds is an absolute indication of the ex-
istence of pregnancy. After the completion of the normal
term of pregnancy in such a patient, the appearance of
spurious labor, the cessation of fetal movements, and the changes.
which come under observation months later, may greatly
increase the obscurity of the condition.
A patient came under my observation who supposed her-
self pregnant, and who suffered from a bloody discharge, with
considerable pain, at the end of the second month, which led
her to think that an abortion had occurred. The supposed
abortion occurred in February. Her abdomen consequently
became enlarged, and in the following October she went into-
labor. Pains continued for two days, and after the move-
ments ceased her menstrual periods returned. In April, when
she came under my observation, she presented a tumor as
large as in a pregnancy at full term, over which there was dis-
tinct fluctuation and marked resonance. A thin-walled sac
was recognized, but there was no sign of a resistant mass. Vag-
inal examination disclosed behind the uterus a tumor which
filled Douglas' pouch. Tlie uterus was enlarged and was situ-
ated directly in front of the tumor. On percussion, there
was resonance everywhere. Ko dulness could be distinguished,.
604 GYNECOLOGY.
although fluctuation was distinct. The diagnosis was an ectojnc
gestation, with death of the fetus, decomposition in the fetal
sac, and the formation of gas. This diagnosis was confirmed j
by opening the abdomen and finding posterior to the uterus j
a sac which contained a macerated fetus and a considerabk
quantity of offensive fluid.
5. Peritonitis. — Peritonitis may take place as a result of
rupture of the sac, the escape of its contents into the peritoneal
cavity, the accumulation of blood from a large hemorrhage,
and its irritation upon the pelvic peritoneum. Unless relief
is afforded, extensive matting together of the intestines and
pelvic structures occurs, which will require early operative inter-
ference for relief. Peritonitis may be produced, also, by the
death of the fetus and infection of the sac. Its occurrence
is indicated by pain and tenderness over the abdomen, the
distention of the belly, assumption of the dorsal position, dis-
tress during the evacuation of the bladder or movement of
the bowels.
6. Suppuration. — Suppuration in an ectopic gestation may
follow its rupture, so that the contents of such a sac becomes
sanguinopurulent. Suppuration also takes place in later stages
of a pregnancy which has gone on to full term ; the fetus has
subsequently become macerated, mummified, or even a lith-
opedion has formed. Suppuration may take place months or
even years after the occiirrence of a pregnancy, leading to the
evacuation of the sac or to its rupture into the intestine, the
bladder, the vagina, or through the abdominal wall. In such a
case the fragments of the fetus and its bony structure will be
discharged. Suppuration will be indicated by increased pain
and distress, by recurring chills, sweating, elevation of tem-
perature, and the ordinary symptoms associated with sup-
purative processes. That the suppuration has originated in
an ectopic gestation will be demonstrated by the prerious
history of the case. This is made absolutely certain when
the bony fragments of the fetus are discharged.
552. Differential Diagnosis. — Tubal and uterine pregnancy
may coexist. Uterine pregnancy may follow tubal, or re-
peated uterine pregnancies may occur subsequent to the for-
mation of a lithopedion. Tubal pregnancy may be bilateral.
Its frequent occurrence in the remaining tube after remo\*aI
of a tubal gestation sac has led some operators to advocate
the removal of both appendages in every case of tubal gesta-
tion. Tubal pregnancy may coexist with ovarian and tubo-
ovarian tumors. In a case I saw with Dr. J. M. Fisher the
symptoms justified his diagnosis of rupture of a tubal gesta-
tion sac. From its outline a mass upon the left side of the
EXTRA-UTERINE PREGNANCY,
605
/is was considered to be a large extraperitoneal hemato-
!, which I decided to evacuate by a vaginal incision. A
;e quantity of clotted blood was evacuated, above which
i a smooth cyst, too large to remove through the vagina.
! ruptured tubal gestation sac was upon the opposite side.
! removal of the cyst was effected by an abdominal incision.
The following conditions may be confounded with ectopic
ation: first, uterine pregnancy; second, pregnancy in a
nuate uterus; third, a retroflexed gravid uterus; fourth,
nous pregnancy; fifth, ovarian tumors; sixth, uterine tumors;
snth, intraligamentary tumors; eighth, accumulation of
s in the rectum.
First, uncomplicated uterine pregnancy is generally more
ily recognized by the change in shape and size of the organ.
ectopic gestation the jug-like shape or outline of the fundus
ranting. A sac or mass, rather sharply defined, will be found
Mw of the tubes, if rupture has not occurred, and the sub-
int vessels will pulsate more distinctly than upon the oppo-
side. After rupture the condition is distinguished by
re or less severe shock, profound anemia, and the appear-
e of a large mass in the pelvis without a history of previous
ammatory phenomena. The introduction of the sound
606 GYNECOLOGY.
and the use of the curet to secure decidual tissue have been
advocated, but are procedures which are not free from danger.
In possible uterine pregnancy and abortion the danger of in-
fection must not be overlooked. The investigation for decidua
may be misleading, as it may have been previously exfoliated.
The tissue removed by a curet can not be certainly distinguished
from that which will be caused by inflammation, and the pro-
cedure endangers the development of septic processes, which
will complicate a tubal gestation if any exists.
Second, pregnancy in one horn of a bicomate uterus may
be impossible to differentiate from a tubo-uterine or an inter-
stitial pregnancy. Fortunately, the treatment of the two
conditions is similar, and is almost equally urgent. A tubal
gestation is situated at a greater distance from the uterus.
Third, the retroflexed pregnant uterus is recognized by
palpation, in which we are able to trace the tumor back from
the cervix, and the smoothly outlined fundus is capable of
considerable movement.
Fourth, careful analysis of the symptoms, associated with
the accurate consideration of physical signs, will guide to a
correct diagnosis. It is a grave error to mistake, after the ab-
domen has been opened, an extraperitoneal pregnancy for
sarcoma or myoma.
Fifth, ovarian tumors are usually differentiated by their
history. It is only when one of these growths has produced
no symptoms by which its presence could be suspected, and
is suddenly complicated by an acute attack, during which
or subsequent to which examination discloses its presence
more or less fixed in the pelvis, that error is possible. Such
a train of symptoms is readily produced by twisting of the
pedicle of a small ovarian or a broad-ligament cyst. A young
unmarried woman came under my observation with a history
of having had a severe attack of pain upon the right side, which
was pronounced appendicitis. While a movable mass could
be felt above the brim of the pelvis upon the right side,
there was no indication of inflammatory exudation. Not-
withstanding the good character of the individual, ectopic
gestation was regarded as a possibility. An abdominal incision
disclosed a broad-ligament cyst beyond the ovar\% closely
attached to the outer part of the tube, whose pedicle had twisted,
causing hemorrhage into the cyst and twisted portion of the
tube, with the effusion of a large quantity of bloody serum
free in the peritoneal cavity.
Sixth, when, in an extra -uterine pregnancy, the fetus is
dead, the fluid portions have been absorbed, and the mass
is hard and firm, with its sac closely adherent to the side of the
EXTRA-UTERINB PREGNANCY. 607
Uterus, the physical signs are frequently insufficient to establish
tiie diflFerential diagnosis between it and an intraligamentous
myoma.
Seventh, intraligamentary tumors are easily confounded
with ectopic gestation. Frequently the diagnosis can be deter-
mined only after abdominal incision. A patient was brought
to me with the following history: She had been married nine
years and had never been pregnant ; six weeks before admission
she was seized with severe pain in the left side, and subsequent
inflammatory symptoms, which confined her to bed the greater
portion of the time. A mass, quite resistant, was felt to the
left and in front of the uterus, which was firmly fixed by ad-
hesions. The long period of sterility, sudden onset, and more
or less fixed tumor, not previously recognized, led me to sus-
pect tubal gestation with intraligamentary rupture. The
incision, however, disclosed an intraligamentary ovarian cyst
with thick walls, which had undergone a degenerative pro-
cess, and which probably explained the sudden onset.
Not infrequently the diagnosis can be determined only
by incision, and an ectopic gestation is found when opera-
tKWis are performed for other conditions, and the reverse.
Eighth, careful examination should exclude fecal accumu-
htion; ordinarily, the latter condition is determined by the
possibility of indenting the fecal masses. When there is any
doubt, an expression of opinion should be withheld until a
complete evacuation of the bowels can be secured through
the employment of an active purgative, supplemented by
free rectal enemas.
The differential diagnosis of tubal rupture is often difficult.
Rupture is simulated by lesions of the abdominal viscera, such
as perforating ulcers in the stomach, duodenum, small in-
testine, and vermiform appendix; rupture of a pyosalpinx;
torsion of the pedicle of a small ovarian cyst; acute intestinal
obstruction; renal and biliary colic. A case of tubal gestation
has been brought to operation as a supposed strangulated
hernia. The diagnosis of tubal rupture can always be rendered
certain by a puncture through the posterior vaginal fornix,
^hen the rupture will be indicated by the discharge of dark-
colored blood. The vaginal puncture affords, in addition,
<Jpportunity for the digital exploration of the pelvic \^iscera.
Such an investigation permits palpation of the tubes and ovaries
^d the recognition of existing abnormalities.
The following table, modified by Greig Smith from Web-
ster, presents in a convenient form a summary of the pathologic
*nd clinical features of ectopic gestation:
608 GYNECOLOGY.
A. Ampullar. — Gestation beginning in the ampulla of the tube.
I. Persisting (rarely goes to full term).
II. Rupture (the usual result) :
1. Into broad ligament:
(o) Gestation continues there.
(6) Secondary rupture into peritoneal cavity.
(c) Gestation terminates:
(a') By formation of hematoma.
(6') By suppuration.
(c') By mummification.
2. Into peritoneal cavity:
(a) Gestation continues, the placenta remaining in the tube, the
fetus and the membranes being in the cavity.
(6) Gestation terminates:
(a') The patient dying from hemorrhage or shock.
(6') By absorption of the mass.
(c') By mummification or by adipocere or lithopedion fonna*
tion.
III. Destruction of gestation:
1. By tubal abortion.
2. By formation of mole.
3. By hematosalpinx.
4. By suppuration.
5. By absorption after early death.
B. Interstitial, when the gestation develops in the interstitial portion of
the tube:
I. Persisting (the gestation may go on to term).
II. Rupture:
1. Into the peritoneal cavity.
2. Into the uterine cavity.
3. Into both the peritoneal and uterine cavities.
4. Between layers of broad ligament.
III. Destruction of gestation and retrogressive changes in fetus and envelops*
C. Infundibular, when the gestation is in the outer end of the tube.
The ovary may form part of the wall of the sac.
553. Prognosis. — Extra-uterine pregnancy at any stage of
its progress must be regarded as a condition fraught with the
greatest peril to the individual. It should be regarded as just
as positive an indication for treatment as would be the presence
of malignant disease. If discovered before the rupture of the
sac, the patient is in danger from hemorrhage. The longer
the condition progresses, the more grave is the peril. After
rupture, with death of the fetus, the patient is not free from danger,
as the collection of blood — the hematocele — may become infect^,
from its proximity to the hollow viscera, and cause the formation
of an abscess or the development of pyemic symptoms. If the
fetus survives the rupture, its subsequent development only in-
creases the danger. A secondary rupture, with escape of the sac
contents into the peritoneal cavity, or the frightful hemorrhages
which result in some conditions, may prove immediately fatal.
The woman goes on to full term ; the fetus dies, then undergoes
retrogressive processes, which may at any time, even after years
of quiescence, become infected, resulting in the formation of ab-
scesses, perforation of viscera, and escape of the contents of the
EXTRA-UTERINE PREGNANCY. b09
sac. As the nutrition of the fetus in the majority of cases is de-
fective, from unfavorable implantation of the placenta, frequently
from pressure upon it, the fetus is generally imperfectly devel-
oped, often undersized, suHering from hydrocephalus, spina
bifida, club-foot, and other deformities. The preservation of
the life of such an individual should not be considered when
it is recognized that the life of the mother is constantly in peri].
Furthermore, the fact that, even under the most favorable
circumstances, the chances for the fetus are very greatly de-
creased, and that, even when delivered alive, its duration of
life is short, should be taken into account. The statistics of
Dunning, however, indicate that an operation for the delivery of
the child during life, when viable, is more favorable for the life
of the mother tlian is the delay of the operation until after the
death of the fetus.
554. Treatment. — In a condition replete with such dangers
as that of ectopic gestation it does not seem the province of
the physician to practise any other method than one which
will afford the greatest certainty of relief and which can be
accomplished with the least danger. This, in our judgment, is
through surgical manipulation; but, as other methods of treat-
ment have been advocated, before entering upon the considera-
tion of extirpation we will consider the substitutes. The sub-
stitute methods recognized are evacuation of the hquor amnii,
injection of poisonous substances, elytrotomy, and the ap-
plication of the electric current.
The evacuation of the liquor amnii was advocated by Simp-
son in 1864. He treated a case by puncturing the cyst through
the vagina without killing the child, and the mother died in
three days. Braxton Hicks tried a similar method in 1865,
which killed the child, but the mother died of hemorrhage.
Greenhalgh, in 1867, had a successful case. James, of Phil-
adelphia, in 1867, had a successful case after much tribulation.
This plan of treatment, owing to the great mortality, has been
generally abandoned.
The injection of poisonous materials into the fetus and
its enveloping fluids was advocated by Joulin in 1863. Morphin
is the drug most frequently used. Other remedies, such as
strychnin and ergotin. have been similarly employed. In-
unctions of mercury, the administration of potassium iodid, and
repeated bleeding have been advocated, but it is difficult to explain
why. The injection of morphin with a hypodermatic syringe is
practised before the fifth month. Two injections are usually
«ven, containing J of a grain each, at an interval of from eight to
ateen days. The treatment may result in severe hemorrhage,
Mpticemia, and perforation of an intestinal loop, so that, wl "
610 GYNECOLOGY.
apparently a simple procedure, it is attended with greater
danger than an abdominal operation.
Elytrotomy, or the removal of the fetus and its contents
through a vaginal incision, was instituted as early as 1817 by
Dr. King, of Georgia. This operation, which has been lately
revived, is not by any means a new one. In the discussion di
hematocele vaginal incision has been advocated as a justifiable
method of procedure when the condition has become chronic;
in other words, some time after the hemorrhage has taken
place, when the vessels are occluded and the fetus is more than
likely to be dead. In such cases vaginal incision affords an
opportunity for clearing away the debris without subjecting
the patient to so serious an operation as would be that through
the abdominal wall. But before ruptiu"e, or immediately
following rupture, in order to arrest the hemorrhage, the ab-
dominal incision should be preferred. When the patient has
reached full term afid the death of the fetus has occiured, but
as yet without the appearance of suppuration, the vaginal pro-
cedure may be chosen: (i) When the fetus presents the head,
breech, or feet, so that it can be extracted without altering
its position; (2) when it is certain, from the thinness of the
structures separating the presenting part from the vaginal
canal, that the placenta is not situated over this part of the
sac, and we are not absolutely certain that the placenta may
not be inserted on the anterior abdominal wall. If it is neces-
sary to turn the child in order to deliver it, the vaginal pro-
cediu"e should not be considered. Robertson advocates dividing
the perineum, septum of the vagina, and rectum, but this is an
unnecessarily severe proceeding.
The application of electricity for the destruction of the
fetus has been practised since 1853. There is a difference d
opinion, however, among electrotherapeutists as to the greater
value of the faradic and galvanic currents, each having its
advocates. This procedure is preferable to all those which
have been named, but is advisable only in the earlier months
of pregnancy. In the early stages we must take into con-
sideration the fact that the diagnosis is not always certain.
Without doubt, many of the cases reported to have been cured
by electricity were cases which had tmdergone rupture, and
in wliich the tubal mole or embryo had escaped and lost its
vitality, and the electric treatment has possibly served to ex-
pedite the absorption of the exudation — an absorption which
would have taken place had electricity not been applied. Many
cases in which electricity has been applied were undoubtedly
cases of mistaken diagnosis. It is true that advanced methods
of examination w^ll more certainly differentiate the condition,
EXTRA-UTERINE PREGNANCY. 611
Imt the violence required to accomplish this will greatly en-
ianger the rupture of the fetal sac. The application of electric-
ly has occasionally been fotind to intensify the contraction
x the muscle-fiber of the tube and to result in ruptiire and
evere hemorrhage. When the death of the fetus occurs the
langer does not cease, and we will frequently find the placenta
notinuing to grow, or ruptiire may follow, associated with
evere hemorrhage and later with septicemia. In the applica-
ioa of the current one pole of the battery, generally the neg-
itive, is applied through either the rectum or the vagina in
lie neighborhood of the ovum. The other pole' or a large
fcctrode is applied to the abdominal wall directly over the
Mc and an inch or more above Poupart's ligament. The c\ir-
wit is used for from five to ten minutes, increasing it as the
KDsitiveness of the patient will permit. When necessary,
Ehe application should be repeated. The practice of this pro-
cedure is of doubtful utility, and, as has already been men-
tk)ned, it is not without danger. It temporizes with a condition
which menaces life and may excite severe tubal contractions
which often result in rupture with subsequent hemorrhage.
The risks and difficulties of operative treatment will largely
depend upon the stage of gestation and the condition of the
phcenta and gestation sac. The surgeon, to be properly prepared
to meet all emergencies, should consider the following: (i)
The measures to be employed before primary rupture or abor-
tion; (2) the measures required at the time of primary rupture;
(3) what shall be done for the patient coming under obser-
vation subsequent to rupture — (a) with intraperitoneal hemor-
ihage; (b) with extraperitoneal hemorrhage; (4) the method
of treatment advisable in advanced growth of the embryo —
(a) the child alive; (6) the child dead, mummified, or reduced
to a lithopedion; (c) following decomposition of the fetus and
wppuration of the sac.
I. The Measures to be Employed before Primary Rupture or
Abortion. — Cases in which opportunity is afforded to operate
prior to the rupture of the sac are more frequent than form-
eriy, owing to our improved methods of diagnosis and to the
grater significance given to disorders accompanying pregnancy.
Too frequently, still, the disorder will be overlooked until the
danger-signal of rupture appears. When the symptoms pres-
Oit make it evident that an ectopic gestation exists or is ex-
tremely probable, the patient shpuld be subjected to operation
at the earliest possible moment. The danger arising from
Hipture is so great that the patient should be considered in
peil of her life until the condition is corrected. The abdominal
^J^on is the preferable procedure, inasmuch as it affords a
612 GYNECOLOGY.
better opportunity to explore the field, to manage adhesions,
and to secure bleeding vessels. The removal of the entire
sac rarely affords any special difficulty. In a tubo-ovarian
pregnancy it is possible that a knuckle pf intestine may have
become adherent to the sac. In such cases the removal of
the latter must be carefully managed, because the changes
which take place in the adherent intestine render it easily torn.
Failure to recognize this possibiUty in my own experience led
to the necessity of resecting a knuckle of intestine for an ex-
tensive tear. The patient, however, fortunately recovered.
2. The Measures Required at the Time of Primary Rupture,^
Unfortunately, the attention of the physician is much more
frequently directed to the occurrence of primary rupture or
abortion than to the existence of an ectopic gestation prior
to this event. Very frequently the efforts employed to
arrive at a correct diagnosis may be the means of the pro-
duction of this catastrophe. Therefore, I would again em-
phasize the importance of delicate manipulation in a case of
suspected ectopic gestation. Indeed, prior to the careful
examination of a patient in whom an extra-uterine pregnancy
is suspected it would be well to have ample provision for re-
sort to immediate surgical procedure, in the event of collapse
or rupture of the ectopic sac. Should the disaster occur during
an examination, or the physician be called upon to attend a
case in which rupture had recently occurred, he should endeavor
to keep the patient perfectly quiet and free from armoyance,
with her clothing loosened. The foot of her bed should be
elevated and a hypodermatic injection of morphin should be
administered with a view not only to quiet the pain, but to
lessen the nerve irritability and restlessness. An ice-bag should
be applied over the abdomen, and immediate preparations
made for opening the abdomen, in order to secure the bleeding
vessel. The patient should be placed under the influence
of an anesthetic. If the operator is at all in doubt as to whether
the condition has resulted from an internal hemorrhage, he may
confirm his suspicions and satisfy all doubts by cleansing the
vagina and making a puncture through the posterior fornix,
which will permit the recognition of the escaping blood.- In-
deed, through such a puncture the tubes may be examined
and the presence of the sac recognized. Moreover, a skilful
operator may be able to secure the bleeding vessels through
the vaginal incision. Indeed,, it has been advocated that the
ruptured tube should be brought down, the surfaces cleansed,
and sutures so introduced as to control the bleeding vessel
and close the opening, leaving the tube in place. Such a plan
of procedure, however, is inadvisable. The fact that the caliber
EXTRA-UTERINE PREGNANCY. 613
rf the tube is so obstructed as to have caused an ectopic preg-
ancy would indicate that its retention must necessarily subject
lie patient to the danger of a recurrence of the condition. The
ibdomen opened, the bleeding vessel secured, with aseptic pre-
autions, no great effort need be made to free the peritoneal
avity of blood, for, if the patient is kept under proper regimen,
ht blood is quickly absorbed and serves in some degree to
ustain and support her. The absolute indication at this stage
s to arrest the hemorrhage, and this is most effectively accom-
;dished through an abdominal incision. As soon as the abdominal
incision is made there will be a gush of blood. The pelvis
iill be found more or less occupied with blood-clot ; do not stop
to turn out the clots, but proceed through the clotted blood
to the fundus of the uterus and along either tube to discover
the sac. The site of the gestation is recognized as a soft, boggy
enlargement of varying size and consistency, according to
whether the ovum is, or is not, in situ. The sac is brought up
and examined for the rent. When the hemorrhage is marked,
the pedicle is at once secured with pedicle forceps until the
cavity can be cleansed and ligatures applied. After ligation
the sac is cut away. If the patient is very profoundly anemic,
no time should be lost by attending to the toilet of the abdo-
men, but it should be simply irrigated with normal salt solution
to carry away the principal clots.
3. The treatment of the patient subsequent to rupture — (a)
with intraperitoneal hemorrhage. The patient, having rallied
from the shock, will in very many cases recover without opera-
tive interference by keeping her perfectly quiet, promoting
drainage through the intestinal canal by frequent purgation,
and limiting the amount of food and drink that is given. She
is thus obliged to live upon her tissues, which will promote the
absorption of even a large collection. As we have already
leen, the tube which has been the seat of an abortion will gener-
ally be found distended with clots, and the same material will
fin up the retro-uterine pouch. The convalescence of the patient
will generally be enhanced by the removal of the tube and the
clotted blood. This is particularly true when the tube is the
seat of a perforation from the villi, for frightful hemorrhage
niay be found, and, besides, under such conditions it is likely
to continue. Even when the hemorrhage arises as a result
of rupture, we are not certain that the clot which plugs the
vessels may not be loosened and a recurrence of bleeding follow.
to spite of every precaution that may be observed it is not
infrequently found that a collection of blood in the peritoneal
cavity becomes infected from its proximity to the intestine,
^ thus a suppurative process is engendered which prolongs
614 GYNECOLOGY.
the patient's convalescence. Even should this not cxxrur,
the blood-clot, becoming organized, gives rise to thickening,
extensive adhesions, and more or less crippling of the function
of the pelvic organs for the remainder of the patient's life
If the patient comes under observation some days subsequent
to the evident rupture, thus affording sufficient time for the
vessels to become occluded by clots, and with an accumulation
of blood in the pelvis, which frequently is walled off by plastic
exudate from the general peritoneal cavity, the preferable
plan of procedure would be to make a free incision into the
vault of the vagina. Two fingers should then be introduced
through this opening, the clots broken up and evacuated, the
cavity thoroughly irrigated with normal salt solution and
packed with iodoform gauze. The tube may frequently be
brought down and secured by ligature or clamp between the
seat of rupture and the uterus, and the mass be thus removed.
This is particularly true when the tube is occupied by a large
blood-clot. When the tube is situated high up in the side rf
the pelvis or the lower part of the abdomen, and in a position
not readily accessible through the vagina, the abdominal incisiofl
is preferable, as it affords a better opportunity to inspect the
condition of the pelvic organs, to remove the occluded tube,
and, if necessary, the associated ovary. It has been urged
that where one tube has been the seat of an ectopic gestation
which has ruptured and led to operative interference, the other
tube should likewise be removed in order to prevent the possible
occurrence of an ectopic gestation within it. The many cases
in which a normal intra-uterine pregnancy has followed a tubal
pregnancy would render such advice unwise. While numerous
cases are recorded in which an operation for the removal of
an ectopic gestation has been followed by the occurrence of
gestation in the remaining tube, this, however, is not the nile,
and it would be just as logical to forbid matrimony because an
occasional marriage is unfortunate.
(6) Extraperitoneal hemorrhage is a result of rupture of
the tube between the folds of the broad ligament. A hemato-
cele is thus produced which is situated in the cellular tissue
between the layers of the peritoneum. The amoimt of hemor-
rhage is necessarily limited by the size of the vessel opened,
the blood pressure, and the distensibility of the structure into
which the hemorrhage has occurred. Where the collection
is small, it may be sufficient to treat the patient expectantly,
watch her progress, and trust to nature to absorb the exudate.
Even in this condition it should not be forgotten that in rare
cases the embryo may survive the accident and continue to
grow. The continuation of the growth of the fetus presents
EXTRA-UTERINE PREGNANCY. 615
additional and more serious problems. Prior to the fourth
month the embryo, tube, ovary, and adjacent portion of the
broad ligament, including the placenta, can generally be re-
aM)ved. Subsequent to this period, however, the placenta
nay have attained such a size as to render its removal difficult.
Not infrequently the life of the patient is endangered by a
wbsequent ruptiu^e. The placenta extends upon the pelvic
surface, covering over and surrounding the vessels and the
meter. Moreover, the intestines may aid in forming the sac
ivaD of the developing embryo and a condition result which
vrould render any operative interference exceedingly serious.
Where the patient shows marked symptoms of internal hemor-
cfaage and an examination reveals a collection of large size,
an immediate operation is preferable, for the depressed con-
dition of the patient increases the danger of infection of the
effused blood from the walls of the adjacent intestine. When
infection enters the sac, suppuration will follow. This, of
oourse, greatly endangers the life of the patient. Early inter-
ference with such a collection is preferably made through the
abdomen, for the reason that it affords a better opporttuiity
of exposing and securing the bleeding vessel. Having opened
tbe abdomen, the peritoneal cavity so far as possible should
be carefully walled off with a large quantity of gauze, the blood-
dots evacuated, and the bleeding vessels searched for and
Kcured. If the blood collection has been a large one and the
pdvis is covered with adherent blood-clot, an opening should
be made into the vagina, through which the end of a piece
of gauze sufficient to fill the cavity should be carried. When
the collection has been extraperitoneal, the abdomen can be
^ed off with gauze before the broad ligament is opened,
the clots should be turned out ; the bleeding vessel secured ; the
cavity packed with gauze, the end of which has been carried
through an opening in the vagina, thus allowing the peritoneal
wound to be closed. Care must be exercised, however, in this
procedure not to injiu"e the uterine artery or the ureter.
4. The metliod of treatment advisable in advanced growth
of the efnbryo — (a) the child alive. From the foiirth month
to the completion of pregnancy the existence of a quick placenta
presents a condition which is generally regarded as the most
laagerous in the whole realm of surgery. The sac has ruptured,
lie placenta has formed new and more extended attachments.
Vhile the condition of the patient can not be considered other-
rise than grave, the immediate danger is not so great but that
re can afford to wait until a later stage of the pregnancy for
atcrference and thus give the fetus a chance for its life. The
adstence of the live placenta and the profound hemorrhage
a few weeks, or at most months. Therefore th
the life of the mother should not be endangered
life of a defective child. Experience, however,
that the extra-uterine fetus may be well develoj
it is evident that the mother can be saved only
procedure, it seems cowardice that this should no
at such a stage as will give the other being ai
for continued existence. Fortunately, the inv
Dunning have demonstrated that the matema
enhanced by operation during fetal life. Th
of extra-uterine pregnancy, then, should lead to
tion for operation at a certain definite time prio
pletion of the gestation, preferably at about eighi
months. In resorting to operative procedure we
it from two additional standpoints: (i) As to th
the sac; (2) the method of disposition of the j
sac is composed of remnants of the expanded t
broad ligament, thickened and in parts expand
places coils of intestine or the adherent omenti
into its formation. The removal of the sac,
is fraught with danger, not only to the adjacen
vessels and ureters, but to the abdominal visce
When the pregnancy has passed the fifth mont
evidence of a living child, we would advise tha
be postponed until after the eighth month. It she
taken, however, not later than at eight and one
in order to afford the fetus the best chance
The operator is compelled to adapt his procedui
dition immcdialelv confronting him. The po:
EXTRA-UTERINE PREGNANCY. 617
The fetus is then removed and given to an attendant to be
."ored for. We now come to the decision of the question we
lave already mentioned, namely, the management of the sac
and the disposition of the placenta: (i) The sac, as already
aicntioned, is composed of remnants of the distended tube
..or the broad ligament, thickened and in parts expanded. In
other places coils of intestine or portions of the adherent omen-
tum assist in forming it. The removal of the sac, consequently,
.fc associated with great danger, not only to the adjacent large
Uood-vessels, but to the viscera and ureters. The ideal plan,
nhere possible, is to follow the delivery of the fetus by the re-
' moval of the sac, including the placenta; where the removal of
the sac can not be safely accomplished, the operator should
ftitch its edges to the skin margins of the abdominal wound. In
well-advanced pregnancy we may possibly be able to push the
peritoneum from the anterior abdominal wall and to penetrate
the sac without opening the peritoneal cavity, but the chief dif-
ficulty would be to determine — (2) how we shall manage the pla-
centa. The method employed will entirely depend upon its situa-
tion. Its management is most promising when situated in the
pelvis below the fetus. When above the fetus, the placenta may
bcinjiu^ and result in furious bleeding or, indeed, even death
of the patient. Even prompt seizure and ligation of the uterine
»de of the sac may fail to arrest the bleeding. The abdominal
iorta may then be compressed, the cavity packed with sponges,
and an application made of perchlorid or persulphate of iron.
The danger of bleeding has frequently induced surgeons to
leave the placenta and allow it to slough away, employing
proper measures for securing external drainage. When the
removal of the placenta can be accomplished without too much
risk, it should be done. In addition to avoiding the placenta
in opening the fetal sac, we should exercise the precaution
to prevent discharge of the amniotic contents into the peri-
toneal cavity. After delivery of the fetus the operation is com-
peted in one of three ways : ( i ) The extirpation of the entire
»c; (2) the removal of the placenta without the sac; (3) the
retention of the placenta and the sac.
1. Whenever it can be safely accomplished, the entire sac
should be removed. By this method the operation is more
complete and convalescence is more likely to be insured. This
can be accomplished whenever we can construct a pedicle and
the sac wall is made up of tissue that can without disadvantage
he removed. The pedicle may be narrow or broad, as in an
ovarian cvst.
2. Extirpation of the Placenta with the Sac Remiining. — The
placenta should be removed whenever it can be peeled out
'rithout hemorrhage, or when it is so situated that the vessels
618 GYNECOLOGY.
supplying it can be securely ligated and the mass removed,
or when its position is such that effective control of hemor-
rhage can be accomplished by tampons of iodoform gauze.
After removal of the placenta the gauze may be removed and
replaced by a large drain.
3. The Retention of the Placenta and Sac. — When the pla-
centa is firmly attached or it is evident that its detachment
would result in dangerous hemorrhage, it should not be dis-
turbed. The operator should exercise the greatest care in '
the management of the live placenta, as the hemorrhage in
such cases is frightful and exceedingly difficult to contrd.
Where the placenta is partially detached, it may be necessary .
to proceed with its removal. This should be accomplished
quickly, making firm pressure over the parts with iodoform
gauze. If the attachment is of such a character as will peniiit,
the parts should be quilted together by a ligature which is
tied firmly around the base of the placenta. Where it is neces-
sary to retain the placenta and the sac, one of the following
methods can be practised : The sac can be fixed to the abdominal
wall and the cavity drained, or the opening in the sac can be
closed, covering over the placenta and shutting off the latter
from the peritoneal cavity. In such cases the cord should
be cut off close to the placenta, after previous ligation with
chromic catgut, or the electro-angiotribe can be employed.
This instrument appeals to me as an efficient means of con-
trolling hemorrhage and insuring the removal of a portion ^
of the placenta. To accomplish this, it will require a modifica-
tion of the angiotribes at present in use, employing one witli j
a more flattened surface, thus allowing a good portion of the
placenta to be subjected to the slow action of heat. The pla-
centa and sac should be closed and returned to the peritoneal
cavity only when we have been able to seciu^e absolute and
rigorous antisepsis. The presence of a single microbe may
lead to putrefaction of the placenta and suppuration. The
disadvantages of the retention of the placenta are that its
separation and discharge are tedious and present continuous
risks of septicemia and peritonitis. Fecal fistula may fomi.
These risks are decreased by irrigation of the sac, by the ligation
of the cord close to the placenta without disturbing the latter,
by carefully sponging the cavity, and then, as has been sug-
gested, by hermetically closing it. Even though we are able
to exclude the germs from the cavity, it must be remembered
there is danger of their entrance through adhesions to the in-
testines. Intestinal micro-organisms may gain access to the
placenta and produce decomposition. The following rules have
been formulated by Sutton: (i) When the placenta is situated
above the fetus, attempt its removal; (2) if the placenta has
EXTRA-UTERINE PREGNANCY.
619
become partially detached during the course of the operation,
no choice is left but its removal; (3) the placenta below the
fetus can be left; (4) if the placenta is left, the sac closed,
and subsequently symptoms of suppuration occur, the wound
must be at once laid open and the placenta removed.
(b) The Child Dead, Mummified, or Reduced to a Lithopedion.
— The death of the child at any stage results in very early arrest
of the circulation in the placenta. The continuation of the
growth of the placenta after the death of the fetus has been
considered as a possibility, but this is very improbable. The
placenta does not decompose, but undergoes slow and complete
atrophy. The vessels in the maternal portion atrophy and dis-
appear. This, consequently, leaves much less of the placental
structure than would be found in an extra-uterine pregnancy.
The absorption of the placenta continues until, in those cases
in which the lithopedion is formed, the placenta is found to
be entirely absent. Should the patient come .under observation
when the history would lead us to suspect that the fetus has
but recently perished, it would be wise to postpone operation
a few weeks later, when arrest of the circulation in the pla-
centa may become complete. The sac is exposed by the ab-
dominal incision, the general peritoneal cavity is well pro-
tected by gauze packing, and care exercised that the contents
of the sac shall be removed without soiling the peritoneum.
The escape of the contents into the peritoneal cavity should
be prevented by the employment of an aspirator and the
sac should be carefully guarded by sponge packing before
it is opened. The fetus is withdrawn and the sac then
examined, with a view to its removal, if possible. Where
the condition will admit, the entire sac, with the enclosed
placenta, should be removed. If knuckles of intestines are
adherent to the sac, the greatest care should be exercised in
their separation, in order to avoid inflicting injury to them.
Where the adhesion is very firm, the separation should be made
at the expense of the sac wall, leaving a portion of it attached
to the intestine. When a large portion of the intestine enters
into the formation of the sac wall, the removal of the sac will
not be feasible. In such cases the placenta should be peeled
out, the cavity thoroughly sponged with carbolic acid and
afterward with alcohol, dried, packed with gauze, and its edges
stitched to the abdominal wound. Where the sac is dependent
and in close approxinia.tion to Douglas' pouch, an opening
should be made through its base into the vagina, through which
drainage may be effected and the upper part of the sac closed.
The vaginal drainage of the sac should be employed whenever
ible. as the dramage is from the most dependent portion
the convalescence of the patient is much shorter and
620 GYNECOLOGY.
the dangers of subsequent ventral hernia greatly decreased
Following the death of the fetus marked changes occur
The fetus itself may become mummified, its watery portioQ
absorbed, forming a flattened mass. Or, again, the entir
fetus undergoes a substitution of fat for its original structures
forming a lardaceous condition; or, again, we may have tb
fetus and its sac filled up with calcareous deposit, causing i
rather dense, hardened mass. Some of these conditions ma;
continue for years. A lithopedion has been found in a woma
of ninety. Their presence, however, always predisposes t
infection, which may result in suppuration, with subsequen
discharge of particles of the calcified mass. Wherever pos
sible, the entire mass should be removed. Wherever it is rec
ognized, after an abdominal incision, that the mass has fonne(
extensive adhesions to the intestines and other structure
of such a character as to preclude the probability of successfu
removal, the sac should be opened, its contents so far as pos
sible removed, the sac wall stitched closely to the abdomina
wound, and its cavity packed with gauze. The removal a
the fetus and the drainage of the sac result in its complet<
obliteration and the restoration of the patient to health.
(c) Following Decomposition of the Fetus and Suppuratim
of the Sac. — Decomposition of the fetus and supptiration ol
the sac are indicated by symptoms of inflammation, the sau
becoming tender to pressure with evidence of localized peri-
tonitis. The temperature of the patient will be elevated; pos-
sibly recurring chills, night-sweats, progressive emaciation,
and symptoms of low continued fever will be manifest. Lique-
faction of the sac by pus-formation causes thinning and ex'en
rupture of its walls, with the escape of its contents into the
peritoneal cavity, the bladder, the intestine, the vagina, or
through the abdominal walls. The rupture results in the for-
mation of a sinus, through which often will be found passing
fragments of small fetal bones. The existence of suppuration
should be considered an indication for immediate operation.
To open the sac without entering the peritoneal cavity is, of
course, more satisfactory, and this occasionally can be accom-
plished. If the adhesions between the peritoneal surfaces are
not extensive, the opening may be a small one, and by gauze
packing and other means the adhesions may be extended-
Where parietal adhesions do not occur, the sac should be opened
and its contents thoroughly evacuated, but the peritoneal
cavity must be thoroughly protected from soiling by gauze
packing. Every fragment of bone should be removed, for
otherwise the obliteration of the sac will not take place and
suppuration will continue as long as the irritation remains.
The cavity of the sac should be thoroughly packed ^vith iodo-
GENITAL TUMORS.
621
gauze and the sac itself be stitched to the skin edges,
g the convalescence the cavity should be frequently irri-
with antiseptic fluids. We may sometimes be able, es-
ly where the opening has taken place through the
linal wall, to dilate the sinus and empty the sac with-
pening into the general peritoneal cavity. This method
ocedure can be effectually employed in the opening
jh the abdominal wall and the vagina, but openings into
adder or intestine will require abdominal operation. How-
efforts should be made to remove the sac, if possible,
) close the intestinal or vesical openings.
GENITAL TUMORS.
5. Definition. — In the broad sense of the term any unusual
ng or protuberance of a part can be called a tumor, but the
lation is properly restricted to a new-growth which is inde-
nt of the results or productive of inflammation. Such a
h is distinctly circumscribed, has a marked course, can be
tely differentiated, and is associated with febrile symptoms
ivhen degenerative changes exist.
l6. Classification. — Tumors of the genitalia, like those
ring in other portions of the body, are divided clinically
the benign and malignant; pathologically into neoplasms
ysts, and histologically into those which originate in adult
embryonic tissues. The following table, prepared for me
r. P. B. Bland, presents the subject in a readily compre-
ve form :
f Fibroma
j Myoma
Fibromyoma
Fibro-adenoma
^ Angioma
Lipoma
Myxoma
, Chondroma
Solid ^ I Osteoma
Adult connective tissue
1
1^ Adult epithelial tissue
Retention
^ Cystic j «^p^,lt^ [ Dermoid
Vaginal cysts
I
1
I Xeuroma
Papilloma
Adenoma
'3b
lant 'z '
X
Embryonic epithelial tissue
Embryonic connective tissue
Carcinoma
•j Chorio-epithelioma.
malignum
{
Sarcoma
Endothelioma
622
GyNECOLOGY.
When we come to analyze the arrangement into groups i
these growths, we find that any arrangement must l>e more (
less arbitrary, and the transition from one form to another is 8
subtle as to make the assignment of some gro^s-ths ver\' difficult
and uncertain. The definition into benign and malignant is of
classic origin and necessarily is of great importance. A benign
tumor may be defined as one which in the course of its develop-
ment inclines tti remain local or confined to the structures in
which it originated. It develops from adult tissue, in its prog-
ress is not usually destructive to life, and displays no dis-
position to metastasis nor to recur when removed. The malig-
nant tumor, on the contrary, is supposed to have its nidus in I
embryonic tissue, gradually breaks dowTi its original barriers,
invades the surrounding structures, extends by metastasis until i
the entire organism may become infected, and displays a marked |
tendency to recur after surgical intervention.
The study of the structure of growths shows a marked ]
difference in the cellular tissue of the two classes, each having '
well-defined tissue changes which render them recognizable,
and from which the future progress may be predicated.
In the differential diagnosis it is often difficult to draw the |
line and assert that the benign terminates here and the malignant
begins there. In some of the uterine and ovarian growths, par-
ticularly the glandular varieties, we are forced to rely upon the
life history of the growth in order to determine its proper classi-
fication. Notable examples are the glandular and maHgnant
adenomata of the uterus and the papillomata of the ovary.
VnLVA, VAOIRA, AND BLADDER.
557. Characteristics of Benign Neoplasms. — -The benign
growths have been divided into solid and cystic, and the former,
from their structure, into the connective-tissue and the epithelial
tumors. The connective-tissue growths predominate among the
benign, and while they may be found in all the tissues of the geni-
taha, they to the greatest degree characterize those springing from
the uterine parenchjTna and are known as the myomata or fibro-
myomata, according as the muscular or connecti^'e tissue pre-
dominates, or the fibromyomata in a combination, of the two.
Cystic tumors are those which consist of the envelope, sheath, or
sac containing thin serum, blood, pus, mucin, sebaceous material,
parasites, hair, cartilage, or bone. These tumors have their
origin in the ovaries, broad ligaments, vulva, and vagina, in con-
genital remains, as the \\'olffian bodies, the parovarian and 1
remnants of the ducts of Gartner, and the Mullerian ducts. ,
Cystic growths of the ovary present considerable difficulty in 1
GENITAL TUMORS, 623 J
classification, inasmuch as twenty per cent, of them prove to be '
malignant. Even careful microscopic examination of the growth
win not always enable it to be properly classified, because a
mahgnant nodule or portion may be engrafted upon what other-
wise seems a benign growth, and may be so situated that it can
readily escape observation, for the examiner would be entirely
unable to subject the parts of a large growth to such an investi-
gation. Certain of these growths— the papillomatous variety —
show a disposition to grow through the enveloping sheath or
cyst wall, and when it is ruptured, their contents are infected or
become implanted upon the peritoneal surface, causing a low
grade of peritonitis and an extensive ascites. Such behavior at
once answers to the description of malignant disease, but experi-
ence reveals that in the majority of cases the removal of the origi-
nal source of infection, the ovarian growth, produces atrophy and
disappearance of the secondary infection of the peritoneum.
In many of these growths the surgeon is compelled to deter-
mine the final diagnosis between benignancy and malignancy by
the subsequent chnical history of the patient. In discussing
specific grovt-ths, comparison can more readily be made by con-
sidering separately the tumors, benign or malignant, which are
prone to occur in each portion of the tract.
558. Unclassified. — In the former editions I discussed some
conditions under genital tumors, using the term in its unre-
stricted sense, which I will now consider separately. These condi-
tions are hernia, hydrocele, varicose veins of the vulva, edema,
elephantiasis, and urethral caruncle.
559. Hernias. — The gaseous cysts are hernias which present
in the vulva in two varieties— the anterior labial or inguinal and
the posterior labial. The anterior labial hernia is analogous to
the scrotal hernia in the male. It is formed by a portion of
intestine or omentum descending through the inguinal canal and
distending the large labium. (Fig. 448.) This form of hernia is
comparatively rare in women. Femoral hernia is much more
frequent in the female. In the latter the hernial sac emerges
below Poupart's ligament and makes its exit as a lump in the
groin, which, as it increases in size, pushes up over the ligament.
In the sac of an inguinal hernia has been found an ovary and
tube and even the fundus of the uterus. Instances have been
recorded of an ovarian cyst or a tubal gestation coraphcating
such a hernia. The posterior labial hernia (Fig. 449) is formed
by the intestine driving the peritoneum through the pelvic
aponeurosis and the levator ani muscle. The sac appears at the
side of or projects through the vulvar orifice. Labial hernia
may sumetimes be difficult to differentiate from hydrocele or a
fatty tumor of the labium. A double hernia with an ovar>- in
624
GYNECOLOGY.
each labium associated with a large penis-like clitoris may cam
some doubt as to the sex of the individual.
560, Hydrocele. — A well-formed serous cyst which is cm
tinuous is sometimes situated in one or the other labium maju
or when the canal of Nuck is patulous it may, by slight pressure. 1
emptied back into the peritoneal cavity to recur as soon as tl
patient assumes the upright. This tumor is known as hydrocel
and is analogous to the serous collection sometimes found in th
scrotum of the male. The sac is thin walled, quite translucent
and affords a distinct sense of fluctuation. The swelling grad
ually increases in size and may become so large that it is uncoo
fortabie in sitting or walking, and may prove an obstacle to tb*
sexual relation. Hydrocele is readily distinguished from soli'
tumors by its translucency and distinct fluctuation; fromheniis
by its being more continuously distended, except in the ft'
GENITAL TUMORS.
625
; in which the canal of Nuck remains patulous, the more dis-
sense of fluctuation, its translucency, a less amount of pain
iscomfort, the absence of any swelling over the line of the
inal canal, and the failure of the protrusion to increase during
hing or straining.
'reatifient. — The contents can be readily removed by punc-
, but recollect rapidly. Obliterative inflammation may be
Fig. 449. — Posterior Labial Hernia.
Midered after the removal of the fluid by the injection of
e irritating agent, and pressing it about t(j bring it in contact
1 the entire cavity of the sac, but care must be exercised to
^ent it being forced through an cipen canal into the peritoneal
ty, A safer and more satisfactory procedure will be to make
X opening into the sac and pack it with iiidofnrm gauze,
i6t. Erectile or vascular tumors are rare in the labium, but
n they occur, present characteristics similar to those in other
626
GYNECOLOGY.
portions of the body. Vascular growths about the uret
much more frt-quent. Pozzi indicates that the hymen i
simple is()lated structure surrounding the \'ulva, but coi
first, the masculine frienum vestibuU ; second, the ring ii
the urinar>' meatus; and, third, the hymen. The stni'
the undeveloped matrix tissue of the corpus spongiosun
male, and has not become erectile. These considerati
asserts, thn)w light up^m the origin of some of the i
growths of the uretl
meatus. The reter
the erectile tissue
female, which is no
the male, results, i
efforts at micturitioi
formation and extn
a polypus, known a:
tliral caruncle.
562. Aurethialc
appears as a brig!
fragile looking pn
from the urethral
It is largely comp
dilated capillaries
small amount of con
tissue, and is cover
pavement epitheliui
a recent study of so
croscopic sections 0
growths I discovei
presence of glandula
ture quite well markt
growth is amply s
w^th ner\-es, which a
or less exposed. Th'
ture of the growth ai
for its vascularity an
sensitiveness. (Fig.
E/i"o/t)(; v.- -The j
may otTur ;it :iny age. They are frequently seen in
i-hiiilren, an- iimr: frcqui^nily found in middle life, and ha'
si.'on in w.mu-n iis l;Uf :is the seventy-fifth year. They occ
;il«'ut c(iu:il jVf(ju<.'iu-y in the married and unmarried.
Syiupkvii.'i.- The growth usually projects from the u
urifii-i- and is generally situated uj»nn the posterior wall.
rating widely, the vulva causes the tumor tn be pushed E
and rendered niMiv ]irominent. Its sensitiveness varie
hral Caruncle.
GENITAL TUMORS.
627
lifferent individuals. In some it produces no marked symptoms,
irhile others complain of continuous burning, a sensation of full-
ness in the urethra, and marked pain during and for several
minutes following urination. Occasionally the distress is so
marked that the act of micturition is prevented and the employ-
ment of a catheter is rendered necessary. Its extreme sen--
ritiveness frequently causes it to be a barrier to the sexual re-
lation, hence it is one of the catises of dyspareunia.
Diagnosis. — The tumor
is readily recognized by its
bright rei3 appearance, its ex-
treme sensitiveness, and its
fr^ilily. A varicose condi-
tion of the urethral vessels
may occur, but this is char-
acterized by bluish projec-
tions from the urethral ori-
fice, which are plainly recog-
niied as distended veins,
somewhat resembling hemor-
Aoids about the anus. A
prolapse of the urethra may
otist, but this condition
forms a rounded projection
which partly or completely
encircles the urethral orifice.
(Kg. 4SI-)
Treatment. — The only
treatment that affords any
hope of success is excision.
Tlus may be done under co-
cain anesthesia, the mass
picked up and cut off at its
base with scissors, and bleed-
ing arrested by coaptating
the surfaces T.\'ith a suture.
It is much more satisfactorily
accomplished, however,
under general anesthesia, as the i>atient is then quiet and the
iianipulatiun can be more deliberate. The excision of the mass
with scissors and the application of the ihermocaulery to the
hasearevery elBcicnt. In tlicemi»]nymcnt of the thermoL'autcry
aiCiXKlen rod the size of a cathettT should bf previously intro-
duced to [treserve the urethra from di'slruL-tion. iCspivial care
"lUst l>e exercised to control the hi.'miirrii;igc. as I have seen
'rightful bleeding occur from such an operation.
62S
GYNECOLOG
563. Varicose Veins. — Varicose veins of the vulva are not in-l
frequent during gestation. (Fig. 452.) Holden reports a case 1
in which the labia majora were the size of a fetal head. The pa-
tient died of phlebitis. The tumor presents a bluish color on
the surface of the integument, violet on the mucous surface, and
gives rise to a sensation of weight in walking or when the patient
is in the upright position. The rupture of such a tumor may
cause serious or even fatal hemorrhage. Tlie patient should be
cautioned to wear her clothing loose, having no constriction about
the waist, and the varicose parts should be supported. The most
effective treatment is the excision of the principal veins.
564. Edema. — Anasarca is frequently accompanied by ex-
tensive swelling of the labia. The cause is readily recognized by
the associated condition. When edema exists without general
dropsy, it is indicative of some obstruction to the circulation in
the pelvis. Edema confined to one labium is generally the result .
of injury or inflammation. A hard, dense exudation in one la- ,
bium will usually be found to be due to a hard chancre, situated
upon the same side at the margin of the vagina,
565. Elephantiasis. — Elephantiasis consists in chronic inflam-
mation of the lymphatics, with dilatation of their canals. It is
very rare in our climate, but is more likely to exist in hot cUmates,
The cause of the condition is unknown. Tlie affection consists
GENITAL TUMORS.
of more or less considerable hypertrophy of the entire \'ulva.
sometimes localized in certain regions, as, for example, in the
clitoris. The large hypertrophied labia form voluminous masses,
which may exceed the dimensions of an adult head, (Fig. 453.)
Three forms are described ; first, the entire derma is hypertro-
phied, with vast dilatation of the lymph-spaces; second, the
engorgement of the lymph in the capillaries and large trunks;
third, the lymphatic ganglia become the seat of fibrous altera-
tion.
Symptonts. — The enlargement is frequently so great that
walkii^ and urination are interfered with. Friction of the sur-
face leads to ulceration, which is slow to heal. The thickened
tissues invade the viilva and the perineal and anal regions, and
form enormous tumors. When the surface of the sldn is smooth,
it is called glabrous; when roughened, with warty projections,
verrucous; and papillomatous when the papillse are much
hypertrophied.
Diagnosis is easy. The h>-pertrophy and swelling of lupus
are always accompanied by ulceration. The papillomatous veg-
etations are situated directly on the skin. In fibromata and
myxomata which become pedunculated the tumors are isolated
and circumscribed, while elephantiasis is diffuse. The cause of
the condition is unknown, although it has been attributed to
syphihs. It is due to an acute lymphangitis, mth intense fever.
The only effectual treatment is ablation and the suturing of the
surface in order to secure union by first intention.
566. Tumors of the vulva are comparatively rare and com-
prise cystic and solid, benign and malignant, growths.
567. Serous cysts would naturally be expected to occur in a
region so well provided with glands as is the vulva. Retention
cysts of the gland of Bartholin belong to this class. (See Section
394.)
568. Sebaceous cysts rarely attain to any size. They are
found upon the labia majora, the labia minora, in the sulcus
between them, about the chtoris, over the mons veneris, and
sometimes upon the edge of the hymen.
569. Blood cysts are occasionally found. These may origi-
nate in a preexisting hematoma, through a hollow, round liga-
ment ( Koppe), in the sac of an old hernia, in the site of a throm-
bus, or from dilatation of lymph-vessels.
Cysts are also found in the liymen — ^Doderlein says, from
fusion of adjoining surfaces; in the urethra, either from ob-
literation of Skene's glandules or the dilatation of a terminal
and unobliterated vestige of Gartner's duct.
\
030 GYNECOLOGY.
Hematoma of the vulva and vagina has been describedi!
(Section 534.)
Abscess. — (Section 391.)
570. Neuroma of the vulva is a rare condition. PainI
nodules are occasionally recognized, and their presence
casions vaginismus.
Treatiticnt would be to excise the painful spots.
571. Simple Vegetations. — Vegetations appear upon the vialva
in the form of papillomata or condylomata, occasionally having
the appearance of a cauliflower. They may be situated at
the edge of the vulva in isolated projections, or may cover, by
a voluminous growth, the whole surface of the external genitalia.
The mass may extend backward around the anus, and may
attain the size of a fetal head. The growth presents a pale
red color, often a deep wine tint, and is situated upon the v-ulva,
perineum, and margin of the anus, sometimes extending for-
ward over the mons veneris and over the inner surface of the]
thighs. (Fig. 453-) A profuse leukorrheal discharge is gener-
ally present, which is retained by these vegetations, and causes
an extremely disagreeable and fetid odor. The decomposing
discharges irritate the surface, which becomes greatly inflamed
during walking and exercise. They are generally considered an
indication of venereal infection, and are produced by either gonor-
rheal or syphihtic virus. Transmission of the disease has been.
obsen^ed by contact. The presence of vegetations, however,,]
is not always an indication of specific infection, as these growths
arise in pregnant women from a simple leukorrhea. The sur-
faces upun which they are implanted may become thickened
by inflammation, undergo ulceration, and be covered by a glairy,
fetid mucus which increases the resemblance to malignant
disease. A vertical microscopic section of a growth, however,
will reveal its true character. In the vegetations are dilated, tree-
like capillaries embeilded in connective tissue, and covered with
several layers of epithelium, thus presenting a marked con-
trast to the nests or tubular masses of epithelium embedded
in connective-tissue stroma, which indicate the presence of
epithelioma.
Treatment. ^Keep the parts thoroughly clean, irrigate
bichlorid solution (i : aooo), and dust the surface with eqi
parts of alum and sugar or paint it with carbolic acid and af
ward wash with alcohol. When the vegetations are very
tensive, the most etYective method of treatment is to place
patient under an anesthetic and with scissors cut away the vegeta-
tions, cauterize the base with nitric or chromic acid, or, still
better, with the thermocauter},-, and subsequently keep the parts
clean and dusted with a drying powder. The pain foUowing th«
I
GENITAL TUMORS.
ation of the thermocautery will be greatly lessened by
ng the burned surface with carbolic acid. The convales-
will be rapid. The existence of pregnancy need be no
tr to the method of treatment indicated, as the danger to
atient from sepsis following delivery is much greater than
rhich could result from the removal of the growths.
GYNECOLOGY.
General anesthesia can he avoided by saturating the partflj
with a ten per uent. solution of cocain. Removal of the growths J
by the curet has been advised, but the scissors affords a cleaner 1
of the Vulva.
and more effective instrument. Excision pnxluces less irritation
of the subjacent skin. The hemorrhage may be controlled by
the application of a strong solution of persulphate of iron, but
UENITAL TUMORS. 633
lermocautery will prove more satisfactory. The bum-
the latter can be lessened by the application of a corn-
wet with a 5 per cent, solution of carbolic acid. The ap-
on of a lo to 40 per cent, solution of formaldehyd two
■ee times will cause the vegetations to slough, but this
lainful application.
1. Fibroma and myxoma are tumors which are found in
rge labia, though they may also develop in the nymphas
the perineum. They are benign tumors of slow growth.
ti they occasionally attain to large size. The former be-
pedunculated. The tumor may be enucleated or the
B may be cut without danger of hemorrhage. Figure
tows a fibroid tumor that occurred in the practice of Dr.
Cox, of Nashville, to whom I
M}ted for the illustration.
}. lipoma. — A lipoma is a
tomor of the labium which
resemble elephantiasis.
g^ the kindness of Dr. E.
ed, of Atlantic City, I was
tted to see a lipoma the size
orai^ on the vulva of a,
a who consulted him from
iTthat it was a hernia. Lipo-
are usually small, but Stiegel
ed one that weighed ten
s.
4. An enchondroma is an ex-
gly rare cartilaginous tumor
affects the clitoris. It may
le as large as the fist and Fig. 4SS— Fibroid of Labium.
it calcified portions. Bartho-
xnts a Venice courtesan who wounded her paramour with
sified clitoris.
5. Malignant Disease of the Vulva.— Malignant disease
t in the vulva in the form of epithelioma, sarcoma, and
as adenocarcinoma. Primary cancer of the vulva is
Epithelioma is the most frequent form and begins in the
latnum or in the cleft between it and the lesser labium,
equently in the cHtoris or the meatus. The disease origin-
rom the squamous epithelium and usually appears first as
warty nodules covered with thick layers of epithelium.
:imes it follows irritation about the base of a preexisting
omaorwart. It is frequently preceded by psoriasis. The
•Jium covering the nodules undergoes degenerative changes
auses a dischai^e of thin watery fluid mixed with blood.
634 GYNECOLOGY.
Groups of the embryonic cells fracture the limiting membrane I
and penetrate deeper tissues, supplanting the normal tissue and
forming the characteristic epithelial pearls. Sometimes the
cells will be found in the act of penetrating the walls of the
blood-vessels, thus expediting the propagation of the disease.
As the infiltration advances, superficial ulcerations occur, which
gradually become deeper and involve the neighboring structures.
(Fig. 456.} The inguinal glands are first sympathetically in-
Fig. 456. — Cancer of the Vulva.
volved and later become infiltrated with the malignant cells.
The disease occurs upon one side and then spreads to the oppo-
site, possibly by inoculation through apposition. Adenocarci-
noma results when the disease begins in the glands of Bartholin.
Sarcoma occurs in the simple form as the melanosarcoma.
Symptoms.— The patient suffers from intense pruritus, in
scratching for which the nodules, previously unnoticed, are
discovered. These become excoriated and cause a bloody J
GENITAL TUMORS. 635
11^ and an exceedingly fetid odor; not infrequently the
.e is a wart which has become irritated at its base and
quently infiltrated. The noduJes may be sessile or pedun-
^, and subsequently coalesce. When the disease occurs
; the urethra, the orifice may become contracted, and
;anal may appear as a hard, indurated cylinder. The
ition presents excavated borders, with the adjacent skin
•ated and hard, and the pubic hair may fall out. In the
;;. — Appearance of the Vulva allt-r aiV Operation for Cancer of the Vulva.
Stages the skin and tissues fnr some distance around the
I become indurated and h;ird. and tlic plands of the groin
ifected. With the extensive inllamniation, the discharge,
f bloori, loss of rest, and the mental anxiety produce emacia-
and death follows from marasmus, sepsis, or metastatic
opment. The latent period is a long one, the disease
ining for some length of time with but slight cin^umjacent
ore extensive involvement. Death occurs in the second
ird vear.
63G GYNECOLOGY.
Diagnosis. — The history of continued genital psoriasis; in-
tense pruritus, with small nodules; arrangement of the epithehal
layer, which shows a tendency to break down ; the irregular ul-
ceration, with infiltrated base and margins; and, later, glandular
involvement, are sufficient to indicate the character. Papillary
vegetations extend over a considerable surface, are comparatively
free from induration, and in no sense resemble cancer. A pol-
ypus or caruncle of the urethra has a base free from induration.
Chancre is an indurated sore without disposition to spread, and
is associated with glandular involvement, and later with the
syphilitic eruption. Chancroid is a superficial ulceration without
induration. The contiguous surfaces readily become inoculated.
The lymphatic glands promptly go on to suppuration and to
the formation of buboes. In lupus the ulceration is serpiginous,
with a tendency to cicatrization in the tissues first affected,
and glandular involvement is rare.
The prognosis of malignant disease of the vulva is bad.
The cases usually come under observation after extensive
involvement, generally after the lympliatic system has. become
invaded by the malignant process. Operative treatment delays
the progress of the disease and renders the patient more com-
fortable.
Treatment. — The only hope for the patient consists in total
removal of the disease. Some prefer the thermocautery or
galvanocautery to the knife, as affording less danger from
secondary inoculation. The scissors or the knife, however,
are preferable, as by their use we shorten the convalescence
and leave the structures less distorted. Care must be exercised,
when possible, not to injure the meatus. In peri-urethral cancer,
however, the sound should be introduced into the bladder,
which will aid in the dissection, and the neoplasm, if neces-
sary, should be followed to the neck of the bladder. In one
case I removed the urethra up to the neck of the bladder without
the patient suffering from incontinence. The incision should ex-
tend well around the disease, as far as possible within the bounds
of healthy tissues. Bleeding vessels, rather frequent in this
region, are secured with clamp forceps, and hgated if neces-
sary with catgut hgature, or the sutures closing the wound
are so introduced as to constrict the bleeding vessels. Care
must be exercised that the bleeding vessel does not retract and
continue to bleed. The retraction thus of branches of the
internal pudic caused hemorrhage which followed the pelvic
muscles backward, broke through and formed a large hematoma
upon the posterior surface of the sacrum, in one of my early
operations for this condition. In such a case, if the vessel can
not otherwise be secured, it will be better to tie the internal
GENITAL TUMORS. 637
pudic over the external surface of the spine of the ischium.
fig. 456 illustrates the case of a woman who underwent opera-
in which both labia and clitoris were removed, and the
subsequently imited, as seen in Fig. 457. Any inguinal
^SJids involved should be extirpated, as well as the principal
chain of lymphatic vessels leading to them. The circumjacent
fat and cellular tissue should also be removed. When the disease
lias progressed too far to render radical operation successful,
the putrid discharge may be temporarily controlled by the use
of the curet and cautery. When the disease is too far advanced
for this, the surfaces may be kept sprinkled with iodoform and
pure charcoal, and dressed with gauze. The surface can be dusted
irith the following powder:
K . Salicylic acid P:^^
Boric acid, ^ j
Iodoform, 3 ij
Ext. eucalyptus, q. s.
Kraske advises in extensive disease that the parts be thor-
oughly cureted, the lacerated parts cleansed, and the surface cov-
ered with flaps of healthy skin, as this procedure renders the
course of the disease slower and the symptoms less painful.
VAGINA.
Tumors originating in the structure of the vagina are infre-
quent.
576. Cysts of the vagina are very rare, and are generally
fcnned in the remains of congenital structures. (Fig. 458.)
Tliey are fotmd as isolated tumors in the mucous and submucous
membrane, in the former usually directly beneath the squamous
epithelium. Rarely more than two or three occur in any indi-
vidual case; Schroder, however, removed six from one patient.
They are more frequently found upon the anterior wall, and
are exceedingly rare upon the posterior. They vary in size
from that of a pea to a hen's egg. The contents of these cysts
are serous, more or less viscid or gummy, and are sometimes
found mixed with blood. The epithelial lining of the sac may be
either cylindric or laminated. The epithelium of some is cihated
(Abel). The origin of these growths is exceedingly difficult to
determine. They have been attributed to the remains of
MtUler's, Wolff's, and Gartner's ducts, to vaginal glands, or,
according to Klebs, to dilated lymphatics. Neugebauer attri-
butes most of them to remains of Gartner's canal. Hematoma
of the vagina may serve as the origin for a cyst. Glands of the
urethra may form retention cysts, and, as they develop, may
project into the vagina.
638
GYNECOLOGY.
The sytnptoms will depend upon the size of the cysts. Or-
dinarily, they produce no inconvenience nor discomfort. Re-
cently a patient underwent examination for some pelvic dis-
order, when a cyst the size of a walnut was found upon the
posterior wall.
Diagnosis.— 1\it condition may sometimes be mistaken for
cystocele or urethrocele. The use of the catheter during the
examination will demonstrate the thickness of the septum
and the presence and siie
of the cyst. In the upper
part of the vagina c>'Sts a-t
confounded with small tu-
mors in Douglas' cuidesac,
such as prolapsed ovaries,
a noncystic inflammaton'
condition of the tubes, and
other inflammatory collec-
tions. A second vagina.
which is closed and filled
with retained secretion, may
simulate a cyst.
Treatment. — Only the
large cysts require any
treatment. The c«t may
be opened and the sac
cauterized most effectually
^rith the actual cautery;
or it may be packed with
iodoform gauze, which af-
fords drainage and sets up
sufficient inflammatii-'n i'.'
obliten-tte it; or the entire
sac may l>e enucleated.
577.' Fibroid Tumors asl
Polypi. — Fibroid tumors
originating in the vagina
are very rare. They de-
velop in the submucous ■:'T
deejicT layers of the mucos:i and push into the vagina. As
they increase in size they become polypoid, and liaiig by a
pedicle. The structure is similar to that of uterine fibRiids-
iiml the growth is slow. The most common situation is the
su]itTiiir portion of the anterior wall. They are of ten adherent
111 thu urethra, and ilistend the vulva. They arc usually snUil.
altiiouj;]! they have been reported as weighing two and cm*-
lialf ]i(iun'is. Bandicr and Oremlier report one weighing 'i'^-
Fig- 4>-'
-Cysts fif tlif Vagina.
GENITAL TUMORS. 639
s. I am indebted to Dr. John C. DaCosta for the illustra-
""'B- 459) oi a specimen which he removed from the vagina.
sse growths increase in size, they become softened and
X. They are much more likely to develop during the
of sexual activity, although Tratz reported one in a
)f fifteen months which attained the size of a man's fist,
artin one J of an inch long in a child two days old.
mptoms. — ^The symptoms of the growth are largely de-
it upon its size. If small, the tumor may remain unrecog-
Larger growths cause
a and retention of
They project from
ilva, and the traction
:es bleeding, ulcera-
nd erosion.
ignosis. — The growths
adily determined by
ituation, slow growth,
echanical disturbance.
ftening, ulceration, and
rhage may sometimes
) a diagnosis of raalig-
lisease.
joimenl. — The treat-
:onsists in the removal
growth by enucleation
ile tumors, and by see-
the pedicle in polypus.
rrhage is controlled by
TB or suture.
). Papillomata. — Papil-
r warty growths are
in the vagina, gener-
association with simi-
iwths about the vulva.
illy they appear as
isolated projections over the walls, but occasionally the
vagina i,vill be filled.
). Malignant Neoplasms. — In the vagina malignant growths
nary origin are very rare. They most frequently extend
,he uterus, rectum, vulva, urethra, or bladder, in one of
'orms: first, papillary; second, infiltrated or nodular, both
ich are included histologically under epithelioma; third,
la, either diffuse or circumscribed. They most frequently
Ji the papillary form, although we may have carcinomatous
640
GYNECOLOGY.
infiltration, either circumscribed, forming a broad-based exc^e^ \
cence. or a substitution of scirrhous for the normal tissue. ,
Etiology. —Ma.lignant disease is most frequent during middle
age, and is rare in youth, although I have seen one case of cancer
of the vagina in a woman twenty years of age. Hegar once sa«
it in a woman in whom it was attributed to the irritation pro-
duced by a pessary. Epithelioma of the papillary form usually
affects the posterior wall, as a broad-based excrescence which
rapidly invades ibe
culdesac and ex-
tends down\rard to-
ward the vulva.
Epithelioma of the
nodular or infil-
trated form appears
as nodules wluch
become conflueni,
sometimes localized
about the wall of
the urethra. The
ulceration advances
rapidly, and mav
burrow into neigh-
boring organs, pro-
ducing rectovaginal
or vesicovaginal fist-
ula. The disease ex-
tends by the lymph-
atics to the pel«
cellular tissue ; when
it is situated in the
anterior wall, the
lymphatic glands of
the groin are also in-
volved.
Sj'iH/'/oHir.— Va-
ginal epithelioma
very early causes
hemorrliagc, which will be aggravated by locomotion, coition,
and the Viirious procedures in examination. There is a profuse
purulent discharge which is exceedingly offensive ; pain is not so
marked as in disease nf the uterus, unless in the later stages. The
principal symptoms are the mechanical obstruction to coitjiin
and to delivery from stenosis, and the waterj', bloody, andoffen-
si\-e purulent discharge. In a case recently under observation
the <liseaKe hatl involved the anterior wall of the vagina. JiaWng
l-"ig. 460.
GENITAL TUMORS.
apparently originated in the urethra, and formed a large scirrhus-
like mass extending upward over one-Iialf the anterior vaginal
wall. The patient suffered from great inconvenience in urina-
tion, having frequent attacks of retention and severe pain.
Sarcoma. — Sarcoma occurs in two varieties: first, the dif-
fuse sarcoma of the mucous membrane, often seen in yotmg
children; second, fibrosarcomatous growths, or melanotic sar-
coma. Epithelioma, or cancer, may be distinguished from sar-
coma by the use of the microscope. In the former we note the
characteristic assemblage of the epithelial cells, forming the
pearly bodies, and preservation of the walls of the blood-vessels;
while in the latter, the cells are more or less unconfined by
connective-tissue stroma and the blood-vessels appear as mere
sluiceways or blood-channels.
Treatment. — The thin wall of the vagina is very slightly
resistant to the progress of malignant disorder, and the dis-
ease is rapidly transmitted by the lymphatic vessels to the deeper
cellular tissue of the pelvis, so that by the time the patient
affected with cancer or sarcoma comes under observation, very
little can be done in the way of treatment beyond reheving her
from the discomfort produced by the accompanying symptoms.
Complete recovery is rare. Eiselsberg, in a case of cancer which
involved the whole of the rectovaginal septum, resected the
coccyx and established an artificial anus in the sacral region
after extirpating the whole of the diseased part. The patient
rapidly recovered and had control of her stools. In a patient
of mine, when the disease had proceeded from the rectum,
involved the posterior wall of the vagina and the perineum,
and extended close to the cervix. I removed the coccyx, re-
sected the sacrum, excised six inches of the rectum, removed
the ovaries, tubes, entire posterior wall of the vagina, and
the posterior commissure of the perineum. The rectum was
stitched to the sacrum posteriorly, and to the anterior wall
of the vagina anteriorly, the peritoneum having been pre-
viously closed, (See Ftg. 530.) A colostomy had been per-
formed upon the patient before she came under my obser-
vation. After the patient had recovered from the pelvic opera-
tion the opening in the intestine was dissected out and the
two ends of the bowel were reunited. The patient was under
observation for nearly thirteen months. The contraction of
the intestine at the site of the former colostomy was sufficient
to give the patient warning of the passage over it of feces, so
that she could prepare herself for the evacuation of her bowels
and avoid soiling her clothing.
M
642 GYNPCOLOGY.
BLADDER.
580. Tumors of the Bladder. — Benign new-growths of the
bladder are claimed to be very rare in the female; the most
frequent are the villous polypi, called by Rokitansky villous
cancer. Albarran declared that every tumor of the bladder
was malignant. The frequent deaths from uncontrollable hemor-
rhage and relapse would seem to justify such a diagnosis, but
after careful microscopic investigation of the anatomic structure
of the tumor by Virchow, he asserted that it was not correct,
and called the tumor fibropapilloma or villous polypus. The
growth is most frequently situated on the lower surface or over
the trigonum, though occasionally found upon the fundus
and in vesical diverticula. It is sometimes completely pedun-
culated, so that several berry-like masses are situated upon
a single stem, which is easily torn. In women these tumors
are more frequently pedunculated, while in men they have
a broad base or present as multiple tumors. With water in
the bladder they float about like a water-plant. Sometimes
there are several masses of various dimensions, like grapes
or raspberries, upon a single pedicle. The tumors grow very
slowly. These growths absorb water, and consequently be-
come very much shriveled when kept in alcohol. Microscopic-
ally, they consist of a thick portion, which ends in villi of thin
connective-tissue frame and many large vessels. Vessels are
often so well developed that they completely supplant the
frame. The epithelium is then situated almost completely
upon the vessels. In other cases the connective-tissue frame
is thicker, so that one would incline to pronounce it a fibro-
papilloma. The under layers of the epithelium are cylindric
in form, while the superficial are polygonal and the epithelium
sends in no processes. We do not find nests or alveoli in the
connective tissue, so the characteristic structure of cancer
is wanting. The base of the bladder- wall is thickened and
infiltrated, a centimeter in thickness, which forms a crust dis-
tinctly recognizable during operation. The tumor itself is firm
or soft, according to the thickness of its stroma. The pedicle is fre-
quently so soft that, in an operation, an attempt to tie it results in
the tliread cuttini^ through or tearing it off. The large blood-
vessels contained in the connective-tissue frame lead to engorge-
ment, and not infrequently to strong venous hemorrhage. This
is the princip:il sym|)tom of the villous polypi. These polypoid
multi];le tumors m.'tv iill tlie entire bladder. They may even
pass through the ureilm't t' > the external orifice.
581. Mucous Polypi. — In cystitis not only enlarged papillae,
but also mucous polypi, arc ol.)served. These growths have
GENITAL TUMORS. 648 '
a smooth surface without papillomatous arrangement, and
are poorly supplied with blood-vessels. Occasionally, they
attain considerable size — from five to seven centimeters in
diameter.
582. Myoma. — A myomatous tumor of the female bladder
is much more rare than in man. The tumors are hard, whitish
upon the cut surface, arise from the vesical muscular struc-
ture, and grow into the wall or become pedunculated. With
the gradual thinning of the pedicle the tumor loses vitality
and becomes partly destroyed.
Cystic or softened myomata are also recognized.
Dermoid of the bladder has been observed (Thompson).
Symptoms.— The most characteristic symptom is hemor-
rhage. The bleeding is very likely to occur in the night, per-
haps owing to congestion from being warmly covered in bed.
Bleeding takes place without any other symptom, and must
be carefully investigated, as the patient will frequently assert
that it comes from the vagina. The hemorrhage may sud-
denly cease, and the urine the following day be perfectly clear,
to continue so for a number of weeks, when bleeding again
recurs. After the tumor exists for some time, bleeding will
become continuous.
Pain may be absent for years.
Cystitis does not necessarily exist. Indeed, small tumors
may have no influence upon the mucous membrane; floating
in the urine, they do not injure its epithehal surface. In spite
of long-existing growths, we will find the bladder surface pale
from the general anemia.
When hemorrhage leads to the suspicion of the existence
of vesical tumors, the use of the catheter must be practised
with care. The touch of the instrument causes injury; por-
tions of villous growths float into the eye of the catheter and
are torn off. Such masses should be carefully examined.
Tumors of the trigonum float into the internal urethral orifice
and obstruct the flow of urine. In long-existing tumors the
urine becomes progressively bloody, coffee-like, or bro^^Tiish.
The surface of the tumor, from which the blood arises, appears
black, red, sometimes opaque, or a bright red. The continuous
vesical hemorrhage leads to intense anemia, although it is sur-
prising how long the patient will endure it. Gradual emacia-
tion, and finally cachexia, appear. The disease may extend
over a period of many years.
Dia^nosis. — Examination is practised by palpation with
two fingers of one hand in the vagina, while the fingers of the
other are placed over the abdomen. The patient lies upon a
table or hard couch. If the bladder is emptied with a catheter,
\
644 GYNECOLOGY.
one must remember its danger. The examination is made
slowly, carefully, and systematically. Generally, the abdominal
walls are easily depressed. When the patient is unable to
relax them, an anesthetic should be given. By careful in-
vestigation a tumor as small as a hazel-nut can be recognized,
but pedunculated growths may easily be displaced to one side
and elude the grasp, and leave one in doubt as to their presence.
The ovaries are not unusually so situated that they may be
felt, and lead to the belief that a vesical tumor is present. The
cystoscope aids in clearing up doubt. Diagnosis should not
be based alone upon palpation. The urine should be examined
chemically and microscopically. Cylinder-like cells are char-
acteristic of papilloma. The older writers placed great stress
upon the character of the hemorrhage — whether fluid blood,
worm-like clots from the ureters, blood only, in the first or
last portion of urine, or pure blood followed catheterization.
These distinctions afforded differential diagnosis between renal
and vesical hemorrhage, but are now considered of little value
as compared w^ith cystoscopy. By direct investigation the
relation of the tumor to the vesical wall is observed, and bloody
urine can be seen flowing from the orifice of a ureter. The
bladder can also be investigated by touch wdth a finger intro-
duced through the urethra, but this should be practised with
the greatest prudence, and, preferably, with the little finger
only, because overdilatation may result in incontinence.
Treatment. — The one treatment for vesical tumors is opera-
tive. Following the diagnosis, the operative procedure should
be employed as soon as the condition of the patient will per-
mit. High fever, suppuration, cystitis, and marked anemia
are considered as contraindications.
The removal of the gro\\'th is surprisingly easy. New loss
of blood is endangered by every day's delay. Suppuration
is not a contraindication. If the tumor is large, irrigation
with the syringe does not secure disinfection, and suppuration
ceases only after the complete removal of the mass, and thus
the danger of nephritis is lessened.
The tumors may be reached through the urethra by the
urethral speculum. The masses are seized with forceps and
torn off, cut through by the galvanocaustic loop, cut away
with scissors or forceps, or scraped off with a sharp curet. The
latter instrument, however, should be used only when the
tin^or can be introduced as a guide. Whatever method is em-
ploNOvl should be thorough. In large, broad-based, friable
tuir.ors much injury maybe done by scraping or tearing. The
M.uKlor s^x^n fills with blood, which is hard to remove and
vUvv^m|v^sos, and the necrotic masses often cause cystitis and
GENITAL TUMORS. 649 j
suppuration. Syringing the bladder with ice-water and as-
tringents is painful.
If the pain, loss of blood, and cystitis are aggravated by
the operation, it is hard to convince the patient that anything
has been done for her relief. In extensive involvement or growths
with a broad base the preliminary incision of the bladder is
more effective and satisfactory, as by it the diseased structure
and the field of operation are exposed to view and to more
effective manipulation.
Vaginal Incision. — As a guide a catheter is introduced into
the bladder, upon which a longitudinal incision is made through
the middle line of the vagina, about five centimeters long, of
sufficient length to permit the introduction of two fingers.
The incision can be enlarged with scissors or with a knife above
and below, affording considerable exposure of thebladder and
its morbid growths.
Bleeding vessels are secured by pressure forceps. The
growths are then removed with forceps, scissors, knife, fingers,
the galvanic loop, or the Paquelin cautery. In copious hemor-
rhage syringe with either ice-water or quite hot water; cotton
sponges wet with the latter may be pressed upon the bleeding
surface. Sutures can not well be used, because they cut through.
The precaution must be exercised to avoid injuring the ureters.
Hemorrhage is very severe in these operations and greatly
obscures the view. The fistula should be closed, a catheter
introduced, and the vagina tamponed to compress the bladder
and decrease the bleeding. An ice-bag should be applied over
the lower abdomen.
The trifling mobility of the bladder in the region of the
trigone renders it difficult to expose a bleeding vessel through
the vaginal incision, and the bleeding renders the field but
little more accessible to view than through the dilated urethra,
while through the latter the organ can be tamponed even more
effectively than by the vaginal incision. It has been advised
that operation for removal of tumors of the bladder shouM be
preceded by dtiuble nephrotomy for tlie establishment of drain-
age. Such a procedure may be of value in extensive vesical
operations, but the discomfort of lying continuously in a pool of
urine is so great that it should be infrequently employed.
Abdominal Incision. — The sovereign procedure is the high
bladder incision. A transverse incision gives more room than
a vertical, though the two may be combined in a T-shaped
cut. The difficulty in securing firm union and thus avoid-
ing subsequent ventral hernia, however, precludes its practice.
The vertical incision requires strong traction to be made on
each side. Fritsch prefers the transverse incision, claiming
\
646 GYNECOLOGY.
that recovery is excellent if the incision is not made too long-
not over six or seven centimeters. The scar so disappears
under the hair of the mons veneris that subsequently it is no
more seen, even if the wotmd heals by secondary intention.
It has the additional advantage that large vessels are not likely
to be cut. He has seen a number of cases in which extensive
hernia had formed above the sjmiphysis, but these were cases
in which the object of the operation had been castration, supra-
pubic transverse section had been employed in the operation
for castration, or cases in which the Trendelenburg posture
had been employed for operations upon bladder fisttda. In
all these cases the scar tissue could still be seen. In twelve
of these cases the incision had been twelve or more centimeters
long. Such an extensive incision is unnecessary in bladder
operations. If the incision is made shorter, the recti unite
with a firm scar to the pubic bone.
Fritsch describes the procedure as follows: The patient
is placed in the Trendelenburg posture, with pelvis elevated,
and the mons veneris and vagina are thoroughly cleansed.
The bladder must also be thoroughly irrigated; the vagina,
for the reason that the fingers may be required to be intro-
duced into it, in order to penetrate the bladder from above.
The bladder should be irrigated with several liters of boric-
acid solution. It is better to employ a large quantity of water
than a trifling quantity of disinfectant solution. If the urine
is clear or the discharge of blood quite fresh, syringing is un-
wise, as it can easily cause a hemorrhage. An assistant places
his hands upon the abdomen in such a way as to keep the mov-
able skin fixed, while a transverse incision is made above the
symphysis. The point at which the incision is to be made
should be fixed before the skin is put upon the stretch; other-
wise upon drawing it up it may be found that the incision is
too low. It should be made directly over the upper border
of the symphysis. While one is operating in the loose fatty
tissue behind the symphysis, an assistant pushes up the bladder
with a thick male catheter. The projection made by the end
of the catheter is readily seen, the tissue above it is picked
up with a tenaculum, and the bladder-wall is cut transversely
above the end of the catheter. As soon as the bladder is opened
the margin on either side is seized with a pair of pressure for-
ceps and the bladder is prudently drawn down so that the
forceps will not tear. The catheter is removed and the incision
extended right and left by scissors until a broad woimd is made
in the vertex of the bladder, which will permit one conve-
niently to enter it with two fingers and inspect its inner wall
In this, as in all operations, it is important to proceed rapidly.
H^^K^ S1UTOU
GENITAL TUMORS. 647
The margin of the bladder is seized by ten or twelve pressure
forceps, which hold the bladder open automatically and make
its cavity visible. To sew the bladder to the margin of the
wound would take more time. If the tumors are large and
deeply situated, they may be discovered to the right or left
by two fingers. The pedicle is seized between the lingers and
the tumor prudently drawn up. As the structure tears easily.
the bleeding point may sink back and vanish from view; when
the bleeding is copious, one may be in doubt just what shall
be done. It can be controlled promptly only through tam-
ponade, which takes time; consequently, it is important, if
possible, not to tear the tumor.
Having fixed the situation of the tumor, one must make
accessible the pedicle. This not infrequently may require
an enlargement of the skin and bladder section. To avoid
this, an assistant seeks to enter the vagina, and presses up-
ward in the region of the pedicle. Hemorrhage may be con-
trolled by a PaqueUn thermocautery. The smallest points
should be employed, in order to avoid extensive burning of
the epithehura of the bladder. The ideal procedure is the
employment of the galvanocautery. In small polypi and
very small tumors the galvanocaustic loop does not act so well.
To tie them off is, of course, difficult, as the thread easily cuts
through. Frequently the base can not be encircled, on account
of the proximity of the ureters. If we pass a ligatiue deeply
in the firm tissue, we may inj_ure or occlude the ureter. A
hot iron is not effective in arresting the bleeding, and vet this
must be controlled in order to proceed. More favorable action
is accomplished by long and continued direct compression
of the wound from the vagina and bladder. A strong vaginal
tampon has a good influence. Ice-water may be used with
advantage, and influences the closed bladder still better. In
the open bladder the influence is not direct on the bleeding
vessels, as the bladder muscle, like that of the uterus or the
placental part, contracts on the bleeding surfaces. When
the pedicle is quite visible, so that with the Paquelin one can
touch the proper place, we should employ the scissors to cut
the growth away. The smooth, well-marked, cut surface can
be compressed by the finger of the assistant, in the vagina,
with a certain advantage. It may he necessary to tamponade
both vagina and bladder and to apply a firm abdominal bandage.
This method is effective in controlling hemorrhage.
The means by which hemorrhage is to be controlled must
be rapidly determined upon, whether it be the Paquelin, the
application of a solution of iron, syringing with ice-water, or
surrounding with needle clamp forceps. The tampon should
648 GYNECOLOGY.
be prepared beforehand, and should be ready. In large, broad-
based, villous growths we should work with sharp curet and
scissors. Hemorrhage is often quite considerable. If the
tumor is situated in the trigonum, so that there is no danger
of injury of the ureter, the base of the bladder- wall can be
penetrated and Hgated. The possible discharge of urine through
stitch-holes is of no significance, for in Shucking's operation
for uterine fixation it is probable that the needle has frequently
entered the peritoneal cavity, and it is only in rare cases that
peritonitis appears. The necessity of preventing hemorrhage
by a tampon after the operation excludes the p>ossibility of
complete suturing of the wound. We can, of course, draw
together the bladder wound somewhat, as well as diminish
that in the skin bv lateral sutures, but in the middle it must
be kept open for the eventual renewal of the tampon. In
such cases it should be the rule to sew the bladder to the skin
wound, in order to make its cavity accessible and to secure
the tissue behind the bladder from overlying urine and wound
secretion. As the patient recovers, the bladder suture cuts
through, the organ sinks back, and the wound opening is gradu-
ally closed by granulations. When the opening continues too
long, it should be narrowed by suture after artificial freshen-
ing of the wound. A permanent catheter should be intro-
duced, which is necessary in all bladder injuries. With an
incision into the bladder vertex, or in bladder resection, do
not completely close the bladder wound, but place a strip of
iodoform gauze in the opening left in the woimd. It has re-
peatedly occurred that the patient accidentally or purposely
has had the catheter removed, when the urine can flow from
the wound without injury; but if the wound is entirely closed,
the removal of the catheter would work injury to the processes
of recovery. After the bladder tampon is removed hemor-
rhage rarely occurs. Bloody urine disappears in from twenty-
four to thirty-six hours after the removal of the tampon. While
the catheter remains, the bladder should be irrigated with
astringents or a weak solution of liquor aluminii acetici. This
direction applies also to the external wound, and the pledget
should be wet with the same solution. The upper wound
has a great tendency to close. If the granulations are weak,
as in anemic patients, they can be stimulated by dilute alcohol,
camphor, silver salts, or tincture of iodin. The appetite, which
is lost through an excessive flow of blood from the tumor, im-
proves, and the patient gains rapidly in weight. The patient
should be permitted to rise from bed as soon as the wound
is healed. When tlie operation is very late in the progress
of the disease, the wound remains unaltered, the patient does
GENITAL TUMORS. 649' |
not recover from the anemia, and does not regain her appetite.
Whether the patient dies from loss of blood, from loss of strength,
or from the influence of the operation, is difficult to determine,
583. Carcinoma. — Klebs asserted that cancer of the bladder
always began in the prostate. Had this assertion been correct,
woman should be exempt from the disease. Primary cancer
of the bladder has been described by a number of investigators.
Bode alone has seen fourteen cases. Cancer appears as a harden-
ing and thickening of the bladder-wall, which is covered mth
several layers of epithelium. Small tumors form in the per-
iphery, sometimes as isolated masses, while complete infiltra-
tion of the entire bladder is very rare. Following the destruc-
tion of the epithehum, destructive ulceration of the cancer
occurs. This takes on a malignant character if putrid germs
appear in the bladder.
Symptoms. — The urine smells like carrion; there is pain
and vesical tenesmus. By rapid increase the carcinoma breaks
through externally. High fever appears. The bladder with
rapid growth of carcinoma is fixed in contraction in the para-
vesical tissue. With the peritonitic irritation there is increased
sensibility. The disease extends up to the ureters, and develops
pyelitis on both sides, interstitial abscesses, or nephritis. If
death has not already taken place, it occurs from high fever
and profound cachexia. It is found that the ureters become
dilated as a result of the pressure upon those portions situated
within the bladder-wall.
Uterine cancer presents syniptoms similar ti.' those induced
by villous tumors. If infiltration of the bladder-wall takes
place, symptoms of cystitis appear. It is sometimes asserted
that after extirpation of villous tumors carcinoma occurs in their
place, but pathology does not seem to sustain this assertion.
The existence of malignant disease docs not contraindicate opera-
tion, though it is necessary, in order to remove the matrix of the
tumor, that a portion of the bladder-wall should be removed in
order to ojierate in healthy tissue. In the adoption of this prin-
ciple a portion of the bladder-wall, the trigonum, must be
omitted. To remove it, we must remove the ureters, or at
least the place at which they enter the bladder. Bardenheuer,
in a case of extensive disease of the bladder, through an abdom-
inal incision upon it, shoved back the peritoneum, loosened
the bladder as far as possible from the perivascular tissue,
raised it up, incised it longitudinally, secured it with sutures,
and drew it into the abdominal wound. The now exactly
determined tumor is. with an elliptic piece of the bladder -wall ,
excised, and the wound margins are united by continuous
suture, sparing the mucous membrane. Finally, the belly wall
650 GYNECOLOGY.
is sutured and a continuous catheter introduced. Wassiljew
reports a case of total extirpation of the bladder for malignant
tumor. The ureters were secured outside the bladder and
sutured in the belly wall. The patient recovered, althougji
both ureters became necrotic in two centimeters of their course;
but the pyelonephritis improved, as well as the general con-
dition. Bensa describes a case in which a greater portion
of the bladder was extirpated on accotmt of an infiltrated car-
cinoma of the right bladder-wall in a woman fifty-one yeais
old. The operation was accomplished by a median incision
in the mons veneris: the symphysis- pubis was separated and
the bladder opened and loosened subperitoneally, except on
the right side, where the peritoneum tore, but was immediatdy
sutured again, then loosened on the left side; the left ureter
was resected, and the under part of the right ureter, because
it had been invaded by carcinoma. The ureters were replaced
in the small remains of the bladder, which was closed by sutures.
The symphysis was then closed with silver wire sutures and
the wound tamponed above and below the symphysis. The
patient died the day after the operation. Bensa holds total
bladder extirpation as indicated, first, in benign tumors if
they are multiple and produce sufficient disturbance of the
bladder function; second, in infiltrated malignant tumors if
they occupy the greater part of the bladder- wall ; third, in
large, broad-based tumors of the base of the bladder. The
entire bladder has also been resected for tuberculosis. How
much advantage is to be obtained from these procedures is
a question. Narrowing of the ureters in the artificial bladder
and small abscesses from implantation and sutures cause dis-
turbance for months, even though the case has been quoted
in literature as a successful resiilt. After extirpation of the
bladder the ureters have been implanted in the vagina. Whik
the vagina is normally aseptic, it is questionable how long
it will so remain with this additional abnormal ftmction.
UTERUS.
584. Fibromyomatous Tumors. — Myofibromata are benign
gro\\^hs of the connective-tissue order which occur in the cenix
as well as in the body of the uterus. Their structure consists of
connective tissue or of muscular combined with connecti\'e
tissue. Where the connective tissue predominates, they are
designated by the term fibromata, and where the muscular tissue,
as my(^mata or fibromyomata. The pure myomata consist onh'
of muscular structure and exist only in the early stages. They
usually appear singly and may attain rather a large size.
GENITAL TUMORS. 651 I
The myomata are the most frequent form of uterine growths.
Carefu] examination will disclose such a growth in 20 per cent,
of all the women who have reached the age of thirty-five yeare
(Bayle), in 40 per cent, of women of fifty years (Klob), but
in the great majority the tumors are smaU. The growth of a
tumor is very slow; when rapid increase in volume is observed, it
arises, not from an increase of tumor elements, but from a dis-
turbed condition of tissue fluid, which will be considered later.
The most favorable condition tor rapid growth is an intimate
vessel union with the uterus. •
It is the generally accepted \'iew that fibroid growths in-
crease in size only during the period of sexual activity, and
remain stationary or undergo atrophy after the climacteric.
It is quite probable that no myoma ever originates in the uterus
prior to puberty or subsequent to the menopause. A tumor
has been reported as having been found in the uterus of a girl
aged ten years, but no opportunity was afforded to demon-
strate the correctness of the diagnosis by microscopic inves-
tigation.
Sutton has reported a childless widow, who had never men-
struated, as having carried such a tumor for ten years. Peter
Muller and Joseph Taber Johnson both assert that the growth
sometimes continues to increase after the cessation of men-
struation. Hofmeier says that such increase occurs in those
myomata which stand in nutritive union with the peritoneum
through organized bands of adhesion. The truth of this is
especially indicated in omental adhesions, which greatly in-
fluence the progress of the growth. He cites a woman in whom
a thirty-five pound myoma, with numerous interstitial and
omental adhesions, had continued to grow for a year after the
menopause.
A myoma is rarely found alone in the uterus. The dis-
ease generally e.xists as a multiple tumor formation. Over
fifty growths have been found in one uterus. J. Bland Sutton
recently removed a uterus which contained one hundred and
twenty myomatous growths, varying in size from a pea to an egg.
They vary from a tumor the size of a pea to an enormous growth.
Hunter removed, after death, a tumor that weighed 145 pounds,
while the woman weighed but 95 pounds.
How much the growth of myomata is influenced by the
activity of the sexual organs remains difficult to determine,
but the fact that myomata originate and ha.ve their greatest
growth during the years most favorable for procreation can not
be without significance. Myomata occur with about equal fre-
quency in the married and unmarried. Observation does not
justify us in the assertion that the size to which they attain or
^52 GYNECOLOGY.
the rapidity of. their growth is influenced by the married or the
single state. Some regard sterility as a cause of myomata,
others as a consequence.
Winckel and Schroder consider that the following conclusions
are justified:
1 . Fibroid growths originate without relation to marriage or
to pregnancy.
2. Sexual excitement favors growth.
3. The presence of a growth inclines to prevent child-bearing.
4. Pregnancy promotes growth.
585. Pathologic Anatomy. — Whatever the origin, they are
found in either the body or the cervix of the uterus, but in
larger proportion in the former situation, and more frequently
in its posterior wall.
The consistence of the growth varies with its structure.
A soft muscular mass presents, upon section, a reddish-pink
color, with wavy, glistening bands running in every direction,
but with a tendency to form whorls about individual centers,
owing to the origin of the disorder along the course of blood-
vessels. The cut surface of a fresh section presents an uneven
appearance, owing to the elasticity of the fibrous tissue causing
the softer muscle surfaces to bulge. The mass is enveloped
by a false capsule, produced by compression changes in the
uterine structure. The capsule varies in thickness according
to the site of its development. If the growth has originated
in the middle layer, the capsule is thick and well formed;
but if immediately beneath the peritoneum or the mucous
membrane, the capsule will be very thin or may even be
absent.
About the tumor is a layer of loose connective tissue which
permits ready enucleation. Occasionally, there are numerous
fibrous bands to the capsule, which render enucleation difficult,
and are so frequent as to appear like a hyperplasia.
The tumor is surrounded by numerous large vessels, from
which it is nourished, but which do not penetrate its substance
to any great depth.
The vascularity of the structure is slight as compared to
that of the uterine wall, for well-formed vessels are rarely found
away from the circumference. In the softer variety the blood-
vessels are comparatively numerous; in the harder varieties
they are very scant.
586. Microscopic Appearance. — The comparative amount of
muscular and connective tissues varies 'widely. In young
and rapidly growing tumors the muscular tissue predominates
and the capsule or line of demarcation between growth and
uterus is ill defined. As the tumor becomes older and more
GENITAL TUMORS. 65J
Cure, there is a substitution of connectiveJ,for muscular
ue, and it becomes hard and dense. {Fig. 461.) The
noo differs in appearance according to its direction. A
^tudinal section presents cells of an elongated shape with
■like nuclei, while a transverse section resembles groups
round cells. Occasionally, between the muscle bundles
spores — lymph-glands lined with endothelium. They
elop from cellular proliferation about the capillaries,[ and,
h increase of connective tissue, may grow to large size.;^ (Fig.
:;. ,, / > ' , # ,
- -'f ^ ' p, .,
Fig. 461 .—Microscopic Section; Myoma Uteri. — (Copliti.)
(87. Varieties. — Bishop follows Gusserow's classification and
ies myomata into the multiple and encapsulated and the
le and nonencapsulated. The former are found most largely
le body of the uterus, while the latter grow from the cervix.
, division is based upon structure. The multiple growths are
I and firm. They largely consist of fibrous tissue, apparently
ure, and no longer continue to grow. They are also called
rniata. The single growth is soft and elastic. It is largely
jlied with vessels and is rapid in growth. In its structures the
654 GYNECOLOGY.
muscular tissue will be found to predominate. They are known
as liomyomata or fibromyomata. All myomata originate within
the uterine wall, but upon their proximity to its inner or outer
surface will depend their future progress. The most frequent
classification, and that which we find most useful in practice,
is a division of myomatous growths according to their situation
into: (i) Submucous, intramural, or concentric (capsulated, non-
encapsulated) ; (2) interstitial, mural, or centric; (3) subperito-
neal, extramural, or excentric (capsulated and nonencapsuiated);
and (4) fibromyomata of the cervix.
Degenerative changes which may occur in the life-history
of such a growth are indicated by the terms edematous, cd-
loid or myxomatous,
fibrocystic, calcific,
necrobiotic, necrotie;
but these chaises are
not sufficiently con-
stant to justify their
employment to iniii-
cate a distinct classifi-
cation.
The same sUt^
ment can also be ap-
plied to the further
division which is
sometimes given: sar-
comatous, adenorayo-
matous, telangiectatic,
lymphangiectatic.
588. Submucous
fibroids, according to
the proximity of their
origin to the mucous
surface, present tm)
varieties — the encapsulated and the nonencapsulated or free. The
former develop in the wall and are extruded beneath the mucous
membrane by the uterine contractions. The second variety, the
free, originate immediately beneath the internal surface, and
are not supplied with a capsule, but are closely enveloped by
the mucosa. An encapsulated tumor may become free thro\^
absorption or thinning of its capsule from pressure.
The encapsulated variety is much larger than the free.
Nature regards such growths as foreign bodies and endeavors
to extrude them from the uterine walls. Under this action
a submucous fibroid may, become pedunculated, when it is
known as a submucous or fibroid polypus. (Fig, 463.) The
GENITAL TUMORS. 655
njlar capsule may resist expulsion and prevent peduncula-
while the tumor bulges into the uterine cavity from a
t or less broad base, and is called a sessile submucous
id. (Fig. 464-)
"he sessile and pedunculated submucous tumors enlarge
organ and increase its vascularity. (Fig. 465.) The re-
jd contractions, together with the expulsive efforts, lead
trpertrophy of the muscle-wall to such a degree as to simu-
Fig. 463. — Submucous Myoma (Polypoid)
pregnancy. The circulation in the entire mucous mem-
j, and especially in that portion covering the tumor, be-
s obstructed, leading to severe hemorrhages.
he severe pressure frequently causes atropliy and ulcera-
in the free variety, and the production of gra\'e secondary
ges, such as sloughing and gangrene. Compression of
leck of a polypus may cause edema, and, when acute, can
ice gangrene or sloughing of the mass, and a fatal termina-
GYNECOLOGY,
Pig. 464. — Sessile Submucous Myoma. ^^^H
-*^ "^ J
J. 465-— Submiic I'-u lu-rine Cavity. ■ ^^H
GENITAL TUMORS. 657
jn. In the slower form the chronic edema may often be
istaken for a cyst. Uterine contraction may lead to elongation
: the pedicle of a pedunculated fibroid and cause its extrusion
om the external os into the vagina, where it can be readily
iCC^ized and removed. fFig. 466.) The elongation of the
edicle may become sufficient to permit the mass to hang from
he vulva. The expulsion into the vagina may be sudden,
fut it generally occurs slowly. Very rapid expulsion of a tumor
nth a short pedicle may produce partial or complete inversion.
S'ot infrequently the polypus may be felt projecting from the
s during menstruation, while it disappears during the intervals ;
iis condition is known as intermittent polypus.
Fig. 466. — Submucous Myoma Extruded into the Vagina.
Rarely by the efforts of the uterus the tumor may be com-
etely and spontaneously separated and extruded.
The pressure of the uterine or vaginal wall upon the tumor
■metimes causes ulceration, from which adhesions may form
id by which the nutrition is maintained. A polypus may be
firmly gripped by the cervix as to cut off its supply of nu-
ition and cause it to slough. The gangrene may spread up-
ird and produce a fatal result. Such a condition can easily
: mistaken for cancer.
S8q. Interstitial, mural, or centric fibroid growths develop
ihe parenchyma of the uterus, frequently attain to enor-
ous size, and involve the entire structure of the uterus, when
658
GYNECOLOGY.
they are then known as the diffuse or the gigantic fibroid. (Fig.
467.) A second variety ts the circumscribed general form
(Fig. 468); the third, the local interstitial fibroid. (Fig. 469.)
In the genera) circumscribed variety, as described by Schroder,
the wall of the uterus may be filled by a large number of growths.
In the localized fibroma a single or two or three interstitial
fibromata may be found. These growths are situated in the
wall of the organ, surrounded by muscle-fibers and the loose
connective-tissue capsule. , from which they can be readily
enucleated. In the diffuse form the entire structure of the
uterus seems to be taken up by the growth, and it is difficult
to fix a sharp border of limitation between the growth and
Fig. 467. — Volutninous Myomata Occupying Anterior and Posterior W«lb.
the uterine wall. These growths, when they attain a
size, not infrequently draw out the lower portion of the ute
as a pedicle, which may be attenuated to the thickness of the I
finger and twisted, as seen in one case by Kuster, where, islM
the twist, the torsion was two and one-half times. The cer-^
vical canal had been obliterated. Occasionally, the uterine^
body is found separated from the cervLx. The muscular struc-'
ture of the uterus itself undergoes hj'pertrophy in these cases,
particularly when but few growths occupy the wall. The
uterine wall becomes thickened, its ca\-ity is increased, and
the cavity undergoes various changes in its shape and size,
GENITAL TUMORS.
Fig. 468. — Circumscribed Interstitial Myomata
Fig. 469. — Local Imcrstitial My
660 GVXECOLOGY.
according to the development of the tunior and its projection
into it. (Fig. 470.) The influence of the grow-th upon the
endometrium is most marked. In a large interstitial myoma
it may become strongly distended, not infrequently thin aod
atnipliiul. (Figs. 471 and 472.) In other cases there isahj-per-
trophy of tlif entire mucous membrane, occasionally only of the
glands; in others, the interstitial tissue between them is in-
creased. iTig. 47,^1 Occasionally, the condition is complicated
by malignant edema. In the great majority of cases h\-pertrophy
uf the mucous membrane is found associated with these growths.
(Fig. 474.) Indeed, the enilometrium ma)4be three or four
its niirmal tliickncss.
590. Subperitoneal growths (also called subserous,
or extramural) are generally spheric or ovoid masses sprineni
from the external surface by a more or less distinctly manai
pedicle. Like the submucous, these growths are sessile or
pedunculated. While the latter class are polypi, that term
is more generally applied to intra-uterine growths.
The surface of the growth may be smooth or irregular,
according to the contraction of the connective tissue, A division
inuj free ami encapsulated is made: the former co\-ereii by
GENITAL TUMORS.
Fig. 471. — Serous Surface nf Siime Specimfn:
662 GYNECOLOGY.
the serous layer, which is closely attached, without capsule,
to the surface of the tumor; the latter, or encapsulated, are
covered with a layer of muscle- wall beneath the peritoneum.
The free are hard and only attain a small size; the encap-
sulated are soft and often become enormous. The pedicle
of the tumor varies in length and thickness. It may be short,
thick, and permit but little movement between the tumor
and the uterus, or long and attenuated, affording such marked
freedom as to cause doubt whether the growth is coimectai
with the uterus. The pedicle can sometimes become so twisted
as to cut off the circulation of the tumor and lead to its loss
of vitality, the development of gangrene, and subsequently to
septicemia or peritonitis ; or the tumor, in more fortxmate cases,
may become adherent to the surrounding viscera and lose its
association with the uterus. Such a growth is nourished by
its adhesions. Not infrequently a very movable tumor causes
ascites, and thus simulates a malignant growth.
591. Fibromyoma of the Cervix. — Cervical myomata, like
those of the uterine body, are submucous, interstitial, and sub-
serous. These growths originate in the body of the orgao.
GENITAL TUMORS. OtU
and, by the process of enucleation through contraction, may-
have been driven downward, either through the cervical canal
or into its structure by splitting it externally or, as in the single
noncapsulated tumor, had its origin in the cervix and grown
ather upward or downward. The latter may be either pedun-
culated or sessile, and rarely attain a size larger than a goose-
egg, although they may completely fill the pelvis. (Fig. 476.)
They cause contraction and prolapse of the uterus, and simu-
late inversion of the organ. They may be divided into two
(A) Those of the external os, in which the tumor is formed
by a cylindric or elongated lip in the interstitial variety. (Fig.
477.) The submucous growths of the cervical canal are oc-
casionally polj'poid, which, like slender stalactites, descend
through the cervix by the splitting process.
(B) Tumors from the subvaginal portion. These are more
664
GYNECOLOGY,
important when developed from the external surface and sltoatedV
between the layers of the pelvic floor. They become intra-
ligamenlary and exceedingly dangerous by pressure upon the '
ureter or upon the pelvic vessels; also when posteriorly they
press upon the rectum and push the uterus forward and up-
ward. Occasionally, the tumor crowds anteriorly against the
bladder, between it and the uterus. Most generally these
tumors are found surrounded by a loose capsule, which permits
of ready enucleation. Sometimes, however, there is no line
of demarcation between the tumor and the uterine structure.
592. Etiology. — These growths occur more frequently than
any other to which women are subject. Not infrequently
they may attain to considerable size without the patient being
F'S- 475- — Subserous My
aware of their existence, and are then recognized only by ac-
cident. The causes of their development are unknown. Reck-
linghausen attributed their origin to embryonic tissue, the
remains of the Wolffian bodies. The irritation which char-
acterizes fibromata is not a phvsiologic irritation, like that of
pregnancy, but a diseased impetus. It is an unusual kind
of local irritation, associated with a weak or debilitated con-
dition of the concerned spot. This introduces Colinheim's
view of tumor origin, which was that the local irritation was
brought to development by the presence of tumor germs. The
influence of sexual irritation is appreciated, in that statistics
demonstrate that in the majority of cases the first indications
GENITAL TUMORS.
665
X diiring the second half of the third decad: i. e., between
wentieth and thirtieth years. The tumor forms in the
mlf of the fourth decad, shortly after the thirtieth year.
: growths rarely develop before or after these periods,
ugh Biegel is reported to have seen one in a girl ten years
!, and Leopold the beginning of a myoma in a child. There
een much discussion as to the influence of the married or
: state upon the development of these growths. The in-
jations of Moller show that 32.8 per cent, occur in virgins,
per cent, in those who are not, b;it one-half of the latter
iterile. Hofmeier says that the number of births does
Fig. 476. — Pedunculated M;
amd in any relation to the causal formation of the growth,
Winckel believes that the married are more predisposed,
Jiat the myomatous formation decreases the number of
i. Shoemacher, on the contrary, asserted that the un-
ed are more frequently so diseased. Hofmeier accounts
le relatively lai^e number of unmarried women who suffer
myomata by the explanation that the tumor formation
; of the few causes which lead them to consult the g>'ne-
st. Prochownik gives syphilitic infection as a cause,
he growths occur so frequently in individuals in whom
has been no possibility of such infection as to render
660 GYNECOLOGY.
this view of little value. Olshausen and Gusserow assigned
local irritation as the etiologic factor. Shoeraacher also looks
upon menstrual congestion as a cause, but to give these reasons
for the development of the disease is equivalent to giving none,
as it is necessary to seek further for the cause of the irritation.
M611er, already referred to, frequently found that a myoma
the size of a pin's head was separated from the uterine muscle
by a distinct layer of connective tissue. Small arteries could
be traced into the growths, which still retained their three
coats; consequently he doubted the theory that myomata arise
from the muscular coat of the blood-vessels. The cause is
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sometimes considered as congenital. The influence of heredity"
as to whether there is a predisposition to the development
of such growths in families, may be questioned. Heredity
seems to be manifested in the greater apparent and comparative
susceptibility of the colored race to the development of fibroid
groft-ths. It is not unusual to find several members of one family
suffering from myomata. Among the \-arious causes it is
probable that sexual irritation should have the first place,
and this irritation may have been engendered without the
uterus having undergone the changes incident to pregnancy
and labor. The abnormal irritation mav be the result of mas-
GENITAL TUMORS. 667
turbation, of psychic disturbances, of such unnatural processes
as the evasion of maternity, of the psychic phenomena engen-
dered by body-contact with man, of sexual agitation, and of
other factors which may produce repeated injurious influence.
It is quite possible that defective development or an abnormal
position of the uterus may exert a marked influence in the
development of these growths. Mann reports a childless widow
at the age of forty-tlu-ee, twice married, who had never men-
struated, and for ten years had had a large fibromyoma. It
still remains evident, however, that in any individual myoma
we can not positively assign a cause which can be considered
a. definite reason for its development.
593. Symptoms. — The symptoms which lead us to suspect
the existence of myomata are: Hemorrhage, pain, and abdom-
inal cramp, especially when associated with progressive enlarge-
ment of the abdomen. The symptoms of the individual case
will depend largely upon the variety of tumor present. In
the subperitoneal and in the interstitial, which have not en-
croached upon the uterine mucous membrane, the growth
may attain to considerable size wthout the manifestation
of any symptoms which would attract the attention of the
patient. Not infrequently, especially in the unmarried, such
growths attain to a size so great as to be remarked by the friends
of the patient, before she is herself aware of its existence. The
growth will be suspected when the patient has a history of a
slow but progressive enlargement of the lower half of the ab-
domen. Not infrequently one of the first symptoms will be
inability of the patient properly to evacuate her urine. In-
deed, there may be even complete retention, which will re-
quire the aid of the physician to secure relief, during which
the presence of the tumor may be for the first time recognized.
It may, in such a case, be situated in the pelvis, completely
filling it and pushing the uterus above it. If the growth simply
presses against the bladder, it may only slightly interfere with
the evacuation, or, which is more likely, cause frequent mic-
turition, because of the inability of the bladder to distend.
Urination may be so painful and so frequent as to lead the
patient and her physician to suppose that an inflammation
of the bladder exists. Such a growth may press upon the
rectum, causing constipation, retention of gas, tympanitic
abdomen, interference with the circulation in the lower portion
of the rectum, the occurrence of hemorrhoids, prolapse, marked
anal pruritus, or burning of the anus, the existence of a fissure,
and not infrequently the veins of the anus as well as those
the vulva become exceedingly varicose. Such a growth.
; incarcerated in the pelvis, may cause severe pressure
^^^^gmmg mcar
issure, ^
lose of ^fl
h, be- M
~essure ^H
OOS GYNECOLOGY.
on the surrcunding structures, wHth sloughing and gangrene of the
pelvic soft parts. (Fig. 479,) An intraligamentary' tumor may
push the uterus to the opposite side, and the organ may be so
small compared with the tumor that its situatinn is with difficulty
detem::;ied. (Fig. 480.) Pressure of the tumor on the pelvic
nerves may produce pain extending down the posterior sur-
face of the leg in the form of sciatica or a crural neuralgia over
the front of the leg, or marked pain in the sacrum. While
these symptoms may occur in any form of myoma, they are,
however, characteristic of the subperitoneal and interstitial
varieties, especially when the latter has not encroached upon
the mucous membrane. In the interstitial growth, which
grows toward the mucous membrane, giving rise to obstruction
in its circulation and leading to engorgement and degeneration
of the overlying mucosa, hemorrhage is a marked sjTnptom.
In the submucous varieties bleeding is a more or less constant
and characteristic symptom. Hemorrhage may be manifested
by an increase of the menstrual flow (menorrhagia) or an ir-
regular bleeding (metrorrhagia) may result. Hemorrhage, as
before stated, is a very prominent symptom of all submucous
growths. The bleeding varies, and is not affected by the size
of the growth, since a small polypoid gro^vth will very frequently
cause just as severe hemorrhage, if not greater than that
which occurs from a large tumor. In these growths the menses
become profuse and prolonged, resulting in marked anemia
and great debility. The bleeding may be continuous and
very free for a few days, then a period of brown secretion, to
be again followed by profuse bleeding. Blood may be dis-
charged as a bright fluid blood or in large clots. Clotting has
no significance, and depends upon the size of the uterine cavity
in which the accumulation occurs, or it may take place in the
vagina; pedunculated polypi may be associated with severe
flooding. Intermenstrual hemorrhage may alternate with
periods of amenorrhea, which may continue for months, and
when the patient is congratulating herself that she has recovered,
another severe hemorrhage occurs. The bleeding occurs from
two sources! (i) From the covering mucosa of the tumor; (2)
from the general uterine surface. The former is the active
primary site of bleeding and is very vascular, particularly
in the free variety. In some of the smaller growths the tumor
will be found to be quite anemic. In these the hemorrhage
is undoubtedly due to the irritation of the circumjacent uterine
mucosa and the production of an interstitial endometritis.
Metrorrhagia from rupture of veins in the superimposed mucosa
is frequently associatetl with a pn:>fuse watery discharge, which
adds to the depression and prevents the patient from regaining
her health.
GENITAL TUMORS. 669
Leukorrhea, or discharge other than blood, is increased
during the development of these growths, The extrusion of
the growth into the uterine cavity increases the normal watery
discharge from the uterine glands. The interference with the
circulation and the consequent hypertrophy of the glandular
tissue cause a profuse secretion. This may be truly glandular
in character and mixed with the desquamated epithehum.
Pus-cells and blood-cells may also be found, according to the
degenerative processes, which sooner or later ensue. As the
cervix becomes dilated, its glands add their thick, viscid secre-
tion to the abundant discharge. The partial or complete ex-
trusion of the growth influences its circulation, not infrequently
causing necrosis of portions of its surface or even the entire
structure, according to the extent of the constriction. The
discharge is often bloody, purulent, or watery, contains necrotic
masses of detritus, and produces an extremely offensive odor.
The patient, and not infrequently her attendant, has cause
to suspect the existence of mahgnant disease.
In all varieties of the tumor the blo(.id supply of the growth
itself is \'ery slight, as no large vessels directly enter the tumor.
Where the neoplasm is ftf some size, this deficient blood supply
must affect the nutrition of its structure, and causes the pro-
duction of toxins which have a deleterious influence upon the
health of the individual. This is evident from the appearance of
such patients where hemorrhage and leukorrheal discharge are
not a factor. It is probable that these toxins have an influence
upon the heart muscle and other structures of the body, causing
conditions which are so frequently found assfxriated with the
presence of fibroid growths. It is probable that in these tox-
ins will be found the explanation for the mental disturbance that
is so frequently associated with the development of such growths
and which usually clears up with their removal. It may also
explain the occurrence of ascites which frequently is assix;iated
with subperitiiineal growths.
» Pain is not a constant symptom. It is frequently more
a sensation of weight or pressure in the pelvis and upon the
surrounding organs. Intense pain may characterize very small
growths, but is conditioned somewhat upon their situation.
A growth pedunculated or so situated upon the uterine wall
that it projects into the internal os may act as a balUvalve,
and be the cause of the most agonizing labor-like pains. I
have seen this form of dysmenorrhea in many cases. (Fig. 478.)
In one patient it was so severe as to require the administration
of two grains of morphin at each menstrual period to render
it endurable. An operation subsequently revealed that the
patient had a double \-agina and a bicomate uterus with two
670
GYNECOLOGY.
distinct cervical canals in a common cervix. In one of these
cavities was found a submucous tumor which, by a nipple-
like projection, filled up the internal os, and explained the
violence of the dysmenorrhea from which this patient had suf-
fered.
Sterility is a common symptom and conception is the ex-
ception. The inflammatory changes consequent upon the pres-
ence of the growth render it unfavorable for the reception
and retention of the fecundated ovum. More frequently than
is generally appreciated, the tubes have undergone secondary
changes which result in the occlusion of their abdominal ex-
tremities, and they are found to form retention cysts. Further-
Fig. 478.— Bicornate Uterus. Both Comua Containing Myomata.
more, pathologic conditions of the ovaries are sometimes found,
and this fact, also, is not given the consideration it merits. Con-
stipation, hemorrhoids, anal fissure, prolapse, and pain arising
from pressure upon the rectum are more or less constant symp-
toms and signs. Vesical tenesmus, cysts, frequent micturition,
retention of urine, dilated ureter, and hydronephrosis are pro-
duced by disturbance and obstruction of the urinary organs.
Not infrequently the first symptom which leads to the discovery
of the growth is the retention of urine, from pressure upon
the vesical neck. The myomata may also be the cause of
retention of urine from pressure upon the ureters interfering
with the entrance of the secretion into the bladder, and, as a
consequence, we may have renal dilatation even to the extent
of sacculation of the kidneys. In one of my early operations
GENITAL TUMORS. 671 ^^H
for myoma, upon a patient who had carried a large tumor for ^^|
some twenty years, death occurred very shortly after the opera- ^^M
tion. The autopsy revealed that both kidneys were distended, ^^M
forming thin-walled sacs, that the ureters were several times their ^^H
normal size, and that their walls had become greatly thinned. ^^M
The protracted hemorrhages, profuse discharge, severe labor- ^^M
like pain, and pressure upon the neighboring viscera are prone ^^M
to result in a profound anemia, which is characterized by a ^^M
straw-colored appearance of the skin, often so marked as to ^^M
simulate cachexia and plainly indicate the gravity of the pa- ^^M
tient's condition. ^^H
594. Diagnosis of Myomatk.— The existence of a fibroid growth ^^M
of the uterus may be suspected when there is a slow but progres- ^^
sive enlargement of the lower part of the abdomen. It may occur
in either the single or married woman, and need not be associated
with any special indication of ill health. The physician should
have in mind the possibility of its existence in every patient
who consults him regarding a sensation of weight or pressure
in the pelvis, disturbance of urination, such as frequent mic-
turition, difficulty in evacuating the urine, or even sudden
attacks of severe retention, which may necessitate the use of a
catheter. Indeed, in every such case the condition of the
pelvic \"iscera should be examined preliminary or subsequent
to the use of the instrument. Uterine growths should be still
further suspected if the patient is complaining of hemorrhoids,
fissure of the anus, frequent bleeding from the bowel, pain
and distress during, and difficulty in, defecation. The surgeon
should never be misled into subjecting a patient to operation
or treatment for hemorrhoids until he has examined the con-
dition of the uterus. Only recently I was asked to operate
upon a Sister of Charity for severe hemorrhoids, when examina-
tion of the pelvic cavity revealed a group of subperitoneal and
interstitial fibroids completely filling up the pelvis, the ex-
istence of which she had never suspected. Profuse menstrual
flow or irregular bloody discharge occurring in an unmarried
woman or in one who does not give a history of the interruption
of a recent pregnancy or abortion should lead to the suspicion
of the existence of a submucous fibroid growth, particularly
where this hemorrhage is associated with pain, often of labor-
like character, as if the uterus were making an effort to expel
a foreign body. This hemorrhage will often produce a marked
anemia without emaciation, which distinguishes it from that
associated with malignant disease. It should be remembered
that no characteristic symptoms of myomata occur, and, there- J
fore, the physician is forced to rely for diagnosis and confirma- ^
K tion of his suspicions upon the pliysical signs. An important ^|
672 GYNECOLOGY.
factor in this recognition is the consistence of the tumor or tumors
in contrast with the surrounding soft structure of the unin-
volved portions of the uterus, which permits the determination
and dehmitation of the growth. The alterations in the shape
of the uterus, according to the situation of the tumor, are of
interest. A good -sized growth may fill out the organ and
give it a spherical shape. The further contraction of the uterus
forces the mass into the cervix, where it may distend the en-
tire organ and be palpable at the external os. An intra-uterine
polypus is determined only by palpation through the cervical
canal. If the os is sufficiently open, the pedunculation can be
inferred by the mobility, and definitely determined by reaching
the pedicle with the finger. In small fibroid growths with a
long pedicle the growtli may be felt through the uterine walls
to move under the pressure of the finger, even though the cervix
is undilated. During the menstrual period with profuse menor-
rhagia, the oflending growth is frequently extruded or the
cervical canal is sufficiently dilated to permit its recognition
by the examining finger, A growth may be extruded during
the flow and drawn back in the interval, pnxlucing what is
known as an intermittent polypus. A growth filling up the
pelvis may make pressure upon the large vessels and so interfere
with the return circulation of the lower extremities as to pro-
duce enlargement of the superficial veins in compensation for
the obstructed abdominal vessels. Pressure upon the ureters
causes dilatation of these ducts, hydronephrosis, dilatation
of the pelvis of the kidney, not infrequently a sacculation of
the kidneys with destruction of the secreting tissue, the forma-
tion of renal calculi, and even the occurrence of suppurative
changes. These are characterized by more or less pain and
discomfort in the region of the kidney— so much so as possibly to
mask the pelvic lesion. Interference with the cardiac or renal
functions causes profound anemia and the appearance of cach-
exia, not infrequently interference with the veins of the lower
extremities, phlegmasia, blocking of important vessels by
particles of coagulated tissue, and possibly the formation of
pulmonary and cerebral emboli. The diagnosis is determined
by the bimanual examination, the introduction of one or two
fingers into the vagina or the finger into the rectum, and the
other hand over the abdomen. In this way the uterus is care-
fully palpated and any enlargement of its structure recognized.
If such enlargement or hardening of the organ exists, its size,
relation to the organ, and its resistance are carefully studied.
The fibroid growth has a definite shape, is smooth in outline,
is well defined, and has a characteristic resistance. It is im-
portant in the study of such growths to arrive at a diagnosis
GENITAL TUMORS. 673
not only as to the existence of fibroid, but also as to the character
of growth which may be present. The decision, then, is made
^riiether the growth is an intra-uterine or a submucous tumor.
The endeavor is made to ascertain by palpating the cervix,
irtien patulous, as to whether the growth is a sessile or polypoid
tamor. If the uterus is occupied by interstitial growths, their
Anation is determined, whether they occupy the anterior or pos-
terior wall or the fundus; if subperitoneal, from what portion
(rf the organ they spring. The latter growths are divided into
three types: (i) When the growth proceeds from the fundus
or the anterior wall, grows upward and in the progress of develop-
c meat becomes pedunculated ; (2) whether it is pushed out through
; the lateral wall of the uterus between the folds of the broad
■ l^ament. practically splitting and spreading this out and dis-
Fig. 479. — Intraligamentary Myoma.
placing the uterus to the opposite side (Fig. 479) ; (3) when it
grows downward from the posterior wall and is beneath the
peritoneum, but probably not even in contact with it. 'When
the tumor is small and as yet nonpedunculated, it may be difficult
to determine by conjoined manipulation from which wall it has
originated. This can be accomplished either by the intro-
duction of the sound into the uterus or, better, by the dilatation
of the organ and the introduction of the finger. With one
finger in the uterus and the hand over the abdomen or a finger
in the rectum, the physician is enabled accurately to determine
tJie relation of the growths to the uterine wall. The factor
which should be fixed in mind as an essential one for the recog-
nitioR of fibroid growths is their smooth, regular outline. In
the fibromyomata of the cervix the tumor presents a mass which
674 GYNECOLOGY.
is situated in the vagina, not infrequently filling it, is quite
movable, and between it and the vaginal walls the finger can
be easily passed. Its situation external to the cervix pre-
cludes the probability of it having undergone necrosis from
pressure, but occasionally inflammation may be developed in
the vagina from the pressure of the growth, which will lead to
agglutination between the tumor surface and the vaginal wall.
The attachment of the tumor is recognized by bimanual pal-
pation with traction upon the tumor.
595. Differential Diagnosis of Myomata. — An accurate diag-
nosis of any condition is secured only by carefully reviewing
the conditions with which it may be confused. The conditions
with which myomata are likely to be confounded are:
Normal pregnancy.
Extra-uterine pregnancy.
Desmoid tumor of abdominal walls.
Inversion.
Carcinoma.
Sarcoma.
Incomplete abortion.
Subinvolution with endometritis.
Uterine displacements.
Ovarian displacements.
Ovarian cysts.
Pelvic infiltrations.
Sactosalpinx.
Floating kidney.
Normal Pregnancy, — The amenorrhea, subjective symptoms,
regular growth of the uterus, absence of hardness in its walls,
and a sensation of elasticity are generally sufficient to determine
the diagnosis of pregnancy. We have already seen that a
limited amenorrhea mav be characterized bv a submucous
myoma, and a patient may go for months without a hemor-
rhage. On the other hand, hemorrhage may occasionally com-
plicate the early months of pregnancy. I formerly attended
a patient who always suspected herself pregnant if the menstrual
flow was especially free, and she continued to menstruate for
two or three months following the occurrence of each preg-
nancy. The myomata may be present as small, edematous,
subperitoneal nodules, which may be mistaken for the extremities
of the fetus. Calcification of a fibroid has led to the growth
being mistaken for tlic fetal head. The existence of the tumor
does not preclude the possibility of pregnancy as a complication.
The occurrence of ])rc!L(nancy associated with fibroids should be
suspected when the growth takes on more rapid enlargement,
when the rapidity of the growth is greater than that which
GENITAL TUMORS. 675
tisually characterizes a fibroid tumor, and when a portion of
tlie mass presents a sensation of elasticity. The regular shape,
size, and outline of the uterus under the bimanual, with the
contractions of the pregnant organ, which are absent in the
nonpregnant, contrasted with the more or less firm resistance,
the irregular enlargement, and the smooth nodular outline,
should establish the diagnosis. In diagnosis the following case
very graphically illustrates, as shown in Figs. 489 and 490, that
fibroid tumors under certain conditions may simulate pregnancy.
The patient, about forty-two years of age, had applied to her
physician because of an uncomfortable sensation attended
with enlargement of the lower portion of the abdomen. On
examination, he pronounced her pregnant. This diagnosis
was repeated by him after a subsequent examination, and
coincided in by other physicians. She came under my obser-
vation some length of time after having completed the supposed
normal period of her pregnancy and was referred to me as a
case of delayed labor. Upon examination, the cervix presented
its normal size. Above it, in front, however, could be felt very
distinctly two rounded masses with a sulcus between them,
"^hich was taken by the examiners to be a fontanelle. The
abdomen was enlarged, about the size of a pregnancy at six
months. There was a sensation of elasticity or rather of dis-
tention in the abdomen. When pressure was made against it, a
mass could be felt which was pushed back on deep pressure, and
could be felt impinging against the abdominal wall when the
land was suddenly removed. This sensation was taken to be
hallottement of the fetal body. Bimanual examination, however,
convinced me that if this was a. pregnancy, it was extra-uterine,
as the mass could be felt too readily through the anterior vaginal
wall to be within the uterine cavity. It was found that the
woman continued to menstruate, that the enlargement had
increased only to a very slight extent in the last few months.
The investigation of the condition caused me to pronounce it one
of multinodular myomata, one of which was a large mass with
a rather thick pedicle, permitting it to be pushed away, but
firm enough to bring it back against the abdominal wall, and
thus produce the sensation of ballottement. The freedom
of movement was accounted for by the presence of free fluid
in the peritoneal cavity. This diagnosis was confirmed by
operation.
Extra-uterine pregnancy will present symptoms in the early
stage similar to those of a normal pregnancy, as amenorrhea,
nausea, mammary changes, etc., associated with a history of
colic-like pains on one or the other side of the pelvis, with later
a marked tearing pain, possibly attended by fainting, and symp-
676 GYNECOLOGY.
toms of internal hemorrhage. Subsequently a mass will be
f oimd in the side or an increase in the size of the abdomen will
take place, but this enlargement will be less symmetrical than
is the case in a normal pregnancy. The examination of the
patient will ordinarily reveal the uterus slightly enlarged, some-
what softened, free from any irregular or nodular masses, pos-
sibly displaced to one side, or crowded forward by a mass which
is situated in the side of the pelvis or in Douglas' pouch pos-
terior to the uterus. In the advanced stages the parts of the
fetus may be felt, probably with greater ease than if the fetus
was contained within the uterus.
Desmoid tumor of the abdominal walls presents the same hard-
ness and resistance as does a fibroid growth of the uterus, but de-
veloping; in the muscular structure of the abdomen it generally
becomes by its weight more or less pendulous and usually does
not attain to large size, so is readily distinguished from the deeper
seated uterine growths. In my clinic in the spring of 1905 a
colored woman of thirty years, who had given birth to twochildien,
presented herself with a distention of the abdomen which was
quite symmetrical and extended from the pelvis to beneath the
ribs. Palpation disclosed a firm, hard mass, occupjdng the entire
abdomen and quite movable. The diagnosis was made of intersti-
tial uterine myoma and resort made to operation. Incision in
the median line, however, exposed the tumor as continuous with
the abdominal wall, and did not afford access to the peritoneal
cavity until it had been carried some distance above the umbili-
cus. The growth sprang from the right side of the abdominal
wall, was covered upon its inner surface with peritoneum, and
had no association with the uterus. (See Fig. 480.) The tumor
weighed nineteen pounds. (Fig. 481.) Notwithstanding that
this growth grew inward from the under surface of the muscular
walls and filled the abdominal cav^ity, careful bimanual examina-
tion should have revealed that it had no connection with the
uterus and that the abdominal walls could not be moved over it.
Incomplete Abortion. — The uterus may be larger than nor-
mal and the patient give a history of irregularity and more or less
continuous bloody discharge from the uterus. Careful question-
ing will afford a history of amenorrhea and belief of the patient
that she has been pregnant. The uterus will be large, softened,
and when the cer\ix is patulous, the finger can be introduced, re-
vealing the enclosed embrj^-onic tissue.
Inversion, — Inversion of the uterus may be associated with
a myoma with a short pedicle, attached near to the uterine
fundus. The efforts at extrusion of such a mass, after dilatation
of the cervical canal, may cause a dragging upon the fundus
and gradual inversion. A polypus with a moderately thick
GENITAL TUMORS.
Adipose tissue of abdominal wall ; b. b, recti muscles from which tumor orig-
inated; c, aponeurotic sheath of recti muscles: d, portion of tumor projecting
downward into pelvic cavity.
678
CYXECOLOGY.
pedicle, when extruded from the os, may be distinguished from
the body of an inverted uterus with difficulty. A myoma is
said to be less sensitive than the uterus, but this is not sufficiently
characteristic to be of much value in diagnosis. The inverted
uterus shows upon inspection the orifice of the tube upon either
side. In each comlition the neck of the uterus can be felt
encircling the pedicle of the tumor like a cuff. The diagnosis
is best established by introducing a finger into the rectum, while
traction is made upon the tumor. In case of inversion the
cup-shaped cavity of the inverted uterus will be felt, where in
ordinary cases the uterine fundus should be situated. The
exercise of recto-abdominal touch, while traction is made upon
, Blood-vessel; 6, t
— Histologic Section of Desmoid Tumor.
I of Bpecimen showing edema; e, long spindle-shaped
cells; note scarcity of nuclei.
the protruding mass, will afford an unfailing method of deter-
mining the diagnosis. A sound passed into the uterus in a
case of a cervical tumor will be found to pass at one side the
entire length of the ordinary uterus. In an inversion of the
organ the sound will pass an equal distance on all sides of the
tumor. The diagnosis, ordinarily, however, can be accom-
plished without the use of the sound.
Carcinoma and Sarcoma. — Profuse bleeding, pain, and dis-
charge are common to both fibroid tumors and malignant dis-
eases of the uterus. In the majority of cases the offensive
discharge associated with malignant disease is not found ixKm
GENITAL TUMORS. 679
myomata. The recognition of this fact has sometimes led
to error in judgment; thus, in a case where a myomatous growth
has pushed through the cervix, has been for a length of time
constricted by it, caries or superficial necrosis follows as a re-
sult of the interference with the circulation in the tumor, from
which the careless observer may be led to a diagnosis of malignant
disease. A digital examination of such a patient, however,
reveals the fact that the vagina is occupied by a tumor which
is firm in consistence, is smooth and regular in outline, is not
friable nor easily broken down, and thus differs materially
from the friable necrotic mass which is found in the vagina in
the cauliflower growth of mahgnant disease. A sloughing
fibroid within the uterine cavity may afford some difficulty
in the diagnosis. It causes a thin, watery discharge, which
is exceedingly offensive. It may have caused repeated attacks
of hemorrhage. The associated loss of blood, with the absorp-
tion of the products of decomposition from necrotic tissue,
produces a condition of sapremia which is with difficulty differ-
entiated from malignant disease. In such cases, however,
the diagnosis is determined by dilatation of the uterine canal.
The necrotic growth forms a large tumor, one which is more
resistant, in which fragments broken away and examined pre-
sent the regular lamellated structure of a fibroid growth, but
nowhere is seen the nesting or collection of epithelial masses
surrounded by a connective-tissue stroma pathognomonic of
carcinoma or the homogeneous mass of cellular tissue with
an absence of true blood-vessels which characterizes the sarcoma.
Subinvolution with Endometritis. — Subinvolution is a chronic
inflammation of the uterine parenchyma, and when it has existed
for a length of time, the uterus becomes firm and hard, indis-
tinguishable from the hardness of myomata. The enlargement
of the uterus is uniform, involving the cervix as well, while in
fibroid growths the enlargement is pronounced only in that part
of the uterus which comprises the growth.
Uterine Displacements.^¥\eidons of the uterus are the
varieties of uterine displacements most readily confounded
with fibroid growths. Indeed, it should not be overlooked
that a fibroid growth may be the cause of the displacement.
The growth, by its smooth outline and situation, may form
such an angle as to cause one to regard it as the fundus uteri.
These are the cases in which the sound can be successfully
employed to ascertain whether the direction of the uterine
canal corresponds to the position of the tumor. The cases
are rather few, however, in which the gynecologist can not
acciirately locate the fimdus uteri and detect the relations of
the growth thereto by practising the bimanual examination
bSO GYNECOLOGY.
in association with the vagino-abdominal or recto-abdoi
touch. Such an examination will reveal the greater consistence
of the growth, its rounded, smooth outhne, and the extent
of its association with the uterus. In a flexion, when the organ
is straightened between the internal and external fingers, the'
normal outline of the uterus is found restored.
Displacements of the Ovary. — The ovary is likely to afford
confusion of diagnosis only when it is firmly fixed to the uterus
by inflammatory exudate or has become somewhat enlarged.
Its situation, the inability to recognize the ovary in any other
situation, and its extreme sensitiveness should reveal its true
character.
Ovarian Cyst. — It is frequently difficult to differentiate be-
tween a fibroid tumor with a long pedicle, which has become ede-
matous, and an ovarian cyst of the glandular or dermoid variety.
If the cer\-ix is grasped ■tt-ith a double tenaculum, while an
assistant, with the hand over the abdomen, draws up the tumor,
we are enabled through a rectal examination to ascertain a
more exact determination of the relation of the pedicle of the"
tumor to the uterus. Tliis examination, with tlie patient
under the influence of an anesthetic, will generally be sufficienti
to determine the diagnosis. It should not be forgotten, how-
ever, that the existence of a fibroid tumor does not necessaril]
preclude the possibility of pregnancy, as we can have pregnane;
complicating fibroid growths. I narrowly escaped operatii _
some years ago upon a patient who had a history of having had a"
very profuse bleeding during the preceding three weeks. "Die
right side of the uterus presented a growth, which was firm and
hard, and was recognized as a fibroid. Upon the left side of the
abdomen there was more sensation of elasticity or indistinct
fluctuation, and it was believed tliat we had an areolar glandi '
ovarian growth closely adherent to a fibroid of the uterus,
the day set for the operation, on starting to cleanse the vagina,
foot and leg of a fetus were found projecting from the dilated os,
and a partly macerated fetus was delivered. Upon removal of
the placenta the uterus contracted and disclosed a pretty good-
sized fibroid upon the right side of the uterus. The patient re-
covered, and with marked decrease of the fibroid growth during
the progress of involution, rendering operation for its remov^
urmecessary.
Pelvic infiltrations are recognized by the previous history
of inflammation and the irregular and undefined outhne of
the masses which are found.
Saclosalpinx is usually preceded by a history of inflam-
mation. The mass is felt at one side of, or posterior to, the
uterus. When adherent to the latter, the connection is so
irregular and imdefined as to reveal its character.
inct ^^
:u1b£^H
la, a^H
GENITAL TUMORS.
681
Floatittg kidney fonns a tumor which is generally situated
-t a higher level. The fingers can be pushed between it and
he symphysis and the promontory of the sacrum, and both can
►e palpated below the supposed growth. This would be impos-
ible in a growth connected with the uterus. The floating kid-
ley can generally be pushed back into its normal situation.
Fig. 481. — Myoma Uteri with Large Intraligamentury Fibromata.
a. Anterior and posterior leaflets of broad ligament; b, tumor.
596. Alterations and Degenerations. — During the active prog-
iS5 of a myoma it becomes larger, swollen, and more ede-
latous as each menstrual period approaclies; and, following
le flow, it decreases in size and becomes more firm and re-
stant. In the submucous and interstitial varieties cessation
f the menstrual function or the establishment of the climacteric
1 delayed for from five to ten years longer than would (jccur in a
!**.«
(kvj gynecology.
wom.iii >vluisc ulcnis was free from disease. With the establish-
nu'iu of I ho nuMiojiausc, however, the growth usually diminishes
in si/o and nnilori^oos a imx^ess of atrophy. The gro\i-th be-
oonu's tinn and liard. and its size remains fixed : or it may become
soli . .mil. will) ihis. a jmvess of metabolism follows, by which the
i^rowili i^radiially disaj^jvars. In small growths the same length
oi \\\v,c afior ilio olimaoierio the tumor may have almost entirely
\,i:ns:u\:. Tb.oso ob.ani^os also txcasionally take place during
tl'.o •o:\v.ivssoi a ]Mvgnanoy orin nonpuerperal cases without our
Iviv.i: ..'*'':o to assii^n a oatise. Xv^t infrequently a patient has been
,,'...vv.'.i\'. ,.: tl'.e o.isovAory. tlirotigh examination, of the presence
o: ,-. :".'^'.\ i.l ^^:\\v:V.. .i:\: some montr.s or years later another in-
\ V >:•::. .'.*.^'* •.vxo.f.s r.v^ ir.^'.ioativ'n of i:s existence. If the second
•.•*.Nv'>: •.!:.,:•..*:* :\.s ':\\!; r.\i0.o bv a:i :::er ohvsician. he mav be
•.•'.v*--*.v\' : / ':v'.'.o\c : ■*..,: .i !v.:srivroso:::.i:: :: :Vi.: been made, and
^*. * ■ >,.vv ... L^-^-^'is.^^;-^ ?*>*... •. >^^ -- ^1 >U^|-Ui.lOH,
. X.*.. s^t >. t > ..K.^. -.i-.\ ■- . L-.e iiixcr-
>....«>. ».%..> K v. «.4. ... . ^ ..;.«............ .> \.«...a2*c>^ l>\ v.*>'Ii-
«.,.-. > . **. ..V ,* ... .K . .S. ... . y. . . ^ > V — t *■-' •. mIXIIl* 111
. . ■ . . > . >:>'..,;. ; ,- v..\r.". : >■.> ..*-.. ir.iiTSiices 'if the
• •■ *» ««•• «
..^«> |» m . • *«■_*««* "» H* ■ ^ ^ ^ ^"^ ^^i^k ^ ^» v^ ^
.L5ser:e.:
GBNITAL TUMORS.
_ that other and more vital tissues of the body were
equally vulnerable to such deposits. In the examination of
Sprowths which have undergone such change, the sensation given
of pressure against bone renders such a tumor harder and more
resistant than the ordinary mature fibroids. Not infrequently
-plates of bone will be felt to break beneath the palpating finger.
Undoubtedly the cases reported of the expulsion of uterine cal-
cuH were myomata which had undergone this calcareous change.
A submucous or interstitial fibroid so changed may subsequently
Fig. 483. — Fibrocystii Tumor of the Uterus.
be expelled by the uterine contractions. Amyloid degeneration
has been reported in one patient. Fatty degeneration has been
evident from the macroscopic appearance of tumors I have re-
moved, although it has been asserted that fatty degeneration
of such growths is never confirmed by the microscope.
Colloid Myxomatous Degejieratton. —This condition, accord-
ing to Virchow, is an effusion of mucous fluid between the mus-
cijar bands. The presence of a mucin proliferation of the
684 GYNECOLOGY.
nuclei and small round cells permits of its being distinguished
from simple edema.
Inflammation, Suppuration, and Gangrene. — Inflammation
of a jjrowth may result from injury, traumatism, compression
or obliteration of nutritive vessels of the tumor, and from septic
infection following an exploration. Septic inflammation may
follow an exploration or the delivery of a patient. The rapid
cliangcs which take place subsequent to the delivery of a patient
who IS suffering from a large fibroid may result in interference
with its nutrition and in the development of inflammation
and suppuration. Suppuration may take place external to the
capsule, in the cellular tissue about it. or in the structure of
^.:»caslr. or ^Kf
^^nh li>5 lost its
GENITAL TUMORS. tttfO
1, which must speedily terminate her life. The his-
if profuse hemorrhage and of an exceedingly offensive
rge, and the appearance of profound anemia and a
ion resembling cachexia, affordeil apparent confirmation
: correctness of his suspicion. The finger disclosed a
mass filling the vagina, which, instead of being soft and
:, as a cauliflower growth would be, was roughened on
Fig. 485. — Myoma of the Body and Cancer of the Cervix.
srior, but smooth upon its upper, surface, was quite mov-
md a distinct pedicle could be recognized, which pro-
from the cervical canal. The neck of the uterus was
^liable, and without any infiltrate, which demonstrated
;he diagnosis of malignant disease was incorrect, and
le patient was suffering from a fibroid polypus ^\'hose sur-
as necrotic. In cases of doubt the history, more or less
686 GYNECOLOGY.
firmness of the growth, the distinct arrangement of the struc-
ture, even when gangrenoiw, and the absence of any cellular
infiltrate are sufficient to afford a correct diagnosis. An abscesi
may develop either in the wall or within the growth itself.
Malignant Degeneration (Fig. 483). — Cancerous degeneraticn
of a fibroid growth has not been demonstrated, nor is it easy to
understand how it could occur, unless the growth contains gland-
ular tissue and is, consequently, a fibroid adenoma. The preseaa
of the growth renders the uterus less resistant and facilitate
s Incised, Displaying Numerous FibromyomatousGrowtluiiii
Incipient Cancer of the Cervix.
ervix by cancer.
the probability of malignant degeneration of the endometriuni.
The most frequent malignant degeneration, however, is the infil-
tration of the fibroid growth by sarcomatous processes.
597. Mixed Growths. — Enchondroma, Sarcoma, Osteoou, aitd
Carcinoma. — The origin of these growths is uncertain. It
is possible that they must originate in one of two ways— either
in transformation of the cells which produce other tissue species,
or in an invasion in which the growth is penetrated by the
neighboring proliferating masses. Thus, we have myochon-
GENITAL TUMORS. 0»7
droma, myosarcoma, and rayocarcinoma. The first of these
is very rare. The second is less rare, and grows rapidly from
a small invasion. The normal filamentous structure of the
fibroid growth is soon lost in a homogeneous mass, which rapidly
becomes necrotic; the tumor then forms a mere thick shell.
With the necrosis of the mass, not infrequently vessels are
eroded, and extensive hemorrhage may take place into the
cavity. The disease is not confined to the growth, but invades
the surrounding healthy tissues. The enveloping cells are
large, irregular, rich in chromatin, and contain several nuclei.
Sanger asserts that all myomatous growths containing irrita-
tion cells are sarcomatous.
AJyocarciftoma arises from carcinomatous alteration of the
surface of the polypus, or by development from the glandular
constituents of an infiltrated adenomyoma.
598. Complications. — The study of the progress of a fibroid
growth from its origin in the wall of the uterus to its subsequent
extrusion, and the changes and lesions to which it may be readily
subjected, will afford reasonable explanation for many com-
plications which are associated with it and influence the prog-
ress of the growth. Of these complications, the most im-
portant, because one of the most frequent, is that of inflam-
mation and the resulting adhesions.
1, inflammation, as we have already seen, may involve
the structure of the growth or may influence only its super-
ficial surface. The structure of the growth can undergo in-
flammation from decreased nutrition by its extrusion into
the peritoneal cavity, when it becomes a foreign body, which
nature, in its efforts to protect the general structure, surrounds
with plastic material, from which the tumor may receive ad-
ditional and necessary nutrition, and which fixes it in relation
to the structures immediately about it. Such adhesions may
take place with the intestine, the mesentery, or the abdominal
wall, and may lead, through traction upon the tumor, to still
further thinning or attenuation of its pedicle, and, finally, to
separation from the body of the organ, so that occasionally such
growths are found removed from the original attachment and
nourished through the inflammatory adhesions. The causes
for inflammatory changes may be divided into — {i) those incident
to alterations in the tumor; (2) to irritation changes in the
peritoneum from the presence of the growth as a foreign body ;
{3) to infection. Infection may arise from disease of the ap-
pendix, the Fallopian tubes, or through direct transmission
from the intestinal cavity.
2. Ascites. — A second, though less frequent, complication
of myomata is ascites. (Fig. 489.) This is attributed to irritation
K
GYNECOLOGY.
of the peritoneum from pedunculated subperitoneal gromhs.
(Fig. 490.) It is more probable that it may be engendered by
- t)ie development oi a toxin from lowered vitality in the growth
which makes it a foreign body and causes irritation, which pro-
duces ascites. Ascites is much more frequent in mal^nant than
in benign growths, and its presence should always awaken the
suspicion that very gra\-e changes are taking place in the growth.
3. Disease of the Tubes (Fig. 487). — Disease of the Fallopian
tubes as a complication of the presence of fibroid tumors is \'ay
Fig. 43s.— Uterus Containing Several Fibroid Tumors Complicated by a L»rp
T 11 Ix) -ovarian Cyst, a, a. Shows sites of fibromata : b, round ligament
common. It may be a simple hydrosalpinx or a pyosalpinx.
Adhesions may be extensive, and very greatly complicate any
operative procedure. The most frequent cause of this condition
is undoubtedly the result of infection which has traveled through
GENITAL TUMORS. 689
e uterus. The presence of the fibroid growths favors the
ngestion of the pelvis, and makes the tubal mucous mem-
ane a more favorable soil. Pressure of the growth upon
Fallopian tube may interfere with its circulation, cause a
stention of its cavity, and the formation of a tubal collection,
bis defective drainage causes regurgitation into the pelvic perito-
tun from the abdominal end of the tube, which sets up a peri-
leal inflammation and produces a closure of the tube and
3 formation of a hydrosalpinx or pyosalpinx, according to
3 exposure to or absence of infection.
5. Ovarian Hematoma. — The distention of the ovary by the
simulation of blood is not an unusual complication of myo-
ita. The ovarian sac is usually adherent and filled with a
690 GYNECOLOGY.
thin, dark, bloody colored fluid. The sac wall is easily ruptui
and is rarely dissectt-d without rupture occurring.
6. Pregnancy. — The presence of fibroid grovs'ths is a caxise of!
sterility, but does not necessarily preclude the occurrence ofB
pregnancy. The early recognition of the CLimplication is of the-l
ver\' greatest importance, as the progress of the pregnancy may ,
have a marked influence upon the rapidity of the growth, while
the growth may favor the premature interruption of the course
of pregnancy. This complication is of so much importance that
it may be studied from various standpoints.
Sgg. (a) The Influence of the Myoma upon Conception.-
It can be readily understood that the presence of a fibroid
growth — for instance, of the polypoid or submucous character —
renders the mucous membrane of the uterus unprepared for
the retention of the fecundated ovum, and not infrequently
the removal of a polypus from a woman who has been sterile
for a number of years is very shortly followed by conception,
even though years of sterility had preceded. The engorge-
ment of the uterine mucosa, occasioned by the presence of a
sessile submucous or of an interstitial growth, which encroaches
upon the uterine canal, the profuse and irregular hemorrhages
accompanying its progress, associated with the constant and •'
GENITAL TUMORS. 691
excessive secretion from the glandular structure, present con-
ditions exceedingly unfavorable for the fecundation of the ovum.
600. (6) Influence of Pregnancy upon the Myoma. — The in-
creased congestion of the uterus incident to pregnancy causes
greater nutrition of the growth, results not infrequently in its
rapid increase in size, and the growth which was situated in the
pelvis is of itself raised out of it. and forms a more formidable
mass. In some cases the growth is slow, adhesions may so fix
and bind down the uterus that it can not rise out of the pelvis,
and we may have as a result an impaction of a mass in the
pelvis similar to that which occurs in the gravid retroflexed uterus.
Sometimes the rise of the growth in the pelvis may be rapid, or
Fig. 4^!. — 'Myoma Complicated by Pregnancy.
it may be situated low in the pelvis, and not emerge from it
until between the sixth and seventh months. Intraligamentary
growths become altered by the pressure and cause very marked
distress. The fibroid polypus or submucous tumor is sometimes
extruded into the vagina, whence it may be removed without
any indication of interference with the pregnancy. Marked
changes in size, form, and consistence of the uterine growth may
be noticed. The increase in size is often due to edema. Venous
engorgement frequently occurs as a result of obstruction of the
veins, while the blood is continually poured into the structure by
the less readily controlled arteries. (Fig. 490.) Where a num-
ber of fibroid growths are situated together in the pelvis, they not
i the less rea<
f ber of fibroi
t)90 GYNECOLOGY.
thin, dark, bloody colored fluid. The sac wall is easily niptir
and is rarely dissected without rupture occurring.
6. Pregnancy.- — The presence of fibroid gnjwths is a cause trf"
sterility, but does not necessarily preclude the occurrence of
pregnancy- The early reciignition of the complication is of the
very greatest importance, as the progress of the pregnancy may
have a marked influence upon the rapidity of the growth, whilej
the growth may favor the premature interruption of the cou
of pregnancy. This complication is of so much importance thatl
it may be studied from various stand])uints.
599. (a) The Influence of the Myoma upon Conception.-
Fig. 490. — Tumor Shown after Removal.
It can be readily understood that the presence of a fibroid 1
growth — for instance, of the polypoid or submucous character — ^ 4
renders the mucous membrane of the uterus unprepared for I
the retention of the fecundated o\~um, and not infrequently f
the removal of a polypus from a woman who has been sterile j
for a number of years is very shortly followed by conception,
even though years of sterility had preceded. The engorge-
ment of the uterine mucosa, occasioned by the presence of a
sessile submucous or of an interstitial growth, which encroaches 1
upon the uterine canal, the profuse and irregular hemorrhages j
accompanying its progress, associated with the constant and i
GENITAL TUMORS. 891
excessive secretion from the glandular structure, present con-
ditions exceedingly unfavorable for the fecundation of the ovum.
600. (b) Influence of Pregnancy upon the Myoma. — The in-
creased congestion of the uterus incident to pregnancy causes
greater nutrition of the growth, results not infrequently in its
rapid increase in size, and the growth which was situated in the
pelvis is of itself raised out of it. and forms a more formidable
mass. In some cases the growth is slow, adhesions may so fix
and bind down the uterus that it can not rise out of the pelvis,
and we may have as a result an impaction of a mass in the
pelvis similar to that which occurs in the gravid retroflexed uterus.
Sometimes the rise of the growth in the pelvis may be rapid, or
Fig. 491, — ^Myoma Complicated by Pregnancy.
it may be situated low in the pelvis, and not emerge from it
until between the sixth and seventh months. Intraligamentary
growths become altered by the pressure and cause very marked
distress. The fibroid polypus or submucous tumor is sometimes
extruded into the vagina, whence it may be removed without
any indication of interference with the pregnancy. Marked
changes in size, form, and consistence of the uterine growth may
be noticed. The increase in size is often due to edema. Venous
engorgement frequently occurs as a result of obstruction of the
veins, while the blood is continually poured into the structure by
the less readily controlled arteries. (Fig. 490.) Where a num-
ber of fibroid growths are situated together in the pelvis, they not
by2 GYNECOLOGY.
infrequently become nonpedunculated subserous growths, and!
often become Battened from pressure. The circulation can \
obstructed to such a degree as to result in necrotic changes.]
Such changes require early and prompt interference in order t
save the life of the patient.
6oi. (i:) The Influence of the Myoma upon Pregnancy.—
intra -uterine growth, covered as it is by mucous membrane, f
Fig. 491.— Uterus Containing Large Filirojd Tumor and Three Months' Pat
disposes the subject to increased bleeding. This hemorrhage a
the changes in the uterine mucous membrane may be so ma "
as to result in premature interruption of pregnancy ; or the o
may be lodged low in the uterine cavity, causing the formati
of the placenta over the cervix, — what is knovm as pla(
previa, — in which the life of the mother will become moi
endangered as the pregnancy progresses. The situation of t
tumor may favor retroversion of the gravid uterus and its i
GENITAL TUMORS. S93
paction in the pelvis, or the tumor itself may be impacted with
the development of the pregnancy. The presence of a fibroid
growth, with its pressure upon the tubes, may cause the develop-
ment of a tubal pregnancy, which may remain unsuspected until
its rupture into the abdominal cavity occurs, with the accom-
panying peril to the patient.
602. (d) Influence upon Labor. — In the majority of small
fibroid growths, especially those which ha\-e not attained to a
size larger than a walnut or an orange, the presence of the growth
produces but slight, if any, influence upon the progress of the
labor. Tumors of a larger size, which are situated in the pelvis,
may interfere with labor and require operative interference for
their previous removal. Occasionally, with changed position of
the patient and elevation of the hips, the tumor may be pressed
out of the pelvis, or a tumor situated low in the pelvis, under
the dilatation of the os and elevation of the cervix as the dilata-
tion progresses, may be lifted out of the pelvis. Interstitial and
subserous growths, with a broad base, cause irregular and in-
eflective uterine contractions, which affect the progress of labor.
The existence of myomata has been found to complicate greatly
the results. Winckel, comparing the statistics of X)ne himdred
and forty-seven cases of labor comphcated \%'ith myomata with
those suffering from contracted peK'es, said 5 to 6 per cent, of
parturients with contracted pelves perish during labor, but when
complicated with myomata, 50 per cent, succumb. The infantile
mortality is often more serious. Nauss found the infantile mor-
tality to be 66 per cent. Lefour, in three hundred cases ob-
served, gives 77 per cent. Large subserous growths, when above
the pelvis, in or near the fundus of the uterus, exert no influence
upon the progress of the labor. CePiical growths, however, are
very important, as from their situation they may occupy a
position below the level of the cer\'ix, and necessarily interfere
with the dehvery of the fetus, but even when the growth is thus
found in the pelvis, it is often spontaneously raised as the process
of dilatation proceeds. Submucous growths may be extruded
into the vagina pre\'ious to the inception of labor and then be
removed. If the tumor becomes edematous, it is more com-
pressible and less of an obstacle to the progress of delivery.
603. Course and Prognosis. — Many of these growths, espe-
cially when small, produce very few symptoms, and those quite
vague. Others cause serious disturbance imtil the occurrence of
the menopause, after which the great majority of tumors undergo
atrophy and diminish by induration during the process of in-
volution. The process of atrophy is occasionally hastened by
pregnancy, so that patients who have been recognized as suffering
from a fibroid growth have the tumor entirely disappear by the
092 GYNECOLOGY.
infrequently become non]3edunculated subserous growths, and
often become flattened from pressure. The circulation can be
obstructed to such a degree as to result in necrotic changes.
Such changes require early and prompt interference in order to
save the life of the patient.
6oi. (i:) The Influence of the Myoma upon Pregnancy. — An
intra-uterine growth. co\-ered as it is by mucous membrane, pre-
Pig. 493. — Uterus Containing Large Fibroid Tumor and Three Mooths' Fetus.
disposes the subject to increased bleeding. This hemorrhage and
the changes in the uterine mucous membrane may be so marked
as to result in premature interruption of pregnancy ; or the ovum
may be lodged low in the uterine cavity, causing thj
of the placenta over the cervix,^ — what is knowji
pnevia, — in which the life of the mother \vi]"
endangered as the pregnancy progresses. Th^
tumor may favor retroversion of the gravid uft
GENITAL TUMOIJS. 093
paction in the pelvis, or the tumor itself may be impacted with
the development of the pregnancy. The presence of a fibroid
growth, with its pressure upon the tubes, may cause the develop-
ment of a tubal pregnancy, which may remain unsuspected until
its rupture into the abdominal cavity occurs, with the accom-
panying peril to the patient.
602. (d) Influence upon Labor. — In the majority of small
fibroid growths, especially those which have not attained to a
size larger than a walnut or an orange, the presence of the growth
produces but slight, if any, influence upon the progress of the
labor. Tumors of a larger size, which are situated in the pelvis,
may interfere with labor and require operative interference for
their previous removal. Occasionally, with changed position of
the patient and elevation of the hips, the tumor may be pressed
out of the pelvis, or a tumor situated low in the pelvis, under
the dilatation of the os and elevation of the cervix as the dilata-
tion progresses, may be Ufted out of the pelvis. Interstitial and
subserous growths, with a broad base, cause irregular and in-
effective uterine contractions, which affect the progress of labor.
The existence of myomata has been found to comphcate greatly
the results. Winckel, comparing the statistics of -one hundred
and forty-seven cases of labor complicated with myomata with
those suffering from contracted pelves, sajd 5 to 6 per cent, of
parturients with contracted pelves perish during labor, but when
complicated with myomata, 50 per cent, succumb. The infantile
mortality is often more serious. Nauss found the infantile mor-
tality to be 66 per cent. Lefour, in three hundred cases ob-
served, gives 77 per cent. Large subserous growths, when above
the pelvis, in or near the fundus of the uterus, exert no influence
upon the progress of the labor. Cervical growths, however, are
very important, as from their situation they may occupy a
position below the le\-el of the cer\-ix, and necessarily interfere
with the delivery of the fetus, but even when the growth is thus
found in the pelvis, it is often spontaneously raised as the process
of dilatation proceeds. Submucous gjrowths may be extruded
into the vagina previous to the inception of labor and then be
removed. If the tumor becomes edematous, it is more com-
pressible and less of an obstacle to the progress of delivery.
603. Course and Prognosis. — Many of these growths, espe-
cially when small, produce very few symptoms, and those quite
vague. Others cause serious disturbance until the occurrence of
^the menopause, after which the great majority of tumors undergo
phy and diminish by induration during the process of in-
The process o£ atrophy is occasionally hastened by
that pati*"'*" •"ho liave been recognized as suffering
■'owt^ '•imor entirely disappear by the
690 GYNECOLOGY.
thin, dark, bloody colored fluid. The sac wall is easily ruptured
and is rarely dissected without rupture occurring.
6. Pregnattcy. — The presence of fibroid gro%vths is a cause of
sterility, but does not necessarily preclude the occurrence of
pregnancy. The early recognition of the complication is of the
very greatest importance, as the progress of the pregnancy nay
have a marked influence upon the rapidity of the growth, while
the growth may favor the premature interruption of the course
of pregnancy. This complication is of so much importana that
it may be studied from various standpoints,
599. (a) The Influence of the Hyoma upon Conception-
Fig. 490. — Tumor Shown after Removal.
It can be readily understood that the presence of a fibrmd
growth — for instance, of the polypoid or submucous character-
renders the mucous membrane of the uterus unprepared for
the retention of the fecundated ovum, and not infrequently
the removal of a polypus from a woman who has been sterile
for a number of years is very shortly followed by conceptioii,
even though years of sterility had preceded. The engorge-
ment of the uterine mucosa, occasioned by the presence of a
sessile submucous or of an interstitial growth, which encroaches
upon the uterine canal, the profuse and irregular hemorrh^es
accompanying its progress, associated with the constant and
GENITAL TUMORS. 691
ocessive secretion from the glandular structure, present con-
litions exceedingly unfavorable for the fecundation of the ovum.
600. (b) Influence of Pregnancy upon the Hyoma. — The in-
:ieased congestion of the uterus incident to pregnancy causes
^ter nutrition of the growth, results not infrequently in its
rapd increase in size, and the growth which was situated in the
pdvjs is of itself raised out of it, and forms a more formidable
mass. In some cases the growth is slow, adhesions may so fix
ind bind down the uterus that it can not rise out of the pelvis,
ud we may have as a result an impaction of a mass in the
pelvis similar to that which occurs in the gravid retroflexed uterus.
^metimes the rise of the growth in the pelvis may be rapid, or
Fig. 491. — Myoma Complicated by Pregnancy.
may be situated low in the pelvis, and not emerge from it
itjl between the sbcth and seventh months. Intraligamentary
owths become altered by the pressure and cause very marked
stress. The fibroid polypus or submucous tumor is sometimes
truded into the vagina, whence it may be removed without
y indication of interference with the pregnancy. Marked
anges in size, form, and consistence of the uterine growth may
noticed. The increase in size is often due to edema. Venous
gorg;ement frequently occurs as a result of obstruction of the
ins, while the blood is continually poured into the structure by
e less readily controlled arteries. (Fig. 490.) Where a num-
r of fibroid growths are situated together in the pelvis, they not
692 GYNECOLOGY.
infrequently become nonpedunculated subserous growths, and
often become flattened from pressure. The circulation can be
obstructed to such a degree as to result in necrotic changes.
Such changes require early and prompt interference in order to
save the life of the patient.
601. (c) The Influence of the Myoma upon Pregnancy. — An
intra-uterine growth, covered as it is by mucous membrane, pre-J
Fig. 403. — Uterus Containing Large Fibroid Tumor and Three Months' p4
disposes the subject to increased bleeding. This hemorrhage a
the changes in the uterine mucous membrane may be so marki
as to result in premature interruption of pregnancy ; or the ovu
may be lodged low in the uterine cavity, causing the foroiatii
of the placenta over the cer\'ix, — what is known as placentl
pra;via, — in which the life of the mother will become mra
endangered as the pregnancy progresses. The situation of t
tumor may favor retroversion of the gravid uterus and its i
GENITAL TUMORS.
603
k
paction in the pelvis, or the tumor itsel£ may be impacted with
the development of the pregnancy. The presence of a fibroid
growth, with its pressure upon the tubes, may cause the develop-
ment of a tubal pregnancy, which may remain unsuspected until
its rupture into the abdominal cavity occurs, with the accom-
panying peril to the patient.
602. (d) Influence upon Labor. — In the majority of small
fibroid growths, especially those which have not attained to a
size larger than a walnut or an orange, the presence of the growth
produces but slight, if any, influence upon the progress of the
labor. Tumors of a larger size, which are situated in the pelvis,
may interfere with labor and require operative interference for
their previous removal. Occasionally, with changed position of
the patient and elevation of the hips, the tumor may be pressed
out of the pelvis, or a tumor situated low in the pelvis, luider
the dilatation of the os and elevation of the cervix as the dilata-
tion progresses, may be lifted out of the pelvis. Interstitial and
subserous growths, with a broad base, cause irregular and in-
effective uterine contractions, which affect the progress of labor.
The existence of myomata has been found to complicate greatly
the results. Winckel, comparing the statistics of -one hundred
and forty-seven cases of labor complicated with myomata with
those suffering from contracted pelves, said 5 to 6 per cent, of
parturients with contracted pelves perish during labor, but when
complicated with myomata, 50 per cent, succumb. The infantile
mortality is often more serious. Nauss found the infantile mor-
tfility to be 66 per cent. Lefour, in three hundred cases ob-
served, gives 77 per cent. Large subserous growths, when above
the pelvis, in or near the fundus of the uterus, exert no influence
upon the progress of the labor. Cervical growths, however, are
very important, as from their situation they may occupy a
position below the level of the cersix, and necessarily interfere
with the delivery of the fetus, but even when the growth is thus
found in the pelvis, Jt is often spontaneously raised as the process
of dilatation proceeds. Submucous growths may be extruded
into the vagina previous to the inception of labor and then be
removed. If the tumor becomes edematous, it is more com-
pressible and less of an obstacle to the progress of delivery.
603. Course and Prognosis. — Many of these growths, espe-
cially when small, produce very few symptoms, and those quite
vague. Others cause serious disturbance until the occurrence of
the menopause, after which the great majority of tumors undergo
atrophy and diminish by induration during the process of in-
volution. The process of atrophy is occasionally hastened by
pregnancy, so that patients who have been recognized as suffering
from a fibroid growth have the tumor entirely disappear by the
d94 gynecology,
completion of the pregnancy ; or, in other cases, during t
sequent convalescence. Occasionally, there is a marked breaking-
down of the health, associated with fibrous cysts or fibromyomata,
and particularly after the critical age. The tumors that remain
quiescent are not necessarily small, but can reach to the level of
the navel, so that the patient may be entirely ignorant of their
presence and only be made aware of the existence of the growth
by an examination that is made for some intercurrent condition,
or for the treatment of symptoms produced by the tumor, of the
cause of which the patient had previously been in ignorance. In
the majority of cases the tumor does not threaten life either
directly or indirectly. In tliis respect these growths are quite
different from carcinoma or an ovarian tumor. The carcinoma
demands immediate operation, as soon as discovered, for life is
destroyed by its progress ; but in myomata such advice must be
modified, for in many cases the growth is not even the cause of
the disease for which the aid of the physician is sought. In
others it may be productive of disturbance. In myomata of large
size, which reach above the umbilicus in young individuals, the
prognosis as to time is good, but there are possibilities of it
becoming worse. In a woman who has not reached the age of
thirty -five years, and a tumor attains a size corresponding to that
of a pregnancy at full term, one can with security assert that the
life of the individual is threatened, and the capacity for suffering
must be limited. Attention should be directed to the symptoms
that threaten life. The operation in such cases is no longer
elective, but necessary, as the percentage of danger from Sie
operation is more trifling than from the unfavorable influence
produced by the growth of the tumor. In such cases, in order to
produce conviction, the physician should be able to assert that the
operation is advisable, and can not be postponed for ten or twenty
years with the hope that the patient will still manifest good
powers of resistance and a fair chance for recovery. If the
tumor comes under observation at a later date, near the middlftj
of the fifth decad.-— about forty-three to forty-five years of a_
ad\^ice must be governed by the symptoms. It is possible that*
the tumor may swell during menstruation, and foUoftdng its
final cessation a m{:)re secure and much more considerable diminu-
tion appears. In such cases tlie patient can be advised to wait
until symptoms appear. In all cases the prognosis is dependent
upon the age and its relation to the tumor. Great size of 1"
tumor and its complex symptoms affect the future course.
compHcations that increase the size of the tumor render 1
prognosis the worse the younger the age of the patient. In'l
these cases we have to determine that not the tumor but the com- j
plications are the cause. Complications that may be regarded as j
GENITAL TUMORS. 695
hazardous in the young are less serious in the older, because the
longer duration of the disease renders the organism more ac-
customed to its existence. The prognosis is very bad in cases of
severe heart affections, as fatty degeneration, though this is
difficult to recognize in the living. Other complications may
render the prognosis of the myomata bad, but not necessarily
make the prognosis of operation worse. The first indication
of heart affection should be regarded as an indication for prompt
operation. The prognosis is rendered much worse if the myoma
has tmdergone a malignant degeneration, which, however, is
rare. The rapid growth of the tumor is not necessarily an in-
dication of malignant change, but more of cystic degeneration,
which renders the prognosis of the further continuation of the
growth worse, approaching in this respect the ovarian condition.
The prognosis of all small tumors, especially those which cause
more or less hemorrhage, is not necessarily unfavorable. The
danger is never so great as it appears to the patient. The dis-
comfort produced by the condition and the anxiety about further
duration and increase of bleeding impel the patient to consult
her physician. In such cases it is difficult to arrive at a correct
judgment, as the patients do not appreciate the fact that life
is not necessarily threatened when menorrhagia is profuse. In
the consideration of methods of treatment the fact must be kept
in mind that the productive activity is injured, even though a
bad prognosis is not to be asserted. The danger lies in the long
duration of hemorrhage, which thereby renders worse the general
condition. The prognosis is more grave when there is more
marked general disturbance. In many cases the appearance
of hemorrhage can be regarded as a favorable indication, as it
proves that the spontaneous discharge of the tumor is taking
place, following which the prognosis is imi)roved.
While it is true that a fibroid growth usually undergoes an
abatement of its symptoms with the advent of the menopause,
yet it should not be forgotten that the existence of such a growth
generally delays the climacteric beyond the ordinary period of
Bfe at which it should occur. Occasionallv, the natural evolution
of a tumor, which results in its conversion into an extraperitoneal
or intraperitoneal growth, may cause rupture of its pedicle, from
the weight of the tumor alone or from thinning of the pedicle.
By straining in defecation or in vomiting, a polypus may be ex-
pelled. The rupture of a pedicle may limit the subsequent prog-
ress of the growth, or it may remain grafted to the point where
it has formed adhesions and be subsequently nourished, or it may
lie free in the peritoneum and undergo mummification. A more
serious spontaneous extrusion is mortification or gangrene of a
tumor which has been expelled toward the uterine cavity. Per-
696 GYNECOLOGY.
foration of some of the neighboring organs may occur, as the
bladder, the rectum, the rectovaginal pouch, or the abdominal
wall. The two former conditions end in death; the latter, in
possible recovery ; or, finally, the tumor may be absorbed.
Causes of death are profound anemia from repeated hemorrhage ;
successive attacks of chronic peritonitis; disease of the kidneys;
uremia and heart failure ; rupture of cyst ; or inflammation and
gangrene. Sudden death has been observed as a restJt of em- ,
holism. Exploratory puncture favors the production of thrombi
in the large venous sinuses. Death from shock after intravenous
rupture has been reported. In very small growths which have
been extruded beneath the peritoneum, and by their relations
show no evidence of taking on growth, it is preferable that the
patient should be left unaware of their existence. The various
complications to which these growths are subject ; the alterations
which they may undergo during their progress; the influence
upon the health of the individual from pressure upon important
viscera ; the danger from separation of growths and subsequent
gangrene ; the possibility of their continued nutrition and growth
subsequent to the menopause ; and the occasional malignant de-
generation of the mass, associated with the diminished mortality
by early operative procedure, particularly that of hysterectomy,
would render it advisable that the extirpation of the growth '
should be practised. In the young the possibility of the occur-
rence of pregnancy with its attendant dangers is an important
factor, and one which may be an indication for treatment.
When a woman possesses a condition which insures a maternal
mortality of 50 per cent, and an infantile loss of 75 per cent.
or o\'er, it becomes a serious question whether she should be
advised to marry, or, if married, should not be subjected to
prompt operative interference.
604. Treatment. — The mere discovery of the existence of a
myoma must not be considered as a necessary indication
for its removal, or. even treatment. In this respect myomatous
tumors differ from ovarian growths and from cancer, for the
latter must be removed early, because its continued existence
results in destructive influences upon the organism. The
myoma must cause symptoms in order to indicate interference.
The external relations of the patient must play a great r61e
in the method of treatment— the capacity of resistance, the
ability to undergo rest during menstruation, and to a^^oid severe
bodily labor; consequently the treatment is different in women
of the working class, who can not rest, from that which must be
practised in those who are able to take care of themselves. There
are some cases in which hygienic and dietetic rules must govern.
Neither the growth of the tumor nor the severity of the hemor-
GENITAL TUMORS. W7
rhage will necessarily be influenced by the methods of treat-
ment; but by the avoidance of severe bodily effort and the
promotion of nutrition disturbance of the health equilibrium
is avoided.
The patient should be cautioned as to her manner of dress,
and advised to wear loose clothing, since it would be exceed-
ingly detrimental to force down into the lower part of the pelvis
a myomatous uterus by wearing a tight corset, Tight clothing
over an abdomen containing such growths may very readily
produce inflammation which will lead to extensive and un-
fortunate adhesions. When the abdominal wall has become
greatly weakened by previous distention or the weight of a
large tumor following the climacteric, the comfort of the pa-
tient may be greatly enhanced by wearing a binder or support
which wiU prevent the organ from falling forward. In such
cases and in growths predisposed to the occurrence of torsion,
a radical operation is indicated, Schroder attempted to fasten
very movable tumors by sutures through the abdominal wall.
Such a plan of treatment is not only unsatisfactory, but dangerous.
The very profuse hemorrhage which frequently occurs requires
that the nutrition should be carefully maintained and that
all excesses of Bacchus and venery should be avoided. Pre-
ceding and at the menstrual period the patient should be kept
in bed and an ice-bladder or cold applications should be placed
over the abdomen. Tea and coffee should be interdicted, be-
cause experiments have demonstrated that both these articles
increase the tendency to profuse bleeding. Various baths
and mineral waters have been advocated as especially efficacious.
Among these are the Kreuznach. Tolz. and Halle, in upper
Austria, which are largely impregnated with iodin and bromin,
and the Franzensbad and Elster, in which sulphur is an im-
portant element. These waters probably exert their influence,
not so much by their direct effect upon the tumor, as by
the improvement of general nutrition. The health is built up,
complete rest is secured, and the appetite is improved, and
thus more or less relief is obtained. The treatment may be
divided into:
(a) Medical.
{b) Electrical.
(c) Surgical.
605. (a) Medical Treatment. — The medical treatment should
consist in the employment of remedies and hygienic measures
directed to promote the general nutrition of the patient and
to ameliorate the unpleasant symptoms. Such treatment must
be largely symptomatic. Tlie hst of remedies advocated for
the txeatment of uterine myomata is very extensive; but, as
698 GYNECOLOGY.
is usually the case, the larger the list of remedial agents, the
less beneficial the influence exerted. Notwithstanding the
effective results that have been attributed to many different
remedies, the history of myomatous growths discloses that they
normally undergo peculiar changes, becoming sometimes lai^er
and at others smaller. Occasionally the growth disappears
without any assignable cause. Such fortunate results have
added to the reputation of certain remedies, when similar con-
ditions would probably have taken place had they not been
administered. The agents which are most likely to exert an
influence upon the progress of the growth are those which pro-
duce an effect upon the muscular coat of the organ, and belong
to that class known as oxytocics, of which ergot is the prindpaL
Ergot may be administered by the stomach, by the rectum,
or by hypodermatic injection. Its employment by the stomach
causes more or less disturbance of the digestive tract, nausea,
and vomiting. Moreover, in order to secure any beneficial
effect from its employment, it must be continued over a loi^
period of time, which renders this method of administration
objectionable. Ergot in combination with a vegetable astringent
will sometimes exert a favorable influence in decreasing and
arresting a severe hemorrhage. It may be employed in the
following combinations:
R . Ext. ergot. , f5J
Extract, hamamelis, __
Tinct. cinnamom ^k f 3 ss. M.
SiG. — f^j every two or three hours.
Or:
R . Ergotin, gr. ij
Hydrastinin. hydrochlorat. , gr. }. M.
Ft. capsulae No. xxx.
SiG. — A capsule to be taken every three or four hours.
The fluidextract of cotton-root or an extract of iistilago
maidis, the ergot of com, acts similarly to ergot, though to a
less marked degree. When a patient suffers from expulsive
efforts of the uterus, these may be ameliorated by the addition
of extract of cannabis indica, gr. \ to each dose. Ergot is most
effective when administered by hypodermatic injection, uang
either the sterilized fluidextract, the normal liquid, or ergotin.
The ajT^ent should be thoroughly aseptic, should be injected
in close proximity to the tumor, preferably in the abdominal
walls, and the caution should be taken to make the injections
deeplv into the muscle, since thev 'VNill then be less likelv to be
the cause of abscess. Ergot acts in two ways: by stinmlating
the muscular coats of the blood-vessels, thus cutting off the
supply of blood sent into the uterus ; and, secondlv, bv increasing
i
GENITAL TUMORS. 699
activity of the musctilar structure of the organ. Fibroid
Kiowths which are situated in the uterine wall are, by its in-
oience, more readily expelled, either intraperitoneally or extra-
Heritoneally. To be efficacious, the drug must be continued
over a long period of time. When thus employed, it exerts an
Snfluence upon the muscular coat of the blood-vessels through-
oot the body, increases the danger of arterial sclerosis and the
•rtablishment of pathologic processes more serious than those
&r which the drug was administered. Among some of the
drugs for which a reputation has been made by the retrogressive
ytocesses through which fibroids naturally pass may be named
the potassium and ammonium salts, particularly the bromid, the
iodid, and the chlorid of ammonium. How much influence
any of these drugs will exert upon the progress of the disease
ii an undetermined question. Among other drugs that have
been employed are sulphuric and gallic acids, turpentine, can-
jDabis indica, extract of hamameUs, extract of hydrastis can-
adensis, and the active principles of the latter agent, hydrastin
and hydrastinin. The latter agents exert a very favorable
influence by constringing the blood-vessels, and thus serve to
control hemorrhage. Efforts have been made to bring about
tiie absorption or destruction of fibroid tumors to compensate
for the deprivation of certain nutrient elements which enter
largely into the composition of the growth. A diet composed
of the carbohydrates seems to have been in some few cases effec-
tive. Sir J. Y. Simpson, recognizing that the calcareous de-
generation of a fibroid limited its further growth, purposed
to accomplish this phenomenon by the administration of large
doses of chlorid of calcium, but he soon found that this drug
produced calcareous plates in the aorta and in the valves of the
heart, and thus caused conditions much more grave than that
for which it was given. In recent years the extract of thyroid
Inland has been advocated to reduce the size of growths and
assist in the arrest of hemorrhage. As patients vary to a great
degree in their susceptibility to the influence of this agent, it
must, therefore, be employed carefully, increasing the dose
gradually from three to five grains a day to the largest amount
fhe sensibility of the patient will permit. In exophthalmic
K"ter, or in irritable conditions of the heart, the drug is badly
ne, even in small doses. In some cases of fibroid growths
in which I have employed it, the- drug has produced such an
effect upon the nervous system that its use had to be discon-
tinued. Without question, it exerts an influence upon the
Iming structure of the uterus, and to this extent is beneficial in
leMening the tendency to hemorrhage. Polk and Mann claim to
liave seen very pronounced effects from this drug in the dim-
700 GYNECOLOGY.
inution of the size of the tumor, but that it has any permanent
influence is very questionable. Shober employed the mammary
gland extract with apparent benefit in a limited ntimber d
cases, but the results do not seem to have given sufficient encour-
agement to continue it. Probably the extract of the suprarenal
gland or its active principle, adrenalin, is more effective than any
of the other agents we have mentioned in stimulating the muscular
coat of the blood-vessels, thus lessening the tendency to hemor-
rhage. Various local measures have been employed, such as
injections into the vagina. These, however, can have no in-
fluence on hemorrhage from the uterus, as the coagulation of
the blood in the vagina will be insufficient to afford any ob-
struction to the severe uterine hemorrhage. Ice-water was
formerly employed, later hot water. Both agents are efl&cacious
in the field of obstetrics, but they have but Uttle influence upon
fibroid tumors. The agent must come directly in contact with
the affected endometrium to be of any service. When hemor-
rhage is very marked and uncontrollable and threatens the
life of the patient, the vagina or even the uterine cavity may
be packed with iodoform gauze, which acts as a tampon and
thus controls the bleeding. When the uterine canal is opened,
its cavity may be irrigated with hot water or vinegar and water,
or a solution of perchlorid of iron, tincture of iodin, and other
agents for the purpose of arresting hemorrhage. These agents
are sometimes quite effective for a length of time, but their
use is not unattended with danger. The uterine canal should
be so patulous that the subsequent drainage can be complete,
but even in such cases the method of treatment is not infrequently
attended with danger. I well remember a patient in my early
experience who had a large fibroid tumor, which occasioned
frequent attacks of profuse bleeding. The cervical cavity was
quite patulous, and with a uterine syringe I injected tincture of
iodin into its cavity. Almost before the syringe could be with-
drawn the patient complained of tasting the drug, and within
a few moments she had a most violent attack of pulmonary
edema, which threatened her life, and from which she recovered
only after a protracted illness. Moreover, this state w^as followed
by prolonged mental disturbance. Needless to say, I have
not been inclined to regard this plan of treatment with a great
deal of confidence.
606. (b) Electric. — Electricity has been practised in the
treatment of fibroid growths for many years. The methods
of application of the agent were crude, and not infrequently
were attended with great danger, especially when punctures
were made through the abdominal wall directly into the tumor
by an insulated needle, which thus produced a direct and localized
GENITAL TUMORS. 701
influence upon the structure immediately in contact with the
yoles. It remained for Apostoli, by his method of measuring
the current and fixing the direct dosage, to evolve a plan of
treatment which can be practised with a certain degree of pre-
cision. Under ordinary means the passage of a current of
ftom five to ten, or at most twenty milliamperes is attended
irith considerable discomfort. By his apparatus and method
of procedure from loo to 200 milliamperes are employed. This
j( accomplished by the application over the external surface
of a large, comparatively inactive electrode, while a more active
dectrode is introduced into the vagina, or, preferably, into
the uterine cavity. He further defined the influence of the
positive and negative poles. The positive pole was recognized
as producing a decomposition of the fluids about it, which
resulted in the accumulation there of an acid, while about
fhe negative pole accumulated alkaline fluid. The former
is the more destructive in its influence, and hence is more par-
ticularly of value in diseased conditions of the mucous mem-
brane which cause hemorrhage. The application of the posi-
tive pole within the uterus causes an electrolytic or cauterizing
action, which results in coagulation of the blood in the vessels
and in the arrest of bleeding. The negative pole, on the other
hand, by its influence produces edematous infiltration of the
tissues at some distance from the pole, and the subsequent
absorption decreases the size of the growth. For the practice
of Apostoli's treatment, then, are required: First, an electric
battery sufficiently large to give a current strength of from
SOD to 300 milliamperes without its wearing out too rapidly;
second, a galvanometer capable of measuring 500 milliamperes;
third, a rheostat, by which the strength of the current can
be gradually increased. The current -chooser — an instrument
by which the current can be changed from positive to negative
without the removal of electrodes — is important. It must
be kept in mind in the use of this instrument, however, that
the strength of the current must be very greatly reduced before
such a change is made, as otherwise the patient would receive
a violent and painful, if not a dangerous, shock.
Electrodes. — The external electrode, to be placed over the
abdomen, is of large size, and consists of the clay pad of Apostoli,
of the bladder or water electrode, as advocated by Martin, or
of a towel w^et with a salt solution and over which the electrode
is placed. The intra-uterine electrode consists of a probe in-
sulated within a couple inches or more of its point, as may
be desired. An ordinary probe with a gutta-percha hood which
can be slid over it affords an efficient electrode. The electrodes
are placed in position before the current is turned on. The
702 GYNECOLOGY.
latter is applied gradually, watching the galvanometer and the
expression of the patient to ascertain the sensibility. The
internal electrode is made of platinum or carbon, these agents
having more endurance. As large quantities of strongly acid
material accumulate about the electrode, the less durable metals
would be very quickly destroyed by electrolytic action. In
the application of electricity the vagina should be thoroughly
cleaned in order that no infection shall be carried into the uterine
cavity. It is recognized that electricity is a powerful anti-
septic, but it is only in the stronger doses that it exerts such
an influence. The application of electricity may be made
two or three times a week, according to the intensity. When
strong currents are used, but once a week is preferable. The
seance lasts from five to fifteen minutes. Previous to the
application of the external electrode the skin of the abdomen
should be carefully examined for breaks in the corium, by
denudation from scratching, or from the presence of furuncles.
Any irritated points should be treated, and should be excluded
from contact with the electrode by the appHcation of collodion
or pieces of plaster to insulate it. The external electrode is
placed upon the abdomen and is connected with the battery;
the internal electrode, also connected, is introduced, but with
the precaution to have the current closed. The current is
then opened slowly and carefully, and is gradually increased
to the point of tolerance. The current is gradually reduced
before the withdrawal of the electrode, to prevent the patient
from Ixnng sul^jected to a severe shock. In the beginning of
the treatment it is important that the current should be governed
with the greatest care, and currents of moderate intensity
only employed, until the degree of toleration is determined.
It is diflficult to fix the number of applications to be required —
generally from twenty to thirty.
ElectropiDicture of the Myoma. — Occasionally, the situation
of the tumor may be such as greatly to displace the external
OS and to render the canal tortuous and difficult for the intro-
duction of the electrode. In such cases puncture may be made
into the myoma through the anterior ccr\'ical wall. Just as
rigid antisepsis should be practised for this procedure as for
the most seriotis operation, and as it is not infrequently quite
painful, an anesthetic should be employed. The pimcture of
the vagina is frr)m one-half to one centimeter deep, and is per-
formed without the em]^l(n-ment of a speculum. Previous
examination will disclose the j)osition of the uterine artery,
which should be avoided; also, care should be exercised not to
injure the bladder or intestines.
GENITAL TUMORS.
703
Electricity exerts its influence in three ways:
(a) In the diminution of the tumor from one-fifth to one-
half of its original size. Complete disappearance is exceedingly
rare.
(b) In a most marked influence upon the hemorrhage.
(c) In the relief of pain.
The disappearance of pain and the arrest of hemorrhage
necessarily result in the improvement of the general condition
of the patient. ApostoU gives the following contraindications:
First, hysteria; second, intestinal catarrh; third, pregnancy;
fourth, malignant degeneration of the tumor; fifth, fibrocystic
tumors.
Some of his followers do not consider hysteria an absolute
contraindication, but ApostoH has made the observation that
the hysteric possess a very great intolerance to the electric
current, making it impossible during the coiu*se of a sitting to
introduce a sufficiently high current to bring about favorable
results. In intestinal catarrh the current has a strong in-
fluence on the solar plexus, which calls forth severe contraction
of the intestinal muscle. It can be readily understood that
the presence of malignant growths must necessarily offer a
direct contraindication to the electric treatment. The diag-
nosis is sometimes difficult to determine. Kellogg has asserted
that in a myoma which, after the menopause, shows a rapid
growth, mahgnant degeneration is undoubtedly taking place,
and that electric treatment should be withheld. In fibrocystic
tumors the gas accumulation after the electric treatment may
lead to suppuration. Gehrung. in order to avoid this, employs
a puncture cannula, so that the fluid contents of the tumor
can be drawn off. The presence of pus in the adnexa, as men-
tioned by Apostoli, is a very frequent complication, and one
often difficult to recognize. The employment of electricity
in such cases is unexceptionally harmful. It is unnecessary
that the inflammation should have gone on to suppuration in
order to make the treatment objectionable. Very acute or
subacute inflammation in the environment of the uterus is a
positive contraindication to electrotherapeutics.
Further, a verj' important contraindication for electric
treatment depends upon the situation of the tumor and its
relation to the uterus, and justifies the following statement:
(a) In subserous tumors, particularly when they are pedun-
culated, electric treatment will ha\'e but little beneficial effect,
and is likely to prove injurious.
(b) A pedunculated submucous fibroid affords no special
advantages for electric treatment.
In^an inconsiderable number of cases suppuration of
5 special ^
f a poly- ^^M
704 GYNECOLOGY,
pus has resulted from intra-uterine electric treatment. Not
infrequently has a fatal result appeared, or total extirpation
of the suppurating organ been performed, with or without
favorable result. Other contraindications, in addition to those
named, are heart failure and acute nephritis. In very hard
tumors the employment of electricity is opposed by Parsons,
as they can not be influenced by it.
C'/lossal Tumors. — In studying the influence of electricity
upjn the tissues we must take the polar and the interpolar.
I. T!i€ Pclar Injiuencc. — This incidentally depends on the
progress of electrolysis of the soft tissues. In the passage of
the currer.t from the metallic bodv. in fluid destruction which
takes ylace in the salt solution. an«l about the positive pole
an acil is !jrme«l. w:ii!e the metal surroimds the negative.
Sirr.flar chancres «x:cur in the tissues of the body, so that about
:hr r . sirive jOle ac:.: material, such as carbonic acid and chlo-
r:::. is 5v: :ree. I:: the catho«:e water\' material — the alkalies —
arv _ '!r-:ei. I: is asserted that these materials in' the nascent
s:..:v exvr: a str:::^^ chemic inrluer.ce. Albumin is coagulated,
ti-.T v.sicls are r.^-.rr.'.vei. a::! a hard. dr\-. brown-red slough
:•: _ur5. v.jiile ur. ler l.r.cer err-.r-.-vmer-t the tissues are destroved.
A" lut th-j negative t-.le a s:ft. succulent, glue-like, easily
vhite s'. UjTh recurs, as i: v-ne had employed con-
tash. Crnsecutive hemorrhages may follow
:':\c rn:^' y:nt:n:. The ne^rative current is abs-z^rbent. and is
rr.uih :n rr ::. sinful than t;:e -.sitive. Investiisrations have
Irn: ::f:r.i:. i th..t t/.r : :s::i 'e rrlr a:ts n::re on the cell germs
he : rrv.ir has a shari^r limita-
C'_- «.i . -i, .. -..
,^"-"__ ._i ^» ^^'i ^
r
. . ^ rv. . - .
s .rltics assert that
7'.: vnnciral daneers
. I Sv;ys:s- hut we have
:s s<:r.LS :: dangers —
• n: :'•*. . r.irrm— with-
•■u:r::i.n When we
k. h an:a^cs of electric
.: i: >'■. V." ". re o^nnned
:a>;< ■ ".u.h th-eaten
607. Sureical. — .! r -urj: ./. :-...:n--: f :". r :.: cro'.vt
ns
he
GENITAL TUMORS.
The vaginal procedures consist in :
I. Dilatation :
a. Incision of the cervix.
3- Incision of the capsule.
4 Removal.
(a) Torsion.
(6) incision of the pedicle.
(c) Enucleation.
iai Morcellement.
5. Ligation of the vessels.
6. Hysterectomy.
The abdominal route includes:
7. Castration.
8. Ligation of vessels.
9. Myomectomy.
10. Enucleation.
11. Supravaginal amputa
la. Panhysterectomy.
r partial hysterectomy.
Vaginal Procedures.
608. (i) Dilatation and Curetment of the Uterus. — Dilatation
of the uterus may be indicated as the first stage in treatment of
the uterine growth or for the purpose of diagnosis. It may be
accomplished by the mechanical dilators of Hegar, but without
tearing the neck they will not afford sufficient dilatation of the
cervix to permit the introduction of the finger. The preferable
method of dilatation is the employment of a laminaria tent, and
the vagina sliould be thoroughly cleansed and rendered as nearly
aseptic as possible before its introduction. The os is exposed
by a Sims speculum or perineal retractor. The cervix is seized
with a double tenaculiun, the os exposed, the plug of mucus
filling the cervical cavity remo\-ed, and the canal thoroughly
disinfected; then as large a tent is selected as can readUy be
introduced, or, when the canal is pretty well dilated, a nest of
tents may be employed. Time can he saved by the introduction
of several bougies preliminary to the insertion of tents. The
larger number of tents which can thus be inserted permits the
cervix to be so dilated by the first set of tents that the uterine
cavity can be explored by the finger upon their removal. These
tents previous to their insertion should be sterilized by heating,
placed for a few minutes before their employment in a saturated
solution of iodoform and ether in a mixture of equal parts of
carbolic acid and alcohol, or, better still, in tincture of iodin.
After the introduction of the tent iodoform gauze is placed be-
neath it to protect the parts from infection and to keep the tent
from being extruded. Usually, at the end of twelve hours the
cavity will be sufficiently dilated to permit the introduction of
the finger. If the dilatation is insufficient, the canal can be en-
4
GYXECOLOGY.
largeil by the cmpldyment <>i Hcgar's bf,>ugies or with a second
series of tcnls. Tlic exposure by flilatation permits the situalicrii
to Expose Intra-uterine Stj-om;
ot" till.' i,'rii\vi]i ;inii iis size ami relations to be ret'oi^iiizeil. Ti;e
curet is used in ;i manner similar to that described in t\K treat-
GENITAL TUMORS. 707
It for endometritis. It should be done thoroughly to remove
hypertrophied mucous membrane. This removal of the
■ertrophied tissue ruptures and scrapes away the diseased
kIs, and is effective in the arrest of hemorrhage. It should be
ywed by careful irrigation of the cavity, and subsequently by
iting the canal with tincture of iodin or carbolic acid, or with a
Pig. 494- — Cervix and Capsule Incised, the Latter Pushed Back.
ture of these two agents. When there is much hemorrhage
■wing the use of the curet, the uterus should be packed with
iform gauze. Curetment of the uterus, while effective in
easing the hemorrhage, is not unattended with danger. The
ry to the surface of the tumor may cause an inflammation,
ih will interfere with its nutrition, and, by the presence of
.'.^>
OYN-ECOLCGY.
■ m
tec. 2 Iziisio:: of the Cerrix. — .lu? rr:cei:rr» is anrther
— - - -^ — — t.r^'^ — ■•
• • • • •
*<" ■*
- -,i
- --»r -5
- "-J --j;
GENITAL TUMORS. 709
jkjyed as one of the preliminary stages for the purpose of the
lenoval of the growth.
6ii. (4) Removal of the Growth. — (a) Torsion (Fig. 495)- —
When the growth is situated in the vagina, after having been
ortnided from the cavity of the uterus, and hangs by a pedicle,
it can very readily be removed by torsion. The technic of the
procedure consists in placing the patient in the dorsal position
and exposing the tumor (after thorough asepsis) with an Ede-
bohls speculum or with retractors. The growth is seized with a
itrong vulsellimi forceps, preferably four-bladed, and turned
Bpon its axis imtil the pedicle of the tumor is twisted off. When
F*£ 49S — Remova] of Myoma by Torsion of Its Pedicle.
such forceps are not at hand, the same piirpose can be accom-
plished by seizing the tumor upon opposite sides with double
tenacula and rotating it by traction with these instruments.
When the tumor has not been extruded from the cervix, the os
can be enlarged by a bilateral incision until the intra-uterine
tumor is exposed, when it can be removed, if the tumor is pedun-
culated, in the manner described.
(6) Incision of the Pedicle. — When the tumor has been ex-
truded from the uterine cavity, it may be seized and dragged
upon with a pair of forceps until the finger can be passed over
it as a guide, when with a pair of scissors (Fig. 496) the pedicle
can be cut ; or the intra-uterine tumor can be rendered accessible
by dilatation with tents, or through bilateral incision of the
7 m GYNECOLOGT.
iwrviK, Til* cmifloynient of the wire fcraseur or the gal\-aiio-
(idKlwry Wiro l» l»y icrtiie advocated for the cutting of the pedicle,
)iut (iriy Iwni'irrhiiKe likely to occur can be controlled by gauze
iwi'liInK, Hriil Uio pnKedure, outside of the possibility of lessened
iImii|{»I' fl'uni litiniorrhage, affords no advantage which will com-
)i«liwil.ii Uir tho oxtPU I'JM of time. In all these operations rigid
HiK|»lii itiunl Itti nnictiHed.
(i) /udd/cuKuH. — Knucleation was first practised upon sub-
nnu'iiilM Itlii'nlil Krowthpi of the sessile variety. Here, when the
Ulitinia li "Itlutflil, nr lifter its dilatation, the tumor is exposed,
Hdifuil wllli II t'lilr o( forceps, drawn upon, and, with the finger or
n liliml i|ln«i"rliir, llu' utlachmeiit to the uterus is broken and
GENITAL TUMORS.
711
he anterior wall may be made accessible by a vertical inci-
through the anterior Hp until the base of the tumor is
osed, when it is seized and the tissue bluntly dissected
■ from it. (Fig. 498.) Occasionally, when the cervix is
ilated and the tumor is in the anterior wall, it may be
osed by a transverse incision above the cervix, and subse-
ntly-by a vertical cut at right angles to the former (Fig. 499) ;
flaps are turned back, after which the tumor is enucleated.
Fig' 497- — Enucleation of Tumor through the Vagina.
:n necessary, the bladder should be dissected from the ante-
surface of the uterus until the peritoneum is reached, and
atter can be opened. Retro-uterine tumors are made acces-
I through a posterior vaginal incision, which will permit the
Ins to be rotated backward. Through this opening the enu-
tion is accomplished and the line of incision carefully closed
utures before the organ is returned to its normal position.
■ 500.)
713 amcoLocT.
(/J) AforeeUftwnt.Sot infrequently, as we proceed in the
mtlaUmUfjti lA Ihcw KT07f\ht.. it will be found that a tumor is so
Urff* Ihntwettre tmahle U> complete our enucleation or to deKver
lh« Uitrun thr(rti((h the vagina. In such cases the tumor may
\m fwiiHrwl In siKc by the prrxicss described by the French as
m>ifm\\Mr\nui, wlifch consista in cutting out sections of the mass
wUh vAvmirn ht knife, itnd working up on one side untU the tumor
^•fl )m drHwn 'l"wii and the remaining portion completely enu-
H««*^
GENITAL TUMORS.
readily pass through the vagina. It consists in splitting the
ix by vertical incision, then removing wedge-shaped masses
leach side. Avoid nearer approach than one-half inch to the
714 GYNECOLOGY.
lateral surfaces of the uterus. DuriBg the procedure the parts
are made tense by traction upon the mass with a double tenacu-
lum. (Pig. 501) Care must be exercised to secure a new grip upon
the remaining portion before any piece is excised. Upon the com-
pletion of the detiven' of the uterus, the hemostasis is accom-
plished as in hj-sterectomy, which will be described later. After
the remo\*al of the growth by enucleation there will remain a
considarable cavity, which is lined by tissue of low Wtalit^-.
jJHil** gllMiL. Wife lh» TMBMI <»-
««a««l lift 4w4«r ifcwm»» *e^:
^ JaiJgbt
GENITAL TUMORS.
715
acked, or a drainage-tube shotild be inserted, through which
rrigation can subsequently be practised. When the cervix has
tea incised, the wound should be sutured zis in an operation
w lacerated cervix. All incisions, whether bilateral, through the
nterior bp, or in the wall of the uterus, should be dosed by
uture.
6i3. (5) Ligation of the Vessels.— The usual observation that
iTomata decrease in size with the cessation of the periodic^con-
VsHon of the uterus at the establishment of the menopause
Fig. SOI. — Removal of Myoma by Morcellement.
iduced Gottschalk and Martin to endeavor to decrease the
lood-supply to such growths and thus avoid the necessity for
icrificing the function of procreation. Gottschalk was the
ioneer in vaginal operations for this special purpose. He limits
le operation to extraperitoneal tumors, and in seven years
iind but twenty cases in which it was applicable. Of sixteen
' these, which continued under observation, decrease in pain and
anorrhage was experienced by the majority. In a few the
716 GYNECOLOGY.
good results were delayed. The treatment is as follows: The
patient is placed in the lithotomy position, the uterus explored,
and any submucous myomata removed, followed by cureting as
a routine measure. A circular incision in front of the cervix is
prolonged as far as its posterior surface. The bladder is bluntly
dissected from the uterus and broad ligaments and the vaginal
mucosa loosened upon each side posterior to the broad ligament
The uterine artery and its branches are palpated and secured
by three silk ligatures upon each side, which are cut short and
buried by vaginal suture of the mucosa. The operation is fol-
lowed by severe pains, and a few days later by a cast of the
endometrium. In but three instances did the first menstruation
occur at the normal period. Franklin Martin pursued the fol-
lowing course: With the patient in the lithotomy position he
dilated, cureted, irrigated the uterus with i : looo bichloiid
solution, and loosely packed it with iodoform gauze. He pulled
the cervix to one side, made a lateral curvilinear incision over
each uterine artery, and pulled the bladder away from the ante-
rior surface of the broad ligaments for over two inches, while the
latter were partially isolated upon their posterior surfaces. Tte
vessels were recognized and guarded by the finger, a ligatiu^ was
passed upon each side, and the ends were cut short. Care had
to be exercised that a ureter was not included in the ligature.
He advised that in large timiors the broad ligament shoidd still
further be spread out and the ovarian artery upon one side
seized and ligated. The ligated tissue was btuied by suturing
the vaginal mucosa, and the vagina was loosely packed with
iodoform gauze. Both the vaginal and uterine packing were
removed at the end of two days and bichlorid douches were
subsequently employed. This confines the future blood supply
of the timior to one ovarian artery. Martin found that this
plan of treatment resulted in arrest of hemorrhage and decrease
in the size of the growth. The main objection to this plan of
treatment is the possibility that in the ligation too much of
the supply of blood may be cut off, and cause a loss of \dtality
and subsequent necrosis of the growth, which will greatly increase
the danger to the patient.
613. (6) Hysterectomy. — Removal of the uterus with the
offending growths can be done with advantage through the
vagina when the latter is large and roomy and the uterus is
not too large and freely movable. The operation should not
be considered when the growth extends higher than midway
to the umbilicus, when the broad ligaments are occupied by
growths, or when the growths affect the nulliparous woman.
There are two principal methods of operating: (i) The ^e^lO^•al
of the uterus without section, and (2) division of the organ in
GENITAL TUMORS. 717
order to reduce its bulk. The first procedure bears the name of
P6an. His technic is as follows: The patient is placed in the
Kthotomy position, the cervix exposed with perineal and lateral
retractors, seized vnth strong forceps, and a circular or oval in-
cision carried through the vaginal mucosa nearer the os in front
than behind. The finger or a blimt instrument separates the
bladder from the uterus and broad ligaments. This procedure
pushes the ureters out of the way. The posterior fornix, or
Douglas* pouch, is opened in the same way. Freeing the uterus
before and behind leaves it attached only by the broad ligaments.
With the finger as a guide, a needle is made to transfix the
broad ligament at about one-third its height and carry a ligature
tipon its withdrawal. The ligature is tied and the portion of
structure under its control cut. Its repetition upon the opposite
side permits the uterus to be drawn down, when a second series of
stxtures can be employed. This course soon permits the fundus
to appear at the vulva, accompanied by the tubes and ovaries.
When the uterus is removed, the ligatures upon both sides are
temporarily left long, all bleeding vessels are secured, and the
anterior and posterior flaps imited by suture, securing them at
either angle above the cut ends of the broad ligaments, or of the
tube when the latter have been left. The ligatures are now cut
short and the vagina loosely packed with gauze. By the second
method, with section of the uterus. Landau, after exposing the
cervix as described in the former operation, seizes it w4th a pair
of vulsellum forceps at either angle of the os. The incisions of
the vagina and of the bladder are accomplished as already de-
scribed, when the anterior wall of the uterus is split in the median
line with scissors, one blade of which enters the cerv^ical canal,
while steady traction is kept up upon the cervix. As the entire
exposed surface is split, the finger is introduced and the bladder
pushed away until the fundus appears. A fresh grip of the for-
ceps is taken upon the sides of the incision ; the splitting may be
carried over the fundus and down from the posterior surface tmtil
the uterus is divided into two portions. If the uterus is still too
large for delivery, it can be still further divided or the growths
may be enucleated. The broad ligament can be ligated from
above downward or from below upward ; clamps maybe employed,
though they are not secure. Schauta lost seven patients out 6i
forty from the use of clamps. The most of the deaths were due
to secondary hemorrhage following the removal of the clamps.
The clamped portion of the ligament will become necrotic and
may greatly delay convalescence. The wound is treated as
in the previous procedure. Doyen modifies this operation
by first opening the Douglas pouch and exploring the pelvic
cavity. He next incises the anterior fornix, separates the blad-
718 gynecology'.
der, and crushes the lower and middle third of the broad ligament
with a special angiotribe. The uterus is drawn down, anterior
hemisection is performed by a median or V-shaped incision, and
the fundus is drawn downward and forward. Pressure forceps
are then applied to each broad ligament and the uterus remov^.
The upper part of the ligaments is crushed and tied with a
silk ligature in the groove made by the angiotribe. The remain-
ing portion of the wound is closed with catgut sutures. Should
the uterus be too large, it can be reduced in size by morcellement,
described in Section 537. Bishop cites eight htmdred and thirty-
six cases of vaginal hysterectomy with twenty-nine deaths, a
mortality of 3.4 per cent. Some operators pride themselves on
being able to remove per vaginam growths which extend to the
umbilicus, but such a course is attended with so much increase
of danger as to render it an tm justifiable method of procedure.
Abdominal Route.
614. (7) Castration. — As early as 1872 Hegar advocated the
removal of the ovaries to establish premature menopause in order
to accomplish reduction in the size of fibroid growths. This pro-
cedure was devised in recognition of the fact that fibroid timiors
generally decrease in size with the establishment of the climac-
teric. The operation consists in the removal of the ovaries and
tubes or the performance of oophorectomy. It was found, how-
ever, that the removal of these organs was not infrequently
attended wdth great difficulty, as the size of the growth led to a
very vascular condition of the broad ligaments, and often the
ovary was spread out upon the surface of the tumor, which ren-
dered its enucleation and removal exceedingly difficult; some-
times the tumor related in such a way as to carry one ovary
posterior, rendering it absolutely inaccessible without reduction
of the size of the tumor. Moreover, the o\'ary might be wedged
between two multinodular growths, wlience it could not be re-
moved without injury to both. Tlie i)roce(lure, unfortimately,
was not always successful, as, indeed, many patients who were
not victims of fibroid ^c^rowth continued to menstruate or to have
a bloody discharge subsequent to the removal of both ovaries.
This is more probably due to the fact that the ovarian stroma ex-
tends along the ccnirse of the ovarian ligament, and the removal
of the mass in the c)rdinary method of j^roccdure did not remove
the entire ovarian structure. So long as any portion of it re-
mained, t« ) mature and tlirow oil ova, just so long would bleeding
from the uterus occur. Tait advised the entire removal of the
Fallopian tulles as a sure method of establishing the climacteric,
attribtiting the influence dominating menstruation to these organs.
The advantage of this suggestion doubtless was that the ligature
GENITAL TUMORS. 71fl 1
was carried deeper and the ovarian artery ligated, which bad
escaped in a more superficial ligation. To insure the ligation of
the artery it is generally recommended that the ligature should
be placed sufficiently deep to include the round ligament. The
advantage of castration is that in typical cases it can be done in a
very few minutes and with very slight danger ; but, unfortunately,
in large fibroid growths the ovaries are not always typically
situated. In every such operation, then, the first consideration
should be to examine carefully the situation of the ovaries and the
relation to the growth, and see whether both ovaries can be
thoroughly removed. The removal of one would be powerless
to exercise any influence on the progress of the growth or the
correction of its abnormal symptoms. Occasionally, the tumor
causes torsion of the uterus, by which one ovary is moved toward
the front, and the other behind, the tumor in such a situation that
it can not be reached ; or, as noted, the ovary can be so intimately
connected with the surface of the tumor that any attempt to
enucleate or remove it would be attended with more serious
hemorrhage than would be occasioned by the removal of the
growth. Another objection to the operation is that it does not
always control the hemorrhage. In the performance of the opera-
tion it is absolutely necessary that every portion of both ovaries
should be removed. The smallest amount of ovarian tissue re-
maining insures the continuation of the hemorrhage. When the
fibroid is large, the entire removal is frequently attended with
the greatest difficulty, as the adherent ovarian stroma can not
be readily separated from the surface of the tumor. The opera-
tion is still further complicated by the existence of tubal diseases,
such as pyosalpinx, in which extensive adhesions bind together
the ovaries, tubes, and tumor in one mass, so that castration will
be attended with greater obstacles and danger than would be the
removal of the uterus and ovaries. The operation should not be
considered in cases of pure submucous myoma or in cystic de-
generation of the fibroma. In pedunculated subserous and ad-
herent tumors, and in very large interstitial growths, it is also
contraindicated. In a freely movable uterus, in which the cervix
can be readily reached, the operation affords no advantages over
supravaginal amputation. Castration has a further disadvantage
in not infrequently producing vasomotor symptoms, such as
congestion, sweatings, hot flashes, pain in the head and sacrum.
These symptoms are worse in the young than in those who are
near the climacteric. Other symptoms are rather more rare, as
obstinate vertigo, profuse leukorrhea, cardialgia, and occasionally
vicarious bleeding.
615. (8) Ligation of the Vessels. — The operation of castration
having demonstrated the beneficial influence of ligation of the
i
720 GYNECOLOGY.
ovarian arteries, it was a very natural step to proceed to ligation
of these vessels through the abdominal incision in preference to
the more radical operatioHs of partial or complete hysterectomy.
Hofmeier reported a case of Schroder's in which extirpation of
the myoma seemed impossible, and where, in order to decrease
the size of the tumor, the lateral and median vessels of the
ovary were tied, with good result. Antal, at an earlier date,
after ligation of the vessels observed an atrophy of the ovary,
and, in place of castration, thereafter incidentally employed the
mere ligation of the vessels in order to affect the function of the
ovaries. Rydygier tied all six uterine arteries of a patient on
the 27th of June, 1889. The spermatic arteries were ligated;
then, after splitting the peritoneum near the cervix uteri, the
uterine arteries were tied; and, finally, a ligature was placed
about each round ligament. At the end of four months the
tumor had decreased to three- fourths its former circumference;
but after a year hemorrhage, which had completely ceased, re-
appeared in a stronger degree, and the patient perished from
marked anemia before radical operation could be performed.
Byron Robinson has advocated the ligation of both ovarian
arteries and the upper part of the uterine artery at the side of
the uterus. This procedure is more effective in the smaller
growths, and where hemorrhage is a marked symptom.
616. (9) Myomectomy. — -In more or less pedunculated sub-
peritoneal fibroids there should be no question as to the ad-
visability of myomectomy. The operation consists, when the
pedicle is small, in cutting through it with scissors or knife and
uniting the edges of the cut surface with sutures so deeply
placed as to make sufficient pressure to control the bleeding.
(Fig. 502.) When the pedicle is not large, its peritoneal covering
should be cut through by the circular incision, turned down like
a cuff, and the base of the pedicle ligated with chromic catgut
and the tumor cut away, after which the peritoneal cuff can be
united over the stump. In larger pedicles the operation consists
in making peritoneal and muscle flaps, which can be brought
together. In this way a single grovi-th or a number of growths
may be removed, leaving a normal uterus and the ovaries and
tubes undisturbed.
617. (10) Enucleation. — ^The ease with which smaller fibroid
growths can he enucleated from their beds has led to the practice,
by Martin and others, of shelling out interstitial fibroid growths
from the uterine wall, leaving the uterus in place. (Fig. 503.)
The procedure is performed as follows: The uterus is raised up,
the position of the growths determined, and an incision made over
the more prominent growth in a ^-ertical direction in order to
injure as few vessels as possible. The incision is made into thft
ide mto the^^
GENITAL TUMORS.
Uterine wall and through the capsule, and the tumor is exposed.
The tumor is then seized with a double tenaculum and drawn up.
1 and Method of Closing the
while with a blunt dissector the tissues are pushed off and the
enucleation is accomplished. The removal of the tumor is fol-
lowed by firmly packing a gauze pad into its cavity. If large
722 GYNECOLOGY.
vessels bleed, these should be seized and controlled with presstire
forceps. The wall is still further investigated, and, when possi-
ble, other fibroid growths situated within it should be brought
through the first incision. This, in some cases, however, may
involve more extensive mutilation of the uterus than would a
separate incision over the mass.
The advocates of this procedure generally limit it to the cases
in which but a few growths are foimd in the uterine wall, and it
was formerly particularly directed that the uterine cavity should
not be opened. When we consider the investigations, however,
of Menge and Kronig, which demonstrate that the uterine cavity
is free from pathogenic germs, there should be no hesitancy in
opening it, if necessary, to remove growths. In one patient I
thus enucleated thirteen fibroids from the wall of the uterus,
five of which were removed from the uterine cavity. After the
operation the patient recovered without a single abnormal symp-
tom. From another woman nine gro\vths were removed. In
another woman (unmarried) twenty growths were enucleated.
What remained of the uterus was pretty well riddled, but it
was sutured together and the patient completely recovered.
In an unmarried woman nine growths were removed, five of
them from the anterior wall. The loose tissue, being of low
vitality, subsequently became necrotic, and in the sixth week
after the operation this was withdrawn through a sinus in the
abdominal wound ; convalescence subsequently was rapid. Prom
an unmarried woman, a fibroid, which projected into the cavity
of the uterus and had filled it up so that the tumor could be
touched through the cervix, was enucleated through the ab-
dominal cavity by posterior uterine incivsion. A gauze drain was
passed throuj^^h the cer\'ix and the uterus closed over it. The
patient recovered.
After the enucleation of growths the wounds in the uterus
should be carefully sutured by deep and superficial layers of
chromic catgut, exercising the precaution to include and
secure with tlie suture any large vessels in the wall which may
bleed, and by the superficial suture to bring a good portion of
the peritoneal surface of the uterus in apposition. Before the
abdomen is closed all the wounds must be thoroughly inspected
to see tliat hemorrhage is completely controlled. Should there be
a tendency to excessive bleeding, it would be better to Hgate
the ovarian arteries as an additional safeguard. This operation
is unsuital)lo for very large growths in which the uterus would be
very extensively mutilated, or where the tumors are situated
laterally and involve to a greater or less degree the Fallopian
tube. In enucleation of intrahgamentary growths^ the broad
ligament is split, in order to expose the growth. In these cases
GENITAL TUMORS. 723
care mtist be exercised that the ureter has not been displaced
upward by the tumor. It is important, also, to avoid injury to
the ureter or its ligation in the subsequent closing of the broad
ligament.
6x8. (ii) Partial Hysterectomy, or Supravaginal Amputation
(rf the Uterus. — This procedure was the earliest abdominal opera-
tion performed for the removal of myomatous growths, and the
earlier operations were cases of mistaken diagnosis, the pro-
cedure having been undertaken for the removal of ovarian tumors.
The first deliberate operation seems to have been performed by
Bumham, of Lowell, in 1853, in which the patient recovered.
A large proportion of the earlier operations were imsuccessf ul ;
the diflficulty in controlling hemorrhage from the elastic stump
rendered its intraperitoneal treatment exceedingly dangerous, so
that the plan was practised of treating the stump extraperitoneally .
The first to form a systematic method of operation was Koberle,
of Strasburg. The method of performing the operation was as
follows: The patient was placed in the dorsal position, and a
long abdominal incision made in the median line, through which
the uterus and tumors were delivered. The peritonetun above
the bladder, was incised and the latter stripped down, an elastic
figattire or serre-noeud was placed about the cervix as low as
possible, and pins were passed through it above the serre-noeud.
The uterus and ttimors were cut away sufficiently above the pins
to prevent the traction of the stump from the grip of the instru-
ment, the abdominal wound was closed down to the stump,
while the latter was subjected to cauterization, and an applica-
tion of persulphate of iron or tannin made to its raw surface
to sectire mummification. By some operators the parietal peri-
toneum was fastened to the peritoneal covering of the stump by
a continuous catgut suture. This procedure was done to promote
the rapid imion of the peritoneal surfaces and thus preclude the
possibility of the discharges from the sloughing stump gravitating
back into the peritoneal cavity.
Occasionally, imder this plan of treatment, the stump would
become dry and gradually be thrown off without suppuration.
It resulted, however, in an excavation, by the retraction of the
stump, which had to close by a process of granulation, making
convalescence prolonged. Often it was difficult to prevent
putrefactive changes from taking place and resulting in suppura-
tion. The weakened abdomen favored the subsequent develop-
ment of ventral hernia. The difficulty in maintaining asepsis,
the delayed convalescence, the weakened abdominal wall, led to
the study of methods by which the stump could be treated within
the peritoileal cavity. One of the earliest operators to attempt
the intraperitoneal treatment was Schroder, who pubHshed in
724 GYNECOLOGY.
1880 an account of his cases. He opened the abdomen by a
median incision, ligated that portion of the broad ligament con-
taining the spermatic arteries with two ligatures, and cut between
them. A similar course was ptirsued with the roimd ligaments.
The stump, consisting of the cervix, was constricted by a rubber
ligature, the mass cut away above the ligature, the stump caught
with vulsellum forceps before the division was completed, and the
cervical cavity cauterized with a 10 per cent, solution of carbolk
acid. The divided surfaces were united near to the mucous
membrane with sutures ; the raw surface quilted in with several
rows of suture, and, finally, the peritoneum was sutured over the
sttunp, after which the rubber ligature was removed. He em-
ployed carbolized silk, and later juniper catgut, for sutures.
Other operators have modified this procedure, as Zweifel, with
partition ligature, and H. O. Marcy, with cobbler suttire. Gow
makes the following modifications : After delivery of the tumor
through a median abdominal incision he ligates each round
ligament on a level with the internal os, marks out an anterior
peritoneal flap, and divides the round ligament and the anterior
portion of the broad ligament between the uterus and the Ugatuies
with scissors, carrying the incision toward the middle of the
Fallopian tubes. The anterior flap is stripped down, the ovarian
vessels and the Fallopian tubes enucleated and tied, so that at
least one ovary is left. The broad ligaments are divided on the
uterine side of the ligature, and bleeding from vessels coimected
with this portion may be temporarily controlled by clamps. He
then marks out a posterior flap and dissects it dowTiward for a
short distance, seizes the uterine arteries with pressure forceps
at the level of the os intemimi, cuts the ttmior awav with a knife,
seizes and draws up the stump with vulselltun forceps, ties the
uterine arteries, inserts a precautionary ligature by thrusting
needles armed with silk through the stump from before bacb^'ard,
avoiding the peritoneum, so as to include the outer portion of the
stump. This, done upon both sides, controls oozing or spurting
from vessels which may have been given off obliquely. The
bleeding area may also be encircled with a ligature passed by
a needle. Two anteroposterior sutures are introduced throtig^
the muscular surface of the stump, avoiding the peritoneum;
the raw surfaces, as a rule, are sewed together, the peritoneal
flaps united, the peritoneum cleansed, and the abdomen closed.
Baer modifies this operation. His cotirse is as follows : The patient
is placed in the Trendelenburg posture, and after separation of the
adhesions the tumor and uterus are delivered through an abdom-
inal incision, gauze is placed front and back, each broad ligament
is transfixed by a single silk ligature, which, when tied, controls
the ovarian arteries and veins. The ligated parts are then
GENITAL TUMORS.
725
■evered external to the tube and ovary, incision being car-
lied close to the cervix. The peritoneal reflection anterior to
the uterus is cut through with scissors, the bladder stripped
down with the handle of the scalpel, the uterine artery tied
close to the cervix on each side and the cervix amputated just
above the vaginal attachment. A small posterior fold is formed
by stripping up the peritoneum while the amputation is made.
Tlie sturap is now held in the grasp of tenaculum forceps. When
Fig. 504- — Supravaginal Removal of Myomatous Uterus.
the main sirterial branches have been properly ligated, the raw
end of the cervix will remain dry. (Fig. 504.) When all bleeding
has been controlled, the peritoneal folds are loosely adjusted
over the stump with Lembert sutures and the abdominal incision
is closed. (Fig. 506.) The occasional accumulation of blood or
serum beneath the peritoneum over the stump and its infection,
fonning a cellulitis or pus-collection, may delay convalescence.
Le Bee, after abdominal section, draws out the uterus and
l2o GYNECOLOGY.
fibroids, ligates the broad ligament with a double ligature, and
severs it between the ligatures. The round Hgaihents are
ligated separately and the bladder with the peritoneal flap dis-
sected down into the vagina. The tumor may be decreased
in size by throwing a rubber ligature around the cer\'ix and
cutting away the mass above, or the tumor can be drawn over
the pubes, a long cur\-ed forceps inserted into the vagina so
that, when opened two or three centimeters, the posterior fornix
is stretched. A small incision is made into the pouch of Douglas,
and widened by opening the forceps. The tumor is drawn back^
Fig. 505. — Cervix Cut Ai
and forceps are introduced so as to protrude against the anl
fornix, when the latter is treated in the same way. Care must
exercised, however, not to rotate the tumor to one side and thus
injure the large uterine veins. One end of a long silk thread is
seized by forceps, carried into the vagina, and brought up again
through the opening in Douglas' pouch. Another thread is
similarly applied on the opposite side. Both are tied, thus con-
trolling the uterine arteries. The timior is removed horizontally
just above the ligatures, and only leaves a pedicle. This pedicle.
aa. ^H
GENITAL TUMORS, 727
>lit in the median line and as much cut away from each side as
able, only leaving sufficient to hold the ligatures. The long
i of these are seized with the forceps and drawn downward,
peritoneal flaps sutured together with catgut, and the abdo-
i closed. The Pryor-Kelly modification of the operation con-
i in the ligation of the ovarian vessel and round ligament
the division of the ligament upon one side. An anterior
toneal flap is formed and the peritoneum and bladder stripped
n. This exposes the uterine artery and veins, whichjare
ted by a ligature carried with a curved needle beneath them
e to the side of the uterus, the organ is drawn to the opposite
:, and the uterine vessels are divided. The uterus is cut
»ss just above the vaginal junction. A pad of gauze is placed
Fig. 506. — Stump Covered with Perit<
■ath the upper cut surface to prevent the intra-uterine dis-
■ges from escaping on to the wound while the canal below
iped out. When near the opposite edge of the cervix, the
don is carried up one to two centimeters so as to leave a
shell of cervical tissue and to expose the uterine vessels at
gher level, where they can be more easily tied and with
risk of including the ureter. The uterine vessels are clamped
divided, the uterus is rolled still further over, the round
nent clamped and cut through. With still more traction the
ian vessels come into view, when they are clamped and cut
the whole mass becomes free. All clamped vessels are then
Kelly ties all important vessels twice— once during the
Jeation and again after it is completed. After control of the
orrhage, the stump is closed over the cer\'ical canal by three
728 GYNECOLOGY.
to five catgut sutures. These sutures do not include the mucous
membrane, the anterior peritoneal flap is drawn over the stump
and united by continuous catgut suture to the posterior peri-
toneum. Where a large space has been left in the cellular tissue,
it is advisable to unite the peritoneum with interrupted or mat-
tress sutures, so that blood can run into the peritoneum and be
absorbed instead of forming a hematocele. Bishop modifies the
operation by removing the cer\Tx entire. When the broad liga-
ment is Hgated, having reached the stage of hgation of the
uterine arter>' upon one side, instead of cutting across the cervix
he has an assistant push up the lateral culdesac of the vagina
and cuts down upon it, and thus enters the vagina. With the
scissors the vaginal wall is then cut through entirely around the
cervix, which is bodily lifted up with the rest of the uterus and
rolled o\'er toward the opposite side. The ce^^■ix is seized with
strong forceps and pulled up against the free surface of the
uterus. It has been previously plugged and, consequently, gives
no trouble from the tlischarges. This procedure affords a ready
method of enucleating intraligamentary fibroids, especially if
they are situated upon one side of the abdomen. The entire
removal of the uterus has another advantage, that there is no
obstacle to drainage from the pelvis. He draws down into the
wound a roll of iodoform gauze and closes the peritoneum o\er
it. The abdomen is closed without drainage. E. C. Dudley
claims that the union of the peritoneal flaps by transverse sutures
permits the pelvic floor to sag down. Therefore he advocates the
union of these surfaces by an anteroposterior line of sutiu^e.
Where the cervix is left, a fiap is made on each side. These
are united, and over them the peritoneal flaps are drawn and
secured by an anteroposterior line of sutures. The study of the
evolution of any operative procedure would lead us to think that
the originators of the plan studied to make it difficult. The
constant aim of the operator should be to simphfy procedures and
secure the greatest expedition in the completion of the operation
compatible with safety. With these purposes in view, after draw-
ing out the uterus containing the growths, the most accessible
broad ligament is clamped externally to the ovary and tube.
One blade of the forceps being thrust through the hgament below
the roimd hgament, and the tissue thus controUed, cut between
the forceps and the uterus, the broad hgaments should now be
spread out and the peritoneum divided anterior and posterior,
the former flap can be easily made and the bladder pushed out of
the way. The uterine artery is now readily seen and clamped,
when the cer\-ix can be cut across and, being dragged upon, ex-
poses the uterine artery and later the ovarian, both of which
should be clamped. Where the two sides of the pelvis are equally
i
GENITAL TUMORS. 729
accessible, the operator may prefer to proceed from above on each
side. The vessels can now be seciired, making sure that hemos-
tasis is effective, after which the peritoneal flaps are united and the
abdominal wall closed. An effort has been made in the fore-
goiiig pages to present to the student a r6sum6 of the various pro-
cedures for the treatment of myomatous growths of the uterus.
It is, however, recognized that when we come to treat the patient,
lie may be doubtful as to which method may be most applicable.
I feel it but proper to indicate what I believe to be the preferable
method of procedure. The operative procedure just described
affords a ready method for dealing with those intraligamentary
tumors which occupy only one side of the pelvis, but where we
liave the uterus filled up with fibroid growths and extending into
the broad ligaments upon both sides and we can not reach Doug-
las' pouch posteriorly, the problem for removal seems a most
complicated one. The operation in such cases, however, can be
very expeditiously performed by making a vertical section through
the uterus and tiunor from the fundus downward, dragging the
masses to either side as the incision is made. The intestines, of
course, are held back by gauze introduced behind the ttmior,
while the bladder is rendered visible as we proceed in the division.
In this way the entire uterus may be split down to and through
the cervix, or, if preferred, each side may be cut through at the
vagino-uterine junction, leaving the cervix as a simple stump.
As the lower portion is drawn upward, the uterine artery be-
comes visible and is secured with clamp forceps. Further trac-
tion upon the mass rolls out the fibroid growths from the broad
Kgaments, and later renders visible the ovarian artery, which is
also secured. The broad ligament is clamped external to the
ovary and tube, and the mass removed. A similar course upon
the opposite side leaves us with the uterine and ovarian vessels
clamped ready for the application of the ligature.
The remaining steps of the operation may be completed as
described in the previous operative procedures.
619. (12) Panhysterectomy, or total extirpation of the uterus,
18 the procedure of election in those cases in which the cervix has
been largely taken up by the extension of the growth, or when
it has undergone extensive disease. Tliis operation may be per-
formed by a number of methods :
I. The method of A. Martin^ of Berlin: With the patient in
the dorsal position, through a large median incision the tumor
is drawn out, and, if necessary, can be made more movable by
the enucleation of masses after the capsule has been split. The
xnfundibulopelvic ligament is ligated and the broad ligament
divided until the cer\'ix is reached, beginning usually upon the
left side, but in all cases on that in which the procedure would
1
730 GYNECOLOGY.
be most complicated. Having completed ligating one side before
attacking the other, a pair of clamp forceps is applied on the
uterine side of the line of ligature. The broad ligament is then
divided between the forceps and ligatures to the cervix. The
uterus can then be brought over the symphysis pubis, the pos-
terior fomLx is cut through by scissors, close to the cervix, and
the two edges of the wound united by sutures. Sometimes bent
forceps are passed, and from the vagina made to tear through
the posterior fornix into Douglas' pouch, and, by separating the
blades, the structures are torn with less danger of bleeding. A
ligature is passed around the lower attachment of the broad
ligament on the one side, which is then divided. The os is
seized with a pair of forceps, which both closes the cervical canal
and draws the cervix upward and backward into the peritoneal
cavity. The other side of the broad ligament can now be secured
in a similar manner. The anterior vaginal fornix is then divided,
and the firmer bands of connective tissue one will meet in this
situation. When these are cut through, the cervix separates
easily from the bladder. Bleeding vessels are secured with the
ends of the ligatures drawn down into the vagina. The periton-
eimi is united by transverse sutures over the vaginal wounds and
the abdominal wound closed without drainage.
II. The method of Christopher Martin, of Birmingham: With
the patient in the dorsal position, he delivers the tumor through
a median incision and packs gauze pads above and below. A
double thread is passed through the broad ligament at the
junction of its upper and middle thirds, and midway between
the uterus and pelvic wall. These two sutures do not interlock.
By pulling them forcibly inward and outward, the punctured
aperture is torn with a transverse slit and the two ligatures are
tied as far apart as possible and the intervening broad ligament
divided. The same process is repeated on the opposite side.
He prefers, where possible, to leave one ovary and tube. The
other is removed with the uterus. A second ligature is passed
through the broad ligament about the level of the internal os
and nearer to the uterus than the first one. The aperture punc-
ture is again stretched, when the ligature is tied as far apart
as possible and the intervening tissue divided. The bladder is
then separated from the anterior surface. He also ad\'ises the
use of the sound in the bladder, to define its upper edge. A
curved incision, two-thirds of an inch from the upper edge of
the bladder, is made from one broad ligament to the other,
and the bladder is stripped down. The surgeon can determine
when he has reached the vagina by following the tip of a pair
of forceps pressed into the anterior fornix. The vagina is opened
upon these with scissors and the opening enlarged. The posterior
GENITAL TUMORS. 731
similarly treated. The ureters, when seen, are pressed
, The uterine arteries now remain to be tied. Ligatures
id through the remaining portion of the broad ligament,
close to the mucous membrane of the lateral fornix of
na, and are tied upon either side. The uterus is then
B, keeping the scissors as far as possible from the two
.tures. The cut edges of the vaginal walls are drawn
with forceps and carefully inspected. All blood-clots are
-Panhysten-ctomy. Doyen's
nade from Douglas' pcjiich ir
reps.
out of the pelvis and all bleeding points Ugated. The
may be cut short or may be k-ft long and the ends em-
D draw the stumjis into the vagina. The vaginal wound
osed, but is filled with a thick roll of iodoform gauze
irough into the vagina. The abdomen is closed byinter-
ilkworm-gut sutures. The gauze placed in tlie vagina
sd on the fifth or sixth dav.
732
GYNECOLOGY.
III. Doyen's metliod: With the patient in the Trendelenb-org
posture, the tumor is lifted out through an abdominal incision
and drawn forward over the pubes. A long, cun^ed forceps,
previously passed into the vagina, is made to project into Doug-
las' pouch, upon which an opening is made into the v^inal
canal. (Fig. 507.) Through this opening the cervix is seiz^bv
the anterior lip, if possible, and drawn upward and backward.
While held in this position, the entire circumference of the attach-
ment of the vagina to the cervix is under \*iew and can be di\Tded
by scissors, (Fig. 508.) The cer\'i>; is separated from the blad-
der by traction upward until the peritoneum above the bladderis
reached, which is broken through and pushed back. Thebroiui
ligament external to the ovary and tube on the right side is
clamped and incised with scissors. Clamp forceps are then applied
to the broad ligament of the opposite side, when it tikemse is cut
through external to the ovary and tube. Frequently, by this
method of procedure, the uterine arteries are not injured. The di-
vision is so close to the cer\'ix that the main brancli is notdirided.
and it is only the smaller branches that are torn, and consequently
do not bleed. The pedicles of the broad ligaments are ligated.
The uterine arteries are also Hgated and forceps removed. The
GENITAL TUMORS. 733
"Vaginal mucous membrane can be united by two or three sutures
^th the peritoneum to prevent subsequent prolapse. The ends
erf the ligatures on the arteries are turned down into the vagina,
the pelvic peritoneum can be united by a purse-string suture
the pelvis, so as to invert the stump of the broad ligament
l)elow this structure. The abdominal wound is closed without
drainage. Doyen, in his earlier operations, trusted to the angio-
tribe alone, but later applied a catgut ligature in the groove. The
latter procedure is preferable.
rV. Schauta's method: The tumor and uterus are drawn out
through a median incision and the broad ligament on each side
divided between clamp forceps. The anterior peritoneum is
divided and, with the bladder, stripped down to the vagina;
the tissues are clamped upon each side and the vagina opened
right and left between the clamps and the uterus. The tumor
is now held by the anterior and posterior vaginal walls, which
are secured by curved clamps, and the uterus removed. Liga-
tures are substituted for the clamps, which are left long and
employed for vaginal drainage. The abdominal cavity is closed
by tinion of the peritoneal folds over the vagina.
V. Richelot, through an abdominal incision, first separates
the anterior peritoneal fold and bladder. The uterine arteries
are found, clamped by forceps, and cut close to the uterus.
The anterior culdesac is found and opened ; the cerv^ix seized and
drawn upward and forward. The cervix is separated from the
vagina by a circular incision, and the broad ligaments are separated
in sections from below upward. This plan affords an effective
procedure when there are extensive adhesions following disease
of the appendages. All the clamped vessels are securely ligated
and the vaginal wound is closed with catgut.
In difficult cases Bishop employs what he calls the combined
method, which may be begun either from below or from above.
In the former the patient is placed in the lithotomy position,
the uterus exposed by retractors, seized, and drawn down with
vulsellum forceps. The cervix is cleansed, packed with gauze,
and if there is much discharge, the os is closed by a suture.
A circular or ovoid incision is then carried around the cervix,
completely dividing the vagina, when, \vith the finger hooked
closely to the uterus, the bladder is separated from the anterior
surface of the uterus and well to either side. In large tumors
this can not be accomplished to a great extent, but should be
sufficiently to expose the uterine vessels. Douglas' pouch is
opened, and, with the one finger behind and the thumb in front,
the uterine artery should be defined, ligated, and the ligament
cut as far as the ligation extends. Hemorrhage is carefully con-
trolled and the vagina loosely packed with gauze. The patient
734 GYNEQOLOGY.
is then changed to the Trendelenburg posture And the abdomen
opened through the rectus sheath of one side. All adhesions to
omentum and intestine are separated, and, where indicated,
ligatures applied. A gauze pad is placed over the intestine.
When the ovaries and tubes are healthy, they are to be left.
When diseased, part of the ovary at least is retained. One
ligature is made to embrace the ovarian ligament, if the tube
and the round ligament near the appendages are healthy enougji
to permit of their being retained, and is tied as near to the
uterus as the retention of the ligature will permit. The ligament
is cut close to the side of the uterus. The lateral incisions are
joined by a cur\''ed incision anterior to the uterus, about half
an inch above the line of the bladder, which is stripped down
tmtil the previous separation has been reached. The uterus is
now attached only by the central portion of the broad ligament
upon each side, which is ligated and the uterus cut away. Bleed-
ing vessels are ligated and the ligatures cut short, the pelvis
dried, a roll of gauze pulled through into the vagina, and the
peritoneal flaps closed over it with a continuous catgut suture.
All raw edges are carefully inverted into the vagina, so that the
peritoneal wound is perfectly smooth. Bishop closes the ab-
dominal wound with catgut for the peritoneum, crtn de Fiorina
for the aponeurosis, and horsehair for the skin. With the inser-
tion of the last layer, the skin should be cleansed, dried, and
painted with celluloidin, which forms an air-tight covering.
Bouilly preferred to begin from above and finish from below.
He delivers the tumor through the median abdominal incision
with the patient in the Trendelenburg posture, divides the
broad Ugament between double ligatures, incises the peritoneum
in front of the uterus, and pushes down the flap with the bladder,
ligates the broad ligament so as to include the uterine arterfes,
amputates through the cervix, and closes the abdomen. Then,
with the patient in the lithotomy position, he removes the
cervix per vaginam, sutures the peritoneal flaps from below,
and plugs the vagina with gauze. This procedure is particularly
valuable in a sloughing fibroid which communicates with the
vagina.
620. Summary. — Notwithstanding the recent able contribu-
tions to the literature of this subject, in which the WTiters advocate
radical measures, in the great majority of the victims I remain con-
vinced that the aim of the surgeon should be to save and not
sacrifice. A hysterectomy, partial or complete, should be his
practice only when it is impossible to preserve a functionating
uterus. In submucous growths, with hemorrhage as a marked
factor, the tumor, when accessible, should be removed by torsion
or excision of its pedicle. When the timior is still within the canty
GENITAL TUMORS. 735
of the uterus, th^ cervix may be dilated with laminaria tents, and
if sufficient room is not thus secured, the os can be split by a lateral
or an anterior incision, as may be most convenient, and the tumor
removed by torsion, by excision of its pedicle, or by enucleation.
K the tumor is too large to permit of its ready extirpation, it
should be removed by morcellation. Vaginal hysterectomy should
be confined to uteri containing growths which are not too large to
permit of their ready passage through the vagina, and yet in which
the uterine structure is so taken up and involved as to preclude
the retention of a healthy organ, or in which the ovaries and tubes
are secondarily involved, making the retention of the uterus
after the removal of the growths of no value. Of the various ab-
dominal operations, myomectomy, enucleation of the growth, or
partial or complete hysterectomy can be performed. Of the
abdominal operations named, the principle already enunciated,
that no organ should be sacrificed the function of which can be
maintained, must govern as well in the abdominal as in the vaginal
procedures, and when the ovaries and tubes are in a condition to
justify the retention of the uterus, myomectomy or enucleation
should be practised, even though a number of growths are present.
The objection to enucleation frequently advanced, that the cic-
atricial changes in the uterine wall which will result from the
enucleation of a number of growths will unfit the organ for the
exigencies of gestation, labor, and the puerperium, would seem
to be valid and can be combated only in the line of experience.
To contribute to this service I would relate the history of the
following patient: Miss L., a Japanese woman aged thirty-
three years, a patient of Dr. A. B. Shimer, of Atlantic City, was
sent to me in February, 1903, because of an abdominal tumor.
An irregular nodular mass was found in the median portion of
the abdomen, projecting two inches above the symphysis and a
little to the left. Careful physical examination made it manifest
that it was a part of the uterus and that it filled up the pelvis.
Hysterectomy was advised. She entered St. Joseph's Hospital
the latter part of April, 1903, when the growths were exposed by
abdominal incision. They were found so situated in the anterior
and posterior walls of the uterus that enucleation seemed pos-
sible. The growths, thirteen in number, were enucleated, but
without opening into the uterine cavity. The anterior wall of
the uterus was much mutilated, but was quilted together, pro-
ducing a very satisfactory appearing organ. To prevent the
uterus from falling back into the pelvis the fundus was secured
to the abdominal wall by two turns of the ccmtinuous catgut
suture closing the parietal peritoneum. She developed an in-
fection of the abdominal wound from which considerable pus
was discharged. Four weeks following the operation a slough
736 GYNECOLOGY.
was removed from the depths of the woimd, which contained the
catgut sutiires employed to close the uterine wotmd, after which
the recovery was rapid and the patient was discharged cured.
A commimication from Dr. Shimer, dated Jtme i6, 1906, in-
forms me she was married on the 14th of October, 1903, and in
November, 1904, gave birth to a healthy child weighing seven and
one-half pounds. As the presentation was a vertex in an cxxripito
posterior position, the delivery was instrumental. Subsequent to
her delivery her health has been excellent. The history demon-
strates that excessive cicatricial change in the uterus does not render
such a patient unable to meet the exactions of pregnancy. A
number of instances have been reported where examination has re-
vealed unsuspected malignant degeneration complicating the
tumor ; also reports of recurrence in the stump, the danger of which
is lessened by panhysterectomy. Another disputed question is
whether the ovaries shall be removed or one or both be retained.
Those who advise the retention of an ovary claim that its pres-
er\^ation prevents the distressing symptoms associated with the
premature menopause. I formerly practised the retention (rf
ovarian stroma whenever possible, but such unused organs early
atrophy, and the distressing phenomena become just as acute. Not
infrequently will it be found necessary'' to reoperate because of neo-
plastic changes in the ovary. In many cases the changes in the
tube and ovary already exist, making the removal of these organs
desirable. When the uterine structure is greatly involved or when
ovarian, uterine, or tubal disease complicates the condition, the
operator may be forced to resort to either partial or complete
hysterectomy. My experience inclines me to advise complete
hysterectomy, for the retention of the cervix affords no special
advantage. Its complete removal does not add to the difficulty
nor prolong the operation. It affords better drainage and ex-
pedites the recovery of the patient. In nearly all cases the clean
removal of the uterus, ovaries, and tubes is more readily ac-
complished than is the retention of an ovary. No one operation
can be made applicable to every patient. In the majority the
Doyen operation v^ill prove the most satisfactory. WTien the
broad ligaments are shortened by inflammation and the pel\TS
filled up by myomata, the operator may be unable to reach the
cervix. Then, of course, another method of procedure must be
chosen. The uterus containing the growths may be dindedby
vertical section, and through the culdesac portions of the tumor
mass can be enucleated, thus decreasing the size of the structure
and affording more room. Proceeding from below upward in-
traligamentary growths are shelled out with but little danger to
the ureters, and better facility is afforded to secure hemostasis.
Where access to one side of the pelvis is partially barred by in-
GENITAL TUMORS. 737
flammatory shortening or the ligament is occupied by myomata,
the Bishop modification of the Pry or- Kelly operation permits
ready removal of the uterus and growths.
621. Accidents during Operation. — Hemorrhage is an accident
which is avoidable with careful application of ligatures. WTiere
the tissues are ligated en masses the angiotribe, by the com-
pression of the tissue, forms a groove in which the ligature may lie
with less danger of its loosening. Where the ligated mass is large
and vessels are greatly distended, it is prudent to place a second
ligature back of the first upon the more important vessels. The
compression ftimishes a button over which the ligature is unlikely
to sUp. When the cervix is retained, bleeding from the stump is
avoided by applying ligatures upon each side to control the blood-
supply from the uterine arteries. One advantage of the entire
removal of the uterus is that hemorrhage, when it occurs, is at
once revealed by its discharge from the vagina. Internal hemor-
rhage will be indicated by symptoms of increasing shock, and the
occurrence of such symptoms should be considered an indication
for prompt reopening of the wotmd to secure the open vessel,
for, should the patient rally from the hemorrhage, the large
accumulation in contact with the intestine in the weak state of
the patient adds to her subsequent danger from the possibility
of sepsis. All bleeding vessels should be firmly secured before
the peritoneal wound is closed. Care must be exercised in short
broad ligaments that the ovarian arterj'- is not retracted behind
the peritoneimi from the grasp of the ligature, there to produce a
concealed hemorrhage or thrombus which may become so large
as to open into the peritoneal cavity.
Injuries to the Hollow Viscera. — In the injuries to the viscera
the bkidder is most likely to be affected, as it is often drawoi up
by the growth and is closely attached to its anterior surface.
Its relations to the uterus and tumor will largely depend upon the
situation of the growth. A tumor which has originated in the
lower part of the anterior wall of the uterus may very readily drag
up the bladder and cause it to be displaced upward. The bladder
may be displaced to one side, and not cover the anterior surface
of the uterus and tumor. This may readily occur because of
partial torsion of the neck of the uterus or from the size of the
growth. In one case I accidentally incised the bladder when
opening the abdomen, as it was displaced upward and to the left
side and formed a quite distinct tumor that did not entirely dis-
appear after the employment of the catheter. The opening was
immediately sutured, the bladder separated from the surface of
the growth, and the recover}- of the patient was unrotarded.
Inflammatory adhesions may bind tlic bladder to the anterior
surface of the tumor, and in the subsequent development may
47
738 GYNECOLOGY.
drag it so high that it is overlooked in the separation of adhesions.
In such a way I was so unfortunate as to incise the fundus where
adhesions were extensive, involving both anterior and posterior
surfaces. In this patient recovery took place after the bladder
wotmd was sutured. AVhen the bladder is injured, the wound
should be closed by sutures at once, whether it occurs upon the
peritoneal or on the nonperitoneal siuiace. Precaution should
be excised in the use of the sutures that they do not enter the
vesical mucous surface. It is well to have a double row of sutures,
in order to bring a larger surface of bladder-wall in apposition,*
and in the subsequent convalescence the bladder should be
frequently evacuated. When the wound has been extensive,
it would be advisable to employ a permanent catheter for the
first week, and for the second week to have the luine drawn
at frequent intervals. . The possibility of displacement of the
bladder by the growth should always be considered, and care
should be exercised to avoid its injury.
Injuries of the Ureter, — The situation of the ureter alongside
the cer\4x makes it particularly vulnerable in the removal of
large fibroid growths and especially where the growth has de-
veloped low in the broad ligament. In some cases the growth
shoves the ureter upward \mtil we find it in a groove between
the tumor and the uterus. In such patients the dissection should
be most carefully practised in order to avoid injury to the ureter.
The Doyen operation lessens the danger to both bladder and
ureter ; the cervix is pulled away alike from the bladder and the
ureters. In the intraligamentary variety the ttunor is dragged
away from its relations to the ureter. In cases of injury, and
particularly where the ureter has been cut, the proper coiirse
would be to establish: (i) An anastomosis between the ends of
the divided ureter. (Fig. 234.) The union can be end to end, the
cut surfaces being made oblique. Another method is to split
the vesical end and scrape the mucous surface and insert the renal
end, securing it by sutures ; (2) the transplantation of the renal end
into the bladder. (Fig. 233.) In introducing the ureter, it is im-
portant that it should be anchored in the bladder in such a way
as to prevent it slipping back or drawing away from its attach-
ment to the bladder surface, which would permit the xirine to es-
cape into the peritoneal cavity. If the imion with the bladder is
difficult, because the injur\^ of the ureter is situated so high that
the latter reaches the bladder only upon slight stretching, it is
better to anchor the bladder to the side of the pelvis at a higher
level, so that no traction shall be made upon the shortened
ureter. When the ureter is too short to permit of an anastomosis
with its vesical end or its transplantation into the bladder, the
following alternative procedures have been suggested: (3) carry
GENITAL TUMORS. 739
the tireter across and anastomose it with the ureter on the oppo-
site side. This procedure in my judgment is only to be mentioned
in order to be condemned. If long enough to permit of this, it
should be introduced into the bladder. I should hesitate about
imperiling the patient by disturbing the remaining conduit.
(4) The introduction of the ureter into the correspond-
ing colon. This operation has not been attended with very
satisfactory results. The infection and gases from the intestine
have been known to be carried through the ureter to the pelvis
of the kidney, producing fatal inflammation. The contact of the
urine with the intestine will cause considerable irritation and
produce a marked diarrhea.
(5) Bring the extremity of the ureter out through the ab-
dominal wound or make a fistulous opening upon the skin sur-
face. Such a procedure is attended with no little discomfort
to the patient, as the constant soiling of the person and cloth-
ing with the urine is very distressing to a cleanly patient a-nd
annoying to those who have to be associated with her.
(6) Ligate the ureter and drop it back. This ligation should
be made by a double ligature, for the reason that, imder
the process of pressure-atrophy, the ligature becomes loosened
and, when single ligatures are used, the urine escapes into the
peritoneal cavity and causes urinary infiltration and septic
peritonitis. This condition is less likely to occur when a second
Hgature is applied from half an inch to an inch above the first.
The tirine continues to be secreted until the pressure within
the cavity of the kidney is equal to the blood pressure, when
the secretion is arrested. In such cases the kidney, unable
longer to secrete the urine, becomes a useless organ and atrophies,
while the extra work is taken up by the remaining kidney.
The restdt of the procedure, of course, will depend, as it would
in nephrectomy, upon the condition of the other kidney.
(7) Removal of the kidney.
Intestinal Injuries. — Injuries of the intestine are less fre-
quent. They may occur as a result of extension and firm ad-
hesions to the surface of the growth. The injury is much more
Hkely to take place in the sigmoid flexure of the descending
colon and the rectum. As a result of chronic inflammation,
the adhesions may be very extensive and firm, and lead to the
injury of the intestine before its possibility could be suspected.
In ail cases of extensive adhesions, after the removal of the
growth careful examination should be made to ascertain the
existence of intestinal injury. Such adhesions may also result
from complications incident to suppurative disease of the tubes
associated with the growth. Very frequently an opening will
occur between a tubal abscess and a knuckle of intestine through
740 GYNECOLOGY.
which the contents of the abscess have been partially drainec
During an operation for the removal of a fibroid growth associate
with pelvic suppuration I found an opening from the left tubo- 1
ovarian sac into the anterior surface of the sigmoid, through which
the thumb could be introduced. This sinus had served to empty
the abscess at frequent intervals. In closing an intestinal open-
ing its edges should be carefully trimmed and thus remove tissue
of low vitality or such as has been injured during the procedure,
and secure contact of the surfaces by a double row of sutures.
Continuous chromic catgut suture is a very serviceable material,
' but, as has been previously mentioned, the suture should be so in-
troduced as to hold extensive surfaces in apposition. The patient
should subsequently be kept upon an albuminous broth diet, and.
early evacuation of the bowels should be accomplished, afford-
ing no opportunity for hard fecal masses to form in this portion
of the intestine. In these inflammatory fistulous cases gauze
packing drainage is generally advisable, for it is always difficult
to make certain that aU tissue of low vitality has been excised
and that a fistulous opening may not recur. When the abdominal
wound is closed, leakage may cause fatal infection of the peritoneal
cavity before the gravity of the condition is recognized. If a
small fistulous opening follows in such a patient , it is preferable
to keep the wound open and the cavity thoroughly cleansed by
frequent irrigation both by the rectum and the abdominal wound,
and to permit nature an opportunity to close the opening by
granulation. Nature soon shuts off the tract of the general
peritoneum and prevents the possibility of its infection. To
reopen such a wound in order to close the fistula increases the
danger of general infection. Where the caliber of the intestine
is free and unobstructed, a fistula wiU close by granulation, but
should the intestine be obstructed or kinked below the fisttila,
the latter will not close. The effect of a fistula will depend upon
its size and position in the intestinal tract. Free discharge from
the intestine high up means that much nutritive fluid is removed
from the processes of absorption. Therefore a corresponding
loss of vitality results. A fistula in the large bowel, however,
may exert but little influence upon the fjeneral nutrition.
622. Causes of Death Following Hysterectomy. — The most
frequent causes of fatal results are : shock, hemorrhage , and
septicemia. Shock is a vasomotor disturbance which may result
from severe hemorrhage during or previous to the operation. It
is especially prone to occur in individuals in whom the percentage
of hemoglobin is small. It is promoted by prolonged operations,
injudicious administration of anesthetic, exposure of the viscera
to cold, or drying in the atmosphere. It is more likely to occur
in the neurasthenic and poorly nourished, in victims of tuber-
GENITAL TUMORS. 741
culosis, or in patients who have been suffering from prolonged
inflammatory complications. In fibroid growths complicated
by dense inflammatory adhesions the traction upon important
sympathetic ganglia in breaking up adhesions may be attended
by fatal shock. Hemorrhage may be the cause of death during
or shortly following an operation, from rupture of a large artery
or vein, or from failure to control bleeding during the procedure.
These occurrences should be rare, as the operator and his assistant
should be alert to sectu-e vessels before they are injured or upon
the first spurt when the vessel is severed or torn. A fatal hemor-
rhage may result from the retraction of an important vessel or
from the slipping and loosening of an insecurely placed or tied
ligature. This is more likely to occur when the pedicle is short
and thick and is tied en masse. Unless the gravity of the con-
dition is appreciated at once, the hemorrhage may be rapidly
fatal. If the enfeebled condition of the patient leads to the for-
mation of a clot and arrest of bleeding, the large accumulation of
blood in the peritoneal cavity may still be a source of danger to
the patient through its infection by its contact with the intestine
or from pathogenic germs which may have been left in the ab-
dominal cavity. In this sense it may furnish the cause for the
subsequent death of the patient from septicemia. The danger
from septicemia is greatly enhanced where the operation has been
difficult, due to intraligamentary growths; when the operation
has been complicated by extensive adhesions, suppurative proc-
esses in the tubes, and hematoma of the ovaries. Less frequent
but none the less to be regarded catises are pneumonia, pulmonary
embolism, ileus, tetanus, and secondary manifestations of sepsis,
as phlebitis. (For after-treatment see Post-operative Treatment,
Sections 206-220.)
623. Puerperal Tumors. — Physometra.— An unusual form of
enlargement of the uterus, giving the appearance of a tumor,
results from the condition just named, which is an accumulation
of gas in the interior of the uterine cavity. This affection
may be produced during the puerperium or .without it. After
the woman is delivered the uterus is large and air will enter it.
If expulsion is delayed by inelTecti-ve contraction of the organ, in
the course of the convalescence the placental fragments or re-
tained portions of membrane undergo decomposition and pro-
duce a putrid gas, which, by larger accumulations in the organ,
produces the condition known as physometra. It may develop
in the nonpuerperal uterus, as is well indicated in the following
patient, as cited by Auvard; A negress, forty-six years of age,
reached the menopause and presented considerable abdominal
enlargement. Her periods had not been seen for three months.
According to her calculation, she was certainly pregnant. The
742 GYNECOLOGY.
term had passed four months; she called a physician and ar-
ranged that he should attend her in labor. Under an attentive
examination of the patient to determine the cause of the uterine
enlargement a hysterotome was introduced into the ca\'ity of
the uterus, when, in less than a minute's time, with great
impetuosity, an offensive gas was driven out. After this evac-
uation the uterus returned to its normal proportions and the
patient recovered. In the acceptance of this condition we
must admit the possibility of the secretion of gas in the uterine
cavity, or the putrefaction of retained intra-uterine debris
after the occlusion of the cervical canal. Decomposition of
the debris results in the formation of gas and the distention of
the organ. The treatment consists in the establishment of
the permeability of the canal.
624. Hydrometra is due to any cause by which the internal
orifice of the uterus becomes closed and the secretion retained
in a woman who suffers from amenorrhea or in one suffering
from endometritis after the climacteric has occurred. It prac-
tically produces a mucometra, or, when the liquid is serous and
clear, it is denominated hydrometra — a term which includes
all seromucous uterine collections. If the endometritis is pur-
ulent, we have a pyometra. Hydrometra is exceedingly
rare.
625. Hematometra is an accumulation of blood in the in-
terior of the uterus, and has been described under malforma-
tions.
626. Pyometra.— Pyometra is an accumulation of pus in the
uterus, and is more likely to be found in women some years after
the climacteric.
G27. Hydatid Cysts of the Uterus. — The condition called
hydatid cysts of the uterus is, however, free from the presence
of hydatids. There are a large number of cysts, which form
in the mucous membrane of the uterine cavity — a condition
which generally follows labor or abortion, and is known as cystic
mole. It is so closely associated with the condition known as
deciduoma malignum that its consideration will be postponed
until the discussion of the latter disease.
628. Mucous Polypi of the Uterus. — These are growths which
arise from the uterine mucous membrane, and are distinct from
the fibroid polypi, with which they are often confounded. (Fig.
50Q.) The latter arise from the muscular wall and push before
them the mucous membrane. The former result from hyper-
trophy of the glandular structure of a limited portion of the uterus,
which causes them to push out and form a polypoid growth. A
number of these may occur within the cavity of the uterus and
interfere with the performance of its functions. They are associ-
GENITAL TUMORS. 743
ated with endometritis. They are due to a localized inflammation
and hypertrophy of the glandular tissue. These growths may
vary from the size of a filbert or less to a growth consisting of a
grape-like cluster of glands attaining the size of a small orange,
which is extruded from the ceridx and hangs by a pedicle from
the uterine caWty. These growths may occur upon any part of
the mucoiis membrane; frequently they arise from the cervix
and protrude from the os in small masses. The treatment of
these growths is the same
as that of the inflamma-
tion with which they are
associated: thorough
curetment of the uterus ;
removal of the growths ;
disinfection and steriliza-
tion of the uterine canal,
and gauze packing to pro-
mote subsequent drain-
age. The operation
should not be devoted
to the removal of the
growths alone, as the
cervical canal is likely
to become irritated and
cause subsequent peU'ic
inflammation.
Another form of uter-
ine tumor is placental
polypus, which consists
of a mass of coagulated
blood, in association with
a portion of the placenta
or the decidua, which
hangs by a pedicle from
the uterine cavity and
acts as a source of irrita-
tion until its removal.
The mass becomes corn-
Fig. 509.
Polypi.
pressed in the uterine cavity and forms a firm growth, which
can subsequently become partly organized, or, under the influ-
ence of insufficient nutrition, may become decomposed, and cause
putrid intoxication. The treatment will consist in the thorough
removal of the growth. This can be done with the finger or by
the introduction of forceps, which seize and twist off the tumor.
629. Malignant Tumors. — Malignant neoplasms, as seen by
our classification, originate in embryonic tissue and are divided,
744 GYNECOLOGY.
according to their origin, into two classes : the epithelial and the
connective tissue. They differ from the benign in having no
limit to their growth and extension. A malignant tumor is one
which destroys the organ in which it originates and penetrates
to the surrounding structures without limit to its growth. There
is no tissue of the body which can offer effective resistance to its
encroachment. Malignant growths are further characterized by
a tendency to extend themselves to remote tissues and organs by
transmission through the lymph- and blood-vessels. Loosened
pieces of tissue or infectious products are washed away from
their original source to new locations, thus affording development
to new foci of the structure similar to that from which they
originated. A further characteristic is that they exhibit a dis-
position to recur after removal. The limit between malignant
and benign tumors is difficult to fix. Thus, papillary ovarian
cysts may rupture and subsequently implant themselves upon
and infect the general peritoneal ca\4ty. Syphilis and tuber-
culosis manifest an inclination to extend to the surrounding
structures and to be reimplanted through the blood-vessels. But
the manifestations of syphilis and tuberculosis are capable of
modification, of arrest, and even cure. The papillary infection
generally tmdergoes atrophy and disappears when the original
source of infection has been removed.
630. Classification. — Pathologic classification of malignant
disease of the uterus can be arranged as in other organs of the
genital tract, in tumors springing from the embryonal epithelial
cells, of which there are two varieties, namely: carcinomata and
chorio-epithelioma, and from the embryonal connective-tissue
ttmiors, of which there are also two varieties of malignant dis-
ease, namely: sarcoma and endothelioma. The carcinomata
may develop from any portion of the uterine mucous membrane
from the cervix to the fundus, and in either the surface epithe-
lium or that lining the glands. Chorio-epithelioma develops in
the second layer of cells, known as Langhans' cells, covering the
chorionic villi. Sarcomata may originate in the connective tissue
of the endometrium or in the tissue of the mural portion of the
organ. Endotheliomata develop from the endothelial cells of
the lymph-vessels, blood-vessels, and the serous covering of the
uterus. Furthermore, they are, as a rule,, without any alveolar
arrangement.
631. Anatomic Classfication of Carcinoma. — Carcinoma may
arise from any portion of the mucous membrane lining the
uterus or that covering the cervix external to the os, the latter
being the portion denominated by the Germans as the portio
vaginalis. According to the anatomical location, carcinoma is
classified into : i , Carcinoma of the vaginal portion of the cenix,
GENITAL TUMORS. 745
that portion between the external os and the vaginal vault; a.
carcinoma of the cervical canal, which is bounded below by the
external os and above by the internal; and, 3, carcinoma of the
corporeal mucous membrane, whose inferior boundary is the
internal os. Carcinomata are further classified histologically
into squamous-cell carcinoma and the cylindric-cell carcinoma
or adenocarcinoma, Squamous-cell carcinoma is the form of
disease found in the epithelial covering of the vaginal portion of
the cervix. In rare instances it has been described as having
originated in the endometrium of the uterine body, and its origin
there can be explained only by the presence of parasitic epithelial
cells. According to Cullen, but three authentic cases have been
recorded in literature. Cylindric-cell cancer develops from the
epithehai covering of the mucous membrane and from the epithe-
lial cells Hning the glands of the cervix, and also in similar struc-
tures of the uterine body. Of the different anatomic varieties,
the squamous cell of the portio vaginalis is the most frequent.
Next in order of frequency is the cyhndric-cell cancer of the cer-
vical canal, while the least frequent is the cyhndric-cell cancer of
the uterine cavity. Carcinoma of the uterus ranks in frequency
next to cancer of the stomach. In 31,482 cases of carcinoma
Welch found 29,5 per cent, were of the uterus. Williams estimates
that death from cancer in women over thirty-five years of age is
one in thirty-five. In a survey made by Dr. P. B. Bland of the
vital statistics of the city of Philadelphia extending over a period
of twenty-five years, from 1878 to 1903, 9777 women were foimd
to have died from cancer. Of this number, 3172 were attributed
to cancer of the uterus, 2139 to cancer of the stomach, and 1776
to cancer of the breast. These statistics demonstrate the greater
frequency of uterine cancer. During this period 1980 men died
of gastric cancer, making a total from cancer of the stomach in
males and females of 41 1 9. Thus it is demonstrated that cancer of
the uterus is by far the most common form of malignant disease,
and it is for this reason that twice as many women as men die
from cancer. The squamous-cell form of carcinoma is by far the
most frequent mahgnant disease of the uterus — more frequent,
indeed, than adenocarcinoma of the cyhndric form of disease in
both the cervix and body. The squamous-cell variety develops
from the atypical proKferation of the squamous epithelium cover-
ing the vaginal portion of the cervix. In women who have borne
cluldren and in whom repeated lacerations of the cervix have oc-
curred, cicatricial changes may lead to the extension of the squa-
mous epitheliimi some distance into the cervical canal, and tliis
explains the occasional existence of the disease some distance
within the cervical canal, and that mixed forms not infrequently
are present.
746 GYNECOLOGY.
632. Development of Squamous-cell Carcinoma. — This fonn
of malignant disease may develop on the anterior or posterioitip
of the cervix and frequently on the site of an old laceration.
CuUen distinguishes three stages, according to the degree of in-
filtration and disintegration of the part affected : (i) A rapid pro-
liferation of the squamous epithelial cells : the lesion appears first
as small, papilla-like nodules, hard at the base, more or less
friable on the free surface, which bleed easily on examinatico.
They present a glistening, bluish-white appearance on the surface,
and on section two zones are recognized — the first or peripheral is
composed of a more or less friable, brain-like consistence and of a
yellowish-gray, brain color. The second or basal zone lies in
juxtaposition to the cervical tissue, is of a yellowish-white color,
and of a dense, cartilaginous consistence. Close inspection of these
nodules reveals fibrous striations or trabecule occurring thiouf^
Fig. S'o — Squamous-cell Carcinoma of Cervix.
a, Cervical canal; b. portion of vaginal wall involved in the maligntuit paxta.
out their tissues. These bands surround or isolate nests of friable
homogeneous tissue, the so^alled cancer assemblages or canar
nests. These areas may be emptied of their contents by com-
pressing the tissue, and small shallow depressions remain. It is
important that siich areas be not confounded with dilated cer-
vical glands containing inspissated mucus — the so-called Naboth-
ian cysts. The small papillary projections or processes manifest
in the nodules grow and spread rapidly, forming a large cauli-
flower-like mass. Such a neoplasm has been designated the
cauliflower cancer. In this stage the disease may be so extensive
as to fill the entire vaginal vault. The extension of the papillaiy
process into the vaginal wall appears a determination of the
malignant disease to follow nature's law and travel in the line of
least resistance. While this external proliferation occurs, there
is a simultaneous invasion and consequent involvement of the
subjacent tissue, which becomes dense, hard, and indurated.
GENITAL TUMORS.
747
Section of this nodule reveals the neoplasm appearing as a hard,
cartilaginous, yellowish-white groirth extending upward toward
the internal os, and outward toward the vaginal vault, and later,
also, in the direction of the parametrial tissue. Such neoplasms, if
closely inspected, disclosed glistening trabeculas of fibrous tissue,
constituting the stroma, which formed the walls or spaces in wliich
assemble the parasitic epithelial cells. Thin sections made from
such an area when compressed and washed out present a sieve-
like structure. It is unfortunate that squamous-cell epithelium
in this stage is so frequently undiscovered. It is rare, indeed, and
usually only by accident, that the disease is recognized in this
formative stage, as it is then wholly devoid of symptoms. It is
at this stage that radical treatment would present better results
than now obtain, because the lesion is then most probably con-
fined to the uterus. (2) The stage of moderate disintegration of
decided symptoms and the period at which the disease most
frequently comes under observation. The palpating finger will
discover at this period the partial or total destruction of the cervix,
and substituted therefor an irregular, cauliflower, fimgating mass
of tissue of a grayish-yellow color, friable and brain-like in con-
sistence. The tissue breaks down under manipulation and
bleeds freely. Instead of the cauliflower mass, which may have
disappeared bv sloughing, a large, irregular, crater-Hke ulcer
exists, the floor and sides of which are irregular, hard, and covered
with a sloughing, gangrenous tissue. The disease will be recog-
nized as having invaded the structures beyond the cervix, and the
latter organ may have been to a great degree destroyed. After
the removal of the uterus, the base of such an ulcer appears to be
composed of a yellowish -white, hard, cartilage-Uke tissue. This
tissue ramifies the structure of the cervix by finger-like projec-
tions, as in the cauhflower growth. The disease extends, in-
volving the vaginal vault and connective tissue of the broad lig-
aments. The third stage is characterized by extensive or com-
plete disintegration of the cervix and the involvement of the cir-
cumjacent structures. It is usually recognized from the history
and physical symptoms alone, without a vaginal examination.
Palpation reveals an entire destruction of the cervix, and at its
site a. cone-shaped, sloughing, crater-like cavity. This has been
described by some as resembling the cavity of a decayed molar
tooth, its walls and floor covered with necrotic tissue. In pal-
pation the tissue feels hard, granular, and presents numerous
elevated nodules due to the presence of tliese finger-like processes.
The disease reaches first that portion of the vaginal wall most
contiguous to the original nodules. It is generally first upon the
sides, then the anterior, and lastly the posterior, wall. With the
invasion of the parametrium the broad ligament becomes hard
748 GYNECOLOGY.
and dense, the bladder becomes adherent to the uterus, and the
disease extends into its wall. The tireters are frequently sur-
roimded by masses of this infiltration, and finally become in-
volved therein. Fisttilotis commimications may take place be-
tween the vagina and bladder and rectum. The disease may
extend upward into the cervical canal as well as outward, but this
course is less frequent.
633. Histology of Squamous-cell Carcinoma. — ^The histologic
picture of this disease depends upon the stage at which it is
subjected to microscopic study. In primary proliferation and
induration previous to disintegration, several characteristic
elemental changes are observed. The tissue secured for study
should be so excised as to secure both healthy and diseased tissue,
and the sections made therefrom should include both. The
section of this tissue near the margin of the growth appears under
the microscope similar to tissue showing a reactionary inflam-
matory change. Small round-cell infiltration and polynuclear leu-
kocytes are present. As the edge of the neoplasm is approached,
disturbances will be noted in the squamous epithelium. These
occur in the form of piling up or proliferation outward of the
cells. Occasionally a superficial loss will be seen, but always is
seen an ingro\\i;h or dipping down of the cells in cone-like proc-
esses into the cervical tissue. The mucous covering of the cervix,
as a rule, remains intact until the growi;h is well advanced. It
will be seen that the invasion of the parasitic cells is not limited
to one line of the stratified squamous epithelium alone, but that
all layers take part in the process and that the normal basal layer
of large cuboidal cells forms the boundary of the advancing
column. If the section extends through one of the finger-like
processes, these cuboidal cells will be seen as forming the outer
zone. The finger-like projections external to the line of cuboidal
cell are surrounded by a network of fibrous tissue, which contains
some muscle-fibers and is known as the stroma. In some areas
keratinization or hardening of the central portion or even d
nearly all of the epithelial nests is seen. These areas are the so-
called epithelial pearls, which are of a yellowish color and dis-
posed in layers resembling an onion. Epithelial pearls, however,
are less numerous in the squamous-cell epithelioma of the cenix
than in the same form of disease in other tissues of the body.
This is incident to the fact that one layer of epitheliiun in the
cervix is less well developed and often entirely absent. Active
nuclear division in the parasitic cells is especially prominent.
One characteristic of these wandering cells is the increased amount
of coloring-matter (chromatin) fotmd in them. Cullen asserts
that the pathologic diagnosis can be determined by this and the
increased size of the cells. The cells vary in size, but are generally
GENITAL TUMORS. 749
somewhat enlarged. The fibrotis stroma enveloping the assem-
blage of cells, the cell-nests, is composed largely of fibrotis tissue.
It contains, however, a few muscular fibers and springs from the
normal cervical tissue. Throughout this stroma, in varying
amount, will be seen roimd-cell infiltration. It is most marked in
the margins of the growth and is due to the irritation of the invad-
ing neoplasm upon the circumjacent tissues. The appearance of
inflammatory cells about the margins of the growth is an apparent
effort upon the part of nature to construct barriers against the
invadinp: hostile cells. This round-cell infiltration is especially
marked in cases where the development of the neoplasm is slow,
while in those in which the growth is rapid the roimd-cell infiltra-
tion is slight. In other words, natiu-e is overwhelmed by the rapid
progress of the disease and has no time to erect its defensive
barriers. In the fibrotis stroma are situated the blood-vessels,
lymphatics, and nerves. The stroma is variable in amount, and
depends upon the rapidity of the growth. In tumors of rapid
growth it is more frequently indefinite, the tumor being largely
cellular. A malignant tumor of this variety grows in two direc-
tions: I, as an ingrowth and invasion of the cervical tissue
proper; 2, as an outshoot or outgrowth of both stroma and cells,
forming the cauliflower mass.
In the later or middle stage of development, the stage of
moderate disintegration, the disease appears under the micro-
scope to invade tissue to a greater degree, but the margin of the
growth shows the same histologic picture as seen in the earlier
stage. The older portion of the tumor betrays the changes
incident to necrosis and is found covered with broken-down
tissue, blood, and detritus, welded together by fibrin. The tissue
immediately beneath this older growth discloses more or less
degenerative change. As the disease progresses, hyaline degen-
eration occurs in the cells, both in the protoplasm and nuclei,
and in some instances giant-cells will be found. In the stage of
disease with marked destruction of tissue the necrosis and dis-
integration changes are more marked. The cell-nests are fre-
quently broken down and contain necrotic tissue and pus.
634. Adenocarcinoma of the Cervix. — Cylindric-cell cancer or
adenocarcinoma of the cervix finds its origin in the mucous
membrane lining the cervical canal between the internal and the
external os, and may arise either from the epithelium of the sur-
face or from the cells lining the glands. It has been a greatly
disputed question whether cancer of the cervix arises from the
cover epitheliimi or the gland. Some contend that it arises from
the free surface epitheUimi, while others that it has its origin
from the epithelium of the glands. Winter asserts that the dis-
ease most frequently develops from the combined point of origin
750 GYNECOLOGY.
of the glandiilar and surface epithelium, but it is now generally
accepted that this form of malignant disease may originate in
either one of these structures. The disease presents itself in a
number of forms — sometimes occurs as a rounded nodule which
may involve almost the entire cervix before disintegration r^ults.
It may appear in the lumen of the cervical canal in the form of
tubercles, nodules, or papillary growths which fill up the cavity or
are extruded from the os, while the external surface of the cervix
is scarcely involved. Not infrequently the entire cervical canal
is involved in the cancerous process without any pathologic
changes being manifested outside the external os. The growth
often appears as a hard, firm, waxy mass. In other cases ex-
tensive inflammation of the diseased mucous membrane as well
as of the muscle and cervical wall follows, causing thickening
and hardening of the entire cer\4x. The carcinomatous nodule
or nodules gradually undergo necrosis, lea\dng a sloughing, crater-
like ca^*ity in place of the cervical canal. AMien the disease is
confined to the upper part of the cer\-ical canal, it may remain
for a time totally unsuspected, because it is hidden behind an
unin vol veil external os. As the disease progresses it gradually
extends do^^^lward and creeps through the external os, but much
more frequently has broken through the cervical wall into the
parametrium l^fore any change is manifest at the external os.
The g^o^^"th may be fairly well developed before the vaginal
portion of the cervix exhibits any indication of its existence.
Paliwtion at this stage discloses the organ to be hard, gritty, and
nvxiiilar. Occasionally a fungus-like mass projects from the ex-
t enial v>s. A sov t ion through the cervix in this form of disease dis-
cK>sos an advancovi stage and a condition resembling a worm-eaten
oavitv. With tb.e disintocration of the carcinomatous tissue an
extensive excavation is formed, which enlarges the external os in a
nssurt* ot cv^r.siv:crab-e broadth. A large ponion of the cer\-ical
cana' :v..iy il.ns Iv vlisinto^n^itod. This description indicates that
the oxtcr.siv^r. ir. avio:ux\\rcinoma differs essenually from that in
the c.\ro:r.o:r.a v^f ::.o ivrtio vairinalis. In the latter, as has been
ir.dic.Ucxl. ::.c ir.vasiv^n is suivrr.ci.U. laceration follows early,
bx:: ir. : -.o ov>;:.dnc-vcl' c.;r.cor of the cer\-ix :he in\-asion rapidly
ix^notni-.vs :-.o cenio.r. w.ii: into the p.\rantetrial connective
tissue. \v/::o : '.0 v..v-v..vl :\ rtiv^r. of :::o CT?r\-ix is involved late, if
.iT ./.* VXur.sivo ::.vas:. :t .ir.vt c.ocor.cni::;r. . f the cer\4cal canal
in :: ;^ .:: :\\;:--^- f :;\- s^;u:n us ev::hehA: covering of the
txr:: v,.p-.;::< Wh.u nc c.ns:/:c?s' the changes which the
ct?r\ \ u:- u-i: vs ,.< .1 r;<u*: . f cxtcr.svc ^.^nAulu- indammation,
whcu : V .\'* \o ^-v-o.v: .\.\:: :< :uv. /.-A :n ^vsttc degeneration
f :::e o^r. tc,i: ;:linis, it is easy to
% « V.
■^ •^^ * '^.^* *^ •■*"•* ■»•* N* » *^% •*»•*(
GENITAL TUMORS. 751 J
appreciate how tlie malignant growth in such a field wouldJ
rapidly penetrate to the parametria! structures before becomii^B
evident in the vagina. The disease occasionally extends down-
ward, involving the vaginal walls, but its usual direction is to-
^va^d the body of the uterus and outward into the parametria!
tissue. It occasionally passes through the internal os and in-
volves the mucous membrane of the uterine body. Only a small
portion of the uterine endometrium may be thus invaded or the
entire mucosa. Occasionally the uterine mucous membrane may
be the seat of isolated cancer-nests, the result of metastasis. In
the progress of the disease it may penetrate to the peritoneum,
but the vesicocervical septum is much more frequently involved,
extending to the bladder and surrounding the lower ends of the
ureters ^th masses of infiltration. The ureter is probably more
frequently involved in this form of malignant disease than the
bladder, for in attempting to remove the disease I have frequently
been compelled to excise portions of one or both ureters in order
to afford a hope of the removal of the involved parametrium.
The infiltration about the extremities of the ureters causes ob-
struction to the fiow of urine and dilatation of the ureter and
pelvis of the kidney, producing hydronephrosis, and when asso-
ciated with infection, pyonephrosis. The extension of the dis-
ease to the bladder and ureters, and backward to the rectum,
with disintegration and ulceration, may produce fistulous com-
munications by which the contents of the bladder and the rectum
pass into the vagina. The posterior cer\-ical wall and its en-
veloping peritoneum are not so frequently involved in cancer of
the cervix, but more frequently than when it originates in the
portio vaginalis. Extensive peritonitis is infrequent, as the in-
vasion of the disease is preceded by inflammatory barriers. Oc-
casionally, however, perforation may result and a suppurative
peritonitis follow.
635. Histology of Adenocarcinoma. — The term adenocarci-
noma ■will imply that the structure is of a glandular character.
The disease generally develops in the glandular epitheHum,
although it may sometimes originate in the cover epithelium.
The epitheHum lining the glands proliferate, projecting into and
filling up the lumen of the gland as small processes. These pro-
jections unite with one another and in this manner one gland may
be subdivided into fifteen or twenty smaller glands. The epi-
thelial cells lining the glands are tall, columnar, narrow, and
somewhat irregular in size. The cell nuclei are generally located
at the base of the cell, but occasionally are found near the center.
When a tendency of tlie cells to form new glands exists, the epi-
thelial cells will be seen piled upon each other. It is often if-
ficult, according to Waldeyer, to trace the connection of the
752 GYNECOLOGY.
carcinomatous growth with the orifice of the gland, yet he has
seciJred sections demonstrating such connection. Ruge and
Veit have shown that the glandular epithclitun which ordinarily
consists of but one layer becomes several layers thick, and that
the original arrangement of the epithelium is lost. This feature
of the disease is always evident, and the parasitic cells, when com-
pared with cells lining the normal glands, will be seen to have
special characteristics of their own. The first tendency to pro-
lifemtion is intraglandular, the cells piled over each other, form-
ing several layers in which intraglandular outshoots are pro-
jected, dividing the original gland into numerous compart-
ments, Extraglandular proliferation occurs later. The base-
ment membrane is fractured, followed by a wide proliferation
and projection of the epithelial cells into the interglandular
fibrous stroma. The interglandular proliferation may be so
extensive as completely to fill the gland lumen. Cross-sections
of such occluded glands appear under the microscope as similar
to epithelial nests found in squamous-cell carcinoma. Wlien
papillary projections appear from the external os, they will be
found microscopically to be composed of papillae covered with
one or more layers of cyhndric epithelium. The stroma structure
supporting these processes will be found more fully developed than
that which exists in the squamous-cell carcinoma. Generally
the epithelial cells of adenocarcinoma of the cervix decidedly
differ morphologically from those seen in the cer\"ical epithelium.
Active nuclear division is always well marked. The stroma has
its origin in the cervical tissue and is usually infiltrated with
small round cells. The inflammatory infiltration in adenocar-
cinoma is not so marked as when this process occurs in the squa-
mous-cell epitheHoma. This may be accounted for by the rapid-
ity with which the adenocarcinoma develops. As the tumor
matures, interference with its nutrition results, which is followed
by necrosis and sloughing. Tlie older portion of the tixmor,
therefore, is often covered with disintegrated tissue, and im-
mediately tmder the surfiice, for a considerable depth, marked
necrosis will be seen.
636. Adenocarcinoma of the Body. — In the body of the uterus
adenocarcinoma has its origin in the mucous membrane lining
the interior of the uterine cavity, and arises either from the sur-
face of the epithelium or from the epithelial lining of the tubular
glands. This is the rarest form of epithelial mahgnant disease
of the uterus, and is more likely to occur in women later in life
or in those who have not borne children. As it more frequently
occiu^ in women following the climacteric, it is the most hopeftil
of the different varieties of uterine carcinoma. The disease
may originate at any point in the uterine cavity fropi the internal-
GENITAL TUMORS. 763
OS to the fundus. It is unusual for the neoplasm to extend to-
ward the internal as, and rarely does it reach the external. There-
fore, in making a positive diagnosis it is necessary that the uterine
ca'v'ity should be dilated to permit of its exploration with the finger,
and frequently the diagnosis can be confirmed by the examination,
under the microscope, of the scrapings and fragments removed.
The disease may begin as a circumscribed nodule, springing from
the surface of the mucous membrane, which consists of several
delicate papilla-like processes. These processes may be irregular
and wart-like in appearance, and the surface of the growth ap-
pear perfectly smooth. This is particularly true in the early
stage of the development, and the disease at this period may
appear simply as a locahzed hypertrophy of the endometrium.
The nodule gradually increases in size, and about its base, as the
disease progresses, several smaller nodules will be found. Oc-
casionally it may appear simply as a polypus with a very small
pedicle. This growth may be so large as to fill up the entire
uterine cavity. Such a growth may not be unlike the benign
mucous polypus and consequently be confused with it. It is
usually, however, more fragile and its surface less smooth. The
proliferating mass is also much larger in comparison with
the size of its pedicle than is found to be the case in the benign
growth. It is probable that these malignant polypi develop
from the infection of distended uterine glands, or they may be
produced by the malignant transformation of a benign mucous
poh'pus. Epithelial malignant disease of the endometrium gen-
erally begins as a localized growth, although occasionally the
lesion, even in its earliest stages, simultaneously involves the
entire mucous membrane. As it progresses, outshoots or finger-
like projections are produced, which grow in the line of least re-
sistance— that is, into the uterine cavity, gradually filling it. Such
a uterus ■will be found enlarged, soft, and more or less boggy, and
a digital examination of its interior will reveal the cavity com-
pletely filled with a soft, friable, grayish-yellow, brain-like tissue.
This tissue is broken off and, displaced by the examining finger,
makes its exit through the external os. Such a uterus com-
pressed between the fingers \vithin the vagina and the hand over
the abdomen will oftentimes allow the discharge of disintegrating
material. With the proliferation into the uterine cavity there is
also a corresponding invasion of the uterine wall, although this
is not so rajDid. Section through the involved uterine wall or
the basal portion of the tumor reveals a structure of more or less
dense and firm consistence and of a yellowish-white color, which
projects distinctly from the muscle. The growth gradually pro-
jects through the uterine wall and may present beneath the
peritoneal surface. As it advances and ages interference with its
^ ^
i
[ 752 GYNECOLOGY,
carcinomatous growth with the orifice of the gland, yet he 1
secured sections demonstrating such connection. Ruge a
Veit have shown that the glandular epithelium which ordinal
consists of but one layer becomes several layers thick, and tl
the original arrangement of the epithelium is lost. This feat'
of the disease is always evident , and the parasitic cells, when ca
pared with cells lining the normal glands, will be seen to hi
special characteristics of their own. The first tendency to p
liferation is intraglandular, the cells piled over each other, foi
ing several layers in which intraglandular outshoots are p
jected, dividing the original gland into numerous compe
ments. Extraglandular proliferation occurs later. The bs
ment membrane is fractured, followed by a wide proHferal
and projection of the epithelial cells into the interglandf
fibrous stroma. The interglandular proliferation may i^
extensive as completely to fill the gland lumen, Crc
of such occluded glands appear under the microscope a
to epithelial nests found in squamous-cell carcinoma.
papillary projections appear from the external os, they x
found microscopically to be composed of papillas covi _^
one or more layers of cyhndric epithelium. The stroma SO^
supporting these processes will be found more fully develoj*
that which exists in the squamous-cell carcinoma. Gt.J
the epithelial cells of adenocarcinoma of the cervix d-
difier morphologically from those seen in the cer\ical ep:
Active nuclear di'vision is always well marked. The s^
its origin in the cervical tissue and is usually infitte "
small' round cells. The inflammatory infiltration in
cinoma is not so marked as when this process occurs u
mous-cell epithelioma. This may be accounted for by
ity with wliich the adenocarcinoma develops. As
matures, interference with its nutrition results, whicT
by necrosis and sloughing. The older portion of
therefore, is often covered with disintegrated tist:
mediately under the surface, for a considerable di
necrosis will be seen.
636. Adenocarcinoma of the Body.— In the bod'
adenocarcinoma has its origin in the mucous mc
tlie interior of the uterine cavity, and arises eithe.
face of the epitheHum or from the epithehal lining
glands. Tliis is the rarest form of epithelial m>
of the uterus, and is more likely to occur in wor
or in those who have not borne children. As it
occurs in women following the climacteric, it is -
of the different varieties of uterine carcinor
may originate at any point in the uterine cavity
GENITAL TUMORS. 753
OS to the fundus. It is unusual for the neoplasm to extend to-
ward the internal os, and rarely does it reach the external. There-
fore, in making a positive diagnosis it is necessary that the uterine
ca\nity should be dilated to permit of its exploration with the finger,
and frequently the diagnosis can be confirmed by the examination,
under the microscope, of the scrapings and fragments removed.
The disease may begin as a circumscribed nodule, springing from
the surface of the mucous membrane, which consists of several
delicate papilla-like processes. These processes may be irregular
and wart-like in appearance, and the surface of the growth ap-
pear perfectly smooth. This is particularly true in the early
stage of the development, and the disease at this period may
appear simply as a localized hypertrophy of the endomctriiun.
The nodule gradually increases in size, and about its base, as the
disease progresses, several smaller nodules will be found. Oc-
casionally it may appear simply as a polypus with a very small
pedicle. This gro\\i:h may be so large as to fill up the entire
uterine cavity. Such a growth may not be unlike the benign
mucous polypus and consequently be confused with it. It is
usually, how^ever, more fragile and its surface less smooth. The
proliferating mass is also much larger in comparison with
the size of its pedicle than is found to be the case in the benign
growth. It is prubable that these malignant polypi develop
from the infection of distended uterine glands, or they may be
produced by the malignant transformation of a benign mucous
polypus. Epithelial malignant disease oi the endometrium gen-
erally begins as a localized growth, although occasionally the
lesion, even in its earliust stages, simultaneously involves the
entire mucous meml.)rane. As it progresses, outshoots or finger-
like projections are produced, which grow in the line of least re-
sistance- -that is, into the uterine cavity, gradually filling it. Such
a uterus will be found enlarged, soft, and more or less boggy, and
a digital examination of its interior will reveal the cavity com-
pletely filled with a soft, friable, grayish-yellow, brain-like tissue.
This tissue is l.)roken off and, dis])laced by the examining finger,
makes its exit through the external os. Such a uterus com-
pressed between the fingers within the vai^^ina and the hand over
the abdomen will oftentimes allow the discharge of disintegrating
material. With the proliferation into the uterine cavity there is
also a corresix)nding invasion of the uterine wall, although this
is not so rapid. Section through the involved uterine wall or
the basal portion of the tumor reveals a struciurc of more or less
dense and firm consistence and of a yellowish-white color, which
projects distinctly from the muscle. The growth gradually pro-
jects through the uterine wall and may j^rcsent l)eneath the
peritoneal surface. As it ad\'anccs and ages interference with its
4S
7fi4 GYNECOLOGY.
nutrition results and necrosis and disintegration of the older or
superficial portions of the tumor follow. This necrotic material is
gradually discharged and a scooped-out, crater-like cavity forms
the uterine interior. The foul-smelling vaginal discharge is pro-
duced by the necrosis of the tissue.
Occasionally the cervical canal becomes completely occluded
by the maUgnant growth, resulting in the accumulation of dis^
integrating necrotic tissue within the cavity of the uterus, fo:
ing a pyometra.
637. Histology of Adenocarcinoma of the Body of the Uterus.
— The microscopic picture presented liy adenocarcinoma of the
body of the uterus seems to differ in almost e\'ery specimen
nea
dis^^H
irm^^H
r
Fig. 511-— Squamous-cell Ep thel oma of the Uterus.
a. Eeratinization of cells forming ep thel al pearls b Connective-tissue n
rix. c. Collection of alyp cal cells
examined. These differences occur in the e])ithelial cells cover-
ing the surface of the endometrium and in those lining the glands.
In the early stages of the disease occurs a piling up or stratification
of the cells, which may be localized. These local proliferations
gradually increase in size and project into the uterine cavity. In
the interior of the nodules is found a well-marked supporting
structure, composed of fibrous tissue containing muscle-fibers
which con^'Cy the nutrient vessels. These nodular projections
vary in size. Some are short and some are long-drawn-out bodies
which resemble somewhat the benign papilloma, but the cells
covering the papillary projections are characteristic, and one cA «
GBNITAL TUMORS.
76S
heir strong feattares is the increased amount of coloring-matter
hey contain. The cells covering the processes are, as a rule,
rrc^ular in size, and very rarely, indeed, are they found iiniform.
Che celltilar irr^ularities are marked throughout the tumor,
ome appearing short and others quite long. The epithelium
overing the projections may be arranged in a single layer when
he cells remain cylindrical. As a rule, more than one cell cover-
ng is noted, and the secondary layers are poljTnorphous in
Fig. 512, — Adenocarcinoma of the Cervical Canal.
. Cervical canal, b. Shows extension of disease to internal os. c, Hypertrophied
endometrium.
liaracter. In other instances the picture presented under the
nicroscope is more of the adenoid type, and the histology of the
leoplasm is similar to adenoid carcinoma found in the cervix.
'Jumerous glands are found of varying size, lined with colum-
lar epithelial cells. These are irregular and contain oval,
leeply staining nuclei. The cells lining the glands may be dis-
tosed in a single layer, but in many areas an intraglandular piling
756
GYNBCOLOGY.
up or Stratification of the cells will be seen, and in other areas
fracture of the limiting membrane with an extraglandiilar pro-
liferation of the cells is rect^nized. In these areas the cells will
be found wandering in the fibrous stroma between the glands,
and this perhaps is the distinctive stamp of the true malignant
character of the tumor. Cullen believes that in those cases
characterized by marked papillary arrangement the growth is
started in the surface epithelium; whereas in the cases having
distinct adenoid arrangement, the epitheli\im lining the glands
has possibly been their origin. As the disease Eiges there is a
Fig- 513. ^Adenocarcinoma of Body of the Uterus,
I. Cells fracturing basement membrane and infiltrating fibrous stroma. 6, t. J-
Intraglandular proliferation of cells. (, c. Irregularity of cells, d, i
Epithelial cells infiltrating stroma. ,
breaking down of the peripheral portion of the growth; the sur-
face undergoing destruction shows marked inflammatory in-
filtration, and the gland in the deeper portions of the tumor may
show degenerative changes. As the necrotic process advance
degeneration of the uterine muscle takes place and both muscleaal
glands are filled with inflammatory cells.
638. Dissemination of Carcinoma. — Carcinoma is not con-
fined in its development to the infiltration of the contiguous
tissues already described, but manifests a disposition to spread
through the lymphatics and blood-vessels to the structures more
or less remote from that in which it originated, and here to fonn
GENITAL TUHOaS.
757
i or nests of a similar character. Experience demonstrates
It this spread of the disease through the blood-vessels is rare.
J^nant ulceration of the blood-vessels, however, does take
tce, and metastases follow through the blood stroma. Seelig
ected attention to the fact that the capillaries for a long time
oained intact between the existing carcinomatous projections.
! once saw a carcinoma ring around a vein which had infected
! wall of the capillary up to the intima. Goldman has ob-
"ved penetration of the thin walls of the vein by cancer with
eration of the lining endothelium. In this case circulation
s obstructed, with the formation of a thrombus. Abel recites
: history of a patient, thirty-seven years of age, who had suf-
Fig. 5:4. — Cauliflower Growth Involving the Vaginal Part.
■ed two months with irregular bleeding and discharge. Ex-
lination failed to reveal any indication of involvement of the
ginal wall or parametrium. Total extirpation of the uterus
rough the vagina was done, with as extensive removal of the
oad ligament as possible. Subsequent microscopic investi-
tion disclosed at some distance from the carcinoma, in a per-
.■tly healthy looking area, a mass of carcinomatous tissue
lidi infiltrated the wall of the vein. The occurrence of such
□ditions demonstrates the possibility of the transmission of
rcinomatous masses through the blood stream. The principal
■thod of extension, as already mentioned, is, however, through
758
GYNECOLOGY.
the lymph-channels. The epithelial cones project into the coo*
nective-tissue folds until they gradually reach large lymph-spa{
Having reached one of these spaces, it rapidly extends itself.
The more rapid de\'elopnient of the disease in pregnant women
is undoubtedly caused by the increased size of the lymph-channels
and the increased energy of the lymphatic circulation at this
period. All observers recognize the rapidity with which malig-
nant disease invades the tissues when it has developed in youn|_ '
women. This is undoubtedly due to the activity of the lymph cir-
culation. Following the
climacteric, and especially
in senile women, the vessels
become atrophied and small.
The lymphatic circulation of
the pelvis is very inactive.
In such individuals, there-
fore, the disease spreads
slowly, and it is only when
the deeper structures have
undergone infiltration that
the lymph-spaces are opened
and the disease is more
rapidly transmitted. Seelig,
in his careful investigations
on the progress of the dis-
ease, noticed the projection
forward of carcinomatous
masses into the endothelial
lining of the lymph-spaces.
These masses more or less
obstruct the large vessels,
although the vessels them-
selves could still be recog- '
nized in the structure. The I
largest lymph-spaces filled"
with carcinoma were situated in tlie margin between the middle
and peripheral muscle layer of the corpus uteri, while the inter-
nal muscular branches anastomose vertically. Investigation
demonstrated that carcinomatous masses press against the con-
nective-tissue or muscle-fibers until they are able to invade
the lymph-spaces. Obstruction of the lymph-vessels not infre-
quently results in a regurgitation, by which portions of the
malignant tissue are carried backward in the lymph-spaces in a
direction opposite to that of the normal current. The invasion
of the anterior wall of the vagina with cancerous disease, when it
has originated in the cavity of the uterus, maybe thus explained. J
Hg. s's
GENITAL TUMORS. 799
As the disease enters the lymph-spaces it is carried by the larger
paths into the parametrium, where the Ijrmphatics are not infre-
quently filled with carcinomatous masses. Emboli are carried
from the lymph-spaces into the next lymphatic glands without
the vessels themselves being involved. While it is generally
recognized that the principal channel of invasion is through the
lymph-vessels, yet it seems apparent that malignant disease of
the uterus produces lymph-gland involvement at a later date
than in cancer of other portions of the body. The later trans-
Pis. 516. — Cervical Wtdl Infiltrated while the Vaginal Portion is Largely Des-
mission of the disease to the lymph-glands is undoubtedly due
to the more frequent occurrence of the disease at or subsequent to
the climacteric, when the lymph-ducts of the pelvis have become
atrophied as a result of the lessened activity of the genital organs.
In women under forty years of age, however, this does not exist,
and it is in these patients in whom the disease makes the most rapid
progress and the prognosis for cure is most unfavorable. Much
difference of opinion exists among investigators in this field as
760
GYNECOLOGY.
to the frequency of glandular involvement, and necessarily the
decision of this question has an irnportant bearing upon the plan
of treatment. Ries, Pryor, Wertheim, and others assert that as
a result of careful investigation they have found a large propor-
tion of the next lymph-glands infected very early in the prepress
of disease. Schauta concurs in the frequency of gland infection,
but insists that it is the deep or inaccessible glands which are
generally invoh-ed, and frequently at a time when those next
are unaffected. Those who doubt the early gland infection
point to the number of cases in
which the operation by either
the abdomen or the vagina has
been followed by failure of the
disease to recur for so long a
period as to justify the assertion
that the patient is cured. When
iiicurrence follows, it in the ma-
jority of cases is found in or near
I lie vaginal scar and not in the
i ymph-glands. Experience would
«^em to indicate that the involve-
iiient of the glands is not neces-
■-ririly followed by recurrence of
the disease. The removal of the
original source is evidently in
some cases followed by atrophy
of the infected glands.
Cullen accounts for the failure
to involve the Ij-mphatic glands
as early in carcinoma uteri as
in mammary carcinoma, by the
fact that in the uterine disease
there is a greater disproportion
between the size of the epithelial
cells and the lymphatic vessels,
that the epithelial cells rapidly
attain a size too large to permit
of their passage through the lymphatic vessels, and it is only
after the disease has reached the large lymphatic spaces and
vessels that lymphatic gland infection occurs. The investiga-
tions of Blau and Dybowsky particularly emphasize the infre-
quent involvement of lymphatic glands in women who have
died from cancer in the Berlin Charity. The former found
the lymph-glands of the pelvis involved but thirty times in
ninety-three sections, whUe the latter in one hundred and ten
cases found only ten of lymphatic infection. In cancer of the.
I
GENITAL TUMORS.
ervix Blau found the lymphatic glands infected in scarcely
me-third of the cases. Tlie experience of operators would seem
o confirm the claim of the majority of investigators that lymph-
P'G- 5 '9- — Adenocarcinoma o( Uti
GYNECOLOGY.
atic gland involvement occurs much later in uterine cancer than
in other portions of the body.
639. Clinical Forms. — We have already seen that cancer
is divided, from a histogenic standpoint, into two forms, the squa-
mous-cell and the cylindric-cell cancer; clinically it is dividec'
GENITAL TUMORS.
763
0 carcinoma of the portio vaginalis, of the cervix, and of the
dy of the uterus. It is still further divided cUnically accord-
1 to the course that the disease, pursues and the physical
;ns presented. Thus, a collection of epithelial masses may
eak down upon the involved surface or in its center. The
jwth can project from the portio vaginalis into the lumen of
» vagina, or, at the same time, the connective tissue of the
rtio is occupied by the stroma and penetrated to its depth by
Qcer masses. These masses most frequently develop in cancer
the portio above the ]e\'el and toward the lumen of the vagina.
Fig. 513. — Conununication between Bladder, Vagina, and Rectum.
• which is formed a superficially situated tumor known as a
tilifiower growth. It exists as a more or less roundish, polypoid
mor in tihe vagina, completely distending it, and presents a
mor the size of a fist, which becomes more contracted and
mer a^ the healthy structure is approached. The surface of the
uliflower, after desquamation of its pavement epithelium, re-
als exposed carcinomatous masses and presents an irregular or
.pillary condition. When the disease has had a longer duration,
th unfavorable nutrition of its interior surface and with com-
cssion of its vessels, large portions become necrotic and the
uliflower growth is covered with a grayish, greenish, smeary
764
GYNECOLOGY.
mass. Such growths most frequently originate in the posterior
lip. In many cases the disease develops in one commissure and
extends from it to the lip ;_ rarely the entire portio vaginalis is
simultaneously degenerated. In other cases processes of epithe-
lial growth project into the substance of the portio, and in deep
infiltration there Js thickening of one lip of the commissure. In
rare cases the entire portio vaginalis becomes involved and the
more allected lip grows toward the lumen of the vagina. This
form differs from the cauliflower growth by being polypoid and
by having a mucous membrane drawn over it, which is rarely
quite intact. Frequently the mucous membrane is thrown off
in superficial layers and is followed by
disintegration of the surface of the infil-
tration, or it begins in the center and
opens through the infiltration to the out-
side. A smooth funnel or fissure will
thus be formed, with jagged, often
undermined borders, sharply lying
toward the circumference and appear-
ing under the level of the healthy sur-
roundings. In such a fissure an ulcer
will occasionally dissect deeply into the
portio. Movable polypoid tiunors will
project into the ulcer or around the
cervical canal, without special alteration
of the canal itself. (Fig. 523.) Smooth
ulcers are occasionally observed, similar
to the erosion, which extends to a very
trifling depth. Why these variations in
the progress of the tisease exist is as yet
undetermined.
640. Etiology. — Our knowledge of
e causes of malignant disease is s1
of Disease. ' " largely speculation. Among some of
the more important theories as to its
development are: Virchow's, that while cancer is of epithelial
origin, it is only through metaplasia or mesodermal elements that
it originates; in other words, a transformation of the connective-
tissue cells. Cohnheim advocates the theory that it was trans-
mitted from embryonic carcinoma germs. Riberts believed the
epithelial cells separated from their connection without anaplasia ;
Thiersch and Waldeyer. that by primary growth of the epithelium,
without alterations of biologic properties of the epithelial cells.
All agree that there is no distincti^-e cancer-cell.
In recent years increased attention has been concentrated
upon the determination of some micro-organism which shj "
GENITAL TUMORS. 765
prove to be a causative factor. Such a theory seems favored
by the natural history of the disease, its local origin, its invasion of
the surrounding structure, and its transmission by the blood- and
lymph- vessels. The mere fact that a specific micro-organism has
never been isolated and recognized is not a convincing objection,
for syphilis has baffled all attempts to recognize its essential
organism, yet no one doubts that it is so transmitted. Klebs and
others have presented various micro-organisms, but none of them
have stirvived careful investigation. The presence of cancer
results in the development of micro-organisms of various kinds,
just as is found in other inflammatory processes, but none of
them will reproduce the disease. Various degenerative proc-
esses in the cells have been indicated as possessing the parasitic
demients, only to be proved untenable. Schwarz has most con-
vincingly demonstrated that the majority of cell alterations
favoring the parasitic theory have so far resulted from degenera-
tive processes of the epithelial cells, leukocytes, or their deriva-
tives. A fimdamental pathologic difference exists in that with
the malignant a fiuther extension of the processes in the organ-
ism is influenced by the cell activity, and there is as yet abso-
lutely wanting any proof of isolation of a parasite from which
the disease can be generated by its employment. The absence
of any history of the transmission from man to animal or from
one animal to another has been cited.
The occiurence of carcinoma in the penis of the male who
has cohabited with a cancerous female is so rare as to be the
exception to the rule, yet these negative arguments are only
additional evidence that we do not loiow the micro-organism or
its natural history. Surgeons not infrequently injure themselves
while operating, but no authentic case exists by which the
development of cancer can thus be traced. Experimental ob-
servations, however, have demonstrated the fact that carcinom-
atous tissue when transferred from one animal to another of
the same species will continue to grow, while carcinomatous
cells developing in the human individual when implanted in the
tissue of another person may refuse to grow ; the tumor-cells when
placed in a raw surface distant from the original site of the growth
may develop a secondary tumor. I have operated upon patients
for carcinoma of the cervix who have subsequently developed
secondary malignant disease of the abdominal incision. In one
of them the disease developed nine months after the operation ;
in another after a period of over three years. In the latter patient
the abdominal scar was involved in a hard, indurated mass,
which upon incision revealed the intestine adherent and its walls
infiltrated with carcinomatous tissue. The abdominal scar was
excised with the affected intestine, and the patient made a com-
766 GYNECOLOGY.
plete recovery. There was no evidence of recurrence of the dis-
ease in the pelvis at the time of operation. Evidently, increasing
age predisposes the cell to carcinomatous degeneration. Statis-
tics indicate that cancer of the uterus before the twentieth year
is extremely uncommon and that it is but rarely observed during
the next ten years. The disease perhaps makes its appearance
most often immediately preceding or about the period of the
menopause. Carcinoma of the body, however, usually appears
later, Gusserow, in 3.^85 cases, found but 2 originating before
the twentieth year. It develops with increased frequency during
the fourth decennium, but the majority of cases are recognized
in the fifth. Thiersch believed the greater frequency of cancer
with advancing age was due to atrophy of the connective tissue,
whicli favored the deeper infiltration of the epithelial tissue, but
this is a mere hypothesis. Undoubtedly carcinoma occurs with
much greater frequency now than formerly. Reybtim and
Lewers attribute this to diet, and direct the attention to the in-
frequency of this fiisease among rice-eating populations. They
assert that the disease is largely due to the consumption of large
quantities of meat.
Heredity. — Inherited predisposition to the development of
cancer has been regarded as an important factor, but careful re-
searches by Gusserow showed but 7.4 per cent, favoring such a
tendency, while von Winckel found but 6.3 per cent. Inherited
lowered resistance to disease, as shown in families predisposed to
tuberculosis and chronic renal disease, favors the development of
malignancy.
Sex. — Twice as many women suffer from cancer as men. N*
to the mammary gland, the disease occurs more frequently in the*
uterus. According to Hofmeier, fully one-fourth of all cancers
in women are uterine,
Comiition of Life. — Cancer of the uterus greatly preponderates
in the poorer classes, in whom the feeble nutrition, great toil, and
more exacting lives favor degenerative processes.
Sexual Activity. — All statistics prove that malignant disease
preponderates in those who lead an active sexual life, especially
in the multiparous woman. Gusserow's investigation of a large
number of cases gave the average of fruitful labors in cancerously
afflicted women as 5.1 per cent.^a proportion of births consider-
ably above the average for women taken together. Accepting.
the irritation theory of Virchow as a factor, we can readily apprfr^.
ciate the greater frequency of cancer of the cervix. The possi-^
bility of cancer of the cervix in the chaste virgin has been doubted,
but I have seen several single women of unquestionable virtue
who suffered from cancer of the cervix. Cancer of the body of
the uterus is comparatively more frequent in the unmarried and
GENITAL TUMORS. 767
nuHiparous women. The theory that cancer can be produced by
excessive coition is not borne out in the lives of prostitutes. Car-
dnoma may be secondary in the uterus, having originated in the
Uadder or vagina. Myoma of the uterus is sometimes associated
with cancer, but not so frequently as to render it noticeable as a
predisposing catise. Landau is inclined to assign sjrphilis as a
predisposing cause, but my observation does not incline me to
accept it. Von Winckel's assertion that gonorrhea is an im-
portant factor in the development of cancer needs confirmation.
mth all our investigations we are driven back to irritation,
chemical or mechanical, as a cause for malignant disease, but its
existence does not always determine such a degeneration. We are
forced to acknowledge that we do not know why cancer develops.
641. Symptoms. — Unfortimately, in the early stages no S3rmp-
toms, either subjective or objective, are sufficiently marked to
give warning of the impending danger. As a consequence, the
physician rarely has an opportunity for early investigation of the
disease. Cancer has no pathognomonic signs; the principal
symptoms — hemorrhage, more or less offensive discharge, and
pain — are not constant in all cases, and each one or all may be
produced by other than malignant conditions. Bleeding is the
symptom of greatest significance, and may occur when the canal
of the cervix is affected, though the vaginal margin is iminvolved.
The quantity of blood lost will probably be slight and irregular,
as a few drops after severe exertion, straining at stool, or follow-
ing the act of coition. In the married, post-coitive hemorrhage
is a most constant and suggestive symptom. Generally the first
intimation will be an increase of the amount of blood lost at
menstruation, or the flow will be continued unduly long, but this
is not constant. In other cases the first indication will be a
proftise bleeding. After the occurrence of the climacteric, an
occasionally more or less profuse bleeding will occur at intervals,
which causes the patient to think that her menses have returned.
Post-climacteric pudendal bleeding should always be regarded as
a serious danger-signal until careful and painstaking examination
has demonstrated the contrary. As the disease advances, hemor-
rhage becomes more active, the blood is discharged in a continu-
ous bright stream, or more frequently in large clots, which are
formed in the vagina. Frequently the hemorrhage is accompa-
nied by a discharge of fragments of disintegrating tissue. The
continuation of hemorrhage produces marked anemia and pro-
motes the cachexia, but is rarely the direct cause of death.
Unfortunately, women generally regard increased and irregular
bleeding as a necessary concomitant to the climacteric, a view
which is maintained too frequently by the attending physician.
On the contrary, any excess and irregularity in the flow should
768 GYNECOLOGY,
always be regarded as an indication of grave danger, demanding
most thorough investigation of the genital tract, supplemented
by microscopic investigation, if necessary, to ascertain the
specific cause. Nothing should be taken for granted or left to
chance. No palliative measures or remedies to arrest bleeding
should be employed prior to an examination. If the physician
is unable to satisfy himself as to the cause, duly to his patient
demands that she shall have the benefit of further consultation.
Offensive discharge is next to hemorrhage in the time and
frequency of its appearance. In an early stage the discharge is
slimy and serous and does not have an especially penetrating
and ofTensive odor. As the disease advances and is associated
with ulceration and disintegration of tissue, the secretion changes ;
it becomes yellowish; then, with a mixture of blood and dis-
integrating tissue, reddish and brownish; and, finally, a dark,
smearj' mass. At first it has a stale, sweetish odor, becomes more
disagreeable, and finally presents an intensely penetrating, stink-
ing smell, alike disgusting to the patient and to her attendants.
When patients have suffered from cervical discharge possibly for
years, Httle attention is given to the increase of the amount
imtil the odor becomes so marked and disagreeable as to demand
consideration, when it will frequently be found that the time for
successful treatment has probably passed. Decomposition of the
secretion is undoubtedly due to saprophytic or putrescent germs,
and the greater accessibility of the cervix causes the odor of
its secretion to become earlier affected than that of the uterine
cavity.
Pain is a comparatively late symptom. The cervix, as is well
known, is not a specially sensitive structure, and the severe pain
occurs with the involvement of the parametrium, and is later
increased by pressure upon nerve-trunks. In uterine cancer, or
when it involves the cervical canal, pain is more marked, and is
an earlier symptom, owing to encroachment upon the internal
OS and obstruction to the canal. The absence of pain leads many
patients to regard the increased bleeding and discharge with less
suspicion. When an effort is made to impress a woman so
afflicted with the gravity of the situation, she vnW doubtingly
exclaim: "Why, I have no pain!" Slightly extended nodules
near the cervix, by pressure upon the nervous plexuses in the
retroperitoneal connective tissue, may produce a lively, persistent,
boring pain in the depth of the pelvis, which is increased to
an extraordinary degree by the slightest extension. It causes
persistent lancinating pain, which is not alleviated by continuous
rest in bed, and only the persistent employment of narcotics
affords any mitigation. As the disease approaches the peritoneal
surface the pain is increased, serious reaction in the nutrition,
GENITAL TUMORS. 769
18 induced, from which inflammatory adhesions with the sur-
rounding structures are the result, and an extensive peritonitis
» thus caused. The abdomen is sensitive to pressure, and,
according to Schroder, vaginal examination reveals the uterus
ttirrounded by board-like hardness. Not infrequently the symp-
toms may be aggravated by compression and narrowing of the
rectum through advancing infiltration of the pelvic connective
tissue.
The mechanical obstruction to the passage of fecal masses is
generally associated with severe, agonizing pain ; obstinate con-
stipation arises, partly from the mechanical hindrance, but much
more from the desire to avoid the severe pain at stool. In
cancer of the neck of the uterus, when the disease is transmitted
to the bladder- wall, even before the entire wall is penetrated
there is a btuning sensation during the evacuation of urine, soon
followed by tenesmus, frequent micturition, bloody, clouded, or
purulent urine, with persistent vesical pain. With the infiltra-
tion and necrosis of the structure a direct communication follows.
The admixture of ammoniacal urine with the offensive vaginal
discharge aggravates the already lamentable condition of the
patient by a horrible stench. The profuse, irritating vaginal
discharge produces an extensive erythema* of the vulva and
inner sides of the thighs, and causes the patient to complain of
the intense itching, or pruritus vulvae.
The offensive character of the pudendal discharge may be
still more aggravated when the disease involves the peritoneal
surfaces of Douglas' pouch and is transmitted to the rectum and
upper part of the rectovaginal septum, which breaks down and
forms a rectovaginal opening. Occasionally, a large cloaca is
formed, into which are discharged urine and feces, mixed With
decaying tissue, and forming a most deplorable condition. For-
tunately, the rectum is less frequently involved than the bladder.
Frommel asserts that vesical fistula appears in one-third of all
cases, rectal fistula in one-sixth. In the progress of the cancerous
infiltration on either side or in front of the cervix the ureters
will sooner or later become involved. The infiltration extends
about and compresses their lumina, attacks the structures of the
wall, and may finally completely occlude it. So long as the
passage of urine remains free, the patient experiences no ill
effect, but the compression causes a gradual dilatation of the
ureter and pelvis of the kidney; a condition of hydronephrosis
follows, and indications of uremia. If but one side is affected,
the other kidney does compensatory work, and, beyond a possible
sense of fuUness and weight in the affected organ, there is but
little discomfort. When both organs are compressed, uremic
symptoms follow, though never violent, rarely convulsive, and
40
768 GYNECOLOGY.
always be regarded as an indication of grave danger, demanding
most thorough investigation of the genital tract, supplemented
by microscopic investigation, if necessary, to ascertain the
specific cause. Nothing should be taken for granted or left to
chance. No palliative measures or remedies to arrest bleeding
should be employed prior to an examination. If the physician
is unable to satisfy himself as to the cause, duty to his patient
demands that she shall have the benefit of further consultation.
Offensive discharge is next to hemorrhage in the time and
frequency of its appearance. In an early stage the discharge is
slimy and serous and does not have an especially penetrating
and offensive odor. As the disease advances and is associated
with ulceration and disintegration of tissue, the secretion changes;
it becomes yellowish; then, with a mixture of blood and dis-
integrating tissue, reddish and brownish; and, finally, a dark,
smeary mass. At first it has a stale, sweetish odor, becomes more
disagreeable, and finally presents an intensely penetrating, stink-
ing smell, alike disgusting to the patient and to her attendants.
When patients have suffered from cervical discharge possibly for
years, Uttle attention is given to the increase of the amount
until the odor becomes so marked and disagreeable as to demand
consideration, when it will frequently be found that the time for
successful treatment has probably passed. Decomposition of the
secretion is undoubtedly due to saprophytic or putrescent germs,
and the greater accessibility of the cervix causes the odor of
its secretion to become earlier affected than that of the uterine
cavity.
Pain is a comparatively late symptom. The cervix, as is well
known, is not a specially sensitive structure, and the severe pain
occurs with the involvement of the parametrium, and is later
increased by pressure upon ner\-e-trunks. In uterine cancer, or
when it involves the cervical canal, pain is more marked, and is
an earUer symptom, owing to encroachment upon the internal
OS and obstruction to the canal. The absence of pain leads many
patients to regard the increased bleeding and discharge with less
suspicion. When an effort is made to impress a woman so
afflicted with the gravity of the situation, she will doubtingly
exclaim: "Why, I have no pain!" Slightly extended nodxiles
near the cervix, by pressure upon the nervous plexuses in the
retroperitoneal connective tissue, may produce a lively, persistent,
boring pain in the depth of the pelvis, which is increased to
an extraordinary degree by the slightest extension. It causes
persistent lancinating pain, which is not alleviated by continuous
rest in bed, and only the persistent employment of narcotics
affords any mitigation. As the disease approaches the peritoneal
surface the pain is increased, serious reaction in the nutritJoi
GENITAL TUMORS. 771
of the putrid changes, from a collection of organisms which exert
a very painful influence upon the general condition. The skin is
pale, and gradually becomes a smutty yellow from increased
emaciation. The eyes are sunken and the skin is thrown into
loose folds or appears to be drawn over the skeleton. A patient
exhibiting such changes is said to be cachectic. The indications
of suffering are stamped upon the countenance so indelibly as
to be readily recognized by the experienced observer. From
other conditions causing uterine hemorrhage, as myoma espe-
CJally, a cancerous patient is recognized by the tanned appearance
of the sldn and the progressive emaciation. In myoma she may
become pale, anemic, and often yellow, but there is no loss of
flesh. Indeed, the embonpoint seems increased. In cancer the
loss of strength is aggravated through the increased disgust for
food occasioned by the foul-smelling atmosphere in which she is
forced to li\-e. Gusserow's view is undoubtedly correct, that the
intense odor occasions the nausea and is made manifest by the
return of appetite, when by any medical or surgical procedure
this symptom is temporarily removed. Vomiting is generally a
late symptom, and most frequently the result of uremia. Rarely,
it may he occasioned by invasion of the peritoneum. The loss
of strength and flesh is progressive, until finally the patient dies
in profound marasmus. Occasionally, she suffers no convulsive
attacks from uremia, but just sulficient coma to render her
insensible to the discomfort of the condition. In some cases
septic or carcinomatous peritonitis, pleurisy, pneumonia, lung
772 GYNECOLOGY.
embolism, or amyloid degeneration of the large glands leads t
a premature end.
642. Physical Signs. — In the previous discussion it has I
asserted that carcinoma has no pathognomonic symptoms, conse- 1
quently its early recognition will largely depend upon the correct I
interpretation of the physical signs. Unfortunately, the patient J
may have no symptoms affording such discomfort that she will 1
feel it necessary to consult a physician, and, as a natural conse- I
quence, the disease will often be in an advanced stage before the T
patient comes under observation. Many patients do consult a
physician, however, and are subjected to local treatment for
other conditions than the grave one which should attract the
attention of the observer, and valuable time is thus lost. It is
to save these cases that, at the risk of reiteration, this section
is written. The disease in many cases is hidden within the
uterus and the physical signs consequently obscured. Fortu-
nately, in the great majority of patients the disease affects the
cervix and cervical canal. The squamous-cell cancer affects the
external portion of the cervix and appears as a small tubercle
or projection upon one or the other lip of the cervix. In the
majority of cases a more or less extensive laceration of the
cervix will be present. This tubercle will give the sensation to
the examining finger of a shot-like mass, but manipulation of
it is associated with slight bleeding and often the papule will
be friable and can be broken off. As the disease advances the
surface presents a superficial ulceration, which is above the level
of the surrounding healthy structure. Its edges are prominent,
infiltrated, ragged, often overhanging; its surface more or less
excavated, covered with friable tissue, portions of which are
easily broken off, and it has an infiltrated base. Pressure against
such a surface with a sotmd permits the point of the instrument
to become buried in friable tissue. The most careful examination
is attended with bleeding. Frequently the vagina will be found
occupied by a mass wliich may vary from the size of a filbert
to that of a good-sized fist. Such a tumor presents an irregular,
pinkish-gray surface, often covered with a greenish-yellow exu-
date. The mass is continuous with one lip or the entire cervix
may be involved. The surface has a granular, friable feel, will
readily give way under the pressure of the finger or of an instru-
ment, and is associated with a very offensive discharge. Adeno-
carcinoma within the cervical canal may make extensive progress
before it becomes visible. Even when in\'isible, the external
portion of the cervix appears paler, gives a sensation of hardness
or resistance to the examining finger, which is firmer and less
elastic than when due to inflammatory exudation. The cervix
will often feel hard and dense when carefully palpated, and the
GENITAL TUMORS.
pressure usually causes a discharge of blood from the os. Very
frequently the existence of a laceration will permit access of the
finger, wliich will reveal the presence of hard nodules, fragments
of which are easily broken away. The surfaces instead may
present a large mass of infiltration, the center of which has
become necrosed, affording an excavation with infiltrated, over-
hanging edges and a pultaceous. friable surface. In more ad-
vanced cases the cervix may be a mere shell, a large part of
the uterus being involved. The infiltration can be recognized
to involve the walls of the vagina, the lumen of which is con-
tracted by the disease. Carcinoma of the uterine body may be
inaccessible to touch until well advanced, unless its uterine canal
is subject to dilatation. Intra-uterine indagation reveals an
outgrowth from a portion or the whole of the uterine cavity,
which, soft and friable to the finger, rests upon a firm and
indurated base. When the wall of the uterus is extensively in-
filtrated, the increased resistance can be recognized by recto-
abdominal palpation. The penetration of the uterine wall by
the infiltrate is recognized in the nodules beneath the peritoneum,
which roughen the otherwise smooth surface of the uterus. No
discussion of the physical signs of carcinoma is complete without
a consideration of the revelations of the microscope, but as they
have been partially studied under the various forms of disease,
and will be furtiier under diagnosis, I will not discuss them here.
643, Complications.^ The more frequent complications of
uterine cancer are myoma, ovarian tumor, peri-uterine iniiamma-
tion, and pregnancy. The myoma usually does, and the ovarian
tumor may, precede the development of the carcinoma. Atten-
tion has been recently directed to the association of myoma and
carcinoma in the same patient (see Fig. 485), with some effort to
indicate the causative relation ; but with the great frequency of
uterine myoma it would not be surprising should we find, even
more frequently than is now recognized, the coexistence of car-
cinoma. The disease begins in the uterine mucous membrane,
and may subsequently extend and infiltrate the growth. The
growth can be primarily affected only when there is included in
it some glandular structure. It has occurred to me that the
irritation induced by the prolonged use of electricity for its
influence upon the fibroid growth may favor tlie development of
malignant disease. I have seen carcinoma occur in two cases
subsequent to the apphcation of electricity, but the cases under
observation have been so few that to make this assertion would
be no more correct than to assign myoma as the cause of the
cancer. Ovarian tumor may be benign or mahgnant. Benign
growths may become secondarily involved. The cancerous tumor
774 GYNECOLOGY.
of the ovary, however, varies greatly in its influence and in its
manner of progress from the benign.
Peri-uterine Inflammation. — Peri-uterine inflammation may
precede or be the consequence of the mahgnant disease. In the
latter instance it is simply a reactive inflammation in which
nature endeavors to bar the progress of the malignant disorder.
It is important, in investigation of the case, however, to differen-
tiate between the peri-uterine exudation and the cancerous
infiltration, as such a diagnosis would influence the operator in
his treatment of the cancerous uterus.
Pregnancy is a not infrequent complication of mahgnant dis-
ease. Carcinoma in its earliest stages does not contraindicate the
occurrence of pregnancy. The association of uterine cancer with
pregnancy and labor presents the gravest danger for two human
beings. The frequency of the complication may be determined
by the consideration of the fohowing statistics: Von Winckel, in
20,000 labors, reported 10, and Stratz 7 in less than 18,000; in
the Tubingen clinic, in fifteen years, out of gooi labors there
were 7 complicated with carcinoma. One cause of the few cases
of association of pregnancy and carcinoma is the fact that the
latter exists in the great majority of cases in the later years of
life after the period of fertility is more or less nearly passed.
The situation of the disease will have something to do with the
possibility of pregnancy. In 89 cases of associated pregnancy
and carcinoma the mahgnant disease was found 38 times in the
cervical canal and 47 times in the portio vaginalis. In 4 cases
the site was not determined.
The disease, when complicated by pregnancy, presents no
symptoms essentially different from those in the iincomphcated
cases, but, with the necessarily increased congestion of the pelvic
organs, makes more rapid progress, so the characteristic symp-
toms— hemorrhage, discharge, and pain— rapidly become aggra-
vated. Hemorrhage is increased, is more or less copious, and
is associated with an offensive odor. A profuse, watery, exceed-
ingly offensive discharge, at times purulent and brownish, is
constant. The discharge is more abundant and putrid the more
marked the tissue destruction in the new formation.
It is of interest to study the effect of carcinoma on pregnancy
and labor. The disturbances which such complications can
induce in the course of pregnancy and labor must necessarily
depend upon the situation and extension of carcinomatous dis-
ease ; sometimes they are only trifling, but occasionally they may
mean the death of mother and child. The progressive and severe
hemorrhage, the profuse leukorrheal discharge, associated with a
complication of pregnancy, result in general anemia, which pro-
duces a gradual loss of strength. The existence of the trouble
GENITAL TUMORS.
775
renders the development of cancer much more rapid, and conse-
quently early interference should be considered as indicated.
The influence upon the labor, when the pregnancy goes to full
term, depends entirely upon the situation of the disease. The
accompanying endometritic processes can lead to existence of
placenta previa. When the disease is confined to the vaginal
portion of the cervix, it will not be impossible for labor to be
spontaneous, but obstructions occur as soon as the portio is circu-
larly seized in its entire circumference; or, if the cervical canal
has become strongly infiltrated, the tissue is absolutely unyield-
ing. Unless prompt measures are resorted to. such an individual
may suffer from hemorrhage, exhaustion, and fatal termination,
with the fetus still intra partum.
Among the complications with labor we can have premature
rupture of the amniotic bladder and weak labor-pains. If the pains
remain active, the embrj'O is forced through, and the process
results in extensive tearing of the cervix, which may extend to
the pericervical connective tissue, cause the most extensive
bruising and crushing of the birth canal, and the cervix may
even be torn away above the infiltrated ring. Equally significant
is the influence of pregnancy and labor upon the cancer. As
has been mentioned, it was considered that the existence of
pregnancy had a beneficial influence on the progress of the cancer
growth. Von Siebold is reported to have observed the spon-
taneous recovery of genital cancer from a simultaneous preg-
nancy. The experience of recent years combats this idea. The
rapidity of the growth depends upon the character of the disease.
being much more rapid in the soft and medtillarj- form than
in the scirrhous variety. The labor can cause the most extensive
destruction of the parts, and, not only this, but be followed by
infection of the tissue, which can result in thrombosis, sepsis,
and pyemia.
644. Diagnosis. — Hope for radical relief from cancer will, in
the majority of cases, be dependent upon its early recognition.
The investigations of Virchow dismissed the idea of cancer being
in origin a constitutional disease and demonstrated its purely
local character. A study of its chnical course, however, in-
dicates that while the disease is local in character at its origin,
transmission to the surrounding structures takes place, when the
disease practically becomes constitutional. It is important.
therefore, that the practitioner should recognize the gravity of
the disease at the earhest possible moment. When the condition
is one of doubt, the attending physician, in the interest of his
patient, should ha\'e the doubt resolved by securing the advice of
a more experienced man. Only by early recognition and by
radical treatment before the extension of nests into the para-
776 GYNECOLOGY.
metrial tissue can we hope to avoid the fatal termination of this
disease. It is well recognized that many patients fail to appre-
ciate the gravity of their symptoms and postpone consulting a
physician until the favorable period for intervention has passed,
but it is equally true that many others are subjected to general or
"local treatment or are advised to await the change of life until the
disease has become hopelessly inoperable. This is frequently
brought about through aversion of the patient to the gynecologic
examination, but the physician will be wiser in absolutely de-
clining to accept the responsibility for the treatment of a patient
who declines to permit him to employ the necessary means to
determine her condition. Should he yield to her request, she
and her friends will subsequently hold him responsible for any
untoward results.
The ease with which the diagnosis can be made will depend
upon the situation of the disease. Following the division already
given of cancer involving the portio vaginahs, the cervical canal,
and thejbody of the uterus, prepares one to find different physical
signs according to its situation. The association of hemorrhage,
foul discharge, and pain should awaken a profound suspicion
that should be satisfied only by careful examination. Carcinoma
of the portio vaginahs is, as a rule, easy to recognize. It is
accessible to the investigating finger, and is readily exposed to
vision by the speculum. The most characteristic form is the
cauhflower growth, which springs by a narrow base from one
or the other lip, and may fill the vagina. It presents to the
finger an irregular, nodular mass, which bleeds upon the slightest
touch, is very friable, and is frequently covered by a greenish
exudate or slough. The mass may vary from a nodule the size
of a bean to a growth the size of a fist. Instead of an exuberant
growth the disease may present an excavated cavity with in-
durated wall and base and undermined edges. In diseases of the
cervical canal the external os may present a crater-like opening
or may appear healthy. In the early stage the disease of the
cervical canal affords no external or apparent indication of the
disease. The infiltration involves only the mucous membrane of
the canal.
If we follow the rule to secure an accurate examination of
such cases, it may be necessary to explore the intra-uterine
cavity. This procedure is best accomplished by the use of
laminaria tents. These tents should be sterile, and should be
removed from a saturated solution of iodoform and ether, or.
better, be soaked in tinctiire of iodin for a few minutes before
their insertion. Tissue occupied by carcinomatous infiltrate
will not readily dilate. The scrapings obtained by the curet will
often show fragments which are easily broken or crumbled, in
GENITAL TUMORS. 777
place of the long, thickened pieces removed in endometritis. The
ciiret and, still better, the finger will disclose a roughened, in-
dtirated canal, which is characteristic. In a very early stage the
cervical cancer appears as small, indurated nodules, which later
become friable. It should be recognized that cancer of the
vaginal portion does not manifest a disposition to involve the
cervical cavity early, which knowledge enables us to determine
that the cervix remains free tmless in advanced cases. In doubt-
ful cases the suspected tissue, either in the form of scrapings or
an excised piece, should be subjected to microscopic examination.
The portion of tissue excised should involve both healthy and
diseased tissue, when the transition from one to the other can
be better studied. It is objected to the microscopic examination
that it takes valuable time to prepare the specimens, but Smyly
suggests the following two methods for rapid examination : First,
a small piece of firm tissue is selected, dipped in mucilage, placed
in a freezing microtome, partly frozen sections of which are cut,
transferred to Muller's fluid or to a 2 per cent, solution of potassii
dichromas, and, after from a few minutes to an hour, stained
and motmted. In the second method a piece of the tissue the
size of a bean is placed in twenty times the quantity of methylated
spirit or, preferably, in alcohol for a few hours, then a few hours
in running water, dipped in mucilage, and sections made after
freezing. The sections are removed from water to the slide,
where they are stained with either picrocarmin or rubin and
orange. These methods are too complicated for the general
pxactitioner.
. Spiegelberg has emphasized the closer adhesion of the mucous
membrane to the underlying tissue in cancer over that which
exists in inflammation. Our diagnosis must comprise, naturally,
the recognition of the presence of cancer, and, also, the extent
of structure involvement and the probability for radical removal.
Digital examination through the rectum affords accurate in-
formation as to the extent of the disease in the parametrial tissue
of the pelvis. Nests or nodules may be found upon the posterior
surface of the broad ligament, which cause firm fixation by the
extension of the disease to one or both broad ligaments. We
should endeavor to distinguish between fixation from previous
inflammatory trouble and cancerous infiltration. In the latter
the involved surface is more irregular, presents small, hard
nodules, and a more distinct limitation, which can be determined
through the rectum. The latter examination can be more
eflfectively accomplished with the patient under an anesthetic.
A rectal examination should be a matter of routine. Twice I
have fotmd coexisting rectal cancer in women who otherwise
would have been favorable cases for uterine extirpation. In
778 GYNECOLOGY.
neither of these patients did there seem to be any connectid
between the cancerous growth of the rectum and that of thl
uterus.
The conditions wlilch can be confused with cancer are:
Chronic cer\'ical catarrh with laceration.
Papillary erosion of the cervix.
Necrosis of fibroid polypus.
Syphilitic ulceration.
Partial retention of the products of conception.
Chorio-epithelioma,
Sarcoma.
In chronic cervical catarrh mitk laceration nature makes i
effort to repair the injury, the increased weight of the organT"
and its situation lead to eversion of the lips, and the fissures
are occupied by hard, resistant tissue. The exposure of the
tender cervical mucous membrane causes inflammatory changes,
thickening and eversion, obstruction of the ducts of the glands
of Naboth, and the formation of Nabothian cysts. The surface
not infrequently is covered with granular tissue, which readily
bleeds upon the slightest touch; the patient consequently has
increased bleeding during menstruation, more or less bleeding
upon exercise, and bleeding following coition. The indurated
surface with a tendency to bleed, the increased leukorrheal dis-
charge, the nodular condition produced by the distended glands,
might readily lead an inexperienced physician to believe that he
had to deal with cancer. Indeed, many of these cases are so
close to the border-line as to render it difficult to arrive at a
certain conclusion. The treatment of the case will frequently
remove the doubt. Puncture of the cysts and the application of
caustics cause cicatrization of the surface, and demonstrate that
it is not malignant. It has been said that Nabothian cysts abso-
lutely contraindicate the existence of cancer, but cases have been
observed in which Nabothian cysts are filled with their secretion
in the immediate vicinity of cancerous degeneration. The ab-
sence of tissue friable to the touch, the use of the speculum, and,
when necessary, the examination of an excised piece should
render the diagnosis of a benign condition positive. -
Papillary erosion of the cervix is sometimes mistaken for &■
carcinomatous ulcer, but the latter is covered with friable tissue
and bleeds easily. In carcinoma the affected structure is raised
above the level of the healthy cervix; in erosion it is depressed.
The latter has a regular outline, the carcinomatous ulcer an
irregular, ragged line of demarcation.
Necrosis of a fibroid polypus is a condition in which the sub-
jective symptoms are very similar to those of cancer. I recently
saw a patient, a widow, forty-five years of age, who was suffering. .
GENITAL TUMORS. 779
from a profuse menorrhagia, from a copious foul-smelling dis-
charge, and had been assured by her physician that she was
suffering from an inoperable cancer of the uterus. The appear-
ance of the patient and the odor in the room apparently justified
the assertion; but a digital examination revealed a large mass
filling up the vagina, which was firm and resistant, and could be
turned about from one position to another. The lower surface of
the mass was somewhat roughened, but its upper surface was
smooth. The finger, carried well over it, could reach a distinct
pedicle, which could be traced upward to the uterus ; the cervix
was thinned, and at no place hard, indurated, or infiltrated ; con-
sequently, I had no hesitation in assuring her that she could be
cured.
In necrosis of a fibroid situated within the vagina the diag-
nosis is readily made. The firmer resistance, the recognition of
a pedicle, the absence of any infiltration about the external os,
and the smooth outline render its character certain. When the
growth is situated within the cavity of the uterus, however, it
may be more difficult. Here a sloughing fibroid causes hemor-
rhage and a profuse offensive discharge, but the discharge is
usually thinner, watery in character, and may contain particles
of the growth. These particles are more in the nature of a
slough. The uterus is larger in outline, the cavity of the
organ is frequently open, so that the finger can enter and come
in contact with the mass which fills the uterus, and, by man-
ipulation, occasionally fragments of the tissue may be broken
off and examined under a microscope, or often under macro-
scopic examination the fibrous structure is recognized, which
should exclude cancer. Dilatation of the uterus sufficient to
permit the introduction of the finger discloses the cavity occu-
pied by a mass which is more or less resistant, not friable, nor
easilv broken down.
Syphilitic Ulceration. — Syphilitic ulceration should be readily
distinguished from cancer by recognition of the fact that it does
not present an excavated surface with indurated base and edges,
that it is associated with evidence of syphilis in other portions of
the body, and by the absence of friable tissue upon the ulcerated
surface. Microscopic examination to fix the diagnosis is gener-
ally tmnecessary.
Partial Retention of the Products of Conception. — The retained
tissues may be the embryonic envelope, a portion of the placenta,
or blood-clots, which, when retained, are subjected to infection,
cause an exceedingly foul-smelling and offensive discharge, and
their presence is a frequent cause of bleeding. The history of
recent abortion or delivery, the dilated os permitting the intro-
duction of the finger, and the recognition of the retained products
780 GYNECOLOGY.
by exploration determine the condition. The retained products
scraped away, a smooth surface is left, which is the normal
uterine wall. The absence of further irritation following cleans-
ing of the cavity demonstrates its true character.
Ckorio-epithelioma presents a history of a previous abortion^
or labor within a few weeks or months, following which th«]
patient suffers from profuse, irregular bleeding, which leads th(
physician to make a curetment in which there is a large amount
of soft, friable tissue removed. This treatment arrests the hem-
orrhage for a very brief time, when the conditions recur, and a
second curetment will disclose the fact that the structure found
in the first curetment has been reformed. The disease shows a
marked tendency to early metastasis through the blood-\'essels.
It occurs in patients at an earlier age than carcinoma. The age
of the patient, the history of previous pregnancy, the severftj
hemorrhages, the rapid development, and the recurrence should'
lead to its diagnosis. The structure can be positively differen-
tiated from cancer only by the use of the microscope. This re-^
veals that the material is epithelial, but it differs from cancer in
the absence of the well-marked stroma. In this respect it re-
sembles sarcoma, but differs from it again in the fact that it is
composed of epithehal and not of connective-tissue cells. The
further investigation discloses that this epitheHum is the product
of fetal life and has originated from the covering chorionic villi,,
the syncytial ceUs.
Sarcoma causes symptoms similar to those of carcinoma. It
may be differentiated, however, when it affects the cervix, by
the polypoid masses projecting from it, sometimes grape-like in
form. Where the disease involves the body of the uterus, the
organ is Hkely to become much larger than is the case in car-
cinoma. Sarcoma, however, is much more rare than carcinoma.
The microscope affords the only means for arriving at a positive
diagnosis. The structure of the sarcoma is homogeneous, and
consists of connective-tissue cells, either round, spindle, or giant
cells, -without a well-defined stroma; the walls of the blood-
vessels are invaded and made to appear as mere sluiceways
throughout the structure. In carcinoma the structure is m
like, with a well-defined stroma, the vessels are situated in
stroma, and their coats are not destroyed.
It is seen that the existence of carcinoma does not preclude
the possibility of pregnancy. The occurrence of this complica-
tion renders it important that we should study its course and
be able to determine its presence. The diagnosis is rendered
easier by comparison of the hard, firm, infiltrated carcinomatous
parts with the softer, edematous, healthy tissue of the uterus in
the pregnant condition. The carcinomatous nodules of the
i
i
d
a
s
e
/ays ^
lest-^^H
es OL COB ^^m
GENITAL TUMORS. 781
vaginal portion of the cervix may be recognized by touch, and
often as intervening between the finger and the parts of the
child. In some cases the initial stage of the malignant disease
may be so slight as to be overlooked, and if the observer is in
doubt as to the correctness of the diagnosis, a microscopic inves-
tigation of excised tissue should be employed. More difficult
even than the recognition of carcinoma is the determination of
the existence of pregnancy in the earlier months. Pozzi claims
that it is impossible to diagnose the existence of pregnancy with
uterine cancer prior to the fourth month. A nimiber of cases
axe recorded in which pregnancy was first recognized during or
following a total extirpation. It can thus be readily tmderstood
why pregnancy can be overlooked in the second and third months.
The earher recognition of the condition is of extreme value, for
observations have demonstrated the fact that the increased con-
gestion which occurs in the uterus favors the more rapid develop-
ment of malignant disease. It was formerly believed that the
existence of pregnancy during cancer allayed or arrested the
progress of the latter, to be accelerated subsequent to its ter-
mination, but careful observation has demonstrated the fallacy
of this view. On the contrary, the increased tiutrition which is
directed to the uterus by the occurrence of pregnancy favors the
more rapid development of malignant disease. The recognition
of the existence of carcinoma, as determined by the microscopic
investigation of the excised tissue and the simidtaneous enlarge-
ment of the uterus, should cause the complication to be sus-
pected.
645. Duration of Cancer. — The duration of life in this disease
is hard to fix, because we know scarcely anything of its first
beginning. We have no means of knowing how long a period
transpires between its origin and the ulceration which produces
the first symptoms for which the patient is induced to consult
the physician. The form of cancer is also a determining factor.
The soft, medullary cancer is rapid in progress and destructive
in its action. The final catastrophe occurs much sooner than in
scirrhus. The earlier in life the disease develops, the more rapid,
as a rule, will be its progress. The period of survival varies,
according to different authors, between six months and two or
three years; in squamous-cell cancer, from three to four years;
in cylinder-cell cancer, from one to two and a half years. A
somewhat longer period is ascribed to cancer of the body.
The normal duration of life can be materially altered by thera-
peutic measures. Cases are seen in which, after operation,
months or years passed without any indication of relapse.
This is true not only after radical operation, but the patient
80 improves after the arrest of hemorrhage and discharge by
782 GYNECOLOGY.
some palliative measure as almost to catise the patient and
her friends to doubt the possibility of the disease being of so
serious a character.
646. Prognosis. — It is only necessary that one should study
the clinical course of carcinoma to be convinced that the prog-
nosis must be bad. The improvement of the prognosis lies, firsti
in the early recognition of the disease ; second, in prompt resort
to radical operation. The first provision requires its recognition
even before the characteristic symptoms of the disease are mani-
fest. A patient in whom the irritative conditions favorable to
the development of malignant disease exist should be kept under
observation, and during the period of greatest susceptibility
shovdd be subjected to a quarterly, at least a semi-annual, exam-
ination. Causes of special irritation should, as far as possible,
be removed by appropriate treatment. Second, radical treatment
should be imderstood as a procedure which will insure removal
of the diseased structure within the limits of healthy tissue.
Always to accomplish this, the operation must necessarily be
early. The probability of rapid invasion of the deeper structure,
and of the establishment of secondary nests more or less remote
from the original site, is less marked in cancer of the body of
the uterus than in that of the cervix or the vaginal portion.
Cancer of the uterus in a woman prior to the age of forty years
is more acute in its progress and much more likely to recur than
when it occurs in women of more mature years. The prognosis
of the disease is materially affected by the thoroughness of the
operative procedure and by the precautions which are exercised
to prevent reinfection of the new woimd. Our inability to de-
termine when and to what extent metastasis has occurred renders
us unable to fix the prognosis after operation with any degree of
certainty in the individual case. An apparently hopeful one
will soon relapse, and one for whom the outlook seems uninriting
will remain for a long time relapse free, dependent upon obscure
processes whose rationale we do not fully comprehend.
The outlook for length of life of the patient suffering from
cancer of the uterus is affected largely by the occurrence of
pregnancy as a complication. The prognosis of pregnancy de-
pends upon the kind and the course of labor and upon the
general condition of the patient ; above all, upon the extension of
carcinoma. The more difficult the labor, the poorer the general
condition of the patient, and the more progressive the disease,
the more certain will be the unforttmate result and probable
death. The outlook of the woman suffering from cancer with a
pregnant uterus is far worse than for the nonpregnant, because
pregnancy and labor occasion extremely dangerous results. The
rapid progress of the disease during pregnancy, the severe trauma
GENITAL TUMORS. 783
uring labor, and the rapid carcinomatous degeneration of the
ssue aflEect the result. Chantretiil reported that in sixty preg-
ant carcinomatous diseased women twenty-five died during or
lortly after childbirth. Cohnstein, in one htmdred and twenty-
X cases, saw seventy-two die. Hermann had one htmdred and
!ghty cases in which seventy-two died. The uterine rupttire
lone had six victims out of Chantreuil's sixty cases ; eleven out
f Hermann's one hundred and eighty ; nineteen out of one him-
red and twenty-six women, according to Cohnstein, died imde-
vered — about 8.1 per cent, of all the cases. Under the tmiform
lethods of treatment employed of late years, the mortality is
imewhat decreased. It is now admitted that the treatment of
implications of pregnancy must be consigned to operative pro-
sdure, either gynecologic or obstetric. Formerly the treatment
"as limited to artificial abortion and premature labor. But little
Kperience, however, was required to demonstrate that such
leasures were ineffective. The course then advised was to pro-
)ng the pregnancy as long as possible with a view to secur-
ig viability for the child, and the obstetric operation became
ie important consideration. Later experience in the various
lethods of treatment has led to the following conclusions : ( i ) In
ases in which the cancer has reached a stage where radical
peration is impracticable every effort should be made to prolong
he pregnancy until the child becomes viable; (2) where the
atient, however, is recognized to have the disease in its early
tages, with a reasonable hope for successful removal, the ovtun
iiould not for a moment be permitted to prejudice the chances
>r the mother, and radical operation should be undertaken
ithout reference to the child.
647. Treatment. — Our previous study of the anatomic struc-
ire and progress of development indicates that cancer originally
insists of a primary nest, from which invasion of the surrounding
tructiires occurs. The rational treatment, then, consists in the
3moval of the diseased structure within healthy limits. Upon
kie extent of involvement will depend our ability to remove com-
letely the disease, and hence the division into two classes —
perable and inoperable. The following scheme represents the
lethods of treatment which may be adapted to each class :•
I. Partial extirpation, Vaginal.
I ( (a) Vaginal.
I a. Total extirpation -j (6) Abdominal.
(i4) Operable. I (c) Sacral.
/ i la) Cureting.
\ 3. Palliative operations, \ (h) Caustics.
(c) Cautery.
{T • .. / (a^ Hypodermatic.
4. Injections | (^^ Cleansing.
5. Anodynes.
(B)
5. Anodyn
784 GYNECOLOGY.
648. (A) Operable. — Partial Vaginal Operations. — As car-
cinoma uteri largely preponderates in the cervix, it is quite con-
ceivable that the early operations were directed to the extirpation
of that section of the organ involved. Von Grafenberg, as early
as 1600, reported that the uterus had been normally extirpated
in a number of cases, but it is most probable that the majority
of these were amputations of the cervix, particularly as the
subsequent continuance of menstruation is noted in several
women, and, indeed, the birth of children. In the early cases
hemorrhage was controlled by styptics, and many of the patients
succumbed to hemorrhage and sepsis.
Partial extirpation has remained, until the last fifteen years,
the principal, if not the exclusive, operative method of combating
carcinoma, It consisted in the removal of the diseased parts with
knife or scissors, and the control of hemorrhage with the cautery
or strong fluid caustic. The difficulty in controlHng hemorrhage
led to the employment of the chain or wire €craseur. by which
the diseased tissue is crushed off. A marked improvement was
the employment of the galvanocautery loop — the galvanic loops
placed upon the cervix above the margin of the disease, tightened,
and the cervix amputated. This procedure was extensively
pmctised by C. Braun and Byrne, with extraordinary results.
The latter made the procedure still more effective by substituting
the galvanic knife for the loop.
Neither the employment of the ^craseur nor the use of the
loop can be considered as an ideal surgical procedure, for, with
the first, injury of the neighboring organs can not always be
avoided, and, with the second, it is not always possible so to
place the loop that amputation of the vaginal portion of the
cervix results with certainty in healthy tissue. A more progres-
sive method was instituted by returning to amputation with
the knife and union of the wound surfaces by sutures. The
procedure was introduced by Hegar, who made a funnel-shaped
incision. Schroder perfected supravaginal amputation of the
cervix, a method capable of meeting all the requirements of the
present partial uterine extirpation per vaginam.
Amputation of the Cervix with the Galvanocautery Loop. — The
preparation for vaginal operation fSection 182) is made, exercis-
ing care to penetrate and disinfect the neck. The cervix is ex-
posed with specula or retractors, seized with hook forceps which
dip into the healthy tissue, and drawn upon, while the platinum
loop is placed as high as possible, coming immediately under the
transverse folds which indicate the position of the bladder, and
is so tightened that it cuts into the tissue. As the excision pro-
gresses the vagina is protected from heat by wooden plates and
syringed several times with water in order to thus cool the^
GENITAL TUMORS.. 785
tissues and preserve them from burning. The wire must'be kept
at a red heat in order that the surfaces shall be well scorched.
The wire should be tightened slowly until the cervix is cut
through. When the operation is accomplished with due delibera-
tion, there is no subsequent tendency to bleeding. The higher
the wire is placed upon the cervix, the more probable it is that
Douglas' pouch will be opened. The occurrence of such an acci-
dent, however, requires no more consideration than to pack the
cavity with iodoform gauze. By the employment of the galvano-
cautery knife Byrne improved the operation. He cut arotmd the
vagina, separated it from the cervix, and was enabled to remove
the latter at a higher level.
Hegar's Operation, — ^The ftmnel-shaped amputation of the
cefvix described by Hegar is accomplished as follows: The
cervix is fixed by double tenacula and drawn downward. A
knife is introduced as far away from the limits of the disease
as safety for the bladder and ureters will permit, and is carried
about the cervix, held at such an angle as to cut out a cone-
shaped mass, the apex of which would be high in the cervical
canal. The hemorrhage is controlled by sutures and tamponade.
Baker operated in a similar manner, but controlled the hemor-
rhage with the cautery, while Van de Warker cauterized the
surface with zinc chlorid.
Schroder's operation is a supravaginal amputation, of which
the following is a description : The cancerous portion is exposed
by Simon's retractors. With a sharp curet all removable tissue
is scraped away from the new formation until the curet reaches
firm tissue, when the entire bleeding surface is scorched with
a hot iron, the vagina being protected from the heat and fre-
quently irrigated as the operation proceeds. The cervix is
seized with a vulselltun and drawn downward as far as pos-
sible. An incision — ^if possible, one centimeter from the dis-
ease margin — is carried about the cervix; with the index-finger
or a gauze pledget the bladder is blimtly separated from the
anterior uterine wall. The bladder and ureters are thus shoved
upward, when the anterior wall of the neck can be removed at
a high level. In this operation Douglas' space is frequently
opened, but the cervix is retained in connection with the lateral
TOrametrium. The cervix is pulled to one side, while with a
Deschamps needle a ligature is passed as far away from the
cervix as possible, tied firmly, and the tissue cut between the
neck and the ligature. If the tissue is thick, a number of liga-
tures may be applied, one above another, and when the op-
posite side is likewise treated, the cervix is cut away. When
necessary, all the cervix below the internal os can be removed.
If Douglas' pouch is opened, the circumstance may be^made
60
786 GYNECOLOGY.
useful in closing the parametrium, as the needle can be passed
upon the finger, introduced through the opening. The cervix
is then amputated at the level of the internal os. The section
is made through the anterior vaginal wall to the cavity, and,
before proceeding further, the anterior vaginal wall is stitched
to the anterior cervical wall with from two to four sutures.
The amputation is completed by cutting through the posterior
wall, when the surfaces are sutured as in the anterior. A num-
ber of sutures are now applied to the lateral portions of the
wound to insure closure. The sutures should be carefully
placed in the lateral angles in order to secure the uterine arteries.
When they are ineffectually secured, hemorrhage may be free
and threaten a fatal result. The patient can arise in from
ten to twelve days and be discharged after from eighteen to
twenty days.
The high amputation of the cervix has had many advocates,
who champion it in preference to extirpation as being safer
and less prone to subsequent relapse. The employment of
the galvanocautery knife may produce a beneficial influence
in the destruction of cancer nests which would be o\-erlooked
by the scalpel. An objection to the operation is that the cer-
vical opening may contract and become closed, causing subse-
quent distress, and necessitate further operative procedure
to relieve the dysmenorrhea or hematometra. Cases of preg-
nancy have been reported, but the difficulty in labor was so
great, because of the scar tissue, that operative delivery was
required and the patients died. Similar experience has been
observed in the Hegar operation, owing to the difficulty in
introducing the sutures. All these disadvantages are avoided
by the Schroder operation.
The investigations of Seehg have demonstrated that in-
fection has been carried through the lymphatics to the cervix,
and even to the body, of the uterus. Such an occurrence would
render anything less than extirpation of the entire organ of
no ser^e, and no positive means exist for determining when it
has taken place. An additional reason for preferring the entire
extirpation is that the cicatricial tissue is always irritable, and
is a source of danger in a woman predisposed to undergo malig-
nant change. The removal of the uterus and ovaries brings
about a lessened congestion of the pelvic tissues, and will cer-
tainly leave the patient free from subsequent periodic engorge-
ment of the peh-ic structures. The cases suitable for the partial
operation are infrequent.
649. Total ExtiiT>ation of the Uterus. — Isolated examples
of total extirpation of the uterus have been mentioned as hav-
ing occurred at various times during the eighteenth century,
GENITAL TUMORS. 787
but it remained for Czertiy and Freund to formulate procedures
which have led to the more complete satisfactory methods as
represented in the operations of vaginal and abdominal hyster-
ectomy of the present day.
Total extirpation may be undertaken in one of two stages
of development: first, when no evidence of involvement of
the parametrium exists, when the object is to eradicate the
disease by ablation of the organ and the surrounding portions of
the vagina and parametrium, or to operate within healthy tissue ;
second, when there is some involvement of the parametrium
with fixation of the uterus. The latter operation is not cura-
tive, but may ameliorate symptoms.
In performing the radical operation two purposes should be
kept in mind: (i) To keep beyond the confines of the disease
by- operating in healthy tissue; (2) to protect the patient from
any possibility of reinfection.
1. The recognition of the processes of development and
the extension of cancer make it absolutely uncertain in any
individual case that this purpose has been accomplished. The
operator is absolutely unable to determine, prior to operation,
that circulatory or irritative extension has not involved the
parametrium beyond the safe limits of operation. In some
this transmission may occur early in the disease, in others
late, so that in a woman with but slight involvement and no
demonstrable evidence of extension a favorable prognosis is
usually given. However, not infrequently in these cases the
physician is horrified to find a recurrence after a very brief
period, while in others the entire vaginal cervix may be destroyed,
and he operates radically, though only with a hope of amelio-
ration, but the patient remains free from recurrence for years
or even permanently.
2. The possibility of reinfection or of the transplantation
of portions of cancerous structure upon a healthy wound and
the reproduction of the disease from it is questioned. Such
a view would seem a reasonable explanation for the redevelop-
ment of cancer in a wound where microscopic investigation
indicated that the operator was well beyond the confines of
the disease. The opponent of infection, however, justly in-
stances the possibility of metastatic nests in the parametrium,
discoverable only by the microscope, from which the recur-
rence has followed. Such statements for the vicinity of the
wound are difficult to combat, but if, in a single case, the dis-
ease can be transplanted to the abdominal wound in an abdom-
inal hysterectomy, it should be considered proof that such
reinfection may occur, for that region would be entirely out of
the usual route for metastatic extension. Such an infection
788 GYNECOLOGY.
came under my observation in the practice of one of my col-
leagues, in a young unmarried but not childless woman. Within
two months of an abdominal hysterectomy nodular masses
were observed In the abdominal wound, which subsequently
progressed. In two cases of my own experience transplantation
has occurred. In both of these patients there were extensive
involvement and obstruction of the cer\'ix by a squamous-
cell carcinoma. In the first patient a sinus remained in the
abdominal wall following a stitch abscess, in which prolifera-
tion of the epithelium occurred. This resulted in a spreading
sore, involving the tissue circumjacent to the abdominal in-
cision. As this patient had pelvic involvement as well, the
possibihty of continuous involvement must, of course, be con-
sidered, although I was apparently able to excise the infected
abdominal tissue without opening the peritoneal cavity. The
second patient, an unmarried woman, underwent operation
June 19, 1900. The entire cervix was involved in a cauliflower
growth to such a degree that her attendant, a surgeon of con-
siderable experience, questioned the advisability of operation.
She was exceedingly anemic and broken down by repeated
hemorrhages. She was continually nauseated and vomited
everything taken for five days subsequent to the operation. At
the close of a week it was found that all the sutures had cut
through, the wound was gaping, and the intestine protruding.
The wound had been closed with silkworm-gut sutures for all the
tissues above the peritoneum, and continuous chromic catgut for
the latter and the aponeurosis. The intestines were packed back
with gauze, and a week later the wound was closed with through-
and-through silkworm-gut sutures under cocain anesthesia.
The patient left the sanatorium five weeks subsequent to the
performance of her operation, with good union in the abdominal
wound. Much to the surprise of her attendant and myself
she enjoyed, barring a very small ventral hernia, excellent
health for over two and one-half years. She began to have dis-
comfort and swelling in the line of the wound, and a lump could
be felt which was thought to be a strangulated and inflamed pro-
jection of the omenttim. However, the mass gradually increased
in size and became painful, and, therefore, a provisional diagnosis
of reciurent malignant disease was made. This was excised
June 18, 1903, three years from the date of her previous opera-
tion. Now, three years after the second remo^•al. this patient
is in the enjoyment of excellent health and exhibits no indica-
tion of further recurrence.* A mass of infiltrate as large as a
GENITAL TUMORS. 789
ben's egg occupied the center of the cicatrix. The omentiam
and a portion of the ileum were adherent and had to be sepa-
rated with scissors ; a portion of the intestine was also involved
in an annular band of tissue, for which three inches were
excised and united by an end-to-end anastomosis. Careful
examination failed to reveal any other evidence of the dis-
ease, the pelvis disclosed no sign of any infiltrate or glandular
enlargement, although careful obser\'ation was made. It may
seem that the two and one-half years which inter\'ened before
the development of this growth would argue against trans-
plantation, but is it any more difficult to consitler transplanted
cells as lying latent and inactive in tliis area than those which
have been transmitted to the parametrium to develop within
the five years, a period which all authorities admit should
transpire before a case can be pronounceil as cured?
790 GYNECOLOGY.
Whether we accept or reject the theory of infection, the
precautions taken to prevent it are only such as will be of ser-
vice in rendering the parts sterile and in preventing infection
from pathogenic germs, which every one will admit are present.
Preliminary Treatment. — In every extirpation of the organ,
whether by the vagina or the abdomen, in addition to the prepa-
ration indicated in Section 182, precautions should be exercised
to remove all diseased and disintegrated tissue. The surface
should be gone over with a sharp curet, all loose and ragged
edges trimmed iivith scissors, and the entire surface thoroughly
scorched with the thermocautery. Sutures should then be
placed to close up the diseased surface. If the entire vaginal
cervix is more or less involved, incisions should be made upon
each side which will permit flaps to be turned down and sutured
over the diseased structures. The vagina should be continu-
ously irrigated during the process of closing off the diseased
surface and this procedure followed by careful sponging with a
solution of sublimate in alcohol (i : 500).
650. Vaginal Hysterectomy. — Many isolated cases of ex-
tirpation of the uterus per vaginam are fotmd in the literature
of the last century, notably those of Langenbeck and Sauter-
Recamier. Czemy, on August 12, 1S73, revived the opera-
tion. The operation has also been variously modified. The
following method should be pursued:
1. After the preliminary preparation directed (Sec. 182),
place the patient in the lithotomy position, expose the uterus
with an Edebohls speculum and lateral retractors, make traction
upon the cervix with double tenaculum and vulsellum or a silk
loop passed through it, draw it down as near to the vulvar orifice
as possible, and close the cervix by sutures, making flaps where
necessary to close in the diseased tissue. Sterilize the hands
and the instruments so far used.
2. Separate the cervix with scissors, knife, or thermocautery
(preferably the latter) from the vaginal wall by an ovoid incision,
extending it as far away from the diseased tissue as safety for
the bladder and ureters will permit. This can be carried higher
on the posterior surface without the fear of injuring the rectum.
The thermocautery knife has the advantage that it decreases
hemorrhage, destroys additional infected tissue, and prevents
immediate union, thus favoring better drainage.
3. Push back the bladder from the anterior wall of the
uterus and from the broad ligaments. Where desirable to re-
move a large portion of the parametrium, expose each ureter
and place upon it a traction ligature, as suggested by Bov^.
when the uterine artery can be traced out and ligated near
its origin.
GENITAL TUMORS. 791
4. The fundus of the uterus is turned down through the
anterior vaginal fornix, the broad ligament seized upon the
left side, crushed by the angio tribe, ligated in the groove, and
the uterus separated. Repeat this process upon the right.
Seize any bleeding vessels with hemostatic forceps and ligate
them.
5. Unite the peritoneal surfaces with a continuous catgut
suture, taking the precaution to secure at either angle the stump
of the broad ligament. Cleanse the cavity and loosely pack
the vagina with iodoform gauze.
All sutures should be of catgut, as silk is likely to become
infected and produce a discharge and maintain a sinus until
it comes away, which may require months, unless previously
removed. Such a patient will be in constant apprehension
that the disease is returning. The disposition of the ovaries
and tubes will depend upon their situation and the extent of
the disease. If they are easily displaced downward, they
should be removed; if high up, requiring considerable manip-
ulation to displace them, they should be permitted to remain,
as they cause no trouble. With the completion of the opera-
tion the wound should be carefully inspected for any bleed-
ing vessels, as it is not impossible that a ligature may slip from
the stump and a fatal hemorrhage result. Bleeding points should
be picked u]) and secured with separate ligatures.
The treatment of the wound will depend on the condition
of the patient. Thus, if the patient is very much debilitated
and it is undesirable to keep her long under the influence of
an anesthetic, the wound may be packed between the stumps
with iodoform gauze, carrying the latter sufficiently high to
prevent the intestine from coming in contact with the raw
surfaces. The gauze packing is lightly placed in the vagina
and the vulva covered with a pad. This packing, when the
bloorl control has been complete, may be permitted to remain
for from four days to a week. Upon its removal the cavity
is irrigated with a i : 2000 formalin solution, and may be lightly
repacked, although the packing should not be carried so high
as the first portion. The anterior and posterior walls of the
vagina are thus permitted to fall together and become adherent.
If there is no tendency to displacement of the viscera down-
ward and the belly of the patient is Tiot distended, the gauze
need not be replaced, and the vagina may be kept clean by
irrigation. In relaxed vagina, or when the condition of the
patient will permit of more time for the o])eration. the ends of
the broad ligaments should be united and the stumps drawn
well into the vagina ; the sides of the vagina are united to each
stump by a deeply passed suture, which, when tied, holds up
792 GYNECOLOGY.
the vagina and avoids its subsequent relaxation for want of
support. The patient should be confined to bed for two weeks ;
frequently cases are permitted to rise earlier than this, but the
long rest in bed is no disadvantage. The pelvic floor is firmer
and is less likely subsequently to prolapse.
Various modifications of the operation of vaginal hysterec-
tomy have been suggested. Three years after Czemy introduced
it, Sanger was able to collect thirteen different methods of operat-
ing, and with each year subsequent other modifications have been
suggested. Mikulicz was the first to use the curet. Billroth and
Olshausen added scorching the surface with the thermocautery ;
others, in addition, cauterized with carbolic acid or chlorid of
zinc, or used iodoform, liquor fern chloridi, alcoholic bromin solu-
tion, and absolute alcohol, Tauffer made his preliminary prep-
arations several days before the operation, and Leopold advo-
cated disinfection as the first step. Schauta began the operation
with the thermocautery. Bottini, Wecchi, and Calderini am-
putated with the galvanocautery loop, and followed with ex-
tirpation. When cancer is situated high in the cavity of the
uterus, antiseptic syringing is practised, the cavity packed
with iodoform gauze, and the os closed over it with sutures
or with clamp forceps. In order to limit the discharge of secre-
tion in carcinoma of the body, Schauta introduced a tupelo
tent into the cervix. This tent was somewhat constricted in
the middle from perforation, and a thread was introduced,
the ends of which were armed with needles. These needles
perforated the cervical canal anteriorly and posteriorly, and
the ends of the suture were tied over the end of the tent. The
swelling of the tent acted as a plug to the cervical canal. Mac-
kenrodt introduced the formation of flaps from the anterior
and posterior vaginal siu^aces, which we have described. Lan-
dau advocated an ovoid incision, the posterior surfaces some-
what higher than the front, as such an incision gave greater ac-
cessibility to the operation field. Doyen lengthens the circular
incision by one right and left, in order to create a still larger
opening, and especially to be able to separate about the bladder
and the ureters more securely. Fritsch incised both sides q| ?
the vagina; the base of the broad ligament is cut and tied, sol
that in this manner the uterus is easily movable and readily™
drawn down before the cervix is separated from the anterior '
and posterior union. Schatz opens into Douglas' space; then
the uterus is completely freed from its lateral union, and, finally,
the bladder is separated from the cervix. The ureters have
been injured in this method of operating. Billroth separates
by degrees the broad ligament, hgates the individual vessels,
and fastens the broad ligament in a properly prepared clamp
GENITAL TUMORS. 793
forceps. Schroder drew the uterus through the opening of
Douglas' space into the vagina. This procedure is not always
performed with ease. Fritsch rotated the uterus through the
anterior peritoneal opening. Olshausen operated with the
uterus continually in situ, and endeavored to separate it first
on that side which showed the least invasion by cancer. Corradi
and P. MuUer rendered removal of the uterus easier by dividing
it into two portions by a sagittal section, and then removing
each half singly. Kelly divides it into four or more. This
procedtu'e, without question, renders the removal of the uterus
more easy, but if we believe in the reinfection of the wound,
it greatly increases the danger. The ligation of the broad
ligaments has also given great variety of procedtu-e. Some
l^te small sections; others ligate in mass. Olshausen, in the
beginning, attempted to surround the broad ligament with a
single ligattu'e, but the stump would shrink and the vessel re-
tract from the ligature and considerable hemorrhage result.
Liebmann attempted to ligate the parametrium in such a manner
that the ligature is knotted on the vaginal mucous membrane in
order to limit its slipping. The superior part of the broad
ligament, with the spermatic vessels, repeatedly slips from
the ligature and requires supplementary ligation, which is
accompUshed with great difficulty. Veit fastens the superior
part of the stvimp with hook forceps and ties the Hgament be-
hind them.
With regard to the removal of the ovaries there has been
considerable discussion. Czemy, in his first case, removed
the appendages supplementary to the removal of the uterus.
Schroder, Olshausen, and others leave them when no indication
of disease is found. Von Teuffel and Kaltenbach urge their
removal; the latter emphasized the possibility of infection
of the peritoneum by leaving inflammatory diseased portions
of the tube. The retention of the appendages in carcinoma
of the uterine neck is not found to favor the appearance of
relapse. The course of the lymph-channels arising from the
cervix has no relation to the appendages of the uterus. They
should always be removed whenever pathologic alterations
are recognizable. After Reich, in several cases of carcinoma
of the body, had demonstrated cancerous disease of the ovary,
the removal of the appendages was advocated in all cases
in this form of uterine cancer. Formerly surgeons employed
irrigation freely with strong antiseptics during the early part
of the operation. To-day, the majority of gynecologists, after
radical disinfection of the field of the operation, proceed with
sterilized instruments without irrigation. Irrigation should
be employed only when necessary to cleanse the field, and it is
794 GYNECOLOGY.
better then to use nothing stronger than normal salt solution
or a 1 per cent, saline solution.
The vagina] operation will be especially difficult if the canal
is narrow and rigid or the uterus very large. Under such cir-
cumstances the majority of operators have incised the vaginal
wall or the paravaginal tissue, by which procedure the lumen
of the vagina is considerably increased. Von Winckel, in one
case with enormous narrowing of the vagina and a large uterus,
split the entire rectum and rectovaginal septum up to the vaginal
vault. The large vaginorectal wound was sutured with silk,
and recovered by primary intention. Duhrssen made a deep
vaginal incision, which penetrated from the vaginal vault and
completely opened the ischiorectal cavity and the entire vagina.
Section on the right side penetrated the vagina, and also the
rectum, to the depth of six or seven centimeters. By this
incision not only the vaginal tube, but also the surrounding
muscular structure, the levator ani, and the constrictor cunei
are separated. The direction of the incision is in the middle
line, between the tuber ischii and the anal opening. By such
an incision the entire field* of the operation is incidentally in-
creased, and the resistance of the soft parts of the pelvic cavity
is removed. The hemorrhage from the vagino-intestinal in-
cision is either controlled by ligature or through pressure of
retractors. After the removal of the uterus the wound is closed
by sutures. After such an incision relapses have occurred
in the scar tissue, which are evidently infection relapses. Schu-
chardt creates a still larger accessibility to the field of opera-
tion by opening more widely the ischiorectal cavity. He makes
two accessory incisions. One splits the entire lateral vaginal
wall, from below to the neck; on the other side a long vaginal
incision from behind progresses to the sacrum and encircles
the rectum, bow-like, in an incidental sagittal section. The
long incision is made upon the side in which the parametrium
is strongly involved, and extends to the outside of the convex
bow at the side of the anus. The extirpation of the uterus
in these operations dilTers from the usual vaginal extirpation
only in that the parametrium has been opened up so that some
cancerous nodules can be removed therefrom without exposure
of the ureters. The vagina is closed from above downward
by knotted suture.
While it cannot be denied that these extensive vaginal
cisions permit greater freedom in the manipulation of the utei
the ease with which it can be reached from above would seem to
contraindicate such a method of procedure, especially in \*iew
of the increased danger of reinfection of parametric tissue that
must be associated with so extensive a dissection. To facili-
i^ard
GENITAL TUMORS. 795
tate the removal of larger portions of the parametrium with
safety, Pawlik, Kelly, and Clark advocated the previous intro-
duction of catheters into the ureters to establish their position
more definitely and permit, with safety, the extensive removal of
large portions of the parametrium. The dissection and guard-
ing of the ureters, as Bov^e suggests, are preferable and safer, for
one case of catheterization has been reported in which the cathe-
ter was broken ofT and the patient died. Its employment inflicts
more or less trauma and, therefore, predisposes to infection.
Mackenrodt, in total extirpation, cuts about the vagina some
distance from the portio and prepares anterior and posterior flaps,
which are dra-v^Ti over the portio and sutured so that the diseased
tissue is completely covered. He splits the anterior vaginal
vault by a median incision from the urethral swelling to the cir-
cular incision. The accessibility of the operation field is still
further increased by a deep vagino-intestinal incision. The
bladder is dissected from the cervix, and especially from the broad
ligaments, and therewith the ureters are separated some dis-
tance ; and, finally, the uterus, with as large a portion as possible
of the parametrium, is extirpated. The peritoneal wotmd is
closed after the contraction of the stump, the vagino-intestinal
incision narrowed by suture, and the vagina, with the supra-
vaginal wound, packed with iodoform gauze. Later, Macken-
rodt performed an operation in which the extirpation of the
uterus and of the greater part of the vagina was accomplished
with the hot iron. He believes that a larger extent of the
vagina must be removed than is customary, because we do not
know that a latent contact infection of the vagina does not
already exist. He performs the operation as follows:
With cutting instruments, Paquelin cautery, or galvano-
cautery the entire vagina, or at least the upper half of it, is
separated; a vaginorectal incision is made which extends to
the portio and lays open the operation field; then the vagina
is seized with forceps and separated downward by hot iron.
If the upper part of the vagina only is removed, we begin with
a circular incision in the middle of the vagina. After extirpa-
tion of the vagina the portio is secured with forceps and Douglas'
cavity is opened with a hot iron. The bladder and the broad
ligaments are separated from the cervix by a properly con-
structed shovel forceps, drawn as far as possible to the outside,
and separated by the cautery. After the separation of the
base of the broad ligament of both sides spiuting vessels are
seized with Koeberle forceps, which are placed in the higher
part of the broad ligament, separated by the cautery, and the
stump scorched. The now very movable uterus is easily in-
verted. The upper parts of the broad ligaments are fastened
796 GYNECOLOGY,
with Richelot's clamps and a ligature is placed on each side,
after which the separation of the stump results. After the
removal of the uterus the rectovaginal incision is closed by
sutures, when, in spite of the scorching, primary union is usually
obtained. The perineum is not sutured. The burned cavity
is filled with iodoform gauze. Elevation of temperature follows.
Of ten cases subjected to this operation, two suffered from
sepsis.
Byrne has removed the entire uterus by the galvanocautery,
but used the knife instead of the loop. Winter and Frommel
combat the possibility of the danger of contact infection of
the vagina being great enough to justify such a procedure,
Czemy, Franck, and others have pursued the method suggested
by Langenbeck of separation of the uterus from its peritoneal
envelop, and the several resulting tears in the peritoneal cover-
ing were united by sutures. This operation is sometimes very
easily done, but in others is extremely diiBcult, Richelot and
P^an advocate the use of clamps instead of the ligature. The
preliminary steps of the operation are performed similarly
to those already described. After opening the peritoneum in
front of and behind the uterus, the organ is held by the broad
ligaments, through which enter the uterine and .ovarian arteries.
Clamp forceps are appHed at each side of the cervix, upon about
one-half of the broad hgament, and the structure is cut between
the cervix and the clamp. The uterus is drawn down, if pre-
ferred, and the fundus is brought forward and through the
anterior fornix; clamp forceps are applied from above upon
the remaining portion of the broad ligament. The section
between the clamp and the uterus frees that organ, which can
be removed. The clamps are then held apart, the surfaces
are separated by retractors, and careful inspection is made to
determine that all bleeding vessels are controlled. Any spurting
vessels should be secured with smaller clamp forceps or the
arteries should be ligated. The clamps are held apart and iodo-
form gauze is carried into the vaginal canal between them
to the point at which the peritoneum lias been separated, and
is loosely packed between the clamps. The gauze should be
carried over the end of the clamps, so that the coils of intestine
shall not impinge against them and become injured. The
operation has the advantage that it can be performed very
expeditiously, and requires much less time than the application
of the ligature. It has the disadvantage that the tissue within
the grasp of the clamp undergoes sloughing, causes a foul dis-
charge, an offensive odor, and sloughing tissue which endangers
the infection of the peritoneal cavity. The convalescence of
such patients is usually attended with considerable elevation
of temperature.
GENITAL TUMORS. 797
Tuffier reports twenty-seven cases of vaginal hysterectomy
without the use of forceps or ligatures. The uterus was bisected,
one-half drawn out of the vulva, the finger passed behind the
upper part of the broad ligament, and the included tissue grasped
between the blades of a powerful clamp, the angiotribe, which
is tightly screwed. The tissues are thus crushed and the artery
is occluded. After the crushing of the tissues the ligament
is cut through and the upper part of the broad ligament crushed
in a similar manner. It is very important that the handle
should be secured as tight as possible and the blades kept in
the axis of the vagina. In none of the cases reported had any
accident occiured during the operation, and absence of hemor-
rhage was particularly noted. This procedure is also advocated
quite strongly by Dr. Newman, of Chicago. The angiotribe,
however, cannot always be relied upon for the control of hemor-
rhage, and in some cases it tears the vessel, making its control
by ligature difficult. Dr. Downes, of this city, has greatly
improved upon this method by the use of electro-hemostasis.
The late Dr. Joseph Eastman placed the patient in the Sims posi-
tion, stretched the anus to allow greater readiness of access to the
pelvic cavity, retracted the perineum with a Sims specultim, and
made an incision about the uterus, which opened the Douglas
culdesac posteriorly and between the bladder and uterus ante-
riorly. He then passed a curved staff over the broad liga-
ment, by which a ligature was carried and the broad ligament
secured en masse, then over it was passed a pair of interlocking
forceps by which the broad ligament was constricted, preliminary
to its being severed, after which the ligament could be ligated in
sections or the clamp permitted to remain. Tlie other broad Hga-
ment was treated in a similar manner. The advantage he claimed
for this procedure was greater security and control of hemor-
rhage, and that the vagina was held at a lower level and its
prolapse prevented. The position of the patient, with the pre-
liminary dilatation of the anus, gives greater freedom of access
to the uterus.
651. Accidents of Vaginal Total Extirpation. — The most
frequent injury is that of the bladder, which can take place
in various ways. Thus, it may occur in the blunt separation
from the anterior cervical wall. The danger of this becomes
the greater the more closely the new formation has approached
the bladder. If it has passed over on to the external layer
of the bladder-wall, we may very readily puncture the bladder
in the most careful separation. When the bladder is infiltrated,
the preferable plan is to cut out the diseased tissue and close
the opening by sutures. Injury of the bladder is recognized,
however, most frequently for the first time at a longer or shorter
798 GYNECOLOGY.
period after the operation, when a part of the urine is lost through
the vagina. Either a small bladder injur>' has been overlooked,
or, what is probably more frequent, the bladder has not been
sufficiently separated from the ligament, and in placing the j
ligatures upon the parametrium a portion of it is fastened in I
the ligature, so that a slough of the affected bladder-wall occurs. "
A spontaneous closure not infrequently results from the scar
retraction. When it has not closed, the repair of the fistula
must be undertaken by operation. Kaltenbach claims that
injury of the urinary apparatus occurs in about lo per cent,
of all cases; tliis, for the last few years, should be too high.
An injury of otie or both ureters is occasionally observed. The
injury can be avoided if the bladder and ureters are well pushed
back. It does not require the previously mentioned sounding
of the ureters to avoid ureteric injuries. One should exclude
cases from operation in which the parametrium and the sur-
roundings of the ureter are infiltrated with carcinoma. In such
cases the shoving back of the ureter is exceedingly difficult, and
not infrequently is associated with injury. The most serious
injury of the ureter consists in the application of a hgature
upon it or upon the tissue about it so that it is laterally com-
pressed. Ligation of both ureters is, without question, fatal,
and the ligation of one manifests considerable injury. Schatz
does not believe the ligation of one ureter necessarily unfavor-
able, as the other kidney performs increased duty. He also
believes that in one case after ligation of the ureter the canal
again became penetrable a few days later. A number of operators
have had to remove the corresponding kidney as a result (rf'l
the ligation of the ureter. Zweifel, tn double-sided ureteric
ligation forty-eight hours after the operation, loosened the
ligatures on the one side, and the strongly swollen ureter was
made accessible again to the bladder; hut as urine retention
continued six days after the operation, the ligature on the
other side was removed and the restoration of the ureters at-
tained.
Injuries of the rectum are more unlikely to occur. They
take place in especially unfavorable cases where adhesions exist
between the uterus and the rectum. Frommel reports a case in
which, in an attempt to open Douglas' space, the adherent rec-
tum was injured, and, in spite of the most carefully introduced
sutures, he lost the patient from septic peritonitis. In rare cases
communication between an intestinal loop and the vagina, with
involuntary fecal discharge, has occurred, most generally from
relapse in the operation scar, in which the carcinoma extendai
upon an adherent loop of intestine. Numbers of cases
reported in which ileus has resulted from adhesions in the op
GENITAL TUMORS. 799
peritoneal wound. It was my unfortunate experience to have
this occiir nine years after the original operation. In symptoms
of ileus the intestinal loop should be separated from the vagina
after reopening the wound. In old cases the condition is best
treated through an abdominal incision. If this fails, an arti-
ficial anus should be made or the affected loop of intestine should
be resected.
652. Abdominal Hysterectomy. — The first systematic opera-
tion for the removal of a uterus for malignant disease through
an abdominal incision was performed by W. A. Freund, on the
30th of January, 1878. The operation has undergone a ntmiber
of modifications since his introduction of it. After preliminary
preparation (Sections 173 to 183) the operation is performed as
follows :
1. The patient is placed in the lithotomy position, the friable
tissue is removed from the cervix with the finger and spoon
curet, all loose and ragged edges are trimmed with the scissors,
the surfaces seared with the thermocautery, and the lips sutured
to close in all infected tissue. Where this cannot otherwise be
accomplished, flaps should be dissected. Before proceeding
further, the hands and instruments should be resterilized.
2. The patient is placed in the Trendelenburg posture and
an incision made in the median line from three centimeters
above the symphysis to a short distance below the umbilicus,
through which the intestines are pushed toward the diaphragm
and walled off by gauze.
3. The uterus is secured by a double tenaculum and vulsellum
forceps or sutures which have been passed through the fundus,
drawn up, and each broad ligament clamped, one blade of the
clamp being passed through the ligament in such a way as to
include the round ligament.
4. Cut the broad ligaments internal to the clamps, secure
bleeding from the uterine side by hemostatic forceps, join the
extremities of the broad ligament incision by one through the
anterior peritoneum above the bladder, and strip it and the
bladder away from the cervix and broad ligament.
5. Find and secure the uterine artery upon each side with
hemostatic forceps and cut between them and the uterus.
6. Tilt the uterus to one side and open into the vagina,
making sure the opening is well below the infected area. Through
this opening the cervix can be followed around and severed from
the vagina.
7. The clamped vessels are ligated — the uterine by simple
chromic catgut ligature, the ovarian en masse, after being crushed
with the angio tribe.
8. The surface is carefully inspected for bleeding vessels and
800 GYNECOLOGY.
infected glands, the peritoneal folds are stitched over the vagina
with a continuous chromic catgut suture, inverting all ligated
stumps into the vagina.
9. Remove all gauze pads, cleanse the pelvis, and close the
abdominal wound, cleanse and apply dressing. Where the con-
ditions make it desirable, after stripping back the anterior peri-
toneum and bladder the broad ligament can be spread out, the
uterine artery traced outward and ligated near its source, the
ureters raised, held to one side by traction ligatures, and a
much larger portion of the parametrium removed.
The vaginal opening can be packed from above with iodoform
gauze, an end of which is carried into the vagina, while the
portion above covers the injured surfaces and prevents the con-
tact of intestines. This gatize should be permitted to remain
from four to six days, until the peritoneal surfaces have been
closed over the vagina, and have made it an extraperitoneal
surface. Some surgeons prefer to suture the peritoneal flaps,
and loosely pack the wound from the vagina with iodoform gauze.
The gauze, however, can be used more effectively from above,
sewing the peritoneal surfaces over it. It thus forms an effec-
tive tampon and can some days later be removed through the
vagina.
In Freund's first procedure the broad ligaments were ligated
external to the appendages, a second ligature was placed on the
portion of the broad ligament which included the rotmd ligament,
and a third secured the base of the broad ligament by being
introduced from the vagina through a trocar needle which
Preund dex-ised for the purpose. The last ligature was tied upon
the base of the ligament as firmly as possible. In this way
three lis^atures were inserted, one tmder another. The other
broad ligament was secured in the same manner. The perito-
neum above the bladder fundus was cut transversely upon the
anterior uterine wall. A similar section was made upon the pos-
terior wall, somewhat lower, and these wound margins were
united ^^-ith a silk loop after the removal of the uterus. The
uterus was separated bv knife or scissors. Hemorrhacre from
small x-aginal arteries was controlled by ligation. All the liga-
tures were carried into the vagina, and by traction the stump
was dra\\Ti down. This dragging made the peritoneum of tl^
bladder approach that of the posterior wa!! o: the p«rt:ch of
Dousrias. These r^o walls could be urited bv c»?ntint:?us catcat
suture. A most careful toilet of the peritcnetim was accom-
plishei. the eventratei intestines were retumei. ani the belly
wounvi was close! with sutures. The stittires :h.\: ^v»?re rtished
into the vaeina cou!i r-e remove! rv tractirr. at the er^i of
GENITAL TUMORS. 801
three weeks. The greatest danger of the operation was infection
of the peritoneal cavity.
This operation has undergone various modifications. Cred6
proposed to resect a part of the anterior pelvic wall several days
before the operation, but found no imitators. A. Martin made a
moon-shaped abdominal incision from the one anterior superior
spine to the other, by which he hoped to be better able to keep
the intestines in the abdominal cavity. He has not continued
the procedure. The separation of the bladder from the uterus
prior to the introduction of the base sutures has been a great
improvement, decreasing the danger of injury of the bladder
and of ligation of the ureters. Kuhn raised the uterus by
means of the colpeurynter in the vagina, and made it more acces-
sible. Eastman accomplished the same thing by a grooved staff
through the posterior vaginal fornix. Bardenheuer advocates
leaving open the peritoneal wound for drainage, but his results
were not such as to make the plan acceptable.
Modifications of the operation are, first, to make an incision
through the vagina around the cervix ; pack the cavity with iodo-
form gauze and complete the operation from above. Another is :
separate the front and back, open into the vagina, and complete
the operation by the application of clamps to the broad ligament.
Veit operated by ligating and cutting the broad ligaments as far
as the vault of the vagina; then he completed the operation
through the vagina. Gubarroff, of Moscow, advocates the ab-
dominal procedure, because of the impossibility of the removal
of lymph-glands and the tissue at the base of the broad ligament
in vaginal total extirpation.
In marked involvement of the cervix Rumpf proceeded by
the following plan: He ligated the broad ligament above, opened
up the parametrial connective tissue, and proceeded to expose
each ureter in its entire course from the psoas muscle to the
bladder; thereby the uterine arteries were severed and ligated,
and the parametrial tissue could be removed bluntly nearly to
the uterus without incidental bleeding. Subsequently, the ante-
rior leaflet of the broad ligament was cut through, the peritoneum
over the surface of the bladder divided transversely, and the
latter bluntly separated from the cervix. The parametrial tissue
beneath the ureter could be still further removed. The vagina
was separated by means of a Paquelin csLutevy, after the removal
of the uterus, was filled with iodoform gauze, and the peritoneum
was closed over the rest of the broad ligament. Rumpf reports a
case operated upon in this manner which rcmaineci free from
relapse for over two years. Clark and Kelly eflVcted tlie s(ime
purpose by introduction of fine bougies into tlie invlers to render
them perce})tible.
51
802 GYNECOLOGY.
Ries advocates the removal of the lymphatic glands
account of their being the source from which redevelopmi
occurs. He operates in the following manner:
1 . Through the vagina he amputates the portio vaginalis ai
tampons with iodoform gauze.
2 . Through the abdominal incision from the symphysis to
umbilicus he ligates the ovarian artery in the infundibulopelvic
ligament near the pelvic wall, and splits the peritoneum over
the common iliac, exposes the vessel by blunt and sharp dissec-
tion until the bifurcation is exposed, when the ureter is separated
as far as the bladder.
3. The broad ligament is ligated toward the pelvis in sectiona
and the part toward the uterus is secured with clamps. The
bladder is separated bluntly from the surrounding broad ligament
and the uterine artery tied peripherally.
4. The collected fat tissue with the glands is removed from
between the large vessels, the external and internal iliac.
5. The vagina is opened, the uterus removed, and the vaginal
canal filled with iodoform gauze, while the peritoneal flaps are
united with continuous silk suture and the belly cavity com-
pletely closed. i
When infection is so great as to require so extensive a separa*^
tion, the danger from sepsis and from relapse of the disease is
so marked as to render the operation of questionable value.
Werder, of Pittsburg, in order to lessen the danger of wound
reinfection, advocated an abdominal hysterectomy in which,
after ligation of the broad ligaments, the bladder is pushed off
not only from the anterior surface of the uterus, but from the an-
terior portion of the vagina for one-third to one-half its length.
The tissues are also separated from the vagina posteriorly and-
laterally, the abdominal wound is closed by a previously intro-.'
duced suture or hooked forceps ; the uterus is then drawn throi^h 4
the vaginal outlet and the remaining portion of the operation
completed by the vulva, which saves the wound from contact'
with the infected portion.
In order to control hemorrhage in an extensive dissection of
the pelvic structures, Polk advocated ligation of the anterior
trunk of the internal iliac artery, (Fig. ^26.) The distribution
of vessels from these trunks is, however, somewhat irregular, the
vessel itself is short, and the structures supplied by the posterior
trunk are so bountifully nourished by anastomotic vessels that
I have tied one or both the internal ihac vessels, which permitted
a most extensive dissection free from bleeding. In all of these
cases the involvement of structures was so extensive that the
operation was of doubtful utility. The first patient survived
the operation and returned home, but soon perished from a re-
I
GENITAL TUMORS 803
lapse ; the second case developed tetanus at the end of ten days
after the operation, from which she died.
Schroder, after ligation of the infundibtilopelvic ligaments
and the portion of the broad ligaments containing the uterine
arteries, amputated the fundus at about the level of the internal
OS. After bleeding vessels had been secured and the stump dis-
sected out, the vaginal surfaces were united, over which the peri-
toneal flaps were sutured. The operation is objectionable because
of the danger of reinfection. Mackenrodt urges not only the
Fig. si6.— Ligatio
Trunk of the Internal Iliac.
removal of the glands of the pelvis, but also an extensive re-
moval of the parametric tissue, since in the latter metastatic
nests were most frequently found, which were the chief cause
of recurrence. In order to accomplish this most effectively, he
advocates the following procedure :
I. A large crescentic abdominal incision from one iliac spine
to the symphysis and upward to the opposite is made, through
which insertions of the recti muscles are divided without opening
the peritoneum, and the abdominal muscles are separated from
the pelvic attachments.
804 GYNECOLOGY.
2. The peritoneum is pushed off to its reflection over the
anterior wall of the bladder, when it is cut through and pushed
behind the uterus.
3. The uterus is drawn out and the ovarian arteries ligated
in the usual manner. The peritoneum is then sutured behind
the uterus from the right side of the pelvis across to the left,
covering the sigmoid flexure, which permits the subsequent steps
to be extraperitoneal.
4. The pelvic peritoneum is dissected up as high as the iliac
vessels, where the glands are found and removed with fat and
connective tissue. During this stage the ureters are careftdly
protected.
5. The bladder and recttim are separated, the entire vagina
freed.
6. The broad ligaments and paravaginal tissues dissected out,
the vagina clamped and divided with cautery below the clamps.
7. The space between the bladder and the abdominal wall is
drained through the lower angle of the external woimd. The
divided recti are united by silver wire sutures and the abdominal
woimd closed. Considerable suppuration is usually expected
between the bladder and the rect\un. In none of the cases thus
treated has the absence of recurrence been sufficiently long to
make the performance of so extensive an operation seem justi-
fiable.
Wertheim, Kronig, Kundrat, and von Rosthom are very
earnest in their advocacy of the removal of the parametrium and
lymph-glands in all cases of carcinoma. While I woxild agree
with them as to the importance in getting well beyond the dis-
ease, in the removal of a large portion of the parametriimi and of
the vagina, my experience leads me to believe that the attempt
to remove the glands is of little avail, as it is impossible for the
most skilful surgeon to remove all the glands, and the investi-
gations of Schauta seem to indicate that the inaccessible lumbar
glands are frequently infected before those in close relation with
the uterus. Fortunately, the involvement of glands does not
always indicate that these structures \\411 be the cause of recur-
rence when the original source of the disease has been removed.
In the great majority of the cases coming under my observation
recurrence has followed in tlie vagina and cicatrix rather than in
the pelvic glands. When the increased mortality incident to
the prolonged operatii.>n, the tedious convalescence, the aggra-
vated suffering from ureteral and vesical complications are con-
sidered, it becomes a serious question whether anything is gained
by the extensive and more thorough procedure. Wertheim, the
apostle of this procedure, had an immediate mortaHty of 12 in the
first 30 cases, 5 in the second, and 3 in the third series of thirty.
GENITAL TUMORS. 805
Even the latter, which equals lo per cent., is a much larger mor-
tality than men of equal experience usually have in ordinary
hysterectomy.
653. Comparative Advantages of the Two Proceedings. — The
principal danger of the abdominal procedure arises from septic
infection. The investigations of Menge and others have demon-
strated the presence of pyogenic germs in the discharges of
uterine cancer. The much longer duration of the operation, the
increased exposure to infection, and the lessened powers of resist-
ance favor its development. In the vaginal procedure the peri-
toneum is less exposed to infection, and the operation can proceed
without any, or with scarcely any, soiling of the peritoneal cavity.
In our present methods of procedure the operation is more expe-
ditious ; with the separation of the bladder from the cervix and
the broad ligament the uterine artery can be ligated without
danger to the ureter.
The claim for the abdominal procedure, that it permits the
extirpation of the lymphatic glands, is of but httle significance
when it is remembered that the 'glands are rarely involved until
very late in the disease ; and when the disease has extended to the
lymphatic glands of the pelvis, the operation is but little better
tiian a mutilation, for it will scarcely have any influence upon
the subsequent progress of the disease.
Notwithstanding the vaginal operation can be done much
more expeditiously and with less danger to the patient, with less
discomfort during the convalescence, it can not be denied that
in cancer of the uterus, where the disease is confined to that
organ, the abdominal operation should be preferred. This prefer-
ence is granted it not because it permits us to extirpate the
lymphatic glands, — for I believe that no operator is sufficiently
dcilled to make sure that all the lymphatic glands are removed,
and even if they .were, the extensive lymphatic system woxild
still afford opportunities for the retention of infection, — but
because it enables the operator with greater safety to remove
the parametrial tissue. The large number of cases in which
vaginal hysterectomy has resulted favorably, the fact that where
recurrence takes place it is in the cicatrix, in the vaginal wall,
or in the parametric tissue, lead me to believe that the assertion
regarding the infrequency or lateness of lymphatic gland infection
is correct, and that where the disease has resulted in the involve-
ment of the glands, no operation affords much hope of cure.
In cases in which it is evident that the disease has extended
outside the uterus and the operation is done for its palliative
effect, removing only the infected tissue, the vaginal operation
may be preferred, where the vagina is large and roomy and
the uterus not unduly large. .
S06
GYNECOLOGY.
A narrow contracted vagina, a large or fixed uterus, extensive
invoh'ement and destruction of the cer\-ical walls, which afTcrd
no firm tissue to be seized, and more or less fixation of the uterus
from inflammatory lesions, render the vaginal procedure very
difficult. Complications of the diseased uterus with abdominal
growths, such as myoma, ovarian tumors, and extra-uterine _
pregnancy, should be attacked through the abdomen. When i
come to the duration of after-results, the advantage seems 1
favor the abdominal procedure.
Injuries of the ureters occur less frequently by the abdominal '
route, but the operator, in all cases of extensive involvement of
the parametrium, should ascertain the position of the ureter by
following it down from above before blindly applying a ligature.
Through neglect of this precaution I have twice ligated a ureter.
If the ureter is unavoidably or accidentally injured, an attempt
may be made to unite it by suture, as was done by von Tauffer
and Westermark, or the ureter may be implanted in the bladder.
In extensive parametria! involvement, where the infiltrate
surrounds the uterus, I have in several cases purposely cut
through one or both ureters, dissected out the involved structure to
the pelvic wall, and reinserted the ureter into the bladder at ahigher
level. In all of these patients the ureter was distended to the
size of a finger as a result of compression from the infiltrate. All
recovered from the operation, but four succumbed some months
later to recurrence of the disease. Kustner, when unable to ac-
complish a \'esical transplantation, formed a vesicovaginal fistula, ,
followed later by a colpocleisis in preference to a nephrectomy. ■
654. The Sacral Method.^ Kraske, in 1885, introduced aa J
operative procedure, under the title of the sacral method, for
the purpose , of extirpating the upper part of the rectum for
carcinoma. It consisted in resecting the rectum after the re-
moval of the coccyx and a portion of the sacrum: Hochenegg,
in 1888, after a series of brilliant successes, adapted the opera-
tion to the treatment of some of the disorders of the female
sexual organs, and the following year reported the application
of the method to the removal of the uterus. The operation was
performed as follows: The patient was placed in the Sims posi-
tion, with the pelvis slightly elevated, an incision was made
from two to three centimeters above the right sacro-iliac synchon-
drosis to within one centimeter of the left side of the anus.
After cutting through the skin and fascia, the under part of
the sacrum and the entire c<x;cyx were exposed. Now follows
the bone operation. If the coccyx is large and broad, its re-
moval is sufficient ; otherwise a portion of the left sacral 1
is also resected. If a part of the sacrum is to be removed,
cut through the sacrosciatic ligaments, and with a ■
GENITAL TUMORS. 807
cut away the left side of the lower two segments of the sacrum.
The prevertebral fascia is spUt the entire length of the wound;
ihe now free-lying rectum is bluntly separated on the left side
and displaced to the right. Later experience demonstrated
the advisability of opening upon that side of the rectum on
which the parametrium was most infiltrated. The rectum
is shoved aside, and Douglas' space opened by a transverse
incision, which is recognized as the hardest part of the opera-
Fig. 537. — Skin Incision for Sacral Resect
tion. One or two fingers are introduced into the opening,
the uterus and its appendages are explored, and the practic-
ability of their removal is determined.
In removal of the uterus it is seized and drawn through the
incision of Douglas' space into a position of strong retroflexion.
The broad ligaments upon both sides are cut between double
ligatures: when the uterus becomes so movable that it can
be further drawn down, its anterior surface is inspected. The
808 GYNECOLOGY.
peritoneum above the vesico-uterine reflexion is cut ■
versely. and, together with the bladder, pushed downwarc
The uterine arteries are generally ligated under the eye,
the ureters easily pushed aside, although they have been in-
jured. After the separation of the lateral appendages the organ
remains in union only with the vagina, A transverse incision
through the peritoneum in front of the uterus is made, whicbg
1 and sewed t*.i the peritoneum of the anterior '
of the rectum. The vagina is closed in two stages. lodofonrti
gauze is packed about the remaining portion of the wound
and brought out at the center of the posterior wound, both
ends of which have been closed. This operation was extended
by Herzfeld, who found that, in the majority of cases, only
the removal of the coccyx was required. He penetrated the
right side of the rectum, for the reason that the vagina is situated
more to the right, is more accessible, and there is less inter- _
GENITAL TUMORS. 809
ference with the rectum. The transverse opening is made
in Douglas' space, the right and left broad ligaments are lied
and cut, after which follows a complete closure of the perito-
neum before further extirpation. There is no possibility of
soiling the peritoneal cavity by contact with cancer. The
rectal peritoneal surface is sewed to that of the bladder, and
the stumps are fastened in the wound laterally, making them
Fig. 53g. — Rectum Pushed Aside; Uterus Exposed,
extraperitoneal. Hegar cut transversely in the anterior uterine
wall above the bladder fundus, and shoved back the bladder
and ureters. The remaining removal of the uterus is similar
to that described in Hochenegg's and Herzfeld's operation.
Schede protests earnestly against sacrificing the sacrum. In
a large series of operations he never found it necessary to re-
move enough of the sacrum to involve the lower sacral foramen
and its nerve. He designates the removal of the lower two
SIO GYNECOLOGY.
sacral nerves a crime, as the destruction of these nerves para-
lyzes the detrusor vesica uterini and causes a very severe in-
flammation of the bladder, which increases the distress and
peril of the patient. Zuckerkandl introduced a still more
conservative method, in which there was no bone resection.
Skin section was from the left side of the tuberosity of the
ilium until midway between the end of the coccyx and the
anus. At the sacral margin it formed a bow bent hard to the
right. The gluteus maximus muscle, the sacro-iliac and sacro-
sciatic ligaments, the musculus coccygeus, and part of the
levator ani muscle were cut through at the margin of the sacrum
and coccyx. The rectum is set free and the operation pro-
ceeded with as previously described.
Wolfller places the skin section to the right of the sacrum,
over the somewhat narrowed part at the union of the coccyx
and sacrum; the section forms an easy curve, with its concavity
to the right, and ends near the rectum, in the neighborhood.
of the vulvar commissure. The gluteus maximus and the
levator ani are cut near the rectum, and the deeper structures
become accessible. Zuckerkandl designated his and WolfHer's
methods as parasacral section. These operations are more
bloody, because the sacral, the median, and the inferior hemor-
rhoidal arteries and the pudendal artery and vein are in the
range of the incision. Hegar made an osteoplastic resection
of the sacrum and coccyx. A V-like incision, with the arms
beginning one centimeter beneath each inferior posterior iliac
spine, converged to the point of the coccyx. After separation
of the soft parts and bands near the sacral margin the rectum
was bluntly separated from the anterior sacral surface, a chain-
saw was introduced between the third and foiuth sacral open-
ir^, the sacrum cut transverselv through to the jKJsterior
periosteum, which was retained, and the sacra! part turned
up. After the operation this flap was returned to place and
secured by sutures. Consolidation usually took place in a
very short time. In two cases necrosis resulted, and the flap
had to be removed. After the operation the skin wound was
closed, with the exception of a small drainage opening, and
the advantage of the procedure is that the anatomic relations
are exhibited as before. Tliis osteoplastic resection of the
sacrum is applicable to the removal of carcinomatous uteri as
well as retro-uterine tumors.
Kocher and Heinecke recommend the splitting of the sacrum
in the middle and the separation of the sides from one another.
Le\-\' and Schlange, in opposition to Hegar, turned the flap
toward the anus, while Rydvgier made the incision in the soft
parts on one side, and, after transverse incision, turned f
GENITAL TUMORS. 811
sacrum toward the other side. Borelius changed this method
in the remo\'al of a carcinomatous uterus as follows : He began
with the skin section in the middle line, about two centimeters
above the sacrococcygeal articulation; then, somewhat to the
left, approached the point of the coccyx forward, through the
rectosciatic fossa, three to four centimeters from the anal aper-
ture ; from this point he progressed forward, and again approached
the middle line until led to the posterior commissure. After
laying free the left border of the coccyx, the sacrococcygeal
angle is cut through. The skin section, in its entire length,
is sufficiently deepened, and the coccyx, together with the anal
portion, is held to the right; after separation of the rectum we
can proceed from the posterior vaginal wall to the extirpation
of the sexual organs. After the operation the coccyx is replaced
and fixed with periosteal sutures.
Various modifications of Hochenegg*s procedure for the
extirpation of the uterus have been introduced; by proceed-
ing, as Herzfeld suggested, to the right of the rectum, Douglas*
space will not be missed. In the search for the space — made
incidentally easy by having an assistant introduce the finger
into the rectum to indicate the plica transversalis recti, as the
cup of Douglas' space always lies at the height of this fold — we
only need to make the incision to enter the space. The difficulty
in finding Douglas* space has occasioned tlie majority of operators
to renounce the primary opening in the peritoneal cavity en-
tirely, and to proceed to the extirpation of the uterus by the
opening from the vagina.
Incidentally an easy way of accc)mj)lishing the uterine
extirpation would be to follow the pn^cceding of Czerny, who
from the vagina cuts about the portio in the same manner and
separates the structures as in the vaginal method. After com-
pletion of the operation most operators fill out a somewhat
fist-sized wound with iodoform gauze and treat it as an open
wound, with the exception that the wound in the skin is partly
closed, leaving an opening in the center, through which the
iodoform gauze is carried out; also, in the osteoplastic resection
we can not well renounce the use of this drain, and iodoform
gauze is placed on each side. Steinlhal brought the gauze
out through the vagina, and thus closed the entire posterior
wound. Zweifel, Schauta, and Wertheim have operated in
similar manner with favorable results. One objection to this
operation is the long convalescence, requiring fully six weeks
for the patient to recover, after which time necrosis of the
bone may cause fistulous openings, which may continue for
a much longer period. The osteoplastic resection seems to
shorten the convalescence. The complete suturing of the
S12
GYNECOLOGY.
sacral wound, with drainage through the vagina, is the mcit
satisfactory procedure. It can be claimed for the proceJ-j«
that the entire operation can be accomphshe<1 more readily
under the eye. and ligation of the uterine arteries is accomplished
separately, and not by mass ligature. Injuries of the uretere
are also easy to avoid. Such injuries, howe\-er, do occur.
The operation may be found advisable in cases in which
Fig. i;io. — Falicnt from Whom Uterus. Ovark-s, Posti-rior Wall of Vafia.
"Perint'um. and Five Inclios of tilt- Ructuni Have Been Removed.
.\, Artificial amis. B. Anterior wall of vagina. C. Vulva.
there is reason io sup]X)se that the ureter is embedded in ia-
nitration. In one case Schede resected a piece of the bladder
three centimeters long, together with a long piece of the uretet.
Von Winckcl objects to the operation on the ground that he
could nut sec the ureters. Hochenegg reported ninety-eight
with eighteen fatal cases — eight times sepsis or pelvic plil'egmoa.
The loss of blood is much greater than in the vaginal opera-
GENITAL TUMORS. 813
tion. In the course of the after-treatment life may be endan-
gered by btirsting of the peritoneal wound. Hochenegg points
out that, by reason of the sacral method, a large series of cases
are reported of carcinomata of the bladder; the ureter and
parametrium have become more or less involved and in-
creased the technical difficulties that complicate the opera-
tion. I have removed the uterus, ovaries, and tubes by sacral
resection in one case without injuring the rectum, and in two
cases with resection. of the rectum. All these cases recovered.
In one of the latter the operation consisted in the removal
of five inches of the rectum, the uterus, ovaries, and tubes,
the posterior wall of the vagina, and the perineum. The rectum
"was stitched to the skin over the sacrum and to the anterior
-wall of the vagina. This operation was performed for epithe-
lioma involving the rectum, extending to the perineal margin
around the anus, and in the parametrial tissue behind the uterus.
The patient had previously undergone a Maydl colostomy.
After the recovery of the posterior wound an incision was made
around the artificial anus and the two ends of the bowel were
raised and reunited, after which all fecal discharges took place
through the sacral anus. Thirteen months after the opera-
tion the patient returned to her home in Ireland, since which
time no knowledge has been obtained of her progress.
655. The Perineal Method. — Zuckerkandl, in the year 1889,
presented a method for extirpation of the uterus by an opening
between the vagina and rectum. With the patient in the lith-
otomy position, the intestine was raised toward the sacrum with
a / \ -shaped flap incision, whose nearly seven centimeters
long transverse portion lies in the half oval line in front of the
rectum, and whose angles upon each side extend to the ischial
tuberosities. After separation of the skin and superficial fascia,
and separation of the skin-flaps from the under layer, the pro-
jecting bundle of the external sphincter, which penetrates the
labial commissure, is separated and the lower part of the vagina
loosened from the rectum. The remaining part of the septum
is bluntly dissected until Douglas' fold is reached, when the
vagina is opened transversely, the uterus drawn out from be-
hind, and its extirpation occurs as readily as in the sacral method.
The peritoneum is closed, and, after removal of the uterus.
the ligament stumps can be buried in the peritoneal cavity or
placed by sutures extraperitoneally, as in the vaginal method.
Frommel seems to be the only one who has found this operation
practicable. He holds it advantageous to cut about the vagina,
as in the vaginal method, push back the bladder, pack the
vagina with iodoform gauze, and then perform the perineal
operation. The operation is quite bloody, as the numerous
814 GYNECOLOGY.
venous plexuses between the vagina and rectum are opened.
The operation seems an unnecessary interference with the
pelvic floor, as the same increased room will be secured bv
enlarging the vagina and the danger from infection must neces-
sarily be very greatly increased,
656. The Mortality of Abdominal and Vaginal Operations.—
The operative mortality must necessarily be governed by the per-
centage of carcinomatous cases submitted to operation. The
surgeon, who finds but 20 per cent, of his cases operable, accepts
less risk than the one who operates 50 or 60 per cent, Thtis,
in a Berlin clinic, out of 402 carcinoma cases, but 83 were found
operable. Wertheim, in his first series, operated but 29 per cent.,
while in the last, 5 1 per cent, were operable. The mortality may
also be influenced by the character of the operation. The radical
procedure, which aims to remove the parametria! tissue and the
infecte<3 glands, must necessarily be attended with a large mor-
tality. Wertheim had from 10 to 40 per cent, respectively in
his last and first series. The mortality may be fixed at 6 to 10
per cent, for abdominal hysterectomy where ordinary care is
exercised to remove the adjacent parametrium without reference
to the glands, and from 3 to 5 per cent, for the ^■ag^nal pr<
cedure.
657. Duration of Recovery. — In the earlier operative work"
it was considered that if a patient survived the operation two
or three years without recurrence, she might be pronounced
cured, but further experience has demonstrated that recurrence
may take place up to the fifth year. After this lapse of time
the probability of permanent recovery is very great. There are
occasional cases in which recurrence after partial operation has
been disco\'ered as late as six, seven, or eight years. It would
be a question in these cases, however, whether it might not be
considered a condition similar to that whicli would take place
in a woman whose susceptibility to malignant degeneration was
great, and that the irritation produced in scar tissue would
favor such development and should be considered a primary,
rather than a secondary, condition. Frommel, in his investiga-
tions, has never seen recurrence follow after four years,
one hundred and eighty-eight cases of cancer of the neck
twenty-six cases of cancer of the body reported by Fritsch,
saw sixty-five free of recurrence at the end of one year, or 58.5
per cent, of the cases in the neck and 6g.2 per cent, of those in
the body. At the end of two years Olshausen saw one hundred
and forty-one, or 44.7 per cent., of the neck, and sixteen, or
8r.2 per cent., of the body, free from recurrence; at the end of
three years he reported one hundred and twelve, or 37.5 per
cent., of the neck, and thirteen, or 69.3 per cent., of the body.
;!ga- ^^
and^H
GENITAL TUMORS. 815
At the end of fotir years he found free from recurrence of cancer
of the neck eighty-eight, or 29.5 per cent.; of the body, eleven,
or 63.6 per cent. From this collection it is rendered evident
that in the first and second years after operation the great ma-
jority of recurrences appear, and then more and more the num-
ber falls off. The duration of life following an operation largely
depends upon the stage of advancement of the disease. Leopold
is quoted by Williams as having recorded a recurrence of 23.7
per cent, in early cases as contrasted with 66 per cent, in a more
advanced stage.
The final results of individual operators, however, are so
very different that it is impossible in general to draw valuable
conclusions from them. Thus, Kaltenbach, with his brilliant
primary operative results, evidently extends the indications
for the operation quite far, and subjects all cases to it in which
it seems technically possible. It is quite readily understood
that in such a number of cases there must be a few in whom
the new formation has advanced proportionately far, and that
relapse is not surprising. Leopold, on the other hand, drew
the indications very narrowly. The investigation of statistics
demonstrates that the vaginal operation has given excellent
primary results, but, on the other hand, it shows that, of all
the radical operations to which patients are submitted, after
a year in one-half recurrence has followed, and that it recurs
in the second year in a still considerable percentage. The
gravity of the disease can be still further appreciated when
we realize that only a small percentage of the cases which come
under the observation of the gynecologist are in a condition
to permit of radical operation.
658. Recurrence. — Those cases subjected to radical opera-
tion when the parametrium is without doubt extensively in-
filtrated are not only immediately followed by recurrence of
cancer, but a fatal termination is also very rapid. Tannen
has proved that the duration of life in such recurrence of the
disease is briefer than it would have been had the disease been
let alone, for duration of life of eight and nine months for
patients in whom the disease thus recurs is less than would
be secured by such palliative treatment as partial resection or
energetic cauterization of the diseased area. Sanger and Thorn
have shown that by the latter the duration of life is lengthened.
Surgeons, from their experience in mammary cancer, are in-
clined to combat these views, but statistics do not support
them. As contraindications, then, against total extirpation
are to be considered great enlargement of the uterus and ex-
tensive adhesions, especially with intestine. Those uteri should
be excluded from vaginal operation which can not be removed
816 GYNECOLOGY.
through the vagina without morcellation. To this class belong
those carcinomata which are complicated with myomata. Preg-
nant and puerperal uteri are proportionately easy to remove
by the vagina, in spite of their enlargement, as has been demon-
strated by Olshausen, Hofmeier, and others, and the compara-
tive narrowing of the vagina observed in the nullipara and in
old women exhibits no contraindications to the vaginal opera-
tion.
The primary operations are so satisfactory that we could
scarcely wish them otherwise. Olshausen's one hundred total
extirpations with but one death, when some of the patients
were already pyemic, are positively brilliant resxilts. Winter
describes three forms of recurrence: (i) Local or recurrence
in the wound — a return of the cancer in its primary kind within
the compass of the field of operation; (2) lymph-gland re-
currence, and return of the tumor in any lymph-gland of the
body; (3) metastatic recurrence. Dissemination by the blood-
vessels leads to the development of the tumor in the more in-
ternal organs. The first is produced either by portions of carcino-
matous growth which have been overlooked in the operation
or fragments that have been broken off and foimd lodgment
in the folds of the wound. These correspond more or less to
the neighborhood of the previous operation, which demon-
strates the correctness of Thiersch's view, confirmed by Heiden-
hain's investigation on mammary cancer, that the carcinoma
frequently extended itself far over the lateral or immediate
limits in small sprigs, and that, after the removal of the new
formation, the mass is seen to be separated by healthy tissue
from visible sprigs or microscopic cancer-nests that may be
the source from which the cancer redevelops.
Our study of the progress of the disease has already illus-
trated the extension of carcinoma of the vaginal cervix in the
vault and parametrial connective tissue. Mackenrodt and
Leopold, in their anatomic investigations of extirpated parts
of the parametrium, have demonstrated fine, microscopically
perceptible sprigs situated in remote parts of the parametrium,
and it is quite possible that such fine sprigs may be foimd out-
side of the incision as well. It is, consequently, difficult to
be certain whether wound relapse occurs from sprigs of cancer
growth in the parametrium or from small masses which have
been broken off from the diseased tissue and been implanted
upon the new wound. Most generally the patient gains in
body-weight and improves in appearance after the operation,
but individual cases will be found to exhibit pain in the depth
of the pelvis at an early period, which radiates from the lower
extremities, and frequently becomes very distressing. In
GENITAL TUMORS. 817
its further course there is edematous swelling of the lower ex-
tremities, not rarely venous thrombosis; in other cases, bleed-
ing and discharge, which cause the patients to return for in-
vestigation.
The diagnosis of carcinoma recurrence is mostly fixed with-
out difficulty if we make a combined investigation from the
rectum, with the thumb in the vagina, by which the penetrated
parametrium can be fixed between the finger-tips. Hemor-
rhage may sometimes take place in granulations which are
formed about the ligatures, especially if silk has been used.
When the appendages have been left, a mass may be felt in
the vagina that has a soft sensation. The cause of bleeding
upon an exact examination is recognized as the fimbriated end
of the tube. The absence of infiltration and the impossibility
of separating the small tumor masses from a polypus of the
vagina contraindicate carcinoma. In doubtful cases the tissues
should be examined with the microscope. Another form of
recurrence is that of which Winter speaks as infection-relapse ^
in which portions of carcinoma are broken off, come in contact
with healthy tissue, there lodge, and develop the original dis-
ease. In a single woman upon whom I operated to remove a
small uterus through the vagina the operation was attended
with considerable difficulty; the fundus uteri was torn open
in attempting to bring it down, and some jelly-like material
escaped into the peritoneal cavity, which was thoroughly ir-
rigated as soon as the operation was completed. I^ss than
six months later the patient developed a mass upon the side
of the pelvis corresponding to that into which this fluid material
had escaped, and, upon opening the mass, material similar
to that which had escaped from the uterine cavity was found,
and the disease progressed and eventuated in the death of the
patient.
The second form of recurrence is a lymphatic gland recur-
rence. The investigations of Poirier and Leopold have demon-
strated that the lymphatic vessels of the middle and upper
thirds of the vagina and from the cervix proceeded to the iliac
glands along the course of the iliac vessels and at the sacro-
iliac articulation in the angle formed by the separation of the
external and internal iliac vessels. The lymphatic vessels
of the uterine body proceed to the upper margin of the broad
ligament and follow the spermatic artery to the vertebral column,
where they open into the lower lumbar lymphatic glands, which
are situated behind the peritoneum in the neighborhood of
the large vessels. Fortunately, lymph infection occurs late
in cancer of the uterus, so that lymphatic ^land recurrence after
total extirpation is a rare condition. After chloroform narcosis
52
820 GYNECOLOGY.
to j^rotect the vagina and external genitalia with wooden re-
tractors. To avoid too much absorption of light from the depth
of the cavity by their dark color, their inner surfaces should
be coated with a thin layer of qtiicksilver. In addition are
needed sharp carets, scissors, forceps, needle-holder, and needles,
the latter for use in case of fistula, though they are seldom
required. We should also have ice- water for irrigation, and
sponges or pads or, still better, cotton or gauze pads upon long
forceps. Although the use of the curet is not painful, it is
advisable for the patient to be under an anesthetic, as the fear
of burning would be so great that an effectual application of
the hot iron could not be made.
While the patient may not ask the character of the dis-
ease, her fears cause her to anticipate the worst, and her con-
fidence in what is being done for her will be dependent upon
its apparent gravity, and the abatement of the s>Tnpioins
which follows the procedure permits her to secure new courage.
It is well that she should be assured that we do not expect
to remove completely the discharge, and that subsequent treat-
ment may be necessar}-. She is thus saved from utter desc^
upon the return of the discharge.
The procedure is as follows: The patient, narccdzei is
placed upon an op^erating table and the parts are clearsed
as thomughly as the condition will permit; the new frmaM
is exposevi with retractors and as much as p-:s5irle :: the rssae
is scrajxxl away with a sharp curet, reaching tbe frm irflra-
tion zone. In the softer parts of the cancer tbe hem.rrrhaac
is considerable, but becomes less as the innlmiti'rn rcre is
reached, because there the vessels still retain their c-mtrscie
power. To limit the bleeding, then, it is intprrtant t: zry
ceed rapidly with the curet. As we proceei. the scrarei n^ssses
are removed by irrigation with ice- water, cr. rrrrahl-r er^aly
etfectively. with water at a temperature of i -z- r T:^ m-
gation enables us the better to inspect the operative
fingvr must be employed occasionally to ;t:ii?e :f t
and of the amount of resistance, especiaZ^r r: thin re
ticu'arly in the posterior \*aginal \-ault ani r^-er t
to assure ourselves that perforation wiZ n*:t :or:rr ir-i ±s^
t::e r.ew :om:ar:on has been surrcfently remr-.-^l
ourt^: oar. be entrloyed to remove ftmher mr:s m t
c.i\*".:y. Shre-.:s and ragged masses which el:i?£e the rr^t £^
sei-rei w-:::: :\ rcers and cut away with sctssrrsw an-i the rJse--
:nc :s .\n:r:lle\i bv nrm rressure with ci:i::e -Ieh£-=:? A
GENITAL TUMORS. 821
It has been advised that the thermocautery be followed by
coating the vaginal walls with vaselin, impregnating the diseased
structure with alcohol and igniting it, allowing it to bum for
one-half minute to a minute and a half, but it is difficult to con-
fine the injury produced by this procedure to the diseased struc-
ture. WTiere there is a disposition to bleed after the application
of the cautery, it may be controlled by injecting with a hypoder-
matic syringe i part of a i : looo solution of adrenalin chlorid to 4
of distilled water. After the oozing has been controlled, the ex-
cavated cavity should be packed with a 2 per cent, solution of
formalin. This agent has a caustic action and is more particu-
larly selective of the malignant infiltrate. The packing must
be carefully covered in order to protect the healthy structures
from contact with the acrid discharges. In the most favor-
able cases cicatrization is produced. With cicatrization the
cavity shrinks and is much diminished. The action of the
Paquelin thermocautery must be prolonged to be most effective.
It must be frequently removed, because blood and shreds of
tissue rapidly coat it. The removal is also done to permit the
tissues to cool, that undue scorching may not occur at undesir-
able points. When the hemorrhage is quite profuse, •it is im-
portant to bring the entire cavity at once in contact with the
cautery. After the hemorrhage is incidentally controlled,
we see, here and there, blood trickling and oozing from small
points, which must be resubjected to the cautery until the
cavity is lined by a thick, dry eschar. Especial care must be
exercised toward the vaginal margin, for bleeding will con-
tinue there the longest.
To secure a deep, dry eschar, we use irrigation with ice-
water at intervals only in the early part of the treatment, and
later withdraw and cool the retractors, or retain them in the
vagina and cool with a pad wet with ice-water or, better still,
control the oozing with the injections of adrenalin. Should these
precautions be omitted, the vagina will become severely burned
in prolonged operations. With the wooden retractors the danger
of burning is lessened, but the long employment of the cautery
will require an occasional cooling of the cavity. The procedure
concluded, the cavity should be packed with formalin gauze. •
In properly selected and carefully managed cases the danger
of the procedure is slight, and it can be accomplished with-
out injury to the bladder or the peritoneum. Injuries to the
latter are usually not serious. The hemorrhage may be con-
siderable, though it is generally controlled without difficulty
by the methods suggested. A ligature is rarely required, for
the cautery is competent to control even arterial bleeding.
In the rare cases of inoperable cancer of tlie uterine body great
822 GYNSCOLOGY.
prudence must be exercised to prevent the cautery from per-
forating the thin walls. The finger can generally enter the cavity,
by which the weak places can be recognized and undue pressure
against them avoided. The procedure is usually borne with
but little discomfort. The patient will scarcely complain, unless
we ha\'e unfortunately made an eschar upon the external geni-
talia, which is very painful and soon becomes edematous.
After the procedure is completed the vulva should be covered"
with vasehn, and, in the most trifling external burning, a;
pad should be applied, which is frequently wet with lead-water
and laudanum, or a carboHc-acid solution should be appUed
to the external genitaUa. Slight elevation of temperature is
generally noticed after such operations, but they exert no marked
influence upon the general condition, and the temperal
subsides in a few days.
Parametritis and septic processes are rarely observed,
tampon should remain five or six days. The eschar will be
found to have partly separated under trifling suppuration,
and the cavity will be more or less diminished. After with-
drawal of the tampon the loose-lying tissues are carefully re-
moved. The exercise of force must be avoided, because it
causes hemorrhage. The cavity is sponged, and we await the
complete separation of the slough. Treatment after the re-
moval of the eschar is directed to the securing of cicatrization.
Olshausen lauds for this purpose tincture of iodin. He employs
the stronger solution:
rjcea ^^
.tUTQ^^H
Th<I^|
It is applied by a saturated pledget of cotton, which is pressed'
lightly against the cervix. The superfluous portion flows
back into the bowl of the speculum, from which it may be used
over and over. The alcohol is an excellent antiseptic.
The patient should be advised to wear a napkin after the
application to protect the clothing. The appHcations are made
every two or three days until the cavity contracts and becomes
clean. In favorable cases a watery discharge, sometimes tilled
with blood, follows, which has entirely lost its offensive odor
and is so slight that the patient considers herself cured. Torg-
gler tampons the vagina with iodoform gauze saturated with
peroxid of hydrogen and permits it to remain for three or four
days. The surface is scraped with the sharp curet, subjected
to the thermocautery, and covered for a few minutes with
cotton soaked with a 40 per cent, solution of formaldehydi
Six to ten days later a slough is thrown off, which leaves a dryj
wound.
GENITAL TUMORS. 823
Caustics. — Sims followed the use of the curet by an applica-
tion of zinc chlorid solution. Hemorrhage was controlled by
pledgets wet with a solution of persulphate of iron, which were
removed and followed by tampons wet with the zinc solution.
Van de Warker used a 50 per cent, solution of the chlorid of
zinc. After the use of the curet small pledgets, squeezed from
a 50 per cent, solution of zinc chlorid,. are placed against the
diseased surfaces. The healthy tissues are previously pro-
tected from injury by an ointment of bicarbonate of soda in
vaselin. These medicated pledgets are so placed as to come
in contact with the entire diseased surface; over them a piece
of dry absorbent cotton or gauze is laid, after which the vagina
is filled with a wad of cotton wet with a saturated solution of
bicarbonate of soda.
The carbonate causes a decomposition of the zinc salt, which
renders it nonirritating to the tissues. The nurse can press the
superfluous agent out of the pledgets without injury to her fingers
by first anointing them with vaselin. Without the precaution
above directed, the vagina, and especially the introitus, would
be badly burned; indeed, in spite of every precaution the vagina
is frequently seriously injured. Where the wall is thin, as over
the bladder, the weaker solution (5vj to f.^j) employed by Sims
should be substituted. Sims left the tampons undisturbed for
four or five days, imJess earlier removal was indicated by eleva-
tion of temperature. He ascribed to the agent no especial influ-
ence upon the cancer beyond its active destructive effect, but
Van de Warker believes the drug to have a special affinity for
the cancer tissue, selecting it and leaving the healthy tissue. The
microscopic investigations of Ehler upon this subject, however,
demonstrate the contrary — that the cancerous tissue is only super-
ficially affected, while necrosis of the healthy tissue extends to a
considerable depth. Frankel employs the zinc salt, but previ-
ously scorches the surface with the thermocautery. He leaves
the pledgets in contact with the affected surface for twenty-four
hours. Great care must be exercised in the cases for which this
treatment is employed. Should the bladder or posterior vaginal
wall be infiltrated, or if these parts are insufficiently protected,
fistulae may form, which greatly aggravate the subsequent con-
dition of the patient. A slough resulting from the application
may open the bladder, rectum, or peritoneal cavity. During or
following the separation of the slough, a hemorrhage so severe
as to cause a fatal result may readily occur. When the slough
has separated, exuberant granulations develop, and later strong
cicatricial contraction and shrinking, which Fritsch indicated as
the cause of extraordinarily severe pain, which is aggravated by
the increased infiltration above the scar tissue.
824 • GYNECOLOGY.
Ricard relates the history of a patient in whom hematometra
and hematosalpinx followed the introduction of zinc chlorid
pencils into the uterus. The scar tissue was so dense that the
collection could not be reached per vaginam, and the woman
perished from hemorrhage after laparotomy. The cervix and the
greater part of the uterus had degenerated in cancer. Many
patients in whom this treatment has been employed have been
so much improved as fully to justify its practice in similar cases,
but strong solutions and the paste should, be absolutely in-
terdicted.
Fraipont advocates the use of liquor ferri sesqui chloridi, from
which he obtained excellent results. This agent has a superficial
action upon the surfaces to which it is applied, and forms a
slough, following the discharge of which hemorrhage is likely to
recur. The bleeding following the curetment can only be incom-
pletely controlled by pressure with an iron solution. A better
application is a tampon of iron chlorid. Cotton is saturated with
this substance and packed against the surface. These pledgets of
cotton form hard lumps, which are difficult to move, and are
only slowly separated under strong suppuration or discharge. An
early attempt at their removal is attended with severe pain and
hemorrhage.
Leopold advocates the use of a concentrated carbolic add
treatment which he continues from one to two months. After
radical scraping and scorching with Paquelin's cautery he felloe's
it by cureting the surface every three months and plunging
the cautery into the new-growths so that the tissue is rapidly
scorched. Chrobak used, after cureting, repeated cauterization
with nitric acid. Out of sixty-five cases so treated, he attained
good duration results. In one of these cases, after radical slough-
ing of the carcinoma of the cervix three years and nine months
later, because of the strong scar tissue, there had formed a hema-
tometra, which was emptied twice. In other cases after repeated
cureting and cauterization strong scar formation was seen at the
end of three years without recurrence. The third patient still
Kved five years after operation, free from recurrence.
This treatment does not seem to have stood the test of time,
and is now scarcely considered. Goodell advocated in inoper-
able cancer the use of applications of powdered pepsin and sal-
icylic acid — pepsin to digest and eat off the diseased tissues,
salicylic acid to prevent decomposition. Cucca and Ungara
advocate tampons wet with:
B . Methyl-blue, gr. xc
Alcohol (95 per cent.),
Glycerin aa f 7 iij
Water ^ 3 vij. M.
Apply to the diseased surface.
GENITAL TUMORS. 825
•
It arrests hemorrhage, aborts discharge, and prolongs life.
Parenchymatous Injections. — Various agents have been em-
ployed as injections into the structure of the cancer with a view
to moderating its course or destroying it. Thiersch used nitrate
of silver; Schramm, chlorid of sodium and sublimate. Mosetig-
Moorhof and Stilling employed pyoktanin. Schultze has lately
used injections of absolute alcohol in a large series of cases. Bern-
hardt employed a 6 per cent, solution of salicylic acid in 60 per
cent, alcohol. VuUiet, independently of Schultze, has practised
the treatment with absolute alcohol. Under this treatment the
bleeding and discharge were trifling or ceased entirely. After ten
or fifteen injections the evil smell of the discharge disappeared
and the pain ceased. Treatment, in the beginning, should occur
at intervals of a few days. During the intervals the vagina may
be tamponed with iodoform gauze. In the course of weeks or
months the ulcer heals and the infiltrate disappears. Schultze
suggests that when the injection is in the neighborhood of the peri-
toneum, the after-treatment is painful. Schramm found the in-
jections painful and without special influence. The treatment
has to be continued over weeks and months — a requirement that
can be carried out only in rare cases. Without question, better
results will be obtained by the use of the curet and the thermo-
cautery.
A. Martin, in inoperable cases, advocates suturing the wound
surface occasioned by the curetment. Tlie carcinomatous masses
are removed with the sharp spoon and the parametrium is ligated ;
then, drawing down the uterine stump, strong curved needles are
passed under the entire wound surface to the border of the neck
or to the mucous membrane, and the thread is so secured that it
brings together the wound surfaces created by the curetment. In
a very extensive wound the entire pelvic body is protected by a
mattress suture, when the mobility of the stump is so limited that
it is impossible to accomplish the partial sewing of the wound
surface. The vagina is so sutured in the depth of the crater that
a continuous series of firm sutures come to lie about the opening.
The operation, however, is frequently impracticable, because ex-
tensive cavities with strong infiltrated walls are involved. The
advantages offered by the method are that hemorrhage is
securely controlled and that after-hemorrhages do not appear.
The patient is spared the suppuration which follows the caustic,
and it forms a firm scar. Houzel and Chrobak have seen good
results from suturing. The method, however, is applicable only
to a limited number of cases, and frequently offers great technical
difficulties. Sutures will often cut through the carcinomatous
tissue ; sometimes the wound surfaces break apart, and suppura-
tion again follows. The reported good results are less from the
826 GYNECOLOGY.
suture of the wound surface than from the union with the para-
metrium.
A class of cases will be found in which the disease is so exten-
sive that no palliativ^e operation will afford relief, but the phy-
sician endeavors to make the patient comfortable and must
relieve the distressing symptoms. These are hemorrhage and pro-
fuse offensive discharge. The latter becomes so disgusting as to
be distressing to the patient and to those about her. Local treat-
ment is demanded. Syringing and tamponade with w^et or dry
dressings come under consideration. The control of hemorrhage
is accomplished more effectually by the tamponade than by
syringing with astringents. Kehrer employed the tampon ^ith
cotton gauze saturated in an 8 to lo per cent, solution of acetic
alum. Iodoform gauze also exercises a good influence upon the
smell of the discharge, but through long employment the odor
of the iodoform bec(>mes persistent and annoying.
The dry treatment, introduced by Sanger and employed by
Fritsch, often proves beneficial, though it requires medicinal help
in order to carry it out. It may be employed alternately with
injections. The dry treatment follows curetment and cauteriza-
tion. Iodoform is blown into the vagina, which is then firmly
tamponed with iodoform gauze. Tamponades covered with iodo-
form may be introduced, and may remain as long as possible.
This treatment should be repeated once or t\^dce a week for some
time. It controls hemorrhage, but especially keeps down the
unpleasant smell of the discharge. The unpleasant odor of the
iodoform and the existing danger of intoxication have led to the
substitution of tannin and boric acid and salicylic acid for similar
purposes. Torggler employed charcoal pow^der w4th iodofonn.
which deodorized the mixture ; the ulcerated surfaces were rap-
idly cleaned. Long-continued sitz-baths often have a beneficial
influence and afford the patient great relief. When penetraticffl
of the bladder occurs, the patient may keep herself comparatively
comfortable by wearing a urinal.
It is important that the patient should be kept out of bed as
long as her strength will permit. When once she becomes bed-
ridden, her condition is made worse, and the psychic depression
is more marked. It requires the greatest cleanliness and most
continuous care upon the part of the nurse to limit the occur-
rence of bed-sores, as the continuous and abundant discharge
keeps the parts wet, and in emaciated persons with feeble powers
of resistance the skin becomes broken and extensive bed-sores
follow. In these enfeebled patients it is not to be expected that
the loss of substance will be recovered, and scarcely that the
wound surface can be kept clean. By the processes of absorption
GENITAL TUMORS. 827
from the wound surface and the breaking-down cancer, the
patient soon has regular elevation of temperature, which aggra-
vates the discharge. It is not worth while giving antipyretics
for the elevation of temperature in these cases, as they have but
trifling influence, and soon break down nutritive processes. A
mixture of salol and aristol has been employed with advantage.
When the patient is imable to be continuously under medical
treatment, resort must be had to irrigation. The entire series of
antiseptic means have been employed; injections of permanga-
nate of potash, one to two teaspoonfuls of 5 per cent, solution in
a gallon of water, is one of the best. The drug is cheap, and
possesses the advantage that the patient is using a substance that
does not irritate or burn, is completely odorless, and is an excel-
lent disinfecting fluid. It has the advantage over the phenols
that the peculiar smell of the latter, mixed with that of the
cancer discharge, soon annoys the patient. Martin recom-
mended for a deodorizing injection a solution of 3 per cent, hy-
drogen peroxid with i per cent, thymol. Various astringent
fluids, as pyroligneous acid and alum solution, are favored.
If penetration of the bladder and rectum has already resulted,
the patient is in a condition wliich makes it impossible to render
her comfortable. Tampons saturated with fatty or oily mix-
tures, such as bismuth salve, can be employed. The discharge
is thus sometimes held back, but the continued irritation of the
parts results in an excoriation eczema of tlie external genitalia,
which is a new source of torment f(.)r the unfortunate patient.
In such cases the removal of tlie disagreeable odor is no longer
possible. In patients suffering from edematous external geni-
talia covered with excoriations and ulcers, an<i from already
existing edema in the lower extremities, irrigati(ni is verx^diflicult,
and is practicable only under increase of pain. C(.)vcring the
lower extremities with a rubber skirt, by wliich the odor is pre-
vented from rising, has been advocated, but the moist warmth
thus engendered soon renders it unbearable. Fritsch advocates
completely covering the vulva and the inner surface r>f the thighs
^^'ith frequently changed pads wet with chlorin water, and tlms
destroy as much as possible the offensive odor.
When the disease is far advanced, neither the greatest clean-
liness nor the admission of fresh air to the sick-room is sufficient
to drive out tliis odor, and the patient becomes a source of dis-
comfort to herself and to those who attend her. Anorexia makes
itself noticeable early. This is undoubtedly due to the influence
of the^sickening odor upon the appetite. Every form of food be-
comes absolutely repugnant, and the i)atient is obliged to confine
herself then to the smallest quantities of liquid nourishment.
Sometimes these are more readily taken when cold. Patients
828 GYNECOLOGY.
frequently live for a remarkable length of time with scarcely any
nourishment. The relief occasioned by the removal of the odor
usually results in the improvement of the appetite. Obstinate
constipation becomes a marked symptom, which also acts unfa-
vorably on the appetite. When evacuation occurs, it is so
extraordinarily painful, because of the hard infiltration in the
pelvis, that the patients are constrained to avoid defecation in
order to escape the pain. Large enemas are better than purga-
tives in such cases. An enema of one-half to one pint of kero-
sene will frequently have a salutary'- effect in emptying the
bowel. Of course, if a rectal fistula exists, the enema can
not be employed. The uncontrollable vomiting which marks the
advent of a uremic condition is an exceedingly distressing s\Tnp-
tom. Occasionally, the administration of diuretics will relie\'e
it. The condition of the urinary secretion should be obsen-ed;
any failure should be an indication to administer diuretics, by
which the appearance of vomiting can be prevented.
In the later stages the third distressing symptom is pain,
which can be avoided only by the free use of narcotics. The only
hesitation in the administration of narcotics should be to avoid
their too lavish use early. The patient who becomes accustomed
to large doses of the narcotics, when she reaches a stage at which
they are still more seriously needed will have become so inured
to the drug that she can no longer find relief. Early in the dis-
ease it is better to employ remedies which will give a sHght
anodyne effect in place of the narcotics. Antipyrin has been
found effective. In extensive infiltration involving the lateral
and posterior parts of the pelvis this remedy is useless. Such
cases are relieved by rectal suppositories containing:
Uk . Morphin sulph gr. i
Pulv. opii pur., . gr. |
Pulv. belladon gr. \
01. theobrom , ad gr. xx.
Ft. supposit.
Such a suppository, given at night, relieves the distress, secures
sleep, and delays the need for the larger doses of morphin. An
additional advantage is that by such a combination we can in-
crease the dose and give the patient the prescribed daily ration
which she will require. Codein may be given in pill form. In the
later stages of the disease only the subcutaneous employment of
large doses of morphin will afford relief. Fortunately for the
patient and her relatives, toward the end of the disease' the com-
pression and obstruction of the ureters occasionally cause
sufficient uremia to obtund the general sensibility and lessen the
discomfort. The soporose and comatose conditions are frequent.
and increase the comfort of the patient. Cumston's proposition
GENITAL TUMORS. 829
to relieve the obstruction by establishing a ureteral fistula or
performing a nephrotomy should receive no consideration. In
advanced stages Drszewczky claims benefit from an ointment of
extract of condurango and vaselin.
660. Pregnancy Complicating Carcinoma. — We have already
Sf)oken of the occurrence of pregnancy as a complication of car-
cinoma— a complication which is fraught with the greatest danger
to two lives. It was stated that the treatment would entirely
depend upon the progress of the disease. Thus, if the disease
was inoperable, and there was no possible chance for the mother,
every effort should be made to prolong the pregnancy to full
term or to viability of the child, in order that it should have a
chance for its life; when, however, the disease is operable and
there is hope for a radical cure of the patient, no consideration
for the child should operate against the mother's chances. The
continuation of the pregnancy is doubtful, and it is attended with
improbability of the child being delivered alive. Danger to the
mother is very greatly increased, with almost the certainty that
the progress of the disease will be so rapid that at the termination
of pregnancy the time for radical treatment will be found to be
past. Under such circumstances the proper consideration is the
life of the mother. If the pregnancy has not reached the fourth
month, we may proceed to the removal of the uterus per vaginam.
Emptying the uterus reduces its size and renders easier its sub-
sequent removal through the vagina. During and after the
fourth month the operation should be performed through the
abdomen. Between the fifth and seventh months we may be
governed by the condition as to whether we wait for viability
or proceed to immediate operation. If the disease is apparently
progressing rapidly, an operation should be done immediately,
without regard to the child. We may resort to an abortion,
and then operate through the vagina, or the abdomen may be
opened. In advanced pregnancy Martin has advocated the
supravaginal amputation of the uterus and the extirpation of
the carcinomatous cervix by the vagina. The advantages of
this procedure are that the abdomen is kept open but a short
time, that the hemorrhage can be better controlled frofn below,
and that the carcinomatous masses are not drawn back through
the abdominal cavity. Of six patients thus oj)erated upon,
one died of septic peritonitis. In the last two months of ])reg-
nancy we have to consider the treatment which has in view
the preservation of two lives. Cesarean section should be per-
formed, which is followed by a I^'^round abdominal, the Zweifel
combined, or, finally, the jmre vaginal total extirpation. Of
these procedures, the alxlominal o])eration seems ]^referable.
We come next to the consideration of operable carcinoma in
830 GYNECOLOGY.
labor. Here we have the possibility of a spontaneoiis ending of
labor through the diseased passages. This may be considered, if
the disease is still in the early stages. If the carcinomatous infil-
tration has not involved the entire portio, and a more or less
large zone of the uterine margin remains free and capable of
dilating, the ovum may be thus extruded. When the carcino-
matous masses can not be crushed by the head, they should be
cut away with scissors or the thermocautery as a preliminary,
and the child should be delivered by forceps or by version. If
the ovum is dead, its size may be diminished by perforation or
by piecemeal operation, whichever will end the labor most effect-
ively and in the best manner for the mother. Follo^ving the
delivery we may consider immediate vaginal total extirpation,
or its delay until the second week of the puerperitmi. The delay
in these cases is suggested because of the size of the uterus. The
advantages of the procedure, however, are that the uterus permits
itself to be readily drawn down to the vulva, and that the wall
of the vulva and the vagina have been so distended by the pas-
sage of the fetus that they do not afford an artificial hindrance.
Occasionally, the size of the uterus affords difficulty. It can then
be reduced by splitting it into two parts in the median line, but
this endangers the reinfection of the wound.
66i. Summary. — In the discussion of the subject of cancer I
have endeavored to give a comprehensive view of the methodSi
by which the disease can be combated, .^s such a statemeafel
must be, however, more or less confusing to the student, it is
my purpose in this section to briefly present the indications for
special treatment. The two principal methods of treating
operable cancer are by the abdominal and vaginal routes. The
sacral method affords no advantages which render it worthy of
consideration. When the uterus is large and the disease has
evidently extended to, if not into, the parametrium and is com-
plicated with myoma, ovarian tumor, or the later stages of
pregnancy, or when the vagina is undilated and narrow, ab-'
dominal hysterectomy should be preferred. Vaginal hysterec-
tomy when carcinoma is limited to a uterus freely movable, not-
too large and accessible through a roomy vagina, has been thO'
operation of election. The after-results, however, have demon-
strated that Vaginal hysterectomy, as ordinarily performed, is'
ineffective in that it does not afford opportunity for the remo\'al
of sufficient tissue to insure against early recurrence. The
operator should keep two objects in mind in proceeding to per-
form any operation for carcinoma : ( i ) To insure the removal of
a diseased organ in a healthy field, wliich is accomplished where
possible by the removal of the upper part of the vagina and
as much parametrial tissue as safety for the ureters and bladd<
I
GENITAL TUMORS. 831
will permit, thus getting beyond the isolated nests, which may
be situated in the parametrium; (2) the exercise of such pre-
cautions as will avoid the implantation of cancerous material
upon the healthy wound.
In the vaginal of)eration we have the choice of three methods
of procedure for the control of hemorrhage. These are the
employment of pressure forceps or clamps, the electric cautery,
and the ligature. The clamp procedure has the advantage of
being more expeditious, enabling us to remove the uterus in
favorable cases in a very few minutes. It has the disadvantage
that it produces an increased amount of pain, from the weight
and dragging of the clamps and the necessity of the patient being
confined to the dorsal position. The retention of the clamps
produces a certain amount of necrotic tissue in the peritoneal
cavity after removal of the clamp, and causes increased danger
of septic infection. The removal of the clamps, often as late
as forty-eight hours, is sometimes attended with quite free after-
bleeding, which may require their reapplication, under very great
disadvantage, in order to prevent the death of the patient from
hemorrhage. In a large hospital where there is a convenient
electric-light plant or connection with the street current can be
made, the electrocautery is ideal, otherwise it means the employ-
ment of special apparatus, which is cumbersome and requires
expert skill to manage and maintain in order. The ligature method
is slower than the clamp, but the hemostasis is more sure and the
comfort of the patient is enhanced during convalescence. Cat-
gut is j)referable to silk for the ligature, l^ecause the latter liga-
ture is likely to l)ecome infected, after which the silk will cause a
sinus granulation and a discharge, which continues until the
ligature disintegrates, sloughs away, or is removed, and causes
worr\'' and distress to the patient, inducing her to believe that
the disease has recurred.
In performing an abdominal hysterectomy the method sug-
gested in Section 578 is the i)ro]XT course. The uterine arteries
should be ligated separately near their origin, the course of the
ureters ol)ser\'e(l, and an extensive removal of the parametrium
and u])per part of the vagina made. This ])rocedure, in my
judgment, is more important than the removal of glands. Before
closing the wound, bleeding vessels are carefully secured. When
there is much oozing or a large surface has been denuded of
peritoneum, gauze is carried through the opening into the vagina,
packed into the cellular tissue upon each side, and the peritoneum
united over it by a continuous catgut suture. The abdominal
ca\4ty is cleansed ; the wound is closed as in ordinary abdominal
procedures. The gauze packing in these cases may be left in for
fr »m six to eight days and then removed through the vagina.
832
GYNECOT.OGY.
662. Chorio-epithelioma Malignum. — Some fifteen years a^o
a condition was recognized as a form of malignant disease n^hich
is intimately associated -with pregnancy. (Fig. 531.) It has
been described under the various names of deciduoma malignum.
deciduomatous sarcoma, sarcoma deciduo-cellulare, blastema,
deciduo-chorion cellulare. syncytium carcinoma, syncytio malig-
num, the destructive bladder mole, destructive placental rxilvf!.
and the title of our section, chorio-epithelioma malij;nura.
These various designations indicate the attempts upiin the pan
()f the dilTcrent investitti'tors to name the structural origin of the
P'H' 5jii--Chorio-i7iithdioma of the Utems.
a. a. a, a. Nodules of neoplasm, b. Stump of round ligiimcnt. c. TUrombu* prj-
jfi-ting from ovarian artery.
condition. (Fig. 532.) It was formerly supposed to be due to
the degenerative changes resulting from a cyst mole, from which
metastases were carried by the veins to different points, and
growths of the similar epithelial structure followed. Later in-
vestigations, ho\\-e\-er, have disclosed that the mole is not nei-es-
sary to its development, although favoring its growth. Later in-
\'estigators agree with JIarchand that it arises from the sync>ii;u
cells, although there is still want of agreement as to whether these
cells are fetal or maternal (page 833).
Etiology. — -The disease occurs during the period of active
reproductive life and follows an abortion, either intra-uterine or
tubal, a normal labor,, and frequently a hydatid mole. The dis-
ease is not necessarily dependent upon pregnancy, for it has been
recognized in the unmarried woman and in the testicle of the
GENITAL TUMORS.
V".
Fig. S3*. — Chono-epithehoma Maligniim. (Section furnished by Dr», C. P.
Noble and S. E. Tracy.)
a. a. Large syncytial cells, b, Blood detritus.
A
Fifi- 533— Histologic Section of Chorio-epitliflioma.
a. Collection of large decidual cells. 6, b, b. b. Chorionic villi showing proliferation
of their cellular coverings, c. Large multinucleated cdl containing a vacuole.
834 GYNECOLOGY.
male. In such cases it has arisen from inclusion cells. It has
been attributed to want of nourishment in the villi. The condi-
tion has occurred during pregnancy, as Pick reports a case in
which a tumor was situated in the posterior wall of the vagina,
which, upon removal, contained distended chorionic villi with
proliferated syncytial cells.
Symptoms. — In a few days to a few months following the
termination of a pregnancy a patient suffers from repeated
bleeding, increasing in severity, the patient becoming markedly
anemic. There will also be a profuse dirty, watery discharge.
The continued drain, the hemorrhage and discharge, give rise to
extreme weakness and a cachectic appearance. Curetment of the
uterus in a condition like this results in the removal of a vanong
quantity of soft, friable material, which looks like placenta and
bleeds freely. Oftentimes it will contain necrotic tissue, causing
an extremely offensive odor. Very frequently a metastasis in
the form of small round masses will be observed on the anterior
wall of the vagina, which, on being opened, will present tissue
similar to that removed from the uterus. Similar metastases
result in the formation of growths in other portions of the body.
Thus we may find it carried to the lungs, pleura, diaphragm,
spleen, pericardium, kidney, liver, intestines, and even the brain.
When the diseased tissue is cureted from the uterus, the patient
has but temporary relief ; hemorrhages again return, and a second
curetment will remove tissue similar to that which was found
in the first employment of this instrument.
Diagnosis. — Diagnosis is easy in the advanced cases, but diffi-
cult in early stages. It is determined both by clinical obser\'ation
and microscopic investigation. The rapid return of hemorrhage
after the curetment, in which no fetal products are found, the
foul discharges, the profoimd anemia, elevation of temperature,
large uterus, dilated os, soft friable tumor, and the metastasis,
with the revelations of the microscope, should render the diag-
nosis positive. The disease so closely resembles both carcinoma
and sarcoma as to render it difficult to differentiate between
them. Its structure having no stroma and being disseminated by
the blood-vessels rather than by the lymphatics, makes it closely
akin to sarcoma. From sarcoma, however, it is differentiated
by the fact that it is composed largely of epithelial elements.
Prognosis, — The prognosis is extremely grave. The only hope
will be in its early recognition and the prompt extirpation of the
uterus. Marchand reports twenty-eight cases with twenty-four
deaths. It is one of the most malignant of growths, and gen-
erally terminates in six months, whether operation is done or not.
Veit reported recovery after metastases had occiured, but this
is contrary to the general experience. In the extirpation of the
GENITAL TUMORS. 836
disease the abdominal operation is preferable, for the reason
that there is less danger of fragments of the tissue beir^ forced
into the veins.
663. Endothelioma Uteri. — A recently recognized form of
malignant disease which occurs in various tissues of the body
is known as endothelioma, and has its origin in the endothelial
lining of the blood- and lymph-vessels and the serous membranes.
These growths manifest themselves in many ways, according to
the structxares involved and the particular endothelium from
which they have originated- (Fig. 534.) The disease may occur
in the cervix, although extremely rare, and is very similar to that
Fi([. 534- — Endothelioma of the Utenw.
. Endothelial cells infiltrating lymph-spaces, b. Blood-cells.
of the squamous-cell carcinoma, and the diagnosis can only be de-
termined by the employment of the microscope. The examina-
tion of the section of tissue revealsthe squamous epithelium intact,
free from any infolding process projecting into the underlying
tissue. The growth consists of spaces lined by one or more layers
of cells, resembling lymph-spaces. Where these spaces are ob-
literated by masses of proliferative cells, there is a resemblance
to the squamous nests, but jn the latter the outer layer assumes
a cuboidal or more cylindrical form and tlie nuclei are more
vesicular. (Fig. 5.1,5.) When the ihsease involves the body of
the uterus, it is likely to form a tumor of considerable size.
836 GYNECOLOGY.
and in its course and progress will resemble sarcoma. Metastases
usually occur through the blood-vessels. In my own experience,
I have noted that it is very prone to extend upon the peritoneal
surface and result in the formation of numerous nodules over
the peritoneum, and even eventuate in intestinal obstruction.
Unless the latter symptoms occur, the disease is singularly free
from pain, the patient complaining rather of the progressive
emaciation and the continuous loss of strength. The prognosis
is very unfavorable, since the disease progresses by both the
lymph- and blood-\-essels, but more frequently by the latter.
664. Sarcoma Uteri. — Sarcoma of the uterus can involvOr
either the mucous membrane or the wall of the organ, and
hence is divided into two groups. Clinically it is found either in
the body or in the cervix,- more frequently in the former,
and this holds true in both its anatomic varieties. Sarcoma of
the mucous membrane is one and one-half times more frequent
than the same infection of the wall. It differs from carcinoi
in that it is a growth which springs from the connective-tis!
cells, the latter from the epithehal.
665. Varieties.— Sarcoma is divided into sarcoma of the cervix
and sarcoma of the body. Sarcoma of the cervix occurs generally
as grape-like clusters, protruding from the cervical mucous mem-
brane, and it is also called sarcoma colli uteri hydropictun pa-
pillae, and, from its grape-like appearance, sarcoma botryoides.
From their soft appearance they have been described as myxo-
matous, but Pfannenstiel says this condition is due to a form
of lymphedema. In the body of the uterus the disease may
occupy the mucous membrane or the mural structure of the
organ, and be either diffuse or circumscribed. Sarcoma of the
uterine wall arises in either the mural portion of the uterus or
from degeneration of a fibromyoma. The latter origin is regarded
as the more frequent. It is often very difficiolt to make certain
whether the disease has originated as a primary sarcoma of the
wall or from a myoma. When it is recognized as situated in
myoma or surrounded by myomatous tissue, the latter is evi-
dently its source. Where the myoma is associated with a sar-
coma which involves the adjoining tissue as well, the origin ma;
remain doubtful. Sarcoma of the mucous membrane overlying;
a 6broma is not infrequently observed.
666. Pathology. — Sarcoma involving the mucous membrane
occurs in the diffuse and pol^^poid forms. The former does not
necessarily involve the entire surface, like a fiingous endometritis,
but appears as a more or less circumscribed growth, from the siir-
face of which there are irregular projections, giving the new forma-
tion a roughened, often villous appearance. The polypoid variety
is nearly three times as frequent, both in the body and in the.
in
1
4
GENITAL TUMORS.
837
cer\-ix. Sarcoma of the mucous membrane is twice as frequent
in the body as in the cervix. The grape-Hke clusters, already
mentioned, protrude from the external os by the pedicle. The
extremities of these are soft, oftentimes easily broken down,
and they form a dense cluster, projecting from the os, in which
the different portions of it are molded or flattened by pressure.
They arise by a firm, more or less broad pedicle from the mucoTis
membrane of the cervical canal and project from the external
OS into the vagina, showing a great resemblance to the bladder
mole. While the foundation part of the new formation of the
cervical canal consists of firm, fibrous tissue, the vaginal portion
*. .. %• -. ...1' '*
Fig- iJS- — Sarcoma of the Body of the Uteruf.
a, a. Characteristic appearance of blood-vessels minus distinct wall, the wall
being formed by the malignant cells.
is strongly edematous, soft, almost fluctuating, and easily broken
down. The growth has a pedicle which is often thinned and
drawn out, made up of a number of individual berries which
are situated so close together that they are flattened. (Fig. 535.)
These vary in size from a grain of com to that of a grape, and
their stalk shows a smooth, moist, gUstening surface of a yellow-
ish-white, brownish, or blue-black color, alterations which are
produced by the entrance of blood into the tissues. The berries
are most often bluish in color, and in some places vitreous
changes are seen. The berry contains a bright or light yellow
fluid and collapses upon its escape. These projections, however.
838 GYNECOLOGY.
usually have about the appearance, if not the consistency, of
a mucous polypus. The growth takes its origin from the superior
layer of the mucous membrane and assumes the grape-like form
only after its extrusion into the vagina. This form is produced
by interference with the circulation from pressure upon the
pedicle, which, as a rule, causes edema and swelling of the intra-
vaginal portion. The disease progresses slowly, but is often
carried and disseminated by the blood-vessels. The indi\'idual
cells are mostly of the roundish or spindle form. Between them
is almost uniformly found a very fine intercellular substance.
Parts of the new formation are divided by fissures or ramifying
spaces, which, from the high cylindric epithelium and the nuclei
situated in the cells, are recognized as the cervical glands. These
glands are not sufficiently numerous to justify the appellation of
adenosarcoma, a term sometimes applied to the condition. The
diffuse form affects the body. Its progress is slow and it extends
upon the surface, showing great reluctance to the invasion of
the subjacent wall. As it follows the surface it is manifested
by large or small nodular papillary or villous projections. The
mucous surface begins to degenerate and hemorrhage appears.
In rare cases the muscular structure is rapidly involved. Gener-
ally the tissue involved exhibits a reduction in its vascularity.
When the vessels are specially abundant, it is designated as the •
hemorrhagic or telangiectatic variety. J
The appearance of a section of sarcoma is quite varied. The!
less the connective tissue present, the more homogeneous it!
appears. Most generally it is marrow-like, and, in advanced
stages, presents a soft, smeary, and very fragile mass. With an
increase of the connective tissue the borders are folded and irreg-
ular, inclosing a homogeneous section. The structtire undergoes J
marked changes under myxomatous alteration or serous penetra-1
tion, and not infrequently apoplectic nests are recognized and^
cysts are formed.
The muscular walls are especially resistant, and become
thickened, while the disease extends in the direction of the least
resistance, which is into the ca\'ity of the uterus. The uterus is
usually not enlarged; when it becomes so, it is uniform. The
uterus is hard or soft, according to the degree of extension. In
rare cases the growth of the disease and uterine hypertrophy are
simultaneous. Under these circumstances it attains to the size
of a child's head; in rare cases it shifts to the internal os and
causes severe hemorrhage, serous discharge, or purulent destruc-
tion. In rapid extension the tumor can reach the ribs. Occa- 1
sionally it penetrates the uterine wall, projects upon the peritc
neal surface, involves the peritoneum or the intestine, results ia
suppurative peritonitis, and death rapidly follows. It can become;'
GENITAL TUMORS. 839
encapsulated and penetrate the intestine or the abdominal wall,
and form a fistula. Fistulae of the rectum and bladder are rare
in sarcoma, but frequent in carcinoma. The disease seems
inclined to limit itself to the uterus, and metastasis to other
organs occurs late. The disease can grow through the uterus
and involve the parametric tissue, but this only in advanced
cases. A polypoid growiih may extend and fill up the uterine
cavity and lie upon healthy tissue without involving it.
Sarcoma of the wall appears in a rounded form, with folded
or lapped borders. The uterus is hypertrophied. Section of
such a tumor shows a yellowish-white or grayish-red surface.
The discharge is a milky, soft tissue, and its structure would
indicate that it had originated in a fibromyoma. It is very
difficult to decide whether the myoma is a cause or a coincidence.
A myoma is not infrequently situated near a sarcoma of the
mucous membrane, from which it can become involved. Polypoid
growths are occasionally the size of a fist, and may have a broad
base or a long, thin pedicle. When a polypoid growth pushes
into the cavity, the remaining portion of the mucous surface may
remain long uninvolved. The existence of the new formation
develops an inclination to expel it as a foreign body, by which
the OS is dilated, and the tumor, hanging by a pedicle, is ex-
truded into the vagina. Portions of the tumor may disintegrate
and be discharged. The cervical form of the species is rare,
but sometimes projects from the os as a grape-like cluster, which
may fill out the vagina and may even project from the vulva.
These polypi most frequently originate from the posterior cervical
wall and are soft growths, which show but little inclination to
break down.
A second form resembles the cancroid, but is softer, less easily
broken down, and does not so rapidly seize upon the other lip.
The spindle-cell structure predominates in the cervical tumors.
Myxosarcoma and angiosarcoma are very frequent. Sarcoma of
the cervix shows but little disposition to invade the uterine body
(^r the vaginal vault. It most frequently penetrates the cellular
tissue of the parametrium.
Growths are described as spindle-celled or round-celled, ac-
cording to the variety of these cells which predominate, as none
are pure. The diseased structure is surrounded by a zone of
irritation cells, which are difficult to distinguish from the small
round cell. Weil reported the growths occurring in the relative
frequency of 35 per cent, spindle-cell, 45 per cent, round-cell,
and 25 per cent, mixed -cell tumors.
Ruge recognizes four groups: First, giant-cell sarcoma. The
cells of the intervening gland tissue arc largely increased. The
cells — of round, sometimes spindle, form — arc irregularly ar-
840
GYNECOLOGY.
ranged, and their nuclei often exceed in size the usual cells.
Second, the intermediate tissue cells, which are changed in the
large spindle form to resemble the decidua cells. They are dif-
ferentiated by their size, situation, and irregular form. Third,
small round or spindle cells, between which lie irritation cells.
Fourth, smaller round-cell sarcoma, which shows a great increase
of cells, irregular in size and form.
The influence upon the glands of the mucous membrane gives
variety. Generally, the glands are compressed and disappear,
but occasionally they are retained, and form extensive areas
within the tumor, producing what is known as adenosarcoma.
The origin of sarcoma is difficult to fix ; the microscopic appear-
ance would indicate that it was from the coats of the vessels. A
tumor in which there is a great increase of the vessels is knoi
as an angiosarcoma.
Disturbances in nutrition cause edema and swelling of
cells; this condition simulates myxomatous degeneration, and
has been called myxosarcoma. Lymphosarcoma is the name
applied to those cases in which the disease originates in, and
follows the course of, the lymphatic vessels. Myosarcoma is an
engrafting of the disease upon a fibroid, and the term adeno-
sarcoma indicates that glandular tissue has been included within
the growth. Fibrosarcoma usually exhibits a roundish growth.
The entire new formation may present a degeneration into
sarcomatous tissue, so that upon section it exhibits a soft, mar-
row-like structure, or may be somewhat firm and uniformly
opaque, with moist or mottled surface. Frequently the tissue
resembles fish flesh. At other times the myoma has undergone
sarcomatous change only in parts of its structure, and these
points of degeneration give the section a striated appearance, in
which the nodules are distinctly recognized. The sarcomatous
degeneration is most frequently foimd in the center of the mass,
so that it is surrounded by a myomatous crust, Gusserow's
assertion that the fibrosarcoma continually loses its capsule is of
no significance, for not every myoma has a capsule.
Fibrosarcoma can attain an enormous size, forming a tumor
which reaches beneath the ribs. If the tumor is projected into
the uterine cavity, it is generally covered by the mucous mem-
brane which is not penetrated by the disease, and occasionally
the tumor, thus covered, is extruded into the vagina. The sub-
mucous tumor mostly springs by a broad base from the wall of
the uterus, in which no sarcomatous tissue is found. If the sub-
mucous tumor has attained a large size, disturbances of nutrition
may have already occurred which lead to suppuration. The
longer the growth exists, the greater the inclination to destruc-
tion, especially if it is soft and has grown rapidly. In the sub-
A ^^
the^l
GENITAL TUMORS. S41
mucous growth the uterus tends to enlarge, especially when the
tumor is of the interstitial variety. On the other hand, the
intraligamentary subserous sarcoma produces an enlargement or
alteration of the uterus, which should not be overlooked.
These sarcomata, like the myomata from which they mostly
project, are but slightly supplied with vessels, though they fre-
quently have a distinct telangiectatic form.
Much diversity of opinion exists as to what constituent of the
wall affords origin for the sarcoma cell. Virchow attributed it
to the intercellular substance: *' Their cells increase by division,
they consist more and more of round cells, beginning small, later
larger, with considerable nuclei, as large mucous bodies, while the
intercellular substance is looser and more spongy.'' Kahlden
believed that sarcomatous degeneration resulted from the imme-
diate transformation of muscle-cells into roundish cells; their
poles then became oval or blunted. Whit ridge Williams says that
under rapid increase of the number of cells this section of tissue
passes into pronounced spindle-celled sarcoma with irritation
cells. Ricker explains the gro\\i:h "naturally by a growing
through of myoma bundles by the side of the sarcoma tissue."
Ruge says, **The impression exists, as if the fine, small muscle-
cells passed over directly into the sarcoma cells." Gessner, from
extensive investigations, concludes: "The round-cell sarcoma
continually takes its origin from the connective tissue, and, like-
wise, the majority of the spindle-cell sarcomata ; but that in all
probability to the smallest part they lead back to an immediate
transformation of muscle-cells."
667. Etiology. — The cause of sarcoma is unknown. Cohn-
heim's theory'- that it originates from some congenital defect
affords no further information. In other parts of the body sar-
coma is attributed to injury, but the occurrence of rapidly
developing sarcoma following trauma is no indication that the
latter is the cause. Injuries during parturition, difficult delivery
of the placenta, frequent labors, and blows upon the sacrum
have been assigned as causes for its development. Labor, how-
ever, does not seem to be a factor, as two-thirds of the cases are
below the average in child-bearing, and in a great majority there
is a long interv^al between the last labor and the development of
the disease. The cervix is most subject to injury during labor,
while the body of the organ is more subject to the disease.
Predisposing factors are: Age. The cases of sarcoma of the
mucous membrane preponderate between the ages of fifty and
sixty, although a large number are found between the ages of
five and twenty; sarcoma of the wall is absent in the young,
while the maximum number is found between the ages of forty
and fifty. Trauma^ parasitic irritation^ syphilis^ and the presence
842
GYNECOLOGY.
of fibroids are included, but, if factors, the query becomes im-
portant. Why are the cases not more frequent? Gusserow
believed that it originated from changes in the fibroid, and Mar-
tin saw the disease follow the ergot treatment of fibroid in six
cases. The latter number, however, is too small for a definite
conclusion. Heredity as a factor is undetermined. Poverty has
been given as a cause, but Weil has shown that one-fourth of
the cases of sarcoma of the mucous membrane have occurred ial
the well-to-do. I
668. Symptoms. — Sarcoma, like carcinoma, presents no char-
acteristic symptoms. The more important indications or signs
which should awaken suspicion of its existence are hemorrhage,
discharge, pain, and, in advanced stages, cachexia. In more
than one-half of the cases bleeding is the first symptom, and]
is rarely absent. It begins by increased menstrual flow, then
bloody, watery discharge, wliich is not sudden, as in fibroma,,;
but more or less continuous. It comes from the associated]
endometritis, while a stronger flow is indicative of destruction
of the new formation. Rupture of vessels and more or less
severe hemorrhage occur in the diffuse variety, but the polypoid
form does not readily break down. In the cervical variety the
disease occurs quite early in life. It has been observed at two
and one-half years and displays a preference for the young at
the period of awakening to sexual activity. The earlier symp-.j
toms are similar to those of mucous polypus, such as hemorrhage-]
and discharge. During sexual activity there is first increased
menstruation, then irregular discharge of blood, later pain,
which results from the pressure of the increasing growth upon
the cervix. The extension of the disease to the parametrium
causes pressure upon the pelvic nerves and the formation of
masses which press up the uterus and hft it out of the pelvis.
The hemorrhage and diffuse discharge result in a high degree of
anemia, and finally cachexia appears, and the patient ultimately
perishes from marasmus and the penetration of the disintegrating
tumor into the abdominal ca\^ty with fatal peritonitis. In the
frequently recurring sarcoma of the mucous membrane, which
appears at the climacteric, hemorrhage is the first, and often for
a long time the only, indication of the disease. The obstruction
to the uterine discharge will frequently result in the formation
of a pyometra or hematometra and the development of a tumor,
which will reach to the ribs. The uterine collection may be bloody j
or mixed with tissue and it often attains an enormous size. Di»-'
charge is the first symptom in about one-fourth of the patients
and does not cease with the further progress of the disease. It
begins as a quite abundant, thin, watery fluid, wliich is later
mixed with blood. Such a discharge continuing for a length of.
e,
m
GENITAL TUMORS. 843
time as the only symptom should arouse a suspicion of the
existence of sarcoma. It is true that discharges of this character
are not rare as a symptom of submucous fibroids, but its occur-
rence after the menopause is an almost positive indication of
sarcoma. In the first stage there is no disagreeable odor beyond
the stale sweetish smell, but with the destruction of the new
formation the discharge becomes purulent, sanious, and has a
foul odor. The carrion-like smell so characteristic of cancer is
not usually present, because the large collections in the uterus
are retained by the obstruction, and, owing to the arrangement
of the vessels, are afforded better nutrition, so that the new
structures do not so easily break down. The disease generally
appears in the polypoid form. Sanious discharge occurs when
the uterus forces the new-growth out, the os is dilated, and the
diseased mass is extruded into the vagina. The extruded parts
are to some degree deprived of nutrition, and this results in
further destruction. The discharge in the vagina has abundant
opportunity for exposure to infection from saprophytes, which
accelerate the rapidity of destruction. It is then mixed with
ulcerative pieces of tissue, which are often thrown off in large
masses, and these still further disintegrate in the vagina. A
bloody discharge will follow and pyometra can occur, but this
never attains the same extent as the hematometra. Pain is
absent at the beginning of the attack, but is aggravated with
the increase in the size of the uterus, the persistent pressure in
the pelvis, and the sensation of fullness in the abdomen. As the
uterus becomes enlarged, pain is referred to the ilium or to
the sacrum and radiates down the thighs. The extension of pain
is due to the involvement of the uterine nerve-endings by the
new formation. Pain is greatly aggravated when the disease has
passed beyond the boundaries of the organ and infiltrated the
pehnc tissues and made pressure upon the large nerv^e-trunks. In
the polypoid variety the pain becomes labor-like when the struc-
ture attains a size which leads the uterus to expel it. Painful
attacks do not occur at such regular hours as in carcinoma.
Inversion of the uterus has been caused by the efforts of the
organ to expel its contents. Vesical symptoms are comparatively
frequent when the disease is confined to the uterus and are
manifested by more frequent desire to urinate, pain in evacua-
tion, and distressing vesical tenesmus. These symptoms are
more particularly seen in the circumscribed variety and are, con-
sequently, not the result alone of increased weight. In advanced
stages constipation is marked from pressure of the infiltrate upK^n
the rectum and partly from decreased nutrition. Such patients
apply for relief from constipation and the pain at stool. The
infiltration of the uterus can attain to considerable dimensions,
844 GYNECOLOGY.
but, unlike carcinoma, shows but little inclination to compress or
involve the ureter. As the cervix is rarely invoh'ed, vesical
and rectal fistula are infrequent. The constant drain will neces-
sarily affect the general health, and the cachexia is greater than
in cancer. In sarcoma of the uterine walls, frequently known as
fibrosarcoma, the great diversity of symptoms depends upon the
situation of the disease, and makes it impossible to present a
clinical history, as in other forms of trouble. However, one of
the first signs is an irregular bleeding, following the menopause,
in a woman who has had a myoma. The myoma rarely delays
the climacteric longer than the fifty-fifth year. The continuation
of the menses at an advanced age or their return after ceasing
should indicate the probable degeneration of an existing myoma.
Following the climacteric, the myoma ordinarily ceases to grow.
or decreases in size, while a sarcoma of the uterine wall increaseSij
A rapid growth subsequent to the climacteric is with rare ex-
ceptions an indication of sarcomatous degeneration of a myoma.
A symptom constant in sarcoma and always absent in myoma
is a premature and rapid cachexia. From great loss of blood
the myoma may cause anemia, but the sarcoma causes emaciation.
When the cachexia occurs without much loss of blood, it indicates
an unfavorable influence upon the blood composition and forma-
tion. The cachexia is preceded by a sense of weariness, pain
in tlie head, nausea, sleepiness, and universal pain throughout
the body. Furthermore, there is a sensation of tension in the
belly without marked increase in the tumor. Difficulty in
urination without compression is also present, and disturban)
of nutrition without other assignable cause is quite marked,
profuse watery mucous or watery bloody discharge occurs simili
to that from an ulcerating submucous myoma, except that in
the latter the growth is not discharged in pieces, but the tumor
retains its integrity and disintegrates from the surface, while in
sarcoma large portions of the mass are thrown off or are easily
broken off by the hand. Pain js produced when the disease
breaks through the walls of the uterus and undergoes great
extension. Labor-like pains are caused if the uterus attempts
to discharge its contents. Sarcoma occurs in but a small per-
centage of cases of myoma, yet sufficiently often to justify
being reckoned as a factor. While the possibility of this do*
generation is no indication that every patient suffering from
myoma should be subjected to an operation, still it is a warning
which should awaken suspicion when adverse symptoms develop
in the tissue thus affected. Paget described a peculiar form of
this disease under the designation of recurrent fibroids. Whether
in these cases successive mucous fibroids were discharged or the
condition was sarcoma from the beginning only the microscO]
in ^^^
GENITAL TUMORS. 845
could have determined. Schroder made a vaginal extirpation in
a patient from whom he had removed seven successive polypi,
the last three of which were sarcomatous. The removal of the
sarcomatous growth long years after previous removal does not
prove that the former was malignant. The possibility of such
changed tumors occurring should be decided by more fre-
quent examinations with the microscope, in order that extirpa-
tion may be promptly resorted to when malignancy is demon-
strated.
It is asserted that metastasis is late in its occurrence in
fibrosarcoma. This assertion is correct only as to the length of
tune symptoms exist prior to such manifestations, but does not
indicate the long existence of sarcoma.
669. Duration. — The duration of the disease in sarcoma of
the cervix is about the same as that of cancer of the part —
namely, about one and one-half years. It is more difficult to
fix the term of the disease in the variety involving the uterine
mucous membrane, as the earlier symptoms do not come under
the observation of the physician. Cases have been reported as
having survived several years; the average duration, however, is
about two years. The polypus is slower in its progress, probably
dependent upon a slighter inclination of this form to invade the
muscle wall. Metastases occur in about one-fourth the cases and
affect any tissue in the body. The structures most frequently
affected are the lungs, peritoneum, lymph-glands, and intestines.
In the cervical variety it is likely to extend to the vagina, where
the involvement is superficial and does not interfere with cure
if extirpation of the uterus is performed, provided the operation
is done early. To afford hope of recovery the diagnosis must be
made early, and not after the recurrence of the disease following
curetment or amputation of the cervix has demonstrated its
malignant character. The polypoid growths from the cervix
should be recognized by their peculiar appearance, and the micro-
scopic examination of the cureted scrapings should render the
diagnosis certain. The reformation of the polypus should lead to
the suspicion of malignancy, and a careful microscopic examina-
tion should be made to determine its true character. In the
fibrosarcoma it is still more difficult to fix the duration of the
disease, as we have no means of knowing when the degeneration
of the fibroid begins. Cases have been reported in which tiunors
existed for ten years. These are probably cases in which the
myoma has existed for a long period and only in the later years
become malignant. Metastases in this form appear late, follow
the course of the blood-vessels, and, like the other forms of the
disease, involve the lungs, pleura, liver, rectum, omentum, and
kidneys. Fibrosarcoma is frequently regarded as a compara-
846 GYNECOLOGY.
tively benign tumor, because it remains proportionately bmiied
to the uterine cavity, but this is incorrect, for this property is
common to mucous membrane sarcoma and cancer of the body
of the uterus as well. If metastasis is any criterion as to malig-
nancy, we must regard parenchymatous sarcoma as more malig-
nant than the mucous, for in the latter metastases occur in
only one-fourth of the cases, while in the former but one-fourth
escape. Although it is impossible to fix the duration of life, it
would seem to be longer than in the other forms of malignant
disease. Its progress is attended with the same symptoms as in
other forms of malignancy. Its termination is usually death
from exhaustion, bleeding, and discharge, and by the further
extension of the disease into the various parts of the body.
Sepsis plays a less important part than in the mucous variety,
and ulceration does not appear so frequently, and, when present,
by the evacuation of the ulcerating mass does not usually cause
general symptoms, though a purulent peritonitis has been fre-
quently reported as a cause of death.
670. Diagnosis. — Sarcoma of the mucous membrane can be
accurately determined only by microscopic examination. Other
means will be sufficient to render certain the existence of ma-
lignant disease, but the variety is determined only by the micro-
scope. Neither the condition nor symptoms offer anything char-
acteristic of sarcoma, while a majority of the diseases of the
uterus afford similar symptoms.
An elderly woman with a large uterus, who suffers from a
profuse watery discharge mixed with blood, shotdd be suspected
of having sarcoma. Submucous myoma sometimes causes a
similar discharge, but the uterus is greatly enlarged, and it does
not occur for the first time in advanced age, and is always accom-
panied by bleeding.
Senile endometritis may cause a profuse discharge, but the
discharge is purulent, and generally has a disagreeable odor.
rhe organ presents the characteristic changes of old age, and is
not large.
A second suspicious sign is vesical tenesmus, which should
be regarded as an indication of malignant disease when no other
cause exists.
Sarcoma of the uterine body is naturally difficult to diagnose.
It can be completely covered by the cervix and the vaginal
portion, and when a large cauliflower-like mass projects from the
cervix, it can be either sarcoma or cancer, and the microscope
only can determine which. In the differential diagnosis there
are a variety of diseases which must make the diagnosis only
probable.
The uterine body is always enlarged, but does not difier
GENITAL TUMORS. 847
essentially from the enlargement of chronic metritis, myoma,
and carcinoma. The sarcomatous uterus is not so hard as the
myomatous organ. In malignant disease the very much en-
larged organ indicates sarcoma, but the carcinoma may be super-
imposed upon a myomatous uterus. In the latter the form of
the uterus is irregular.
Fungous endometritis, a mucous polypus, and submucotis fi-
broid may require the use of the microscope to differentiate them.
P'E> Sj""' — Fibroma Undergoing Sarcomatous Change.
Positive proof of malignant disease is not obtainable by the
touch. A sensation of softness is common to mucous polypi,
submucous myoma, and mucous membrane sarcoma. Pieces of
the latter can be broken off with the finger, as also from other
growths when ulcerating. Touch with the finger is not always
free from danger. It will be safer to employ the microscope upon
the scrapings obtained by curetment.
The inexperienced investigator may be confused by the resem-
blance between sarcoma and interstitial endometritis, with more
848 GYNECOLOGY.
or less destruction of the glands. In doubtful cases examine all
the parts removed before making the decision that malignant
disease does not exist, and, if then in doubt, keep the patient
under close observation. If she continues to bleed, make a
second curetment, and again examine the scrapings.
The abundance and variety of the cells in a specimen are of
significance in the diagnosis of sarcoma. In round-cell sarcoma
the cells are roimd and thick, and exceed in size those of the
intermediate gland tissue, between which are found irregular
cells. Kellar places particular stress upon the fact that the indi-
vidual nucleus is differently formed and varies in the way it
accepts the color stain, so that the smaller nuclei are always
better colored than the larger. When the glands are absent, the
cells are usually pressed together and the epithelium is flattened.
If the glands have largely decreased in interstitial endometritis,
there are distinctive traces of connective-tissue formation in the
intervening structure, wliich is penetrated in all directions by the
migration of connective-tissue cells. They differ from spindle
cells in that the long axis is drawn out at the ends, and the long
axis of the nucleus does not fill out the body, w^hile in the spindle-
cell sarcoma the cells are smaller, plumper, only rarely with
pointed ends, and the nucleus almost fills out the body.
The distribution of the vessels is also very significant. In
benign changes of the endometrium the blood-vessels are few and
present distinctive walls, while in sarcoma they are much more
abundant, and appear in immediate relation to the surrounding
tissue of the growth. Amann asserts that the recognition of
abundant nuclear division can be employed for the diagnosis of
sarcoma.
In the differential diagnosis of subinvolution of the decidua
and incomplete abortion the clinical history is of advantage ; but
if long-continued, irregular menstruation is followed by severe
hemorrhage, perhaps an offensive discharge, while the uterus
remains large and not especially hard, confusion with sarcoma is
possible, which will require the microscope for confirmation, and
then not always with certainty. The individual decidual cells
closely resemble those of sarcoma of the mucous membrane. The
retained tissue glands will present the alterations of pregnancy in
their epithelium to such a degree that the error is easily avoided.
The difficulty will be greater when a retrogression of the decidua
has occurred, for the uniform structure of the decidua is de-
stroyed. In single sections, however, individual islands of the
decidual structure will be found, while other sections will show a
):rroat irregularity in the cells. The size of the cells is quite
variable ; frequently the decidual cells show a pronounced spindle
*h«^H\ and penetration of the tissues by round cells exists, so
GENITAL TUMORS. 849
that a structure is formed which is extraordinarily Hke a sarcoma.
Differentiation is easily accomplished in such cases by demon-
strating the chorionic villi. If we find the decidual cells by curet-
ment of a woman who has had an abortion months before, we
will also find the chorionic villi present, for the decidual cells
are not otherwise so long retained. In the absence of the chori-
onic villi the diagnosis is fixed by finding, near the large decidual
cells, sections of tissue which show the unaltered mucous mem-
brane with retained glands or with the recognizable alterations
of interstitial endometritis.
Tuberculosis of the endometrium, by the premature loss of the
glands, through the appearance of numerous round cells in the
tissue and the occurrence of irritation cells, causes confusion with
sarcoma. The clinical history, the demonstration of caseation,
the peculiar irritation cells of tuberculosis, and the rarely demon-
strated tubercle bacilli will protect against confusion.
Carcinoma of the Uterine Body, — There are certain forms of
cancer which can not be distinguished microscopically from sar-
coma. We can, however, determine that malignancy is present.
As in the mucous sarcoma, the diagnosis is made only by
microscopic examination of the discliarged or removed pieces of
the growth. Greater difficulties are experienced in securing the
material for study than in the latter. A suspicion that fibro-
sarcoma exists should be awakened :
First, if a myomatous tumor does not cease to grow after
the menopause. Rapid growth does not always follow sarco-
matous degeneration.
Second, if a woman with a myomatous tumor commences to
bleed after the menopause. In rare cases this may occur in ad-
vanced age from mucous polypi, but the association of a profuse
watery discharge should be held to be very suspicious of sarcoma.
Third, if with a myomatous tumor cachexia occurs. Through
excessive bleeding myoma causes anemia, but never cachexia.
Fourth, if a myomatous tumor occasions symptoms which are
explainable neither by the size nor the situation of the tumor.
Fifth, if ascites complicates the tumor. The possibility of its
being caused by other conditions must be excluded. Ascites
occurs from penetration of the peritoneum by the disease, and
may follow a subserous tumor which has become sarcomatous.
Sixth, if a myoma which was previously hard grows rapidly
and becomes soft and swollen.
Seventh, if after the removal of a fibrous polypus another
follows.
671. Recurrence. — The tendency of the disease to return even
seems greater in the fibrosarcoma than in the mucous growth.
It is probable that the explanation of the greater frequency of
54
S50 GYNECOLOGY. ^H^^^H
the occurrence in the former is due to the early recognition and
more prompt treatment of the latter. When a case of mixed
sarcoma remains a year free from recurrence it may be con-
sidered as cured, but not so the fibrosarcoma, for it has been
known to return at a much later date. The great difficulty in
the treatment of this, as in all malignant disease, is the impossi-
bility of determining the diagnosis before the disease has ex-
tended beyond the point at which it can be surely removed.
Our results, must continue bad until both patient and physician
have learned to realize that uterine hemorrhage is a symptom
which demands prompt and thorough investigation. When the
disease has so extended that a radical procedure is no longer
indicated, we direct our efforts to the arrest of hemorrhage, the
decrease of discharge, and the improvement o£ the general condi-
tion of the patient.
Chorio -epithelioma. — This is a condition which it will often
be possible to determine by touch through an accessible cervical
canal. But Uttle satisfaction will be secured by examination of
the tissue removed by the curet, as it will consist mostly of blood-
clot containing a few pieces of necrotic tissue.
672. Treatment. — -Whenever possible, the uterus should be
extirpated. No other measures are worthy of consideration, but
the case must come under observation sufficiently early to admit
of the extirpation of the organ within the limits of healthy tissue.
Operation is contraindicated when the disease has so broken
down the system of the patient that she will be unable to en-
dure the ordeal of a radical procedure. It is also contrain-
dicated when the growth is no longer confined to the uterus.
The existence of metastases and the extension of the disease
beyond the confines of the uterus would render operation of no
avail. This assertion does not apply to extension upon the
vagina if the disease can be removed. The existence of
ascites must not influence against the procedure unless the
involvement of the retroperitoneal glands can be demonstrated.
The removal of the entire uterus, even in slight cases, is indicated,
because it affords greater immunity against return than any
partial operation. When the size of the uterus permits, the
operation should be performed by the vagina. This can usually
be done in cases of mucous sarcoma, as the organ is rarely of
large size. The fibrosarcoma may often be scraped out and
the size of the organ may be reduced by the administration of
ergot for a few days, and then the vaginal operation may be
performed. It is unwise to subject the healthy tissues to in-
fection by cutting up the tumor to reduce its size.
673. Treatment Following Operations for Malignant Dis-
ease.— The after-treatment of such patients will have been greatly
GENITAL TUMORS. 851
simplified by judicious care during and preceding the operation.
This care includes thorough sweeping out of the intestinal canal
with saline purges, the administration of intestinal antiseptics,
as salol or the sulphocarbolates, a restricted diet from which
milk has been excluded, the exclusion of every possible means of
infection by cleansing the patient and during the operative pro-
cedure, the employment of measures to sustain the circulation in
prolonged procedures. Immediately following the operation
she should be under the care of a conscientious nurse, who will
see that she is kept properly covered in a well-ventilated room.
Where necessary, the bodily temperature should be maintained
by artificial means, such as hot blankets and hot-water bottles.
Do not allow this to drift into a routine procedure to be employed
regardless of conditions, as, for example, after a difficult operation,
upon a very hot day, following the patient to her room, I found
her covered with blankets and surrounded with hot bottles ; upon
taking her temperature it was found to be 1 04° P. Obviously this
patient was getting the opposite of what she should have had.
The patient, unless very feeble, should not be confined to one
position, but should be permitted to move from side to side. The
pulse, temperature, and general appearance of the patient should
be carefully watched for danger signals. Where the patient is
uncomfortable and imable to evacuate the urine, it may be drawn
by catheter, but catheterization should be avoided , where possible,
and need not be employed imder sixteen hours imless the patient
complains of distress. For the general principles of after-treat-
ment the reader is referred to sections 206-220, as only details
especially referable to operations for malignant disease will be
here discussed.
If the abdominal wound is closed, the vaginal tampon of
gauze may be permitted to remain for from six to nine days.
In the third week the patient is permitted to arise, and in the
fourth to go about the house. When clamps are used instead of
ligatures, the weight and dragging of these instruments increase
the pain. The distress is aggravated by every movement, and
frequently morphin may be required to make it endurable. The
difficulty is often increased as early as the day after the opera-
tion by an accumulation of flatus. In the majority of cases the
difficulty appears later, and is relieved only after prolonged rec-
tal irrigation. The meteorism, increased abdominal sensibility,
enhanced rapidity of pulse, and elevation of temperature pro-
duce anxiety, which is aggravated by prolonged vomiting
and other signs of ileus. A number of cases are reported of
a fatal result from kinking of the intestine. The continuation
of such symptoms should lead to removal of the gauze, for
fear that it is causing the obstruction. This is done with the
852
GYNECOLOGY.
recognition of the fact that the adhesions are not firm, and
tliat trouble can arise from its premature removal. The cavity
should be tamponed lightly. In the removal of the gauze care
must be exercised that a knuckle of intestine is not drawn into
the vagina. Such an accident occurred in one of my patients,
where the interne withdrew the gauze and found that there
was a large coil of intestine in the vagina, which he could not
replace. I placed the patient upon her side, with the hips el(
vated, and had no difficulty in replacing the intestine, which
was kept in place by a gauze tampon. As to how long the
gauze shall remain, operators differ — from the one or two days
of Doyen to the ten days of Zweifel. The latter prefers the
longer period because the earlier removal of the gauze breaks
up the adhesions and draws down the intestines; at the lal
period the gauze has become loosened and the intestinal ad-
hesions are so firm that they are undisturbed.
The clamps are generally removed at the end of forty-eight
hours. Landau and SeHgman remove them on the second day.
I have had several cases of quite severe hemorrhage after re-
moval at the end of forty-eight hours — -hemorrhage which
is difficult to control. The occurrence of hemorrhage requires
resort to exposure of the cavity by retractors, and the ligament
must be followed up and the bleeding vessels again secured
with forceps.
Another objection to the use of clamps is the danger of
injury to the ureter and the bladder, but this is due to want
of care in pushing away these organs, and is just as likely to
occur from careless use of the ligature. Injuries of the rectum
are also reported, but are less excusable than those of the urinary
apparatus. Among the causes of fatal result sepsis is the most
frequent. fl
FALLOPIAW TUBES.
674. Tumors (Benign). — Tumors or growths of the tubes
are exceedingly rare, except a.s a result of inflammatory changes.
675. Fibroma or myoma is infrequent and of smaU size. It
develops from the muscular tissue of the tube, and may grow
inward or become subperitoneal, but rarely obstructs the lumen
of the tube. Inflammatory and tuberculous changes have
been mistaken for myoma, particularly the condition known
as salpingitis nodosa. Under the name of adenomyoma or
cystadenoma Recklinghausen describes a peculiar form of
myoma which occurs only in the uterus and tube. It is char-
acterized by the usual constituents of the fibroid, which include
glandular structure. In the tube he attributes it to some re-
mains of the primordial structure — the Wolffian body.
Ot » I
ys
he
GENITAL TUMORS. 863
676. Fibrocyst. — A unique new formation is described by
Sanger- Barth, which consists of three tumors collected from
a conglomeration of various large cysts and firm tumors that
were in part pedunculated from the fimbria of an otherwise
healthy tube. Microscopically, the wall of the cyst consisted
of fibrous connective tissue with smooth muscle-fiber, and,
within, a nest of embryonic tissue. Its surface was covered
with ciliated epithelium, and the contents of the cyst were
detritus. The principal mass of firm tissue partly consisted
of gelatinous myicomatous and partly of loose cell tissue. The
products greatly resembled a teratoma.
677. Enchondromata are small, semi transparent, cartilagin-
ous masses, which are occasionally situated upon the ends of
the fimbriae.
678. Dermoid of the tube is exceedingly rare. Ritchie de-
scribes a plum-sized bone removed from a dermoid of the
tube. Pozzi, in a recent edition of his work, presents a diagram
of a dermoid cyst removed from the tubal wall, which was ad-
herent to the ovary. It had developed within the tube and
ulcerated through the overlying wall.
679. Cysts of small size are frequent, though their true
cystic character is denied. The large irregular bullae so common
in association with fibroid growths are said to be dilated lymph-
spaces. Cysts varying from the size of a pea to that of a walnut
are found in all the walls of the tube, but most frequently be-
neath the peritoneum. Cysts within the tube are not infre-
quently the result of inflammatory changes by which the ad-
joining folds of the mucous membrane become adherent. Cysts
of the tubal fimbriae become pedunculated and resemble the
hydatid of Morgagni, which is by some regarded as a cyst.
The cysts contain clear serum, colloid masses, or chalky bodies.
Sanger divides these cysts into:
1. Serous cysts, which arise by the accumulation of serous
fluid between the lamellae of the new mucous membrane. They
can attain the size of a child's head, and may be either single
or double.
2. Lymphangiectasis and lymphangiectatic cysts in three
forms: (a) As small vesicles upon tube and ligament, identical
with those of older authors; (6) winding, ramifying tubes with
constrictions and cystic distentions ; (c) lymphangiectatic cysts —
large, tough-walled, isolated cysts in the tubal serous cover-
ing or the mesosalpinx. The two latter occur especially with
uterine myoma.
3. The hydatid of Morgagni, regarded as a physiologic cyst
of the end of a tubal fimbria.
Inflammatory cysts of the tubes — known, from the character
854
GYNECOLOGY.
of their contents, as hydrosalpinx, pyosalpinx, and hemato-
salpinx— have been discussed under inflammation. (Section
453.)
680. Polypus is a rarely recognized growth. Lewers re-
ports a case in which, upon the inner surface of each dilated
tube, were numerous growths, varying in size from a pin's
head to a pea. Amann speaks of a growth of the mucous mem-
brane consisting of connective tissue covered with enormously
folded cylindric epithelium. Rokitansky and Klob describe
connective-tissue growths of the iimbrite,
681. Papillomata, denominated by Sutton as adenomata,
are allied to the condylomata, or warts, found upon the vulva.
The villus consists mainly of epithelium, Sanger has collected
six cases, and divides them into two forms: (i) Simple cystic;
(2) hydropic.
The simple cystic is an indefinite soft growth from the mucous
Pig- S^7■
membrane, of a cauliflower-like appearance (Fig, 537), and its
villous structure may flll out the tube and distend it into a
considerable sized tumor.
In the second form (cystic and vesicular papillomata) the
tubal end becomes closed and the villi are so swollen as to give
the appearance of a cystic mole. This form differs from the
first in the greater size of the cavity, from the inner surface of
which spring the papillary masses. Doran and Sutton have
attributed the occurrence of papillomata to previous gonorrhea,
but with such a cause they should occur more frequently. They
are difficult to diff'erentiate from sarcoina and cancer. Their
benignity, however, is proved by the absence of any tendency
of their epithelium to atypic growth, and there are no metastases.
GENITAL TUMORS. 855
682. Malignant Tumors. — Carcinoma of the tube may be
either primary or secondary, though the latter is the more
frequent. Secondary involvement of the tubes from cancer
of either the ovaries or the uterus is comparatively late, as we
not infrequently find the ovary forming a large tumor from
cancer or sarcoma without any involvement of the tube. Doran
divides primary cancer of the tube into two forms:
1. When the cancer develops in the mucous membrane
of a normally formed tube.
2. When it forms in a malformed tube bearing a cyst the
wall of which becomes infected.
In the first form its situation shows its origin in the papil-
lary structure — whether from degeneration of papilloma, as
believed by Doran, or directly from the tubal mucous mem-
brane, as asserted by Sanger-Barth, remains to be determined.
The occurrence of the disease in the middle and external por-
tions of the tube indicates that it is a sequel of inflammatory
trouble.
In the second form the disease develops in a cyst of the
ostitim. Doran describes a specimen in which the end of the
right tube was dilated for an inch and a half, was very tortuoxis,
and formed a tumor an inch in diameter at its widest part.
In its wall was a solid deposit, over a quarter of an inch in thick-
ness. At its outer part it communicated with a thin-walled
cyst, situated in the anterior part of the broad ligament, lifted
up its anterior fold, and raised the serous coat of the uterus.
The cyst was about six inches in diameter, and its interior
contained a thick deposit which appeared encephaloid in char-
acter. Under the microscope the stroma was scanty, with wide
alveoli containing great masses of cubic epithelial cells, as in
encephaloid cancer.
Amann is inclined to believe that cancer of the tube will
prove to have developed through metastases from the uterus.
The disease is generally confined to one tube. The recognition
of its existence is necessarily difficult. When, after previous
pelvic inflammation, a patient who has reached her forty-fifth
year shows a sudden or steady growth of subjective and ob-
jective symptoms, cancer, says Doran, may be suspected, and
watery or sanious discharges greatly increase the suspicion of
malignancy.
Treatment should consist in the prompt removal of all
infected structures.
683. Sarcoma of the ovary is frequent; of the tube, very
rare. Occasionallv, the sarcomatous nodules are found scattered
over the peritoneal surface of the tube, but the disease more
frequently passes from the ovary to the omentum. Kahlden
856
GYNECOLOGY.
reports a case in a woman o£ fifty-one years, in which the tube
formed a sausage-shaped mass filled with soft, cauliflower-like
material. Under the microscope it showed various degenera-
tions, such as round-cell and spindle-cell sarcoma, and a papil-
lary structure wanting in connective tissue. These forma-
tions were found to arise from the endotheUum of the lymph-
vessels, which was increased several layers. As important,
constituents could be shown irritation cells similar to thoset
in sarcoma.
684. Chorio -epithelioma Malignum.— Just as malignant de-
generation can occur in a portion of placenta or chorion which
is retained in the uterus and produce a large tumor and subse-
quent metastatic deposits in the abdominal and thoracic viscera,
a similar malignant change may follow an ectopic gestation
in the tubal sac. Sanger advances this as an additional argu-
ment for active interference in such cases, and for the extir-
pation of tubal moles and of the appendages when tubal abor- ^
tion has occurred. I
BROAD LIGAMENTS.
685. Cysts of the broad ligament varying in size from a
pea to a pigeon's egg are frequent, and generally of but little
clinical interest. They may be situated upon the surface of
I
Fig. sj8. — -Broad Ligamcol Cyst.
T. Fallopian Tube. P. Parovarium. O. Ovary.
the hgament or may lie deeply within its folds. Their wa]
thin and the contents of the cyst consist of a watery or palsJ
colored fluid. Superficial cysts are of undetermined origin,r
while the deeper growths are attributed to changes in the par-^
GBNITAL TUMORS. 857
ovarium. I recently removed a multilocular cyst from the
anterior surface of the broad ligament by opening the over-
lying peritoneum and enucleating the cyst. The ovary was
not affected and was left undisturbed. These cysts are fre-
quently pedunculated, but rarely attain to any great size.
They are generally called microcysts, and are often developed
in the structure or suspended from the organ of Rosenmuller.
Only those which develop from the vertical tubes of the parova-
riiun have ciliated epithelium and are liable to form papillary
growths subsequently.
Parovarian Cysts. —(Section 702.)
686. Echinococcus cysts are rare, except in certain districts,
notably Iceland and Mecklenburg. In the majority of cases they
primarily occur in the pelvic connective tissue, and always near the
Fig. 539. — Broad Ligament Cyst, with Torsion of Its Pedicle.
intestine. In rare instances the ovary proves to be the primary
seat of the disease. The wandering of the parasite causesa chronic
inflammation, characterized by round, elastic tumors situated
near the rectum, which are slightly movable, but not painful.
Bimanual palpation reveals that they are not connected with the
uterus or ovaries. A positive diagnosis is to be determined only
by a careful examination of the fluid obtained from the cysts,
either by spontaneous rupture or by puncture. The danger of in-
fection from it is so great that the certain determination of
the disorder will not compensate for the increased peril induced
by the puncture.
Treatment. — The proper plan of treatment consists, when
possible, in the removal of the sac. If we are unable to scoop
out the cyst, then it should be fastened to the abdominal wall
S5S GYNECOLOGY.
and drained. I'ozzi advocates, when we have had to open
the peritoneal cavity, that the opening over the cyst should
be packed with iodoform gauze for from twenty-four to forty-
eight hours, until adhesions have formed, before the cyst is
opened, when it can be done without danger of infecting the
peritoneal cavity. If the tumor is situated low in the pelvis,
a vaginal incision should be preferred. The sac ca\'ity should
be emptied and packed with gauze.
687. Parovarian Varicocele.— Phleboliths. — A varicose dila-
tation of the veins of the pelvis is common, and frequently,
according to Klob, results in the formation of phleboliths. Their
frequent occurrence is attributed to the unusual existence of
valves in the veins of the broad Hgament. These masses attain
the size of a pea or bean, and occasionally cause inflammation
and thrombus formation. When situated so that they can be
palpated through the vagina, they are often mistaken for ureteral
calculi.
688. Lipomata. — Small collections of fat are not infrequentljH
found in the mesosalpinx of the broad ligament near the under^
surface of the tube. They can attain the size of a bean,
casionally the size of a walnut.
689. Fibroma. — As the same muscular structure is found
the broad ligament as in the uterus, it is not siUT}rising that
fibroids should occasionally be found in the ligament independent
of the uterus and its structure. Such growths may spring
from the round ligament or are found in the broad ligament.
The latter have been considered as aberrant uterine fibroids
which have become separated from their first attachment.
Sanger found these growths most frequently upon the right
side. They may be situated intraperitoneally, in the fold.
of the groin, or in the labium majus. The mass may have a
pedicle or may be sessile. It does not attain a large size, is'
quite movable, and is not painful. The condition may be
confounded with fatty hernia, an epiplocele, or an ovarian
hernia. The fatty hernia is frequently reducible, painful to
the touch, quite soft, and ill defined. The irreducible epiplocele
becomes like a fibroid, but has a cord stretched behind the
abdominal wall. In an ovarian hernia the tumor retains the
shape of the organ, is exceedingly sensitive, and increases at
each menstrual period, while the uterus is displaced to one.
side. The treatment is extirpation.
690. Malignant Growths. — Carcinoma and sarcoma of the'
broad ligaments are usually the result of extension of the dis-
ease from the uterus or ovaries. The rectum, the bladder, or
the retroperitoneal glands may be the source of the infection.
be
*
OVARIAN TUMORS. 859
OVARIAN TUMORS.
691. Characteristics. — The tumors of the ovaries differ from
the neoplasms of the other portions of the genital tract in their
greater propensity to malignant degeneration, often rendering
it difficult to determine whether an indi\'idual growth is malig-
nant or benign. For this reason we will depart from the cus-
tom we have previously followed and discuss the two classes
of tumors together.
692. Classification. — The tumors of the ovary are divided:
Simple.
Clinically ' \ P.?™^^^;
;ic -j
/ Cystic < Proliferating.
Solid
Fibromata.
Sarcomata.
Carcinomata.
Endotheliomata.
Pathologically
Simple.
• I Proliferating.
' Dermoid.
( Parovarian.
According to size J Small.
I Large.
Cysts may originate in any part of the tubo-ovarian struc-
ture, as the cortical, medullary, or parenchymatous portions
of the ovary; in the structure between the tube and ovary
known as the Rosenmiiller organ or parovarian structures;
and in the hydatid of Morgagni, the extremity of the canal
of Muller. We have already spoken of cysts which develop
in the folds of the broad ligament and are recognized as broad
ligament cysts. Cystic growths may become of almost un-
limited size, larger than any other growth of the body, and
occasionally the body may seem but an appendage of the ttmior.
These growths repeatedly reach a weight of loo pounds.
Maritan reported an ovarian cyst weighing 200 pounds removed
from a woman who previously weighed 290. (Fig. 505.) Her
girth measure was ninety inches. Bullitt removed a tumor
whose sac and contents weighed 245 pounds, and Spohn, of Texas,
one of 328 pounds with recovery of the patient.
The solid tumors are much less frequent than the cystic and
closely retain the shape of the ovar5\ The cystic are irregularly
spheric -the more spheric, the larger they become. As a rule,
the surface is a bluish-white, greenish, brownish, yellow, or
a glistening white. Secondary developments may occur in the
wall, giving it an irregular shape, or it may consist of a large
number of small cysts, which give the impression of a solid
tumor.
Cysts are still further divided into unilocular or single cysts,
860 GYNECOUOGV-
and jmultilocular, where the sac is composed of a number of
cavities or smaller cysts. Careful examination of a unilocular
cyst will not infrequently show smaller cysts witliin its walls.
The contents of the various tumors greatly tiiffer; indeed,
the different cysts in the same tumor show radically different
contents. In the unilocular tumors the contents are usually
clear and limpid; in the multilocular, thick, viscid, and gluej
\^ ^^^
5P"
Will :,. .,J
Fig- S40.— Large Ov;
like'in some, clear and limpid in others, while, from various
causes, there may be discoloration by an admixture of blood,
pus, or fat.
The broad ligament cysts are generally unilocular and con-
tain a clear fluid ; those which originate in the hilum are papil-
lary ; and those from the parenchymatous structure of the
ovary, glandular.
OVARIAN TUMORS. 861
Small Cysls. — The small cysts comprise:
Small residual cysts.
Follicular cysts.
Cysts ot the corpus luteum.
Tubo-ovarian cysts.
The large cysts are:
Glandular proliferous.
Papillary proliferous.
Dermoid.
( Hyaline.
Parovarian < Papillary.
( Dermoid.
693. Small residual cysts are growths which develop in
the structure between the tube and ovary, known as the par-
ovarian structure, or the organ of Rosenmuller, Those which
develop in the vertical tubes have ciliated epithelium, and may
Fig. 541 .^Sraall Residual Cysts.
subsequently develop into papillary gi^owths. They may be-
come detached from the ligament and hang from the perito-
neal surface by a slender pedicle. It is possible that from these
cysts may originate large cysts filled with either fluid or papil-
lary contents
Attached to the fimbriated end of the tube is generally
found a small cyst, \'arying in size from a pea to a cherry, known
as the hydatid of Morgagni, which, from its almost continuous
presence, is regarded as a physiologic cyst. This hydatid is
the termination of the duct of Muller It is transparent, has
a thin wall, and has a pedicle often a full inch in length. Doran
describes a supratubal cyst of similar size, appearance, and
structure, which he supposes to be a microcyst of the broad
ligament in this anomalous position.
862 GYNECOLOGY.
694. Simple or Follicular Cysts. — Hydrops Folliculorum.-
These cysts are unilocular dilated follicles, generally multiple
and small. In an ovary that has not attained to twice its
normal size fifteen to twenty of these cysts may be found.
When small, the ovary is but slightly enlarged and the follicle
projects upon the surface or lies embedded in the stroma. These
cysts were long considered the sole source of large ovarian
cysts, but it is only in rare instances that they attain the size
of a fist, occasionally of a man's head. The contents of the
of the Corpus Luteum
cyst are generally clear, but may be blood-stained, and havj
a specific gravity of from 1005 to 1020. The cyst-wall is i
transparent, thin membrane of a light gray color, covered with
columnar epithelium. The cysts may be few and the stroma
excessive, or the former may be very numerous and the latter
scanty. When the latter condition is present, the ovary is
frequently converted into a mass of delicate cysts. It is not
unusual to find an ovary otherwise healthy containing a uni-
OVARIAN TUMORS. 863
locular cyst the size of a hen's egg. The disease is generally
bilateral.
Etiology. — These cysts, even when large, are regarded as
unruptured and dilated Graafian follicles, because of the grada-
tions observed between them and the smaller cysts. In the
smaller ones ovula may be detected, which have been destroyed
or have escaped observation in the larger. Failure to rup-
ture and increase of the fluid contents produce a dropsy of the
follicle. The normal rupture may be prevented by undue
thickness or toughness of the walls, the result of inflammation;
by deposits of exudation over the surface of the ovary; or by
the deep situation of the developing follicle; or failure may
be the result of too slight congestion, which, though increasing
the secretion, is too gradual to produce rupture. Such cysts
have preceded menstruation, being occasionally found in the
l"i™. 543. — Tubo-
fetal ovary. These cysts rarely gi\-e rise to symptoms, as men-
struation, ovulation, and pregnancy continue.
695. Cysts of the Corpus Luteum. — These are unilocular
cysts the size of^a pigeon's egg, occasionally as large as an apple.
They were, first described by Rokitansky, who believed that
only the corpus luteum of pregnancy could be tlius transformed,
but such cysts have been found in nullipara. (Fig. 542.) The
cyst-wall is comparatively thick, lined by a yellow, apparently
folded membrane, in which microscopic examination shows
the bud-like papilke characteristic of the corpus luteum. The
recognition of this structure prevents their confusion with
follicular cysts, or even with suppurative ovaritis.
696. Tubo-ovarian Cysts. — An ovarian cyst in contact with
a distended tube not infrequently results in the formation of
a tubo-ovarian cyst. (Fig. 343.) The tubal inflammation
early causes the formation of extensive adhesions fixing the
864
GYNECOLOGY.
tubal ostium to the ovary. The increasing pressure of the
accumulating fluid gradually absorbs the thin septum until
the two sacs form one cavity, the smaller portion of which is
usually formed by the tube. It does not generally attain a
large size. The uterine end of the tube may remain permeable.
and, as the fluid increases, permits the excess to drain through
the uterus, forming a
condition known as pro-
fluent tubo-ovarian hy-
drops. It resembles the
condition engendered in
hydrosalpinx, known as
hydrops tuba proflucns.
The open tube acts as a
safety-valve, preventing
the increase and over-
distention of the cyst,
frequently leading to its
complete collapse after
every evacuation.
697. Glandular Pro-
liferating Cyst — This
class of cysts comprises
the great majority of
ovarian tumors, and
they vary from the size
of an egg to that of a
tumor weighing over
two hundred pounds,
which m;iy fill up the
entire abdomen and en-
croach upon the thor-
acic viscera. The sur-
face of the cyst presents
a pearly-white, glisten-
ing appearance, the
thinner portions of
which are purple, green,
or black, according to
the color of their indt-.
vidual contents. Tl
oily, and covered with papi
{Figs. 544 and 545.)
external surface may be smooth
lary growths or mucous vegetations.
The term proliferous is applied to those which are highly
organized and abundantly supplied with blood-vessels. The
term proligerous is given to cysts that have the faculty of buddiuj
to
dirfV
OVARIAN TUMORS. 865
or generating new cysts from or within the original growth.
They may be spheric in shape and regular in outline, simu-
lating a single cyst, or may be irregular from the numerous
P'8- S4S- — Ovarian Cyst. Patient Recumbent.
nodules, indicating the presence of a multilocular tumor. These
growths generally have a distinct pedicle.
698. Pedicle. — The attachment of the tumor may be pedun-
culated or sessile. The latter are frequently intraligamentary.
The pedicle may be long or short, thin and band-like, or broad
Fig. 546.— PtdicU- of an Ovarian Cyst,
and thick. It is developed by the traction of the tumor and
the resulting hyperplasia of the ovarian ligament, and by stretch-
ing of the meso-ovarium, of the side of the broad ligament,
and of the suspensory ligament of the ovary. The tube gener-
GYNECOLOGY.
ally remains separated by its mesosalpinx from the tumor,
though the ampulla is often fastened to or approaches the
tumor, because of the strongly drawn infundibular ovarian
ligament, and the tube is usually elongated. In ovariotomy
the tube is generally removed with the pedicle. After the
removal of the tumor the cut surface presents a triangular
appearance, in which the angles are pointed or blunt, small
or large, and formed by the stump of the ovarian ligament,
the transverse section of the tube, and the stump of the sper-
matic artery. The pedicle consists of smooth muscle-fibers.
connective tissue, and hypertrophied blood-vessels.
The pedicle varies in length from four to twenty centimeters ;
Fig. 347. — Intraligamentary Ovarian Cyst.
in breadth, from two to twelve centimeters; and may be en-
tirely absent. The difference in the development of the pedicle
is due, in part, to the insertion of the ovary upon the posterior
surface of the broad ligament, and partly to the origin and
growth of the tumor.
With the ovary originally embedded in the ligament, the
development of the cyst in its external part will result in the
formation of a pedicle; but the growth of the cyst toward the
hilum may result in the spreading-out of the broad ligament
and the formation of a subserous cyst. A cyst growing out-
ward through the ligament may cause it to split and form two
pedicles. As a tumor develops inward in an embedded ovary
and spreads out the ligament, the uterus is pushed to one sid*
OVARIAN TUMORS. 867
and the tumor fills up the side of the pelvis, to displace the
pelvic organs in general. Such a tumor becomes firmly fixed
in the pelvis, pushes the peritoneum off from the uterus, in-
vades the space between it and the bladder or rectum, and
not infrequently partly spreads out the uterus upon its stir-
face. Such growths are known as intraligamentary cysts.
The cyst may be only partly subserous, having spread out
the anterior wall of the broad ligament in advance of it, so
that the inferior surface of the tumor is uncovered by the serous
membrane. The separation of the posterior leaflet in such a
growth reveals a long pedicle formed by the anterior fold. As
an ovarian tumor develops, its increasing weight carries it
Fig. 548. — Cyst Embedded in the Pelvis.
backward into the retro-uterine pouch. It is very rarely found
in front of the uterus. The subsequent development causes
it gradually to fill the pelvis until its size no longer permits
it to remain below the brim, when it rises into the abdomen.
With the change of position there is a partial rotation of the
pedicle, which is without chnical significance unless it exceeds
a quarter of a circle. Occasionally, the withdrawal from the
pelvis is retarded by a marked projection of the promontory
of the sacrum, a roomy pelvis, or extensive adhesions. Such
a tumor as it increases in size compresses the pelvic viscera,
forces the uterus and bladder upward, and may dissect down-
ward until it protrudes at the vagina, as in a case under my
868 GYNBCOLOGY.
observation, which was covered only by the posterior va^nal
wall.
The nonpedunculated tumor, as it progresses, becomes
limited by the lateral walls of the pelvis, after it has spread
out the structure and come in contact with the parametriiun.
In its further growth it is pushed upward and to the opposite
side, carrying the uterus. These changes frequently displace
the sigmoid portion of the colon, placing it above and in front
of the tumor. The intestine is frequently compressed, but not
sufficiently to close its canal, and the large vessels are often
obstructed.
The presence or absence of the pedicle depends somewhat
—Adenocystoma of Ovary, Showing Papillary FormattM
a, a. Papillary projections.
upon the variety of the cyst. The glandular incline to a long
pedicle, the papillary to a short or absent pedicle, and the der-
moid to a short, strong pedicle.
695. Structure, — The consideration of the internal struc-
ture of the glandular cysts justifies their division into areolar,
unilocular, and multilocular. These glandular cysts, accord-
ing to Virchow, originate in an invagination ' of the proliferating
ovarian epithelium into the stroma. Further invagination
and proHferation of the tissue result in the formation of new
gland tubes, from which new cysts form. (Fig. 549.) The
continuation of these processes results in the formation of the ■
OVARIAN TUMORS. 868
many-chambered glandular or adenomatous cyst. Mary A.
Dixon-Jones attributes ovarian growths to inflammation through
which the tissues become embryonal and new-growths follow.
Areolar Cyst. — A conglomeration of small cysts with a thick,
well-developed, and vascular stroma is known as an areolar
ovarian cyst. A number of these cysts may have ruptured
to form a considerable sized one, or the tumor may consist of
a very large nimiber of small masses, none of which will exceed
the size of a plum. (Fig. 550.)
Unilocular cysts often attain an enormous size, but examina-
tion discloses evidences of their previous division into numerous
smaller cysts, so that we can safely assert that all unilocular
cysts have originated from the multilocular. The investigation
Fig. sso- — Areolar Ovarian Cyst.
of a large cyst will usually show the presence of small cysts
in its walls, and not infrequently the remains of septa within
its cavity.
Multilocular cysls contain a number of cysts of varying
size, so arranged as to present the appearance of a single tumor.
As these individual sacs increase, their intervening walls be-
come gradually thinned, until, one after another, they rupture
and the sacs coalesce to form larger single chambers. Not
infrequently the circumference of the septa remains, to be-
come still more stretched as the tumor grows, until it forms a
cord-like thickening upon the inner surface. Occasionally,
the vascular structure alone remains to indicate the former
septum. In sudden rupture the vessels of the septa are torn.
870
GYNECOLOGY.
producing extensive hemorrhage into the sac, which changi
the character of the cyst-contents.
In the principal cyst we usually find a wall of three layers,"]
the outside consisting of pure connective tissue, like the al-
buginea of the ovary. The middle layer consists of loose con-
nective tissue with numerous large vessels, while the inner
layer is rich in cells and contains numerous small vessels.
The external surface of the cyst is covered with columnar
epithelium, which differs from the pavement epithelium of the
peritoneum. The cysts are lined with a one-layered cylindric
epithelium, which presents different forms in different tumors,
and by its structure governs the character of the secretion in
l'''K- .SSI- — Unilocular Cyst.
the various sacs. It is only in the smaller sacs, however,
the true similarity of the epithelium and secretion is observed.
In the larger cysts the epithelium undergoes degenerative
changes; is flattened by pressure; sufTers disturbances of nu-
trition through thinning of the septal wall ; and undergoes fatty
or albuminous changes, which cause the epithelium entirely
to disappear from the wall of the larger cysts. Epithelial
sprouts may remain upon the wall, forming new-growths.
Pfannenstiel directs attention to the possibility of the forma-
tion of papillary growths in the adenomatous cysts. This
formation is of great variety, and is found inside as well as upon
the surface of the tumor. Sometimes these growths are but
OVARIAN TUMORS.
871
sparsely distributed upon the inner surface of a large cyst; in
others they appear as circumscribed tufts upon one side, while
the remaining portion is smooth; or, again, the entire cavity
may be filled with strong, branching growths, while the quan-
tity of fluid is very scanty. The larger the cyst, the greater
the probability that a large portion of the wall is smooth. As
a rule, the papillae are most marked upon the side of the cyst
toward the hilum, while the peripheral side will be scantily,
if at all, involved.
A great variety in the quality of these vegetations exists;
at times only small wart-hke growths, from one to two milli-
meters high, are scattered over the surface, together giving
a velvety or grater-like
appearance; at others,
branching growths of
various sizes, up to that
of an apple, which may
be either broad-based or
with a thin pedicle. All
the changes are present
that are found in the
ordinary papillary cyst.
The growths appear
either as reddish, granu-
lating, cauhflower - like
projections, or as sago-
sized masses; rarely in
the grape-cluster form .
Cyst -contents often
present very great con-
trasts in their color and
consistency ; they may
be found almost color-
less, straw-colored, green, purple, or black in color; thin or thick;
viscid or gelatinous in consistency. The contents of the various
cysts in the same tumor will differ in color and consistency. In
some the fluid will be thin, and in others so viscid that it will not
flow. The fluid in the smaller cysts is more consistent, and be-
comes thirmer as the cysts increase in size, because of changes
in the epithelium.
The specific gravity of the fluid varies from looj to loao,
with an average of about 1012. However viscid the fluid, it is
found absolutely structureless. Blood -corpuscles, epithelial cells,
and crystals of cholesterin are often present. The reaction of the
fluid is neutral or alkaline. Upon analysis various forms of
albumin, as metalbumin, paralbumin, and albumin-peptone, are
fotind.
f'g- sS'-^Mult'Iocular Cyst.
872
GYNECOLOGY,
■Small Papillary Ovarian Cyst.
700. Papillary Proliferous Cysts. — The papillary cysts show
a marked proliferation of the connective tissue, which forms itself
in tufts upon the inner surface of the tumor, as described in the
complication of the
glandular growths
above. These
branching projec-
tions may distend
the sac to bursting,
and these tufts pro-
ject upon the out-
side, leading to
rapid infection of
the general perito-
neum. The vegeta-
tions spring up lux-
uriantly over the
surface of the ovary, ■
are carried to every'
part of the perito-
neal cavity, and not
infrequently, by the
action of the diaphragm, are carried to the upper surface of that
muscle in the thorax.
The contact of this infection with the peritoneum rapidly'
produces ascites.
Similar vegetations
may arise spontane-
ously from the sur-
face of the ovary,
and are then known
as superficial papil-
lomata. It is prob-
able that these are
cases in which a
very small cyst has
opened and afforded
the seed which has
infected the exter-
nal surface. The
papillary tumors
rarely attain a large
size, and are gener-
ally bilateral. The dendritic growths project in every direction,
are reddish or pearly white and glistening, often three or four
inches long, and have the appearance of stems of coral. The
I
Fig- SS4- — Papilla^- Tufts upon Inm-r Wall of Cyat.,
OVARIAN TUMORS. 873
masses have usually undergone a partial calcification, so that
they break easily and without bleeding.
701. Dermoid Cysts. — ^These are growths in which are found
skin and mucous membrane, together with all the structures gen-
erally associated with such tissues. The tissues most frequently
found are hair, teeth, nails, and sebaceous and sweat-glands.
Other structures, occasionally seen, are the mamm^, horn, bone,
unstriped muscle-fiber, and, rarely, tissue resembling brain. Fat
or sebaceous material exists in the largest quantity, often at the
temperature of the body in a liquid state. Occasionally, it is
found in solid balls, Sutton reports finding over three hundred
of these in one sac. Hair is frequently present in great abun-
dance, and varies in color, length, and quantity. The hair may
be blond, brown, or black, but bears no relation to that of the
Fig. SSS. — Surfaces of Ovaries Infected with Papillary Vegetations.
individual. Teeth are found in about one-half the cysts; they
may be loose, fixed, or buried in the wall. Section through the
tooth often reveals it situated in a bony alveolus. Beneath the
liard crust of the tooth is found a white or reddish-yellow medul-
lary substance.
We may occasionally find incisors, molars, and premolars in
the same bone. The number of teeth is often enormous. Schna-
bel described a case which had three pieces of bone and one
hundred teeth. Plouquet found three hundred teeth. Various
bones have been described, as the jaw-bone, tlie petrous portion
of the temporal bone, ribs, and the pelvic bones. A finger with
articulated phalanges, nail, and nail-fold and an entire skeleton
have been recognized. In a double dermoid removed from a girl
874 GYNECOLOGY.
of eleven years I found a well-formed half of the upper jaw,
equipped with teeth, alveolar process, and normal mucous mem-
brane.
Dermoids do not always occur alone, but in conjunction with
large glandular cysts, the dermoid forming but a small part of
the mass. Sometimes the entire cyst will be found filled with
sebaceous material, while careful examination, after washii^,
shows that the skin covers only a small part of the mass.
Teratoma is a more complex form of tumor which is usually
classed with the dermoid. It contains an even more varied
556. — Papillary Ovai
J, ij. Loouli containing papillary growths.
siructun.', and resembles more the solid growths than the c>-3tic.
It olifu attains an enormous size, and contains the various
structures of the dermoid and cartilage and a large anxmnt 0:
connective tissue. I"*ermoid growths may appear at any a^
The>- have been found in chSdren at birth and in women of
ninety years.
Tiie contents of a dermoid are Exceedingly irrrtating. asd
every precaution should be practised to pre\'ent the perhc-Cfial
ca\*i[y from Iving soiled. I saw a patient in whom an attesrptfti
aspiration resulted in drawing out a wisp of hatr: the patieai s:
OVARIAN TUMORS, 875
once developed peritonitis, which an early operation failed to
prevent becoming fatal.
702. Parovarian Cysts. — The parovarium is situated in the
lateral part of the mesosalpinx, and is the remains of the sexual
part of the Wolffian body. It resembles in its arrangement a
comb, the back of which is directed toward the tube, while the
teeth, some twelve to fifteen in number, converge toward the
ovary. They are lined with large cylindric epithelium and ter-
minate in blind extremities. The tumors which originate from
this structure are almost always cystic and subserous, and con-
sequently have a double wall. I^e external peritoneal one is
easily separable. The pedicle consists of the tube and of the
F^'ES57- — Dermoid Ovarian Cyst.
median ovarian and the suspensory ligaments. Torsion of the
pedicle, when long, can easily occur. There are two kinds of
cysts which arise from the parovarium, of which the most fre-
quent are the small pedunculated, connected with Kobelt's
tubules, which rarely become larger than a pea and are of no
clinical significance. The more important are the sessile, which
remain between the folds of the broad ligament and burrow into
it as they enlarge. These cysts are usually small, though Kum-
mel describes one that weighed forty-two pounds. In the lai^e
cysts the tube becomes elongated. The contents of the cyst are
clear and limpid, with a specific gravity of loio and an alkaline
reaction.
The parovarian and broad ligament cysts form about eleven
876
GYNECOLOGY.
per cent, of the abdominal tumors of pelvic origin, and both
proliferating and dermoid growths have been found in this
situation.
These cysts are distinguished from the ovarian, first, by the
ease with which the peritoneum can be stripped off ; second, by
the ovary being generally found attached to the side of the c^-Bt;
third, by the cyst being unilocular; fourth, by the Fallopian tube
stretched over the cyst and never communicating with it; and,
lastly, by the j^radual thickening of the mesosalpinx.
703. Solid Ovarian Tumors. — The solid growths of the ovary
comprise five per cent, of the cases that present themselves for
operation. These tumors are innocent and malignant, and may
become cystic.
704. Fibromyoma, the benign form, is a rare tumor, but is
the most common species of solid ovarian tumor. It closely
OVARIAN TUMORS. 877
resembles the uterine fibroma, and is frequently accompanied by
ascites. Its growth is slow, and the mass retains the normal
shape of the ovary. Adhesions are rare; indeed, owing to the
peritoneal fluid, the mobility is increased. Occasionally, we have
a growth— the fibroma— in which the minute structure consists
of wavy bimdles of closely packed fibrous tissue intermixed with
small roimd cells. Williams describes one of these that weighed
seven pounds seven oimces; Doran, one of seventeen poimds.
The myomatous variety is more frequent, and occasionally under-
goes calcareotis degeneration, when it may be mistaken for an
osseous tumor.
An apparent h3rpertrophy, instead of atrophy, of the corpus
luteum results in the formation of a growth, occasionally reaching
the size of a walnut, which Dr. Mary D. Jones pronounces a
gyroma, and believes to be closely connected with the endothe-
lium. It probably develops from the corpus luteum when in the
cortex, and from the endothelium in the medulla. Leopold de-
scribes a peculiar form of ovarian fibroma containing alveolar
spaces packed with epithelioid cells. They are produced by
(filatation of the lymphatic and capillary channels and the pro-
liferation of their endothelium.
705. Sarcoma of the Ovary. — Sarcoma resembles in form, size,
and color the fibroid, excepting that its surface is smoother. Its
consistence is softer than the fibroid, though it contains much
fibrous tissue, which renders the diagnosis at times difficult to de-
termine. Sarcomata occur as roimd-cell and spindle-cell growths ;
when the latter predominate, the tumor is more solid and more
strongly resembles the fibroma. The muscle-fibers are longer
and the nuclei are more slender and rod-like. The roimd-cell
structure is softer, often presenting macroscopically medullary
properties similar to those of mediillary cancer, and under the
microscope are foimd large layers and nests of round cells, united
with irritation cells, and penetrated by numerous blood-vessels of
every caliber.
Spindle and round cells are frequently combined, while myx-
omatous transformation exists in both kinds, but cartilage and
bone formation rarely occiu^.
Combinations of sarcoma with adenoma are observed in the
walls of the larger cysts, sometimes with sarcomatous degenera-
tion of the stroma. In places, large alveoli are separated by
vascular connective tissue, which contains large cells undergoing
fatty degeneration and resembling carcinoma. This condition
Spiegelberg has called sarcoma carcinomatostmi.
706. Carcinoma of the ovary is a much more frequent condi-
tion than sarcoma. The medullary variety is the most common,
and may form a tiunor as large as a man's head. The disease
occurs primarily, but much more frequently as a secondary
manifestation.
707. Endothelioma of the Ovary.— A growth is occasionally
found in the ovary which originates from the endothelium of the
lymph-spaces or blood-vessels of the organ. It has been pre-
viously classed by pathologists with both sarcoma and carcinoma,
resembling the sarcoma from its frequent metastasis through
the blood-vessels, a carcinoma in consisting of nests of cells with
a fine stroma. The growth rarely attains a great size, — not larger
than an orange or fist, — forms a solid tumor, and is a rather firm
whitish growth. This same structtire not infrequently is found
complicating the glandular proliferating cysts, and gives evidence
that many of these tumors, if carefully investigated, would show
the presence of malignant conditions.
708. Etiology. — Very little is yet known as to the general
cause of ovarian tumors. Three theories for their origin have
been presented: (i) The Cohnheim theory, which attributed
their growth to the retention of embryonic products; (a) the
theory advanced by Mary A. Dixon-Jones, that they were always
the result of previous attacks of inflammation, and that the in-
flammatory condition of the ovaries gave rise to embryonal
tissue from which the growth subsequently developed; and (3)
the theory of parthenogenesis, or the development of the non-
fecundated ovum as the result of some irritation. The first and
second theories are those which have the greatest number of
advocates at the present day. According to the first, der-
moids are derived from the infolding of the ectoderm in embryonic
life, and these cells during subsequent irritation take on active
growth and result in the formation of the various tissues found
in a dermoid growth. It is claimed by the advocates of the
theory of parthenogenesis that there are some structures found
in the dermoid ovary which would require the infolding of all
of the layers of the blastoderm in order to complete their develop-
ment. The advocates of the first theory, however, direct at-
tention to the fact that striated muscle is never found in the
dermoid cysts. The character of irritation which sets in motion
the development of these growths, whether mechanical'or chemic,
ajiimate or inanimate, or whether it differs in the various kinds of
tumors, is as yet unknown. The frequent occurrence in a
cystadenoma of double-sided growth from the covering epithe-
lium favors the belief in a chemic irritation which has proceeded
by way of the uterus and tubes. The theory of the parasitic
origin of tumors is as yet unproved, though the analogous
course of tumor disease with infection has demonstrated that the
development of various kinds of tumors in the different tissues
of the body from metastatic deposits is of great interest.
OVARIAN TUMORS. 879
The susceptibility to the influence of tumor exciters greatly
varies in different individuals ; heredity, acquired disposition, age,
trauma, scar formation, and inflammation are important factors.
Of the influence of heredity little is known, though the occurrence
of ovarian cysts in several women of one family is quite frequent.
The age has no especial significance, as they occur in every
period of life. The glandular cysts are more frequent between
the thirtieth and fiftieth years. All varieties are less frequent in
childhood and old age. Fetal tumors are rare, and generally
consist of simple follicular cysts. These cysts increase in fre-
quency as the child approaches puberty, probably then induced
by the congestive hyperemia.
Ovarian growths are more frequent in the single than in the
married. Scanzoni indicates chlorosis as a predisposing factor,
and Fenwick, tuberculosis ; but these are difficult to demonstrate.
709. Natural Progress. — Proliferating cysts in the advanced
stages grow more rapidly than either the dermoid or solid tumors,
unless the latter are malignant. About the early stage of ovarian
tumors but httle is known, as they are usually well advanced
before they come under the observation of the physician. The
growth is probably slow. In dermoids and in benign solid tumors
the growth throughout is slow. A rapid increase in the size of a
growth, noticeable from day to day, is a symptom due to hemor-
rhage. With the pelvic structures in a normal condition, the
cystic ovary drops by its weight into Douglas' pouch, a little to
one side of the median line. As it increases it advances in the
direction of least resistance, which is upward, and pushes the in-
testines before it, until it rises out of the pelvis and impinges
against the abdominal wall, when it assumes a central position.
Tlie pedicle, at first anterior and inferior, is now directly beneath,
and often becomes posterior. The tumor lies directly above the
uterus, and, resting upon the brim of the pelvis, causes but little
inconvenience. Occasionally, the tumor becomes impacted in
the pelvis through irregularities in its growth or the formation
of extensive adhesions. Sometimes the tumor pushes the broad
ligament before it, or, when it develops in the hilum, it will
spread out the ligament and become an intraligamentary growth.
Once the growth rests upon the pelvis, in its further advance it
pushes the intestines upward and laterally. If undisturbed, the
enlargement becomes very great, the diaphragm is pushed up-
ward, severe pressure symptoms follow, and the action of the
heart and lungs is obstructed. The limbs appear as mere appen-
dages to the enormous abdomen. The pressure affects the circu-
lation, respiration, digestion, and the renal secretion. There are
marked suffering, emaciation, and the characteristic facial ex-
pression known as facies ovariana. The presence of ovarian
880 GYNECOLOGY.
tumors does not interfere with ovulation and menstruation, even
though both ovaries are involved, so long as any portion of the
ovarian stroma remains undestroyed. Thornton reports a case of
pregnancy with bilateral dermoid disease. In solid tumors amen-
orrhea is due to the total destruction of the Graafian follicles.
710. Symptoms. — In their early stages ovarian tumors rarely
produce any symptoms. Movable tumors generally come first to
observation when they rise out of the pelvis. An apple-sized
tumor will occasionally, though movable, cause unpleasant symp-
toms, such as pain in the sacrum, which extends down the leg.
Intraligamentary tumors or those prevented by adhesions
from rising produce symptoms as soon as they fill the pelvis,
especially by obstruction to defecation and micturition. As
the tumor increases, the sensations of pressure and unpleasant-
ness are aggravated. Besides the effects given in the description
of the progress, the skin becomes stretched, forms stride, and
swelling of the navel and hernia occur. More rarely, from the
pressure upon the great vessels, there are edema and varicosities
in the legs, sexual apparatus, and skin of the abdomen.
Albumintuia is present, and diminution of the urine from
compression of the renal veins is observed, which disappears
with the removal of the pressure. Severe compression symptoms
from the presence of very large tumors are now rarely seen.
Uterine or vaginal prolapse sometimes complicates the condi-
tion, but more frequently ascites and fluid collections follow the
rupture of a cyst.
Menstruation is usually unaffected, and sometimes continues
regular when subsequent microscopic investigation has failed to
show any functionally capable structure. Menstruation disap-
pears comparatively early in those cases in which the follicles
perish from the development of sarcoma or carcinoma, and in the
papillary cystadenoma, when bilateral. In contrast to fibroid
tumor, the menstruation decreases, and a disposition to the
menopause is betrayed, not from absent ovulation, but as the
result of constitutional conditions. Amenorrhea may exist for
several years and menstruation may return after the removal of
an ovarian cyst. In intraligamentary growths, especially the
papillary cystadenoma, severe menorrhagia occurs from pressure
upon the uterine veins.
711. Complications. — -Ascites occurs infrequently with cystic
growths, unless from rupture, but is very frequent in the solid
tumors. The cause is unknown. It can arise from pressure
upon the vense cavee and large abdominal veins. Edema may
involve one or both legs. Distention occurs in the pelvis of the
kidney and in the ureter from pressure along the course of the
latter. The most frequent complication is the formation <
OVARIAN TUMORS. 881
adhesions between the surface of the tumor and the omentum,
the intestines, the uterus, the bladder, and the abdom-
inal wall. These adhesions arise from inflammation, peritonitis,
and sometimes painlessly. They possibly arise from the loss of
surface epithelium of the cyst, through friction ; fibrinous exuda-
tion restdts, and the formation of adhesions between adjacent
surfaces. The adhesions become firm, dense, often thread-like,
and between the omentum and the growth may convey vessels
of sufficient size to be an important factor in the blood-supply.
Dermoids are frequently complicated by adhesions. When
adhesions occur between the tumor and the bladder or the in-
testine, the cyst may open into either, and thus discharge its
contents. A tuft of hair may project from a dermoid into the
recttun or the bladder. Adhesions are of importance from the
increased diffictdty in the removal of the growth. It is fre-
quently exceedingly difficult to distinguish the cyst-wall from the
parietal peritonetun.
Torsion of the Pedicle, — ^A moderate twisting of the pedicle to
90 degrees produces no symptoms ; it is only when the torsion is
sufficient to influence the circulation, or above i8o degrees, that
disturbance is occasioned. A slight twisting always occurs with
the elevation of the cyst from the pelvis. The right-sided tumor
tiUTis to the left, and the left-sided to the right. The cause of the
torsion is unknown. Kustner ascribed it to peristalsis and the
changes from the distention of the rectum ; Cario, to sudden belly
pressure; Mickwitz, to contraction of the transversalis muscle.
The influence of pregnancy and changes of position in a relaxed
abdomen which contains a tumor with a long pedicle are factors.
This torsion may readily arise from manipulation to determine
the diagnosis. I saw it occur in a young girl who had been
thrown upon the floor by her companion, who sat upon her abdo-
men. The torsion can occur with very small tumors which are
still within the pelvis, in which it most probably arises from the
varying distention of the bladder and rectimi. The twist may
involve but one or two turns of the pedicle, though as many as
six twists have been observed. The tube usually shares in the
twisting, and torsion of the uterus has infrequently occurred.
Torsion of the pedicle can take place in any variety of tumor,
though from its greater frequency it is found most often in the
cystadenoma. Dermoids and parovarian growths also show a
marked tendency to undergo pedicle-torsion. The tendency to
torsion of the pedicle is favored by the existence of a long, mem-
branous pedicle, a spheric form of the tumor, and a smooth sur-
face. The twisting is still further favored by pregnancy, labor,
and child-bed, through the changing relations of the organs in
the abdominal cavity.
56
Gy-VECOr.OGY.
The results of the torsion are dependent upon the rapidity
with which it has occurred. The torsion causes obstruction of
the vessels, in which the thin-walled veins suffer before the more
resistant arteries. There necessarily results an increased engorge-
ment of tlie blood in the tumor. Solid tumors are completely
penetrated by blood, and cystic growths undergo hemorrhagic.
infiltration of the walls as well as of the contents. The s
presents a black, blue, or dirty brown color, the cyst i _
increases in volimie, and, as a result, easily breaks down. A fatal
result can occur from hemorrhage into the abdominal cavity.
More frequently hemorrhage is arrested, but the nutrition of the
tumor suffers. The covering epithelium is lost, and extensive ■
OVARIAN TUMORS. 883
adhesions occur between the stirface of the tumor and the sur-
roiuiding structures, as the omentum, intestines, and parietal
peritoneimi.
These adhesions are, at first, very loose, then become organ-
ized, and the growth thereby obtains a new source of nutrition,
by which it maintains its size or proceeds to new growth. Further
twisting leads to obstruction of the arteries, which is followed by
necrosis of the growth. Necrosis is followed by shrinking of the
tumor from the absorption of its fatty constituents, though it
rarely disappears. It can become calcified. Peritonitis, with the
formation of extensive ascites, almost always results. The peri-
tonitis arises independent of micro-organisms, and is due to the
irritation from the presence of a foreign body or to the chemic
products of the tumor. An infection can occur through the tube
or from kinking of the intestine. Sometimes suppuration of the
tumor and pyemia ensue. A slight torsion can bring about
edema instead of hemorrhage, and ascites instead of peritonitis.
The pedicle may be foimd attenuated, or its thickness may be
doubled. The dermoid growths are sometimes found free in the
abdominal cavity or in pedicle-like adhesion with other structiu"es.
A dermoid tmder my observation was held in front of the uterus
by adhesions above to the omentum, and below to the perito-
neum; the tube and upper part of the broad ligament upon the
left side had entirely disappeared. The separation was evidently
old, for the wall of the growth had undergone calcareous degen-
eration. Iletis has resulted from the adhesion of a loop of intes-
tine to the timior or to its pedicle.
Symptoms, — Not infrequently there are no symptoms of tor-
sion. Such cases are usually recent or the torsion has been
slight. It may be suspected when the patient is taken with
severe pain in the belly, associated with meteorism, and sensi-
bility to pressure, acceleration of the pulse, sometimes also sin-
gultus, vomiting, and fever. In torsion of high degree indications
of intra-abdominal bleeding appear, with not infrequently marked
collapse. In the chronic condition the pain and unfavorable
symptoms are more gradual, though many patients are bedridden
and show a distinct loss of strength, occasioned by the absorption
of the altered constituents of the tumors producing a condition
resembling cachexia.
Inflammation a>id Suppuration of the Cyst. — Cysts can undergo
inflammatory and suppurative changes, though much less fre-
quently than formerly, as puncture of the cyst is not so often
practised. In some tumors the contents of which resemble pus,
the microscope demonstrates that the material consists of epithe-
lium and cell detritus, but not of leukocytes. The inflammation
is mostly communicated by the tube and intestine; the latter
884
GYNECOLOGY.
especially when adhesions have taken place between the intes-
tine and the sac. The opportunities for infection are increased
by parturition and the puerperium. as a result of the possible
trauma occasioned during the labor. Dermoid tumors are in-
clined to suppuration, formerly supposed to be due to the peculiar
pus-exciting character of their contents, but much more probably
the result of injury which the tumor has undergone during its
long retention within the body. We have already seen that the
dermoid was prone to torsion of its pedicle, and its contents are
an excellent culture-medium for the propagation of bacteria.
Symptoms. — The occurrence of inflammation and suppuration
is characterized by
fever and typhoid
]i]K'nomena, which
\-ar\- in intensity ac-
ci nxiing to the nature
of the infection. The
patient does not ex-
perience much pain
unless peritonitis is
associated. The
pulse becomes very
rapid and emacia-
tion is progressive.
Adhesions to the
suppurating tumor
occur, and the pus
makes its exit, as in
ovarian abscess, into
the bladder, the rec-
tum, or the vagina.
It is but rarely
that the pus is com-
pletely evacuated
and that spontaneous recovery results. Death usually follows
from pyemia. A rupture into the peritoneal cavity is quickly
followed by fatal peritonitis. The evacuation of such a tumor
through the bladder produces the greatest distress, as hair, teeth,
and pieces of bone are discharged, sloughs become impacted in
the urethra and induce cystitis, and there are retention of urine
and marked vesical tenesmus. Fragments which remain in the
bladder are coated over with urine salts, and become the nuclei
of calculi.
Rupture of Cystic r!(»iors.— Rupture of a cyst may occur sud-
denly, the result of a fall or blow, or can gradually result from
changes in the cyst-wall. It occasionally follows from internal
[, 561. — Dcnnoid Which Had Lost Its Orij^na]
Relations and Was Nourished by Adhesions
from the Omentum.
OVARIAN TUMORS. 885
pressure caused by the growth of the tumor. The latter accident
produces no symptoms, and it is only exceptionally that hemor-
rhage complicates spontaneous rupture. In papillary growths
the pressure of the vegetations causes thinning of the cyst wall,
and, finally, rupture ; or the growths project through the wall of
the cyst, to extend over its external surface. Rupture of a cyst
can occur into the surroimding viscera, but more frequently takes
place into the peritoneal cavity. In very thin-walled cysts this
rupture occurs easily. Manipulation to determine the diagnosis,
changing the position in bed, the act of coition, vomiting, may
produce it, and frequently it occurs without assignable cause.
The influence of. the accident will naturally depend upon the
character of the cyst-contents. Often, in the unilocular cysts,
rupture into the peritoneal cavity is attended with no un-
toward symptoms, beyond an excessive flow of pale urine. The
patient will often pass several gallons of urine in twenty-four
hours, and the abdomen, which was large, will become flattened,
flabby, and readily permit the residual sac to be recognized by
palpation. In single and parovarian cysts recovery can occa-
sionally follow the rupture. Generally, the opening is closed
by adhesions, and the fluid reaccumulates. In some cases the
accident is followed by high temperature, rapid pulse, vomit-
ing, pressure at stool, and diarrhea, which indicate the
absorption of the contents and the development of a form
of auto-intoxication. In multilocular and dermoid growths the
rupture into the peritoneal cavity is ordinarily followed by in-
fection, a rapidly developing peritonitis, and, finally, death. Such
a termination is probable not only in dermoid, but also in those
cysts containing colloid material and pus. In the papillary cysts
ruptiu'e results in the infection of the peritoneum, the formation
of ascites, and the development of vegetations over the entire
cavity. Sometimes an artery is torn in the rupture, and marked
hemorrhage, with profound anemia, follows. Profound collapse
has been noted.
The occurrence of rupture is recognized by the disappearance
of, or diminution in the size of, the tumor, the recognition of free
fluid in the peritoneal cavity, peritonitis, collapse, diarrhea, and
diiu^esis. The accident can be mistaken for torsion. Rupture
into the intestine is evident from the character of the discharges
and should be suspected when a profuse watery discharge escapes
from the bowel. External rupture is usually easily recognized.
When the discharge is pus or ichorous material alone, it is often
difficult to determine whether it is from a cyst or an abscess
in the walls.
Complication of Ovarian Tumor with Pregnancy. — The exis-
tence of ovarian growths does not preclude the occurrence of
886 GYNECOLOGY.
pregnancy, though their coexistence is comparatively rare. It is
more frequent in the one-sided, though it occurs sufficiently often
in double-sided, disease to demonstrate its possibility as long
as any functionating portion of ovary remains. The complica-
tion can occur with any variety of ovarian tumor, though it
is more likely to complicate the slow-growing forms — the dermoid
and the pseudomucin — than the others. Numerous cases are
recorded in which the
patient carrying an
ovarian tumor has suc-
cessfullyrun the gaunt-
let of'several pregnan-
cies. The existence of
sucha tumor, however,
does increase the dis-
tressing symptoms and
the danger of preg-
nancy. There is not
the same tendency to
rapid growth of the
cyst during pregnancy
as exists when a fibroid
growth is complicated
by the same condition.
The assertion that the
occurrence of preg-
nancy favors malig-
nant degeneration in
the cyst is unproved.
The occiirrence of car- .
cinoma in a cyst dur- 1
ing pregnancy is no
proof that it was not
previously there, or
that it would not have
occurred had preg-
nancy never existed.
The changing relations
of pregnancy, labor, and the puerperium undoubtedly do favor the
occurrence of torsion of the pedicle, and the delivery of the fetus,
whether naturally or by the use of instruments, not infrequently
crushes or bruises the cyst so that it ruptures or undergoes inflam-
mation and suppuration. While the varying relations of preg-
nancy, labor, and the puerperium exert an injurious influence upon
the progress of the tumor, it can, on the contrary, greatly disturb
these processes. The diminished space in the abdomen affords lesrj
a. Pregnant
OVARIAN TUMORS. 887
room for the nonnal development and increases the danger of
abortion and premature delivery. Abortion has been frequently
reported as a result of the retroflexion of the uterus produced by
the tumor. In labor a large tumor can materially interfere with
the normal forces of delivery by decreasing the activity of the
contractions and by altering the situation of the uterus. Much
more worthy of consideration is the situation of a timior of small
size in the pelvis, below the uterus, where it acts as an obstruc-
tion to the progress of the child's head. If these are not flattened
or pulled out of the pelvis, the head of the child can not enter,
and, unless otherwise alleviated, labor may terminate in rupture
of the uterus, tearing of the vagina, or bursting of the cyst.
Such complications ate necessarily attended with danger. The
puerperium can be complicated by gangrenous processes in the
ttimor and its pedicle, following the injury of laor.
The coexistence of the ovarian tumor with pregnancy, when
large, causes increased difficulty in respiration, through pressure
upon the diaphragm, and can cause danger to life by the pressure
and the tendency to albuminuria and edema. The tendency to
torsion of the pedicle, to rupture of the sac, and to subsequent
inflammation naturally clouds the prognosis.
When the cyst is situated in advance of the uterus, an effort
should be made to push it up,^and, upon failure, we may be left
to the choice between delivery of the growth through a vaginal
incision or its puncture through that canal and its removal after
deUvery. In the early months of the pregnancy operative inter-
ference for the removal of the tumor has but little influence upon
the progress of the pregnancy, and should be considered when-
ever the size and situation of the growth threaten the successful
termination of the pregnancy.
712. Degenerative Changes in the Cyst-walls. — The cyst-walls
can imdergo the following degenerative processes :
First, calcification y which most frequently occurs in the inner
layer of the main cyst-wall in the form of small granules or
plates of lime, or the formation of psammous bodies similar to
those seen in the papillary cysts. The calcification is increased
with the impairment of nutrition following gradual torsion. In
a case of dermoid which came under my observation the deposit
was so extensive that the tumor resembled a calcareous fibroid.
Second, fatty degeneration occurs in the papillary cells and in
the connective tissue of walls of the cyst. This process is en-
hanced by impairment of nutrition. The change in the septa of
cysts occurs from the pressure of their contents, and ends in their
partial or complete destruction. The presence of a large amount
of fat in the walls is an evidence of slow growth.
8S8 GYNECOLOGY.
Third, atheromatous changes, which generally occur in i
inner layer of the wall.
Fourth, changes due to infarctions, which are indicated
whitish, opaque bodies found in the septa and surrounded by a
red zone.
713. Diagnosis.— In the diagnosis of ovarian tumors the
physical signs are ascertained by the employment of inspection,
palpation, percussion, and auscultation. The information de-
rived by these procedures has been given. (Sections 160 to 164.)
The difficulty in the diagnosis will depend upon the size, situ-
ation, relation, and complications of the tumor.
The questions to be considered are: (1) Is the abdominal j
enlargement under observation a tumor? (2) The existence of a '
tumor recognized, is it an ovarian growth? (3) An ovarian
tumor admitted, its relations to the surrounding parts and the
existence or absence of a pedicle or of adhesions remain to be
determined. (4) The variety of the ovarian tumor.
First, Is the distention of the abdomen an intra-abdominal tumor?
This, at first thought, may seem an unnecessary question, but the
frequency with which various enlargements of the abdomen are
mistaken for such growths, and the occasional difficulty in
arriving at a certain determination, fully justify the careful con-
sideration of the subject. For convenience of study we divide the
ovarian growths into small, or those situated within the pelvis,
and large, when they are resting upon the pelvic brim. '
The abdominal enlargements, other than tumors, with which '
an ovarian tumor can be confused are obesity, desmoid tumor of
the abdominal walls, ventral hernia, tympanites, fecal accumula-
tion, distended bladder, ascites, and localized peritoneal effusion.
Obesity. ^A large, pendulous abdomen, from the accumulation
of fat within its walls or in the omentum, is sometimes mistaken
for an ovarian tumor. The history of its development and the
distribution of adipose tissue to other parts of the body, con-
trasted with the general emaciation of an ovarian cyst, should
assist in determining the diagnosis. The thickness of the fat
accumulation can be pretty accurately estimated by grasping a
fold of the skin and subcutaneous tissue between the thumb and
fingers, ]
Desmoid Tuttwr of the Abdominal Walls.^This growth, which J
is infrequent, develops in the muscle-wall, and partakes of the
nature of a fibroid. Generally, from its weight, it forms a depend-
ent tumor, which sometimes extends to the knees. In rare
instances it grows in, pushing the peritoneum forward as a part
of its covering and may fill up the abdominal cavity. It is quite
movable with the abdominal wall, and is superficial and very
hard. Its situation in the wall, covered by the skin and super-
OVARIAN TUMORS. 889
ficial fascia, and the determination by vaginal or rectal examina-
tion of the absence of any connection with the pelvic viscera,
determine its character.
Ventral Hernia. — Twice in diastasis of the recti muscles with a
large protrusion of the viscera have I been called a long distance
to operate for supposed ovarian cyst. Palpation of the intestinal
coils, the resonance upon percussion, and the observation of the
Fig. s^i' — Desmoid Tumor of Abdominal Wall.
peristalsis, readily seen through the thin covering of skin and
peritoneum, should have excluded the diagnosis of a cyst.
Tympanites. — A localized tympanites or phantom tumor, a
condition similar to pseudocyesis, is sometimes mistaken for an
ovarian cyst. The loud volume of resonance obtained by per-
cussion should be considered as contraindicating the probability
of the existence of a cyst. It is true that in rare instances a
communication of a cyst with the bowel will permit it to become
890 ^^^^^^^^^^H
resonant. A similar condition will arise from decompoMtion of
cyst-contents, by which gas forms in the cavity. Even in these
cases a sense of fluctuation can be secured, which is absent in
the phantom tumor. The latter tumor will entirely disappear
while the patient is under an anesthetic, to return as soon as the
patient recovers.
Fecal Accitmulaiion. — An accumulation of feces is sometimes
called a fecal tumor. It forms in the colon, and when in the
transverse portion of the gut, may descend and lie directly over
the pelvis. These accumulations are occasionally quite exten-
sive, but are recognizable by their length, by the peculiar sensa-
tion under palpation, and by the possibility of leaving an imprint
upon pressure, but most of all by the fact that they disappear
under the administration of purgatives and enemas.
Distefided Bladder. — A distended bladder forms a tumor in
the lower part of the abdomen which fluctuates and may very
readily be mistaken for an ovarian cyst. This suspi(;ion is
apparently confirmed by the information that the patient is con-
stantly passing urine. The fixed position, and the bulging of
the anterior wall of the vagina, should be sufficient to indicate
the use of a catheter, when the tumor will disappear. It should
be the invariable rule to empty the bowel and bladder preliminary
to the examination of an abdominal tumor.
In pregnancy, fibroid tumor, or even a simple ovarian tumor
impacted in the pelvis the urethra may be so distorted and
compressed as to render necessary the use of a soft male catheter.
Ascites. — In uncomplicated ovarian cysts the differential diag-
nosis from ascites is not difficult to make. The cysts have, in
common with ascites, enlargement of the abdomen, fluctuation,
and the symptoms arising from pressure against the diaphragm.
Not infrequently both conditions will be characterized by pro-
gressive loss of strength and flesh and by more or less edema of
other parts of the body, but there is a marked difference in the
manifestation of these symptoms when we come to analyze them.
The enlarged abdomen in ascites is more or less flattened and its
widest diameter is transverse, while the ovarian cyst is most
prominent in the vertical diameter and is narrow from side to
side. Fluctuation is very distinct over the abdomen in ascites
and in undocular cysts, but the wave of fluctuation will be found
to extend nearer to the vertebra in the former. In the well-filled
cyst the projection of the vertebra prevents the approach of the
fluid to the lumbar regions. In multilocular cysts the wave of
fluctuation is more broken, and frequently is only recognized as
a sensation of elasticity. The loss of strength is often more
marked in ascites, while the appearance of emaciation is greater
in the cyst. In renal and cardiac dropsy there is much greater
OVARIAN TUMORS.
disposition to anasarca. In a very advanced and large ovarian
tumor the pressure may induce considerable dropsy of the
extremities, but the abdominal distention is in much greater
proportion.
On palpation the ovarian timior presents greater resistance
Fig, 564. — ^Relative Zones of Dullness and Resonance in Ascites.
and can frequently be outlined and its surfaces distinctly deter-
mined. The abdominal surface can be moved over the tumor
and the upper margin is easily recognized. The existence of
adhesions or the presence of a large quantity of fluid may obscure
S92
GYNECOLOGY.
the conditions. Percussion affords the most valuable informa-
tion. In ascites there is a distinct zone of resonance over tlie
center of the abdomen, or the point of greatest prominence, while
the more dependent portions are dull. The zone of resonancej
Pig. 565. — Relative Zones of Dullness and Resonance in Ovarian Cytt.
changes with the position of the patient. In ovarian cyst, on-n
the contrary, there is dullness upon percussion over the whole
surface of the tumor, and resonance only after we have passed
beyond its HmJts, which is unchanged by position. As the tumor,
in its growth, presses the intestines upward and to the opposite 1
OVARIAN TUMORS. 893
side before it, the resonance will generally be discovered above,
and on the side opposite to that upon which the tumor has
originated. Occasionally, in a distended colon, resonance may be
secured over it in ascites. When the abdomen is very greatly
distended, or when inflammatory conditions bind down the in-
testines, resonance will be absent upon superficial percussion, but
may be easily determined when more pressure is used. The pres-
sure displaces the intervening layer of fluid and permits resonance
to be obtained. In tubercular peritonitis and in hepatic dropsy,
when the mesentery has undergone contraction and the peri-
toneiun is very much thickened, the diagnosis can be so obscure
as to require an abdominal incision to determine it.
Ascites may complicate an ovarian cyst, when, by displace-
ment of a layer of fluid, the hand will come in contact with the
cyst. The amount of resistance will afford information as to
whether the tumor is solid or cystic. The complication of ascites
can be regarded as an evidence of malignancy or of some degen-
erative process. The greater the amount of ascites, the more
probable the malignancy. I have, however, seen very large
ascitic accumulations from necrosis of a cyst after torsion of its
pedicle. The uterus is freely movable in ascites, while in ovarian
cyst it is but slightly movable, and displaced either downward
and backward or upward and forward. In ascites arising from
ruptured papillary cysts a dense, thickened mass is recognized
upon each side of the uterus, which should cause a suspicion as
to the character and origin of the disorder.
Localized Peritoneal Effusion. — Localized collections within
the abdominal cavity offer great' difficulties in determining the
diagnosis. Such accumulations are generally the result of tuber-
cular disease, and the history of the development of the disorder,
the general condition of the patient, and careful investigation of
the abdomen will afford an intimation as to its character. It
was my misfortune recently to mistake a collection within the
lesser peritoneal cavity for an ovarian cyst. The abdomen pre-
sented the characteristic appearance of a large ovarian cyst. A
vaginal examination would have revealed the uterus and ovaries
below a collection which did not dip into the pelvis, but, unfor-
tunately, no such investigation was made. The diagnosis of
ovarian growth was accepted upon the external appearance.
Upon abdominal incision the general peritoneal cavity was free
from fluid. An apparent cyst upon which the intestines were
spread projected into the incision, from which over three gallons
of straw-colored fluid were withdrawn, and investigation demon-
strated the character of the cavity.
Secoftd, Is the tumor under observation an ovarian tumor? The
physical signs vary with the size and situation of the tumor. In
894 GYNECOLOGY.
the early stage the tumor is entirely within the pelvis, and its
position varies. When it reaches the size of a hen's egg, the
tumor falls into the pelvis, where it remains until it becomes
too large to be longer accommodated in that situation. Its
relation to the corresponding side of the uterus permits its
character to be determined by conjoined manipulation. When
the growth has been complicated by peritonitis, the diagnosis may
be difficult. Small tumors usually feel firm because they are not
sufficiently large to afford fluctuation, or even elasticity. The
latter is of importance, and is generally absent in proliferating
cystomata. in dermoids, and even in small single cysts. When
Fig. s66.-
I Method of Determining Relation of Tumor to the
we are unable to separate the tumor from the uterus, and conse- ■
quently to determine the existence of a pedicle, the latter can be
ascertained by Hegar's method. This, while the patient lies upon
her back, consists in seizing the uterus with a vulsellum and
dragging it well down, while two fingers in the rectum follow its
borders to determine its relation to the growth, or the hand over
the abdomen can depress the fundus and thus recognize its rela-
tion. When a tumor is not large, it can usually be outlined by
a hand over the abdomen and a finger in the rectum. The great-
est difficulty is experienced when the tumor is complicated by in-
flammatory conditions, is fixed, and often incarcerated. Tumors ,
OVARIAN TUMORS. 895
which have originated in the broad ligament, and which lie in
close relation to the uterus, are usually less spheric and circum-
scribed, and are less movable from their first inception. Fibroid
tumors of the uterus and inflammatory growths of the tubes are
likely to be confused with small ovarian cysts. These growths
are pyosalpinx, hydrosalpinx, and hematosalpinx. The acute
history, marked tenderness, evidence of inflammatory exudation,
thickening, and matting together of the pelvic tissues, associated
with marked pain, should distinguish the pyosalpinx. In hydro-
salpinx the tirnior can be movable, and may give a sensation of
elasticity or fluctuation, but is oblong or gourd-like, rather than
spheric. It is frequently closely adherent to the uterus, and
affords a history of previous inflammation. A hematosalpinx is
at first soft, then becomes hard from the coagulation of the blood.
They are usually situated to one side of the pelvis and posterior
to the uterus. Fibroid growths are firmer and are closely
attached to the uterus.
Large or Abdominal Growths, — A large ovarian cyst distends
the abdomen, particularly at its lower part, rises abruptly from
the pubes, and is sharply defined and generally symmetrically
developed. Its outline, extent, and size are readily determined
by palpation. In a large single cyst the surface will be smooth
and regular, while in the multilocular cysts projections and irreg-
ularities are often found. If it is made up of a large number of
small cysts, it will be more resistant, although it will still present
a sensation of elasticity. These growths are confounded with
pregnancy, hydramnios, extra-uterine gestation, uterine myo-
mata, retroperitoneal growths, and the tumors of the various
viscera of the abdominal cavity.
Pregnancy. — The enlargement of the abdomen is more rapid
than in ovarian tumor. It is generally associated with sup-
pression of the menses and with the presence of such sympathetic
nervous phenomena as nausea, vomiting, disturbed appetite, and,
in the more advanced stage, a florid, healthy appearance of the
patient. Suppression of the menses is not a constant symptom
of pregnancy, for there are some women who continue to men-
struate during the entire pregnancy, nor is amenorrhea always
absent in ovarian growths. Error is more likely to occur in the
unmarried, during the early stage of pregnancy. The physician
should refrain from making a diagnosis until he has had an
opportunity to make a careful examination, and then should
hesitate to express an opinion when there is the least reason for
doubt. An examination a few weeks later will dispel the uncer-
tainty. There is an absence of fluctuation in pregnancy ; but it
is also absent in cysts with thick, viscid contents, or in the areolar
and glandular varieties, which are made up of a large number of
896 GYNECOLOGY.
small cysts. As pregnancy advances, the fetal movements,
heart-sounds, and parts of the fetus are recognizable. The heart-
sounds are pathognomonic of pregnancy, but are not always
heard, owing to the position of the fetus, the large quantity of
fluid, or to fetal death. The conjoined manipulation will afford
information as to the relation of the enlargement to the uterus.
Gestation in one horn of a bicomate uterus can make the diagnosis
difficult, but a careful bimanual exploration will demonstrate the
association of the enlargement with the uterus, and the small
undeveloped comu in association with the enlargement. Under
no circumstances should the size of the uterus be determined with
a probe when there is the least suspicion of pregnancy.
Hydramnios. — Hydramnios is a pathologic form of pregnancy
in which there is a more or less large collection of amniotic fluid
in the uterine cavity. Cases in which the collection exceeds
two quarts have been mistaken for ovarian cysts. In large
collections the abdominal cavity becomes greatly distended;
its surface is smooth, white, and glistening, and fluctuation
is very distinct. The patient suffers all the discomfort char-
acteristic of a large cyst. The history will prove of value in
determining the diagnosis. Hydramnios generally occiu^ sud-
denly, and makes its appearance about the sixth or seventh
month of a pregnancy which has previously run a normal course.
Such symptoms could arise only from an ovarian cyst which
had undergone some marked change in its nutrition, but this
diagnosis would be excluded by the previous indications of
pregnancy. The physical examination of such a patient will
disclose an enlarged uterus, the cervix of which is frequently
obliterated, os open, and covered with a dense membrane,
through which, by manipulation, we are often able to distinguish
parts of the fetus or obtain ballottement. Rupture of the
membrane is followed by the discharge of a large quantity
of water and the evacuation of the uterine contents. It should
not be overlooked that the existence of an ovarian cyst does
not preclude the occurrence of pregnancy, and the presence
of the latter, by the increased flow of blood to the pelvis, may
facilitate the growth of the cyst. As we have already seen, the
rapidity of the growth may be so great as to require early inter-
ference in order to save th^ life of the patient. Careful ex-
amination will usually disclose an enlarged uterus either in
front of or behind the cyst.
Extra-uterine Pregnancy. — An ectopic gestation which has
attained a size sufficient to permit it to be confused with an
ovarian cyst will have presented the symptoms of early preg-
nancy, possibly indications of rupture of the sac, and internal
hemorrhage. Later, the tumor may be found to one side of
OVARIAN TUMORS. 897
or behind the uterus, and so closely adherent to it as to render
the differentiation from it exceedingly difficult. In advanced
stages the fetal movements and the heart-sounds may be heard.
Vaginal palpation will disclose the fetal parts covered with
a thin wall. After the death of the fetus other changes occur
which render the diagnosis still more difficult. The fetus
shrinks, becomes macerated, and the decomposition produces
an accumulation of gas, which, with the distinct fluctuation,
makes the condition doubly obscure. A careful analysis of
the subjective symptoms, associated with a thorough examina-
tion, will generally permit its recognition.
Uterine Myomata. — Generally, the slow growth, the re-
sistance of the tumor, and the usual presence of multiple growths,
their irregular contour, and their demonstrable relation to-
the uterus, should afford confirmation of the diagnosis. A
tumor which has but recently come under the observation
of the patient, and which has, through degenerative or ob-
structive processes, taken upon itself rapid growth, may afford
considerable difficulty in ascertaining its true character. The
difficulty becomes very great in edematous fibroids and in
fibrocystic tumors. It would seem that the demonstration of
the continuation of the mass with the cervix would be suffi-
cient to demonstrate the uterine origin. Double ovarian cysts,
particularly when the pedicle is short or absent, may so drag
upon the fundus uteri as to make it apparent that the growths
are a part of the uterus. The relation of the uterus to the
tumor is best determined by grasping the cervix with a vul-
sellum, which is held by an assistant; a second assistant draws
up the tumor through the abdominal walls, while the principal,
with one or two fingers in the rectum, and the hand over the
abdomen, seeks the pedicle and ascertains its relation to the
uterus. This procedure, even in double growths, will permit
the fundus to be recognized and the nonuterine character of
the growths to become known. In the early history of ab-
dominal work not infrequently the abdomen was opened for
an ovariotomy and a uterine fibroid was discovered. Indeed,
the earlier removals of the uterus were cases of mistaken diag-
nosis. Uterine myomata may complicate the presence of an
ovarian cyst, and the consequent distention of the abdomen
from the presence of two large tumors may render earlier inter-
ference desirable. The ovarian cyst may be situated in front
of the myomatous uterus, and the growth may be unsuspected
until discovered during the progress of an operation.
Retroperitoneal Tumors. — Retroperitoneal tumors are very
rare. They may originate from the tissue in the pelvis or from
that of the subperitoneal portion of the abdomen. The more
57
898 GYNECOLOGY.
fixed position of the mass, the recognition of resonance over
the tumor, and, particularly, the ability to demonstrate, through
rectal palpation, the presence of the rectum in front of the tumor,
will assist in the diagnosis.
Other Abnormal Collections and Growths. — The uterus can
present morbid collections, such as physometra, hydrometra.
and hematometra. Physometra is a collection of gases within
the uterus, the product of decomposition, and is a rare con-
dition. Hydrometra, a collection of watery fluid within the
uterus, mostly occurs in women of advanced years, and is caused
by retention of the secretions after obUteration of the canal.
Hematometra is a collection of blood in the uterus, — as the
retention of the menstrual discharges from occlusion of the
cervix or vagina, — and it mostly occurs near puberty. In-
spection and bimanual palpation are sufficient to disclose the
cause. The situation of renal and hepatic cysts is sufficient
to release them from the suspicion of an ovarian origin.
Third, the relation of the tumor to the surrounding parts, the
character of the pedicle, and the presence of adhesions:
Adhesions. — The mobility of the tumor is dependent upon
the length of the pedicle and upon the absence of adhesions.
A tumor which can be pushed up without much dragging upon
the uterus, be displaced from side to side, and the abdominal
walls be recognized as sliding over it, is reasonably free from
adhesions, and has a long pedicle. A tumor which is situ-
ated upon one side of the pelvis, pushes the uterus to the
opposite side, is quite immovable, or drags upon the uterus
as it is moved, is, without doubt, an intraligamentar}- cyst.
Rapid enlargement, tenderness of the abdomen, and a sen-
sation of crepitus as the abdominal wall is being moved over the
tumor indicate recent and extensive adhesions, the result of
peritonitis. Limited adhesions with omentum, intestines, and
abdominal wall can not be excluded. In very large cysts it is
frequently difficult to diagnose the presence of adhesions. In-
formation can often be secured by observing the respirations.
In deep inspiration we can feel and see the upper pole of the tumor
pushed down, unless it is fixed. The ability to drag the uterus
down will assure its freedom. If the fundus uteri remains high
when the bladder is empty, it is adherent. The history'- is valu-
able, as adhesions occur in torsion of the pedicle, in infiammator}'
•changes, and from traumatism.
Torsion of the pedicle is recognized by the complication
of an ovarian tumor with sudden and severe peritoneal s\TTip-
toms. These are severe pain in the belly, meteorism, vomiting,
elevated temperature, rapid growth of the tumor, and tenseness
OVARIAN TUMORS. 899
of its surface, which indicate that the torsion has been followed
by intracystic hemorrhage or increased exudation.
When the patient is seen long after the torsion, the tumor
is ever5rwhere adherent, and the patient may show distinct
evidences of marasmus. Sudden collapse, followed by symp-
toms of internal hemorrhage and by peritoneal irritation, in-
dicate the occurrence of an internal hemorrhage. In the acute
stages of torsion it is often difficult to arrive at a differential
diagnosis from rupture of an ovarian cyst, peritonitis, perfora-
tion of the stomach or intestine, renal or gall-stone colic, ileus,
and rupture of an ectopic gestation. An attentive considera-
tion of the history and progress of the disorder will lead to a
direct conclusion. Inflammation of a tumor is determined by
the accompanying symptoms. The tumor is very sensitive,
and presents a spontaneously localized, sometimes radiating
pain. The tumor may suddenly enlarge, or the suppuration
may lead to the formation of gas and the development of
a tympanitic resonance. Perforation of a suppurative tumor
into the bladder or intestine is recognized by tenesmus and
irritation of the bladder or by diarrhea and intestinal colic.
Perforation is certain if portions of the tumor or its contents
are found in the discharges. Rupture of a cyst is determined
by the associated phenomena. Sudden oppression, suffocation,
nausea, sometimes vomiting, diarrhea, acceleration of the
pulse, and moderate elevation of temperature indicate the
entrance of fluid into the peritoneal cavity. This is rendered
more probable by marked diuresis and a perceptible decrease
in the size of the tumor, with the presence of free fluid in the
peritoneal cavity. The distinct tumor limits are not found,
and there is no alteration of resonance with change of position.
Fourth, the variety of the ovarian tumor. The glandular
proliferating cyst is the most frequent form and attains the
largest size. These tumors are mostly multilocular, and con-
sequently present a less marked wave of fluctuation upon pal-
pation. Fluctuation is an indication of the cystic character
of the tumor, and is very distinct in the unilocular and large-
chambered varieties. Instead of fluctuation we often find
a kind of elasticity, which can be produced by edematous solid
growths, and in large cysts the contents of which are made
up of colloid or very thick, viscid material. In some cysts,
instead of fluctuation, only a kind of vibration is determined.
In fluctuating or tough elastic tumors which are nodular we
will probably find a cystadenoma. A large fluctuating tumor
is not necessarily a unilocular cyst, because it may contain
within it numerous small cysts.
Generally, a small cyst which presents no symptoms is
900
GYNECOLOGY.
not a cystadenoma. but may be a dermoid, a parovarian, or.
more probable than either, a simple retention cyst of the ovary
or a simple serous cyst, Dermoid tumors are recognized by
their irregular consistency — in some places soft, in others hard.
A doughy feel has been ascribed to them, but this is rare, as
the fatty material at the body- temperature is fluid, and it
is only in the presence of a large amount of hair that the doughy
sensation can be elicited. The determination that the tumor
had been in existence for ten or more years would justify the
suspicion of a probable dermoid. Olshausen says that parovarian
growths are mostly determined by their moderate size, slow
growth, thin and relaxed walls, the translucent fluid contents,
and the very distinct fluctuation. Parovarian tumors, as a
rule, are spheric, though from their relaxed condition they
may assume other forms, especially when pressed into the pelvis.
Large cysts are generally multilocular. The presence of double
intraligamentary growths, as well as of ascites with small tumor
formation, is a presumption, but not a positive indication, of
papillary growths, as the conjunction of such symptoms is found
in all tumors. Superficial papillomata feel firm, nodular, and
are often diffusely extended in the pelvis. In a rapidly develop-
ing ascites, in which renal, cardiac, and hepatic causes can be
excluded, the presence of bilateral resistance in the pelvis should
awaken a suspicion of ruptured papillary ovarian cyst. A
pronounced solid consistency of the growth is common to ovarian
fibromata, sarcomata, endotheliomata, carcinomata, and terato-
mata.
It should not be forgotten that ascitic conditions can coi
plicate in all these ttimor formations. Ascites when present'
increases the difficulty of palpation and renders the diagnosis
more uncertain. The fibromata and the fibrosarcomata are more
or less nodular, of quite firm consistence, and are more frequently
situated upon one side.- Sarcomata and endotheliomata are
generally softer. The solid carcinomata are mostly bilateral,
quite nodular, and offer a sensation of toughness. There are no
positive indications that a tumor is benign or malignant, as a
cystadenoma may contain masses of cancer material, Ascites is
generally regarded as an indication of malignancy, but it occurs
in pseudomucin cysts, papillary growths, and with the fibromata.
Hard consistency and an irregular surface are also reasons for
suspicion, but are not positive indications. Early adhesion of
the tumor, which prevents the vaginal wall from being moved
over it, is an indication of malignancy, when abscess forma-
tion can be excluded.
The age of the patient is of little significance, as the
of puberty is inclined to the formation of cancer, and all vi
OVARIAN TUMORS. 901
ties of ovarian tumor can occtir at any period of life. Proper
metastases, as distinguished from peritoneal implantation, are
of significance, but it is not always easy to demonstrate these
metastases, as they do not always cause symptoms, or are not
perceptible because of the abtmdant ascites. In other cases
metastases will have been discovered in the vagina, the para-
metrium, and the rectal and peripheral lymph-glands before
operation, fixing the diagnosis of malignancy without question.
Pronounced cachexia and marasmus may be produced by certain
complications, such as rupture, torsion, and inflammation;
also in tumors of enormous size. Rapid growth, especially
in children, speaks for malignancy. Olshausen directs attention
to the premature edema of a leg as a symptom of cancer.
714. Exploratory Puncture. — In obscure and complicated
cases it was formerly the rule, before resort to operation, to
draw off a portion of the cyst-contents for chemic and micro-
scopic examination. The fluid may have such pronounced
physical properties as to reveal the true character of the growth.
The thick colloid material from proliferating cysts can be mis-
taken for nothing else. If the fluid is serous, the possibilities
of origin are numerous. It may have been furnished by a
parovarian cyst, a serous ovarian tumor, a cystadenoma, ascites,
hydronephrosis, and echinococcus sacs. In uncomplicated cases
the fluid may possess such chemic properties as will aid in the
differentiation, but frequently these properties are lost through
complications, such as serous transudation and an admixture
of blood. The fluid from a proliferating cyst is thick and colloid,
with a specific gravity of from 1015 to 1030, and contains par-
albumin and cylindric cells. In the papillary cysts there is
an absence of paralbumin, while white blood-corpuscles are
revealed by the microscope. The fluid from the Graafian
follicles does not differ from that of the parovarian cysts. As-
citic fluid is thin and of a light yellow or greenish color, from
which albumin is coagulated upon boiling, but no cylindric
epitheliimi is found, and the specific gravity is from 1008 to
1 01 5. In the cystic fibroma the fluid is of a lemon-yellow
color, has a specific gravity of 1020, coagulates rapidly without
heat, and contains no cylindric epithelium. The fluid from
echinococcus cysts presents hooklets, has a specific gravity
of from 1008 to loio, and does not contain albumin. In
hydronephrosis the fluid is thin, with a specific gravity of from
1005 to 1018 ; its color varies, and it contains urea, leucin, tyrosin,
and kreatinin. Puncture of a cyst is always attended with
danger, and when performed in doubtful cases, for diagnostic
purposes only, — as in the echinococcus cysts, renal tumors,
abscesses, and dermoids, — is attended with the most serious
902
GYNECOLOGY.
consequences; the intestines and bladder have frequently t
punctured; fluid may escape into the peritoneal cavity
cause peritonitis; or air may enter the sac and result in in-
flammation and suppuration; a large vessel in the sac-wall
has been injured, and a severe and dangerous hemorrhage
has resulted. Neither chemic nor microscopic examination
of the cyst-contents affords positive information, and the in-
ferences thus secured do not compensate for the increased
danger the patient undergoes. '
715. Exploratory Incision. — In cases in which we find it
impossible to arrive at a positive diagnosis, as in tubercular
peritonitis, in malignant disease of the ovary, tube, or omen-
tum, or in papillary cysts, a button-hole incision, sufficiently
large to permit the introduction of the finger, will be a far safer
procedure than puncture, and will afford an opportunity to
determine the condition by touch, and will permit subsequent
drainage. It should be done under all antiseptic precautions, ,
and every preparation should be made to complete the opera- j
tion if the conditions will permit. While this procedure is
unattended with great danger, its indiscriminate practice is un-
justifiable. It should not be utilized to secure information that
may as well be secured by the bimanual examination. When
the latter procedure has demonstrated an inoperable malig-
nant condition, for instance, the incision should not be made
merely for confirmation of the decision.
716. Treatment. — That an ovarian cyst is not amenable
to medicinal treatment is evident when we consider that the
fluid is contained within a closed sac, which has its own secreting
surface. The administration of remedies, and the application
of counterirritants with a view to increase secretion and eUm-
ination, must be without avail. Electrolysis has had its
advocates, but when we consider the character of these growths,
and the danger from infection many of them must present, the
folly of such treatment is evident. Surgical treatment should
consist in extirpation. Puncture is but a palliative procedure
at best, for the removal of the fluid is quickly followed by its
reformation, and it requires more and more frequent with-
drawal, which proves a severe drain, tlu'ough the great loss ]
of albumin. As has been stated, it is associated with danger -j
from the puncture of a large vessel in the tumor wall and the l
consequent hemorrhage ; from the possibility of infection by j
escape of the contents of a papillary cyst or the rupture of 1
so thin-walled a cyst and the escape of its contents into and ]
over the peritoneal cavity; and, lastly, from septic infection.
Puncture may be resorted to as a temporary measure in a tumor]
complicating pregnancy, when the cyst is so situated as ■
OVARIAN TUMORS. 903
form an obstruction to labor, and then should be performed
through the vagina, after the most thorough cleansing of that
canal. Ptmcture of a cyst through the rectum, tmder any
circumstances, is an tmjustifiable procedure.
717. Ovariotomy. — Extirpation of the tumor, or, as the
operation is known, ovariotomy, is the only operation worthy
of consideration as applicable to all cases. Success in its per-
formance will depend very much upon the care with which
the diagnosis has been made, the knowledge of the operator
as to the condition of the patient, the dexterity with which
the operation is performed or the readiness in meeting complica-
tions, and the judicious treatment of the patient subsequent
to its performance.
718. Indications. — The recognition of the danger of every
operation upon the peritoneum led the early operators to post-
pone interference until the patient had begun to experience
marked discomfort and was suffering in general health from
the pressure of the growth. The recognition of the principles
of antisepsis and asepsis has rendered postponement unneces-
sary. A more careful study of the progress of the growths
has demonstrated that it is unwise to postpone operation after
a tumor has attained a growth sufficient to permit of diag-
nosis, because of the various complications which can develop.
A large proportion of ovarian tumors are of a malignant char-
acter. Schultze places the proportion of malignancy at 27
per cent, of all ovarian tumors; Ruge, at 15 per cent. These
variations are dependent upon their appreciation of the re-
lation of papillary formations to malignancy. Pfannenstiel
foimd, among 400 cases in which were included parovarian
tumors, that 19 per cent, were malignant. Reckoning the
papillary adenomata, the number equaled 26.15 per cent. —
a proportion that agrees with the estimates of Schultze and
Leopold. It will be seen from these statements that about
every fourth or fifth ovarian tumor can be considered malig-
nant. The diagnosis of malignancy can not be made with
certainty. If it is recognized that safety in these cases lies
in the earliest possible extirpation, it will be evident that in
one-half of all the cases the early extirpation of the tumor
will be indicated. Absolutely benign growths of the ovary
are unlimited in their size, and thus cause symptoms which
imperil the life of the patient and lengthen the time required
for recovery. Delay favors the development of complications
which, if they do not threaten life, create conditions that render
the later operation more difficult and the prognosis less certain.
These circumstances, with the present favorable prognosis
of ovariotomy, render it desirable that every Qvarian tumor
y04 (iYNECOLOGV.
should be subjected to operation as soon as it attains a size
sufficient to permit of its diagnosis. It was formerly advised
to wait until the tumor had reached a size that would permit
it to rest upon the pelvis, but no limit is now known, and the
operator prefers to remove the tumor as soon as the patient's
permission can be secured. The inability to determine the
exact character of the growth, and the possibility of very small
papillary tumors infecting the entire abdominal cavity, make
early operation advisable.
The severity of the symptoms only come into considera-
tion by promoting the early decision of the patient for opera-
tion. The difficulties of the operation should not be a cause
for delay, as they will not become less by waiting. The stage
of life plays no rflle in the decision unless the growth is com-
plicated by acute tubal disease, which may render temporary-l
delay desirable. '
The indication for operation should be considered as urgent
when the tumor begins to grow rapidly or when symptoms
of threatening complications appear. Compression of the
lungs, symptoms of uremia, of ileus, of intraperitoneal or intra-
cystic hemorrhage, or rupture of the cyst must be considered
as urgent and vital indications. More frequent complications
are torsion of the j^dicle and inflammation and suppuration
of the cyst. The existence of peritoneal irritation has been
considered as a reason for delay in operating, but now we realize
that the patient has a much better prognosis through early
operation than when it is delayed. J
719. Contraindications. — The reasons for withholding opera^ J
tion may be transitory or permanent; the former, in severe"
complicating diseases, as intercurrent fevers, bronchial catarrh,
especially in the aged, progressive weakness from loss of blood.
or obstinate gastro-intestinal catarrh. The menstrual period
is sometimes regarded as such a cause, but as it does not in-
crease the danger of infection, it is no bar. The permanent
contraindications are : irrecoverable disease of the heart, lungs,
kidneys, or liver, marasmus, especially senile, and such dis-
eases as will in a short time certainly lead to death. While
pulmonary tuberculosis, valvular disease of the heart, and
nephritis are contraindications, ovariotomy occasionally de-
creases the danger from the lesion.
Age is no contraindication; as a number of successful c _
tions after the age of eighty are reported. The mortality <
100 cases operated upon after the age of seventy was 12
cent, (Kelly). Ovariotomy is not contraindicated by
unless the tumor is associated with some disease which
render death pertain in a short time.
OVARIAN TUMORS. 905
A number of anatomic contraindications were formerly
recognized, among which were adhesions, intraligamentary
growths, and the existence of malignity. Adhesions are no
longer considered a reason for delay, and frequently the re-
lation of the tumor to the broad ligament is discovered only
during the operation. In the majority of cases the attempt
at the operation only terminates with its completion. While
the most trifling hope of recovery exists, and no traces of cachexia
and metastasis formation are present, the operation should
not be considered as contraindicated.
720. General Considerations. — Unless immediate operation
is indicated by torsion of the pedicle, rupture of the cyst, or
indications of cystic hemorrhage, two days should be occupied
in the preparation of the patient, during which the pulse, tem-
perature, condition of the respiratory organs, and urine can
be studied. In complicated cases the procedure may be longer
delayed, until the condition of the patient can be corrected.
In very large cysts, with marked edema and dyspnea, many
authors advocate a preliminary puncture, in order that the
lungs and kidneys may have a few days to recover their
functions before the major operation is performed. Because
of its many disadvantages, puncture should be done very
infrequently. For the performance of ovariotomy the follow-
ing assistants are desirable: First, a principal assistant, who
stands opposite the operator; second, the anesthetist; third,
a nurse or a physician to arrange and serve the ligatures and
sutures; fourth, a second nurse, to care for the sponges; and,
fifth, a nurse to serve in changing the water for the hands of the
operator and his assistant and for counting the soiled sponges.
All these persons should be trained to know and to do their duty.
Directions as to their preparation for the operation are given.
(Section 178.)
Instruments. — A knife, two pairs of scissors, two long dis-
secting forceps, twelve small and six large clamp forceps, two
ligature carriers, a needle-holder, an angiotribe, a trocar, a
tube, two pairs of cyst forceps, and two short and four long
curved needles, each threaded with a double silk loop for carriers,
should be provided. The instruments should be carefully
sterilized and placed in sterile trays. The patient should be
placed upon a suitable table, with her feet toward a good light.
An ordinary kitchen table will serve well. The operator stands
to the patient's left and his assistant opposite. To the right
of the operator is a table, upon which are placed the tray con-
taining the instruments; a smaller one, for the needles and
ligatures; and a basin with sterile water, for the hands of the
operator, which should be changed as often as it becomes soiled.
906
GVNECOLOGY.
Behind the principal assistant stands another table, on which
are two basins for the sponges or pads, and a third for the as-
sistant's hands. The soiled sponges arc collected in one of these
basins, from which they are counted when the operation is com-
pleted. It is important that the exact number employed during
the operation shall be known, and that all should be accounted
for before closing the wound. When dry sponges and pads are
used, it is a good plan for the nurseto have a definite number, say
twelve, placed in a basin, and no more opened until these are
used. As the pads are withdrawn they should be placed aside
in packages of the same number, which makes the enumeration
of the sponges easily made and the number wanting easily de-
termined. Want of care may result in the retention of a sponge,
a pad, or even an instrument within the abdominal cavity,
to the great disadvantage of the patient and to the discredit
of the surgeon. A third table should hold the dressings, ready
for application. There should be on hand in the room hot
Fig. 567. — Cyst Forceps.
and cold sterilized water, — at least five gallons of each, — slop-
buckets, a normal salt solution for irrigation of the abdominal
cavity, and a suitable apparatus for hypodermoclysis or intra-
venous injection, if the condition of the patient should demand
it. In addition, there should be within the reach of the anes-
thetizer a hypodermatic syringe and solutions of strychnin and
atropin, gloinin, and antiseptic ergot.
721. Operation. ^The operation is best described by divid-
ing it into stages and detailing the method of procedure in each
stage. The student can thus secure a graphic outline of the
various accidents which may possibly occur and of the expedients
to which he will find it best to resort as he proceeds. He will
be unlikely to mistake his course on the journey if an accurate
chart of each portion is furnished him.
The different stages are:
I. The incision of the abdominal wall in the median line
or through one rectus muscle, securing all bleeding vessels with >
OVARIAN TUMORS.
907
hemostatic forceps before the peritoneum is opened. (See Sec-
tion 196.)
2. The puncture and evacuation of the cyst.
3. The removal of the cyst and management of the adhesions.
(See Section 197.)
4. The method of controlling the circulation through the
pedicle.
S- The examination of the other ovary and of the general
peritoneal cavity for bleeding vessels; the removal of all gauze
pads. (See Section 198.)
6. Drainage. (Sections 199, 200, 201, 202, 203.)
sc-d; Cyst Exposed.
7. Closure of the wound. (Section 204.)
8. Dressing. (Section 205.)
1. The Incision of the Abdominal Wall. — Great care was
formerly exercised to open the abdominal cavity in the Hnea alba
and not expose the structure of either rectus, but now I prefer
to expose the one muscle and draw it over so that the incision in
the posterior fascia is along its inner edge. Less hemorrhage
thus results than when the incision passes through the structure
of the muscle. The union resulting from the wound made
through the linea alba would produce a feeble and resisting ven-
trum. When there has been previous separation of the recti
90S GYNECOLOGY.
muscles as a result oi the extension, I prefer to expnse b-Mh
recti and s^> introduce the sutures to hold them and their n\<o-
neurotic capsule in accurate apposition. The linea alba is the
weakest part of the abdominal wall. The peritoneum is picked
up, pulled away with two pairs of forceps from the tumor wall,
and an incision is made through it. This avoids injur\- to the
tumor wall or to a knuckle of intestine which might be situated
over.it. • The peritoneum is incised the length of the woundso
that it will not be likely to be pushed off during the subsequent
manipulation.
2. Piinctttre and Kvacitation of the Cyst- The incision cfirn-
■Cyst Punctured and Being Withdrawn.
pleted and bleeding vessels clamped, the surface of the tumor is
explored to <letermine the presence of adhesions and their extent.
They should be broken or separated to permit the exit of the
superficial portion of the tumor. Various more or less ingenious
trocars have been devised for evacuating the contents of the cvst.
What is required is a cannula with a tube attached, through
which the fluid can be carried to a receptacle beneath the table.
The simpler and more readily cleansed this apparatus, the better.
A glass nozle for a fountain syringe, togetlier with three feet of
rubber tubing, will scr\-e very well. A glass tube of larger cali-
ber will pnive more effective when there is a large quantitv of
OVARIAN TUMORS. 909
fluid to be evacuated, or where the fluid is very viscid. In a
specially prepared operating room a cannula, however, is not a
necessary part of one's equipment, for the cyst contents can be
readily evacuated through a knife thrust, but at the expense
of greater soiling of the room and clothing.
The point chosen for puncture should be situated toward
the upper portion of the wound, so that the contraction of
the emptying cyst will not draw the opening within the ab-
domen. The principal assistant should be directed to make
pressure upon the abdomen so that the cyst as it empties shall
be forced toward the abdominal opening and the edges of the
cyst wound can be seized with hemostatic or cyst forceps and
Fig. 5;o.— Withdi
drawn out, serving as a funnel as the cyst empties, and before
it is completely emptied, unless fixed by adhesions, can be with-
drawn from the abdominal cavity. Wlien the cyst is a large
one, I would Jidvise that the patient be turned upon her side,
the assistant making firm pressure to keep the cyst pressed
into the wound as it empties. This position favors the rapid
evacuation of the cyst contents, with the least danger of the
entrance of the fluid into the peritoneal cavity. When the
operator has provided himself with sterile basins, he can col-
lect the fluid and obviate soiling of the body of the patient,
her sterile environment, and the room with its contents. The
lateral position also is favorable in necrotic cysts, as it permits
910
GYNECOLOGY.
their removal with less soiling of the general peritoneal cavity.
The precaution to obviate soiling the peritoneal cavity is es-
pecially important when the cyst contents are purulent. The
careful observations of Watkins have demonstrated that the
contents of these cysts are often especially \4rulent, producing
fatal peritonitis or other form of sepsis whenever the infection
has foimd lodgment within the abdomen. Large vessels in
the cyst wall should be avoided in making the puncture, while
entrance of the cyst contents into the abdominal cavity can be
still further prevented by placing gauze pads between the cyst
and the edges of the wotmd. The operator, by seizing the edges
of the cyst woimd and forcibly drawing them out emptied,
protects the peritoneal cavity from any soiUng, especially when
the patient occupies the lateral position. When a cannula is used,
the relaxed cyst upon either side of the cannula is caught with
suitable forceps and drawn out. In nonadherent cvsts this
Fig. 571. — Ligatures Introduced
through Broad Pedicle.
Fig. 572. — Interlacing of Sutures to
Prevent Splitting of Pedicle.
procedure will permit the removal of the sac, when empty,
without any soiUng of the abdominal cavity. In multilocular
cysts the largest cyst exposed is first evacuated, through which
succeeding cysts may be then emptied, drawing the first out to
serve as. a funnel. Areolar and dermoid cysts are best removed
without effort at their reduction, because the contents, es-
pecially of the latter, are irritating to the peritoneal cavity
and difficult to remove from it. Occasionally, the cyst-con-
tents are so viscid that they refuse to run through the cannula.
The edges of the ptmctiire are seized and the sac is drawn forcibly
against the wound, while the opening is enlarged and the jelly-
like contents are scraped away.
3. Remcrcal of the Cyst and tlte Management of Adliesions. — In
non-adherent cysts the tumor is already delivered, but in the
presence of extensive adhesions its delivery may be attended with
the greatest difficulty and the gravest peril. The aim should, as
OVARIAN TUMORS. 911
far as possible, be to separate old adhesions under the eye. Re-
cent adhesions can frequently be separated by a sponge pad
pressed against them as the sac is drawn out, or the hand may be
passed into the abdomen over the tumor and thus quickly sepa-
rate the recent adhesions. In old cases with extensive adhesions
the conditions are different and it is unwise to separate adhe-
sions except under sight. This purpose may require a much
longer incision to permit of the adhesions being treated under
the eye. The adhesions, where possible, should be torn, but where
this is not feasible, they can be cut with scissors or knife, making
sure that large vessels are secured. Occasionally the adhesions
are so short or the contact so close between the cyst and coils of
intestine that the separation is impossible. The cyst wall can
be cut through, leaving a portion attached, resembling a patch.
Care must be exercised, however, to remove all secreting sur-
faces from the lining membrane of the cyst. Great care must be
exercised in separating old adhesions, as large vessels in the
omentum, mesentery, and pelvis may be torn, producing severe
and even fatal hemorrhage. Injuries to intestines, bladder,
spleen, and liver may occur, and if overlooked, produce fatal
results. When the tumor has been delivered its pedicle, if suf-
ficiently long, should be clamped and the mass removed. A
hasty glance is then given to the condition of the viscera where
dense adhesions have been separated, to make sure that adhe-
sions have not occurred which will cause serious hemorrhage or
permit the soiling of the peritoneal cavity with the contents of
intestine or bladder. If the pedicle is long and thin, a ligature
may be thrown around it and tied. The stump should be folded
under in order that it shall not form adhesions with the coil of
intestine.
4. Management of the Pedicle. — In a short, broad pedicle this
is not feasible, but the section method, illustrated by Figs. 571,
572, and 573, serves an excellent purpose.
When tied in several sections the ligatures should inter-
lace, in order to prevent the pedicle from splitting, and the peri-
toneum should be sutured over the stump. This procedure takes
additional time, but will often save the patient from very imcom-
fortablc if not dangerous adhesions between the stimip and in-
testine. The Downes electric angiotribe affords an excellent
method of securing against hemorrhage, and leaves the woimd with-
out the irritation of a foreign body. In a cyst without a pedicle the
sac should be enucleated and the vessels secured as the operation
proceeds. These cases present some of the most trying problems
within the realm of abdominal surgery. In cutting away the
tumor the precaution must be exercised to provide a sufficient
button to prevent the ligature from slipping. If a ligature
912
GYNECOLOGY,
slips on a short, broad pedicle, the parts spread out, the vessels
retract, and serious hemorrhage occurs, which may be difficult
to control. Sometimes, when the pedicle has been ineffectually
tied, the ovarian or uterine artery slips back and forms a hema-
toma in the stump, which so fills up the tissues as to make
sufficient traction upon the ligature to withdraw the tissue
and permit a fatal hemorrhage to follow. The tendency of
the tissue external to the ligature to shrink after the removal
of the tumor should not be forgotten, and when the traction
is severe, a sec(}nd ligature may be judiciously placed behind
it to secure the ovarian arter>'. Silk, wire, and animal ligatures
have been employed for securing the pedicle. Silk, from its
strength, ease of preparation, and small amoimt of material
required, is most frequently employed. I prefer the chromic
catgut, but the precaution must be exercised to tie it tight
and to leave a secure
button, because of its
greater propensity to
slip. Other methods of
securing hemostasis have
been employed : the ves-
sels have been twisted ;
for many years the pedi-
cle was brought out of
the wound and clamped; Keith applied a temporary clamp and
charred the tissues with the hot iron ; Skene improvised a set of
electrocautery clamps, by which the tissues were slowly burned
through and the application of the ligature avoided. This appa-
ratus has been greatly improved and made practicable through
the ingenuity of Dr. A. J. Downes, of this city.
5. The next step was formerly described as the toilet of the
peritoneum. Unless evidence of hemorrhage makes it incum-
bent to secure bleeding vessels, the next procedure should be to
inspect the other ovar>'. Not infrequently it will be found the
seat of disease, often completely involved by a glandular, papil-
lary, or dermoid growth. Where necessary, it must be removed,
but, if possible (unless in mature women), a portion of the organ
should be saved. The deprivation of the possibility of procrea-
tion is too serious a matter in young women to justify the need-
less sacrifice of ovarian structure. In many cases, even when
associated with large tumors, a portion of the o%'ary capable of
performing all the functions of that organ can be saved. Where
adhesions have existed the omentum, mesentery, and pelvis
should be carefully inspected for bleeding vessels, and any such
should be secured. \\'herever possible the peritoneum should
be sutured over torn and denuded surfaces, clots of blood removei
F'E- 573- — ^Suturcs Interlaced and Tied.
OVARIAN TUMORS. 913
and ragged edges left from adhesions cut away. Should oozing
occur from a large s\u^ace, it may be controlled by infiltration of
the tissue with i to 4 of a i : 1000 solution of adrenalin chlorid
with sterile normal salt solution through a hypodermatic syringe.
Should this procedtire be ineffectual and the surface too large to
permit it to be quilted together with a continuous catgut suttire,
a gauze pack can be employed. The pack has an additional ad-
vantage in extensive denudation that it keeps the intestines
from contact with the raw surface tmtil the peritoneum has had an
opportunity to reform and thus prevents the redevelopment of
firm adhesions. It is true, the packing becomes walled off, but
the adhesions thus formed are soon absorbed after the removal
of the gauze, unless the patient has become infected. The end
of the pack can be brought out at the lower angle of the wotmd,
but the drainage is against gravity, frequent dressing of the
wound is required, the danger of infection is increased, and a
weakened ventrum results in an increased susceptibility to sub-
sequent hernia. For these reasons it is preferable that the end
of the drain be carried into the vagina and the gauze be ultimately
removed through that canal. Drainage by the vagina presup-
poses that the vagina has been sterilized as a preliminary to the
operation, but should this have been neglected, the gauze pack-
ing may be placed in the pelvis and the wound closed, making an
incision through the posterior vaginal vault, which can easily be
done for its removal. All woimds penetrating the intestine or
bladder should be sutured as soon as discovered in order to pre-
vent the peritoneal cavity from being soiled by their contents.
Woimds in the peritoneum should be, as far as possible, sutured.
When the omentum has been torn, making a ragged, stringy mar-
gin or opening in its structure, it should be ligated and the por-
tions external to the ligatiu-e be excised. Otherwise a coil of
intestine may slip through such an opening or beneath a band
and become strangulated. The peritoneal cavity should be
cleansed of blood and cyst contents, preferably by sponging with
dry gauze, but when there are large denuded surfaces, or the peri-
toneum has been soiled with irritating fluids as from a dermoid or
suppurating cyst, it should be irrigated with normal salt solu-
tion and should be closed filled with the solution. The fluid per-
mits the intestines to float, allows the regeneration of the denuded
epithelium, and lessens the danger of unfortunate adhesions.
As a final consideration before closing, the surgeon should be
certain that the abdominal cavity contains no foreign material,
such as gauze pads or instruments. Directions have been given
for keeping tab upon the number of pads used and of insuring
the certainty of their removal. The surgeon should not rely
wholly upon the nurse, but should be certain that he has removed
58
914 GYNECOLOGY.
all the sponges he has inserted. It is a very good plan first to
wall off the intestines with a long and wide piece of gauze and
place the smaller pieces, when necessary, below it.
6. Drainage. — This subject is no longer granted the import-
ance in abdominal work it was vouchsafed when I first began the
practice of surgery. Then the profession gave heed to the
admonition of Tait: "When in doubt, drain." Experience has
taught the wonderful power the peritoneum possesses of protecting
itself, and, outside of a vaginal wick, drainage is rarely employed.
The gauze wick has supplanted the glass drainage-tube. Twenty
years ago I frequently introduced the glass drain, but have not
used one in several years. In extensive denudation of the pelric
peritoneum associated with oozing the gauze tampon is of value.
In repair of the large intestine in its lower portion, especially
where the tissues sutured are more or less friable from inflam-
matory changes, it is wise to cover the surface loosely with gauze
in order to afford a vent should imion fail and a fecal leak occur.
The gauze drain, when possible, should open into, the vagina
and be removed through it. The drain should be permitted to
remain from four to six days.
7. Closure of the Wound. — The aim of the operator is to so close
the wound that like surfaces shall be brought in apposition, and
afford as little opportimity as possible for the accumulation of
fluids (serum or blood) in the woimd. After prolonged obser-
vation of different methods I have chosen the procedure described
in Section 204 as the most satisfactory and the least likely to be
followed by hernia. The one flaw in this procediu-e is the possi-
bility of serum or blood collecting between the peritoneum and
muscle and its infection from its proximity to the intestinal canal.
Should the patient after operation have a continuous elevation
of temperature for which no explanation is apparent, it \\ill be
wise to make a pimcture to ascertain the existence of an extra-
peritoneal collection. Its early evacuation saves a weakened
ventrum.
8. Dressing. — The woimd dressing should be simple and
unirritating. The wound surface should be free from patho-
genic germs and be protected from them imtil recovery has fol-
lowed. The silkworm-gut suttires are left long, the wound is
sponged with 50 per cent, alcohol in sterile water, then covered
lightly about the sutiu-e ends with gauze, then several layers of
gauze, and finally a pad of wood cotton and gauze held in place
with pieces of plaster to which tape is attached to be tied over
the dressing. The whole dressing is then sectu-ed by a Scultetus
binder. This method of securing the dressing affords easy ac-
cess to the wound and with but Httle annoyance to the patient.
General Considerations. — The study of the differential diag-
OVARIAN TUMORS. 915
nosis of ovarian tumors should have prepared the operator
to appreciate the fact that, after the most careful investigation
of his cases, he must not infrequently expect to meet with con-
ditions entirely different from those which the physical signs
have indicated. What appears a simple ovarian cyst will pre-
sent complications that will test the ingenuity of the most
experienced operator to overcome. The inexperienced operator
should prepare himself for every emei^ency, and should have
previously planned for them, as the prudent general plans
for the coming battle. The more carefully the case has been
studied, the patient prepared, and the emergencies anticipated,
.
f^
^
^ d
|h|
UtATURE 1
^^^^s
^Mf£.^^^^^^^
JNOl/rtRIAnJ
|MHH|H
BBKi^r ^^^
f'BTZPy'y
>
^W
Fig. S74. — Splitting of Pedicle when Sutures are Tied without Interlacing.
the more certain will be the success. It is far better to
go to unnecessary preparation many times than to be tm-
prepared once. Patients with large ovarian cysts frequently
suffer from pressure symptoms, and are greatly benefited by
previous purgation, stimulation of the secretion of the kidneys
and skin, and the administration of strychnin and atropin
to strengthen the action of the heart and vessels. In the in-
cision care is exercised to avoid pushing off the peritoneum
and to escape injuring the bladder, a loop of intestine, or the
cyst. The bladder may be drawn up to a higher level by ad-
hesions to the cyst. It is recognized by the arrangement of the
muscle-fibers in its wall. The parietal peritoneum is occasion-
ally inseparable from the surface of the tumor along the line
of incision, when the cyst may be opened and emptied before
proceeding to the separation of the adhesions.
The intestine is rarely in danger of injury during this stage
of the procedure, but occasionally a loop may be situated in
front of the cyst.
The toilet of the peritoneum should not be understood
to mean thorough drying of the cavity; indeed, much spong-
ing and manipulation of the peritonetmi are injurious and favor
the formation of adhesions. The cavity is most readily cleansed,
and with the least injury, by irrigation with normal salt solu-
tion. The retention of a considerable quantity of the fluid
is beneficial, in that it favors peristalsis, and by its absorption
replenishes the hquid waste. Ragged omentum and shreds
or bands of adhesions should be removed, When the irrigating
fluid continues to come away bloody, careful examination
should be instituted to ascertain the source of the bleeding.
The abdomen must not be closed while a considerable quantity
of blood is being lost. Unless the abdomen has been soiled
with infective cyst contents it is better not to irrigate. If
the precaution has been exercised to protect the cavity by
gauze packing, irrigation will be very infrequently required.
A saline solution is probably the least irritating of anything
that can be introduced into the peritoneal cavity, but even it
handicaps to some degree the functions of this extensive ab-
sorbing surface.
Post-operative Treatment. (Sections 206-220.)
722. Incomplete Operation. — The conditions in which the
operation has not been completed are most frequently those
of intraligamentary parovarian cysts, and particularly papil-
lary cysts. The structure of the broad ligament is more or
less involved, and not infrequently adhesions affect a large
portion of the intestine. The more experienced the operator,
the less frequently will the incomplete operation be performed.
With judicious measiu-es, cases in which the operation can
not be completed are exceedingly rare. In the intraligamentary
variety an incision of the peritoneum, where it is situated about
the base of the tumor, is made, the tumor is drawn up, form-
ing a pedicle, and the tissue is pushed off by blunt dissection.
Sometimes the tumor may be opened and an incision made at
its base, by which the sac is then dissected out. Frequently
it is advisable to precede the operation by Hgation of the larger
vessels, particularly the ovarian arteries, after which the dis-
section can be accompHshed with less hemorrhage. Adhesions,
when in the form of cords and bands, can be cut with the Paquelin
cautery. In the papillary variety it is very important that the
OVARIAN TUMORS. 917
mass should be removed, even if it is necessary to extirpate
the uterus to accomplish it. Frequently what seem desperate
cases recover when the original source of the disease is removed,
even though extensive infection of the peritoneal cavity has
occurred. When adhesions .are very extensive and the condi-
tion of the patient is such as to preclude the possibility of com-
plete removal of the sac, its cavity should be emptied, cleansed,
and sutured to the parietal peritonetmi of the abdominal wall,
while the remaining portion of the wound is closed. The sac
cavity is packed with iodoform gauze. Thus it may be kept
open, irrigated from time to time with disinfectant solutions,
and the packing renewed until the cavity fills by granulation.
This procedure is necessarily attended with increased danger
to the patient, as it is impossible to keep such a wound com-
pletely aseptic.
When a timior is deeply situated in the pelvis, the abdominal
opening may be closed after an incision has been made through
the base of the tumor into the vagina, through which the end
of the gauze packed into the cyst may be carried. Over this
gauze the cyst-wall is closed, and covered, when possible, with
peritoneal flaps. Intraligamentary tumors are sometimes pushed
up into the mesentery, and the removal of the mass necessitates
the ligation of important branches of the mesenteric artery.
When a large portion of mesentery is thus ligated, the vitality
of the portion of intestine supplied by it is endangered and
gangrene of the gut may result. Such cases may demand
the excision of the affected portion of the intestine and an end-
to-end anastomosis. In metastasis of the papillary variety
into the omentum, forming, as it frequently does, good-sized
masses involving the entire omentum, the latter should be
removed after ligation of its base with a number of catgut liga-
tures. It was my privilege, in a patient who had double-sided
papillary ovarian cysts, with extensive ascites from the infected
peritoneum, and who had been subjected three times to ab-
dominal section for the evacuation of this fluid, to remove
both ovaries and the greater part of the uterus after an exten-
sive dissection. The entire omentum was also removed. This
patient, in whom the dropsical effusion had previously collected
so rapidly that they were unable to get her out of bed after
operation before the fluid had reaccumulated, had no recur-
rence of effusion subsequent to the complete operation, and
two years later was in good health.
723. Rupture of the Cyst. — In cysts of the glandular variety
which have been greatly distended, or when the pedicle is partly
twisted, the cyst-wall becomes fragile and is easily torn, per-
mitting its contents to escape into the abdominal cavity. This
918 GYNECOLOGY.
accident is not a serious one unless the cyst contents have
undergone degeneration, as in suppurating cysts, or are irritat-
ing in character, as in the dermoid and papillary varieties. Tear-
ing the cyst -wall wiU necessitate a thorough irrigation of the ab-
dominal cavity to neutralize or to remove the contents.
724. Hemorrhage. — The site of the hemorrhage wiU greatly
influence its character. In large cysts with extensive adhesions
hemorrhage may take place from the cyst-wall or from vessels
that have been torn within its walls and threaten a fatal re-
sult. The adhesions should be separated rapidly, the cyst
raised, and its pedicle secured to cut off the blood-supply, The
larger and more vascular adhesions should be separated between
ligatures or clamp forceps. If the hemorrhage threatens life,
the assistant may place his hand within the abdomen, com-
press the abdominal aorta, and maintain the pressure until
the operation is completed. Such a procedure prevents the
further supply of blood, and so arrests the bleeding. Hemor-
rhage may occur from a very extensive surface, particularly
when malignant disease has been the subject of removal, or
extensive papillary growths which are intraligamentary or be-
hind the uterus. Fatal syncope and death may follow the
removal of very large tumors as a result of decreased ab-
dominal pressure. The vessels relieved from pressure become
distended by the blood, and form extensive reservoirs, by which
so much of the blood is withdrawn from the circulation as to
cause cerebral anemia and the death of the patient. Such
a patient can be said to have bled into her own vessels. Such
an occurrence is likely to take place only in very large tumors,
and may partly be obviated by emptying the cyst slowly. When
syncope occurs, the head should be lowered, and an assistant
may compress the abdominal aorta v/ith the hand in the ab-
domen, while the treatment of the pedicle and the toilet of
the abdomen proceed. Occasionally, it may be necessary to
remove the uterus on account of the free bleeding from its
torn and denuded surfaces. The vitality of the patient may
be maintained by hypodermatic injections of strychnin, gr. j'xr— iV
hourly or every two hours, a i : 1000 solution of adrenalin chlorid.
gtt. x-xv every hour, atropin, gr. j^, to contract the blood-
vessels, ergone, "ixx, or a hypodermoclysis of normal salt solu-
tion. The salt solution can be poured directly into the abdominal
cavity while the patient is in the Trendelenburg posture, or trans-
fused directly into a vein. The latter measure affords an in-
creased quantity of fluid by which the vessels can be filled and the
heart have something upon which to contract.
725. Visceral Injuries. — Injuries to the intestine are possible
during complicated operations. In making the abdominalJ
OVARIAN TUMORS. 919
incision it is important that the peritoneum should be raised
with forceps and a small opening made, to prevent not only
injury of the cyst-wall, but of a possible loop of intestine which
may be adherent over it. With the opening, the incision in
the peritonetun can be extended the full length of the external
wotmd by holding it up and incising it imder the eye. In very
dense adhesions the intestines may be torn into, or even across,
during the progress of the operation. When such a lesion
occurs, the parts should be carefully repaired at once, and
measures should be taken to prevent soiling the peritoneal
cavity with the bowel-contents. The intestine should be care-
fully sutured, and when torn through to such a degree as to
render its vitality uncertain, resection should be done and an
end-to-end anastomosis made. This procedure is accomplished
very quickly with the Murphy button or one of the mechanical
devices for holding the ends of the divided gut, especially the
O'Hara forceps. In the absence of these instruments, the
anastomosis may be performed by first suttiring the mesenteric
surface of the bowel by a single suture, another just opposite
to this, and then one on each side between the first two. This
divides the bowel into four sections, each section of which can
be rapidly closed by continuous suture. The needle is passed
through the loop of these sutures at every other insertion, which
prevents puckering and contraction of the lumen of the bowel.
The first row of sutures should be covered by a second, and this
also covers over the sutures we have employed to maintain
the ends together. A still better procedure is to introduce
an interlocking continuous suture from the mucous membrane
side of the bowel, and superimpose this by a similar suture
in the peritoneal covering. Such a closure is rapidly accom-
plished and very effective. The closure can be made with
fine silk or chromic catgut, or the internal may be made with
the former and the external (or peritoneal) with the latter.
The most difficult cases for suture are those in which the
rectum has been torn low down in the pelvis. Portions of
the bowel may be so devitalized that they will not subsequently
hold, and a fecal fistula follows. In all cases in which the in-
jury of the bowel has been extensive, and its condition endan-
gered, the parts should be packed with iodoform gauze, which
affords a vent in case union is not complete. Complete closure
of the wound should be interdicted, because the patient would
develop a dangerous peritonitis before the occurrence of rup-
ture is recognized. The position and relation of the ureter
should be kept in mind in tumors situated low in the pelvis,
or in those which are developed in the broad ligament, and
particularly in the papillary forms of ovarian growth, as the organ
GYNECOLOGY.
mav be pulled up or torn off in the enucleation of such masses.
When the tumor is so situated as to endanger the injury of the
ureter, it is better to dissect out the latter to make sure that
it is uninjured.. When it has been cut or torn, the preferable
nrocedure is to establish an anastomosis between the divided
ends (Fig- ^ 34.) If this is impracticable, then transplantation
into the bladder should be performed. If the ureter is so short
as to cause its \'itahty to be endangered by the necessary trac-
tion to reacVi the bladder the latter should be anchored to the
side' of the pelvis in a position most favorable to relieve the
tension. The ureter may be introduced into the descending
colon or an attempt may be made to introduce its end into
the ureter of the opposite side; but one should hesitate in at-
tempting the latter, as failure means the imperiling of the un-
affected kidney and ureter. Its end may be brought out through
the skin and a urinary fistula estabhshed. but this means
an exceedingly uncomfortable condition for the patient. One
alternative is to ligate the ureter, which should be done with
double hcature, as a single Hgatiu'e is likely, under the process
of absorption, to become loose and permit a subsequent leakage
of urine. The urine is secreted xintil the pressure from the
distended pelvis is equal to that of the blood-pressure, when
secretion no longer occurs. The organ unused becomes atrophied.
Another alternative is the extirpation of the kidney, and, be-
fore attempting this, the operator should be well satisfied that
the kidney on the opposite side is capable of doing the work. ^^
The bladder may be injured during an operation. It may^^|
be drawn up over the anterior surface of the tumor and bC'^^l
incised, or its fundus may be removed before its true character ^^^
is suspected. The peculiar interlaced muscular structure of
the bladder-wall should permit its recognition. When it is
ooened or injured, it should be sutured. In a case of fibroid
tumor in which it was my misfortune to cut away the entire
summit of the bladder the walls were sutured, and the patient
recovered. In such cases it is important that the bladder
should be watched to prevent it becoming unduly distended
during the convalescence. It should be frequently evacuated
in order to avoid separation of weak union and leakage of urine.
726. Prognosis. — The result of the operation of ovariotomy
will depend greatly upon the manner in which it has been con-
ducted. With the exercise of every precaution, there will
frequently be cases of delayed convalescence, owing to latent
or preexisting pathologic conditions; but the danger is greatly
increased when the operation has been carelessly performed
and its details imperfectly practised. The operator and his
assistants should have been so well trained that no deviation ■
OVARIAN TUMORS. 921
from the proper course, even though slight, will be overlooked.
What avails the most rigid cleanliness of person, room, and
instruments when a ligature is employed that has been dragged
over blankets or imclean tables before its introduction? when
the woimd is dusted with iodoform from a box that has been
standing open, and has been used in all sorts of cases about
a ward? when the operator rubs his nose, scratches his head,
or touches nonsterilized objects, and introduces the hand into
the abdominal cavity without precautionary cleansing? Such
indiscretions are often responsible for stitch abscesses and
other septic processes. Pus-collections and cellular inflamma-
tions in the pelvis in the region of the uterus frequently restdt
from infection of serous collections in Douglas' pouch. Ele-
vation of temperature, rapid pulse, and abdominal tender-
ness subsequent to the fotirth or fifth day shoiild lead to care-
ful exploration for their origin. A mass of exudate in the
pelvis shoiild be considered an indication for vaginal incision,
for the administration of salines until free purgation is secured,
and for the use of rectal and vaginal enemas of hot water
at least twice daily. The vaginal incision should be a free
one across the vault of the vagina, after which the cavity should
be thoroughly irrigated with normal salt solution and a good
packing of iodoform gauze introduced. This procedure shoiild
be preceded by careful sterilization of the vagina.
727. Intestinal Complications. — In difficult operations in-
flammatory intestinal sequels are not infrequent. The in-
testines may be obstructed by twists, and this danger is ag-
gravated by bands of inflammatory adhesions, or by openings
in the omentum or mesentery, through which a knuckle of
intestine can slip and become strangulated. Lacerations of
the intestinal coat affect the peristaltic action, and may lead
to paralysis of a section, with ensuing symptoms of obstruction.
A twist or volvulus may become so fixed that nothing will
pass it. In walls that are already weakened a fecal fistula will
result. In a case some years ago in the Philadelphia Hospital
an operation by a colleague was followed five weeks later by
symptoms of obstruction, and the patient vomited stercoraceous
material. The abdomen was reopened and five feet of intestine
were torn up, disclosing a distinct volvulus, which was untwisted,
when the patient recovered after a prolonged convalescence.
The importance of an early reopening of the abdomen in such
a case can not be overestimated, as the obstruction may be
due to strangulation of a knuckle of intestine beneath inflam-
matory bands or to its inclosure between sutures of the woimd.
The latter is unlikely to occur when the wound is closed in the
manner we have suggested.
922 GYNECOLOGY.
728. Causes of Death. — Causes of death after ovariotomy
are, as in hysterectomy, shock, hemorrhage, and peritonitis.
These sequels are much less infrequent, however, as the opera-
tion for ovariotomy is more easily accomplished and the dura-
tion is shorter than in hysterectomy. Tetanus, which for-
meriy occurred frequently after ovariotomy, is now extremely
rare. Ileus may occur in the second week as a result of ad-
hesions or twists of the intestine. Inability to accomplish
the evacuation of the intestine by injections with the pehis
elevated, and especially when compUcated with stercoraceous
vomiting, should require the reopening of the abdomen. The
mortality of ovariotomy is very slight — much less than formerly.
This is partly due to the fact that operations are now performed
early, and it is only in rare instances that the patients are sub-
ject to the deleterious action of the cyst. Early operation,
before the patient experiences complications, is attended with
very slight mortality. Thus, Martin, in more than 1000 ovari-
otomies, has but 2 per cent, mortality; Olshausen reported his
last 100 ovariotomies with only 4 deaths. The uncomplicated
ovariotomy has practically no mortality.
LIST OF AUTHORS QUOTED.
A.
Abel, 50, 55, 637, 757
Abrahams, R., 251
Adams, 530
Ahlfeld, 584
Albarran, 642
Alexander, 496, 528, 530, 533, 549
Alquie, 531
Amann, 848, 854, 855
Amussat, 234
Andrews, 67, 68, 69, 73, 317
Antal, 720
Apostoli, 149, 150, 151, 152, 153, 701,
703. 704
Aran, 430
Arnold, 103
d'Arsonval, 153
Atlee. 708
Auvard, 244, 245, 741
B.
Baccelli, 391
Baer, 46, 724
Baker, 785
Baldwin, 235
Baldy, 498, 536
Bandier, 638
Bandler, 586
Barbour, 169
Bardenheuer, 274, 649, 801
Barnes, 17, 19, 225, 596
Barrows, 392
Bartholin, 75, 167, 330, 333, 335, 339, Cheston, 596
Bissell, 536
Bizzozero, 74
Bland, P. Brooke, 115, 621, 745
Blau, 760, 761
Bode, 649
Boeckman, 108
Bohmer, 55
Borelius, 811
Bottini, 792
Bouilly, 734
Bov^, 250, 496, 543, 546, 549, 790,
795
Bozeman, 268
Braun, 784
Breisky, 343* 344
Bright, 19
Brum, 70
Bullitt, 859
Bumm, 65
Bumham, 723
Burrage, 514, 544
Byford, 176, 181, 357
Byrne, 156, 784, 785, 796
C.
Cabot, 79, 87, 88, 89
Calderini, 792
Camero, 372
Cario, 881
i Cassati, ^33
Chad wick, 23
' Chantreuil, 783
Charcot, 78
352, 366, 629, 633, 634
Bassini, 532
Baum, 249
Bayle, 651
Beat son, 142
B6clard, 245
Belfield, 215
Bensa, 650
Bernhardt, 825
Bemutz, 430
Biegel, 665
Biffi, Qi
Billroth, 792
Bischoff, 314, 316
Bishop. E. Stanmore, 275, 276, 653,
718, 728, 733, 734. 737
923
Chrobak, 824, 825
Churchill, 146, 257
Clark, J. C, 128, 191, 371, 455, 795, 801
Cleveland, 312, 313
Cohnheim, 664, 764, 841, 878
Cohnstein, 783
Colpe, 384
Coover, E. H., 142
Coplin, j;3. S^, 57. ^o. 63, 68, 77, 91, 653
Corneuil, 402
Corradi, 793
Corson, E. R., 271
Coste, 157
Courty, 16, 19, 20, 559
Cowper, 167, 339
Cox, S. E., 633
924
LIST OF AUTHORS QUOTED.
Cred6, 80 1
Cucca, 824
CuUen, 745. 746, 748. 756. 760
Cumston, 123, 828
Cturan, 250
Cxury, 63
Czerny, 787, 790, 792, 793, 796, 811
D.
DaCosta, John C, 639
DaCosta, John C, Jr., 78, 79, 80, 89,
90
Dare, A., 82
Davidson, 104, 258
Deaver, 29, 160, 161, 166, 171, 172,
173. 196, 204
Delafield, 56
Depage, 230
Deschamps, 459, 539, 540, 785
DeSinety, 183, 382, 394, 401
Dickinson, 257
D6derlein, 61, 62, 65, 348, 349. 375.
629
Doleris, 74, 533
Doran, Alban, 854, 855, 861, 877
Douglas, 74, 199, 201, 417, 419. 443.
444, 445. 447. 451. 453» 463. 470. 500.
514, 516, 550, 562, 564, 565. 566, 577.
603, 619, 638, 676, 717, 726, 729, 730,
731. 732, 733. 769. 785. 792. 793. 795.
797, 798, 800, 807, 809, 811, 813, 819,
879, 921
Downes, A. J., 156, 463, 797, 911, 912
Doyen, 717, 731, 732, 733, 736, 738.
792, 852
Drszewczky, 829
Ducrey, 70
Dudley, A. P., 312, 313, 314. 325. 535
Dudley, E. C, 497, 498, 499. 512, 513,
514. 549. 728
Duhrssen, 545, 794
Duke, A., 322, 325
Dunning, 236, 398, 609, 616
Duret, 532
Duvemey, 339
Dybowski, 760
E.
Eastman, Joseph, 460, 797, 801
Edebohls, 24, 42, 46, 49, 50, 259, 408,
532, 709, 790
Edgar, 62, 72
Ehler, 823
Ehrlich, 78, 79. 80, 81
Eiselsberg, 641
Ellinger, 45
Emmet, T. A., 143, 259, 281, 308, 309,
310, 312, 325. 326, 383, 408, 439. 495
Etneridge, no
F.
Farre, 187
Fenwick, 879
Ferguson, 33, 37, 275, 276
Ferguson, A. H., 496, 536, 540
Ferraresi, 231
Finsen, 74, 155
Fisher, J. M., 236, 600, 604
von Fleischl, 82
Fleiss, 220
Flemming, 54
FUck, 364
Fowler, 456
Fraipont, 824
Franck, 796
Frankel, 73, 214. 215, 823
Freund, W. A., 71, 306, 308, 432. 497.
546. 550. 787. 799. 800, 829
Fnedlander, 69
Fritsch, 321, 324, 354. 401. 645, 646,
792, 793. 814. 823, 826, 827
Frommel, 769, 796, 798, 813, 814
Furbringer, 109
G.
Gabbett, 365
Gabritschowsky, 80
Gant, 195
Gariel, 268, 560
Garrigues, 299, 303, 495
Gartner, 191, 622, 629, 637
Gehrung, 490, 491. 7^3
Gersterberg, 572
Gessner, 841
GilHam, 496, 536, 538, 539. 54o, 549
Goldman, 757
Goldspohn, 533, 534
Gooch, 400
Goodell, 39, 41, 46, 824
Gottschalk, 546, 715
Gow, 724
von Grafenberg, 784
Gram, 64, 66, 69, 73, 341
Grawitz, 70
Greenhalgh, 609
Gremlier, 638
Grenach, 53
Gross, 544
Grubler, 58
Gubarrofi, 801
Guerin, 209
Guit6ras, Ramon, 337
Gusserow, 653, 666, 766, 771, 840,
842
Guthrie, 192
Guyon, 362, 372
H.
Haeser, no
Haine, no
Hare, Hobart A., 133
LIST OF AUTHORS QUOTED.
Hanington, Chas., 109
Hams. sC 57. 96. 3'7. 364. 373
Hart, 169
Hegar, 106, 399, 303. 346. 49S. 640.
70s. 7°"*. 7'8, 784. 785. 786. 8og,
810, 894
Hcidenhain. 816
Heinecke, 810
Heller, 343
Hennig, 1S5, 187
Heppner. 304, 307
Hermann, S4, 19S. 783
Herr, 381
Herzfeld, 808, 809, 811
Hewea. 79
Hewitt, Grailey, 490, 491, 510
Hicks, Braxton, 609
Higbee, 39
Hildebrandt, 303, 303, 306, 346
Hirst, 563
Hochenegg, 806. 809, 811, 8ri, 8:3
Hodge, Lenox, 535. S=7- 53=
Hoffman, 491
Hofmeier, 651. 665, 7J0, 766, 816
Holden, 638
HollandeTj ajo
Houston, 196
H ouzel, 8»5
Hunter, 651
, -r. 79
Johnson, J. Tabor, 651
Johnstone, 117
!, Mary Dixon, 869. 877, 878
JouUn. 609
Julien. 360
Julliard, 89
. S3
Klebs-Loeffler, 7 a
Klob, 400, 051.854, 858.
Kobelt, iby. 875
Koeberle, 733. 79s
Koch. 68
Koch, J. H.. 74
Kocher. 810
KOnig, 301
Kraske, 637, 806
Kr&nig. 61, 63, 349, 731, 804
Krusen, 584
Kuchenmeister, 47
Kuhn, 801
Kummel, 875
Kundrat, 804
Kuster. 658
Kiistner, 133, 563, 806, 881
I L.
' Labarraque, 113
I Landau. 384, 465, 466, 717, 767. 79a,
8sa
I Langeobeck, 790, 796
Langhan, 744
I Laucnstein, 178. 370. 3S9, 390. 197,
I 301. 306. 333
LeBec. 735
I Le Clcrc-Dauday. 373
Lefour, 693
I Lembert, 455, 73s
I Leopold, Z09, 665, 793, 8:5, 816, 817,
j 834, 877, 903
' Levy, 71, 810
Lewers, 7O6, 854
I Licberkiiiin, 195. 197
Liebmann. 793
I Lindfors, 544
I Lisfranc. 14
LiUre. 177
I Luschka, 176, 1S7, 199, 300
! Lustgarten. 71
I Lutaud, 371
Kahlden. 841, 855
KaiserlinE. 59
Kaltenbach, 793, 798. 815
Kaltcyer, 78
Kappes. 435
Kchrer, 836
Keith. 125, 134. 451. 9"
Kellar. 848
Kellogg, 703
Kelly, Howard, 94. 95, 96. 109, 37
54'. 7 = 7. 737. 793. 795- 801, 904
King. 610
Kiwisch. 400
Klebs, 73, 637, 649, 765
Mackenrodt. 545, 793, 79s, 803, 1
Mann, 181, 373, S34. S4S. 6^7. S?
Mano, 73
Marchand, 833. 834
Marcy. 560. 734
Maritan, 859
Marmorck, 390
Mars, 343
Marsh, 370
Martin, A„ 69, 305. 308. 313, 316
384. 639, 730, 739. 801, 835,
839, 842, 913
Martin, C, 313. 730
Martin, Franklin, 149, S3», 543.
7'5. 7'6
926
LIST OF AUTHORS QUOTED.
Matthews-Duncan, 430
Maydl, 813
Mayo, Charles H., 70
Mayo, William, J., 70
McBumey, 373
McCosh, 455
McGannon, 273
Menge, 61, 62, 349, 722, 805
Meyer, 70
Mickwitz, 881
Mikulicz, 89, 127, 128, 792
Milieu, pi
Mitchell, S. Weir, 411, 429
MOller, 665, 666
Monsell, 337
Morgagm, 191, 195, 853, 859, 861
Mosetig-Moorhof, 825
Muir, 66
Muller, 4, 157, 158, 224, 226, 230, 231,
232. 235, 326, 584, 595, 622, 637,
859, 8^1
MfiUer.
Peter, 651, 793
Mund^, 255, 256, 490, 525
Murphy, 919
N.
Naboth, 9, 28, 183, 256, 257, 377, 378,
380. 3S3. 5", 746, 77S
Napier, 215, 217
Nauss, 693
Neisser, 65, 66, 350
Nelson, 39
Neugebauer, 637
Newman, 532, 797
Nilson, 106
Nitze, 94
Noble, Charles P , 311, 499, 601, 833
Noble, George H., 321
Noeggerath, 400
Northrup, 116
Nott, 38, 39
Nourse, 513, 515
Nuck, 159, 168, 232, 340, 624, 625
O.
O'Hara, 919
Olshausen, 541, 544, 666, 792, 793, 814,
816, 822, 900, 901, 922,
Orth, 56
Orthmann, 70
Osier, 70
Outerbridge, 311, 312
P.
Pap^et, Sir James, 844
Pankau, 89
Paquelin, 384, 645, 647, 795, 801, 821,
824, 916,
Pawlik, 94, 795
Parsons, 704
I
Pdan, 458, 717. 796
Peter, 343
Petit, 89
Pfannenstiel, 71, 836, 870, 903
Pfluger, 188, 231
Pick. 53, 834
Plouquet, 873
Poirier, 817
Polk, 199, 699, 802
Poupart, 168, 201, 208, 373, 434t435.
438. 531. 582, 611, 623
Powell, S. D., 370
Pozzi, 44, 106, 114, 163, 228, 246. 366,
626, 781, 853, 858
Pratt, 46, 50
Price M., 594
Prochowmk, 584, 66$
Pryor, 26, 65, 546, 727, 737, 760
R.
von Recklinghaiisen, 664, 852
Reed, C. A. L.. 68, 514
Reed, E. L., 633
Reich, 793
Rein, 212
Reverdin, 130
Reybum, 766
Riberts, 764
Ricard. 824
Richelot, 733. 796
Ricker, 841
Ries, 496, 536, 760, 802
Ristine, 320, 321
Ritchie, 66, 853
Robb, 103
Roberts, 68
Robertson, 221, 610
Robinson, 347
Robinson, Byron, 720
Rokitansky, 642, 854, 863
ROntgen. 149, 154, 155
Rosenmuller, 186, igi, 857, 859, 861
Rosthom, 70, 804
Royster, 250
Ruge, 350. 394, 752. 839, 841. 903
Riunpf, 801
Rydygier, 720, 810
S.
Sanger, 67, 266, 281, 319, 320, 326.
687, 792, 815, 826, 853. 854, 856.
858
Sftnger-Barth, 853. 855
Sappey, 181, 183
Sauter-Recamier, 790
Savage, 166, 170, 175. 176. 179. 1Q3,
203, 205, 206, 207, 208, 210
Saxonia, 221
Scanzoni, 400, 408, 879
Scarpa, 435
Schaefer, 431
LIST OF AUTHORS QUOTED.
927
Schaeffer, 15a
Schatz, 792, 798
Schauta, 717. 733, 760, 792, 804, 811
Schede, 285, 809, 812
Schering, 53
Schiff, 220
Schlange. 810
Schleicn, 119
Schmidt, 544
Schnabel, 873
Schneiderlin, 117
Schramm, 825
Schroder, 158, 178, 262, 263, 384, 399,
408, 637, 652, 658, 697. 720, 723,
769. 784, 785. 786, 793, 803, 845
Scnuchardt, 794
Schucking, 545, 648
Schultze, 381. 432, 522, 523. 524, 525,
^27, 825. 903
Schwarz, 765
Seelig, 757, 758, 786
Seligman, 341, 343, 852
Segond. 459
Semmelweis, 387
Sherrington, 81
Shimer, A. B., 735, 736
Shober, John B., 700
Shoemacher, 665, 666
von Siebold, 775
Siegelman, 63, 73
Simon, ^3, 42, 284, 785
Simon-Hegar, 297, 301. 325
Simpson, Alexander, 321, 322, 323
Simpson, F. F., 538, S49
Simpson, Sir James V., 35, 400, 549,
609, 699
Sims, Marion, 23, 24, 25, 35, 40, 41,
42. 171, 23s, 257. 265, 269, 346, 380,
492, 503, 512, 522, 705, 797, 806,
823
Skene, 75. 92, 94, 156, 163, 177, 192,
'355. 356, 357. 629, 912
Skoldberg, 384
Skrobanski, 251
Smith, Albert H., 490
Smith, Greig, 607
Smith, Heywood, 382
Smyly, 777
Snow- Beck, 402
Spaeth. 69
Spiegelberg, 777, 877
Spohn. 859
Stein thai. 811
Sternberg. 65
Stiegel, 633
Stilling, 825
Stimson, 123
Stoltz. 494, 405. 550
Strassman, 216
Stratz, 774
Stroganoff, 61
Sutton, J. Bland, iqo, 213, 618. 651,
854. 873
T.
Taenzer, 58
Tait, Lawson. 318, 319, 321, 326, 582,
914
Talley, F. W.. 39
Tallqvist, 82
Tannen, 815
von Tauffer, 792, 806
von Teuffel, 793
Thiersch, 764, 766, 816, 825
Thoma, 80
Thomas, 379, 384, 490, 510, 525, 560,
710
Thompson, 643
Thorn, 815
Thornton, 880
Thure-Brandt, 147
Tilt, 346
Toisson, 81
Torggler, 822. 826
Tracy, S. E., 833
■ Tratz. 639
Trendelenburg, 23, 26, 273, 452, 454.
646, 724. 734, 799, 918
Treves, 440
Tuffier, 119, 797
Tuholske, 585
Tyson, 569
I
U.
Ungara, 824
Unna, 70
V.
Van De Warker, 785, 823
Van Geison, 57
Veit, 752, 793, 801, 834
Vineberg, 545, 549
Virchow, 400, 430, 642, 683, 764, 766,
775, 841, 868
Von Hacker, 114
VuUiet, 48, 571, 825
W.
Walcher, 270, 274
Waldeyer, 188, 751, 764
Walsh, Joseph, 364, 365
Walthard, 349, 350
Wassiljew, 650
Watkins, 910
Webster, 536, 607
Wecchi, 702
Weigert, 58
Weil, 842
Welch. 745
Wells. Spencer, 100
Werder. X. O., 285, 802
Wcrtheim, 66, 545, 760, 804, 81 1, 814
Wcslemiark, 806
White, 116
928
LIST OP AUTHORS QUOTED.
Widal. 388
Wiggins, 408
WiUiams, W. Roger, 745
Williams, J. Whitridge, 61, 6a, 815, 841,
877
von Winckel, 231, 652, 665, 693, 766,
767. 774. 794. 8"
Winter, A., loS, 740, 706, 816, 617
Wolff, 637
Wolffler, 810
Wright, 79, 91
Wyder, 188, 216
Wylie, W. Gill, 512, 533, 534, 545
Z.
Zeiss, 64
Zuckerkandl, 810, 813
Zwank, 490, 491
Zweifel, 62, 350. 724, 798, 811, 829,
852
INDEX.
A.
Abdominal binder, 406, 697
examination, 96
section, 114
assistants in, 120
details of procedure, 452
site of incision, 121
Abortion, 328, 402, 585, 887
incomplete, 676
tubal, 585, 588
Abscess about appendix. 22
collection in pelvis from appendix,
443
from Bartholin's gland, 340
intraperitoneal, 442
stitch, 788
tubo-ovarian, 420
vulvar. 335, 339
Acarus scabiei, 73
Accidents and results of fistula opera-
tions. 287
Acetanilid, 133, 140
Acetate of lead, 143
Acid, acetic, 53
boric. 140, 143, 370, 637
carbolic, 104, 106, 133, 143. 33^, 337.
343. 361, .382, 383. 399. 400. 630
633.. 705. 707. 822
chromic. 146, 382, 399, 630
eallic, 569, 572, 699
hydrochloric, 146
hydrocyanic, 343, 360
lactic, 384
muriatic. 105, 106
nitrate of murcury. 146, 382, 399
nitric. 146. 630, 824
fuming. 145, 399
oxalic, 106. 370
picric, 57
pyroligneous, 258, 827
salicylic, 359, 384, 637, 825
and pepsin. 824
sublimate 106, 143
sulphuric, 146, 407, 699
dilute, 572
tannic. 146, 569, 572
Acne, 332
Adenocarcinoma of uterus, 740, 752
Adenomata of uterus. 622
Adenomatous cysts, 869
59
1 Adenomyoma, 852
Adenosarcoma, 840
Adhesions, 124, 410, 739, 898
in displaced uteri, 523. 533
in ovarian tumors, 881, 883, 884,
898, 915, 018
indication of malignancy, 900
of abdominal tumors, 898, 910
vascular, 124
Adipocere, 596
Adnexa, suppurative inflammation of,
152
Adrenalin, 142
Agents, deodorizing, 112
various local, 145
Albumin in cyst contents, 871
peptone, 871
Albuminuria, 887
Alcohol, S3, 108, 323. 342, 630, 705,
777, 792, 825, 914
absolute, 792, 825
dilute, 648
Alcoholic preparations, 119
Alexander operation, 530
advantages of, 533
disadvantages of, 533
Alkaline solutions, 337
waters, 353. 368, 406
Alteratives, 141, 147
Alum, 143, 572
and sugar, 630
Alumnol, 337,
Amenorrhea, 18, 149, 152, 214, 217,
403, 424, 668, 674, 675, 880, 895
Aminoform, 360
Ammonium benzoate, 370
' chlorid, 141
I salts. 699
Amputation of the cervix, 261, 492,
i 784 . .
I Amyl nitrite, 100
Anal ulcerations or fissures, 27
Anastomosis of intestine for gangrene,
017
for injury, Qio
of ureter with bladder through ab-
domen, 285
' through vagina, 284
Anatomy and embryology of the
genito-urinary organs of the woman,
I 156
929
930
INDEX.
Androgyna, 244
Anemia, 16, 141
Anesthesia, administration, 117
agents employed in, 115
bromid of ethyl, 1 1 5
chlorid of ethyl, 115
chloroform, 115, 116
ether, 115, 116
nitrous oxid gas, 115
artificial respiration in, 118
contraindications to, 118
indications for, 115
local, agents employed in, carbolic
acid, 118
cocain, 118, 632
ether, 118
ethyl chloride spray, 118
freezing, 118
infiltration, 119
nervous. 15
scopolamin-morphine, 117
spinal, 119
Angiosarcoma, 839
Angiotribe, 462, 463, 791, 797
Anodynes, 135, 147, 427
Anorexia, 362, 827
Anovulvar fistuliu, 290
Anteflexion of uterus, 506
cellulitis a cause, 508
diagnosis, 509
differential from myoma, 509
rectal palpation in, 509
etiology, 508
immobile, 508
indifferent, 508
mobile, 508
pathologic, 508
physiologic, 508
symptoms, 508
treatment, 509
bougies, 512
laminaria tents, 511
operative methods, 512
Anteposition of uterus, 500
Anteversion of uterus. 501
diagnosis, 502
etiology, 502
symptoms, 502
treatment. 502
cincture, 504
dilatation and curetment, 503
hot douches. 502
massage. 504
Sims' operation, 503
Antipyretics. 439, 827
Antipyrin, 828
Antisepsis, 102
of cervix and uterine cavity, 113
Antiseptics, 143, 382, 851
Antispasmodics. 141
Anus, anatomy of, 195
columns of Morgaj^mi, 195
sinuses of Morgagni, 195
Anus, artificial, 799, 813
fissure of, from pressure of uterus,
506
orifice of, 195
Aperients, 450
Apiol, 142
Aponeurosis, union of, 129
Apoplexy of the ovary, 191
ovarian, 567
Appendages, displacements of, 564
diagnosis, 565
symptoms, 565
treatment, 566
instrumental, 566
operative, 566
Appendiceal inflammation, 98
Apf)endicitis a frequent cause of peri-
tonitis, 443
catarrhal, 372
Apf)endix vesiculosa, 191
Applications, antiseptic, 145
astringents, 146
blisters, 144
caustic, 146
counterirritants, 144
croton oil, 144
external, 144
ice-bag, 144
local, 145
pjepsin and salicylic acid, 824
tinct. iodin, 146
various agents, 145
carbolic acid, 145
Churchill's tincture, 146
creasote, 146
iodoform, 146
nitrate of silver, 146, 371
nitric acid, 146
Arbor vitae, 158, 183
Areolar cysts. 869
Argonin, 337
Argyrol, 145. 337, 399
Anstol, 114, 827
Arrangement for operation, 120.
Arsenic, 141, 381, 407
Artery, azygos vaginae, 202
circular, of cervix, 202
inferior hemorrhoidal, 204
internal iliac, 202
internal pudic, 201
middle hemorrhoidal, 202
of bulb. 206
of clitoris, 205
ovarian. 201
puerperal, 202
superficial perineal, 204
transverse perineal, 204
uterine, 201
vaginal, 201
Artificial heat, care in use of, 13a,
135 .
Asafetida, 141, 222
Ascaris lumbricoides, 74
INDEX.
931
Ascites, 662, 687, 872, 880, 890, 893,
900
Asepsis, 102
Aspiration, loi
Aspirator, 10 1
Assistants. 114. 905
operator and, 120, 905
Astringent douches, 143
Astringents, 143, 145, 337, 382, 383,
529, 569. 572, 648, 827
Atmocausis, 573
Atresia, acquired, 237, 264
congenital, 237
diagnosis of, 238
influence on menstruation, 238
lateral, 240
treatment of, 238
of cervix, 3()9
of genital canal, 237
of one horn of uterus, 227
of urethra and vagina, 246
site of occurrence of, 237
symptoms and signs of, 237, 238
vaginal, 264
vulvar. 237
Atropin, 100, 116, 119, 135, 139,
915
Auscultation, 99
Autoinfection, 348
B.
Bacilli coli communis, 68, 90, 329,
441
Bacillus aerogenes capsulatus, 72
anthracis. 90
coli communis, 90
diphtheriae. 72
influenzic, 90
lepra?, 90
mallei, 90
of cocain, ^60
of DOderlem, 61
pestis, 90
pyocyaneus, 72
tetani, 90
tuberculosis, 90
typhosus, 71, 90
Bacteremia, 90
Bacteria found in blood. 90
Bacteriologic cultures, 63
bacilli coli communis, 68
bacillus tulwrculosis, 68
gonococcus, 65
staphvlococcus pyogenes aureus,
63 '
streptococcus pyogenes. 64
Bacteriology of genital tract, 60
Balloon, rubber, for vesical disease.
Bandages, elastic, 489
Barium platinocyanid, 154
Bartholinitis, 339
I
Bartholinitis, diagnosis, 340
treatment, 340
Bartholin's gland, 339
description of, 167
Baths, 143
cold hip, 406
hot hip, 359
medicated, 406
peat, 548
sand, 548
sitz, 143, 353, 426, 548, 826
Battery, electnc, 150
Bed-sores. 826
Belladonna, 369
Benzin, 107
Benzoate of ammonium, 268, 359,
of sodium, 359
Bicycle, 142
Bifidities, 224
degrees of division, 224
Bimanual procedure, 30
Binder, Scultetus, 914
BischoflF's dissection. 316
Bismuth salve, 827
subgallate. 337
subnitrate. 337
Bladder, iq2
anatomy of, 192
bas-fond of, 192
catheterization of, 95
double catheter in, 96
dissected from cervix in vesico-
uterine fistuke. 281
divisions of, 192
duplication of. 248
exploration of urethra, ureters and,
91
exstrophy of, 241. 246
extension of cancer to, 751, 769
inflammation of, 92
of neck of. treatment, 369
injury to, during operation, 920
irrigation of, 568
mucous membrane of, 193
position of, 192
trigone of. ig2
tumors of. 622, 642
carcinoma. 649
symptoms of, 649
of villous tumors simulated
by uterine cancer, 649
treatment of, 649
dermoid. 643
myomata, 643
cystic, 643
diagnosis of. 643
differential, l^tween renal and
vesical hemorrhage. 644
significance of character of,
hemorrhage in, 644
hard. 643
symptoms of, 643
932
INDBX.
Bladder, tumors of, myomata, symp-
toms of, anemia, 643
cachexia, 643
cystitis, 643
emaciation, 643
hemorrhage, 643
pain, 643. 645
treatment of, 645
incision, abdominal, 645
high bladder, 645
suprapubic transverse, 645
vaginal, 645
operation, the, 645
means of controlling hem-
orrhage in, 647
removal through urethra,
644
pol^pii mucous, 642
villous, 642
total extirpation of, 650
Blastoma, 832
Blister, 144, 426
Blood, changes, 76
coagulation, 91
composition of, 82
culture, 90
examination of, 76
plaques, 83, 85
plasma. 82
Bloodletting, 144
Borax, 146
Boric acid, 143, 146
Boro^lycerid, 147, 258
Bougies, Hegar's. 706
in the ureters, 801 '
Bovinin, 134
Brandy. 451
Broad ligaments, 197, 856
cysts of, loi, 856
echinococcus, 857
parovarian, 857, 875
delects of round or, 231
fibroma of, 858
confounded with epiplocele, 858
with fatty hernia, 858
with ovarian hernia, 858
lipoma ta of. 858
malignant growths of, 858
parovarian varicocele, phleboliths,
.858
Bromid salts, 141, 370
of ethyl, 115
Bruit, 99
Buboes, 336, 636
Buchu, 370
Bulb of the vestibule, 167
of the ovary, 207
Bui bocavcrnosus muscle, 167, 192, 292,
346
C.
Cachexia, 643, 671, 672, S42, S44,*9oi
Caesarean section. 820
Caffein citrate, 133
Calcification in cyst walls, 887
Calciiun chlorid, 699
phosphate, 83
tim^state, 154
Calcuh and concretions following fis-
tula operations, 288
Calculus, renal, 369, 479, 568, 884
passage of, 357
uterine, 683
Calomel, 133, 141, 337, 451
and sodii bicarb., 133
Camphor, 360, 648
Canal of Gartner, 191
of Nuck, 159, 168, 625
Cancer of uterus, 649
Cannabis indica, 141,
extract, 698
fluid extract, 141
tincture, 342
Cannula, glass, 112
Carbohydrates, 699
Carbol-xylol, 53
Carbolic acid, 104, 106, 133, 143, 336,
337. 343. 361, 3S2, 383, 399, 400,
630. 705. 707
Carcinoma, 649. 678, 744, 751, 849, 858
circumscribed, 753
classification of, 744
anatomic, 744
clinical forms, 762
dissemination of. 756
method of extension, 744
of bladder and ureters, 649, 751
of Fallopian tube, 855
of ovary, 877
of uterus, 744, 849
of body. 752
adenocarcinoma of, 752
histology of, 754
microscopic examination in
diagnosis of. 753
necrosis of, 754
process of extension, 753
rarity of. 752
of cervix, 74Q
adenocarcinoma of, 749, 752
frequency of, 745
methods of development, 744
of extension, 744
blood-vessels slow to be in-
volved, 757
cauliflower growth, 746, 749,
763
clinical forms, 762
cylindric cell. 745
influence upon surrounding
tissues, 746, 749
involvement of bladder and
ureters, 751
of other organs, 751
process of extension, 747, 756
general. 744
INDEX.
933
Carcinoma of uterus, methods of inva-
sion of vagina from, 758
Ijrmph-vessels principal route
of extension, 756, 758
squamous cell, 745
development of, 746
histology of, 748
structure of stroma, 747
complications of, 773
myoma, 773
ovarian tumors, 773
periuterine inflammation, 773,
774
pregnancv, 773, 774
diagnosis of, 775
curet, 776
differential, from chorioepithe-
lioma, 780
from chronic cervical catarrh
with laceration, 778
from necrosis of fibroid poly-
pus, 778
from papillary erosion, 778
' from partial retention 01 pro-
ducts of conception, 779
from sarcoma, 780
from syphilitic ulceration,
779
laminaria tents. 776
microscopic examination, test
excision for, 777
rectal examination, 777
duration, 781
of recovery, 8 1 4
effect of, upon pregnancy and
labor, 782
pregnancy and labor upon, 782
etiology. 764
Cohnheim's theory, 764
condition of Ufe, 766
hereditv, 766
Klebs' bacillus, 765
origin from micro-organisms.
iLrf
Ribert's theory, 764
sex, 766
sexual activity, 766
Thiersch's theory, 764
Virchow's theory, 764
Waldeyer's theory, 764
glandular involvement, frequency
of, 760
physical signs, 772
prognosis. 782
recurrence of, 760
s>Tnptoms. 767
amyloid degeneration of large
glands, 772
cachexia, 767
degeneration of kidney, 770
dilated ureters. 760
distention of hemorrhoidal
veins, 770
Carcinoma of uterus, symptoms, edema
of lower extremities, 770
of viilva, 770
and clinical course, emaciation,
, 771 ,
hemorrhage, 767
hydronephrosis, 769
lung embolism, 771
metastasis, 770
obstruction of veins and
arteries, 770
offensive discharge, 768
pain, 768
pleurisy, 771
I
pneumoma, 771
sacculated kidney.
770
sepsis, 770
treatment, 783
in labor, 829
in pregnancy complicating, 829
operation in, 829
Ccssarean section in, 829
inoperable cases, 818
caustics, 823
cureting, 819
danger and injuries in,8 19
dry, 826
gauze packing, 821
local, 826
palliative operations, 819
parenchymatous injections,
suture cure ted surface, 825
symptomatic, 827
when disease far advanced,
827
with fistula of rectum and
bladder, 827
operable cases, 783, 784
extirpation, total, 786
by hysterectomy,
dominal, 799
control of hemorrhage
in, 802
Freund's operation,
800
in marked involve-
ment of the cervix,
801
modifications of, 801
by hysterectomy, vagi-
nal, 7QO
accidents of, 707
by perineal method,8 13
by sacral method, 806
catheterization of ure-
ters, 795
clamp forceps in, 792,
7q6
comparative advan-
tages of abdominal
and vaginal routes,
805
ab-
934
INDEX.
Carcinoma of uterus, treatment, oper-
able cases, extirpa-
tion by hysterecto-
my, vaginal, contra-
indications to, 806
control of bleeding
vessels, 795
of bleeding vessels
by hot iron, 795
deep vaginal incision
in, 794
difficulties in, 794
disposition of ovaries
and tubes, 791
injuries to bladder,
. 797
in Junes to one or both
ureters, 798
injuries to rectum, 798
modifications of, 792
mortality of, 814-
nonemployment of
forceps or ligatures,
797
Schuchardt's opera-
tion, 794
treatment of the
wound in, 791
possibilities ot reinfec-
tion, 787
uncertainty of keeping
outside the disease,
787
when it mav be under-
taken, 787
partial operations, vaginal
784
amputation of cervix
with galvanocau-
tery loop, 784
Hegar's operation. 784,
785
SchrMer's operation,
784. 7i^S
preliminary, 700
recurrence, after opera-
lion, 815
diagnosis of, 817
extensif^n to parame-
trium. 816
infection. 817
lymph-gland, 817
metastatic, 8 18
lymph-glands source of
redevelopment, 817
summary. S^o
abdominal operation, 83 r
vaginal operation, S31
Card index system, ^c)
Cardialgia. 710
Carmin. 53. 56
Caruncle, urethral. 27. 346. 626
Caruncuke myrtiformes. 167. 243, 346
Castor oil, 451
Castration for myomata, 718
uterine, 458, 718, 729
Cataphoresis, 150
Catarrh, chronic cervical, 375, 778
intestinal, 152
I Catgut, 129, 130, 724, 919
for ligatures, 107
j juniper, 724
Catheter, double, 96, 114
glass, 139
precautions in use of, 355
self-retaining, 355
j ureteral, 95
I Catheterization, 139, 643
microbes introduced by, 362
of the ureters, 92, 364, 568
I Caustics. 146, 823
' acid, carbolic, 145
I chromic, 146
j hydrochloric, 146
j nitrate of mercury, 146
I nitric, 146
' sulphuric, 146
i caustic iron, 146
potash, 268
chlorid of zinc, 146
creasote, 145
liquid, 146
silver nitrate, 146
soda, 53
Cauterization, 824
for fistula, 268
Cautery, galvano-, 636, 647, 795, 796
loop, 7Q2
Paquelin, 647, 795
thermo-, 636, 647, 790, 830
Celloidin. 55
Cellulitis, abscess from hypogastric
glands, 432
cause of ante version, 502
of atrophy of uterus and ovaries,
432
of dysmenorrhea and sterility, 432
of lateral version, 506
diagnosis, 436
differential, 437
hematoma of broad ligament,
437
myoma of uterus, 437
pelvic peritonitis, 437
division of. 430
etiology of. 432
pelvic parametritis or periuterine
phlegmon. 430
physical signs. 433
al)soess resulting from. 432
diffuse pelvic suppuration, 636
pathologic anteflexion, 432
prognosis. 43S
duration and progress, 438
symptoms. 433
treatment of. 438
INDEX.
935
Cellulitis, treatment of, diet, 439
douches, hot vaginal, 439
pelvic massage, 440
preventive, 438
surgical interference, 439
utero-sacral, 432
Cervix, amputation of, 261, 492
after-treatment, 263
antisepsis of, and uterine cavity,
areolar hyperplasia of, 379
carcinoma of, 748
changes of, 180
chronic catarrh of, 375
cystic degeneration of, 377
divisions of, 178
infra vaginal, 179
supravaginal, 179
double flap, 262
for areolar hyperplasia, 379
for bilateral laceration of. 378
for follicular erosion of, 378
single flap, 262
erosion of, 376
follicular, 378
granular, 376
simple, 376
hvper trophic elongation of, 474,
'483
incision of, 46, 708
complete bilateral, 47
inflammation of, 375
causes of, 379
classification of, 374
diagnosis, 380
physical signs, 380
prognosis, 381
symptoms, 37g
treatment, 381
constitutional, 381
electrical, 384
local, 381
surgical, 384
lacerations of. 254, 378
diagnosis, 255
symptoms. 255
sarcoma of. 836
split in vesico-uterine fistula. 281
Chancre, 636
Chancroids. 334. 636
organism of, 63
Change of life, 221
Charcoal in malignant disease, 637
with iodoform, 826
Charcot's bodies, 78
Chemotaxis. 87
Chloral, 133, 135
Chlorid of calcium, 699
Chlorin water. 827
Chloroform, 115, 1 r6
and oxygen, mixture of, 117
in glycerin. 343
Chlorosis, 16, 879
Chlorosis, cause of delayed menstrua-
tion, 213
Cholesterin, 871
Chorea, 215
Chorioepithelioma malignum, 744, 780,
832, 850
Chromium trioxid, 382
Churchill's tinct., 146, 257
Cinchona, 407
Cincture ifor anteversion, 504
Cinnamon, tincture of, 572
water, 133
Clamp forceps, 792, 796
objections to use of, 461, 852
Richelot's, 796
Clay pad electrode, 151
Cleansing hands, 108
Cleveland's suture in laceration of
perineum, 313
Climacteric, delayed, in fibroid
growths, 695
discharge following, 22
entire removal of Fallopian tubes
to establish, 718
Clitoris. 159, 161
anatomy of, 161
bifid, 246
defects of, 241
hypertrophy of, 27, 241
nervous phenomena produced by,
242
prepuce adherent to, 242
treatment of, 242
Cocain, 118. 343, 360
Coccvx, resection of, for artificial anus,
641
Codein, 45, S28
Cod-liver oil, 407
Coition, 13, 161, 165, 167, 251
a cause of inflammation, 332
in diseased appendages, 565
loss of sensation, 15
painful, 565
Cold pack, 141
Colic, gall-stone, 899
intestinal, 372, 899
renal, 809
uterine, 145. 400
Collapse. 885, 809
atropin in. 451
digitalin in, 451
external heat in, 451
strychnin in, 451
Collection of s])ecimens for examina-
tion, method of, 77
Collodion, 152
Colloid contents of cysts. 001
Colon, malignant disease of. ()8
Color index, 83
Colostomy. 641. 813
Colpeurynter. 268. 801
Colpitis." 348. 818
Colpocleisis. 278, 80O
936
INDEX.
Colpocleisis, methods of procedure in,
279
objections to, 279
Colporrhaphy, anterior, resection of an-
tenor vaginal wall for, 495
Stolz's sutures in, 494
posterior, 495
Coma, 771
Comfort of patient, post-operative, 132
Communications, abnormal, 249
recto- vaginal, 249
recto- vagino-vesical, 250
suprapubic opening of vagina and
urethra, 2^0
vagino-rectal, 250
vesico-vaginal, 250
Commutator, 151
Compresses, cold, 343
Compression of the lung, 904
Compressor urethrae, 192
Condylomata of viilva, 630
Connective tissue, distribution and re-
lations, 200
pelvic, 200
two varieties of, 200
Constipation, 17, 406, 670
with cancer, 828
Copaiba, 360
Copper, sulphate of, 146
Copremia, 17
Copulation, 212, 223
Corpus albicans, 191
luteum, 190, 214
cysts of, 863
of pregnancy, 190
nigricans, 191
Corpuscles, counting the, 80
Cotamin hydrochlorate, 569
Cotton, absorbent, 146, 337
pack. 354
Counterirritants, 144, 407, 426
■Cover glasses, 7 7
Cowper's glana, 167. 339
Crayons, chlorid of zinc, 146
iodoform, 146
silver nitrate. 340
sulphate of zinc, 146
Creasote, 146
Creolin, 112, 143
Croton oil, 144, 426
mixture, 407
Cubebs, 360
Culdesac, utero-rcctal, 199
vesico-uterine, 199, 200
Curet, 258, 790, S25
douche. 51
perforation of uterus with, 254
sharp, 820
spoon, 825
Curetment, 503, 705. 819
method of, 705
Cystadenoma. 900, <;oi
Cystalgia, 364
Cystitis, 361, 643, 644, 884
acute, 361, 567
character of urine in, 362
constitutional disturbances in, 362
etiology of, 361
symptoms of, 362
chronic, 363, 567
condition of urine in, 363
constitutional conditions in, 363
cystotomy for, 372
diagnosis of, 363
from administration of certain
drugs, 362, 367
from foreign bodies, 362, 367
etiology of, 361
hematuria in, 363
symptoms of, 363
membranous, 366
causes of, 366
symptoms of, 366
of gonorrheal origin, 363, 366
pathologic changes in, 362
prognosis in, 367
treatment of, 368
calculi and foreign bodies, 367
irrigation of bladder, 370
medical, 368
prophylactic, 368
surgical, 372
tubercular, 363
Cystocele, 27, 295, 478
diagnosis of, 481
treatment. See Colporrhaphy, an-
terior.
Cystoscope, electric, 94, 156
Cystoscopy, 644
Cystotomy, 372
Cysts, adenomatous, 869
areolar, 869
of BarthoUn's gland, 339
treatment of, 340
of broad ligament, 10 1, 856
echinococcus, 857
dermoid of bladder, 643
of Fallopian tube, 853
of ovary, 680, 859, 873, 875, 881
gaseous, vulvar, 623
glandular, 864, 868
hydatid of Morgagni, 191, 853
intraligamentary, 867
Nabothian, 377, 512, 746, 778
of vagina, 637
parovarian. 857
residual, 861
retention, 377, 637
D.
Dartoid, 159
Death after hysterectomy, 740
after removal of large tumors, 922
causes of, after hysterectomy, 740
Deciduo-chorion cellulare, 832
INDEX.
937
Dendritic growths, 872
Dermoid cyst, 873, 879, 884, 894
diagnosis, 900
of bladder, 643
of Fallopian tube, 853
of ovary, 859, 873, 883
peritonitis from, 884
rupture of, 884
Descent or prolapsus of the ovary, 231
Desmoid tumor of abdominal walls,
98, 676, 888
Desmopycnosis, 535
Destructive bladder mole, 832
placental polyp, 743, 832
Dextroflexion, 546
Diabetes mellitus, cause of vulvitis,
334, 338
Diagnosis, 14
cause of error in, 14
importance of correct, 13
method of procedure in, 14
senses employed in, 22
Diaphragm, pelvic, 170. See Perhteal
muscles.
Diarrhea. 17, 885, 899
Diet after operation, 133
in pelvic cellulitis, 439
in ureteritis, 373
Digitalin, 391
Digitalis, tincture of, 391
Di&tation of the urethra, 91
of the uterus, 571, 705
bloodless, 43
bougies, 571
divulsion, 45
gauze packing, 48, 571
gradual, 46
incision, 46
bilateral, 47
rupture of uterus by, 46
tents, 44, 512
Dilators, Hegar's. 705
Pratt's, 46, 408
Diplococcus intracellularis meningiti-
dis, 90
of Siegelman, 73
Discharge, genital, 21
catarrhal. 21
cervical, 22
effect of age upon, 2 2
origin of, 2 r
simulating abscess, 2 1
s(»urccs of purulent, 21
vaginal. 22
Discus proligerus. 189
Disease, origin of. i
Dislocations of uterus. 500
antcposition. 500
dangers of sound in. 500
diagnosis, qoo
lateral ])osition. 500
retro-position, 500
torsion, 472, 501
f
I
I
Displacements of the appendages, 564,
680
diagnosis, 565
sjmaptoms, 565
treatment, 566
of the ovary, 231
of the pelvic organs, 466
of the uterus, 470, 679
classification of, 471
anteflexion, 472, 506
antelocation, 471
anteversion, 472, 501
ascent, 472
descent, or prolapsus, 473
dextroflexion, 472
dextrolocation, 471
dextroversion, 472
retroflexion, 472
retrolocation, 471
retroversion, 472
sinistroflexion, 472
sinistrolocation, 471
sinistro version, 472
torsion, 472
complications. 546
conditions which cause, 470
diagnosis of, 473
digital examination in, 482
prognosis, 547
treatment, 547
electricity, 547
general, 547
massage. 547
mechanical measures, 547
summary in, 548
Diuresis, 885
Diuretics in cancer of uterus, 828
in gonorrheal and acute cystitis, 374
Divulsion, uterine, 45
Douche, 143, 510, 548, 572
alkaline, 353
antiseptic, 382
astringent, 143. 354
bichlorid, 716
hot, 258, 381, 400, 406, 426, 439,
488, 502, 572
intrauterine, 390
rectal, 143
thymol, 143
urethral, 350
vaginal, 258. 2qo, 359, 381, 400, 426,
439. 548, 572
vesical, 144
Douglas, pouch of, iqq
Drain, gauze, 128, 451, 648
where placed, 12S
Mikulicz. 127
Drainage, 125. 410. 715, 913. 914
management of, 126
objections to, 1 26
postural. 128. 455
tube. 126. 715
Dressing of wound, 131, (>o7, 914
938
INDEX.
Dressings, io8
Dropsy, hepatic, 893
cardiac, 890
renal, 890
Dudley's operation for prolapsus uteri,
499 .
denudation, 314
Duke's operation, 322
Duvemey's gland, 339
Dysmenorrhea, 18, 149, 152, 154, 214,
219, 396, 403, 508, 510, 549, 670
from obstruction of uterine canal,
509
Dyspareunia, 19, 345, 627
Dyspnea from cysts, puncture for, 905
£.
Echinococcus cysts, 857, 901
Ecraseur, wire, 563, 784
Ectopia of bladder, 248
Eczema of vulva, 332, 334, 336, 341
from carcinoma, 827
Edema, malignant, 660
of labium, 575, 628
of leg a symptom of cancer, 901
of vulva, 338
preliminary puncture of cysts for,
905
Electricity, 142, 384, 547, 610
Apostoli's method, 151, 701
apparatus for application, 150
battery for, 150
contraindications, 152
electrodes, 150
faradic, 149, 152, 411
Finsen light, 155
forms of, 149
franklinic, 149
galvanic. i4()
in fibroid growths, 700
in lateral flexion. 547
indications, 152
methods of procedure, 151
Rontgenic, 149
sinusoidal, 149, 153
Electrocautery and light, 155
Electrode, bladder, 151, 701
clay pad, 151. 701
insulated probe, 151, 701
metal, 150, 151
water. 701
wet towel. 151. 701
Electrolysis in ovarian growths, 902
Elephantiasis of vulva, 628
Elytritis, 348
Elytrotomy. 610
Embolism, 138. 741
Embryology and anatomy of the gen-
ito-urinarv organs of the woman,
Emmet s operation for complete lac-
eration, 312
Emmet's operation for lacerated cer-
vix in metritis, 408
on the perineum in relaxation of
posterior vaginal wall, 309
Enchondroma, 633, 853
Endocerv'icitis, 375
symptoms of, 375
Endometritis, 375, 384, 394, 679, 743
acute, 384
chronic, 394
diagnosis of, 387, 397
discharge associated with, 380,
395
vegetations of the mucous mem-
brane, 394
villous degeneration, 395
exfoliative, 396
fungosa, 396
gonorrheal, 384, 396
hemorrhagic, 19, 404
influence of, upon conception, 397
membranous, 396
pathologic alterations, 385, 400
prognosis, 389
results of neglected cases, 398
senile, 396
symptoms of, 386, 396
treatment, 389, 398
caustics in, 399
cureting. 398, 399, 400
contraindications for, ^99
dilatation with laminana tents,.
399
drainage in, 399
hot vaginal douche, 400
intrauterine injections, 399
intravenous injections, 391
irrigation with antiseptics, 398
prophylactic, 398
repair lacerations, 398
scarification. 400
tampons, 399
varieties and source, 385
virginal. 306
Endometrium, tuberculosis of, 849
Endoscope, Skene's urethral, 92
Endothelioma of ovary. 878
uteri, 835
Enema, alum, 134
nutrient^ 133
quinin, whisky, and water, 134,
451
soapsuds, turpentine, and eggs, 134
Enemata, 451, 548, 828
alum. 451
coffee, 135
glycerin, 450
m intestinal distention, 451
inedicatcd. 144
normal salt solution, 134
peptonized milk, 134
rectal. 1.^4, 426, 548
soap and water. 450
INDEX.
939
Enemata. stimulants, 134
whisky, 134
Enterocele. vaginal, 340, 485
Enteroptosis, how avoided, 550
Eosin. 55
Epilepsy. 215, 403
Epiplocele. 340, 858
Episiostenosis, 278
Epispadias, 246
treatment of, 248
Epithelial pearls, 634, 748
Epithelioma of uterus, 748
of vagina, 640
of vulva, 633
Erector clitoridis muscle, 165
Ergone. 135, 918
Ergot. 100, 141, 406, 572, 698
Ergotin, 569, 609
Eruptions, vulvar, 27
Erysipelas of the vulva, 334
Er^'throcytes. 83
increase in number of. 85
pathologic alteration of, 85
Ether, sulphuric. 407
Ethyl bromid, 115
chlorid, 1 1 5
Etiology, 2
hereditary and congenital, 3
h^'gienic, 5
incident to age, 1 1
infective, 10
sexual, 7
traumatic, 8
Eucalyptus. 346
extract of, 637
Examination, 23
abdominal preliminaries, 23. 96
aspiration. 10 1
auscultation, 99
exploratory incision, 102, 902
puncture, 100. goi
inspection, 27, 888
palpation. g8
difficulties in, 99
percussion. 99
preliminaries. 96
tapping, 100
instrumental. 34
precautions. 37
probes. 35
Sims', 35
whalebone, 35
sound. 34
speculum. 37
tenaculum, 41
double, 43
tubular, 37
univalve or duck bill, 41
valvular, 38
microsco|)e. 48
collection of tissue. 40
disposition of tissue, 52
test curetment, 50
Examination, microscope, test excision,
49
pelvic, 23, 27
bimanual procedure, 30, 672
difficulties of. 30
digital, 27, 30, 776
precautions in, 34
in virgins, 30
inspection, 27
position of the patient, 23
preliminaries, 23, 27
preparation, 27
procedure, 27
rectal touch, 31, 819
conjoined manipulation in, 32
recto-abdominal, 31, 32
rectovaginal, 32
recto- vagino-abdominal, 31, 32
recto- vesical, 31, 32
Simon's method, ^^
simple touch, 27
Exercise, rest and, 142
Exophthalmic goiter, 699
Exploration of urethra, bladder, and
ureters, 91
Exstrophy of bladder, 241, 246
Extract, adrenalin, 700
belladonna, 369
cannabis indica, 698, 699
condurango. and vaselin, 829
gelsemium, 426
namamelis, bqq
hydrastis canadensis, 407, 699
opium, 360
thyroid gland, 141. 142,510,572, 699
ustilago maidis, 698
Exudates, pelvic, 154, 434
F.
Facies ovariana, 13, 879
uterina. 16
Failure in microscopic examination, 60
Fallopian tubes. 184, 852
absent or rudimentary, 230
accessory ostia, 231
adherent, 447
anomalies in length, 231
coats of. 184
muco5;a, 185
muscular. 185
serous, 184
subserous, 184
description of. 184
divisions of. 184
ampulla tuba*. 184
timoriated extremity. 184
infundibular tulxe, 184
isthmus tubiu. 1S4
ostium abdominale tubie, 184
ostium utcrini tuba?, 184
]>ars uteri ni. 1S4
epithelium of, 186
940
INDEX.
Fallopian tubes, inflammation of, 411.
See Salpingitis.
length of, 184
openings of, 184
tumors of, benign, 852
cysts of small size, 853
dermoid, 853
enchondromata, 853
fibrocyst, 853
fibroma or myoma, 852
papillomata, 854
nydropic, 854
simple cystic, 854
polypus, 854
malignant, 855
carcinoma, 8^5
chorioepithehoma, malignum,
856
sarcoma, 855
treatment of, 855
Faradic current, 152, 411
Farre, white line of, 187
Fascia, anal, 169
deep, 168
layer of superficial, 168
obturator, 169
pelvic, 169
perineal, 168
pyriform, 169
relation to pelvic structures, 169
superficial, 168, 169
triangular ligament, 1 68
vesico-rectal, 169
Fecal fistula, 264
incontinence, 292
Fecundation, 212, 223
union of spermatozoid and ovum,
223
Feeding, rectal, 134
lic[. sesquichlor., 58
Fern persulph., 569
Fetal heart sounds, 99
Fever, puerperal, 387
Fibrocvst, 853
Fibroid growths in the fundus a cause
of ante version, 502
polypus, 660
tumors and polypi, 638
Fibroids, recurrent, 844
sloughing. 114
Fibroma of broad ligament, 858
and myxoma, 633
submucous. 654
of tul>os, 852
Fibroin yoma of cervix, 662
of ovary, 876
of uterus, 650
Fibroin yoniata. 650
Fibrosarcoma, 840
I-'ilaria, embryo of, 90
Filter paper, 57
Fimbria ovarica. 187
Finson light, 155
Fissure, anal, 17. 506, 518, 667
vesico-urethral, 357
appearance of, 358
. site of, 357
Fistula, 17
Fistuke, 264, 823
causes of, 264
cervical, 282
cervico- vaginal, 291
classification of, 264
fecal, 264. 289, 919, 921
ano-vulvar, 264, 290
treatment, preliminary axMi
after, 290
entero- vaginal, 264, 291
recto- vaginal, 264, 266, 289
genito- urinary, 264
uretero-vaginal, 264
urethro- vaginal, 264. 279
urinary, 920
utero-ureterine, 264
vesico-uterine, 264, 267
vesico-utero- vaginal, 282
vesico- vaginal, 264. 268, 640
intestinal, 751
diagnosis of, 265
etiology of, 264
prognosis of, 267
symptoms of, 265
treatment, 267
accidents and results of. 287, 2Si
calculi and concretions, 28S
hemorrhage, primarv, after
287
secondarv. after-, 287
inclusion of ureters, 288
peritonitis, 288
after-, 277
by cauterization, 268
by colpocleisis. 2 78
combined "with rect o- vaginal fii
tula. 279
objections to, 279
by denudation and suture, 267
by episiostenosis. 278
by flap-formation. 267, 2S9
advantages of. 276
by flap-splitting. 267. 289
by hysterocleisis. 281
by hysterostenosis. 281
preliminary, 2 68
uretero-vaginal-uretero-cervical, 2I
treatment of, 283
by anastomosis throtigh the a
domen. 283, 285
through the vagina. 283. 2I
by introduction of the uret
into rectum or colon. 2S4
by ligation of the ureter. 284
by nephrectomy, 284
urethro-vaginal, 279
vesico-uterine. 280
vesico-uterovaginal, 282
INDEX.
941
Fistulas, vesico- vaginal, treatment, 268
Corson's method of flap-splitting,
271
denudation for, 267
flap-formation, 267, 289
flap-splitting, 26^, 270
flap-transplantation, 274, 290
Flap operations, 270, 280
Flatus, rectal irrigation for, 851
Flexion, anterior, of uterus, 506
lateral, 546
posterior, 514
prognosis, 547
treatment, 547
electricity, 547
massage, 547
mechanical measures, 547, 548
operative procedures, 549
Fluids and secretions, collection of, 75
Follicular cysts, 862
Fomentations, antiseptic, 336
hot, 439, 450
of lead water and laudanum, 343
Forceps, 820
dissecting, 125
Koeberle, 795
needle, 129
O'Hara, 919
pedicle, 613
pressure, 124
shovel, 795
tube, 126
Formalin. 53. 59, 382
Fornix, anterior vaginal, 173
posterior vaginal, 173
Fossa navicularis, 165
Fourchet, 160, 165
Fowler's solution, 133
Franklinism, 149
Freund's denudation in laceration of
perineum, 308
operation for malignant disease, 800
for shortening the utero-sacral
ligaments, 546
in marked prolapse, 497
Friedrichshall water, 141
Fritsch's operation, 321
Fuchsin, 57
Furuncle, 332, 340
G.
Gall-stone colic, 89g
Galvanic current, 149, 343, 347
contraindications for. 152
indications for, 152
Galvanism, 149
apparatus for. 150
contraindications, 1 5 2
in chronic endometritis, 150
in fibroid tumors, 150
indications. 152
pelvic inflammatory exudates, 150
Galvano-cautery, 636
knife, 785
loop, 644, 784
Galvanometer, 150, 151
Gangrene of iibromyomata of uterus,
696
of vulva, 338
G&rtner, canal of, 191
Gauze, 10 j, 113
acetanilid, 113
borated, 113, 258
carbolized, 113, 258
drain, 128, 451, 808, 811, 914
for dressings, 108
for pledgets, 820, 823
formalized, 113
iodoform, 258, 825, 919
pack, 48, 113, 125, 409, 465, 503,
573. 576, 615, 714, 716, 791, 821,
831. 913. 919
pads, 105, 323, 336, 410, 453, 727,
730
salicylated, 113
sterilized, 105, 258
sublimate, 113
tampons, 146, 823, 914
thymolized, 258
wick, 126, 136, 456, 574, 914
Genital canal, atresia of, 237
treatment of acquired, 238
of congenital, 238
laceration of, 291
hemorrhage or bleeding, 574
organs, 159
development of, 156
functions of, 212
copulation, 159, 223
fecundation, 212, 223
injuries of, 250
treatment, 251
menstruation, 213
nubility, 212, 213
parturition, 212
puberty, 212
malformations of, 223
classification, 223
acquired, 27, 224
congenital, 27, 224
tract, bacteriology of, 60
parasites of, 61
tumors, 621
benign, 621
definition of, 622
difficulty of differential diagnosis
in, 622
malignant. 621
Genitalia, division of, 159
external, 159
internal. 172
lymphatics of. 208
Genito-urinary fistula;, 264
organs, bificlities of, 224
degrees of division of, 224
942
INDEX.
Genito-urinary organs, development of,
156
physiology of, 212
tract, inflammation of the entire,
326
Gentian, compound tincture, 407
Germinal epithelium, 188
spot, 189
vesicle, 189
Gefms, pyogenic in discharge of uter-
ine cancer, 805
Gestation, 212
ectopic, 569, 896, 899
aciipocere in, 596
causes of, 582
course and progress of, 585
abortion, tubal, 588
mesometric or intraligament-
ary, 591
moles, tubal, 588
rupture, complete, 592
incomplete, 592
primary, 589
secondary. 589. 594
lithopedion, 595
termination of, 595
diagnosis, 599
differential, 604
from acute intestinal ob-
struction, 607
from fecal accumulation, 605
from intraligamentary tu-
mors. 605
from ovarian tumors. 605
from perforating ulcers in
duodenum, 607
in small intestine, 607
in the stomach, 607
in vermiform appendix,
607
from pregnancy, extrauterine
with dead fetus, 606
in one horn of bicomate
uterus, 605
spurious, 605
uterine, 605
from pregnant uterus, retro-
flexed, 605
from renal and biliary colic,
607
from rupture of pyosalpinx,
607
from strangulated hernia, 607
from torsion of pedicle of
small ovarian cyst, 607
of tubal rupture, 607
uterine tumors, 605
lithopedion in. 595, 596
macerated fetus. 604
treatment of, 620
mummification of fetus, 596
I^athological features of, 607
prognosis, 608
Gestation, ectopic, s>TTiptonis, 596
discharge of decidual mem-
branes, 598
hematocele, anteuterine, 567
circumuterine, 567
hemorrhage, extraperitoneal,
576
intraperitoneal. 576
secondary rupture, 589, 594
treatment, 609
electricity, 155, 609
elytrotomy, 60^, 610
evacuation of liquor amnii. 609
four stages of operation. 611
in rupture into broad ligament,
614
injection of poison into fetus.
609
operative, 61 1
incision, abdominal. 611
extirpation of entire sac,
619
removal of placenta
without sac, 617
Sutton's rules, 618
three terminations. 017
vaginal. 610
varieties of, 584
abdominal. 5S5
tubal, 584
tubo-ovarian, 585
interstitial, 585
Getting up, after operation, 140
Gland, Bartholin's, 167, 339
Cowper's. 339
Duvemey's. 330
obturator, of Guerin, 20Q
Glands, hypogastric or iliac, 208
inguinal, 208
lumbar. 209
lymphatic, 208
sacral, 209
utricular, 217
Glandulae vestibulares minor^s. 102
Glandular cyst, 864
Glass plug. '235
Gloinin, 906
Gloves, rubber, 109
Glycerin, 114, 147. 408
on tampons, 5 48
Glycerin-gelatin. 54
Glycorite of tannin. 147
Gonococcus of Xeisser. 63, 65. 90. 333.
352' 353
examination for. 66
ichthyol destructive to. 354
Gonorrhea, 358, 359. 854
a cause of inflamination, 32S. 320.
330, 332. 372. 411. 441
more dangerous than svphilis. %2q
too frequently regarded unimpor-
tant, 440
Graafian follicles, 189
INDEX.
943
Graafian follicles, corpus luteum of, 1 90
nucleus of, 189
Growths, fibroid, 502, 516, 547, 657
ovarian, ^02, 547, 859
retroutenne, cause for uterine ascent,
^ 473
Gynandna, 244
Gynecology, definition, i
difiiculties in study of, 12
theories of, i
value of notes in, 13
Gyroma, 877
H.
Haniamelis, 141, 143, 407, 569, 572,
698, 699
Hands, preparation of, 108, 120
Hearing, how utilized, 22
Heart failure, 102
sounds, fetal, 99
Heat, artificial. 132, 135
Hegar's operation. 301
modified, 303
Hematomctra, 742
Hematosalpinx, 414. 446, 895
Hemoconia. 83, 85
Hemocytometer, 80
Hemoglobin, 83
estimation of, 81
relation of. to surgery, 84
scale, 82
Hemoglobinometer, 81
Hemorrhage. 18, 147, 330, 566. 643,
733. 737. 740. 741. 784. «o2, 852,
882, 885, 918
a symptom, 566
after removal of clamps, 852
causes of, 19
from urinary tract, 93
genital, 569'
causes, 569
diagnosis. 570
dilatation, 571
with Ixjugies, 571
with dilators, 571
with tents, 571
importance of careful examina-
tion in. 570
geni to-urinary. 566
hematocele, 567
diagnosis, ^67
differential, from jx-'lvic abscess,
579
from rupture of pvosalpinx,
57*)
fn)m retroflexed gravid ute-
rus. 579
extra]K'ritoncal, 567. 576, 578
intraperitoneal, 567, 5 70
diagnosis, 570
symptoms. 578
a cause of uterine ascent. 473
Hemorrhage, hematocele, intraperi-
toneal, a source of peritoneal in-
flammation, 449
prognosis, 580
treatment, 580
incision, abdominal, 581
vaginal, 581
ligation of bleeding vessel,
580
hematocolpometra, 240
hematocolpometrosalpinx, 238, 567
hematocolpos, 238, 567
hematoma, 441, 567, 637
ovarian, 191
vaginal or thrombus, 573
diagnosis, 575
from pressure during labor upon
an ovarian dermoid, 575
treatment, 575
vulvar, 573
diagnosis of, 575
differential, from edema of
labium, 575
from labial tumors, 575
during ovariotomy, 912
treatment of, 575
hcmatometra, 239, 567, 742, 824,
842, 898
unilateral, 366
hematosalpinx. 238, 567, 824, 895
hematoxylin, 55, 56
staining. 56
hematuria, 567
causes. 567
in cystitis, 567
tul)crcular, 365, 367
in disease of ureter and pelvis of
kidney, 567
malarial, 567
site and varieties. 566
symptoms and diagnosis, 567
treatment, 568
astringents, 569
oi)eration, 569
internal. 135. 330, 918
menorrhagia, 567
metrorrhagia, 567
ovarian apoplexy. 567
hematoma, 567
periuterine. 576
causes of, 576
symptoms of. 577
primarv, after fistula ofxjration,
287 '
.secondarv, after fistula operation,
287
treatment. 572
urinary. 567
diagnosis, 567
symptoms, ^67
uterine, thvroid extract in. 141
vesical, 9.^
vulvo- vaginal thrombus. 567
944
INDEX.
Hemorrhoids, 17, 32, 140, 341, 342,
506, 667, 670, 671
from pressure upon rectum, 506
Hemostasis, elect rothermic, 156, 797
in ovariotomy, 800
Heppner's method of suturing, 307
Heredity, 666, 766
Hermaphroditism, 243
androgyna, 245
epispadias, 246
treatment of, 248
fynandria, 244
ypospadias, 246
pseudo-hermaphroditism, 243
divisions of, 243
true, 243
Hernia, 168
fatty, 858
labial, anterior, 623
posterior, 623
ovarian, 623
vaginal, 485
ventral, 98, 723, 888
Herpes of the vulva, 332, 334
causes of, 334
diagnosis of, 335
Hildebrandt's denudation, 306
History, method of securing, 13
Hot fomentations, 439, 450
Hottentot apron, 161, 241
Hot- water bag, 369
bottles, 132, 426
Houston, valve of, 196
Hunyadi Jan6s water, 141
Hydatid cysts of the uterus, 742
of Morgagni, 191, 853
disease, 10 1
Hydramnios, 896
Hydrarg. chlor. mit., 133
Hydrastin, 141, 572, 699
Hydrastinin, 141, 572, 698
Hydrastis, 141, 143, 569, 572
canadensis, 141, 360, 407, 699
Hydrocele, 168, 340, 624
Hydrogen dioxia, 113, 383
peroxid, 822
Hydrometra, 410, 742, 898
Hydronephrosis, 672, 751, 769, 901
Hydrops folliculorum, 862
tub:e profluens, 21, 415, 864
Hydrorrnea, 403, 410
Hydrosalpinx, 415, 419, 446, 895
Hydrotherapy, 143, 406
Hymen, 164
annular. 164, 243
anomalies of, 27
atresia of, 243
biseptus or septus, 164, 243
caruncula? myrtiformes, 165, 243
conjjcnital absence of, 243
crescentic. 164
cribriform. 165, 243
cysts of, 629
Hymen, defects of, 242
falciform, 164
imperf oration of, 243
incision of, 243
infundibular, 164, 243
labia-like, 164
laceration of, 243
linguaformis, 164
rupture of, 165
shape of, 243
supernumerary, 243
Hyperemia of the urethra, 354
treatment, 359
Hyperplasia, 379
Hypodermocleisis of normal salt solu-
tion for hemorrhage. 135, 918
for peritonitis, 136
Hypospadias, 5, 246
Hysterectomy, abdominal, 799
accidents during, 737
hemorrhage, 737
injimes of viscera, 737
injury of intestine, 739
of ureter, 738
after-treatment, 740
causes of death after, 740
pan-, 729
partial, 723
vaginal, 716, 790
by morcellement, 712
description of operation, 716
mortality of, 814
Hysteria, 152, 403
Hysterostenosis, or hysterocleisis, 281
Hysterotome, 742
Hysterotrachelorrhaphy, 259
Ice suppositories, 135, 581
Ice-bag, 137, 263, 337, 369, 425, 427.
439. 450. 489
in dysmenorrhea, 144
Ice-water irrigation, 820
Ichthyol, 147. 258, 383, 426
Ileus, 741, 883, 899, 922
Immunity, natural agents of, 62
Incision, abdominal, 121. Q07
abdominal, for tumors of the bladder.
64s
crescent, 123
exploratory, 102, 902
length of, 121
ovoid, 792
vaginal, for tumors of the bladder,
645
Infection, 102, 327, 355, 356, 357. 36a,
378. 384, 385. 386. 388, 392, 4".
417, 420, 421, 441, 442, 462. 66^.
744. 751. 775. 787. 796, 805, 857,
884, 902
gonorrheal, 358. 363, 379. 411
now favored, 384
INDBX.
945
Infection, localized points of, 392
ovarian, 442
specific, 350, 356, 357, 411
streptococcic, 349
wound, 136
Inflammation, 326
acute, 327
causes of, 328
etiology of, 327, 328, 361
gonorrhea and traumatism
most prolific, 328
micro-organisms as a cause, 327
symptoms of, 330
discharge, 351
disturbances of menstruation,
328
and suppuration of cyst, 883
appendiceal, 98
characteristics of, 329
chronic, 149, 327
classification of, 330
exacerbations in, 329
follicular, of urethra, 356
immunity against, how lost, 327
natural protection against, 327
of bladder, 361
acute, 362
symptoms of, 362
chronic, 363
symptoms of. 363
of cervix and body of uterus, 374
of entire geni to-urinary tract, 326
of Fallopian tube, 411
diagnosis, 419
prognosis, 420
symptoms. 418
treatment, see Sec. 459
of ovary, 421
diagnosis. 425
symptoms, 424
treatment, 425
of peritoneum, acute, 439
adhesive, 444
chronic, 445
serous, 444
suppurative, 444
of ureter, 372
of urethra. 354
treatment, 35g
of vagina. See Vaf^initis.
of vulva. See Vulvitis.
pelvic, 430
erroneous views of, 430
Ix.»ritonitis, parametritis, perisal-
pingitis, and perioophoritis.
See Pdvic peritonitis.
varieties of. 327, 430
acute. 327
chronic. 150. 431
circumscribed, 327
difTust'd, ;^2 7
periuterine. 154
Injections, bovinin, 134
60
Injections, carbolic acid, 113
carbolized water, 359
chlorid of sodium and sublimate, 825
colored fluid in fistulae, 266
deodorizing, 113
dioxid of hydrogen, 113
disinfectant, 113
formalin, 113
guaiacol in olive oil, 371
hot vaginal, 343
hydrogen peroxid and thymol, 827
hypodemuc, absolute alcohol, 825
adrenalin chlorid, 135, 391
atropin, 135. 39 L 45 ^
digitalin, 391, 451
ergone, 136
morphin, 134, 137, 451, 609
pyoktanin, 825
salicylic acid and alcohol, 825
strychnin, 135, 136, 391, 451, 906,
918
intra-intestinal, 451
intrauterine, 113, 400
intravenous, of corrosive sublimate,
391
of normal salt solution, 301, 451
of quinin. hydrochlorid of, 391
lime-water, 342
milk, 266
parartin, 341
parenchymatous. 825
perchlorid of iron. 572, 700
permanganate of potash, 827
persulphate of iron, 573
quassia, 342
quinin. whisky and water, in intes-
tinal distention, 451
silver nitrate, 359, 825
sublimate. 113, 359
tincture of iodin, 700
vinegar water, 700
zinc chlorid. 359
Inspection, 27, 97
Instruments for ovariotomy, 905
for trachelorrhaphy, 259
Insufflator, 146
Internal genitalia, 172
hemorrhage. 135, 330, 918
Interstitial, mural, or centric fibroid
growths of the uterus, 657
Interureteric ligament. 194
Intestinal catarrh, 152
complications, 021
perforations. 441
Intestine, injury to, during operation,
739. 918
kinking of, 740
Intraligamentary cysts, 867, 879, 880
Intrauterine douches, 390
Intiissusce])ti<>n. 137
Inunctions of mercury. 6oq
Inversion of the uterus, and complica-
tions, 551
946
INDEX.
Inversion, degrees, 551
extra- vaginal, 550
intrauterine, 550
intra vaginal, 550
invagination, 551
diagnosis of, 555
differential, from fibroid tumors,
557
etiology, 553
nonpuerperal, 553
puerperal, 553
symptoms, 554
treatment, 557
instrumental, 559
operative, 559
incision of vagina and posterior
uterine wall, 562
taxis, 559
central, 559
lateral, 559
peripheral, 559
Thomas operation, 560
lodin and carbolic acid, 409
and perchlorid of iron, 409
compound tincture of, 337
tincture, 114, 133, i44» i45» 146, 382,
3^3* 399. 409. 426, 503, 648, 700,
705. 707. 776, 822
Iodoform, 145. 146, 409, 637, 705
and charcoal, 637
gauze tampons, 113, 146, 826
pencils, 146
poisonous effects of, 113
lodol, 113
lodophilia, 80
Iron, 141, 381, 409
perchlorid of, 409, 572
persulphate, 569. 573, 632, 723
tincture of chlorid of, 146
Irrigating tubes, 112
Irrigation, 125, 371, 393, 700, 790, 793,
913
continued, no
in suppurative peritonitis, 451, 455
of stomach, 134
vaginal. 112, 140
with antiseptics. 827
Ischioperineal ligament, 168
J.
Judgment, exercise of, 13
K.
Keratinization. 74S
Kidneys, amyloid degeneration of, 770
disease of. 341, 374
floating, 681
removal of, 730, 020
sacculation of, 770
associated with uterine cancer,
m »«-.
Kobelt's tubules, 875
Koch's'baciUus, 364
Kraurosis vulvae, 343
causes of, 344
diagnosis of, 345
division of, 343
pathology of, 343
prognosis of, 345
symptoms, 344
treatment, 345
Kreatinin in cysts, 901
L.
Labia majora, 159
agglutination of, 237
anatomy, 159, 168
tumors of, 27
minora, 160
anatomy of, 160
elongation and thickening'of, 27
Lacerations of cervix, 254
complications of, 257
diagnosis, 255
symptoms, 255
treatment, 257
after-, 263
amputation of cervix, 261
preliminary. 257
trachelorrhaphy, 259
of pelvic floor, 291
causes, 292
degree or extent, 293
operation for complete, 295, 303
for incomplete, 295, 300
after-treatment, 323
choice of operation in, 325
intermediate operation, 298
primary operation, 296
advantages of, 297
contraindications, 298
secondary operation, 299
results. 294
of sphincter ani, 292, 294, 297, 303
of vagina, 263
Lactation prolonged to avoid con-
ception, 217
LanoUn. 360
Lauenstein's method of suturing, 306,
322
Laxatives. 140. 353. 85 1
Lead acetate. 143
Lead-water and laudanum, 33 7, 489, 822
Leucin in cysts, 001
Leukocytes. 83. 87
Leukocytometer. Si
Leukocytosis. 87
experimental. 80
innammator>'. SS
malicrnant. 80
of digestion. 87
of pre.:nancy- and parturition, 87
pathologic. 88
INDEX.
947
Leukocytosis, phagocytosis, 88
posthemorrhagic, 88
terminal, 87
thermal and mechanical agencies in,
87
Leukolysis, 86
Leukopenia, 86
Leukorrhea, 13, 20, 21, 255, 259, 379,
403, 404, 424, 505, 719
in cervical inflammation, 379
sources of, 20
substitute for menses, 505
symptom of metritis, 403
with submucous growths, 669
Levator ani muscle, 165, 169, 292, 297,
305
Lieberkuhn's crypts, 195
follicles, 197
Ligament, broad, 231, 467
infundibulo-pelvic, 184, 197, 565,
566, 729
interureteric, 194
ischio perineal, 168, 169
of rectum, 169
of uterus, 2 1 1
ovarian, 186
Poupart's, 168
pubo- vesical, 191
round or broad, defects of, 231
triangular, 168, 191
uterosacral, 211, 467, 496, 526, 544
uterovesical, 211, 467
Ligature and suture material, 106
catgut, 107, 724
partition, 724
rubber, 724
silk, 106, 716, 724. 912
wire, 912
Linea alba, 121
ani rectalis, 195
nigra, 97
striata, 97
Lint, surgeon's, 337
Liomyomata, 654
Lipoma, 633
Lipomata. 858
Liquor alununii acetici, 648
ferri chloridi, 792
ferri sesquichloridi, 824
sanguinis, 82
Lithopedion, 596, 619, 620
Lupus, 6q
Lymphangiectasis, 853
Lymphatic system, 208
glands, 208
hypogastric, 208
inguinal, 208
lumbar, 209
of Guerin. 209
pelvic, 208
sacral, 209
vessels, 209
Lymphosarcoma, 840
Macroblasts, 83
Macrocytes, 83
Magnesia mixture, 134
sulphate, 133, 407, 439, 451
Magnesium citrate, 1 1 1
phosphate, 83
Malarial plasmodia, ^o
Malformations, classification and defi-
nition of, 223
congenital and acquired, 27
treatment of, 233
Malignancy, proportion of, in ovarian
tumors, 903
Malignant chorion, 832
disease, 10 z
of colon, 98
neoplasms, 639, 743
Malt extracts, 407
Mammary gland extract, 572, 700
Marasmus, 899, 901
Martin's method of suturing in lacera-
tion of perineum, 316
Massage, 142, 147, 411, 429
general, 147, 374
pelvic, 147, 503. 524
contraindications, 149
difficulties of, 149
in ante version, 504
in lateral flexion, 547
indications for, 149
Masturbation, 242, 328, 335, 341
Meatus urethras extemus, 163, 192
construction of, 192
Membrana granulosa, 189
Menopause, 221
chemic changes in blood and tissues,
222
duration, 221
early, 221
hemorrhages during, 222
premature, 221
retarded or delayed, 221
time of occurrence, 221
vasomotor disturbances of, 222
treatment, 222
Menorrhagia, 18, 152, 214. 220, 403 »
408, 424, 438, 505, 567, 668
Menses. 13
Menstruation. 213
after complete removal of ovarian
stroma, 216
amount of blood lost, 214
and ovulation. 213
disturbance of, 18, 216
of mental equilibrium in, 215
duration of. 214
during pregnancy, 217
influence of cessation of, upon the
cervix, 180
of nerves in. 217
of ovarian tumors upon, 880
intervals of, 214
948
INDEX.
Menstruation, purpose of, 215
retained, from atresia, 237
symptoms of, 215
synonyms of, 213
time of occurrence of, 214
vicarious, 217
Menthol, 343
Mercuric oleate, 360
Mercury, 141, 609
Mesenteric artery, ligation of, 917
Mesovarium, 187
Metalbumin in cyst contents, 871
Metastasis chorioepithelioma, 834
of carcinoma, 788, 818, 855, 901
papillary variety ovarian tumors,
917
Methods for examining tissues, 52
Methyl blue, 370, 824
Methylated spirit, 777
Metritis, 375, 384, 389, 502, 516, 546
and endometritis, acute, 384
chronic, 400
a cause of ante version, 502
associated with cancer, 401
course and prognosis, 405
diagnosis and physical signs, 404
differential, 405
from cancer, 405
from pregnancy, 405
from rectal disease, 405
from small fibroids, 405
divisions of, 402
etiology, 402
abortions, 402
cellulitis, 402
congestion. 402
contusions from pessary, 403
inflammation, 402
lacerations of the cervix, 403
micro-organisms, 391
retention of placenta, 402
sul.)involution, 402
symptoms. 403
leukorrhea. 403
menstrual disturbances, 404
sterility, 404
synonyms of, 400
treatment. 405
abdominal binder. 406
amputation of the cervix, 408
counterirritants. 407
dilatation and curetmcnt, 408
douches, 406
draina<j:e of uterus. 410
Emmet's operation. 408
ergot. 406. 407
exercise, 406
extirpation of uterus, 410
hip baths, 406
medicated baths and waters,
400
pessary. 40O
]>reventive, 405
Metritis, chronic, treatment, punc-
turing and scarifying the cer-
vix, 408
repair of lacerations, 405
rest, 406
Schr5der's operation, 408
tampons, 408
Weir Mitchell's, 411
diagnosis, 404
differential, between septicemia
and sapremia, 387
infection, how favored, 384
involving the peritoneal coat, 386
localized points of infection, 387
parenchymatous, 374, 400
pathologic alterations in, 384, 401
prognosis, 389
sapremic, 385
septicemic, 385
symptoms of sapremia, 386
of septicemia, 387
treatment, ^89
I hot doucnes, 390
Marmorek's antistreptococcic se-
rum, 390
prophylactic, 389
varieties and their source, 385
Metrorrhagia. 18, 255, 330, 403, 567
Microblasts, 83
Microcysts, 857
Microcytes, 83
Microcytosis, 83
Micro-organisms, 138, 327, 328, 349.
355. 362, 390, 441. 618
as a cause of inflammation of the
genito-urinary tract, 327
Microscope, 48
Microscopic examination of a fresh
specimen, 77
Microtome, freezing, 52
Micturition, frequent, 667
and painful, 91
causes of, 18
Migraine, 215
Milk a basis ifor diet in pruritus, 342
Milliamperemeter, 151
Miscarriage, 13
Moles and cvsts of the uterus, 742
tubal, 588'
Mons veneris, 159
Monsell's salt, solution of, in glycerin,
337
Morcellement, 712
Morgagni, columns of, 105
hydatid of, igi, 853, 859
sinuses of, 195
Morphin, 116. 117, 134,369. 427. 439,
6o(). 828, 851
sulphate. 1 16. 828
Mortality of ovariotomy. 922
Motor and sensory paralysis, 15
Mucilage, 777
Mucometra, 742
INDEX.
949
Mucosa, uterine, alterations of, during
menstruation, 183
Miiller, canal of, 226, 859
ductof, 157,224,230, 231,232,235,326
diverticulum of, 230
Miiller's dirt, 83
fluid, 777
Multilocular cysts, 869
Murphy button, 919
Muscles, 165
bulbo-cavernosus, 167, 192, 292, 346
coccygeus, 170. 292
erector clitoridis, 165
ischio-coccygeus, 170
levator ani. 170, 292, 297, 305, 574
obturator coccygeus, 170
obturator internus, 1 70
of Guthrie, 192
pelvic diaphragm, 170
perforations of, 171
pubo-coccygeus, 1 70
trans versus perinei, 170. 292
Myoma of the bladder, 643
Myomata, uterine, 650, 687, 806, 897
complications of, 687
ascites, 687
disease of the tubes, 688
inflammation, 687
ovarian hematoma, 689
pregnancy, 690
course and pn>gnosis, 69^
cystic degeneration in. 695
death from chronic peritoni-
tis, 696
from disease of kidneys, 696
from heart failure. 696
from inflammation and
gangrene, 696
from rupture of cysts, 696
from shock, 696
from uremia, 696
in heart affections, 695
influence on climacteric, 695
malignant degeneration, 695
mortification and gangrene of
tumor, 695
mummification, 695
perforations of neighboring
organs, 606
rupture of ])odicle. 695
degeneration of, 654, 681
adenomyomatous, 654
amyloid. 683
atrophy, 682
calcification, 654, 682
colloid myxomatous, 654, 683
edema (hematoma), 654, 682
librocystic tumors, 654. 682
inflammation, suppuration, and
gangrene, 684
from coTnpression, 684
from injury, 68 4
from septic infection, 684
Myomata, uterine, degeneration of,
Ivmphangiectatic, 654
malignant, 686
metabolism, 682
sarcomatous, 654
telangiectatic, 654
diagnosis, 671
consistence of the tumor an im-
portant factor, 672
diiierential, 674
from abortion, 674
from carcinoma, 674
from desmoid tumor of ab-
dominal walls, 674
from displaced ovaries, 674
from displaced uteri, 674
from extrauterine pregnancy,
674
from floating kidney, 674
from glandular ovarian cyst,
674
from inversion, 674
from pelvic infiltrations, 674
from pregnancy^, 674
from sactosalpinx, 674
from sarcoma, 674
from subinvolution with en-
dometritis, 674
etiology of, 664
influence of age, 665
of heredity, 666
of irritation, 664, 666
of menstrual congestion, 666
of vscxual irritation, 664, 667
influence of, on conception, 690
on labor, 693
on pregnancy, 692
pregnancy on myoma, 691
microscopic appearance of, 652
multiplicity of, 65 1
necrosis, 657
pathologic anatomy of, 652
consistency, 652
mixed growths, 686
carcinoma, 686
enchondroma, 686
myocarcinoma, 687
myochondroma, 686
myosarcoma, 687
osteoma, 686
sarcoma, 686
vascularity, 652
size of, 662
structure of, 6«;2
symptoms of, 667
abdominal cramps, 667
anemia, 6()8
apparent inflammation of blad-
der, 667
cachexia, 671
constipation. 667
dilatation of ureter and pelvis
of kidney, 672
950
INDEX.
Myomata, uterine, symptoms of, dis-
placement of tne uterus, 668
fissure of anus, 667
frequent micturition, 667
growths filling up internal os,
669
hemorrhage, 667, 668
associated with peduncu-
lated polypi, 668
hemorrhoids, 667
hydronephrosis, 672
inability to evacuate urine, 667
increase of menses, 668
itching and burning of anus,
667
leukorrhea, 669
marked retention of urine, 667
metrorrhagia from rupture of
veins, 668
pain, 667, 669
pressure upon nerves and ves-
sels, 668
prolapse of rectum, 667
pulmonary emboli, 696
renal calculi, 672
retention of gas, 667
sacculation of the kidney, 670
sloughing and gangrene, 668
sterility, 670
tympanites, 667
varicose veins of anus and
vulva, 667
vesical tenesmus, 670
treatment of, 696
electric, 700
Apostoli's, 701
antisepsis, 702
contraindications, 703
acute nephritis, 704
colossal tumors, 704
fibrocystic tumor, 703
heart failure, 704
hysteria, 703
intestinal catarrh, 703
malignant degeneration
of the tumor, 703
pedunculated submucous
fibroid, 703
pregnancy, 703
pus in the adnexa, 703
very hard tumors, 704
ditficulties of, 702
electro-puncture. 702
frequency and duration of
application, 702
galvanism in, 152
influence of, 701, 703
in subserous tumors, 703
interpolar method, 704
of ne<^ative pole within
the uterus. 701
of positive pole within
the uterus, 701
Myomata, uterine, treatment, electric,
Apostoli's, influence of,
polar influence, 704
prevention of shock, 702
general, 696
binder or support, 697
care in dress, 697
mineral springs and bath,
697
medical, 697
adrenalin, 700
carbohydrates, 699
constringents, 699
mammary gland extract, 700
oxytocics, 698
promotion of calcareous de-
generation, 699
pulmonary edema induced
by tincture of iodin injec-
tion, 700
thyroid extract, 699
summary of, 734
surgical, postoperative, 131
bandaging limbs, 135
enemata, 134
hypodermocleisis, 135
intravenous injections, 135
rectal feeding, 134
stomach tube, 134
suppositories, 135
in shock, 13s
palliative, 704
radical, 704
route, abdominal, accidents,
737
and results, hemor-
rhage, 737
injuries of the hollow
viscera, 737
of the intestine, 739
of the ureter, 758
ventral hernia foU
ow-
ing, 723
castration, 705, 718
contraindications of,
1^9
diffic
iculties of, 718
vasomotor symptoms
resulting from, 719
enucleation, 720
advantages of, 720
hysterectomy, complete,
or pan-hysterec-
tomy, 729
advantages of in-
traperitoneal treat-
ment of stump, 723
Koeberle's operation, 723
partial, or supra-vag-
inal amputation of
uterus, 723
ligation of vessels, 719
myomectomy, 720
INDEX.
951
by hysterectomy, 711
treatment of th
Myomata, uterine, treatment, surgical,
route, vaginal dila-
tation and curet-
ment, 705
dangers of curet, 707
dilators, 705
tents, 705
incision of the capsule,
708
of the cervix, 708
removal of the growth,
709
by enucleation, 710
of interstitial tu-
mors, 710
of sessile tumors,
710
;6
the
wound, 716
by incision of the
pedicle, 709
by ligation* of the
vessels, 715
by morcellement, 712
by torsion, 709
varieties of, 653
cervical, 653, 662
diagnosis, 671
extramural, excentric, or sub-
peritoneal, 660
ascites with movable,
662
encapsulated, 662
free. 662
pedicle of, 662
pedunculated, 660
sessile. 660
intramural or submucous, 654
encapsulated, 654
nonencapsulated, 654
pedunculated, 655
sessile, 65^
mural, interstitial, or centric
growths, 654, 657
circumscribed, general,
658
diffuse or gigantic, 658
hypertrophy of the mu-
cous membrane, 658
local, 658
N.
Nabothian cysts, 377, qi2, 746, 778
Narcotics, 768. S 18, 828
Nausea and vomiting, 133, 899
Needle, curved, 129, 825
Freund's trocar, Soo
holder, 820
Reverdin, 130
Needles, 820
straight, 129
Neoplasms, 367, 622
characteristics of benign, 622
malignant, 639
Nephrectomy for ureteral fistulas, 286
Nephritis, 644, 649
acute, 152
Nerves, cocc^eal, 209
hypogastric plexuses, 209
inferior hemorrhoidal. 209
internal pudic, 209
of the pelvic organs and structures,
209, 210
pudic, 210
spinal and sympathetic, 209
splanchnic, 210
Nervous disturbances in menstruation,
215
Neuralgia, intercostal, 15
lumbar, 149
lumbo-abdominal, 149
ovarian, 149
visceral, 15
Neurasthenia, 403
Neuroma of vulva, 630
Nitrite of amyl, 100
Nitroglycerin, 118
Nitrous oxid gas, 115
Noma, 339
Normoblasts, 83
Notes, value of, 13
Nubility, 212, 213
Nuck, canal of, 159
persistence of the, 232
Nurse, duties of, 120
Nutrition, disorders of, 16
Nux vomica, 133
Nymph:e, absence of, 241
defects of, 241
hypertrophy of, 241
O.
Obesity, 16, 888
Observation, importance of, 12
Obturator fascia, 170
Odor, disagreeable, in cancer, 827
Oil, bergamot, 57
birch, 370
castor, 451
cedar, 77
cod-liver, 407
croton, 144, 407, 426
crigeron, 569
sandalwood, 360
Iheobromai, 828
liglii, 144
Ointment, belladonna, 346
and camphorated lanolin, 369
and ichthyol, 138
benzoatcd zinc, 337
Ixjtanaphthol in vaselin, 342
bicarbonate of soda in vaselin, 823
bismuth, 827
952
INDEX
Ointment, camphor, 343
chloral. 343
chloroform, 343
condurango and vaselin, 829
diachylon, 337, 338
^uaiacol in vaselin, 343
ichthyol, 258, 346, 400
iodoform, 146, 346
lead acetate, 343
mercurial, 337
mercuric iodfid, dilute, 426
mercury, ammoniated, 337
opium, 346
sulphur, 342
zinc oxid, 354
Oligochromemia, 83
Onanism, 92, 345
Oophorectomy, 718
Oophoritis, 421
from gonorrheal infection, 421
from septic infection, 421
peri-, 421, 423
serosa. 422
Operation, arrangement for, 120
assistants, 120
closure of wound, 129
clothing of patient, 120
dressing. 131
examination and preparation of
patient for, no
incision, 121
crescent. 122
peritoneum, toilet of, 12^
position of operator and assistants,
120
precautions during, 109
preliminary details. 119
preparation, special. 1 1 r
room and environment, no
Operations, abdominal section, 114,
121. 452
Alexander's, modifications of,
bv Duret, si 2
by Edcbohls. 532
by Franklin Martin, 532
by Goldspohn, 533
by Newman, 532
accidents and results of, 287
calculi and calcareous concre-
tions. 288
inclusion of the ureter, 288
peritonitis, 288
primary hemorrhage, 287
secondary hemorrhage, 287
bladder, for carcinoma of, 649
curcting for inflammation, 372
extirpation of. for cancer, 649
tumors, removal of, through the
urethra. 644
abdominal incision for, 645
vaginal incision for, 645
cervix, amputation of, 261, 492
Baker's, 785
Operations, cervix, amputation of,
flap, double, 262
single, 262, 384
Hegar's, 785
Schroder's, 384, 785
vaginal, for cancer 01 uterus, 784
Van de Warker's, 785
with galvanocautery loop, 784,
792
incision for contracted os, 382
laceration of, trachelorrhaphy
(Emmet), 259, 383
fistula, entero- vaginal, 291
recto- vaginal, 273
uretero - vaginal - uretero - cervical,
vesico-uterine, 281
hysterocleisis, 281
vesico-utero-vaginal, 282
vesico-vaginal, 268, 270
colpocleisis, 278
flap-formation, 275
transplantation, 274
Trendelenbtirg's operation,
273
for absent vagina, 234
for malignant disease, 850
for neoplasms, removal of growth
by incision of the pedicle,
709
by morcellement, 712
by torsion, 709
ovary and tube, by abdominal inci-
sion, castration, 705, 718
for fibroid growths of ute-
rus, 718
for oophoritis, 427
for prolapse of ovary, 566
by ovariotomy, 903
incomplete, for ovarian tu-
mors, 916
removal of, for inflammatory
diseases, 452
with uterus oy vaginal inci-
sion, 458
shortening of infundibulopelvic
ligament for fixation of, 566
pelvic floor, for lacerations of, by
denudation, Bischoflf's,
316
Cleveland's. 313
Dudley's, A. P., 314
Emmet's, 309, 312
Xoble's modification of,
Freund's. 308
Hegar's. 303
Garrigues' modification
of. 303. 495
Heppner's. 307
Hildebrandt's, 306
intermediate operation,
2q8
INDEX.
953
Operations, pelvic floor, for lacerations
of, by denudation, Lau-
enstein's suture, 306
Martin's, A., 308, 316
Outerbridge's, 312
primary, 296
secondary, 299
Simon-Hegar, 301
by flap, 270, 275, 318
Andrews'. 317
Duke's, 322
Fritsch's, 321
Harris', 317
Noble, 321
Ristine, 320
Sanger's, 319, 320
Simpson's, 321
Tait's, 318
for pregnancy, extrauterine,
elytrotomy, 610
incision, abdominal, after
rupture, 613
before rupture, 611
vaginal, 612
for prolapsus. Alexander's, 496
Baldy's. 408
colporrhaphy, anterior, 495
posterior, 495
Dudley's, E. C., 499
Emmet's, 495
Freund's. 407
Garrigues-Hegar, 495
Gilliam-Ferguson's, 496
Hegar's, 495
Hirst, 562
Noble's, 499
Ries, 496
Wiggins, 498
plastic, 140
sacral. 641, 806
Kraske's, 806
modificationsof,by Borelius,8i I
by Hegar, 809, 810
by Heinecke, 810
by Herzfeld. 808
by Hochenegg, 806
by Kocher. 810
by Lew, 810
by Rycfygier, 810
by »Schcde, 800
bv Schlange, 810
by WolfHer, 810
bv Zuckerkandl, 810
to construct a vagina, 233
upon the uterus, for displacements,
anteflexion, abdominal, 514
vaginal, Dudley's, 512
Nourse's, 513
splitting posterior lip, 514
antcversion. 503
Sims' 503
inversion of the uterus, abdom-
inal incision, Thomas, 560
Operations upon the uterus, vaginal
incision, Kustner's, 562
retrodisplacements, abdominal,
Alexander's shorten-
ing of round ligaments,
496, 530
modified by Cassati, 533
Doleris, 533
Duret, 532
Edebohls, 532
Goldspohn, 533
Martin, F., 532
Newman, 532
intraperitoneal shortening
of round ligaments,
Dudley's (desmopyc-
nosis), 535
Mann's, 534
Wylie's, 534
ventrofixation and ventro-
suspension, 541
vaginal. Bovee's, 546
Dixhrssen's, 545
Freund's, 546
Gottschalk's. 546
Mackenrodt's, 545
Pryor's, 546
Ries's. 545
Schucking's, 545
VinelxM;g's, 545
Wertheim's, 545
for neoplasms, abdominal, 799
castrations, 718
enucleations. 720
hysterectomy, modified by
Bardenheuer, 801
by Bishop, 733
bv Clark, 801
by Cred<?, 801
by Eastman, 801
bv Gubaroff, 801
by Kelly, 801
by Kuhn, 801
by Mackenrodt, 803
by Martin. A., 801
by Polk. 802
by Ries, 802
by Rumpf, 801
by Schroder, 803
by Veit, 801
by Werder, 802
supravaginal or partial hys-
terectomy, 723
modified by Baer, 724
by Bishop, 728
by Gow, 724
by Le Bee. 725
by Marcy. H. O., 724
V)y Pryor- Kelly, 727
by Zvveifel. 724
vaginal hysterectomy, in,
716, 790
modified by Billroth, 792
954
INDEX.
Operations upon^theutenis for abdomi-
nal neoplasms, vagi-
nal hysterectomy,
modified by Bottini,
792
by Bovde, 790, 795
by Byrne, 796
by Calderini, 792
by Clark, 795
by Corradi, 793
by Czeray, 790, 792, 793,
796
by Downes, 797
by Doyen, 792
by Duhrssen, 794
by Eastman, 797
by Franck, 796
by Fritsch, 792, 793
by Frommel, 796
by Kaltenbacn, 793
by Kelly, 793, 795
by Landau, 792
by Langenbeck, 790, 796
by Leopold, 792
by Liebmann, 793
by Mackenrodt, 792, 795
by Mikulicz, 792
by Muller, P., 793
by Newman, 797
by Olshausen, 792, 793
by PsCwlik, 795
by P6an, 796
by Richelot, 796
by Sauter-R6camier, 790
by Schatz, 792
by Schauta, 792
by Schroder, 793
by Schuchardt, 794
by Taufifer, 792
by von Teuffel, 793
by Tufficr, 797
by Veit, 793
by Wecchi, 792
by Winckel, 794
by Winter, 796
curctment, 705
incision of capsule, 708
of cerv'ix, 708
ligation of vessels, 715
removal of growth, 709
by enucleation, 710
vulvar. Bartholinitis, 340
epispadias, 248
excision of elephantiasis, 629
of urethral caruncle, 627
of vulvar vegetations, 630
extirpation of malignant disease
of, 636
Operator and assistants, 108
position of, 120
Opium, 324, 369. 427. 439, 450, 828
with belladonna. 36Q
with stramonium, 369
Organ of Rosenmuller, 186, 857, 859
861
Organs, interrogation of other, 13
pelvic, abnormal communications
of, 249
Os, external, 179
internal, 180
tincae, 179
Osteoma, 686
Ovaralgia, 153
Ovarial tubes of Pfluger, 188
Ovarian abscess, 420, 441
apoplexy, 191, 421, 567
growths a cause of anteversion, 502
hematoma, 191, 421, 441
prolapse, 2^1, 565
tumor, bemgn, complicated by ma-
Ugnant disease of uterus, 773
tumors, 366, 689, 806, 859
adhesions of, 900
characteristics of, 859
classification of, 859
dermoid, 873
contents of, 873
large, 859
glandular cystomata, 864
proliferating glandular, 864
proliferous, 872
proligerous, 864
size of, 864
structure of, 868
areolar, 869
multilocular, 860, 869
cyst contents, 860, 87 1
color of, 860, 871
consistence of, 871
specific gravity, 871
unilocular, 860
glandular proUferous, 861 , 864
pedicle of, 865
papillary proliferous, 861, 872
parovarian, 875, 900
contents of, 875
dermoid, 861
how distinguished from
ovarian, 876
hyaline, 861
papillary, 861, 872
proliferating, 872
specific gravity, 875
weight of, 87s
small, 859, 861
cysts of corpus lutexmi, 863
residual, 861
hydatid of Morgagni, 861
simple or follicular (hy-
drops foUiculorum),
862
etiology of, 863
specific gravity of con-
tents, 862
tubo-ovarian, 863
adhesions of, 883
INDEX.
955
Ovarian tumors, complication of, 880
inflammation and suppuration,
883
s>Tnptoms of, 884
pregnancy, 88$ 1
rupture, 880, 884, 917 |
torsion of pedicle, 881 j
differential diagnosis of j
acute, from gall-stone -
colic, 899
from ileus, 899
from perforation of in- j
testine, 899
from perforation of |
stomach, 89^
from peritonitis, 899
from renal colic, 899
from ruptured ectopic ;
gestation, 899
from ruptured ovarian
cyst, 899
symptoms, 883
degenerative changes in the walls,
887
atheromatous, 888
calcification, 887
fatty degenerations, 887
infarctions, 888
diagnosis, 888
(Offerential :
from ascites, 890
from desmoid tumor of ab-
dominal walls, 888
from distended bladder, 890
from extrauterine gestation,
896
from fecal accumulation, 890
from hematometra, 898
from hydramnios, 896 ,
from hydrometra, 898
from inflammatory growths 1
of tubes, 895
from large abdominal tu-
mors, 8q5
from localized peritoneal ef-
fusion, 893
from obesity, 888
from other abnormal collec-
tions, 898
from physometra, 898
from pregnancy, 805
from retroperitoneal growths,
897
from tumors of abdominal
viscera, 805
from, tumors of broad liga-
ment, 897
from tympanites, 889
from uterine fil>roids. 897
from uterine rnyomata, 897
from ventral hernia, 889
questions to l»c considered in,
888
Ovarian tumors, diagnosis, questions
to be considered in,
exploratory incision,
902
puncture, 901
danger and disadvan-
tage of, 902
etiology, 878
natural progress, 879
pedicle of, 865
prognosis, 920
solid, 876
endothelioma, 878
fibromyoma, 876
weight of, 877
gyroma, 877
symptoms, 880
treatment, 902
electrolysis, 902
extirpation, 902
ovariotomy, 903
causes of death after, 92a
hemorrhage, 922
ileus, 922
peritonitis, 922
shock, 922
tetanus, 922
contraindications for, 904
bronchial catarrh, 904
gastro-intestinal catarrh,
904
intercurrent fevers, 904
irrecoverable, disease of
heart, 904
of kidneys, 904
of liver, 904
of lungs, 904
marasmus, 904
nephritis, 904
pulmonary tuberculosis,
904
valvidar disease of heart,
904
visceral injuries during,
918
weakness from loss of
blood, 004
general considerations, 905,
914
closure of wound, 907,
914
drainage, 907, 914
dressing, 907, 914
incision of abdominal
wall, 907
instruments, 905
management of pedicle,
911
operation, 906
postoperative treatment,
916
puncture and evacua-
tion of cyst, 907
956
INDEX.
Ovarian tumors, treatment, extirpa-
tion, ovariotomy,
general considera-
tions, removal of
cyst and manage-
ment of adhesions,
910
of pedicle. 911
toilet of peritoneiun, 916
incomplete operation, 916
indications for, 903
compression of Itings, 904
suppuration of cyst, 883
symptoms of hemorrhage,
904
of ileus, 904
of rupture of cyst, 904,
917
of uremia, 904
torsion of pedicle, 898
intestinal complications, 921
volvulus, 921
mortality of, 922
prognosis, 920
Ovaries, absent or rudimentary, 231
accessory or constricted, 231
anatomy of, 186
axes of, 186
color of, 187
connection with infundibulopelvic
ligament, 187
with uterus and tube, 186
displacement of, 231
electricity in chronic inflammation
of, 152
Graafian follicles of, 189
inflammation of, 56 >
malformations of, 231
situation of, 186
size of, 187
stroma of, 189
supernumerary, 231
tubes of Pfliiger, 188
Ovariotomy, 903
visceral mjuries in, 918
to bladder, 920
to intestine, 918
to rectum, 919
to ureter, 920
Ovaritis, 351, 398, 421
Ovary, abscess of, 420
apoplexy of, 191, 421, 425, 567
bulb of, 207
cancer of, 773
carcinoma of, 877
complications of. 880
adhesions, 881
ascites, 880
distention of ureter and pelvis
of kidney, 880
edema, 880
etiology of, 878
acquired disposition, 879
Ovary, carcinoma of, etiology of. age,
879
heredity, 879
inflammation, 879
trauma, 878
natviral progress of, 879
symptoms of, 880
cirrhosis, 422
function of. 423
hematoma of. 421
inflammation of, 421
acute, 421
chronic, 421
diagnosis of, 425
gonorrheal, 421
septic. 421
symptoms, 424
pain only constant, 424
treatment, 425
care in the use of drugs, 426
ice-bag. 425
removal of ovary, 427
rest, 429
ligament of, 186
prolapse of, 231, 565
sarcoma of, 855, 877
Ovula Nabothi, 183, 377, 380
Ovulation and menstruation, 213
without menstruatioxi, 217
Oxygen, mixture of chloroform an(
Oxytocics, 698
Oxyuris vemiicularis, 63, 73
P.
Pain, 13, 19
in myomata, 667, 669
seats of, 19
accessory, 20
anal or perineal, 20
pelvic, 20
vaginal, 20
principal, rg
hvpogastric, 20
ihac, 19
lumbar, 20
sympathetic, 15
Palpation, 98
Panhysterectomy, 729
Papilloma of the ovary, 622
superficial, 872
Papillomata of tube, 854
of vagina, 639
of vulva, 630
superficial, 872, 900
Paracentesis abdominis, 100, 10 1
Paraffin. 55
melted, 341
Paralbumin in cyst contents, 871
Paralysis, motor and sensory, 15
Parametritis, 330, 430
INDEX.
957
Parametritis chronica atrophicans cir-
cumscriptum et diffusum, 432
posterior, 432
Parametrium, 200
Parasites of genital tract, 61, 63
animal, 73
vegetable, 63
Parauterine pouch, 199
Paris, plaster-of-, injections of, 201
Parotiditis, 137
Parovarian phleboliths, 858
tumors, diagnpsis of, 900
Parovarium, 172, 191
description of, 191
Pars intermedia, 167
Parturition. 212, 2J2
Patient, comfort of, 132
examination and preparation of, no
preparation of, for ovariotomy, 905
Peat baths, hot, 548
Pedicle, 865
management, 911
Pediculi, 27, 341, 342
Pediculosis pubis, 63, 73
Pelvic connective tissue, 200
diaphragm, 170
action of, 170
floor, lacerations of, 291
causes of, 292
complete, 293
degree or extent of, 293
incomplete, 293
results of, 294
treatment of, 295
perforations, 171
inhltrations, 680
inflammations, 430, 884, 921
organs, study of, as a whole, 211
displacements, 466
Pelvis, plane of, 211
Pencils, cocain, 346
copper sulphate, 399
iodoform, 114
silver nitrate, 399
zinc chlorid, 399
sulphate. 309
Penis captivus. 346
Peptonized milk, 134
Perforation of bladder, 899
of intestines, 899
of uterus, 254
Perimetritis, 440
Perineal muscles, 165
bulbocavernosus, 165
erector clitoridis, 165
levator ani, 165, 292, 305, 311,
460
sphincter ani, 165
transvcrsus pcrinei, 165, 202
fascia, 168
ojx'ration for removal of uterus,
septum, 168
Perineum, laceration of, 291
causes of, 292
degree or extent of, 293
results of, 294
treatment of, 295
intermediate operation, 298
primary operation, 297
advantages, 297
contraindications, 298
secondary operation. See Lac-
eration of the pelvic floor.
muscles of, 165
Perioophoritis, 421, 423, 440
Perisalpingitis, 440
Peritoneum, pelvic, 197
depression of, 199
division of pelvic cavity by, 200
reflections of, 198, 199
toilet of, 125, 916
Peritonitis, 135, 351, 416, 430, 440,
019, 922
pelvic, 883, 885, 893, 899
diagnosis, 447
differential, from cellulitis, 448
from pelvic hematocele, 447
etiology, 440
complications during parturi-
tion, 443
favored by appendicitis, 443
following operation for urinary
fistula, 288
gonorrheal salpingitis, 449
idiopathic, 440
new pelvic growths, 442
pelvic hematocele, 441
sepsis, 443
tubal disease, 441
twisting of pedicle of ovarian
cyst, 442, 898
pathologic anatomy, 444
intraperitoneal abscess, 445
suppurative peritonitis, 444,
445
prognosis, 448
symptoms, 446
treatment. 449
medical, 450
preventive. 449
surgical, 451
incision, abdominal, 452
closure of the wound, 456
sutures in, 456
difficulty in adhesions,
* 453
dramage, 455
postural, 455
in collapse, 4<>i
intestinal injections of
cathartics, 455
irrigation. 463
protection of general
]x?ritoneum, 454
steps of operation, 452
958
INDEX.
Peritonitis, pelvic, treatment, stirgical,
incision, vaginal, 451
section, vaginal, and uterine
castration, 458
tubercular, 70, 89^
Periuterine inflammation, 154, 430
phlegmon, 430
Perivaginitis, 331
Pessaries, 490, 524, 548
use of, 490
contraindications to, 527
Pessary, 490
bulb, 490
cup, 491
disc, 490
Gariel, 268
Gehrung, 490
Grailey Hewitt, 490, 510
Hodge. 525, 527
Mund6, 490, 525
ring, 490
Schultze, 525, 527
figure-of-8, 527
sledge, 527
Smith-Hodge, 490
Thomas, 490, 510, 525
Zwank, 490
Phenols, 827
Phlebitis, 138, 387, 741
Phleboliths, 858
Phlegmasia, 672
Phlegmon of the labia, 340
periuterine, 430
Physical signs, 14
senses employed in determining, 22
Physiology of genital organs, 212
Physometra, 741, 898
Picrocarmin, 777
Picrolithio-carmin, 56
Picrotoxin, 222
Pin-worms, 341
Placenta praevia in myoma, 692
Placental polypus, 743
Plaster, mustard, 133, 572
Platelets, blood, 85
Platinum wire electrode, 151
Pledget, 822, 823
cotton, 822, 823
gauze, 820
Plicae pal mat tie, 183
Plug, glass, 235
Pneumococcus, 73, 90
Pneumonia, 102, 741
Podophyllin, 141
Poikiloblasts, 83
Poikilocytes, 83
Poikilocytosis, 8^
Poison, diphtheric or venereal, 357
Polypi, mucous, of the bladder, 64a
of the uterus, 742
uterine, 19, 742, 753
Polypus, fibroid, 657
intermittent, 672
I
Polypus of tubes, 854
placental. 743
Positions for eicamination, 23
dorsal, 23
erect, 27
genupectoral, 2$
&teral, 24
lithotomy, 459. .799. 8^3
semi-prone or Sims', 24, 797, S06
Trendelenburg, 26, 646, 799, 91S
Potassium bromid, 133, 342, 343
chlorate, 407
chloride, 83
citrate, 439
iodid, 141, 407, 408
permanganate, 143, 827
salts, 699
Pouch of Douglas, 199, 201
parauterine, 199
pubo- vesical, 199
subperitoneal, 200
utero-rectal, 199
vesico-abdominal, 200
vesico-uterine, 199, 200
Poultices, 338. 426
Poupart's ligament, 201
Powders, alum and sugar, 337
aristol and desiccated alum, 337
bismuth subnitrate, 337, 361
and chalk, 354
boric acid andf tannin, 826
charcoal and iodoform, 826
compound licorice, 11 1
iodoform, 146, 337, 346, 361
and tannin, 337, 354
lycopodium, 337
pepsin and salicylic acid, 824
seidlitz, 141
starch, 337
talcum. 337
Pregnancy, 152, 670, 682, 690, 691,
774. 885, 895
abdominal, 585
complicating carcinoma, 774
ovarian tumors, 885
extrauterine, 582, 675, 896
causes of, 582
course and progress of, 5 85
mummification, 596
secondary rupture in, 594
symptoms. 596
varieties of, 584
in bicomate uterus, 605
ovarian, 584
spurious. 60^
tubal. See Ectopic gestation, 584, 585
tubo-ovarian, 585
tubo-uterine, or interstitial, 585
with retroflexed uterus, 60 q
Probe, Sims*, 35
uterine, 35
whalebone, 35
Procidentia, 295, 474
INDEX.
959
Prolapse of ovary, 231, 565
Prolapsus, or descent, 473
bandages in, 489
classification of, 474
pseudo-prolapsus, 474
utero- vaginal, 474
vagino-uterine, 474
complete or incomplete, 474
complicating ovarian tumor, 880
congenital, 230
decrees of, 473
hrst, 473
second, 474
third, 474
diagnosis of, 481
diflferential, from cyst in anterior
wall of vagina, 484
from cystocele, 481
from elongated cervix, 482
from enterocele, 485
from fibroid polypus, 484
from inversion of uterus associ-
ated with inversion of vagina,
484
from rectocele, 481
dress and hygiene as a cause, 476
etiology of, 475
abdominal growths in, 477
prognosis, 485
symptoms of, 477
cystocele, 478
leukorrhea, 480
rectocele, 478
treatment, 488
hygienic, 488
mechanical, 489
operative, 492
uteri, congenital, 230
varieties of, 474
Proliferating glandular cysts, 864
Proliferous cysts, 872
papillary, 872
Proligerous cysts, 864
Protargol. 337, 399
Protection from infectious germs, loss
of, 62
Pruritus vulva?, 332, 341
idiopathic, ^41
prognosis of. 342
specific cause of, 341
symptoms, 341
treatment. 342
puaiacol in. 343
with cancer of the uterus, 769
Pryor's operation for displaced uterus,
546
Pseudocyesis, 880
Pseudomucin, 886
Psoriasis vulvae, 636
Puberty, 212
changes associated with. 213, 214
definition of. 212
influence upon discharge, 22
Puberty, precocious, 212
retarded, or delayed, 213
time of occurrence of, 212
Pubovesical ligaments, 191
pouch, 199
Pudendal sac, 168
Pudendum, 159
Puncture, exploratory, 100, 696, 901
of cysts preliminary to ovariotomy,
908
Ptirgation, 136, 828
before ovariotomy, 915
Pyelonephritis, 363
Pyelonephrosis, 102, 364
Pyemia, 775, 883
Pyocolpos, 241
Pyocyanei, 61
Pyometra, 410, 742, 842
Pyonephrosis, 751
Pyosalpinx, 351, 413, 445. 446, 448,
689. 770, 895
Pyrosis, 17
Q.
Quassia, 342
Quicksilver, 820
Quinin, 134, 141, 381, 407, 451
R.
Reconstructives, 141
Rectal douche, 143
feeding, 134, 451
touch, 31
Rectocele, 27, 295, 309, 315. 478
Rectovaginal fistula, 264, 266, 289
Rectum, ampulla of, 195
anal orifice of, 195
anatomy of, 194
crypts of, 19s
injury to, during operation, 919
in vaginal hysterectomy, 798
lymphatics of, 209
mucous membrane of, 197
urinary organs and, 191
Red cells, normal number of, 84
Reflexes, rectal, 17
vesical, 18
Remedies, specific, 141
Renal calculus, 479 .
colic, 809
dilatation, 670
Residual cysts. 861
Rest and exercise, 142
treatment. 420
Retractors, wooden, 821
Retroflexed gravid uterus, 605
Retroflexion of the uterus, 472, 514.
See Retroversion.
diagnosis of. 518
differential, from adherent ova-
rian growths, 520
960
INDEX.
Retroflexion of the uterus, diagnosis
of, differential, from fibroid
growths, 520
from pelvic inflammatory
exudation, 520
etiology of, 516
examination in, bimanual, 520
vaginal and rectal, 520
immobile, 515
indifferent, 515
mobile. 515
pathologic. 515
symptoms of, 516
treatment, 520
Retroperitoneal tumors, 897
Retroposition of the uterus, 500
Retroversk>n, 504
an early stage of prolapsus, 504
and retroflexion, treatment of, 520
adhesions, 533
desmopycnosis, 535
in adherent uterus, 523
in non-adherent uterus, 524
intraperitoneal methods for,
533
methods for replacing the
organ, 521
operative, 530
Alexander's operation. 530
advantages, 533
disadvantages of, 533
massage, 524
pessary in, 524
Schultze's method, 524
use of sound in, 522
vaginal operations in, 544
ventrofixation, 541
advantages of, 543
disadvantages of, 543
ventrosuspension, 541
diagnosis of, 506
etiology of, 504
symptoms, of. 505
constipation, 506
cystitis, 506
fissure of anus, 506
hemorrhoids, 506
inflammatory complications, 506
interference with rectal circula-
tion. 506
menorrhagia. 505
Rheostat, 151
Rima pudendum, 159
ROntgenic rays, 154
Room and environment, no
operating, 1 10
preparation of, no
Rosenmiiller, organ of, 186, 191, 857,
859, 861
Round ligament. extraperitoneal
method of shortening, 530
Rubber gloves, 109
skirt, 827
Rubin and orange, 777
Rupture of cystic tumors, 884, 904, 917
ectopic gestation, 437
uterus, 254, 887
treatment of, 254
S.
Sacral resection, 806
Sactosalpinx, 680
Safranin, 55
Saline. 391, 425, 851
cathartic in suppurative peritonitis,
439. 455
Salol, 113. 268, 359, 851
and anstol. 827
Salpingitis, 351, 411, 546
avenues of infection, 411
cysto-adenosa 416
diagnosis of, 419
hematosalpinx, 414, 854
hydrops tubaj profluens, 415. 864
hydrosalpinx, or sactosalpinx, 413,
854
nodosa mistaken for. myoma, 852
pathological changes in, 414
peri-, 419
prognosis, 420
pyosalpinx, 413
s\Tnptoms, 418
treatment, see Sec. 459
Salts, alkaUne, 370
ammonia, 699
benzoin, 268
bromid, 141, 699
cocain, 118
Epsom, III. 141
iron, 572, 632
manganese. 142
mercury, 1 14
potash, 407, 699
Rochelle, in, 141
zinc, 823
Sand-bag, 138
Sand or peat baths, hot, 548
Sandal- wood oil, 360
Sanger's sutures. 319
Santonin for pinworms, 342
Sapremia, 385
diagnosis of. 387
prognosis, 3 89
symptoms of, 386
treatment of, 389
Saprophytes, 329, 385, 843
Sarcoma, 634, 641, 678, 686, 744, 780,
836, 846, 855. 858, 877, 900
diagnosis, 846
differential, from carcinoma of
uterine body, 849
from choriocpithclioma. 850
from chronic metritis. 847
from fungous endometritis. 847
from interstitial endometritis,
847
INDEX.
961
Sarcoma, diagnosis, differential, from
mucous polypi, 847
from senile endometritis, 846
from subinvolution, 848
from submucous myoma, 847
from tuberculosis of endome-
trium, 849
microscopic examination in, ne-
cessity of, 847
duration of, 845
etiology of, 841
metastasis in, 845
of ovary, 855, 877
pathology of, 836
recurrence, 849
symptoms, 842
cachexia, 842, 844
discharge, 842
emaciation, 844
hemorrhage. 842
increase of tumor after meno-
pause, 844
. pam, 842
treatment, 850
operative, 8 so
contraindications for, 850
varieties of, 836
of body, 836
of cervix, 836
of uterine wall, 836
Scalpels, 124
Schr5der's operation. 390 •
Schucking's operation, 545
Scissors, 830
curved, 272
Kuchenmeister's, 47
Sclerosis, cervical, 379
Scopolamin-morphin narcosis, 117
Seats of pain. 19
Secretion and fluids, collection of, 75
from Fallopian tubes and uterine
cavity, 20
from vagina and vulva, 20
Section, abdominal, 114
antero-posterior vertical incision,
465
control of hemorrhage, 463
dressings. 461
pus sacs in. 463
reason for preferring. 805
steps of operation, 459
vaginal, 458
cutting. 55
Sepregator. 96
Seidlitz powder for nausea, 133
Senna, 342
Sepsis, 102, 411. 662, 77s. 784, 802
Septicemia, 385. 3.S7, 443, 611, 740
puerperal. 64
symptoms, 386
treatment. 380
Serum, antistreptococcic, 390
Sessile fibroid, 663
Gl
Shock, 102, 702, 740, 922
Sight, use of, in diagnosis, 22
Signs, physical, 22
senses in study of, 22
Silk, carbolized, 724
iodoform, 106
ligatures and sutures, 106, 724, 919
Sillo^rorm-gut, 108, 269, 296, 300
Silver nitrate, mitigated stick of, 361
solid stick of, 145, 343, 384
salts, 648
Simple cysts, 862
Simpson s operation in laceration of
perineum, 321
Sinistroflexion, 546
Sinuses of Morgagni, 195
Sinusoidal current, 153
Sitz-bath, 143, 826
hot, 336, 353, 426, 548
Skene's ducts. 163
follicles, 355
Slides, 77
Sloughing fibroids, 114
Smegma bacillus, 72
Smell, how used, 22
Soap, green, 105
potash, 338
Sodii bicarb., 823
Sodium carbonate, 83
chloride, 83
phosphate, 83
Solutions, acetic alum, 826
acid, boric, 139, 336, 353, 370, 371,
372. 646
carbolic, no, 139, 258, 336, 343,
370.. 633. 724
chromic, 399
chromium trioxid, 399
hydrochloric, 109
hvdrocyanic, 343
nitric, dilute, 268
oxalic, 109
salicyUc. 824
sublimate, no, 113, 114
adrenalin chlorid, 125, 369, 821, 913
alum sulphate, 354
aluminum acetate, 573
antipyrin, 125, 337
antiseptic, no, 399
argyrol, 258, 337, 371
atropin, 139, 918
bichlorid, 104, 109, in, 259, 390,
716
bismuth in glycerin, 354
boroglycerid (50 per cent.), 258, 399
bromin (alcoholic), 792
caustic soda, 53
chloral. 346
chloroform in glycerin, 343
cocain. n8. 133'. 343. 350, 369, 633
corrosive sublimate, 54, 109
creolin, 143, 200
ergone. 918
962
INDEX.
Solutions, ergotin, 138
ferripyrin, 125
Flemming's, 54
formaldehyd, 633, 822
formalin, 53, 259, 263, 325, 390, 392,
399, 511, 791, 821
Fowler's, 133
Gabbet's, 365
Harrington's, 109
Hermann's, 54
Hydrastis, fl. ext., 360
ichthyol, 147, 340
in glycerin, 147, 258, 383, 398, 400
lanolin, 383
iodin. tinct. co., 337
iodoform in ether, 114, 259, 383, 776
iron, 409, 503, 647
perchlond, 700
persulphate, 632, 823
Kaiserling's, 59
Labarraque's, 112
lead acetate, 337, 382
liquor aluminii acetici, 648
lysoi. 353
magnesium sulphate, 455
mercurol, 370, 398
Monsell's salt in glycerin, 337
morphin, 135
normal salt, 259
potassium acetate, 53
bromid, 342
dichromate, 107, 777
permanganate, 109, 347, 398
protargol, 347, 370, 398
pyoktanin, 370, 825
pyroligneous acid, 258
saline, 263, 913, 916
saturated aqueous, of acid fuchsin,
7Q
methyl green, 79
orange G, 79
Sherrington's, 81
silver nitrate, 146, 258, 337, 340.
343. 347. 354. 360, 371, 372, 399,
sodium bicarbonate, 259, 399, 823
chlorid (normal), 125, 259, 390,
390, 455; ^'14, 794, 9^3
hyposulphite, 338
strychnin, 141
sublimate, 54, 104, 106, 107, 109,
1 1 1, 263, 325, 336, 372, 390, 630
alcoholic, 790
thymol, 1 12, 143, 827
Toisson's. S i
zinc clilorid, 146, 258, 340, 823
sulphate, 354, 3S2, ^Ss
Sound. 34, 35
dan.i:::ors of. 523
jK'rfurations of uterus by, 37
]>rc'cautions in use of. 37
ro])lacement of uterus by, 522
Simpson's, 35
Specimen, the, 76
Specimens and slides, preservation of
gross, 58
Specula, urethral, 95, 644
uterine, 37
varieties of, Edebohls', 42
Goodell's, 39
Higbee's, 39
Nelson's, 39
Nott's, 39
Sims' self -retaining, 41
tubular. 37
univalve or duck-bill, 41
method of use of, 41
valvular, 38
Talley's, 39
Sphincter ani, 166
extemus, 167
internus, 167
laceration through, 292
tubae, 185
vagince, 167, 176
vesicae, 193
Spigelia, 342
Spina bifida, 230
Spinal anesthesia, 119
Spirilla of Obermeyer, 90
Sponge packs, 615
Sponges, 105, 617
defanite number of, 120, 466, 906
gauze pads for, 105
Spongiopilin, 426
Spray, no
Springs, Elster, 697
Franzenbad, 697
Halle, 697
Kreuznach, 697
Tolz, 697
Stain. Ehrlich triacid, 78, 79
fuchsin-resorcin, 58
hematoxylin, 56
Jenner's, 79
orcein. 58
picrolithio-carmin, 56
Wright's, yc)
Staining of tissue, 56, 78
fixation for, 78
Staphylococcus albus. 63, 328
pyogenes aureus, 63, 90, 328, 349.
362, 441
Static machine, 154
Steel electrode, 151
SteriHty, 18, 379, 404, 438, 448, 504,
670, 690
a cause of ectopic gestation, 583
Sterilization methods, 103
boiling, 103
fractional, 103
heat, 103
steam, 103
of dressings, 108
of instruments. 104
of ligatures and sutures, 103, 106
INDEX.
963
Sterilization of sponges, 105
Sterilizer, Arnold's, 103
Stethoscope, 99
Stitch, crown, 311
Stomach-tube, 134, 136
Stovain, 118
Stramonium, 369
Streptococcus pyogenes, 61, 63, 64, 90,
328. 330, 441
Stricture, rectal, 267
Strontii salicylate, 369
Strychnin, 100, 119, 381, 391, 407, 609,
906, 915, 918
Styptics, 147, 784
Submvolution of uterus, 400, 516, 679
Subperitoneal growths of uterus, 660
Sulphate of zinc, 146, 572
crayons, 146
Sul phonal, 343
Suppositories, 828
belladonna ext., 369
cocain hydrochloride, 369
in cacoa-butter, 360
ice, 135. 581
l^ad acetate, 354
opium cxt., 324, 369
quinin, 391
santonin, 342
tannin and iodoform, 354
zinc oxid, 354
Suture, ligature and, material, 106
Sutures. 129, 456
catgut, 259, 269, 542, 711, 735
cobbler, 724
figure-of-8, 313, 456
interrupted, 129
Lembert, 455, 725
mattress, 825
perineal, 296, 303
purse-string, 733
quill or bar, 302
rectal, 303
removal of, 139
silk, 269, 291, 542, 544
silkworm-gut, 269, 270, 291, 542,
. 544
silver wire, 129, 269, 291, 497, 542,
544. 804
Stolz's purse-string, 494, 550
vaginal, 303, 306
Symptoms, general, 15
anemia, 16
chlorosis, 16
disorders of nutrition, 16
gastric, 15
hemorrhage, 18
pains, sympathetic, 15
paralysis, motor and sensory, 15
visceral, 15
genital, 18
local, 16
objective, 22
subjective, 14
Syncope and death after removal of
lai^e tumors, 918
Syncytio maUgnum, 832
Syphilis and chancroid, 70
organism of, 63
Syringe, bulb, 258
fountain, 258
hypodermic, methods of infection,
138
precautions in use of, 138
uterine, 126
T.
Table, Chadwick's, 23
suitable, 23
Taenia echinococcus, 74 ,
Tait's operation in laceration of peri-
neum, 318
Tamponade in cancer, 826
Tampons, absorbent cotton, 146, 258,
383. 502
borated, 147, 258, 343, 826
boroglycerid in glycerin, 258, 408
carbohc acid, 147, 258, 408
carbolized, 343
cotton and gauze, 258, 408
gauze, 146, 258, 851
glycerin, 258, 399, 548
ichthyol in glycerin, 258, 408
in lanolin, 258, 354, 408
iodoform gauze, 258, 400, 503, 825,
826
iron chlorid, 824
lamb's wool, 146
saturated with fat and oily mix-
tures, 827
sublimated, 258, 343
sulphurous acid and boroglycerid,
343
thymolized, 258
Tannin, 147, 723, 826
glycerite of, 147
Tapeworm, dog, 74
Tapping, or paracentesis abdominis,
loO; 10 1
Temperature, elevation of, 796, 921
Tenaculum, 43
Tents for dilatation. 44, 571, 735
laminaria, 44, 114, 258, 571, 705, 735,
776
preparation or, 44
sponge, 44, 114, 571
sterilization of, 511
tupelo, 44. 114, 571, 792
use of, 114
Teratoma. 874, 900
Tetanus after abdominal hysterec-
tomy, 741, 803, 922
Therajx»utics, 102
classification of. T02
extension of, 102
local, 143
964
INDEX.
Thenno-cautery, 268, 345, 346, 361,
384, 460, 630, 633, 636, 647, 790,
792, 820, 830
Paquelin, 384, 647, 795, 824
Thirst, 133
Thrombi from exploratory puncture,
696
Thrombus, vulvar, 573
vulvo-vaginal, 574
Thyroid extract, 141, 510, 699
Tincture, Churchill's, 146
green soap, 1 1 1
nyoscyami, 268, 370
of aconite, 336
of belladonna, 369
of capsici, 407
of chlorid of iron, 146, 399
of cinnamon, 572, 698
of iodin, 114, 133, 144, 145, 146,
382, 383, 399, 409, 426, 503,
648, 700, 70s, 707, 776, 822
and carbolic acid, 145
and creasote, 257
of nux vomica, 133
of opitun, 132, 396
valerian, 132
Tobacco smoking for pruritus, 343
Toilet of the pentoneiun, 125, 916
Tonics, 381
Torsion of the pedicle, 881, 898
of the uterus, 501
Touch, bimanual, 30
employment of, 22
information afforded by, 28, 29
simple, 27
Trachelorrhaphy, 259
Trans versus perinei muscle, 170
Traumatism, cause of inflammation,
328
of retroversion, 505
Traumatisms, causes productive of,
250
general consideration of, 250
injuries of the genital organs, 250
treatment of, 251, 252
Trays, instrument, 905
Treatment following operations for
mahgnant disease, 850
for absent vagina, 234
for acute inflammatory difficulties,
144
for Bartholinitis, 340
for carcinoma of the bladder, 649
of the tube, 855
of the uterus, 784
of the vulva, 636
for cellulitis, pelvic, parametritis or
periuterine phlegmon, 438
for chorioepithelioma, 834
for chronic pelvic troubles, 146
for cystitis, 368
acute, 368
chronic, 368
Treatment for cystitis, gonorrheal, 366
for cysts of broad hgaments, 857
of the vagina, 638
for defects of clitoris, 242
for displacements, anteflexion, 512,
547 .
ante version, 502, 547
appendages, 566
lateral flexion, 547
retroflexion, 520, 547
retroversion, 520, 547
for echinococcus cysts, 857
for edema of vulva, 338
for elephantiasis vulvae, 629
for endocervicitis, chronic cervical
catarrh, cervical endometritis, 381
for epispadias, 248
for epithelioma of vagina, 641
for erectile or vascular tumors of the
vulva, 627
for extrauterine pregnancy, 609
for fibroid tumors and polypi of
vagina, 639
for fibromyomatous tumors of the
uterus, 696 .
for fistula, 267
for gangrene of vulva, 339
f<5r gas cysts of vulva, 623
for hematocolpometrosalpinx, 238
for hematocolpos, 238
for hematometra, 238
for hematosalpinx, 238
for hematuria, 568
for hemorrhage, genital, 572
periuterine, 580
for hydatid cysts of uterus. See
Chorioepithelioma.
for hydrocele, 625
for injuries of the body of the uterus,
254
of the cervix uteri, 257
for internal hemorrhage, 135
for inversion of the uterus, 557
for kraurosis vulvnp, 345
for lacerations of pelvic floor, 257
for liquid cysts of the vulva, 625
for malignant disease of vulva, 636
for metntis and endometritis, acute,
chrome, 398
for mucous polypi of bladder, 644
of uterus, 743
for myoma of bladder, 644
for oophoritis, 425
for ovarian tumors, 902
for papilloma ta or condylomata, 630
for perioophoritis, 449
for perisalpingitis, 449
for peritonitis, pelvic, parametritis,
perisalpingitis, or perioophoritis,
449
for physometra. 742
for pruritus vulva?, 342
INDBX.
965
Treatment for salpingitis. See sec.
459
for sarcoma of bladder, 644
of tubes, 855
of uterus, 850
of vagina, 641
of vulva, 636
for shock, 135
for tumors 01 the vulva, 630
for t3rmpanites, 134
for iu*eteritis, acute, 373
chronic, ^73
for urethral caruncle, 627
for iu*ethritis, J59
acute catarrnal, 359
chronic catarrhal, 359
for vagiqal hematoma or thrombus,
for vagimsmus, 346
for vaginitis, 353
senile, 354
specific, 353
for villous polypi of bladder, 644
for vulvar hematoma or hematocele ,
575 .
for vulvitis, 336
general, 337
medical. 337
post-operative, 131
general, 140
medical, 140
Trendelenburg posture, 452, 646, 724,
799, 918
Triangular ligament, 168. 191
Trichiasis, 341
Trifacial nerve, 15
Trigone, 192
Trional, 343
Triticum repens, 370
Trocars, 100, 905
Tubal abortion, 586
ostia, accessory, 231
Tuberculosis of endometrium, 849
of genital tract, 69
Tubes, Fallopian, absent or rudimen-
tary, 230
accessory tubal ostia, 231
anomalies in length of, 231
irrigating, 112
malformations of, 230
Tubo-ovarian cysts, 420, 861
Tumors, benign, 621
bladder, carcinoma, 649
myoma, 643
polypi, mucous, 642
villous, 642
broad ligament, carcinoma, 858
echinococcuR, 857
fibroma, 858
lipomata, 858
parovarian varicocele, phlebo-
liths. 858
sarcoma, 858
Tumors, cervix, fibromyoma of, 662
desmoid, 98, 888
erectile or vascular, 625
extrauterine pregnancy, 582
Fallopian tubes, 852
carcinoma, 8^5
chorioepithehoma malignum,
856
dermoid, 853
enchondromata, 853
fibrocyst, 853
fibroma or myoma, 852
hematosalpinx, 238
hydatid of Morgagni, 853
hydrosalpinx, 419
Ijrmphangiectasis, 853
Ijrmphangiectatic cysts, 853
papillomata, 621, 854
pyosalpinx, 689
sarcoma, 621
serous, 853
fecal, 890
fibrocystic, 152
genital, 621
classification of, 621
intraligamentary, 569, 879, 880
malignant, 621, 743
ovarian, 855. 859
characteristics of, 859
cystic, areolar, 869
cysts of corpus luteum, 863
dermoid, 873
glandular proliferating cystoma,
864
hydatid of Morgagni, 861
intraligamentary, of ovary and
uterus, 569
multilocular, 860
papillary cystadenoma, 870
proliferous, 864
parovarian, 875
proligerous, 864
sessile, 865
simple or follicular, 862
solid, 876
carcinoma, 877
endothelioma, 878
fibromyoma, 876
gyroma, 877
residual, 861
retroperitoneal, 897
sarcoma, 877
carcinomatosum, 877
teratoma, 874, 900
tubo-ovarian, 420, 861, 863
unilocular, 859, 863
uterine, carcinoma, 649, 686. 744
enchondroma, 686
fibrocystic, 152, 682
fibromyomata, 650
interstitial, mural or centric
fibroids, 657
myocarcinoma, 687
966
INDEX.
Tumors, uterine, myochondroma, 686
myosarcoma, 687
osteoma, 686
puerperal, 741
hematometra, 742
hydatid cysts. 74a
hvdrometra, 742
physometra, 741
sarcoma, 686
submucous fibroids, 654
subperitoneal growths, 660
vaginal, cysts, 622
fibroid tumors and polypi, 638
malignant neoplasms, 639
papillomata, 639
vulvar, 622, 629
cysts, blood, 629
gas, 623
liquid, 624
gland of Bartholin, 629
hydrocele, 624
sebaceous cysts, 629
simple, 630
elephantiasis, 628
enchondroma, 633
epithelioma, 633
erectile or vascular, 625
fibroma, 633
lipoma, 633
myxoma. 633
papillomata or condylomata, 630
sarcoma, 633
Tunica albuginea, 188
fibrosa, 189
propria, 189
Turpentine, 699
Tympanites, 134, 889
Typhoid bacillus, 71, 388
Tyrosin in cysts, 901
U.
Ultraviolet rays, 155
Unilocular cysts, 860
Urachus, open, 249
Urea in cysts, 901
Uremia, 17, 769, 771
Ureter, accessory, 249
cancer of, 751, 795
catheterization of, 92, 795
description of, 194
disease of. 341
cause of pruritus, 341
exploration of. 91
inclusion of, in listulaj operations,
288
injury of, 73S. 708, 806, 812, 852
involved in cancer, 769
irregular exit of, 249
liji^ament of, 194
palpation of, 93
transplantation of, into bladder, 806,
Q20
Ureter, transplantation of, into rec-
tum, 248
Ureteritis, 372
acute, 372
sjrmptomsof, 372
causes of, 372
chronic, 373
symptoms and signs of, 373
treatment of, 373
Ureterovaginal-ureterocervical fistuls,
28^
Urethra, 191
absent, 246
atresia of, vagina and, 246
attachments of, 191
cysts of, 637
diameter of, 191
dilatation, 91
dimensions of, 191
exploration of, 91
external meatus, 163, 192
follicular inflammation, 356
treatment, 350
granular erosion of, 359
treatment, 360
hyperemia of, 354
use of catheter in, 355
inflammation of, 92
length of, 191
mucous membrane of, 192
ulceration of, 357
symptoms, 357
Urethral caruncle, 27, 355, 626
endoscope, 92
specula, 95
Urethritis, 354
acute catarrhal, 355, 356
diagnosis, 356
svmptoms, 356
chronic interstitial, 354
symptoms, 356
follicular, 356, 361
symptoms of, 357
treatment of, 361
gonorrheal, 359
treatment, 359
varieties, 354
Urethrocele, 499, 638
Urethroscope, 94
Urethro-vaginal fistula, 264, 279
Urinary organs and rectum, 191
Urine, diminution of, from pressure of
tumor, 880
examination of, 92
incontinence of, 92, 265, 365
of separate kidneys, 364
retention of, 362
Urogenital sinus, 157, 246
Urotropin, 369
Uteri, accessory, or trifid, 230
Uterine body, carcinoma of, 752
cavity, antisepsis of cervix and, 113
myomata. electricity in, 152
INDEX.
967
Uterine polypi, 19
Utero-rectal culdesac, 199
Uterus, absent, 228
accessory or trifid, 230
anatomy of, 178
anteflexion of, 472, 506. See Antc-
flexion.
ante version of, 501. See Ante-
version.
ascent of, 472
diagnosis of, 473
atresia of, 227
axis of, 211
bicomis, 225
arcuatus, 225
unicollis, 225
bitidus, 225
biforis, 228
bilobularis, 225
bipartitus, 228
cancer of, 22, 64Q
carcinoma of, 649, 744. See Car-
cinonta.
descent or prolapse of, 473
didelphys, 225
dilatation of, 43
by tents, 44
gradual, 43
dimensions of, 178
dislocation of, 500
anteposition, 500
latero-position, 500
retroposition. 500
displacements. 471
classitication of, 471
divisions of, 178
double, 225
fetal, 2 2g
fibromyomatous tumors of (myo-
mata), 650. See Myonxaia.
fixation and traction upon, 43
forces sustaining, 467
fundus of, 178
hydatid cysts of, 742
cystic mole, 742
incarceration of retroflexed gravid,
366
infantile. 229
inflammation of, 374
acute, 384
causes of, 384
chronic, 375, 394
areolar hyperplasia, 379
cervical catarrh, 375
diagnosis, ^80
differential, from endo-
metritis. 381
from ovules of Na-
both, 377. 380
from papillary ero-
sion, 376
from vaginal inflam-
mation, 380
Uterus, inflammation of, chronic,
cervical catarrh, symptoms, 379
classification of, 374
complicated with retroflexion, 379
diagnosis of, 380
diphtheric, 375
gonorrheal, 375
micro-organisms, 375
physical signs of, 380
prognosis of, 381
relief of congestion in, 383
saproph>^ic, 375
septic, 375
symptoms of, 379
syphilitic, 375
treatment of, 381
constitutional, 381
curet, 384
douches, 381
electricity, 384
local, 381
Paquelin's cautery in chronic
cases of, 384
Schroder's operation in, 384
tampons, 383
tubercular, 375
injuries of the body, 253
treatment, 254
inversion of, 550
extravaginai, 550
intrauterine, 550
intravacrinal, sso
invagination, 551
lateral llexion of, 546. See Flexion.
ligaments of. 2 1 1
malignant tumors of, 743
carcinoma, 744
adenocarcinoma of body, 752
of cervix, 749
chorioepithelioma, 744, 832
classification of, 744
clinical forms, 762
endothelioma, 744, 835
epithelioma, 748
sarcoma, 744
squamous cell, 746
limit between benign and, 744
metritis, 384. See Metritis.
mucous membrane of, 181
polypi of, 742
confoimded with fibroid polypi,
742
treatment of, 743
nonnal position of, 468
pathologic changes and what con-
stitute. 469
causes of. 470
physiologic movements of. 467
influence of distended bladder
on. 4^S
polypus, placental, 743
position of, 178
prola])sus t)f, 473
968
INDBX.
Uterus, puerperal tumors, 741
hematometra, 742
hydrometra, 742
mucometra, 742
ph)rsometra, 741
pyometra, 742
retrodexion of, 472. See Retro-
flexion.
retroversion, 504. See Retroversion,
rudimentary, 228
rupture of, 46, 254
sarcoma. Siee Sarcoma,
subinvolution of, 401, 516
torsion of, 472, 501
unequal development of two sides
of, 226
unicornis, 227
weight of, 178
V.
Vagina, 172
absent, treatment of, 233
anterior fornix of, 173
atresia of, 237
of vagina and urethra, 246
changes caused by pregnancy, 176
closure of vesico- vaginal fistula, 269
complete absence or rudimentary
development of, 232
cysts of, 622, 637
diagnosis, 638
differential, from cystocele or
urethrocele, 638
origin. 637
symptoms, 638
treatment, 638
dimensions of, 172
double, 235
epithelioma of, 640
fibroid tumors and polypi of, 638
diagnosis, 639
differential, from malig-
nant disease, 639
symptoms, 639
treatment, 639
enucleation, 639
lacerations of, 263
lymphatics of, 177, 348
malignant neoplasms, 639
etiology of, 640
symptoms, 640
treatment, 641
microscopic section of wall of, 177
mucous membrane of, 175, 176
secretion of, 176
nerves, 178, 348
papillomata of, 639
posterior fornix of, 173
prolapsus, or inversion of, 474
rudimentary, 232
rugae of. 164, 175, 176, 178
tumors of, 637
Vagina, unilateral, 235
wall of, 172, 176
Vaginal enterocele, 485
fiysterectomy, 716, 790
irrigation, 140
oribce, 159
section, 458. See Section, vaginal.
sphincter, 167, 176
I wall, excision of anterior, for cysto-
cele, 495
Vaginismus, 18, 19, 149, 153, 345
cause of pain in, 19
causes of, 345
prognosis of, 346
superior, 346
symptoms, 345
treatment, 346
Vaginitis, colpitis, or elj-tritis, 348
auto-infection, 348
bacterial forms of secretion, 348
diagnosis, 352
etiology, 351
pathology, 350
of simple, 351
of specific, 351
prognosis, 353
symptoms, 351
S5monyms of, 348
treatment, 353
varieties, 350
diphtheric, 350
dysenteric, 350
emphysematous, 350
exfoliative, 350
phlegmonous, 350
senile. 351
simple, 350
specific, 350
Valve of Houston, 196
Varicocele, parovarian. phleboliths,858
Vascular supply of pelvic organs, 201
Vaselin, 77, 822
Veins, internal, iliac, 207
left ovarian, 207
ovarian, 207
pampiniform plexus, 207
plexus of hemorrhoidal, 205
right ovarian, 206
superficial abdominal enlarged by
pressure, 97
uterine, 206
vaginal, 207
varicose, 628
vesical plexus, 207
Venereal warts or sores, 27, 33a
Ventral hernia, q8, 723, 888
Ventrofixation of uterus, «;4i, 549, 566
advantages and disadvantages of,
543
Ventrosuspension of uterus, 541, 549
Version, lateral, 506
Vertigo, obstinate. 719
Vesical douches, 144
INDEX.
969
Vesical reflexes, i8
tenesmus, 6jo
Vesico-abdominal pouch, 200
Vesico-urethral fissure, 357
Vesico-uterine culdesac, 199, 200
fistula, 264, 280
Vesico-utero- vaginal fistula, 282
Vesico- vaginal fistula, 268
Vestibule, 162
bulb of, 167
Viburnum prunifolium, 141
Violence, external, to genital organs,
250
Virgins, examination of, 30
Viscera, inflammation of pelvic, 152
Visceral injuries during operations,
, 737. 918
Vitellme membrane, 189
Volvulus, 137, 921
Vomiting, 133, 451. 695, 771, 883
following operation, 133
in cancer, 771
obstinate, 133
rectal feeding in, 134
remedies for, 133
rupture of cyst by, 885
stomach tube for, 134
Vulva, 159
absence of, 241
changed relations of structures of,
466
edema of, 338, 628
eruptive diseases of, 334
causes of, 334
eczema of, 334
erysipelas of, 334
herpes of, 334
gangrene of, 338
infantile, 241
kraurosis, 343
neuroma, 630
treatment of, 630
pruritus, 341
S3rphilitic hypertrophy, 338
tumors, 622
benign, classification of, 621
cysts, 629
blood, 629
gas. 623
liquid, 624
hydrocele, 624
differential diagnosis from
hernia, 624
of glands of Bartholin, 629
of nymen, 629
of urethra, 629
sebaceous, 629
serous, 629
treatment of, 630
elephantiasis, 628
aiagnosis of, 629
forms of, 629
S3rmptoms of, 629
62
Vulva, tumors, enchondroma, 633
erectile or vascular, 625
diagnosis of, 627
etiology, 626
sjrmptoms, 626
treatment, 627
urethral caruncle, 626
fibroma and myxoma, 633
lipoma, 633
malignant, 621, 633
adenocarcinoma, 633
epithelioma, 633
sarcoma, 633
solid, 621, 622, 629
neuroma, 630
simple vegetations, 630
condylomata, 630
papillomata, 630
treatment of, 630
varicose veins of, 628
Vulvar atresia, 237
Vulvitis. 331
catarrhal, 336
causes of, 331
chancroidal. 332
diagnosis of, 335
diphtheric, 335
eruptive, 331, 334
follicular, 332
gonorrheal, 328, 332, 334
herpetic. 334
phlegmonous, 331. 335
simple or catarrhal, 331, 336
pruritus a symptom, 332
syphilitic, 333
treatment of, 336
venereal, 331, 332
causes of. 332
Vulvo- vaginal glands, 167
inflammation of, 339
Vulvo- vaginitis in young girls, 347, 348
dangers of, 347
treatment, 347
W.
Water, alkaline, 353, 406
Buffalo lithia, 369
Carlsbad, 369, 407
Friedrichsnall, 141, 407
Hunvadi Jan6s, 141, 407
Londonderry lithia, 369
mineral, 407, 697
Saratoga, 368
Seawright, 369
Seltzer, 369
sterilized, 119
Vichy, 368
Whisky. 134. 451
White line of Farre, 187
Wolffian body, 157, 191, 875
duct, 157
970
INDEX.
Wound, closure of, 129. 9x4
dressing. 131
infection, 156
methods of suturing. 129
post-operative treatment of. 131, 791
X-rays, 154
Z.
Zinc alum sticks. 384
chlorid. 146. 399, 785. 792. S25
crayons, 146
solution. 340
sticks, 824
sulphate. 146. 382. 3S3, 572
crayons. 146
valerianate. 141
Zingiber, s\Tup. 133
Zona pellucida, 189
LANE MEDICAL LIBRARY
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11201 i:ontconiery, E.E,
i:787 Practicta icynecology
1907 52862
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