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'fr

TEXT BOOK

►

MEDICAL AND SURGICAL
GYNECOLOGY

FOR THE USE OF STUDENTS AND
PRACTITIONERS

R. W. Garrett, M.A., M.D.,

Professor of Obstktrics and Gynecology in the Medical Faculty,

Queen's University, Kingston; Gyn-«couOgist to the

Kingston General Hospital.

CONTAiNING OVER ONE HUNDRED ILLUSTRATIONS.

KINGSTON. ONT.
1897.

at the Department of Agiioulture,

TO
FIFE FOWLER,

PROFESSOR OF THK PRINCIPLES AND PRACTICE <>K MKDICINI?, AND

DEAN OF THE MEDICAL FACULTY IN QUEEN's

UNIVERSITY, KINGSTON,

THIS BOOK IS RKHPKCTFDLLY DEDICATED BY

THE AUTHOR,

IN RECOGNITION OF LIFE LONG SERVICES AS A PIONEER AND
STEADFAST LABORER IN THE (JAUSE OF HIGHER
■'- MEDICAL EDUCATION IN CANADA.

PREFACE.

During the many years the author has been engaged
in teaching in various departments of medicine, it always
appeared that much valuable time was lost to the student,
and important points missed, in efforts to secure such
notes as would furnish him with a knowledge of the
teachings of the lecturer.

When it is demanded of a teacher to so arrange his
lectures that his listeners may secure the required notes,
liis efforts are apt to become dry and uninteresting, and
often simply a species of dictation.

In the opinion of the author, lectures, to be interesting,
instructive, and impressive, should assume more the form '
of demonstrations, than set lectures, during which im-
portant features might be made plain, knotty questions
discussed, obscure points elucidated, and methods for
medical and surgical treatment made clear by the aid of
blackboard drawings, maps, plates, and morbid specimens,
leaving the intervening material for study elsewhere.

The large and excellent text books on the market are,
as a rule, too cumbersome to carry backwards and for-
wards to class, and in order that the student might have a
convenient text book for such a purpose, and in which he
might note important points dwelt upon, and in order that
the lecturer might feel he was free to demonstrate the
subject as seemed best, without being confined to set
lectures, it occurred to the author to place his extended
notes in the form of a text book of such proportions as
would not be cumbersome, and yet sufficiently compre-
hensive as to fully cover the subject. By such means it
is hoped to make class attendance less burdensome or

PREFACE.

irksoiiK*, the material imparted more instructive, and
lessen the time required by students in securing an
accurate knowledge of the subject.

While imdertaking the task., acknowledged by the
author to be a difficult one, it occurred to him that by
extending the notes a little further the work might be-
come a useful adjunct to the general practitioner, whose
busy life prevents him securing on all occasions the time
necessary for consulting larger works. For such, however,
it is not intended as a work for extended research, but
from its methbd of compilation, and from its extensive
index, it is hoped that it will serve as a means for ready
reference, as well as an index to the many large and
excellent works on the subject.

With these objects in view, the author has endeavored
to place the subject in as plain and simple a manner as
possible, prefevring simplicity of expression to the adorn-
ment of Iniigup.ge. Each subdivision has been briefly
described, doubtful points, or subjects open to discussion,
discarded, raid oidy such treatment recommended as has
stood the test of experience, believing it better to be
armed with a few reliable methods of treatment than
surrounded by a wilderness of uncertainty.

Iti the method of arranging the various subdivisions,
tiio author has followed that adopted by Grarrigue in his
excellent work, feeling confident that regional classifica-
tion is simpler at least than a pathological one.

In the description of diseases, or of surgical methods
adopted for their relief, names of individuals have, as far
as possible, been avoided, as being often misleading.

While expressing his own convictions, the author has
endeavored to interweave into the pages of the work the
opinions of those who represent the most recent and
advanced thought, and of those who have been separated
out for distinction in the subjects upon which they have
written.

PREFACE.

Mnrgiunl n^ferences mid foot notoH have been nvoid(>(l.
because a knowledge of the source of tlie literature that
has been incorporated is of no advantage to the student
until he has mastered tlie rudiments of the science, and
the practitioner can find in tho large works of reference
all the historical or other facts v;hich he may seek.

Acknowledgment of valuable information is due to
the following sources: — Diseases of Women, Cxarrigue;
Medicdl and Surgical GymvcokHjy, Pozzi; Diseases of
Women, Thomas and Munde; American Text Book of
(rijna'coloyij, Baldy; Clinical Gijna'colocfy, Keating and
Coe; A System of Medicine, Allbutt and Playfair, Vol. II;
Diseases of Women, Lawson Tait; Matnadof (it yna'colo(jy,
H. T. By ford; Manual of Gyna'colotjy, Hart and Barbour,
Surgical Diseases of the Ovaries and FalUrpiau Tubes,
Bland Sutton; Te.rt Booty of Ahdominal Surgery, Keith;
Ahdomiuid Surgery, Greig Smith; Diseases of Women,
Skene; Feuiale Felric Organs, Savage; System of Sur-
gery, DenniH; American Text Bool\ of Surgery; Practice
of Medicine, Osier; American Text Booix of Obstetrics;
Surgical Patfiology and Morbid Amdomy, Bowlby ;
Electricity in Diseases of Women, Massey ; Aseptic
Surgical Teclinique, Hunter Eobb; Manuid of Surgical
Asepsis, Carl Beck; Principles of Bacteriology, Abbott.

In conclusion, the author wishes to acknowledge his
indebtedness to Dr. W, T. Connell for valuable assistance
in the preparation of the work, and to E. J. Barker Ponse,
proprietor of the British Whig, for the facilities offered,
and the generous interest shown by him while the work
was passing through the press.

52 Johnston Street,

Kingston, Ontario.
September, 1897.

CONTENTS.

PART ONE.
PRINCIPLES OF GYNyECOLOGY.

CHAPTER I.

PAGE.

Introduotouy y

CHAPTER II.
Development of the Female Genitals 12

Wolffian diictB. — Wolffian bodies. — Ovaries. -M uUeiian
ducts. —Falloi)ian tubes. — Uterus and vaj^ina.— Urethra. —
Vulva.

CHAPTER III.
Anatomy 16

The pelvis. — Mens > eneris. — Vulva. — Labia inajora. —
I^abia minora. — Clitoris. — Vestibule. — Vestibule- vaginal
gland'*. — Vulvovaginal glands. — Vagina. — Hymen. —
Uterus. — Fallopian tubes. — Ovaries.— Parovarium. — Ortran
of Rosenniuller. — Urethra. — Bladder. — Ureters. — Rectum. —
Pelvic peritoneum. — Pelvic floor. — Pelvic fascia. — Pelvic
diaphragm. — Perineal region. — Perineal fa&cia. — Perineal
muscles. — Perineal body.

CHAPTER IV.

Gyn^colooical Technique 40

Sepsis. — Septic infection. — Principal micro-organisms con-
cerned. — Asepsis. — Principles of sterilization. — Sterilization
by dry and moi&fc heat. — Fractional sterilization. — Chemical
disinfection. — Practical application of surgical asepsis. —
Methods for cleansing the hands and field of operation. —
Sterilization of instruments and instrument ^rays. — A.septic
sutures and ligatures. — Methods for sterilizing catgut. —
Sterilization of silk, silkworm gut, kangaroo tendon. — Steril-
ized dressings. — Preparation and sterilization of sponges. —
Aseptic drainage. — (ilass drainage tubes and gauze drains. —
A8e})tic irrigating fluids. — Dusting powders. — List of instru-
ments for operations.

2 CONTENTS.

PAIJK.

CHAPTER V.
Etiology in (teneral 57

Causes of diseases of women. — Training and uifects of
education. — ^Personal habits. — Infectious diseases.

CHAPTER VI.

An.esthetics 62

Ciioir ^ of ana'sthetics. — Instructions to be observed in
administration.^ — Methods of administration. — Treatment of
dangerous symptoms during administration.

CHAPTER VII.
Examination in General. '. 68

(Jeneral outlines of dih'erential diagnosis. — Form for case
taking. — Physical examination. — Methods of e>:amination. —
Instrumeiiwtl examination. — Examination of interior of
uterus and bla(hler. — C'ystoscopy. — Examination of ureters.

CHAPTER VIII.

Gyn/Ecolooical Therapeutics 86

(jreneral liygiene. — Special gyna'cological drugs. — Local
therapeutics. — External and internal applications. — Medi-
cated pessaries, tampons, and suppositories. — Applications
to uterus. — Vesical injections. — ("uretting — Pelvic massage.

CHAPTER IX.
Post Operative Treatment 96

CHAPTER X.

Gynecological Application of Electric Currents 1(X)

Calvanic and Faradic currents. — Electrodes. — Galvano-
meter. — Rheostat. — Diseases in which they are applicable.

PART TWO.

FUNCTIONAL DISEASES.

CHAPTER XII.

Disorders op Menstruation 107

Amenorrhd'a. — Vicarious menstruation. — Menorrhagia and
metrorrhagia. — Precocious menstruation. — -Dysmenorrhd'a,
neuralgic, congestive, obstructive, membranous, ovarian.

CHAPTER XIII.
Sterility. — Nymphomania. — Leucorrhcea 127

CONTENTS.

PART THREE.
DISEASES OF SPECIAL REGIONS.

CHAPTER XIV.

Diseases of the Vulva "j^^^

Malformations. — Hypogpadias.— EpLspadias. — Heinaph-
rodism.- Hernia.— Hematocele.- Lijui ies. — Phlegmonous
inflammation. —Cysts and absces.ses of the vulvo- vaginal
glands.— Tumors— Vulvitis, simple, puruleat, follicular.—

Eruptive diseases.-Pruritus.— Hypera^sthesia.— Kraurosis.
— Coccygodynia.

CHAPTER XV.

Lesions op the Pelvic Floor 152

Causes of lo.ss of tonicity.— Prolapse of vagina.— Cystoc'ele
-Rectocele. -Anterior colporrhaphy.- Posterior colpor"
rhaphy.— Perineorrhaphy.— Colpo-perineorrhaphy.— Tait's
Hegar's and Emmet's methods of perineorrhaphy. ' '

CHAPTER XVI.

Diseases of the Vagina ...... 171

Malformations of the hymen. - Malformations of "the
vaguia. -Atresia and stenosis. -Vaginitis.-Neoplasms.

CHAPTER XVII.

Genital Fistula. .^.

Urinary tistuhe, vesico- vaginal, urethro-vaginal,' vesJcV- •
uterme, vesico- utero- vaginal, uretero- vaginal, uretero- •
uterme.— Fecal fistula.

CHAPTER XVIII.

Diseases of the Urethra and Bladder. . . 194

Malformations of the urethra. -Malformatmns of the

bladde..^ -Irritable urethra.-Urethritis.-(Jranular erosion

o urethra.-Stricture of urethra. -Urethrocele. -Irritable

Wadder.-Cystitis.- Vesical calculi. - Foreign bodies.-

: . JVeoplasms.— Ureters.

CHAPTER XIX.

Diseased of the Uterus

Malformations. -Uterus unicornis.- Uterus bi'coi
Uterus duplex. -Uterus septus. -Atresia uteri.

207

nis.-

4 CONTENTS.

PACiE.

CHAPTER XX.
Diseases of the Uterus, Continued 218

Laceration of the cervix. — Trachelorrlmpliy.

CHAPTER XXI.

Diseases of the Uterus, Continued 219

Metritis. — ^Acute endometritis. — Acute metritis. — Endo-
cervieitis. — Chronic corporeal endometriti.s. — Chronic me-
tritis.

CHAPTER XXII.
Diseases of the Uterus, Continued 239

Accjuired atresia. — Stenosis of the cervix. — Hypertrophy.
— Supra- vaginal amputation of cervix.

CHAPTER XXIII.
Diseases of the Uterus, Continued 241

Disphicements. — Anteversion. — Anteflexion. — Retroversion
and retroflexion. — Pessaries. — Extra-peritoneal shortening of
the round ligaments. — Alexanders operation. — Intra- ()eri-
toneal shortening of the round ligaments. — Vaginal hystero-
jiexy.— Abdominal hysteropexy. — Latero-versions and lat-
ero-ttexions. — Prolapsus. — Inversion.

CHAPTER XXIV.
Diseases of the Uterus, Continued 261

Benign neoplasms. — Myxoma, glandular polypus. — Fibro-
mata. — Myomectomy. — C<i4iotomy. — Abdominal hysterec-
tomy.

CHAPTER XXV.

Diseases of the Uterus, Continued 276

Malignant neoplasms. — Cancer of the uterus. — Cancer of
the cervix. — Vaginal hysterectomy. — Cancer of the corpus
uteri. — Sarcoma.

CHAPTER XXVI.

Diseases of the Fallopian Tubes 292

Malformations. — Salpingiti.s. — Acute catarriial and puru-
lent salpingitis. — Interstitial salpingitis. — Abdominal aal-
pingo-oophorectomy. — Vaginal salpingo-oophorectomy. —
Pyosalpinx. — Hydrosalpinx. — Ha-matosalpinx. — Atrophy of
the tube.

CHAPTER XXVII.
Pelvic Inflammation 309

Pelvic cellulitis.— Pelvic abscess. — Pelvic peritonitis.

CONTENTS. 5

CHAPTER XXVIII.

Diseases of the Ovaries 320

xMalfoinmfcions.— Displacements.— ProIapHe of the ovary.—
Hernia of the ovary.— Hypera-mia and haanatoma.— Acute
oophoritis.

CHAPTER XXIX.

Diseases of the Ovaries, Continued 330

^ C'hronicoophoricis.—Neopksms.— Cysts of the ovaries. -
Small residual cysts. -Follicular cysts.— Cysts of the corpus
luteum.— Tubo-ovarian cysts.- Proliferatingglandular cysts.
—Proliferating papillary cysts. — Dermoid cysts. —Broad
ligament cysts. —Ovariotomy.— Solid tumors.

CHAPTER XXX.

Ectopic Gestation ^ qkc

Classification. -Tubal pregnancy.— Abdominal pregnancy.

CHAPTER XXXI.
Pelvic Hematocele and Pelvic Hematoma ..... 365

CHAPTER XXXII.
Genital Tuberculosis 3-^2

CHAPTER XXXIII.

Tuberculosis of the Peritoneum 377

PART FOUR.
DISEASES OF THE FEMALE BREAST.

^ CHAPTER XXXIV.

Anatomy.-The Nipples.-Neuroses.-Mastitis -

Mammary Abscess.— Cysts 332

., ; CHAPTER XXXV

Neoplasms ^^^

Cla8sification.-Adenoma.-Fibro-adenoma.-Cvstic adj
noma.-Papilkry cysts. -Sarcoma. -Adeno-sarc^ma. -Car-
: " c.noma.-Scirrhus.-Encephaloid carcinoma. -Colloid car-
cmoma.

LIST OF ILLUSTRATIONS.

FIG. PAGE.

1. Mullei'.s ducts l4

2. Coale.scence of ducts 14

3. Disappearance of septum 15

4. Ap{)earance of fundus and cervix 15

5. Virginal vulva 17

6. Shape and relative length of vaginal walls 19

7. Horizontal section in inferior strait of pelvis 19

8. Varieties of hymen 20

9. Virgin uterus 22

10. Muscular layers of uterus 23

1 1. Sagittal section of female pelvis 24

12. Blood vessels of the pelvis 26

13. Blood vessels of uterus and vagina 27

14. View of uterine appendages .... 28

15. Relations of ureters and uterine arteries to cervix 33

16. Muscles of perineum and pelvic floor 39

17. Shape of perineal body 40

18. Higbei -^ bivalve speculum 79

19. Sims' nculum 79

20. Simpsof "^ound 80

21. Bozeman .-- . essing forceps 81

22. Vulsellum forceps 81

23. Hanks' dilators 82

24. Goodell's dilators 82

25. Skene's endoscope 83

26. Skene's endoscope 83

27. Skene's endoscope 83

28. Double urethral dilator 84

29. Kelly's cystoscope . . 84

30. Kelly's obturator 84

31. Cystoscopic examination of the bladder 85

32. Burrage's cervical speculum 93

33. Intrauterine douche 93

34. Tenacula 94

35. Wire loop curettes 94

36. Sharp curette 94

37. Martin's cutivneous electrode 101

38. Bipolar electrodes 103

LIST OF ILLUSTRATIONS, i

FIG. PA,~.E.

SO. Dysmenorrhieal membrane 1'23

40. P olliciilar vulvitis 145

41. Cystocele and rectocele 155

42. Clover'.s crut'-h 158

43. Stoltz's operation for cystocele and Hegar'-i operation for rectocele 159

44. Operation for incomplete laceration of perineum Itil

45. Operation for laceration of the perineain and sphincter ani 162

46. Complete laceration of perineum extending into recto-vaginal

septum 164

47. Diagram of o})eration for simple rupture of perineum 165

48. Diagram of oj)eration for complete rupture of perineum 165

49. Tail's flaj) splitting operation for incomplete rupture of perineum 166

50. Tait's Hap splitting operation for eom[)lete rupture of perineum. 166

51. Flap splitting operation -appearance of wound and introduction

of sutures 167

52. Hegar's colpo-perineorrhaphy 168

53. Hegar's operation for complete laceration of the perineum 16')

54. Emmet's denudation in colpo-perineorrhaphy 170

55. Emmet's colpo-perineorrhaphy —sutures partially inserted 170

56. Atresia of the vaginal outlet 172

57. Double vagina 174

58. Operation for vesico-vaginal fistula 187

59. Des^elopment of the genito-urinary tract in the female 208

60. Uterus unicornis 209

61. Didelphic uterus and divided vagina 209

62. Uterus duplex . . 210

63. Two-cliambered uterus 210

64. Atresia of the cervix uteri 211

65. Unilateral laceration of the cervix 213

66. Bilateral laceration of the cervix, with eversion 214

67. Multiple stellate laceration of cervix 215

68. Edebohl's speculum 217

69. Lacerated cervix — surface denuded and sutures passed 218

70. Lacerated cervix with sutures tied 218

71. Erosion of the cervix 226

72. Amputation of cervix 238

73. (iehrung's pessary 243

74. Anteflexion of uterus with retropo'jition ... 247

75. Hodge pessary 250

76. Albert Smitli })e.ssary 2i';0

77. Thomas retroflexion pessary . 250

78. Procidentia uteri .... 254

79. Incomplete inversion of uterus 258

8 LIST OF ILLUSTRATIONS.

FIC. PA(iF.

80. (Complete inversion of uterus 2.')8

81. I'olypus Mimulating complete inversion of uterus 2.58

82. Fibrous polypus of uterus 2.59

8.3. Interstitial fibroids of uterus 262

84. Subserous and submucous fibroids 262

85. Pedunculateu fibroid of uterus 263

86. Fibro-cysHc tumor of uterup 264

87. Application of litfntures in hysterecto.ay 274

88. Cylindrical epitiieliomn of the cervix uteri 278

89. Epithelioma of cervix uteri, vagina and bladder 279

90. Vaginal hysterectomy with ligature 283

91. Vaginal hj'sterectomy with clamps 285

92. Medullary cancer of body of uterus 288

93. Salpingitis with pelvic peritonitis and adhesions 295

94. Pyosalpinx and ovarian abscess 306

95. Ovary with dropsical follicles 328

96. Diagram of structures in and adjacent to the broad ligament. . 332

97. Small multilocular cyst 3.34

98. Microscopic examination of fluid from ovarian tumors 335

99. Papillomatous ovarian cyst 3.36

100. Dermoid cyst, showing plates of bone and long tawny hair. . . . 338

101. Unilocular cyst .340

102. Diagnosis of ascites from ovarian tumor 346

103. Ligature of pedicle in three sections 351

104. Staffordshire knot ... 352

105. Spindle-celled sarcoma of ovary. . . 355

106. Retro-uterine hannatocele 366

107. Primary tuberculosis of the tube.s and ovaries 373

lOS. Fibroadenoma of the breast 391

109. Proliferous cyst-adenoma. . 392

110. Section of a breast with scirrhus carcinoma 395

111. Scirrhus carcinoma of the breast 396

Medical and Surgical Gynaecology.

PART ONE.

PRINCIPLES OF GYNAECOLOGY.

CHAPTER I.

INTRODUCTORY.

The term Gynaecology is understood to designate the
afPections of the genital organs in the i ^male sex otlier
than those immediately connected with pregnancy, child-
birth, and the puerperal state, but clinically it is difficult
to disassociate the one from the other, as the accidents
and diseases arising diiring that critical period are the
most fruitful sources of diseases peculiar to women.

Great progress has been made in every domain of
medicine. Every branch of it has felt the new impulse,
but in no department has it been so marked as in this one.

In tracing the development of modern gynaecology it
is difficult to keep pace with, or even estimate the rapid
l^rogress it has made. Twenty years ago it was a mere
appendage to obstetrics, the teaching of it being limited
to a few lectures at the end of the session ; to-day it is one
of the most honored chairs in every medical curriculum.
The teachings and practice of to-day bring hope and
comfort to many a home which in days gone by would
have been the possessor of a wife or mother or daughter
doomed to hopeless invalidism under the label of " weak
spine," "spinal irritation," "chronic ovaritis," "cellulitis,"
" irritable womb," and the like.

10 MEDICAL AND SURGICAL GYNyECOLOGY.

Tlin/U^h itH advnncoK tlioro hns been given to suigery
the oj)erfvtion for the removal of pelvic tumors, nnd to-day
ovarian cysts are removed wiHi a mortality far below any
other cajntal operation. The ingenioxis position of Tren-
delenber!.? has rendered easy the total extirpation of uterine
fibroids: the patiiology and op(>rative treatment of extra-
uterine jjregnancy to-day snatches women from what then
would have been considerotl the very jaws of death.

Vesioo-vaginal and recto-vaginal listuhe yield readily
to operation and permanent relief can with almost certainty
be promised. Uterine cancer, the presences of which until
very recently signed the death-warrant of the sufferer, is
now treated with such good results as to far surpass the
most sanginne expectations, offering at least an increased
term of life and sometimes the total eradication of the
disease. Chronic endometritis, once so intractable, now
readily yields to the use of the curette.

To gyniecology is due many of the advances in general
surgery. From it has sprung the scientitic trentment of
appendicitis, the surgery of the kidneys and gall-bladder,
as well as that of all intestinal and visceral lesions.

While recounting the triumphs recorded, it must
always be a pleasant task to acknowledge the deejj debt of
gratitude which gynecology owes to Sir Joseph Lister,
for without his scientitic discoveries and brilliant teaching,
the successes of modern pelvic and abdominal surgery
could never have been won, and the announcement made
that he has been raised to the peerage, has been received
with the most lively feeling of satisfaction throughout the
medical profession, which is proud to recognise him
among its members and on which he has already shed so
much lustre.

While recognising that pregnancy and child-birth are
fruitful sources of diseases in women, it is not by any
means the greatest source. It is, therefore, the duty of
every student of the subject not to be content with a

INTRODUOTORy. 11

'.:uowl(Hlgu of the aotunl existence of diHense, but to study
out the etioloj^icnl fnctors nnd the methods by which they
mny be nmeiiorated, li^ssened, or prevented.

A hir^e factor m.iv be found in faulty echication. Tlie
chief strain of reproducing falls np'jn woman. She bears
the burden of gestation, parturition, lactation, and of
maternity, and for this great end she needs the most
perfect physical development. The growth and well-being
of her body should, therefore, be as carefully looked after
as the growth and well-being of her mind, a concorddt in
female education not sufficiently maintained. During
girlhood days too much time is spent in the school-
room, or in poring over books at home, when she
should be at play. Just as womanhood is asserting
itself, come the competitive examinations, which select
the brightest and most intellectual, and who are often
the most delicately constructed, for i)romotion to the high
schools and universities. Two to four or even five years,
most precious years for them, years needful for the perfect
development of not oidy their general health but for the
development of the reproductive organs and for the
establishment of their functions, are spent in antagonism
between brain growth and body growth. Possibly after
leaving school, the worn out, rest-needing girl launches
into the married state, and this young girl, wilting under
the double strain of wifehood and motlierhood, remains
ever after an invalid with her uterine and ovarian diseases,
or with nerve prostration and its jjrotean mimicry of
uterine symj)toms.

Undoubtedly some of the worst forms of disease arise
from specific infection by husbands, giving rise to sterility,
miscarriage, oophoritis and salpingitis of every kind and
degree, pelvic and intestinal adhesions, chronic ill-health,
and even death.

Probably the most common of all causes is the pre-
vention of conception. By the methods adopted so much

12 MEDUAL AND SURtHCAL (lYN. ECOLOGY.

en^orj^tMiiiMit and hy[)('ri)lnHifi and diHor^niiization of the
uterine HtructurcH and appendages are apt to take plairo,
that their hi^alth breaks down and they bee.onie (H)iupara-
tive invalids. It is well to remembc^r, when consitU^rin^^
such important factors, that history does not forget to
repeat itself. In the time of Julius Cjesar, celibacy and
childlessness became more and more common; criminal
abortion was frequently practisc^d; pregnancy was con-
sidered a mar to beauty, and the Roman empire, for the
want of tncn, was overrun by northein hordes. Greece,
once the pride of the world, at last (juailed before the
Roman Eagle and became a vassal because she could not
brook to have her classic tastes interrupted by family
cares and family ties.

It cannot but be recognised that those who are the
guardians of the public health are the guardians of the
nation's prosperity and greatness, and this is doubly true
in the case of the health of women who are to become the
mothers of our future men, for unless their health and
strength and well-being are preserved, the brain and bone
and sinc^w of the country will, by progressive decadence,
dwindle towards extinction.

CHAPTER II.

DEVELOPMENT OF THE FEMALE GENITALS.

For a proper understanding of the malformations and
diseases of the female genitals, it is necessary to be able
to trace the various steps in their development.

The ^Volffian Ducts are the first organs belonging to
the genital sphere to api)ear. There is one on either side
of the body and is situated between the proto-vertebral
column and the lateral plates. Originally it is a solid
cylindrical cell mass, but later becomes tunnelled. The
upper end connects with the WolflSan body, the lower end

DEVELOPMENT OF THE FEMALE GENITALS. 13

opens into tlmt pnrt of tiio nllantoiH situatt'd in tlu^ body
of tho embryo nnd communicfttoH with the cloacn. In the
female the Wolffian duct dinappearH mon^ or Ichh vom-
ph^ti^ly, remnantH only of it beinj^ found in the broad
ligannuits.

The Wolffian Bodies are two long prismatic bodies,
one on either side of tlu^ median line, nnd appear shortly
after the Wolffian ducts. The lower end is fasttnied to
tlu^ inguinal region by a liganuMit, which in course of
time becoini^s the round ligament of thci uterus. These
bodies originate from the mesothelial lining of tlu^ body
cavity, and form at first a row of pear-shaped bodies.
Lat(T they separate from it, acquire n lumen and form a
row of vesicles, each of which soon connects with the
Wolffian du(!t by absorption of the tissue betwecui their
cavities and the bore of the duct. In the femah^ the
Wolffian body is transformed into Jiost'tiviullcr's oiujdii or
the pdroniriintt and stray tubes found between the
parovarium and the uterus.

The Ovaries. The sexual glands are situated on the
inner side of the Wolffian body, to which they are fastened
by a fold of peritoneum, the nicsordnKiii. The k)wer end
is fastened to the Wolffian duct by a ligament which later
beconuis the li<j(ini<'td of tlw ovarij. The blood vessels
enter originally at the upper end of the mesovarium
enclosed in a fold of peritoneum, which in time becomes
the iiifundibnlu-ju'lvic ligament. To the outer side of the
mesovarium is attached the mrsosdlpinx or mcsciitrrij of
the tube which later is calh^d the ((l(( vcsju'i'filioni's (bat's
wing), and contains the remnants of the Wolffian body,
particularly the parovarium. The ovaries are also subject
to descent. At birth they are above the ilio-pectineal
line, and descend into the pelvis during the first two
or three months of extra-uterine life.

The Mullerian Ducts appear soon after the Wolffian
body as an extended ridge of thickened mesothelium along

14 MEDICAL AND SURGICAL GYNECOLOGY.

tho outer Hide of tlio upper (muI of the Wolffifui body. The
lower part is nt first formed by n solid eolumii of cells
v" ioh Inter becomi^s tuniu41ed so ns to form n tube. They
form in the female the Fidlopiiiii tubes, ulie uterus, and
vagina.

Fi<;. I. — Mui.i.kk's nucrs. Kk;. 2.— C(iai.f.scknck of Ducts.

The Fallopian Tubes are formed of that part of tin?
Mullerian ducts which lies above tho round ligament of
tho Wolffian body. The cells of tho wall form the fibrous
muscular and mucous coats of tho fully developed tube,
and fringes forming the jimbriiv grow out around tho
abdominal op(^niiig.

Uterus and Vagina. The part of tho Mullerian ducts
b(4ow the round ligament, together 'with the lower end of
the Wolffian ducts, forms a quadrangular cord called the
(jcniUd cord. The walls between tho Mullerian ducts are
absorbed and thus but one canal is formed. The genital
cord is further developed so as to form the uterus above
and tho vagina below. While the fusion of the Mullerian
ducts is incomplete they are separated above, forming tho
two cornud of the uterus, but lator form but one sac with-
out horns. The Mullerian ducts open into the lower part
of the nrachus — that part of tho allantois which is
included in the body — and later forms the bladder. This
lower part, situated below the openings of tho Mullerian
and Wolffian ducts is called tho iiro-f/cnifdl sinus. Orig-
inally this sinus opens into the cloacd, but later the
septum is formed, dividing the cloaca and thereby separ-
ating the uro-genital sinus from the rectum and the uro-
genital opening from the anus, thus forming the perineum.

DEVELOPMENT OF THE FEMALE OENITAL8.

The Urethra in (liftVn>iitinti'(l an a Hpocial organ from
the bladder, with which it hcrotoforo formed one .sac ealU«d
tht* urachuH. Tlio uro-gonital HinuH wiiieii Hoomod to be
the continuation of tho bladch^r, now appi^irH as tho
continuation of thi^ vaj^ina antl forniH the n'sflhiilr. Tho
vagina is next separated from the uteruH by the formation
of a ring and about the name time tlie cervix is being

Fig. 3.— Disappearance nr Septum.

4.— Appearance oi-- Kunuus and Cekvix.

diHtinguislied from the body of tlie uterus. Tlie vagina
becomes mucli wi(U^r, its rolimins and rn(/(i' make their
appearance, and later the lii/mcn is formed by ;. develop-
ment of the posterior wall of the vagina.

The Vulva. Originally the uro-geuital and digestive
tracts open into one common cavity, the clo(U'<i. The
cloaca opens on the surface of the body by n slit calU^l tho
cloacnl opening. In front of this opening app.ears an
elevation called the (fcnitdl iuhn'vlc, surrounded by two
folds calked the f/cniffd folds. A groove is formed on the
lower surface of the genital tubercle, called the (/cnitdl
fur'vow. The genital tubercle becomes tho clitoris; the
genital folds, the l((l)i((. majora; the edges of the genital
fold, the l((hia minora, a fold of which surrounds tho
clitoris forming the prepuce. The separation between tin
uro-genital sinus and the rectum is completed; the genital
folds grow together at their posterior end and unite
with the partition or septum between tho uro-genital
sinus and the rectum to form the perineum.

16 MEDICAL AND SURGICAL GYNAECOLOGY.

CHAPTER III.

■ *

ANATOMY.
THE PELVIS.

Four bones, two ossa hmnmincifa, the sacrum, and
the coccyx take part in the formation of the pelvis. The
pieces comprising the innominate bone — the ilium,
iscltiiini, nnd pubis — in early life are distinct, but later are
fused into one. The space included within these bony
walls is divided into two parts, the part above the ilio-
pectineal line is called the false pelvis, and that part
below, the true pelvis. The true pelvis is a short curved
canal, whose superior strait, inlet or hrini is bounded
behind by the promontory of the sacrum, laterally by the
ilio-pectineal lines, and in front by the ujjper margin of
the pubis. The inferior strait or outlet is bounded behind
by the tip of the coccyx, laterally by the tuber-ischii, and
in front by the lower border of the pubic bones.

The plane of the inlet, when the body is in an erect
position, forms with the horizontal an angle of about
forty-five degrees. The aju's of the inlet if directed up-
ward would pass through the umbilicus, and if prolonged
downward would touch the tip of the coccyx. 7Vie axis
of the outlet if extended upward would meet the prom-
ontory of the sacrum. The bones are united with one
another by four articulations, one in front between the
two pubic bones, the synij)htjsis pubis; two laterally
between the lateral surface of the sacrum and ilium, the
sacro-iliac; and cue behind between the sacrum and
coccyx, the sacro-coccy</eal. In addition to the ligaments
which bind these bones together, there are two important
ones closely associated with the boundary of the true
pelvis— the (jreater and lesser sacro-sciatic ligaments.

ANATOMY.

THE FEMALE ORGANS OF GENERATION.

The Genital Organs are divided into two groups: the
external to which belong the mans veneris, the vulva and
the vagina; and the internal to which belong the uterus,
the Fallopian luhes, and the ovaries.

The Mons Veneris lies in
front of the pubic bones just
below the hypogastric region.
It is composed of stout integu-
ment, abiindniitly suj^pliod
with crisp hair and a thick
cushion of subcutaneous adi-
pose and areolar tissue. The
liair is limited above and does
not extend to the umbilicus as
i'.i man.

The Vulva forms and sur-
rounds the entrance to the
genital canal. It is made up
of the labia niajora, with the
fonrehetfe; the labia minora
with the clitoris ; the vestibule
with the bulbs ; the fossa

Fig. 5. — Virginal Vulva : i, la!>ia majora ; • j • 1 ii T

2, fourcheite; 3. lal.ia.ninora;4,Slans naVICUlariS; aud the VUlVO-
ciiloridis ; 5, meatus iirinarius ; 6, vesli- "77 I

luile; 7, entrance to the vagina; 8, Vaf/in((t (fKUiaS.
hymen ; 9, orifice of H.irtholin's ghmcl ;

10, ant. rior commissure of labia majora ; The Labia MajOra afC tWO

11, anu ; 12, blind recess; 13, fossa •*

navicularis; 14, body of clitoris. COUSpicUOUS loUgitudiual folds

of integument Dne on either side of the median line,
extending from the mons veneris to within about an inch
in front of the anus. The outer surface; is covered with
pigmented epidermis and scattered hairs; the inner sur-
face is smooth, rose-coloured, more delicate in texture, and
where least exposed partakes of the character of a mucous
membrane. The point at which they unite in front is
called the anterior commissure, and behind the posterior

18 MEDICAL AND SURGICAL GYNAECOLOGY.

commissitrc. Immedintely within the posterior commis-
sure, a cresceutic fold extends trnnsversely, the fourchcttc.
The space between the fonrcliette and the posterior com-
missure is the fossd ii(iriciil((ri)^. Each labium includes
A'ithin it areolar tissue, uustriped muscle fibre, and con-
siderable fat, and together are the homologues of the
scrotum in the male.

The Labia Minora or Nymphae are two thin diverging
folds of delicatt^ skin on the inner side of the labia majora.
Just before meeting in front, each divides into two leaf-
lets, the outer or upjier leaflet of each pasting over the
clitoris to unite and form the prepuce; the inner or lower
leaflet passing beneath to form the frciuun. They extend
back to about half way between the clitoris and the
posterior commissure, gradually merging into the sides of
the vaginal orifice.

The Clitoris is a small cylindrical body about an ip.oh
long situated in the median line below the anterior com-
missure. It is composed of the (/kins, a pointed tubercle
which forms the end and is the only part visible, and the
bodij which consists of two distinct corpovd cavernosa
attached to the symphysis by the suspensory ligament and
by their crura to the rami of the pubes. It is supplied
with erectile and muscular tissue, in diminutive similar to
that of the male, and has a prepuce and frenum formed by
the labia minora. The blood supply comes from the
internal pudic, the same as in the male, and the lymplKdics
empty into the inguinal glands.

The Vestibule includes the triangular space between
the clitoris, the labia minora, and the entrance to the
vagina. Its smooth mucous surface is broken in the mid-
lino about one inch behind the clitoris, by the urethral
opening or mecdus urinarius.

The Vestibule- vaginal Bulbs are two leech -shaped
organs, one on either side of the vestibule and together
are equivalent to the bulb in the male urethra.

ANATOMY.

Fig.

-S..ape and relative length of
vaginal walls.

The Vulvo-vaginal or Bartholin's Glands nro two

small round or ovnl bodies situated on either side of

the entrance to the vagina at the posterior end of the

vestibulo - vaginal bulbs_
They are r a c e ni o s e
glandsjSecreting a mucous
fluid.

The Vagina is a mus-
culo-membranous canal
lying chiefly within the
cavity of the pelvis and
exttuuling between the
vulva and the uterus. It
pierces the pelvic floor at
its lower end and is in
relation with the blad-

d«^r and urethra in front and with the rectum behind.

The (uis while corresponding in general with that of

the pelvic cavity, presents a

double or S-like curvature.

When not distended it is fold-
ed, the anterior and posterior

walls being in contact so that

in cross section it resembles in

shape the letter "H." When

distended it is in the form of a

truncated cone, the apex at the

vulva. The lower end dips into

the vulva by a circular opening

surrounded by the consfrietor

Vdjfina' muscle. The upper

end forms a cup to receive the

vaginal portion of the uterus,

and in its adaptation to the

parts forms a shallow pouch in •^■fcr"X'inL:;i;"'s;;:!i;'of^!:

front and behind, the autrrior ^^In^Tr:^^^^^^:^ J^'

MEDICAL AND SURGICAL GYN^COI.OGY.

niul ])osferi()r forniccs. In the adult virgin the anterior
wall is about two and a half inches long and the posterior
about three and a half inches, but after child-birth these
dimensions are increased.

Fif" 8.— Varieties OK Hvmen : Virgin hymen, i,conunonesl form (annular); 2, liynien after
coitus ; 3, after delivery ; 4, fimliriate liynien ; 5, hymen with narrow slit ; 6, cribriform
hymen ; 7, hymen with septum ; 8, horseshoe form.

ANATOMY. 21

In Hfrurfiirc the whUh of tlio vnj^iim consist of a
silicons mcmbrfvno, covmul by stratified stiuanivHis opitlui-
lium nnd i)ossossins numorous papillio; a muscuhtr layer
inado up of longitudinal and circular fibres; and a_///>/-o?/s
tunic of rich fibro-clastic tissue derived from a prolonga-
tion of the recto-vesical fascia. The mucous membrane of
the anterior wall is thrown into folds or rmja' and a less
distinct formation is found on the posterior wall. They
are called the (inferior and posterior eolnmns.

The blood supphj is derived from the vaginal, uterine,
vesical, and internal pudic arteries. The Jijmphdtirs
from the lower fourth join the lymphatics of the external
genital organs and end in the superficial inguinal glands.
The lymphatics of the upper i)ortion proceed outward with
the broad ligament and joining with those from the
oviduct and ovarie.'; terminate in the lumbar glands. The
nerves are derived from the inferior hypogastric plexus of
the sympathetic and from the fourth sacral and pudic
nerves.

The Hymen is a fold of mucous membrane which
closes more or less completely the lower opening of the
vagina. It varies much in shape, the most common being
two lateral strips which touch one another in the middle
line. Sometimes it forms a ring with a round opening,
sometimes a crescent, and sometimes it is represented only
by a low circular or crescentic ridge, and not unfrequently
the border is indented, which condition is not to be con-
founded with a iacerated hymen. At coition the hymen
is usually torn, but at first child-birth it is so destroyed as
to leave only three or four roundish prominences called
the c((niiirnJ<t' mjjrtlformes.

The Uterus is a hollow flattened pyriform muscular
organ situated between the vagina below and the intestines
above, and between the bladder in front and the rectum
behind. It is about three inches long, one and a half
inches at its greatest width, and one inch in thickness.

MEDICAL AND SURGICAL OYN^ECdLOGY.

Of the entire organ, three-fifths belong to the upper part
or hotli/ nud two-fifths to the lower part or neck. The
body is ahnost fiat on its anterior surface but distinctly
convex beliind; the uj)per border is rounded and con-
stitutes the/?///Y//^s,• the lateral borders are slightly convex
and mark the attachment of the broad ligaments. The
neck or vtrvi.r, spindle-shaped in its general outline, is
divided into the vdijinal portion, or that part which
projects down into the vagina, and the snpravcKjimil
portion. The vaginal portion is covered with squamous

Be
Kit;. 9. — ViKGiN Utekus.
A. .Vnterior view. B. Median section. C. Lateral section,

epithet i II tti. the same as covers the mucous membrane of
the vagina, and at its lower end is a transverse or rounded
operung, the os cxterninn or os uteri. That j)ortion of the
cervix in front of the os forms the (interior lip, and that
behind the poi<terior tip.

The interior of the uterus contains a cavity, the uterine
earitij. about two and one-half inches long. That portion
within the body is triangular in shape wlien viewed from
in front, the expaiided base extending between the orifices
of the oviducts and the apex corresponding with the upper
opening of the cervical canal, or os internum. _ _ .-

ANATOMY.

Tluit portion within the c.orvix is fusiform in shape and
on its anterior and posterior walls are found ridges
separated by (h'ep pouclies which go outward and upward
and form the (u-hor niUv or palrmv plirativ of the uteruB.

Structure. The uterine wall is about three-eighths of
an inch thick anil is composed of three layers, a mucous, a
muscular, and a serous. The miirosd lines the whole
cavity and consists of a fKnicd-propria covered by a layer

Fig. io.— AiUtrior Surface of the Uterus, Superficial Layer. I., Ruiiiid liRaiiient ; T,
Tube ; I, iniddle layer ; 2, transverse fibres ; 3. fibres of the rotiml ligament which have
spread over the anterior surface of the uterus ; 4, fibres arising from the posterior portion
of the round ligament which form loose fohls l)efore they join the median fasciculus; 5,
fibres of the cervix uteri ; 6, oblique fibres.

of ciliated columnar cells. Numerous tubular depressions,
the utricular (jlands, lined with ciliated ei^ithelium are
found in it. In the cervix the mucosa is thicker, and in
addition to the tubular follicles, racemose glands lie within
it. Its upper two-thirds is covered with ciliated columnar
and its lower one-tlnrd with stratitied squamous epithelium.
The niHscitlar coat is divided into three layers, an outer
longitudinal which sends prolongations into the oviducts,

MEDICAL AND SURGICAL GYNAECOLOGY.

niul the round, ovnrinn nnd sncro-utorino ligaments; a
middle layer of iuterlaciiij^ longitudinal and circular
fibres, which are in connection with the muscular coat of
the vagina; and an internal traiisverse layer, the lower
portion of which is especially develoi)ed to form a sort of
sphincter at the os internum. The serous codt is formed
by the usual constitutonts of the peritoneum.

Position. The exact position of the uterus in the
living subject is a much discussed question. It may be

Fig. II. — Diagramni.itic sagittal section of the female pelvis. _ u, uterus; r, rectum; s,
symphysis ; v, perineal body ; ii, is beneath bladder. This is the position of the uterus
when the ' ladder is almost empty.

said that the fundus reaches a little above the brim of the
pelvis and lies a little to the right side. With the rectum
and bladder empty, tlie longitudinal axis of the uterus
forms a right or obtuse angle with that of the vagina.

The Supporting Apparatus of the uterus consists of
eight ligaments composed of folds of peritoneum or mus-
cular bands or of both passing from the uterus. The
vesico-utcrine are two small semilunar folds of peritoneum.

ANATOMY. 26

ono on either side of tlio moclinn line and pnHsinfjf from the
bhuhler to the uterus on a kivel witli the iutemnl os.

The sdcro-ufcrine nre fohls of peritoneum passing from
the cervix to become continuous with the serous covering
of the second portion of the rectum. They form the
lateral boundaries of Douf/ldi^' j)oi(ch. Between its layers
unstriped muscle fibres derived from the outer layer of the
uterus extend from the upper part of the cervix to the
second sacral vertebra.

The lateral or broad ligaments are two wide duplica-

tures of peritoneum, one on either side, extending from the

side of the uterus to the pelvic wall, forming a jjartition

between the anterior and posterior pouches. Each jjresents

four borders. The superior or free border encloses the

oviduct as far as its fimbriated end and then diverges

towards the pelvic wall to form the infnmUbnlo-pelvic

ligament. The inferior border is attached below to the

recto-vesical far jia and to a mass of connective tissue

lying at the side of the cervix, called the parametrium or

parametric connective tissue. The internal border is

attached to the side of the uterus, and the external border

to the side of the pelvic wall where it is continuous with

the obturator fascia. This ligament has two layers, an

anterior which covers the round ligament, and a jjosterior

in which there is an opening for the insertion of the

ovary. Between the layers are found the blood vessels,

nerves and lymphatics, together with the parovarium, the

paroophoron, and unstriped muscle fibres which pass from

the uterus to the pelvic wall.

The round licjaments, one on each side, are attached
to the upper segment of the uterus, below and in front of
the oviducts. Each proceeds in a curved direction, first
upward and outward, then inward and forward to the
internal inguinal ring, through which it passes. After
traversing the inguinal canal it emerges at the external
inguinal ring to blend with the tissues of the labium

2(i

MEDICAL AND HUIUIICAL OYN.ECOLOOY.

mnjus. Th(i li^'niiuMit consists of bundlos of oonnootivo
tiH8u^^ mid uiiHtriiH^d inuscK" Hbrt> dorivud from tiu^ utoruH.
It at first runs uiid(^r the aiitorior liiyt^r of tlu^ brond
liKiimont, but nftorwards lias a poritotieal covoring of its
own which, as a rule, stops at the inner rin^. Occasionally
the pouch of puritoiunim accompanies it through the ring,
forming the cdtuil of Nuck, corresponding to the processus
vaginalis in the male.

Fk;. 12.- Hlooil-vessels of the pelvis; the anterior part of t.'ie pelvis has been removed, and
the bladder an<l the anterior vaRinul wall have been partially cut away. The uterus is
drawn up and the Kall-jpi' 'ubes are displaced into the iliac fossic.

Blood Supply . The uterine arteries derived from the
internal iliac pass behind the peritoneum on the posterior
wall of the pelvis down into the parametrium and form
loops in front of the ureters a short distance from the
antero-lateral fornices of the vagina. They then pass up
between the two layers of the broad ligaments following

ANATOMY.

the edges of the uterus ns fnr ns the corriuii, uiul in their
course they send off at ri^lit jin^U'S brmiehes to the
uterus. At the ititenial os brnuclies in front nml behind
form, by nn unnHtomosis, the circular artery.

P"u;. 13. — The ovarian, uterine and vaginal arteries.

The hjinphdlics commence in the endotJielium, those
from the cervix passing to the obturator glands, and those
from the body to the internal iliac glands.

Nerve Supphf. Branches from the second, third, and
fourth sacral nerves join with branches from the hypo-
gastric plexus to form a ganglion on either side of the

MEDICAL AND SURGICAL OYN.ECOLOOY.

corvix. From thin ^an^lioti, brnnchw nro (liHtributtHl to
tlio utcruH, vaK'ini 'i'>'l bladder.

The Fallopian Tubes or Oviducts an^ two loii^
HliMider tubcH which (wtciid from tho Huiu'rior aii^h'H of
th(^ iitoruH witliiii and aloii^ tho free inar^iuH of tho broad
lij^arnoiitH for a diHtauce of from throo to five inches to tho
vi(^iiiity of the ovaricH, where each terminates in n funnel-
8hap(Hl orifice, the itifnndihiilum.

Ea(^li tube is divided into three parts. Tlie isthnivs com-
prises about the inner third, and communicates witli the
uterus by the osliiun internum, an ojjening so small as barely

Fio. 14. — Posterior View of Left Uterine Appendages: i, uterus; a, F.nllopian tube;
3, Fimbriated extremity and opening it the Fallopian tube ; ^, parovarium; 5, ovary ;
6, broad ligament ; 7, ovarian ligament ; 8, infundibulo-pelvic ligament.

to admit a bristle. The amjinlla or middle part is twice as
thick, curved, and follows a 8eri)entine course. Its calibre
will admit a uterine sound. The jimhrim are the outer-
most part, and surround the outer end of the ampulla like
a collar with long flaps. One of these, the Jimhria ovarica,
is attached to the free end of the ovary and forms a gutter.
In the middle of the fimbria) is the outer opening or
ostium abdomvi ale.

ANATOMY. .89

Structure. Tlu^ oviductH nro mndo up of tliroo coats.
The mucouH, contiiiuouH with thnt of tho utoruH, proHonts
numorous lon^itui'innl foldn whivh increriHo in sizo and
comph^xity within thi^ infundibulum, and in lir.od by a
Hinghi layer of (uliatiul cohimiiar (ipithdiuin. The muacuJar
is made up of an inner (circular and an outer h)ngitudinal
layer of uuHtriped muH(!le Hbres continuous with the
muscular coat of the uterus. Tlu^ serous coat consisls of
the peritoneal investment contributed by the upper free
margin of the broad ligament.

The Ovaries are two oval bodtes situated by tlie s'de
of the uterus, bel(.w, beiiind, and to the inner side of the
oviducts. Each ovary appears as an apptuidage on the
posterior surface of th-* broad ligament. The anterior
border alone is attacheil, being inserted there in a hole,
as it were, in the posterior layer. The arched posterior
border 'i id tlx broad surfaces are covered with hexagonal
columnar epithelial cells, the (jcrtuinal epithelium. The
dimensions vary considerably with the individual but
they usually measure one and one-half inches long, one
inch wide, and half an inch thick. The smaller or lower
end of the ovary or uterine pole points toward the uterus,
to which it is united by a Pbro-muscular band about one
inch long, the ovaridu liijaiiient. The upper (uid or tubal
pole after being embraced by the arching oviduct receives
the lower border of the fimbriated extremity of the
oviduct, and is further connected to the wall of the pelvis
by the infundibulo-pelvic ligament through which the
blood supply is conveyed to the ovary by means of the
ovarian artery, a branch of the abdominal aorta.

Structure. The ovary is divided into an outer part,
the parenchymdtous zone or cortex, and an inner, the
vascular zone or medulla. The viortex contains the
Graafian follicles, and the ova, and occupies the outer
one-third of the organ. The medulla embraces the
remaining central portions of the organ into which the

30 MEDICAL AND SURGICAL GYN.ECOLOGY.

V^lood vessels enter through the hilum. The bulk of the
organ consists of peculiarly arranged connective tissue
and of unstriped muscle fibre, the ovar inn stroma, in which
lie embedded the Graafian follicles. Bener '}\ the germinal
epithelium it forms a layer of greater density than the
adjacent stroma, to which the name tnnicd (Uhiujinca is
applied, but it is not an independent envelope. Under
the albuginea is found a zone distinguished by the
presence of small follicles containing an ovum, the so-
called ovisacs or young Graafian follicles. Inside this
zone is found another with much larger Graafian follicles.
The medulla is composed of connective tissue and
unstriped muscle fibre, but much looser in its arrange-
ment, and in this the blood vessels are freely distributed.
There are usually from six to twelve large follicles in
an ovary and it is simply by their increased size that
they seem to form a zone inside the smaller ones.
In growing they push the surrounding tissues aside,
extend deep into the interior of the ovary and at the
same time come closer to the surface, until finally all
tissue between the follicles and the surface is absorbed
aud they are then ready to burst.

The mature Graafian foUicle appears as a clear
elongated vesicle defined from the surrounding tissue by a
condensed layer of ovarian stroma, the theca follicnli,
which by some is described as composed of two layers, an
outer of connective tissue, the tunica fihrosa, and an inner
composed of cells and a tine net-work of vessels, the
tunica propria. Within these are several layers of
epithelial cells, the mcmhrana (/ranulosa, and on one side
these cells form a i)rotruding . ass into the cavity called
the discus prolifcrus. The follicle contains a fluid, the
liq-iior follicnli. In the discus proliferus is embedded the
ovum, about O.B m.m. in diameter, inside of which is
found a fine membrane, the zona pellncida, or vitelline
membrane. The interior is filled with a semi-fluid, the

ANATOMY. 31

vitellus, inside of which there is a small vesicle, the
germinal vesicle, and within this is found a little round
body, the (ferniinal ■ j>of.

On the escape of the ovum the ruptured and partly
collapsed follicle becomes filled with blood. Subsequent
changes lead to the conversion of the follicle into a corpus
luteum, the chief changes in which being produced by the
ingrowth and rapid proliferation of the vascular tissue of
the follicular wall. The history of the corpus luteum is
naturally affected by the occurrence of ijregnancy, instead
of being almost entirely absorbed within a few weekn,
when fertilization takes place it persists until the
end of gestation. It is usual, therefore, to distinguish
between the corpus luteum of menstruation and that of
jiregnancij. The mode of growth is identical in both, the
stimulus of impregnation leading usually to excessive
development.

The Parovarium or Organ of Rosenmuller, a remnant
of the Wolffian body, is situated within tlie two layers
of the broad ligament, between the outer end of the
ovary and the oviduct. It consists of a series of from six
to twelve spiral tubules, lying irregularly parallel, and
made up of connective tissue, unstriped muscle fibre and
columnar ei)ithelium. Additional festal remains in the
form of rudimeiitar tubules are found within the broad
ligament near the ovary and constitute the parooptioron.

URINARY ORGANS.

The Female Urethra is sliort, being only about o^^^,
and one-half inches long, and lies beneath the symphysis
pubis, firmly embedded within the anterior vaginal wall.
It descends from the neck of the bladder in a slightly
curvtnl direction, the concavity being forward, to the
vestibule, where it terminates in the meatus urinarius. It
is surround(Ml by the compressor urethra- muscle and has
a sphincter at the meatus. It is about a quart(*r of an

32 MEDICAL AND SURGICAL GYNvECOLOGY.

inch in dinmetor, but owing to the elastic chnrncter of its
tissues is capable of great distension, a feature of much
advantage in examination of the bladder.

The mucous membrane is covered with stratified
transitional epithelium, and tubular glands occur near the
vesical end. Two small tubes, Skene, s (jlands, lie within
the muscular wall and open into the urethra a short
distance above the meatus.

The Bladder is placed betwc-n the pubic bones and
the vagina and uterus. When empty it is situated in the
true pelvis and is flattened or "Y" shaped; when distended
it reaches more or less into the abdominal cavity and is
ovoidal. The hdse or fundus is the lowest part of the
organ and is connected to the anterior wall of the vagina
and to the neck of the uterus by rather firm connective
tissue. Three openhHjs are found in it. In front is the
internal opening of the urethra, and behind tliere are two
fine lengthy slits, where the ureters open into the bladder.
The triangular surface between these three openings is
called the triijone. The anterior surface has no peritoneal
covering and lies against the pubic bones. The posterior
surface is covered witli peritoneum down to the level of
the internal os. It has three coats, a serous, derived from
the peritoneum; a muscular, composed of an outer long-
itudinal, and an inner circular layer of unstriped muscle
fibre; and a mucous coat which is thrown into folds when
empty. This coat contains numerous lacunar and race-
mose (jlamls, and is covered with stratified transitional
epithelium.

Lifjaments. The bladder has four true ligaments, two
anterior, running from the lower part of the pubis to the
anterior surface, and two lateral, from the outer margins
of the anterior ligaments to the sides of the bladder. The
false ligaments, five in number, are folds of peritoneum.
The two posterior are me vesico-uterine ligaments. The
lateral extend from the iliac fossro to the sides of the

ANATOMY.

bladder, and the siiperior extends from the summit of
the bladder to the umbilicus.

The Ureters are two tubes leading from the kidneys
to the bladder. They are from sixteen to eighteen inches
long and about the size of a goose quill. Starting at the
pelvis of the kidney, they run down parallel with each
other to the brim of the pelvis and there crossing the iliac
vessels slightly below the division of the common iliac

Fig. 15.— Relation of the Ureters and Uterine Arteries to the Cervix : U, uterus ;
Ur, ureter ; A V, uterine artery ; C, cervix uteri ; /', section of the liladiler
at the level of the entrance of the ureters through its walls ; Va, vagina.

arteries, enter the pelvis opposite the sacro-iliac synchon-
drosis. They run on the wall of the pelvis backward,
downward, and a little oiitward behind the peritoneum to a
point near the spine of the ischium. They then bend down-

34 MEDICAL AND SURGICAL GYNECOLOGY.

ward, forward, and inward to converge towards tlie bladder.
They lie outside the internal iliac arteries behind the
broad ligaments, running down to their base and tlien
under them. They cross the cervix from behind at an
acute angle, about one-half inch distant, so as to come in
front of and below it. On reaching the wall of the
bladder they turn sharply inward and run for half an inch
in its wall, finally opening with a sT^nll longitudinal slit
in the interior of the bladder.

The Rectum is formed by the lower end of the large
intestine and extends from the brim of the pelvis to the
anal aperture. It is from six to eight inches long, and
when empty is one and a half inches wide, but is capable
of enormous distension. For convenience of description
it is divided into three parts. The upper or first portion
extends downward, backward, and inward to the third
sacral vertebra, and is covered entirely with a fold of
peritoneum, forming the moso-rectur ' . The second
portion turns forward and extends as far as the tip of the
coccyx, but is covered with peritoneum in front only,
(Douglas' pouch.) The third portion, about an inch
from its end, turns downward and backward at a right
angle to the axis of the vagina to terminate in the anal
orifice. It has no peritoneal covering whatever.

Structure. Besides the peritoneal covering already
described, it has a muscular coat formed of an outer
longitudinal and an inner circular layer of unstriped
muscle fibre. At the lower end the longitudinal fibres are
intimately interlaced with the levator (ini, and inter n<d
antl extermd sphincter muscles. The external sphincter
is a voluntary muscle and surrounds the anal opening. It
is attached behind to the tip of the coccyx, and in front it
blends with the transversus perinei and the sphincter
vaginae muscles. The internal sphincter is only a thicker
part of the circular layer of the rectum and surrounds tl <>
anal canal inside the external sphincter. The mucous

ANATOMY. . 35

coat, thrown into numerous folds when the rectum is
empty, is covered with columunr epithelium and has many
glandular pouches.

Rcldtions. The upper part of the rectum is separated
from the uterus by loops of small intestines; lower down
it is in close contact with the cervix and vagina, and at
the end it forms the posterior wall of the perineal body.

The Pelvic Peritoneum is a continuation of the
abdominal peritoneum and covers more or less completely
the organs in the pelvis. In front it passes from the
anterior abdominal wall to the summit of the bladder,
which it covers as well as the posterior wall down to the
level of the internal os. From there it is reflected over
the anterior surface of the uterus and the fundus.
It then covers the whole of the posterior surface and
extends down behind the posterior wall of the vagina for
about an inch. It next passes over to the rectum, leaving
a pouch between the two folds, Douglas' pouch or the
recto- uterine pouch. From the side of the uterus the
Ijeritoneum passes out to the walls of the pelvis, forming
the broad ligaments.

The uterus and broad ligaments together divide the
pelvic cavity into an antero-inferior and a postero-superior
part. In the anterior compartment or utero-alxloiniudl
jiouch, we find the utero-vesical and round ligaments. Its
lateral parts, ojjjjosite the obturator canal, have been
called the obturator or pord-vesical pouches. The pos-
terior compartment is divided into a central deep part,
Douglas' pouch, and two shallower lateral parts or pora-
nterine pouches. The bottom of these has been designated
particularly as the retro-ovarian shelres. The sacro-
uterine ligaments, one on each side, form the boundaries
between the three compartments. On the side wall of the
para-uterine pouch is seen the ureter running under the
peritoneum. The ovaries project into these pouches and
besides contain loops of small intestines.

36 MEDICAL AND SURGICAL GYNAECOLOGY.

Pelvic Connective Tissue. Loose connective tissue
is found everywhere underlying the peritoneum, forming
one continuous layer. In some plnces it contains adipose
tissue. Just above the symphysis there is a layer, the
pre-])eritone(d fat, continued behind the symphysis as
the retro-pubic fat. Between the base of the bladder
and vagina there is a tight layer of connective tissue
and on the front surface of the vagina there is a loose
layer. A large mass of connective tissue is found on
both sides of the cervix, forming under the broad liga-
ments the p(i7'(i,metri(i. From the parametric region a
thin layer extends between the folds of the broad ligament,
and from there is continued into the iliac fossa and
lumbar region.

The Pelvic Floor. Under this heading there remains
to be considered three important structures, the pelvic
fitscia, the pelvic (Uaphnujm, and the perineal region.

The Pelvic Fascia is a continuation of the iliac fascia.
It is attached to the iliac part of the ilio-pectineal line,
and to an oblique line on the posterior surface of the
pubic bone. It descends on the inner side of the pubes
and ischium about half way down, where a strong sinewy
cord, the lohlte line, or tendinous ai :li, extends from the
spine of the ischium to the pubic bf le. That part of the
fascia covers the obturator internus and is called the
ohturdtor fascia. At the arch the fascia splits into two
layers, an upper, called the recto-vesical fascia, which
bends inward over the levator ani; and a lower, which
follows the obturator internus to the edge of the ischium
and pubes, keeping the name of the obturator fascia. At
the tendinous arch at the upper insertion of the levator
ani, the fascia gives off another layer which runs on the
outer surface of that muscle and is called the anal fascia.
Together with that portion of the obturator fascia lying
below the line, the anal fascia forms the lining of the
ischio-rectal fossa, and is called the ischio-i'ectal fascia.

'rj*!

ANATOMY. 37

The recto-vesicnl fnscia covers the upper surface of the

levator aui down to the base of the bladder, the vagina

and rectum. In front a layer forms the anterior, and on

the side, the lateral true ligaments of the bladder. From

the under surface of the recto-vesical fascia a prolongation

surrounds the vagina, and forms a strong ring around the

vaginal entrance where it joins with the deep perineal

fascia. From the spine a band goes to the rectum, which

follows the rectum down as a sheath and disappears

around the anus. By its distribution the pelvic fascia

forms an irregular fibrous layer under the peritoneal

cavity, strengthening the pelvic floor and giving support

to the organs found in it.

I Pelvic Diaphragm. Under the pelvic fascia is a

horse-shoe-shaped muscular expansion, open in front,

formed by what is generally described as two muscles, the

leiHitor ani and the coccygeus. It is attached above t;>

the jjosterior surface of the pubic bones, to the tendinous

arches of the pelvic fascia, to the front of the spines of

the ischia, and lesser sacro-sciatic ligaments. From these

attachments the anterior portion goes backward and

inward, on either side, some fibres to be attached to the

urethra; some cross the vagina and are interwoven on its

lateral aspects with its structures; some loops go from

side to side between the vagina and rectum, but the

greater jjart joining with the fascial portion goes behind

the rectum, grasping the end curve of that tube and

supporting it. The posterior fibres are inserted into the

side of the sacrum and coccyx.

Function. It strengthens the pel /ic floor and forms a
strong bed on which rests the uterus and bladder. It is
the antagonist of the thoracic diajihragm, being relaxed
in inspiration and contracted during expiration, as may
easily be seen with a Sims' speculum in the vagina. It
lifts the rectum up during defecation and exercises a
similar function for the vagina during childbirth.

38 MEDICAL AND SURGICAL GYNECOLOGY.

The Perineal Region is somewhnt rhomboidal in shape
and is bounded by the rymphysis and descending rami of
the pubes, by the tuberosities and ascending rami of the
ischium, and by the lower edge of the gluteus maximus
and tip of the coccyx. It may be subdivided by a line
drawn across in front of the tuberosities into two jjarts or
triangles, an anterior or uro-yenital, and a posterior or
anal region.

Perineal Fascia and Ligaments. The anterior or
uro-genital region has beneath the skin and adipose
tissue, n layer of dense connective tissue called the
superficial pcrincxd fascia, analogous to that in the male.
Beneath this there is another layer, the deep perineal
fascia or triangular ligament. It has two layers, a
superficial attached at the sides to the rami of the pubes
ischium, and in front to the pubic bones, behind it is
continuous with the superficial perineal fascia and with
the deep layer. The deep layer is likewise fastened to the
rami of the ischium and pubes. In front it is continuous
with the recto-vesical fascia, behind it is continuous with
the anal fascia on the lower surface of the levator ani. It
is jjerforated by the urethra and vagina. Where the
superficial perineal fascia and the two layers of the deep
meet behind, they are fortified by a strong transverse
band, the isehio-perineal ligament. In the anal region
the anus forms an opening in the median line between the
nates, and is there surrounded by its sphincter. Between
the rectum and the ischium is a pyramidal space, the
ischio rectal fossa. '

Perineal Muscles. Situated beneath the superficial
perineal fascia there are three pairs of muscles. The
ischio-cavernosus or erector-cliforidis is attached at one
end to the ramus and tuberosity of the ischium, covers
the corpus cavernosum, and at the other end is attached to
the free part of the clitoris. The hulbo-cavernosus or
sphincter vagina', receives some fibres from the external

ANATOMY.

Hiihincter niul suporficinl traiiBvorsus perinci, pnsHos for-
wnn' on either side nud is attnclied, one part into the
posterior aspect of the bulb, another on the mucous
membrane between the clitoris and the urethra, and
another on the lower surface of the clitoris.
The superfwidl trans-

versiis perinci is attach-
ed to the tuberosities of
the ischia and to the
median raphe. The deep
muscles in the uro-geni-
tal region are not well
developed. They are
the compressor urethra',
the deep tnmsversus
perinei, and the con-
strictor vagina', all situ- S^
ated between the two
layers of the deep perin-
eal fascia.

The Perineal Body
is the name given to
the tissues comprised
between the genital
canal and the rectum,
below the point where it turns backward. In shapr it is
not always the same. Sometimes it is triangular, with the
base down, in some it has an ui^per narrow and a lower
broad part, and in others it is : ^arly quadrangular, or has
the shape of a quadrant of a ci.cle.

In structure it is composed of the posterior ends of
the bulbo-cavernosus, the fibres of the transversus perinei,
the external and internal sphincter ani, and the levator
ani muscles, the ischio-perineal ligament, the jjosterior
part of the superficial and deej) fascia, the anal fascia,
and adipose tissue. It is covered below by the skin,

Fig. i6. — Dissection ol the Muscles of the Perineum
and Pelvic Floor. A. Anus ; li. liulb of the
V.igina ; C. Coccyx ; I,. Larger sacrosciatic
ligament ; P. I'ernical body ; U. Urethra ; V.
V.igina ; Ci. Vnlvo-vaginal gland, i. Clitoris;
2. Its suspensory ligament ; j. Crura clitoridis ;
4. Krector clitoridis muscle ; 5. Constrictor
cunni ; 7. Transversus perinei ; 8. Sphincter
ani ext.; 9, 10. Levator ani; 11. Coccygeus ;
12. Obturatorjext.

MEDICAL AND SURGICAL OYNiECOLOOY.

bohiiul by tho mucous mombrano of tie rectum, nnd
nbovo nnd in front by tho mucous mombrnno of tho vulvn
nnd Homotimes of the vaginn. This body is of great
importance by forming the centre of tho whole perineal
region, and by its muscles, fascia, and ligaments being fast-
ened to the surrounding bones, it bo-
comes the chief support of tho whole
pelvic floor.

The blood supphj by means of tho

internal pudic artery is distributed the

same as in the male. The nerve sui)ply

is distributed from the pudic branches

Fu;. 17.-Trianguiar.si1.-1pe of the sacral plexus and from tho

of perineal body. pudendal branchos of tho small sciatic.

Tho lymphatics lead to the inguinal glands.

CHAPTER IV.

GYNAECOLOGICAL TECHNIQUE.

The number who do not believe it necv?ssar to
observe stringent precautions in operative surgery is
fortunately very small, and is diminishing every day.
The study of bacteriology has placed surgical operations
on a thorough basis. Every surgeon must have a true
conception of the terms sepsis, asepsis, and antisepsis,
and determine nt nil costs to apjily his knowledge prac-
tically to his everyday work, and in order that he may
have a knowledge of the one, and be able to carry out the
other, presujiposes n thorough trnining in the principles
of bacteriology at least. The scientific application of an
aseptic and antiseptic technique can be thoroughly carried
out only by observing every detail, even the most minute,
the utility of which has been proved by bacteriological
research. It is necessary to keep before one's mind an

GYNiECOLOaiCAL TECHNIQUE. 41

cxaltfd idvii of surgical cloaiilinoHH, rtMin'mbfrinK tlmt ns
a chain is no Htron^i'r than its weakest link, ho aHeptio
8ur^'ory is only so far aseptic ns the weakest link in its
chain. Sucei^ss doc^s not apply alone to the Huceessful
termination of larj^e or extiMisive operations, but it ai)plies
e<iually to the lesser details of obstetrical as well ns
gynteeoU)^ical work. In these as well as in the formor,
without that ri^'id attention to surgical cleaidiness, success
cannot be expected to follow, but on the contrary, both
patient and surgeon mny expect to be doomed to disnp-
pointment.

The term sepsis or septic infection includes nearly
all the surgical infections, general or local, resulting from
bacterial invasion. The symptoms as a rule are due not
so much to tluH bacteria themselves but to their chemical
products. When the bacteria have gained entrance into
the general circulation and have multiplied there, the
system becomes more or less overwhelmed with the
bacterial poisons and that condition is called acute
sc pi icivmia. Localization of the pyogenic bacteria in the
organs give rise to multiple abscess formation, and that
condition is called puivmia. The phenomena resulting
from the absorption into the circulation of the products
resulting from the local growth of putrefactive micro-
organisms are included under the term sapnvmid, while
the nbsori)tion into the circulation of tlie products result-
ing from the local action of infective organisms, consti-
tutes an infective toxicmia. General septicaemia or pyjBmia
mny be set up by almost any of the micro-organisms
which have pyogenic i^roperties, but the most frequently
met with in surgical work are the staphylococcus pijofjoies
aureus; the streptococcus pyogenes; and the bacillus colt
communis. Less frequently we have the stttphylococcus
cpidermidis alhus or the staphylococcus pyogenes alhus;
the staphylococcus pyogenes citreus; the gonococcus of
Neisser; the bacillus pyocyaneus, or the bacillus of green

42 MEDICAL AND BUROKJAL OYNiEUOLOOY.

puH; nnd the niicrococrus lanrcohttmi, or (llplorncms
Itnciniioiiio'.

The i)riiicii)al iiiicTo-or^niiiiunH coticfriu'd in sup-
puration are the micro-cocci (Gk. kokkos, a keruol), a
Hinall round body.

The staph i/loroccus (Gk. staph iilos, a bunch of grapi^H)
}>!l<HI<')U's aureus, in more common tlmn any other. It
may be hIiowu on the skin, in the secretion of the mouth,
beneath the finder nails, in water, in the air, and else-
wlu>re. In culture media it forms iarj^e j^olden y(>llow
nuisses. It is the most frequent cause of superficial and
deep abscesses, nnd it lias often b^^en recognized as the
infectious agent in general septicjemia following operations
or child-birth. The other varieties of staphylococci,
namely, the staphylococcus (^pi(h>rmidis albus, and the
staphylococcus pyogenes citreus, differ little from the fore-
going, except as their names imply. The staphylococcus
epidermidis albus being, for instance, found very abundant
on the skin even under normal conditions.

The streptococcus pijof/enes grows in chains (Gk.
strej)tos, a chain) consisting of from four to ten or more
cocci. External inflammations due to streptococci are
characterized by their spreading character and erysipela-
tous redness. It is one of the most frequent causes of
post-operative peritonitis; the pseudo-membranous anginas
of scarlet fever and measles are, as a rule, due to it, and
there is a strong connection between it and the different
forms of liuerperal infection.

The Gonococcus. Much pathological imjoortance has
been attached to this organism, and it undoubtedly plays
an important part in the inflammations of the tubes and
ovaries.

The (liplococcus pneumonic^ is the causative factor in
acute lobar pneumonia, but it is also known to be a definite
pus-producer and has been found in acute abscesses, in
empycBma, in suppurative c litis media, in quinsy, and is

OYN-EC;<)L()OICAL TE(!1INIQIIE. 43

not Hii uncomiuon cause of puerperal and sejitic wound
infections.

The hdcilliiH voli rommiuiin is constantly present in the
fjuces of man and is more oft<Mi than any other tlu^ cause
of acut(> KUpi)urative p(>ritonitiH, especially wln^e there has
betui an opening between the lumen of tlie bowel and the
peritoncfd (ravity.

In practising asepsis w(> aim at bringing about the com-
plete absence of septic material, a condition in its entirety
impossible. Most fresh wounds contain a certain number
of organisms even under a strict aseptic technicpie, but
either tlu^y are non-virulent or present in too small num-
bers to givi' rise to the phenomenon of sepsis, finding
the surroundings inimical to growth and multiplication,
or they are destroyed completely by the natural protective
powcTs of the body tissues.

The maintenance of an aseptic condition is certainly a
most important point to be aimed at in forvnulating a
techni(iue, and when formulated it must not app'y alone
to surgical operations, but to every detail of minor work in
which a lesion in the mucous or serous membranes or in
the skin may permit of the introduction of such micro-
organisms.

In practising nHfisrpi^is we employ the various means
which have been devised for destroying bacteria or in-
hibiting their action, and the agents employed to bring
about this condition are called (mtiscptirs.

Sterilization. Bj' lixis term is meant the process which
brings about the absolute and complete destruction of
bacteria. The ngpnts chiefly used for the purpose are
heat, (Irij and moist, and rhrmicdl (fisinfcvfion.

For carrying out sterilization by means of drji had a
hot air sterilizer is required, and to destroy the ordinary
non-spore bacteria requires their exposure to dry heat at
a temperature of 100° C. for an hour and a half, and where
spores exist, at a temperature of 140°C. for three hours.

■l:..^

44 MEDICAL AND SURGICAL GYNECOLOGY.

Unfortunntoly the procoss at that ti>mi)ornture will dcHtroy
many substances of vegetable^, or animal orij^in, and the
metliod has consec^uently been sui)planted by more sptH^dy
and less risky methods.

Hfrrilization htj vioi'st hcaf. Boiling water is one of
the quickest agents which we jiossess; ijyogenic cocci and
other vegetative bacteria, are destroyed in from one to five
seconds, while anthrax spores succumb in two minutes.

Sterilization hij }<f('(nn is another simple and practical
mc^thod. Several kinds of steam sterilizers have been
recommended, one of the cheapest and most convenient
being the copper sterilizer of Arnold. One of th^ most
ingenious methods of ensuring comjjleto disinfection is
that known as fractional or (liscontinuons sterilization.
It consists in keei^ing the fluid to be sterilized in a steam
sterilizer at a temperature of 1(X)°C. for twenty minutes
on three successive days. By this means any spores which
e8cai)e destruction at tlie first heating will have grown out
into vegetative forms and will be killed by the second
heating. If the process be repeated for a third time, one
can be reasonably sure of a completely sterile fluid.

Steam sterilization is however not ai)plicable to all
objects to be sterilized, as for instance, the hands of the
operator, his assistrait, or the part of the patient to bo
operated upon. For them chemieal disinfection is required.
The ideal chemical disinfection is one that demands a
host of qualifications, and when judged by such a standard,
no single one fills the requirements.

Carbolic acid is a powerful antiseptic but a dangerous
one. Besides being an antiseptic it is also a deodorant
and local ansesthetic.

Corrosive sublimate. The extreme toxicity of this
chemical is well known and some deaths have been directly
traced to its use. It has a strong germicidal power, but
not absolutely so, besides experiments have definitely
provetl that even in weak solutions it injures fresh wounds,

GYNiECOLOGICAL TECHNIQUE. 46

producing when examined under the microscope n distinct
line of superficial necrosis.

Potdssiiiin p('rm(ni(j(()i(itr, in solutions varying in
strength from 1 to 10() to 1 to 10, possesses some germici-
dal power. Other chemical disinfectants such as boric (icUl,
iKiptliol, and salicylic acid are of questionable usefulness.
Tlie day has come • en the use of antiseptics must be
rele^gated to the period before operation, and reliance
placed during operation in the maintenance of an asei)tic
condition.

THE PRACTICAL APPLICATION OF SURGICAL ASEPSIS.

Under all circumstances personal hygienic measures
are (essential, both as to the condition of the whole body
as well as that of the general clothing. It is best to be
provided with an operating sidt after some approved plan
and so constructed as to leave the arms bare. The suit,
previously sterilized, can be slipped on after the removal
of the outer clothing and before the commencement of the
operation. Not only must the operator and his assistants
be thorough in the cicaiisiny of the hands, but all those
who in any way aid in the handling of the materials
employed during the operation. For this purpose Hunter
Robb recommends that the hands and arms be vigorously
scrubbed with green soap and water for ten minutes, the
water used being as hot as can be borne, and changed ten
times. They are then to be immersed for two minutes ia
a warm solution of permanganate of potassium; next they
are to be washed in a warm solution of oxalic acid; next
rinsed in sterilized lime water; next in sterilized normal
salt solution; and finally immersed in a 1 to 500 solution
of bichloride of mercury. Just before beginning the
operation, the hands should be rinsed in sterile salt
solution to rtMuove any excess of bichloride. The use of
the permanganate and oxalic solutions have either never
been used or have been abandoned by many good surgeons
as affording no additional safety.

46 MEDICAL AND SURGICAL GYNAECOLOGY.

One of the newest methods employed for hand disin-
fection is chlorine, produced by mixing household chlor-
inated lime with crystallized carbonate of soda. Its
chemical action is a little obscure, but it is virtually a
production of the so-called chlorinated soda in a fresh and
liquid state and is better known by the familiar name of
Labarraque's solution. It is used in the following way :
After thorough scrubbing with hot water and green soap,
as already described, and the nails carefully cleaned, a small
tablespoonful of the ordinary commercial chloride of lime
or bleaching powder is put in the palm of the hand and
on it is placed a crystal of carbonate of soda or common
washing soda about one inch wide and lialf an inch thick
(of a size that will permit it to be easily rubbed about like
soap). A little water is now added to made a thick cream,
and this is rubbed up and down the hands and arms, and
well under the finger nails, until the little rough grains of
chloride of lime disappear or markedly diminish, or until
the creamy fluid thickens into a pasty mass. This pro-
cedure should last about five minutes, after which the
paste is washed oft' in sterile water. After the final wash-
ing the hands will be found smooth, soft and smelling of
chlorine. If the odor persists after the operation it may
be removed by washing in a one-fifth per cent, solution of
aqua ammonia.

Its efficiency cannot be doubted, for out of forty-two
tests made according to the foregoing method, forty gave
sterile results.

It is advisable to have a patient who is to undergo
some very serious operation, such as an abdominal section,
in bed and under observation for a few days prior to oper-
ation. Light nourishing food should be given until the
last twenty-four hours, when the diet is to be restricted to
milk or broths. The bowels should be moved daily, and
on the night before the operation a purge should be given,
followed the next morning by a rectal enema.

GYNECOLOGICAL TECHNIQUE. 47

The field of operafinn may be rendered prncticnlly
sterile by the following procedures, supposing it to be a
section :

(1) A bath of soap and water and a vaginal douche
daily for three days.

(2) On the evening before operation the abdomen and
pubes are shaved.

(3) The parts thoroughly scrubbed with soap and
water, then with ether, and then with bichloride of
mercury (1 to 1000).

(4) A compress of bichloride (1 to 1000) is afterwards
to be applied, and kept there until the patient is brought
to the operating table.

After being antesthetized and placed on the table, the
field of operation is again scrubbed with alcohol or ether,
next with bichloride (1 to 1000), and finally irrigated with
sterile salt solution.

Trivial operations upon the uterus or vagina should be
carried out with the same due regard for the dangers of
infection. On the evening preceding operation a cathartic
is given; the external genitals are cleared of hair and
scrubbed after the manner of the preparation of the
abdomen, the vagina carefully douched with bichloride
solution (1 to 5000), followed by sterile water, and
the parts carefidly covered over with a large sterile
occlusion pad. On the following morning a rectal enema
is given, and after being anesthetized, the vagina is
scrubbed with a sponge charged with green soap and
water, and after irrigating to remove the excess of soap, it
is washed with a warm solution of bichloride, and then
with sterile salt solution.

Instruments should be so constructed that they can be
readily taken apart and cleaned, and of such material as
to permit of easy sterilization. The method of Schimmel-
busch is by far the most convenient and effective for
general employment, and consists of boiling the instru-

48 MEDICAL AND SURGICAL CxYN^COLOGY.

ments for five minutes in n one-per-cent. solution of
carbonate of soda. Any ordinary dish will serve for the
Ijurpose, but it is convenient to have a specially
constructed apparatus of copper fitted with some sort of
heating apparatus, if stationary, a Bunsen burner. A flat
wire basket fitting into the boiler will facilitate the
introduction and removal of the instruments.

Trays made of thick glass are the most satisfactory
vessels in which to keep the instruments at the time of
operation. By the use of hot water or steam they are apt
to be broken, brt they may be rendered sterile by first
washing them thoroughly with water and then filling them
to the brjm with, or immersing them in a solution of
bichloride (1 to 500), in which they are allowed to remain
for an hour. Just before being used they are washed out
with sterile water' and filled with enough of the same to
cover the instruments.

In the choice of sutures and ligatures certain
points must be taken into consideration. No suture
material will suffice for all purposes, but whatever is iised
the main points to be considered are, that it must be
sterile, smooth and pliable, but not brittle. The substances
commonly employed are surgeon's cable twist silk,
numbers 1, 2, 3, 4 and 5; silk worm gut, fine and coarse;
kangaroo tendon; and catgut, sizes A, B, C, D and E.
For the preparation of silk lufdturcs or siitHvcs, each size
after being cut in appropriate lengths are wound on
sejDarate glass reels. On one reel there should be at least
four heavy ligatures, three feet long; on the second, ten
intermediate or deep ligatures, eighteen inches long; on
a third, ten smaller for superficial ligatures, eighteen
inches long; and on a fourth, ten small, also eighteen
inches long, for fine sutures. The four reels after being
put into an ignition tube and the moutii plugged with
cotton batten, are sterilized in an Arnold steam sterilizer
for one hour the first day and for half an hour on each of

GYNAECOLOGICAL TECHNIQUE. 49

the two succeeding days. Tlie tubes so prepared may be
kept in glass jars, but for safety it is best to re sterilize
what may be required immediately before every operation.

Silk-worm (jut is a substance admirably adapted for
suture material. It is smooth, easily introduced, is non-
absorbable, and resists the invasion of bacteria much
better than silk or catgut. In preparing it for use, the
twisted ends of the strands being cut off, eighteen of them
are folded once and placed in a glass tube in which they
are to be kept. They are then sterilize.l after the manner
described for the sterilization of silk ligatures.

Cdffiut is, in many ways, the ideal material for sutures,
but unfortunately there is no method of rendering it
absolutely sterile. Notwithstanding the most careful
preparation, suppuration sometimes follows its use. Many
well known surgeons, having sufficient confidence in their
methods of sterilizaticm, use it not oidy for sutures but
for small and even large i)edicles. The following are a
few of the most reliable methods for its preparation:

(1) The raw material is placed in ether for seventy-two
hours; next in an aqueous solution of bichloride of
mercury (1 to 1000) for twenty-four hours; next in oil of
juniper for forty-eight hours; after which it is to be
transferred to absolute alcohol.

(2) After being in ether for twenty-four hours, it is
transferred to a solution of bichloride (1 to 100) in eighty
per cent, alcohol, and changed daily for three days; after-
wards it is preserved in absolute alcohol.

(3) After being soaked in ether for twenty-four hours
it is wound in three feet lengths on reels, and jjlaced in
botth^s plugged with cotton batting. The bottles are then
placed in a water bath and heat gently applied until the
alcohol boils for five minutes. The boiling process is
repeated for three days after the method of fractional
sterilization.

50 MEDICAL AND SURGICAL GYNyECOLOOY.

(4) The catgut is put in ether for a j^e. od of from two
to seven days, according to tlie size of the gut, the ether
being changed once. It is then transferred to a solution
of bichloride in alcohol (1 to 500) for from two to seven
days, after which it is i)reserved in a solution made by
dissolving two ounces of iodoform in four ounces each of
alcohol and ether.

(5) Five volumes of the formal of commerce with from
forty to one hundred volumes of formaldehyde are turned
into one hundred volumes of distiiieJ water. The threads
to be sterilized are placed in a small i^ask in a glass and
filled with the solution until the mouth cf the flask is im-
mersed, the top of the glass being protected with filter
paper moistened in a solution of formalin (5 to 100). It
is kept at the temperature of the room for twenty-four
hours. The formal is re^jlaced by alocliol, which dissolves
the little formalin remaining, and after decanting again the
flask is filled with alcohol and covered with the formalin
filter paper. This method is advantageous as it requires
no apparatus, no heat, no difficult manipulation and is
applicable to all ligatures, catgut, silk, hair and rubber
material.

(6) Modified Kroniij method. 1. Roll the catgut,
twelve strands, in a figure-of-eight form so that it can be
slipped into a test tube. 2. Bring the tube up to a tem-
perature of 80° C. and hold it at that point for an hour.
3. Place in cumol which must not be above 100° C, raise
it to 165° C. and hold at that point for one hour. 4. Pour
off the cumol and either allow the heat of the sand bath
to dry the catgut or transfer to a hot-air oven at a tem-
perature of 100° C. for two hours. 5. Transfer the rings
with sterile forceps to the test tubes previously sterilized.
In drying or boiling the catgut it should not come in con-
tact with the bottom or sides of the vessel, but should be
suspended or placed upon cotton loosely packed in the
bottom of the beaker glass.

GYNiECOLOGICAL TECHNIQUE. 61

On the part of some surgeons there is nn nnxiety
felt lest the life-time of the catgut may not be sufficient
to accomplish the objects for which it was used.
If absorbed too soon, there is a fear of recurrent
hemorrhage or gaping of an incompletely healed wound.
To overcome this difficulty various methods have been
adopted for hardening it, the principal agents being
chromic acid and bichromate of potash. The catgut is,
as usual, soaked in ether for twenty-four hours; it is then
placed in a one-per-cent aqueous solution of chromic acid
for from twelve to twenty-four hours, according to the
density required; next in a fifty-per-cent solution of
sulphurous acid for twenty-four hours; next in an
alcoholic solution of bichloride (1 to 5(X)) for twelve
hours, after which it is preserved in absolute alcohol.

Kan(f(iro() tendon possesses many excellent qualifica-
tions. It is smooth, pliable, strong, and not too readily
absorbed, from eight to ten weeks being usually required
for its disappearance. After being treated according to
one of the methods described for the preparation of catgut,
it is preserved in a solution of carbolic acid in oil (1 to 20).
When re(iuired, the necessary number are removed with
aseptic forceps, placed momentarily in ether to remove
the oil, then wrapped in a sterile towel saturated with hot
bichloride solution until they are used, when they will
be found clean and soft.

Dressings. When a wound is not to be closed hermet-
ically it is important to apply a dressing which, while
being free from pathological bacteria, will prevent the
advent of micro-organisms fiom the outside and at the
same time absorb the secretions from the wound and jjre-
vent their subsequent decomposition. There is upon the
market to-day an abundance of what is known as "anti-
septic dressings" and "gauzes" which are often of great
utility in the management of wounds when the surrounding
circumstances and conditions render their use necessary.

52 MEDICAL AND SURGICAL GYNECOLOGY.

Good (ihsorhmt cotton in rolls and common chfesc cloth
will suffice for nil ordinary surgical dressings. The cheese
cloth may be prepared by cutting it in lengths of two
yards and boiling for half an hour in a one-per-cent. solu-
tion of carbonate of soda, and then rinsed in sterile water
and rolled up. Atmovtwnt cotton, (jauzcs and l)(in(l<i(/cs,
wrapped in towels, may be sterilized by exposure fo" three-
quarters of an hour to the steam of an Arnold sterilizer,
after which, if not rolled or packed too tightly, may be
considered absolutely sterile. Iodoform (jonzc is occas-
ionally required for various purposes. The gauze, made
ready after the manner already described, is immersed in
an iodoform mixture, prepared by mixing enough castile
soap with twelve ounces of a one-per-cent. aqueous solu-
tion of carbolic acid to make good suds, after which
fourteen drachms of iodoform are added and thoroughly
mixed. Pernio n<j(m(ttc (jduze is not unfrequently used
for dressings, having no objectionable odor in itself and
has the power of diminishing the odor of foul smelling
discharges. It is prepared by saturating sterilized gauze
with a one-per-cent. aqueous solution of permanganate of
potash.

Sponges. Either the ordinary marine sponges or
substitutes made from sterilized gauze are the ones chiefly
used. Marine sponges are more elastic and pliabl(> than
any other material, but unfortunately they cannot be
sterilized by steam without ruining them, and other
methods do not always render them absolutely sterile.
They may be prepared by first pounding them in a muslin
bag to remove all particles of sand and then rinsed in
several changes of water. If so desired they may now be
bleached by placing them for twenty minutes in a warm
solution of ijermanganate of potash (half a drachm to two
pints of water). After being rinsed in warm water they
are them immersed in a warm solution of hj posulphite of
.soda (one and a half ounces to two pints of water), to

GYNJICOLOOICAL TECHNIQUE. 53

wliich Imlf an ounce of hydrochloric acid hos Just hern
(i(l(l('(L and allowed to remain in it until (initc white.
After bein^f thorou^'hly Hoaked in water they are next
plaet'd in a bichloridi^ wolution (1 to 5(X)) for twelvH- liourH,
and after bein^ again washed in sterile water they are
transferred to glass jars containing a three-per-cent. solu-
tion of carbolic acid. Gauze sp(ni<ics may be made by
wrapping absorbent cotton somewhat loosely in squares of
gauze, the corners bcung brought together at the top and
tied with a thread, or they may be allowed to remain tlat,
the edges biung folded under and hemmed.

Drainage. A few years ago nearly ninety per cent, of
all cases of abdominal section were drained, now not more
than ten per cent, are drained, but as it is yet indispen-
sable it is necessary to decide ui)on the safest and best
means. Where tubes are emi)loyt'(l those made of glass
are the best as they can be readily sterilized. When
drainage is absolutely necessary, as in cases of wide spread
injury to the cellular tissue of the j)elvis and it is impos-
sible to check the bleeding, or in cases where a cavity has
been opened, the walls of which can not be entirely
eradicated, or in cases where the pelvis has become in-
fected by the rupture, accidental or otherwise, of a puru-
lent formation, the ordinary glass drainage tube has been
supplanted by iodoform gauze. To make it most effectual,
the gauze is pushed down to the bottom of the cavity,
either inserted in a sausage-shaped bag or in long strips
placed in position by the aid of dressing forceps or sponge
holders, the free ends being brought to the outside through
the abdominal wound or through the vagina, should the
pelvic cavity be opened through that route, or drainage by
that route desirable.

Irrigating fluids. The routine treatment of irrigation
of the pelvic cavity in every case cannot now be considered
a necessary i)ractice. Where the structures are non-
adherent and there have been no special complications,

5-4 MEDICAL AND SUmUCAL OYN.FX'OLOGY.

thoro would hihmii to bi^ no indication for itH (Mni)lovnu>nt,
but lifter till' romovnl of a mass whii'li coutains bloody
fluid, or whi>re there has been a ^reat deal of oozing,
irrij^ation may sometimes be useful. If the fluid whii^li
has escaped be of a septic nature, irrigation is more likely
to spread it further between the coils of the intestines
than to remove it.

In selectiiifif a fluid, it is necessary to endeavor to
secure one that will ^ive the best results with a minimum
amount of harm. The fluid most generally used is plain
water rendered sterile by boiling and when r'^quired for
irrigation may readily be brought to the required tem-
perature, 105° F., by having two vessels, one containing
hot and the other cold water. The jirinciiwl objection to
its ase is that it has a definite deleterious effect upon the
tissues, and to overcome this difficulty, nornud salt
sol lit ion is extensively used. It is so prepared as to
correspond very closely in specific gravity with the normal
serum of the blood. Common salt, in the proportion of
forty-five grains to the pint, is dissolved in sterile water,
and after being put in sterile flasks and plugged with
cotton is sterilized by fractional sterilization. Before
operation, two flasks are re-sterilized and one is kept hot
while the other is allowed to cool, and when they are
required they are mixed to the proper temperature in a
graduated jar containing a thermometer.

The use of strong antiseptic solutions, such as
bichloride of mercury and carbolic acid, must be unhesi-
tatingly condemned, and in the use of mild ones, such as
boric and Thiersch's solutions, it may be said that they
possess no advantages over the ordinary sterile water or
salt solution.

Some form of dry powder is frequently used to dust
over the abdominal wound or after plastic operations, and
the ones most in use are boric and iodoform powders.
The penetrating odor of iodoform is a strong objection to

GYNJICOLOGICAL TECHNIQU— 55

it, nncl it is not to bo forgotten that somo pnticntH nro
t'xtnMnc^ly HUH(H'ptiblo to its toxic efftn^ts, but on the other
hand it in the best germicidal powdc^r in UHe. A coinbiiia-
tiou of iodoform one part and boric acid wevon parts in
an excellent mixture, having the advantage of being non-
irritating to the skin as pure iodoform sometimes is.

INSTRUMENT LISTS.

It is important to write out lists of the instruments
that are used in different operations and to keep them
where they can easily be consulted.

INSTRUMENTS FOK AN ABDOMINAL SECTION.

A8[)itiitor. Nozzles.

Catheters. Retractors, large.
Cautery (l'u<iueliii). " next size smaller.

Forceps, long dressing. Kubber tubing for [jedicle.

" long liii-mostatic. Rubber tubing.

" medium liii'mostatic. Scali)el8.

•• small hiumostatic. Scissors, long.

" bullet. •' short.

" rut-tooth. Sound, uterine.

Drainage tubes. S(»eculum, Sim's.

Irrigator. Sponge-holders.

Needles, large. Tenaculum, straight.

" transfixion, right curved. " curved.

" " left curved. Trocars, large and small.

" " straight. Two Ntilaton's forceps.

Needle- holder.

INSTKUMENTH FOR VAGINAL HYSTERECTOMY.

Catheter, glass. Needles, transfixion, straight.

Curettes, dull and sharp. Needle-holder.

Forceps, dissecting. Retractors.

" lonp^ hit'mo8t«tic. Sealjiels.

•' medium hamostatic. Scissors, long and sliarp-pointed.

" small hii-mostatic. Sj)eculun», Simon's, with handles

•' bullet. and four blades.

Needles, curved, large, medium Sound, uterine,

and small. Sponge-holders.

Needles, transfixion, right curved. Tenaculum, straight.

INSTRUMENTS FOR PERINEORRHAPHY.

Catheter. Retractor, small.

Forceps, hivmostatic. Scalpels.

" long dressing. Scissors, right-angled,
bullet. " left-angled.

" rat-tooth. " straight-pointed.

Needles. Sound, uterine.

Needle-holders. Tenacula.
Nozzle, glass.

MEDICAL AND «U1UHC!AL (lYN/ECDLOGY.

Ciithotor.
Cui'ulluH, (lull and Hhnip.
Diliitoi'H, (litl'ureiit HJ/es.
ForoepH, liiiiiioHtutic.

" It'll^f < I I'OHhI !!{:;.

*' rat-tooth (lre88iiig.
bullet.
Irriyiitor.
NeocUes, asHorted HJzeH.

IN8TRIIMKNT8 FOR TBAOHKLORKHAPIIY.

Neodlo-lioldei'M.

Noz/.lo, j^laBH.

Retractor, Hiiiall.

Scalpels.

HcJHHorH, Htraifflit and curved.

Bound, uterine.

S|>eoulinn, Sim's, or Simon's with

haiulleH and four blades.
Tenacula.

INSTRUMENTS KOR DILATATION OK CERVIX AND CURETTINCJ OK UTERUS.

Catheters.

Catheter, irrigatinj^ two-way.
Curettes, sharp and blunt.
Dilators, three sizes.
Forcei)s, bullet.

" long dressing.

Forceps, rat-tooth.

Nozzles, glass.

Sound, uterine.

SjHiculum, Sims's, or Simon's with

handles and four blades.
Tenaculum.

LIST FOR ABDOMINAL OI'KRATIONS OUTSIDE OK HOSPITAL.

Aspirator.

Instruments in bags.

Basins for instrument*.

Cautery (Piuiuelin).

Coats for doctors and nurses.

Solutions : bichloride (1 to 20).
" crude carbolic acid.

" normal salt.

Crystals of permanganate of potas-
sium and oxalic acid.

Soap and two brushes.

Rubber sheets and ovariotomy pad.

Sterilized towels.

Ether and cone.

Chloroform and inhaler.

Hypodermic syringe.

Brandy.

Strychnine tablets (,5'j grain).

Rubber tubing.

Si)onge8.

Silk ligatures, four sizes (.3 tubes).

Catgut ligatures, three or four sizes.

Silkworm-gut.

Scultetus bandage.

Safety-pins.

Sterilized gauze.

Strips of gauze for dressing.

Celloidin.

Sterilized cotton.

Iodoform gauze.

Iodoform and boric acid powder.

Glass graduate.

LIST FOR PERINEAL AND OTHER MINOR OrEKATIONS.

Instruments.
Leg- holder.
Ligatures.
Sterilized stockings.
Perineal pad.

Douche bag.
Dressings.
Bandages.
Cotton pledgets.

.ETIOLOGY IN (lENEUAL. 57

CHAPTER V.

.ETIOLOGY IN gi:ni:ral.

The causes of the diseases of women arc niniiily
Httributnbl(> to tlio orrors, (lir(>ot or indirect, of modi^rn
life. Tlioy may be tlius clnssifi'/d:

1. Abnormalities produced by hereditary congenital
deficiencies of development. Tho dofectivo heredity
is probably not generally immediate but a gradual
deeleunioii, for tlie most part on the maternal side,
tending, by continuous de^eni*ration, to induce in the
progeny feeble sexual formation. For instance, the first
stage may be found in a woman having a uterus of
moderate development, but contracted at its opening, and
which becomes lacerated in her first confinement. The
offspring, possessing a feebly developed uterus, becomes
pregnant by chance, it may be long after marriage or
after an operation; or she may have a congenitally
contracted upper vagina ; or a tendency to infantile pelvis,
with absence of sexual appetite. She becomes the mother
of one child who has yet a feebler unimpregnable uterus,
with atrophic ovaries and deficient and most likely pain-
ful catamenial discharge.

2. Abnormalities produced by congenital or sub-
sequent arrest of development owing to the effects of
bacterial action. The eruptive fevers, as measles, scarlet
fever, small-pox and probably syphilis also, by the action
of their toxines, directly conveyed to the embryo by
absorption from the maternal blood, destro_y the vitality
and power of growth of the germinal genital cells. After
birth and at any time previous to fail development, these
causes and, along with them tubercalcsis, may effect and
destroy the vitality of the growing cells. The destruction
of vital force in the special germ cells produces arrest of
development, and as a result congenital deficiencies and
arrest of development are found ,in the pvaries, oviducts.

58 MEDICAL AND SUR'ilCAL GYNJICOLOGY.

uterus, vaj.^ina, hymen, or vulva. Should the development
of the genital ridge be deficient or arrested, the ovaries
are so undeveloixnl that they are unable to arrive at their
successive montldy maturity, whence arise amenorrhosi and
sterility. If the growth of the upper part of the Mullerian
ducts ceases, the oviducts are minute or defective, By
the absence of fusion, complete or pat-tial, of tlu^ two
Mullerian ducts in the genital cord, the uterus is double
or bifid. From arrest in one duct and development in the
other, the unicorn uterus results, and, after the normal
fusion, cessation of vital growth may (^ause the uterus to
be diminutive. In a similar manner there may bo two
vaginae, or one defective in size, or no vagina at all.

A uterus, normal in length, but with feeble develop-
ment and deficient in strength, may have a feeble cervico-
corporeal junction and which, as a result, Ik likely to fall and
be converted into the position of anteflexion. Coincident
with this there is usually dericiency in the size of the
opening. Owing to such a condition, the secretions
collect within the cavity, are diflScult to expel, and as a
result there will arise cervicitis and dysmenorrhcea. In
a strong uterus, with a deficiently developed os, there is
liability to laceration at parturition, and if the laceration
bo double, e\ersion of tlie lips and grarular erosion nre
likely to follow. If the fresh raw surfaces of a laceration
absorb septic germs, pelvic cellulitis results. Should the
perineum be deficient in development or rigid, laceration of
it is likely to take place, and when septic infection occurs in
connection with a lacerated cer\ ix, subinvolution of all the
genital structures, as a rule, res ilts. With subinvolution
comes the various forms of uterine misplacements. With
subinvolution and misplacement, aided by special mic-
robes, as those of gonorrhoea or of the imerperal septic
infections, comes endometritis. With its extension to the
tubal mucous membrane, comes salpingitis and ultimately
by overflow of its contents through the fimbriated ex-

.ETIOLOGY IN GENERAL. 59

tromity, arises localized peritonitis or abscess formation.
Thickening of the tunic of the ovary succeeds local
inrtanimatory action and, as a consequence, there follows
painful ovulation and various forms of degenerative
changes in the ovaries.

3. Hereditary constitutional defects in which certain
classes of cells morbidly proliferate forming tumors.
Tlie aetiology of the dermoid tumors is attributable to the
origin and mode of development of the ovfry. From the
mesothelial di ision of the mesoderm the ovary is formed.
The mesothelial layer of the mesoderm is closely connected
with the ectoderm. From the ectoderm are developed the
epidermis and epidermal structures, such as hair, nails,
glands, the eye, and the mouth cavity with the teeth, all
of which structures are occasionally found in the dermoid
cyst. Thus, in the formation of the dermoid ovum, some
ectodermal cells have by inclusion been incorporated with
the mesothelinl layers and, continuing to grow, produce a
cystic tumor with skin-like walls and containing any or
all of the structures formed by the ectodermal layers.

The pdrororian cijst is caused by an embryonic
deficiency of absorption and a subsequent hypertrophic
glandular secretory development of the cylindrical lining
cells which normally remain quiescent in the sexual part
of the female rudimentary Wolffian ducts, sitrated in the
connective tissue of the broad ligaments, and known as
the parovarium.

As to the n3tiology of ovdrian cystomo, in the develop-
ment of the ovary, portions of its germinal epithelium
grow inward and some of the cells become ova while
deeper multiple cells of the same description form the
membrana granulosa. The i)ormal function of these cells
is to conduce to the nutrition and further development of
the ovum. It occasionally happens that the tendency to
continuous proliferation of the cells of this layer is greater
than required and there is multiplication in excess. At

60 MEDICAL AND SURGICAL GYN/ECOLOGY.

the snme time the inner cells rujituro nnd pour their
secretion internally Jirul by such continuous process an
ovarian cystoma is formed which persistently enlarges.
The degeneration being of a type which effects the
develoi)ment of all the cells of Ihis class, the disease does
not attack one follicle alone, but is common to all; hence
the cystoma, on its attainment of some size, is almost
always multilocular.

Mijowa, which is a proliferation of unstriated muscle
fibres enclosed in a connective tissue capsule and usually
multiple, is attributable to absence of pregnancy, from
whatever cause, in a woman of strong sexual development.

Carcinoma or cancer, which is a continuous cell pro-
liferation, of epithelial type, invading the lymi:)hatic spaces
and vessels and always originating in epithelium derived
from the ectoderm or entoderm, has its cause in such sites
and conditions as induce excessive formation of cells of
degenerating quality. Such sites and conditions are
exceedingly common in the chronic granular hyperplastic
face of the lacerated cervix.

Continued irritation from any cause, for instance
of a myoma, may prodv ce a constant proliferation of a
primary or embryonic type in the connective tissue and,
as a result, a sarcoma of the round or spindle celled
variety is produced.

4. The training and effects of education. The long
confinement in-doors during school hours, frequently with
impure air; the absence of exercise of arms and legs,
tending to stagnation of circulation; the stooping posture;
the increased attraction of blood to the brain and great
call upon the mental powers; improper exercise; the
personal competitions culminating in place examination;
all have their deleterious effect and tend to develop mental
at the expense of physical power, and producing as well,
constipation, auiemia, irritable hypersensitive nerves and
derangement of the menstrual function.

iETIOLOGY IN GENERAL. 61

5. Personal habits. That care, so necessary at each
menstrual epocli, is not as scrupulously observed as it
should be, and at times injurious consequences, of a tem-
porary or permanent nature, result. Of all the injurious
influences to which is attributable the great mass of
disease now so prevalent, the greatest is the custom of the
alteration of the form of the body and of the position and
relations of the internal organs by compression of the
lower thorax and abdomc^n, by means of corsets. The
influence is markedly accentuated by the attacliment of
the skirts and petticoats around the waist and abdomen.
In pregnancy the corsets are often worn tight so as to
conceal the condition. Society often demands the ex-
posure of the neck, arms and should(>irs to the suddenly
varying temperatures of heated ball-rooms, corridors,
verandahs, and gardens, while closely associated with
these are, improper diet, irregular meals and late hours.
The influences of absence of marriage, of late marriag(\
and of ineffective marriage, which includes artificial pre-
vention of pregnancy, are highly deleterious.

(). Sexual exhaustion arising from an insatiable sexual
appetite, leads to (h^bility, to weakened nervous system,
and chronic congestion resulting in endometritis.

7. Infectious diseases. Tlie effects of syphilis are seen
in hereditary congenital and in simjjle forms. In the
fornu^r, malformations are present at birth; in the latter
the results, similarly causfMl, may not manifest themselves
for varying periods after birth. The mother may directly
transmit measles, scarlet-fevci, find small-pox to the f(t)tus.
To gonorrhoea is to be ascribed a series of progressive
diseases, which are as liable to be as virulent as they are
continuous. Septicannia, induced primarily by the en-
trance into the system throxigh the blood vessels or
lymphatics of micro-organisms, may, if it does not prove
at once fatal, produce wide spread damage. Tuberculosis
in the geiutal organs may occur by the arrival of the

62 MEDICAL AND SURGICAL GYNECOLOGY.

tubercle bncillus by the intestines, by the blood, or
through the vnginn.

8. Lastly may be mentioned those diseases and con-
ditions due to operative causes, niuong which may be
mentioned the introduction of dirty instruments; the
application of irritants; forcible dilatations; injections of
fluids into the uterus; pessaries; exploratory jiunctures;
and the improper treatment of abortion.

CHAPTER VI.

ANESTHETICS.

The entire civilized world owes a countless debt of
gratitude to Dr. W. T. G. Morton of Boston, the discoverer
of the anesthetic properties of sulphuric other; and to
Dr. James Y. Simpson of Edinburg. who, a year later,
discovered chloroform. Much time has been consumed
in discussing the relative merits and demerits of the two
agents. The views of surgeons regarding their relative
values vary widely, but there can be no doubt each of
them has its advantages and disadvantages.

In the administration of such powerful drugs, the
fact must not be lost sight of, that they are not free from
danger, and in the selection and administration o^ an
anesthetic, the question of safety should dominate all
others. Despite every precaution, and every care taken
in their administration, sudden death occasionally will
occur. For a long time chloroform was enthusiastically
held in favour in this as well as in other countries, but it
has gradually been supplanted by ether, on account of its
greater safety. From statistics collected with the greatest
care, it has been shown that the mortality from chloroform
anresthesia is about one in five thousand, and that from
ether, one in twenty thousand. From careful experiments

ANAESTHETICS. 03

and observations it has been proved that chloroform
exerts a steady, powerful, depressing influence on the
heart, by its action on the heart mus o or its contained
ganglia, and, consequently, a large number of deaths from
chloroform are due to cardiac arrest. When chloroform
paralyzes the respiration, it does so by its direct action
ujjon the resi)iratory centre.

The study of the action of ether on the circulation
goes to prove that the primary influence of the drug is to
stimulate both the vaso-motor centres and the heart. In
etherization there is usually a pronounced rise of arterial
pressure which is commonly maintained, even through a
prolonged narcosis, and may continue after manifest
failure of respiration.

Fatal syncope, by the direct effect of chloroform upon
the heart, is the common cause of chloroform death. On
the other hand with ether, the direct effect of which is to
stimulate the heart, death from syncope is rare.

Notwithstanding the greater safety of ether, there
are c{rciiiiisf(tu<'('s iDlti'cli nuHllftj flic choice of (tiKCfifhciics.
Old people, where the chest has become rigid, do not
seem to respond sufficiently to the demand made upon
them by ether, but bear chloroform well.

Ill obesity also, ether is often not well borne, producing
much excdtement and rt^spiratory irritation, chloroform
being often necessary to secure tranquility of breathing.
In the presence of ovfjditic brain diseoses, including
tumors, the dangers of aiuDsthesia are increased.

Wide spread (dheroma should give to the surgeon, who
desires anresthesia, much anxie'^^v, and when demanded,
chloioform should be given the preference.

In dif«'<ifies of the licart, ether is usually preferable to
chloroform; indeed where the h(^art is very feeble, or the
cardiac muscle degenerated, chloroform becomes a very
dangerous remedy; and where orthoijnoia exists, its use is
never justifiable.

84 MEDICAL AND SURGICAL GYNAECOLOGY.

A mixture composed of nlcohol, one part; chloroform,
two parts; nnd ether, three jmrts; commonly known as the
A.C.E. mixture, if freshly mixed, may be chosen with
advantage in cases of atheroma, obesity, and valvular
disease of the heart. The local irritant effect of ether on
the mucous mmnbrane of the air tubes contraindicates its
use in extensive emphysema, in chronic bronchitis attended
by expectoration, in dyspnoia, and in advanced pulmon-
ary phthisis. In such cases, if anaesthesia is necessary,
chloroform should be employed. In obstructive laryngeal
disease or where there is contraction of the trachea, either
from within or without, the greatest caution must be
exercised, for the irritating effects of ether will increase the
tendency to mechanical asphyxia. Both ether and chloro-
form have a distil ct deleterous influence upon the kidncijs,
but, of the two agents, etlier is the more dangerous. The
great danger arises from swppressiou of urine and death
from ura^.mia. There are L^iome jjatients who, although
ai)parently healthy, liave sensitive bronchial mucous
membranes, show a high rate of respiration in cither
anjBsthesia, and cough, even in deep anjesthesia. In such
cases chloroform should be at once substituted.

Both before and during the administration of ether
or chloroform, certain instructions should be rigidly kept
in mind.

1. Analy7A> the urine, especially before the administra-
tion of ether; also examine carefully the heart and lungs.

2. Examine the mouth for false teeth or foreign boditss.

3. Loosen the clothing to prevent constriction of the
circulation or respiration.

4. Cause the patient to assume the dorsal decubitus,
with the head resting low on a small pillow.

5. Anoint the face with vaseline to prevent irritation
or excoriation.

6. Instruct the patient to close the eyes and to take
deep, full and regular respirations. If excitement or a

ANESTHETICS. 65

dread of danger occurs during the early inspirations, it is
well to drop the mask and, in a few kind words, calm and
encourage the patient.

7. Chloroform must be administered slowly and mixed
always with a sufficient quantity of air. If ether is given,
the precaution is unnecessary and may delay anitjsthesia,
but in case of cyanosis, breatlis of pure air should be
allowed until the cyanosis has disappeared.

8. Do not commence oi)eration until anresthesia is
complete, indicated by paralysis of the palpebral reflex,
and by relaxation of the voluntary muscles.

9. Secure good ventilation.

10. Watch carefully the pupils, dilatation or their
failure to respond to light must be viewed as a sign of
apprc )aching danger.

11. Watch carefully the pulse and respirations. Quick-
ening of the respirations, as well as weak pulse or respira-
tion, may denote that too much aiiffisthetic has been given.
Loud stertor in chloroform anaesthesia is an alarming
symptom, indicating epiglottidean closure of the larnyx.

12. Remove from time to time the mucous which is apt
to accumulate in the mouth or throat by means of a small
sponge on a holder.

13. Watch the color and expression of the face;
lividity indicates asphyxia.

14. Allow no solid food for five hours at least before
operation, nor should liquid food be allowi^d later than
three hours.

15. Very nervous individuals should receive a hypoder-
matic injection of a quarter of a grain of morphia twenty
minutes before the ansBsthetic is commenced.

All plans of administration now in use may be
arranged under two headings: o^x'U (Khiiinisfration,
which admits of the free access of air, and closed <«hnin-
istration, in which the patient breathes out of and into a
bag, with a more or less imperfect supply of air.

66 MEDICAL AND SUROIOAL GYNAECOLOGY.

Open ethorizntion may bo prncticod by simply foldiiip^
ft towel ill the form of n coiio nnd puttiuj^tlio other iusido;
or by making a cone of thick material which fits tightly
to the face, at the apex of which a sponge is placed to
receive the other.

Allis' inhdler consists, essentially, of a series of folds of
muslin on a wire frame-work and surroundcnl by a soft
rubber cover. It allows the air to pass freely through,
mixed with the ether, and, when properly used, does away
with the sense of suffocation and the consequent struggles.

Closed t^thorization is performed by means of an inhaler
such as Clover's or Ormsby's, which are so constructed
that the patient breathes in and out of a receptacle con-
taining ether, the amount of air admitted being regulated
by a stop-cock for that purpose. When ether is first
administered, it should be small in amount and largely
diluted with air, after which the air may be gradually
withdrawn and the ether pushed more energetically. The
patient passes through a stage of bewilderment, the face
becoming flushed, the respirations rapid and the pulse
accelerated. This is followed by one of excitement, which
afterwards passes into a state of muscular relaxation.
While administering ether, the fact must always bo borne
in mind that its vapor commonly kills by asphyxia and
not by syncope, henco, though the pulse is to be watched,
the respirations should be the principal object of solici-
tude, and tlu^ first appearance of dangerous symptoms
should b(> met by prompt and suitable remedies.

Chloroform may be administered by means of a towel
placed over the patie^it's face, but it is best given on an
Esmarch's mask, which consists of a wire skeleton covered
with canton flannel. It fits loosely over the nose and
mouth, thus admitting air freely, while the chloroform is
dropped on it, a few droi)s at a time without its removal.
After inhalation for a few minutes, consciousness is lost,
the conjunctivae becomes insensitive, and the breathing

AN-ESTHETICS. .67

assumes a somewhat stertorous character. Before com-
plete aujusthesia, convulsive movements, accompanied with
cj'anosis, often take place. It is best in such cases not to
straggle with tlie patient, but to discontinue inhalation
until the cyanosis has disappeared. During the entire
period of administration, the finger should be kept over
the temporal artery and the respirations watched. A
patient may die, either on account of asphyxia or on
account of heart failure, the latter being by far the most
frequent cause.

Failure of the pupils to respond to light, or tlieir wide
dilatation is a sign of apijroaching danger. This, together
with paleness of the face, biueness of the finger nails and
a weak, tlickering pulse, should cause the anaesthetist to
at once npply proper remedies.

^A^henever dangerous symptoms threaten, the aufes-
thetic should be discontinued, either wholly or for a time
at least. If the respirations become impaired or the pulse
very weak, it may be possible to finish the operation with-
out further administration. When the symptoms of
resjairatory impediment do not yield promptly, place the
fingers behind the angles of the lower jaw and force the
jaw forward. If the breathing does not then promptly
become normal, seize the tongue with forceps and pull it
forward. If ordinary means do not suffice to restore
breathing, resort must be had to (irtijiciiil rcspiratt'on,
aided by lowering the lu^ad and elevating the body in a
position similar to that of Trendelenberg. These efforts
may be aided by flipping the chest with a wet towel or by
the application of the poles of a Faradic battery, one polo
over the phrenic nerve in the U'^ck and the other over the
diaphragm. The question of the use of drugs in threat-
ened accidents is a very important one. Hypodermatic
injection of ether possesses no advantages, but rather, in
cases of ether anresthesia, increases the difficulty. Alcohol
in the shape of brandy or whiskey is an excellent stimu-

68 MEDICAL AND SURGICAL GYN.ECOLOGY.

lant, but gives best results only when the cardiac failure
results from hemorrhage or other surgical cause. The
influence of hypodermatics of digitalis, or its alkaloid, is
very pronounced, increasing the arterial pressure and the
size of the individual pulse beats. Amyl nitrite, for which
much has been claimed as a cardiac stimulant, has some
effect in increasing the pulse wave, but it must be con-
sidered as a doubtful remedy and used with great caution
in anaesthetic syncope. The best results are obtained from
the hypodermatic injection of strychnia. It causes a
gradual rise of the arterial pressure and an immediate and
extraordinary increase in the rate and depth of respiration.
In order to get the best effect from the alkaloid it is
essential to give it in large doses. To a robust individual,
with serious anjBsthetic heart or respiratory failure, one-
eighteenth of a grain may be given at once.

CHAPTER VII.

EXAMINATION IN GENERAL.

GENERAL OUTLINES OF DIFFERENTIAL DIAGNOSIS.

When a patient presents herself for advice and
treatment, the first essential to a full understanding of her
case, is a complete history. The subject naturally resolves
itself into two parts, the history of the patient f. I the
physienl examination.

THE HISTORY OF THE PATIENT.

The first interview between the patient and the
doctor is an important one, and it is a very good rule to
allow the patient time and oijportunity to state lier case
fully. Not only what is said, but the manner in which it
is said, will give the physician an insight into her dis-
position and character and will enable him to treat her

EXAMINATION IN GENEUAL.

()«.)

mf)n> intclliKriitly mid succoHHfully. The iuv(>Hti^ation
nuiy bt' codvciiii^iitly curried out by observing nnd mnking
note of the t'ol lowing points.

A printed form for ennt^-taking, while not esKential, is
of great advantage. It Faves time and suggv sts objec^ts for
incpiiry, wliieh n.ight bo overlooked, and, besides, is of
gn^nt advantage in the subsequent study of the cases.

FORM FOR CASE TAKING.

Pkehknt Complaints and their Dukation,

1. Hixlory :

Family Hi .story

Previous Diseases

First appearance

Regularity

Duration

Amount and character

Pain, before, during,

or after
Confined to bed
Last appearance

Date. Pregnancy,

/ At full term

9! '

' In head
In back
In abdomen
j^ In legs

During coitus
In sitting
In standing
,In walking

Labor. Puerperium.

.Premature

'^ g j Amount

'■^ < [ Character

^ y I Persistence

> £5 Duration

Appetite

Cause of illness (supposed by
patient)

2. SlalUH PraneiiH :

General Condition

Condition of the Nervous System

Constitution

Breasts

Urination
Defecation

Digestion

Abdomen

Vulva

Pi
H
E-c

Position
Size

Mobility
Shape

Depth of Cavity
'.Secretion

70 MliDlOAL AND SURGICAL GYN.RC'OLOOY.

Pori Ileum

I'HHJtioil

Viiginii

Kliape

Uvoiu\ i^ipimeiits

IjtiuiitU

TllhuM

Density

OvariuM

«1

.Secretion

DouffliiH' I'diich

Internal ()«

BIjk (lor

Kxternal On

Urethra

^Lacerateil

liectiim

Coinpli(;atioiis

Didiiuoiis :

Trtatmeut ami ProiirtiMs :

The age of tlu^ pationt has a cliriHit b(>aring on many
mattiTH. suoli as mrnHtruation and child-boaring, and will
often throw much light on tho nature of the distiase.
Cancor rarely occurs before the thirtieth or fortieth year,
and more often about the time of the menopause.

Social condition and occupation has often a material
bearing upon the disease from which the patient suffers.
It is of the utmost importance to know whether she sijends
her time in sedentary pursuits, or, as a shop-girl, kept
standing or walking about all day long; or, as a charwoman,
whose daily round is one of severe toil <ind often hardship.
Information as to whether the patient is single, married,
a widow, or separated from her husband, is often a
necessary factor in deciding important questions.

Leading symptoms in the case. An important point
is to enquire what brought her to seek advice. In the
majority of cases it will be found that actual pain in some
part or other is the leading symptom. In other cases
pain may be entirely absent, or only i^resent under certain
conditions. Others may sj^eak of a swelling in the
abdomen as the leading feature. It sometimes happens
that the patient complains only of some trivial deviation
from health, yet, if her case be gone into systematically
and carefully, important information will be forthcoming,
which will enable us to suspect the nature of the trouble.

Menstrual history. At the outset, in order to arrive
at a correct opinion as to the contlition of the menstrual

EXAMINATION IN (lENliUAL. 71

function, it iH lUHH'HHnry to nHcortaiii tlu^ normal cluirm't(ir
of iiuMiHtruatioii in the individual, for thrro am ainon^^
woini'U wid(^ individual diH'cnMU'CK consiKtcnt with health.
The [)oints to which attention should be directed are:

1. The (Kjc of rommrurcmcnL Men»trnation usually
coinnitUKU's botwct^n tho ages of thirteen and fourteen
years, but it is often seiMi earlier than that time and
occasionally does not appear until later. Climate, race,
and accidental causes often bring about a n nrked differ-
ence in the time.

2. RIiijIIdii of flic Jloir. It sometimes liapptMis that aft(^r
tlu^ first period or two, the patitint sees nothing again for
some months, perhaps for a year or more, and after that
time, recommences and continues regularly. With most
women the flow comes on every twenty-eight days, but in
some it appears at shorter intervals, and iji some at long(>r
intervals than normal, while in others the menses do not
appear with any regularity. On careful enquiry it will be
found that the peculiarities are natiiral to the individuals
and that the irrcigularity must be looked upon as regular
for them.

3. Diirdfion of the floir. In the majority of women the
period lasts four or five days, but here again consid(>rable
variation is found, within physiological limits. In some it
lasts only a day or two; in others the flow continues seven
or eight days, without the presence of any abnormal
condition.

4. The (hiilij omount. In this also there is consider-
able room for variation, some soiling but few napkins
throughout the whole period, while- others have to change
very frequently. Enquiry as to how often the napkins
have to be changed and the degree of soiling at each
change, will give a fair estimate of the amount lost.

5. The (iffoidaiit si/nipfonis. In some patients there is
no pain and no discomfort, but as a general thing, as the
flow approaches, there is a sense of fulness, congestion,

72 MEDICAL ANb SURdlCAL GYNiiCOLOGY.

disturbance and weight in the pc^lvic organs; often there
is pain in a greater or Ivaa (logree. Sometimes it is
a'^'companied by general disturbance, iiharacterized by
frontal, occipital, or general headache, and by nausc^a and
vomiting. The time at which the jmin begins varies in
different individuals. In some the pain will begin a day
or two before the flow, in others a few hours before, while
in others it comes on with the flow.

0. Lcuvorrluvd. In a healthy woman there is no dis-
charge, but some women have almost naturally a little
discharge of a whitish character for a day or two after the
flow cef "' s. Discharge c £ a thick glairy mucous in large
quantities is however pathological.

7. Abnormal iHuu'aiions. The menses, previously
normal, may have become too frequent or quite irregular;
the duration or daily loss may have increased or dim-
inished; or pain, previously absent, may have become a
promiiAont symptom. In any case we should ascertain,
how far the condition deviates from he: previous normal
condition; what the change has been and .he time at
which it set in. At the menopause the menses are often
irregular; occasionally they stop for a month or two and
even longer, then a re;^ulai period or two follows, after
which they cease altogether. Sometimes they suddenly
cease and the patient sees nothing more; in others again,
the menopause is ushered in by considerable floodings.
It must always b< borne in mind, especially in the case of
flooding, that women are particularly liable to malignant
disease at that time.

Both for future reference and as a guide to the
advisability of examinntion uy ineans of the sound,
enquiry should be made, as to the date of the onsot of the
last period and the time at which the last period closed.

The obstetric history. Tt is most important to have
the obstetric history of the patient, the history of her
labo.s and miser, riages, if any, because a very consider-

EXAMINATION IN GENERAL. 73

ablo ninount of illness which presents itself, is tlie result
of impregnation nnd of disease following upon delivery or
a., rtion. Ascertain the number of the chihlren, the
character of each hi})or, tli<^ date of last delivery, whether
there have been any premature labors or miscarriages,
and, if so, whether any particular cause can be assigned
for the occurrence.

Illness during pregnancy and after delivery. Ascer-
tain whether the health continued good during pregnancy.
Unusual symptoms at that period are to be carefully
enquired into. Illness after delivery is usunlly of a
febrile character and the cause in nearly every case is
attributable to septic mischief.

Previous illnesses. Ascertain from the patient the
nature of previous illnesses and whether associated with
the ptdvic organs or not. Many of the troubles comi)lained
of will be found to date from illness occurring at or soon
after delivery or miscarriage.

The history of the present illness. Ascertain, first of
all, the date at which the present illness began, also the
cause assigned for her illness. Of the particular symptoms
to which attention should be drawn, pain stands first,
because it is one of the most common. The site of the
pain must be noted, whether it be continuous or spasmodic,
and its chav<(cf('v, whether it be sharp and cutting or dull
and aching, and also whether it be associated witli
icnderuess. Pain or tenderness is a symptom of a very
considerable number of diseases to which women are
especially liable, such as pelvic peritonitis, parametritis,
disease of the cellular tissue of the pelvis, luematocele,
hicmatoma, inflammatory diseases of the appendages,
metric.. s, adhesiotis left from previous inflammations, and
finally tumors in the uterus, tubes o" ovaries.

Dyspa;eunia may occur from various causes and is
fre(iuently associated with vaginismus. It may be prim-
ary, tlii '; is, it may have existed from the beginning of

74 MEDICAL AND SURGICAL OYN.ECOLOGY.

attt'mpt.s at iioitus, or it :nay liavo ronxe on nftorwards. Tt
may arise from i-oM^iMiita! di'tVcts, HssurcH about tlu' vulva,
inflamed eonditioiis of the vau^iua, s])eei(ic or otherwiKc,
iiiid it may be found in association with urethral earunele,
or even with rectal tissurt' or piles. Tlio pnin is sometimes
periotlieni, that is, associated with tlu> monthly periods,
and, when so apiumring. becomes (me of the most prominent
symi)toms of dysmi'n<)rrh(i>a. Ascertain where tlu^ pain is
situated, whi'ther it extends into the liips. down tlu> thi,tz:lis,
or for a c()nsideral)le distance over the abdomen; al"o
when tlu' i)ain bej^ins, whetlier bi^fore the tlow or with the
flow, and if before the tlow, the length of time before.

Menorrhagia and metrorrhagia are often symptotns
of severe trouble, and any deviation from the normal How,
j)articularly if exttMisive. is to be carefully encpiinHl into.
It may arise sim[)ly as the residt of sonu^ constitutional
disturbance, as aiiivmia. clilorosis, purpura, but is often a
prominent symi)tom in pelvic hiematcHude and lut^matoma,
extra-uterine pregnancy, fungous endometritis, mucous
polypi of the cervix, fibroids or myoma of the uterus
projecting into tlu uterine cavity, subinvolution after
continenient. and maligiuxnt disi-ase of the uterus.

Amenorrhoea. During pregiuincy, as well as during
lactation, amenorrluim is the ride, but the menses some-
times persist (hiring the early months of pregnaiu^y and
even later. Many women will c \tinue to have their
periods regularly during nursing, comi .icing sometimes
a month after delivery, and it is finite poss'bte UiV a woman
to become pregnant during lactaiion. even if the menses
have not appeared. It is necessary to renember these
facts, because patients are apt to be misled in conseciuence,
and. even when far advanced in pregnancy, are not aware
of their condition.

Local swelling or tumors. We should ascertain
h'oin the patient if any swelling, either in the abdomen or
in the genitals, has be"n noticed, where the swelling first

EXAMINATION IN GENERAL. 75

jippciirc'd, if [HTKistcnt or vnriablo in its olmnvcitor, tlie site
where it was first noticed and the direction in whicli it 1ms
^rown.

Urinary symptoms. Note the elinrneter of the pain,
if prt^sent, and tiie tinn^ at whic^li it (K!curs, whether dnrin^,
previous to, or foUowing inieturition. Note also the
frequency of micturition and whether it takes place more
often at nij^ht than during the day. Inquire if there be
difficulty in gc^tting tlu> water to pass, or whether tlie water
constantly runs away or is i)assed involuntarily on coughing
or straining. The clmrat^tt^r of the urine may be partly
learned from the patient, but should always be tested by
a proper urinalysis.

Intestinal symptoms. Ascertain the frequency with
whicn the bowels are relieved and if defecation be painful,
difficult or associated with tenesmus. Note the condition
of the tongue and incpiire as to the digestion, and whether
nausea and vomiting be present; and. finally, ascertain
what i>r<'ri<)iis trcdhticid, if any, has been adopted, how
long it has been carried out, and with what results.

PHYSICAL EXAMINATION.

In the majority of cases correct inferences cannot Ije
deduced fnnn verbal statements alone, and a physical
examination becomes essential. The chief exception to
this rule is in the case of young girls. It is most often
for irregularities of menstruation and for leucorrham that
young unmarried women seek relief, and as these dis-
orders, in their casi\ are frecpiently depiMident upon the
general health, hygienic measures and drugs will often
accomplish all that is necessary. In fact only when such
measures have been faithfully tried and proved ineffective,
or when there is clear evidence of pelvic disease, is an
examiiuition justifiable. Most examinations may be satis-
factorily made with the patitmt. if at her home, lying in
her bed or on a lounge, or it' the examination is to be

76 MEDICAL AND SURGICAL GYNAECOLOGY.

C50iulnct(Kl in tho office, upon a conveniently arranged
couch or chair.

Position. The two cliief positiouH are the dorsal and
Situs'. Of U>ss importance are the (jciiu-jtci'toi'dl, the
ci'crf, and TrcniU'li'iibcrifs.

In the dorsal position the patient lies upon the back;
the head slightly raised; the knees drawn up and widely
sei)arately; and, if necessary, the heels fixed in some kind
of holes or stirrups. It is the best position for digital and
bimanual examination, and is often employed for ordinary
treatment, on account of its convenience.

In Sims'' position the patient is i)laced on tho left side;
the left side of the face rests on a cushion; the left breast
touches the table, and the left arm is placed behind the
body. Both knees are drawn up, the right being a little
nearer the head and in front of the left. This position
allows the introduction of one or two fingers high up
behind the uterus, permits the use of Sims' speculum, and
does not require such a degree of exposure as the
dorsal.

In the Trcndclcnhcry position, the knees are raised
high above the head so that the body slants upward from
the shoulders. It is rarely used for diagn(^stic purposes,
its chief advantage lying in the additional facilities it
offers the surgeon in operations upon the pelvic organs.

In the (jenu-pectoral position the patient rests upon
her knees, the upper part of the chest, the right side of
the face and the right forearm. It is sometimes used to
replace a retroverted uterus or prolapsed ovary.

The erect position is used to discover a prolapsed
uterus, a cystocele or rectocele.

Examination under anaesthetics. Nearlj' all exam-
inations can be made with a full knowledge on the part of
the patient, and it should be a rule to examine first in *,hat
manner, but it is sometimes impossible, under such 'r-
cumstances, to obtain satisfactory results. Occasionally

EXAMINATION IN GENERAL. 77

palpation is so painful that the patient cannot endure the
slightest manipulation, and, even when no pain is present,
it is often found that as soon as the hand touches the
abdomen, the muscles, more especially the recti, at once
become so tense that it is impossible to feel anything
that may be beneath them. Under such circumstances
the use of an anjusthetic is not only justifiable, but
absolutely necessary, to make a correct diagnosis.

Methods of examination. Three methods, under
ordinary circumstances, are made use of: The visual, the
Dumudl or (lujital, and the instruiiicntal.

VisiKil hispcctioii of the external genitals will often
reveal many facts, such as atresia of tlici hymen, swelling
of the vulvo-vaginal glands, the presence of papillary
growths, venereal ulcers, discharges, urethral caruncle,
a lacerated perineum, or prolapse of the vaginal walls.

Difjitdl ('.rainiii((tion per vfufiHdin. The fingers,
especially the index fingers, are instruments of the
greatest value in acquiring iid'ormntion, the sense of
touch replacing that of vision. The partly closed hand,
with the index finger extended, is passed along the inner
side of the thigh and, on reaching the vulva, abnormalities
of the labia may be detected. The index finger is gently
pushed between them into the vagina, examining at the
sanu^ time for any peculiarity of the hyuKni, obstructions,
pr()la^)sed organs, or gaping from relaxation or laceration.
The vaginal walls are palpated to detect abnormalities in
them, or of the rectum, or of the urethra or bladder. The
finger end next reaches the cervix and is swept around to
examine the fornices. By palpation, tlu^ size, shape, and
consistency of the cervix and the shape of the external os
are made out. The fingers i)ushed up h'lhind will (h^tect
a retroverted uterus or displaced ovary, and, when pushed
up in front, will feel an anteflexed uterus or ti'e trigone
of tiie bladder.

78 MEDICAL AND SUROICAL GYNECOLOGY.

Dtjfital cxfimivaiioii x>er rectum is best porformod in
Sims' position. Besides ovideiico of disease of the rectum
obtained by this method, it is n useful method to empk)y
in the case of virgins with sensitive liymen or small vagina.
Sometimes the uterus and appendag(>s are better felt from
the rectum than from the vagina, and, in case of abdominal
tumors, valuable information is to be obtained tluuH^by.
Abnormal conditions of the coccyx, such as ankylosis or
fracture, can be detected at the same time.

Bi'iikoukU examiiuition. In order to secure the re-
quired information it is often necessary to make use of
both hands. With one index finger impinging on the os,
after the method already describcnl, the other hand is
placed above the pubes and the finger tips pressed down
with increasing firmness until the fundus is felt and the
organ made to lie between the examining fingers of the
two hands. If the body of the uterus is not found, it
should be sought for either in front of or beliind the
cervix. By this method, the outline, size and shape of
the uterus can be made out. By pressing well down
beside the uterus, the tubes and ovaries may be palpated,
and the method is of the utmost advantage in the diagnosis
of pelvic tumors.

Instrumental examination. The vaginal spcoiJiini is
an instrument, by the aid of wliich we are enabled to look
into the vagina and to treat various pathological conditions
found. Of these there are a great variety, but the number
may be reduced to three types, the cylindrical, the pluri-
valve, and the single blade. The cylindrical speculum, as
repri^sented by P^erguson's, once so popular, is now seldom
used, as the exposure is too limited and the space within
it too cramped.

The hiiHihu' speculum consists of two blades, joined at
one end, and looks anil opens something like the bill of a
duck, The lower blade is usually a little longer than the
upper one. It is introduced closed, either in the dorsal

iiiji^

EXAMINATION IN GENERAL.

Fic. i8.— Highee's Bivalve Speculum.

or Sims' position, niid is then expftndod by a screw or
lever. As the bla(U^s are expandcnl, the cervix settles
down on th(^ lower or posterior blade and thus comeB
into view. There are several
varieties, of which Cusco's,
Brewer's, and Higbee's form
fair samples. It is a very
satisfactory instriiment, botli
for inspection and treatnuuit,
and can be used witliout an
assistant. The tri-valve (Nel-
son's or Mott's) has two narrow blades, in place of the
anterior blade of the bi-valve.

Thi^ sin<j;le blade, or Sims' speculum or retractor, is
practically a Hatti'ned blade, made somewhat concave on the
vaginal surface, jind to which a slender liaiidle is attached.
For convenience, two blades of different sizes, one at each
end, an^ attached to the handle. When inserted it shows
the uterus and the anterior wall of the vagina in their
normal position and relations, its object biung to pull

back the p(>rin(ml body
and the posterior vaginal
wall. Besides this ad-
vantage, it readily per-
mits of treatment, and is
the sijeculum chiefly used
for opc^rations upon the
uterus and vagina. If
the cervix does not readily
come into view, the failure

Fig. ro.— Sims' Speculum. • . j. -i. i • i

^ IS owing to its being ob-

scured by the anterior vaginal wall. To overcome this
difficulty, a flat blade, shaped like a spatula, or fenestrated,
and called a dcprcsso)', is made use of. To overcom(> the
necessity for having an assistant when using Sims'
speculum, many ingenious modiflcations nave been do-

80 MEDICAL AND SURGICAL GYNECOLOGY.

vised to make it self-retnining, but in every case their
application is troublesome and often unsatisfactory.

The uterine sound is an instrument made of a more or
less flexible metal, usually copper, with a slightly bulbous
extremity, and at a distance of two and one-lialf inches
from the extremity, is another bulb, indicating the length
of the normal uterus. It should first be bent to correspond
with the supposed curve of the canal, as found by bimanual
examination. When introduced, it indicates the longtli
and direction of the uterine cavity, and its relation to any
mass pn^ssing into or occupying that space. The mobility
of the body of the uterus may be determined also, as well
as the relation which it bears to a tumor or other ma.ss

-ill-

c\JtKTZo

Fig 2o. — Simpson's Sound.

adjacent to it. In is a very useful and, when properly
used, harmless instrument, but in handling it, it must
never be forgotten that it is cajjable of perforating the
uterine wall, and that it is being introduced into a cavity
from which absorption easily takes place. In its intro-
duction much difficulty is often experienced by the point
catching in the folds of mucous membrane in the cervix,
or by the opposition made by flexion. The difficulty may
be overcome by embedding the curved point of a tenaculum
in the tissues of the anterior lip and making counter-
traction, the effect of which will be to straighten out the
canal.

The pvohe is a much thinner and very flexible rod
used exclusively for exploring the inside of the uterine
cavity.

Uterine dressinp forrepF., of which a great variety
have been devised, are invaluable for wiping out the

EXAMINATION IN GENERAL.

cervical mucous while mnkinpf inspection, for disinfecting
the vnginnl foniices, and for carrying medicated material
to the intended point of application.

Bozem.in's Pressing Forceps.

The vuhcllurn is a pair of forceps, each blade of which
ends in a double hook. It is used for seizing and pulling

Fig 22. — Viilsellum Forceps.

tissue, and is thus useful in steadying the uterus, while
introducing the sound or dilating the cervical canal.

Examination of the interior of the uterus. When
bimanual and speculum examinations make it evident that
the disease is seated within the uterus, an exi)loration of
its interior is essential. Usually the cervical canal presents
an effectual barrier to exploratioTi, eithe. by fin,»er or
instrument, and some method of dilatation must therefore
be used. This may be done slowlij by means of tents, or
rdpidly by graduated dilators or dilatating forceps.

Gradual dilatation, by means of tents, has now fallen
into complete disuse, except in isolated cases. From the
fact that it is impossible to render them aseptic and from
the necessity for the use of two or three to obtain sufficient
dilatation, their use exposes the patient to great danger.
For diagnostic puri)oses and as part of treatment, dilatation

MEDICAL AND SURGICAL GYNECOLOGY.

ia bost nofioniplisluHl mpidly by instruiiKMits. For tlio
lower (lejijrcc'H of (lilatnti(jn. Hunks' luinl riibb(^r or Hti^el

Krci. 23. — Hanks' ililators.

dilators, which como in .1 set of six,
embracing twolvo numbers, are very
serviceable. Commencing witli the
largest that will enter the canal, they
are passed in, one after another, until
the r(H|uired degiH^e of dilatation has
bt^en re( quired. For a higher degree
of dilatation, som(^ of tlu> steel
branched dilators may be used. A
very satisfactory instrument, perhaps
the best, is Goodell's modification of
Ellinger's, but being rather thick in
the blades, it niay be: found imposs-
ible to insert them when the cervical
canal is small, lender such circum-
stances it is best to commence with
a pair of lighter blades, such as that known as Wylic^'s.
After insertion, the handles are to be gradually compressed
and, as the parts yield to firm, slow pressure, what is
gained may be held by the screw or ratchet. The use of
this instrument, as well as of the graduated dilators, will
be facilitated if the cervix be steadied with a vulsellum.

Fi<;. 24. Gooilell's Di'ntor.

EXAMINATION IN GENERAL.

8;{

Th<' cuvi'ttc is nil instrument used for scraping ott' or
romoving pntliologicnl or otlu^r structureH from the inside
of the uterus. Althougli mostly used as a theraixnitic
agent, 8om(>times it is used to secure a specimen for gross
or microscopical examination. Tlic^re are two varieties in
use, one sharp and stitt', the other dull and somewhat
flexible.

From the frequent association of urirary symi)toms
with uterine diseas(>s, the best nu'thods for examining the
urethra and bladder should b(^ known to all [)ractitioners.
Some knowlcnlge of the condition of tlu' lower part of the
urethra may bt^ gained by inspection, some bladder and
urethral affections may be recognised by examination with
the linger, but for the deti^rmination of the exact condition
of the lining nnunbrane of th(> urethra, an endoscope is

Fii;s. 25, 26, 27. — Skene's Endoscope.

necessary. By inserting to its full length a simple tube,
sirailar to an ear speculum, the field being illuminated
with a head mirror, the whole urethra may be fairly well
inspected as the tube is being withdrawn. The most
satisfactory urethral endoscope is that known as Skene's.
By means of it, not only the neck of the bladder and
urethra may be inspected, but applications by means of
cotton or a spray may be made to any part of the canal.
The bladder can be explored digitally by first gradually

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MEDICAL AND SURGICAL GYNJIOOLOGY.

dilating tlie urethrn with Simon'R instruments until the
largest has been passed, after which the finger can usually
be inserted into the bladder.

Dr. Howard A. Kelly has extended and simplified the
technique of the examination of the bladder and ureters,
which permits of direct visual inspection of the female

Kio. 28.--noul>le Uretlir.-il Dilator.

bladd(^r and ureteral orifices, and which renders it possible
to complete the catheterization of both ureters within a few
minutes after the introduction of the specidum. The
following instruments are required: A urethral dilator; a
series of specula with obturators; a head mirror with some
form of artificial light; a im'ir of delicate mouse-toothed
forceps; an evacuator for withdrawing residual urine; a

Figs. 29, 30. — Speculum .nnrl Obturator {% natural size).

ureteral searcher, and a ureteral catheter. The hips are
somewhat elevated, and, after the necessary degree of
dilatation, a proper sized speculum is introduced and the
obturator withdrawn. By means of reflected light from
the head mirror, it is possible to examine fully the interior

EXAMINATION IN GENERAL.

of tho bladder. Rosidunl urino obstructiiif? tlu' view may
be removed witli the evacuator, or, if very small in
amount, by little balls of absorbent (cotton held in tlu'
mouse-toothed foreeps. After a litth> prac^tiee the sites of
the urethral oritiees can be located. Dr. Kelly su^^m'sts
the following valuable aid for locatinjj: them: "A point is
marked on 'he cystoscopi^ at a distantn^ of five and one-
half centimetres from the vesical end, and from the jMnnt

Fig. 31. — Cystoscopic examination of bladder and direct catheterization ot ureters.

two diverging lines are draw toward the handle, with an
angle of sixty degrees between them. The speculum is
introduced up to the point of the V and turned to the
right or left, until one side of the V is in a line with the
axis of the body. By elevating the endoscope until it
touches the floor of the bladder, the ureteral orifices will
nearly always be within the area covered by the orifice of
the speculum."

86 MEDICAL ANU SUIUJICAL OYN. ECOLOGY.

Tho RonroluT in itoxt omploytMl, nnd if what, is scmmi is
ronlly the oritici', it will at oiico pass ri'adily into it. Tho
ureteral catheter may then be subHtituted for the searcher
and the iirine coUected, as it passes from t\w kidney.

Examination of the abdomen. In a certain number
of cases inspection of the abdomen is important. The
practiced eyo can distinj^uish the pointed prominence
caused by a tumor or pregnancy, and the Hat enhxr^e-
ment. owin>^ to the presence of ascites or supi'r-abun(hint
adipose tissue; and vdien present, pigmentation, strije
albicantes, and a protruded navel are readily observed.
By paljAtion, the practised touch will show tho size, con-
sistency, and relations of a tumor, its mobility, and its
smoothness or irregularities.

FcrcHSsioii permits of defining, with greater accuracy,
the height to which a tumor rises, and the extent and
mobility of the area of dullness.

Auscultdiiou is of value onl^ in the differential
diagnosis of pregnancy from other varieties of abdominal
tumor.

CHAPTER VIII.
GYNECOLOGICAL THERAPEUTICS.

To be successful in the treatnxent of diseases of
women, pelvic disorders are not to be looked upon as
isolated conditions, but must be viewed, in a large number
of cases, as arising out of an existing or pre-existing con-
stitutional state, or faulty regime of the patient. Thus
the circulation and the digestive and other imijortant
systems may influence or be influenced, by the pelvic
organs, and when deciding upon a line of treatment, the
general condition of the patient must never be lost
sight of.

GYNAECOLOGICAL THERAPEUTICS. 87

Cicucvdl hi/jjicnc is nn importntit fnctor. Tlio mind
Hhould be ns far as possible froo from anxiety hikI strain,
yet at the same time actively (employed in some healthy,
intelle(^tual pursuit, and the body stimulated by exercise
suited to taste and circumstances. The strictest attention
should bo paid to the menstrual period, and every girl
should be taught how to take care of herself during the
performance of that important function. Regularity in
the action of the bowels and attention to their daily
evacuation, regular attention to the calls for micturition,
attention to the functions of the skin, and regularity of
meals and sleep, both as regards time and duration, are
also of great importance. The clothing, while not being
too heavy, should be of such texture and material, and so
distributed, as to keep every part of the body equally
warm. Exercise in some form or other is often bene-
ficial, but should never be excessive. What the particular
form of exercise shall be, must dejjend upon the taste or
occupation of the individual. Each condition with which
we have to deal will suggest points ai)plicable to it.

In the i)elvis, as elsewhere, pain and disordered
functions are indications for rest, and in no department of
medicine is rest more essential than in this. In the
majority of patients, their sufferings are due to fulness of
the vessels within the pelvis, and to overcome this r>»st in
the recumbent position is absolutely necessary. But rest
to be complete must be not only local and general, but
physiological as well.

A very large number of gymecological jjatients suffer
from aniBmia, and often from anorexia. Careful attention
must be given to the diet, and when so prescribing,
precise orders should be given in regard to the time,
the quality and quantity of meals, as well as to a proper
variety.

Drugs. Pi(r<j(ifir<'s In no class of diseases are
purgatives more useful. Constipation, acting locally, maj

88 MEUKJAL AND SURGICAL GYNAECOLOGY.

soriously displnce tlie pelvic, viscera, or by pressure pro-
mote congv^stioii nnd discomfort. In many cases of
chronic pelvic disefxse, a course of jjurgatives, such as
sulphate of magnesia, cascara sagrada, aloes, with an
occasional dose of calomel, will greatly relieve the patient,
and where there if. systemic portal congestion, morning
draughts cf Carlsbad salts, or Hunyadi Janos, Apenta, or
Franz Josef mineral waters will, by their mild laxative
action, afford much relief In acute pelvic inflammation,
saline purgatives aie highly beneficial. Enemata of warm
water, and rectal injections of glycerine, are useful
adjuncts or alternatives.

Tonics. Nearly all kinds may find a place in the
treatment of pelvic disease. Unless contra-indicated, iron,
in some form, is one of the most active, and when ad-
ministered gives the best results when combined with a
purgative. Arsenic is valuable when lucorrhcea is present
in amemic girls with a chronic catarrh of the vagina or
cervix. Combined with iron, it acts well in ansemia and
chlorosis with scanty catamenia. Quinine, aside from its
specific effect, has a special tonic action on the uterine
muscles, and is therefore useful as an adjunct.

Seddtires, especially the stronger ones, should be
administered with great caution, for often the condition
for which they are j^rescribed is a recurrent one, and the
repeated administration may lead to the abuse of these
agents.

Special Gynaecological Drugs. Ergot is used for two
main purposes, to encourage uterine contraction and to
lessen uterine hemorrhage. On this account, it is ad-
ministered for passive uterine hemorrhage, in uterine
fibroids, fungous endometritis, subinvolution, and in
uterine congestion. In chronic hemorrhage, or when it is
given for lengthened periods, it should be combined with
acids and purgatives.

GYN.ECOLOGKiAL THERAPEUTICS. 81)

(losi^/ipiiim, in the form of fluid extract, or decoction
freshly prepared, is an ommenap-o^ue and partvirient. It
has a tonic influence on the uteruB, relieves pain, and
often seems to act better than ergot in arresting imssive
hemorrhage.

Hi/drastis Camidrnsts, in the form of fluid extract or
tincture, has a decided ecbolic action and, if taken regu-
larly, will check chronic hemorrhage, and besides has a
decidedly sedative effect.

HiinKimclis has been accorded a high place i:i the
scale of uterine haemostatics wliere passive engorgement
exists.

CcDinabis ImJica, in the form of extract, is extremely
useful in cases of menorraghia with pain, in dysmenorrhoja,
and in some cases of fibroids. It is apt to affect som<*
women i)eculiarly, and at first must be given cautiously
and in small doses.

Viburnum pr'nnifo] in m is an anti-spasmodic, relieving
painful contraction of both voluntary and involuntary
muscles and is, therefore, useful to prevent abortion in
catses where uterine contraction precedes the death of the
foetus. A large group of anti-spasmodics and sedatives
may be used for the relief of pelvic pain, among which
may be mentioned some of the coal tar derivatives, such
as phcnfivcfine.

The Bromiih'fi allay th.i pain and restlessness due to
increased local tension, as in congestion of the ovary.
They tend to lessen hemorrhage of a passive type, and are
excellent remedies to anticipate the headache and nausea
which precede dysmenorrluwa.

Chloride of Ammoninm acts upon the portal system and
thus tends to relieve pelvic congestion. It is useful in
simple congestion, subinvolution aiul chronic metritis.

Chloride of Colrinni, given thrice daily, in doses of ten
to twenty grains, often acts like a charm in some cases of
menorrhagia.

<.K) MEDICAL ANO SURdlCAL (iYN.ECOLOCJY.

Jicsol rents nro oftou cnlli'd for in chronic inHuniniation,
to prom(>tc absorption of lon^ stmuling iiitiaininntory
exudation. The most important of those arc, iodine in
the form of iodide of potassium, sodium or ammonium;
mercury iu tlu^ form of bichUiride, and gold in the form
of chh)ri(U« of sodium and gold.

The local therapeutic effects to be derived from the
application of Itnif and cold are well known.

1. E.riernal aj>pli('<itioii. Cold, locally applied, is a
depressant, checking the vital action and diminisliing the
bh)od supply, and hence is useful in hypenvMnia or con-
gestion of the pelvic organs. It may be applitnl in the
form of ice-bags, or by means of a Leiter coil. Hc<d, in
the form of hot baths, is mainly sedative, relaxing the
skin and its glands, dilating the i)eripheral vessels, and
thus relieving congestions of internal viscera. It is
therefore useful in congestive dysmenorrhoia, and, by its
power of relieving muscular spasm, is serviceable in
spasmodic dysm(>norrho>a and in cases of uterine, tubal
and other pelvic and abdominal colics. Hot foot and sitz
h(itlt)'- act somewhat similarly and are particularly useful
in relieving pelvic congestion produced by sudden arrest
of the cntamenia. Mustord, added to such baths, increases
their effects. Pout f ices and fonundfitioiis. both as to their
utility and actio'i, may be considered as local baths. If a
sedative effect is required, opium, in the form of laudanum,
may be added; if a stimulating effect is required, turpen-
tine. Heat may also be aj^plied, locally, by means of
hot Wider cans and rubber bags.

2. Iideritfd ((pjdiecdion. Hot water has a far more
extensive field of usefulness in the pathology of women's
diseases than any one agent. Hot water may be made to
enter the vagina while in a bath, by means of a speculum,
but the usual method employed is by means of a dourlie
(ippandns. In all cases, the flow into the vagina should
be continuous, hence, for the purpose, an elevated ci-uJie-

OYN.Et'OLOCilCAL THliUAl'EUTICS. 91

(•nil. or sonip syplion nrran^tMinMit, is bi'ttcr tlum the
ordiiuiry luviul-bulb syriti^o. The vfiKin'il nozzlo should
bo of somo smooth mntorial, easily innde nscptic, and,
during administration, tin* patient should lie flat on the
back witli the pelvis raised on a Ixul-lxitli. For merely
cleansing tlK> vagina, tepid water will suffice, but its eliVit
may be increased by adding a drnm of bicarbonate of
soda, borax, or boracic acid, to the pint. For the relief of
congestion, water, at a temperature of 100° to 105° F. is
indicated, but for the arrest of hemorrhage, a higher
temperature is required. By the addition of medicinal
agents the douche can be rendered antiseptic, anodyne,
astringent, or sedative. Cold water applied to the vagina
is unsafe and should not be made use of.

Counter irritation to the skin may be applied in a
variety of waj'^s by such drugs as mu.stard, turpentine,
iodine, croton oil, or cantharides.

Applications to the vagina may be made in varibus
ways. Donrlicsi are a convenient way of applying medi-
caments. If for antiseptic purposes, bichlori.le of
nuTcury, 1 to 4000 to 1 to 2000, and carbolic acid 1 to 200,
may be used, but their prolonged or frequent use is to bo
avoided, owing to the dangers from absorption. Weak
solutions of potassium permanganate and of sulplio-
carbolate of zinc may also be used, but r.re not so
effectual. If required for astringent purposes, plumbi
acetate, zinc sulphate, alum, and tannin are the best.

Mcdicdtcd ix'SSfirics may be used for tlieir local effect,
as well as for their remote, and when for the latter, double
the usual dose should be administered.

Pessaries of glycerine, combined witli gelatine, will
relieve vaginal congestion and encourage se(;retion. If so
desired, drugs may be added to such pessaries, and it is in
this form that ichthyol has its most useful sedative and
absorbent api)lication. particularly in subinvolution asso-
ciated with endocervicitis and granular erosion. The

\)2 MEDICAL AND SURC.ICAL OYN.ECOLOOY.

dnij;H nu)st oftcMi usimI nn scdativcH nro ctx^nino. niori)1jin,
extract of lu'lladoiin!! and extract of henbane; as astrin-
j^entH. alum and tannin, and. when so ein[)loyed, may be
combined with cocno-butter or gelatim^ For this purpose,
gauze, too, saturated with various int^redients, is readily
ap[)lie(l.

Tdinpons macU' from wool or absorbent cotton, roHed
and tied in sizes most convenient for the work recpiired
of them, may be used to advantage as conveyers of
medicinal agents, such as boric acid, ichthyol in glycerine,
lysol, aristol, balsam of Peru, aciueous solutions of alum,
and other agents; and, when so m(>(licated, serve a good
purpose for stimulating, sedative, or astringent apjjlica-
tions. They are also used as temporary means of Hujjnnrt.
for exerting pressure, and to soften and stretch organized
bands within the pelvis. Tampons may be also employed
to plug or to tightly pack the vagina for the arrest of
hemorrhage and to maintain an aseptic condition.

Direct application of drugs may be made, through a
speculum, to any affected area of tlu^ vagina by means of
a pledget of absorbent cotton held in the jaws of a pair of
uterine dressing forceps. Nitrate of silver, in various
strengths, solutions of sulphate of copj^er, tincture of
iodine, carbolic acid, iodized pheno?. litiuor ferri perch-
loride, ichthoyl, glycerite of tannin and such like, are all
useful therapeutics agents in appropriate cases.

Applications to the uterus. The same drugs used for
the vagina may also be used for the vaginal portion of the
uterus, and are to be applied in the same way. To npi)ly
substances to the cervical canal, it must be exposed, and
by the aid of a Burrage's sijeculum and cotton holder,
the mendicament is directly applied. Until very recently,
it was the practice to make applications of many of the
remedies mentioned to the cavity of the uterus, but it has
now fallen into disuse, and in cases, where previously
employed, the practice of to-day is thorough curettage and

GYNAECOLOGICAL THEKAPEUTICS.

cleniisiiig nnd drainiuj^ of tho canal. Wlioii that has boon
thoroughly douo, it is all that is nocosKary.

Intra-uterine injections nrc nuioh inoro ilangorous
than va^'iual. Largo utorino injootions of w> rni wator,
medioatod or othorwiHo, nmy bo usod for olon using nnd
disinfocting tho utorus, and for chocking lioniorrliago. If
tho corvix has boon thoroughly dilatod, a curved glass

CX:

Fig. .!2. — Burrage's Cervical .Speculum, a, tulie ; fi, handle ; r, movable cl.isp ;
ri •.mall tulie at right angles to main lulie ; ,•, smaller cervical tube to replace a ;
./, ihmrator fitting the two tubes.

single current tube is proforable, but if tho cervical canal
is not so \s,'id'), a metal double-current utorino tube sliould
be used, such as Bosoman's, a Cusco's or other spocudum
having boon previously introduced, and while administer-
ing tho flow should bo carefully watxihed.

Vui. 33. — Intra-uterinc Douche.

Vesical injections are much used in the treatment of
diseases of the bladder. For large injc^ctions, a fountain
syringe with a hard or soft catlu^ter attached and a two-
way stop-cock whi(^h allows tho bladder to bo alternately
tilled and emptied, acts very well. Wluu\ simple irrigation
is required, Nott's doubh^ current catheter proves very
serviceable. A simple, yot very effectual vesical douche
may be made by attaching to one end of a rubber tube a

MEDICAL AND SUUOICAL OYN^COLOUY.

small funnel, or tho barrel of n lar^o ^lasH male syringe,
and to the other an ordinary glass oatlu^ter. Tlu^ tluid is
pour(uI into tlu^ reeeptaele, lu^ld at tlu^ nupiired distance
above the patient, and, when suftieitMit has I'ntered, the
rec(>ptaole is lowered, which permits the
fluid to be syphoned out.

Curetting. In the treatmiMit of
diseases of the uterus this minor opera-
tion is often demanded. It retiuires
the administration of an anaesthetic,
jdthough some can undergo the ordeal
without it. The cervical canal is first
dilattnl carefully with steel dilators to
such a size as will readily admit the
curette. The cavity of the uterus is
next fl\ished through a Burrnge's spec-
ulum, or by means of an intra-uterine
r^ douche, with a 1 to 2000

solution of bichloride.

Fig. 34.-
Tenacula

The cervix being grasped

with a vulsellum or ten-
aculum, to steady the

uterus, the sharp curette

is introduced and the

entire cavity carefully

scrap-id, the persisten 5e
and vigor with which this is done
being governed by the conditions
Ijre-sent. The antierior and pos-
terior walls, the lateral sulci where
these two come together, the fundus, and tlu^ recesses of
the cornua are scraped in turn. The cavity is next
irrigated with the warm bichloride solution, and dried
with a little cotton on a holdi>r. Should circumstance ?
demand it, the cavity may be touched over with carbolic
acid, tincture of iodine, or iodized jjlienol, after which it

Fk;. 35. — Wire-
loop Curettes.

Fig. 36. — Sharp
Curette.

(lYN.ECOUKJIC'AL THEKAl'lirTIOS. 9B

Ih aj^ftiii to b(^ (Irit'd witli cotton. Tf (icemod adviHnblc, tlio
uterus nuiy be draint'd by the introduction of a Ktrip of
iodoform ^auzci, or it may be packed with the Hanm
material. Aa a rule, ^ood draiuag(> is all that is uocesHary
after thorough curettage.

Pelvic massage. Though massage, in its dit1"'erent
forms, enters into tlu^ treatmcMit of various femaU^ afVec-
tions, it is also valuable as a part of the giuieral care of
the body, both to increase the activity of the blood (uimuit
HO as to bring it mori^ fn^quently in contact with the oxygen
of the lungs, and to promote nutrition, by making the
muscles work out what elements they have alreatly taken
up, but have not utilized. By this means, the body at
largi> becomes more vigorous and robust, and thus will
respond more effectually to therapeutics and to the local
treiatment of the organs, the care of which are being
considered. A form of massage, known as pelvic massage,
has been elaborati'd and brought to bear upon the class
of ailments which usually prove most intractable, and for
the treatment of which the means at our commantl have
always been too few. This class of treatment has given
excellent results, when judiciously undertaken, in selected
cases, and when carried out with patience and with a clear
perception of its indications. It is applicable to a great
diversity of ailments, but it may be stated, in a general
way, that chronic; female affections, such as persistent
pain, constantly recurring congestion, displacements, de-
formities and fixation of organs, attributable to lack of
support or increased weight, peritoneal inflammations and
lymph deposits, are the ones which we may hope to benefit
most by this method. As opposi^d to this class, there are
also conditions entirely unsuited to such handling. Mas-
sage should never be attempted in any acute disease, nor
in any acute exacerbation of a pre-existing disease, nor in
the presence of pus tubes or pus in any part of the pelvis,
nor in cases of pregnancy, normal, or still less, abnormal

96 MEDICAL AND SURGICAL GYNAECOLOGY.

or ectopic. The only exception is a retroverted uterus
before the third month. Tuberculosis of the peritoneum
is another contraindication, also ovarian cystoma, cysts of
the broad ligaments, fibroids and malignant growths any-
where within tln^ pelvis.

Massage, in the diseases specified, consists briefly in
kneading the pelvic masses, applying friction to them
to cause their absorption, and in moving the uterus in
different directions to stretch and free its adhesions. The
manipulation is carried out with one hand pressing
through the abdominal wall and with one or two fingers
of the second hand in the vagina. The vaginal fingers
are used mostly for lifting up and fixing the uterus or
pelvic masses, the manipulation being carried on, for the
most part, by the abdominal hand.

CHAPTER IX.

POST-OPERATIVE TREATMENT.

There are certain well-defined principles which may
be followed in conducting the after-treatment of a patient
upon whom an abdominal section has been performed,
the observance of which is of the greatest importance, and
the neglect of which may be attended with serious results.
After operation the patient is to be remov'ed to lu>-r bed,
previously made warm, and hot-water bottles carefully
placed on each side. One-thirty-second of a grain of
strychnine is at once given, and repeated every four hours
for the first twenty-four hours; every six hours for the
next twenty-four hours, and after that, only if required.
It is (extremely difiieult to lay down definite rules regarding
food and drink, as patients respond differently under the
same management, and the greatest ingiuiuity is often
required. During the first twelve hours it will be found

POST-OPERATIVE TREATMENT. 07

preferable to give nothing except small quantities of toast
water, or warm water, from one to two teaspoonsful every
ten or fifteen minutes; or ten to fifteen drops of sherry m
two or three teaspoonsful of soda water, testing the ability
of the stomach to retain and absorb it. This frequency
of administratioTi is not only tolerated, but is very com-
forting to the patient, relieving the thirst and diminishing
vomiting as well, when present. Ice, as a rule, while
grateful to the mouth of the patient, is not as well borne
as warm water, and the patient is never satisfied; besides,
the injection into the stomach of cold wati^r is apt to
cause nausea. The distressing thirst, so often complained
of after operation, may be relieved by frequent injections,
into the rectum, of half a pint of normal salt solution, and
with some it is the practice to inject high up into the
sigmoid flexure a quart of this solution, before the patient
leaves the operating table. After the first twelve hours
small quantities of chicken broth or beef tea, half an
ounce every half hour, may be allowed, the time between
administrations being extended as the amount given is
increased. Albumen water, into which the juice of a ripe
orange has been S(iueezed, is often well tolerated and very
comforting. Milk, as n rule, is not a good substance to
give by the mouth. It is not easily digested in the
stomach, and the thick curds formed are either ejected, or
act as an irritant in the intestinal canal. Peptonized
milk has not this objection, and, as a rule, is well retained,
but many patients object to the peculiar tast(^ Weak
oyster-broth has often been retained with much satisfaction,
when other nutriment has been rejected. Small (piantities
of ginger ale sometimes act as a sedative to the stomach,
relieve thirst and flatulence, and are often eagerly demand-
ed by the patient. At the end of the third day the
dietary may be increased and administered every two
hours. Milk may now be given, combined with lime-
water. Such articles of diet as gruel, light thin porridge,

98 MEI)I(!AL AND SURftlCAL OYN^OOLOGY.

custards, rico, sago, tapioca, thin strips of bread and
butter and poached eggs may be gradually added to the
list until the eighth or ninth day, when some solids may
be introduced.

The arms, legs, and chest may be sponged with warm
alcohol, or with soaj) and water, and subsequently con-
valescence is promoted by frequent sponging and by rub-
bing the body with alcohol. If there is much restlessness,
or if the patient suffers severe pain, a small hypodermatic
of morphia, one-sixth to one-quarter of a grain, may be
administered, but the routine employment of it is to be
condemned. It is much better to encourage the patients
to control themselves and to endeavor to endure the pain.
It delays healing, checks secretion and elimination, as
well as the peristaltic action of the bowels, functions so
much required at this critical time, besides it places the
patient in such a . mood as to be an unsafe monitor of
untoward or alarming symptoms.

Purgatives. It is imperative to obtain a movement of
the bowels at as early a period as possible, and it is
astonishing to note the great change for the better which
takes place when this has been satisfactorily accomplished.
If, at the end of forty-eight hours, a good satisfactory
movement of the bowels has been obtained, and the pulse
below one hundred, the patient is convalescent. If, on
the other hand, the bowels remain unmoved, in spite of
efforts to open them, and tympany appears, with rising
pulse, it is a serious matter. On the second day after
operation, an effort may be made to move the bowels, some
administering grain doses of calomel every hour until five
doses have been given; others recommend teaspoonful
doses oi Rochelle or Epsom salts every two hours until
three doses have been given. Medicines by tlie mouth
for this purp';.->e are, however, often contra-indicated,
causing nausea or the upsetting of the stomach. The
most satisfactory method consists in the administration,

POST-OPEKATIVE TREATMENT. IH)

on the second day, of nn enema of warm water and soap-
suds, introduced as high up as possible, by means of a
rectal tube or large catheter. If the enema is not effectual
it may be repeatt d once or twice at intervals of two or
three hours. Fl( tulcnce, or accumulation of flatus in the
bowels, is often a distressing symptom, but generally may
be effectually relieved by adding spirits of turpentine to
the enema, aided by light massage over the region of
the colon. A few drops of tincture of capsicum or of
essence of peppermint, in water, will often giv(^ material
relief. Tlu^ patient should be catheter i zed shortly after
operation, and, if necessary, every six hours afterwards,
but she is to be encouraged to attempt to void the urine
voluntarily, provided it can be done without much
straining. Nearly every patient is restless and suffers
more or less pain, which may be relieved by some slight
change in position, or by putting a soft pad under the
head and shoulders, or under the bends of the knees.

Shock following prolonged, or any operation, can best
be treated by kc^eping up the dry heat to the body and by
hypodermatics of whiskey or b-andy and strychnine. The
routine practice of injections ot strychnine, commenced at
once after operation, will often prevent the appearance of
the symptoms of shock.

Hemorrhage. Indications of collapse, with a falling
temperature and rapidly rising pulsi^, points to this grave
danger, and no time must be lost in re-opening the wound
and se(Oving for the mischief, and stimulating treatment
afterwards pursutnl by every effort known, (rreat benefit
will be derived from rectal injections of normal salt solution,
but more particularly from injections of the same solution
into the pectoral region by means of a small aspirating
lUHHlle attached to an ordinary enema syringe. Large
quantities can thus be injected, if rigidly persisted in.
The vomiting, due to the anaesthesia, should be over at the
end of eighteen or twenty-four hours, but sometimes it

100 MEDICAL AND SURGICAL GYNAECOLOGY.

persists longer niid becomt's n most troublesome symptom.
When vomiting continues after the third day, especially
wluni the fluid is expelled without much apparent force,
peritonitis is to be feared, lender the circumstances
nothing is to be given by the mouth whatever, but rectal
enema of peptonized milk or beef tea and the white of egg
may be given instead. To allay thirst and dryness of the
mouth it may be frequently rinsed out with cold water.

As a rule the patient should not be allowed to sit up in
bed until the eighteenth day. At the end of the third
week she may be allowed to get out of bed, and at the end
of the fourth week, allowed to walk, but before doing so
she should be furnished with an abdominal bandage, to
prevent any opening of the incision, to be subsequently
followed by a hernia.

The after-treatment of plastic operations for the repair
of the perineum or cervix resolves itself into rest and
cleanliness. The patient should remain in bed for two
weeks, and after that should take another week in getting
up and about. If a gauze tampon has been introduced
into the vagina, it slioul 1 bo removed after forty-eight
hours, and a warm sterile \' iter douche given daily.

Two aloin, strychnine an l)elladonna granules may bo
administered on the second evening after operation,
followed by a rectal enema in the morning.

CHAPTER X.

GYN/ECOLOGICAL APPLICATION OF ELECTRIC

CURRENTS.

But two currents may be said to be in use in gynre-
cologieal therapeutics; the <i<ilr(Uii(' or direct current, and
the Faradic, induced or iutcrrupted current.

The articles considered necessary for the application
of the galvanic current are, a battery, composed of from

APPLICATION OF ELECTUIC CURRENTS. 101

forty-tivo to Bovonty Loolnnche coIIh. set up " in scTios," or
tin- supply terminals of nn inenndesccnt electric li^lit
current. A riirrcid controller, such us the Mnssey, or
some reliable rhcosiot, to regulate or turn off or on the
current; a (jdlvdnometcr, indicating from 1 to 500 milliam-
lieres; rhcophorcs or flexible metallic cords, for conducti ng
the current; various forms of eh'cirodvs for its application,
and a romninfotor or pole chamicr. Instead of such a
bulky battery, many will doubtless prefer a portable one,
excellent varieties of which are to be fo'ind in most
instrument shops. Electrodes, when in use, are distin-
guished by the terms "positive" (anode) and "negative"
(cathode), the former receiving its name from being
attached to th(> first carbon, and the latter from its being
attached to the last zinc of the battery. They are also
distinguished by the terms, " internal " and " external,'
according to the locality to which they are applied.

Various forms of intra-uterine electrodes are in use.
They are made of platinum, occasionally of copper or zinc,
shaped like a Simpson's sound, c

and so insulated as to expose r^—^ f\

orly a small portion of the £_ *

distal end. The external, cutan-
eous, or dispersing electrode is
composed of a large, flat, con-
ducting surface. There are
several varieties. Apostoli uses
moistened sculptor's clay;
Engelman, a flexible plate of ,. ^ , ,

, . '' "'• 37 -iM.irlin s cutaneous electrode.

lead, six by seven inches and

Martin, a large concave plate, covered with a membrane
and capable of containing warm water. This electrode is
usually applied to the abdomen, sometimes to the back.
By using large and wet electrodes, we chiefly get the
interpolar effect, which is that of electrolysis. By using
small and dry electrodes, we chiefly obtain the polar effect,

102 MEDICAL ANU SUIUUCAL GYNAECOLOGY.

which, whi^ii the cunoiit is strong enough, bocomos
chemical cnuterizntion.

By combining largo wot oloctroch'H on the skin with
small dry oloctrodos in the uterus, burning of the skin is
avoided and chemical cauterization of the uterus obtained.
The two poles of the battery have ditFerent physical and
physiological effects. The positive pole attracts acids,
while alkalies collect ut the negative; tli oschai"
produced by the positive pole is dry, that by the nega-
tive is softer and larger and allows the galvanic? current
to penetrate througli it; the negative pole has a
stimulating effect and will draw blood to the parts, the
positive i)ole has a depressing, anti-congestive powiT, and
will disixd it; the negative pole causes pain, the positive
allays it; the positive pole has an escharotic drying
effect, the negative a softening, liquefying effect.

The Faradic current is produced by loading the
electricity, generated in two or three Leclanche cells,
through a short coil of coarse insulated copper wire, called
the primary coil, in such a way that the current is broken
and closed at short intervals. Outside the primary coil
is another, called the secondary coil, which consists of a
much longer and finer one of insulated copper wire. The
current passing througli the primary coil is called the
primary current, and that induced in the secondary coil,
by means of the primary current, is called the secondary
current. Both currents produce muscular contraction,
but the secondary, producing the effect in a higher degree,
is more generally used. With this current, in addition to
the electrodes already mentioned, bipolar intra-uterine
and vaginal electrodes are used by which the effects of the
current are centralized.

Practical application. Amenorrhooa of the functional
type is one of the aft'ections in which we may hope for the
greatest amount of good. Both the galvanic and the
Faradic may be used alternately in this condition. Mild

APPLICATION OF ELECTRIC CUKKENTS.

lo;}

gnlvniiio currents nv t best, from fifteen to rwenty nuUiani-
peres. Tlie positive jjole is to be placed over the abdomen
by means of the large electrode, r.nd if a virgin, the
negative may l)e applied, by meaiiH of a smaller electrode,
over the perineum, or if she Las
borne chiLlron or is married, it
is to be placed in the uterine
cavity. For the application of
the Faradic current the bipolar
vaginal and intra-uterine elec-
trodes may be used alternately.
iSit-iior,,\,()ftli(' uterine candl,
such as congenital pin-hole os
externum, spasmodic contraction
of the internal os, without ap-
parent disease, stenosis due to
sharp flexion forward or back-
ward, are amenable to galvanic
treatment. The negative pole
is to be applied to the constricted
part and the large positive pole
to the abdomen for ten or iifteen
minutes, with a powe" of fifteen
to twenty milliamperes.

Galvanism is also useful for
almost every form of dijsmen-
ovrluva. Here the best results

will be attained by the introduction of the positive jwle
within the uterus, because most painful menstrual states
are attributable to congestion in that region. The mem-
branous form yields better to curettage, but if galvanism
is to be emi^loyed, the negative pole in the uterus gives
the best results.

In suhinvolntion, depending ujjon a low grade of in-
flammation of the uterine tissue, in which the uterus has
engorged vessels with inactive muscular structure and a

Fk;. 38. — Apostoli's Bi-polar Ulcrine and
Vaginal Kxcitors : i, small uterine ;
2, metlium uterine ", 3, large uterine ;
4, vaginal, used in the uterus after
confinement.

104 MEDICAL AND SURGICAL GYNvECOLOUY.

cortaiii amount of lymph thrown out, couKi(h'rnl)U' UHsist-
ance may be obtaimnl from tho use of tho Faradic^ current;
one pole in contaet with the cervix^ the other over tho
ab'lominal or lumbar region.

In mihintJolufioH, in connection with injuries (luring
parturition, notably of the cervix, and in connection with
tubal and ovarian diseases and pelvic exudates, the gal-
vanic current, with t:ie negative pole within the uterus,
must be utilized. Fifty or sixty milliamperes of this cur-
rent, applied for fifteen or twi^nty minutes, twice a week,
will soon soften the uterus and render it capable of
absorbing, as well as promoting the absorption of patholo-
gical products of long standing.

EmIomHritis, In the simple catarrhal form, with
hypersecretion of the uterine follicles, and from frequent
repetition of which the uterus has become chronically
eidarged, the Faradic coil will cause the organ to regain
its tone, and its nutrition may be improved by frecjuent
and mild applications of the galvanic current, the positive
polo being intra-uterine. In the hemorrhagic, or fungous
form, recourse is to be had also to the positive galvanic
pole, seeking to bring it in contact with the entire
surface.

Fl<i>ifie <'.ifii(l(iti()ii. Good results often follow the adop-
tion of this treatment in old parametric and i)erimetric
exudates, but a careful diagnosis that pus is not present
somewhere, must be made, before proceeding to its use.
The positive ball electrode, covered with chamois or clay,
is to be placed within the vagina and the largo electrode
over the abdomen. Beginning at zero, the current is to be
worked up to forty or tifty milliamijeres, and continued at
that point for ten or fiteen minutes. The treatment is to
be repeated twice a week.

CdUirrluil S<ilj)lii</itis. The positive electrode is to bo
pushed uj) as far as possible into the uterine cornu and a

APl'LKJATION OP ELECTRIvJ CUKUIiNTS. 105

morlornto ".ilvniiic riurront of twonty to thirty millinm-
peroK, for t 1 to fift(>(M) miiiutoH, tununl on.

In elm <• rotujcxtiou of flic onirif, without dcciih'd
(U'g(4uirntion, the poHitivo ball oUH!tro(le in to In* plmuMl in
the vajifina or rectum, as near as possible to the eiihirjjjcd
ovary, and a moderate curreni of ten to twenty inilliani-
per(>s. for ten minutes, applied.

Orai'ian (did pclric nciu'dhjia. There »ire eertaiu pains
in the region of the ovaries and deep within the pelvis
which are found difficult to associate with disease, but
which are more likely samples of reflex neuralgia. In such
cases electricity may be used to great advantage. First of
all, use bipolar faradization with the tine wire coil,
graduallv' increasing the strength, then changing to the
coarser wire coil, until the parts either become benumbed
or free from pain.

Uterine jibroids. Before attempting electrical treat-
ment in such cases, a positive diagnosis must be made of
their position, whether sub-peritoneal, intra-mural, or
sub-mucous, and of their quality, whether hard, or of the
soft, cedematous variety.

Snb-miirous pcdniicnldtcd Jihnu'ds will be benefited
by the treatmeni, only by being forced out of the uterus,
and care should be taken not to devote much attention to
sub-peritoneal fibroids. Of the different varieties, the
myo-fibromata are the ones for which the most good can
be accomplished. Next in order stand the pure fibromata,
but the durable effect, when once produced, will be the
most marked in the fibromata. The first variety will
require small amounts of galvanism frecjuently repeated,
the latter will call for high intensities and short
sittings.

The application of galvanism to soft (vdcnudous
tititiors should be avoided, as it often stimulates them to
new growth, or promotes a tendency to break down into
fluid spaces.

1 1
I

10() MEDICAL AND SURGICAL OYN.ECOLOOY.

Fi'hi'o-cijstic tnniorn hImo forbid the use of tin? j^alvnnic
current, on account of their poor vitality, and their liability
to break down and produiie systemic poisoning.

The cases reiK)rted, in which fibroid tumors art'^ said to
have disappeared, are rari^ <u)nsi(lerinf^ the number tn^ated.
In the lar^e majority tluTe is a p(^rceptible diminution in
size which persists for a longer or shorter period. For the
application of the j^alvanic current to uterine fibroids, the
large flat electrode is placed over the abdomen and the
intra-utc^rine pole to be used will (h^pend upon the results
desired. The i)ositive pole is to be used when it is desired
to affect the mucous membrane especially, and to arrest
hemorrhage; the negative for electrolytic treatment. For
the escharotic effect, thirty to fifty milliamperes during
ten minutes and repeated a few times, will usually be
sufficient. For electrolytic treatment the power is to be
gradually increased up to the extreme limit which the
patient will bear. Five to ten minutes will be sufficient,
and the time for the repetition will b(> determined by
observing the effect upon the tumor and upon the patient's
general condition.

Ectopic [fcsidtion. Both the Farad ic, and galvanic
currents have been recommended to destroy the lift^ of the
fcetus previous to the fourth month. With the iiresent
knowledge of the extreme dangers surrountling ectopic
gestation, increased often to their greatest intensity by
even the slightest maniiiulation, it can scarcely be con-
sidered safe to submit a patient to the manipulation
necessary for the application of either current.

Crtjliotomy is a much safer procedure, and consequently
the use of the electric current can only be consideretl
justifiable in localities far remote from skilled hands, or
where removal or delay means grave danger, or in cases
where ^he patient positively refuses to submit to ccDliotomy.

PART TWO.

FUNCTIONAL DISEASES.

CHAPTER XII.

DISORDERS OF MENSTRUATION.

Abnormal changes in the menstrual flow are to be
rc^nrdt'd only ah symptomH whieli linvi^ thoir origin often
in opposite couditions and retpiire diHcrimination in
their treatment. Tlie menstrual tiow may be absent
(<n)i('H(>n'luv(() or scanty; it may be painful {(lijsnioi-
orrlnvd) ; or it may be profuse {)iK'ii()rrlHt<ji(i). When the
hemorrhage is profuse at other times than at the menstrual
period, it is termed mciron'luuiia.

AMEN()RRH(EA.

Amenorrhoea, or absence of the menstrual discharge,
is termed ])i'iniarij, when the patient has never men-
struated, and secondary, when menstruation has previously
occurred.

Primarij (imenorrha'a may be divided into {a) prim-
(irif pcrmdnciit amcnorrhivd, the most marked cases being
those in which the ovaries, or uterus, or both, continue in
a rudimentary condition, or are altogether absent, while
the external genitals are normally formed, {h) Primary
fcmporarij amcnorrJuva may be due to chlorosis occurring
in girls under the age of puberty. Menstruation occurs
later than normal, and, when it does set in, the flow is
scanty and of short duration, (c) Delayed lyuherfy.
Here the general and sexual development is complete, yet
the girl fails to menstruate. It is often caused by over-
work, combined with insuffirnent food, by change of

1()8 MliDIC'AL AND SUIUIIC'AL OYNEfOLOOY.

{ilimiiti^ or luibitH ni about, the (<x[)'H't('(l [U'riod. or by too
long coiiliiKMiuMit (luring acliool lioura, combined witli an
ovor-taxt'd bra.'u.

Sccomldi'ff (imcnon'h<v(( may b»' di.. to rormtitutional
dcrangomiMits, as antomia, chloroHiH, diabi^toH, Hriglifn
(liHt'aso, malaria, cancorouH carlicxia, tubi^rcudosiH, or acuto
ilhu'HHCH. or i^ nuiy bo diu> to the intlucncc of tho norv.niH
HyntiMU. Huoh as Hovore mental Hhoek. alarm or Huddtui
fright, or by tho norvouH system generally being overtaxed.
Among other causes may be mentioned obt^sity, change of
climate, sea voyagi's, and sudden or prolongc^d exposure to
cold, particularly at the menstrual periovl; or it may bo
due to accjuired atrc^sia f)f the cervix, or of the vagina.
Kemoval of both ovaries does not always lead to complete
amenorrluua, some women (continuing to menstruate for
years after their removal. There are ditt't^rent explanations
given, among which may be mentioned, the existence of a
supplementary ovary, by a portion of the ovary being left
in tho pedicle, and by tho law of "persistence of habit."

Symptoms. Besides the absence of the periodic flow,
whi(ch is of course tho chief symptom, there are other
symptoms to be taken into consideration, and which are
for the most part tho.se of the primary disease causing it.

When a case of amonorrluBa presents itself, it should
detinitoly bo setthnl whether it is primary or secondary.
Primary amenorrhom, in which the menstrual flow has never
occurred, leads to questioning whether the uterus, tubes,
and ovaries be present in their entirety. If present, it
becomes necessary to ascertain whether atresia of the
cervical canal, vagina, or vulva exists. If tho prodromic
symptoms of a menstruation be absent, it points to con-
genital deficiencies, but if the prodromic symptoms have
been present, and repeated at lunar intervals, with no
menstrual flow, suspicion of atresia is excited. If the case
be one of secondary amenorrhoia, pregnancy and lactation
must bo excluded. When arising suddenly, as for

DISOUDEUa OF MENSTRI^VTION.

iiistaiico, from taking cold, huoIi HymptomH nn fovor, rnther
Bovero ht>ft(Iu(On% paiiiH in tlu'^ back and pelviH and oxtiMul-
in^ down tiw thij^liH, with irritability of tin- bladdt^r nnd
bowels, ^oncrally appear.

Diagnosis. Tlio most important <u)ndition from which
it niuHt he (tan^fully dia^noHed is pn-^nancy, normal or
ectopic. Evt^ry Hij^n of pre^nanc^y, parti(udarly tht^ early
oncH, must be thought of and carefully brought to bear
ui)ou the caHt\ Upon tluB point the prat^titioner must
"Iwiys be on his guard. Designing women ofttMi consult
.. physician for anuMiorrhoMi, when they know tlu^y are
pregnant, hoping that something will be done to bring on
their courses and thus interrujjt gestation.

Treatment. Before any line of treatment can be satis-
factorily establisluHl, a correct estimate of the symptoms
must be madi^ and a conclusion arrived at, whether it is
physiological or pathological. If the former, no treatment
is needed; if the latter, the treatment will vary according
to the special cause and must aim at the correction of the
underlying morbid conditions. Hot hip and foot baths
are generally useless, unless the function is about to
appear. It is not uncommon for the menstrual function
to be delayed for one or more years, or to be irregular, or
8usi)ende(l, for the first few years after its commencement,
and hence no special remedy is needed, except attention
to hygiene, diet, dress, exercise, and baths. The uterus,
in such cases, being imperfectly developed, time must be
allowed for its normal growth. Acute suppression, such
as that arising from cold, is bost treated by rest in bed, a
hot sitz bath every six hcurs, with a warm water vaginal
douche at the same time, and by the administration of a
laxative. Hot water bags applied to the abdomen and
lumbar region, pediluvia with mustard and water assist
frequently in giving r(^lief. The use of the so-called
direct emraenagogues, as rue, savin, and cantharides, is
objectionable. The uteriiu^ function should never be forced

110 MEDICAL AND SURGICAL GYNAECOLOGY.

when the geuornl system is struggling for existence;
besides very few remedies liave any direct stimulnting
effect on the lining membrane of the uterus. Amenorrhcoa
from malaria calls for the administration of qHiniiK' and
change of climate. Rheumatic amenorrluua sometimes
calls for the salicyldh')^. Ciniicifiu/d and (ina{(icu}ii are
excellent remedies for rheumatic amenorrluxja, but espe-
cially for delayed or painful menstruation. PnhatiUa
is indicated when the menses have been stopped by mental
shock or fright. Apiol is one of the most safe and
efficient emmenagogues, and may be given in capsides
containing five or six drops, three times a day, for a few
days preceding the expected tlow.

Aloes indirectly stimulates the internal genitalia, and
is one of the best adjuvants to other treatmejit when con-
stipation exists. Strijchnhic is a good muscle and nerve
tonic, and will assist the action of iron. Lron is the
hfBmatic tonic, and stands first. It has nn emmenagogue
action, increasing the blood supply of the pelvic organs,
and may be administered in any one of the recognized
forms, such as the dried sulphate, the carbonate, the
muriated tincture, either plain, or in the form of elixir or
glycerole. The citrates, tartrates, lactates, peptonates, or
other mild i)reparations are useful, but not so rapidly
efficient. The therapeutic effect of any of these can often
be improved by the combination of a small dose of liquor
potassre arsenicalis or liquor arscnuci hydrochlor. Bland's
pill, composed ci sulphate of iron and carbonate of potash,
or the modified pill which contains arsenious acid as well,
often gives excellent results.

Among the various combinations the following are
the most generally serviceable :

R. Aloui, grs. xii;

]'il. Ferri Carb., drams isfir

Myrrh, dnim ss; M«

Ft. pil No. XL

Sig. — Take two pills, three times a day, after meals.

DISORDERS OF MENSTRUATION.

Ill

R. Ferri Siili)lmt., Exsiccat., grs. xl;
Quiniii' Sulphat. , grs. xl;
Strychnia' Sulphat.,gr. i;
Ext. (ientian, q.s. M.

Ft. pil No. XL.

Sig. — Take one pill after tneala.

R. Ferri Sulphat., dram i ;
Pot<i8H. (!arb. , dram i;
Quiniii' Sill, 'iat., dram 88 ;
Ext. Nunc. Vom., grs. iv ;
Aloin, grq. iv.

Ft. pil No. XL. M.

Sig. — Take one to two after meals.

R. Tinct. Ferri Mur., drams v;
Liq. Arson. Mur., dram i ;
Acid Mur., C.P. dram i ;
Sj'rup Simplicis, ad., oz. viii. M.

Sig. — Dessertspoonful, in wine glass of water, after nteals.

Pofdssium pcrmaiu/aiKitc or blnovidc of mam/aiicse
sometimes verv efficnciou;?, when administered for a
few days precediiij? menstruation, but the former often has
a distressinjij eft'cot upon the stomach.. The k)cal usi^ of
electricity is the most reliabhi of all emmenagogues, being
the most direct \iterine stimulant we possess. It is well
adapted to stubborn, long continued cases, which have
resisted hygienic and medicinal treatment, more particu-
larly when the uterus has been found small and ill-
developed, or has been atrophied from superinvolution or
chronic metritis, or in cases in which the internal genitalia
have been found markedly dormant and atonic.

Vicarious menstruation is a condition closely allied
to amenorrluea. It means a condition of the female
system in which there is a regularly recurring discharge
of blood from other par' of the body besides the uterus.
The sanguineous flow may come from tlu^ nose, bron-
chial tubes, stomach, intestines, or rectum; generally it
comes from a mucous siirface, but it may take place from
the skin or at the site of a wound. The treatment
applicable is that adapted for ameuorrhoaa.

112 MEDICAL AND SURGICAL GYNECOLOGY.
MENNORRHAGIA AND METRORRHAGIA.

The first of these two words is usod to oxpross nn
excessive menstruation ; the second, for n flow of blood not
only nt the menstrual time but between menstruntions.
Neither condition is a disease, but a symptom of some
well-defined pathological '■ ^udition. Women vary greatly
within the physiological limits in the amount, the dura-
tion, and the frequency of menstruation, and it is thus
difficult sometimes to say where normal menstruation
ceases and menorrhagia begins. Menorrhagia may occur
as an excessive flow of blood during the normal numbi^r
of days, or an ordinary flow extending over an excessive
number of days,

Causes. Hemorrhage associated with abortion, myo-
matous degeneration of the chorion, placenta previa,
retained membranes, and the like, are not to be considered
as having a place under this heading. Women of
hemorragic diathesis bleed more freely at the menstrual
epochs. Hremophilia, scrobutus, and purpura act in the
same way. Chlorosis, as a general thing, tends to
amenorrhcea, but in some cases it leads to menorrhagia
and metrorrhagia. Many other conditions dispose to it,
as long-continued mental depression and other nervous
disturbances, luxurious living and sedentary habits, resi-
dence in tropical climates, malaria, tubercle, the acute
exanthemata, lead and phosphorus poisoning, and
Brlght's disease.

It may be associated with disorders of the circulation,
such as mitral incompetence or stenosis; congestion, from
any cause, of the portal circulation; renal or splenic
disease; abdominal tumors, or even overloaded bowels.
The chief local pelvic causes are ovarian, uterine, and peri-
uterine congestions and inflammations; tubal inflammatory
diseases; the earlier stages of chronic metritis; subinvolu-
tion; chronic endometritis; cervical lacerations; diplace-
ments; uterine fibroids and polypi.

DISORDERS OF MENSTRUATION. • 118

One of the most common onuses is the jirosence of
fungositios within the uterine oivity; and malignant
diseiises of the uterus is nhnost invariably followed by
menorrhagia and metrorrhagia. Many women firmly
believe that the menopause must be attended by an
excessive menstrual flow. Such is not the case; after thti
menopause has once been established, post-climateric
hemorrhages are almost invariably due to a local lesion,
such as senile catarrh, cancer, or the presence of mucous
or fibrous polypi.

Tr('((f)ii('nf. The treatment of menorrhagia resolves
itself into that aijpropriate for the attack, and that for the
menstrual interval. Rest in bed, in the recumbent position,
should be insisted on, light non-stimulating diet, the
— ictum unloaded and the bowels kept open. Chronic
jnstipation, particul- "ly when associated with congestion
of the portal circulation, is to be overcome by a pill of
podophyllin and nux vomica at night, followed, in the
morning, by a teaspoonful of some saline, such as effer-
vescing granular phosphate of soda, or a wineglassful of
Hunyadi Janos water.

The medicinal hemostatics to be used must d(>pend
ui)on the provoking cause. In moderate, persistent, erratic
hemorrhage, particularly where the fault lies in the heart's
action, or in a retarded venous circulation, (lij/itdli)^ is one
of the best remedies. It operates by increasing the arterial
tension and thus improves the atonic circulation. Enjot
is singularly well adapted to conditions of the uterus in
which there are well developed, but relaxed muscular
fibres, with dilated and engorged blood vi^ssi^ls. The more
soft, flabby, relaxed and engorged with blood the uterus is,
the more pronounced will be its effects, hence it is partic-
ularly indi(!ated in chronic hypenemia, active or passive;
in chroiiic metritis, in its first stage, and in subinvolution.
Hiimamclis, in the form of fluid extract, is a most usi^ful
remedy. For sudden outbursts and for active and profuse

114 MEDICAL AND SURGICAL GYNAECOLOGY.

hemorrhage it is inferior to c^rgot, b\it for n slow long
continuous flux, or hemorrhngo pnssivo in chnracter, it is
the remedy j)a?' excellence. The fluid extract of ergot and
hamamelis make an efficacious combination. Hydrastis
Canndeiisis is a vaso-constrictor in congested states of
relaxed mucous membrane and for uterine hemorrhage,
due to endometritis, myomata, or incomplete involution, it
is very valuable. It also combines well with ergot. A
neat way of administering is in the form of hijdt'dstine,
given by the mouth or hypodermatically in a ten per cent,
solution.

The following combinations have been found very
serviceable :

R. (•allic acid, dram i;

Ergot, Fluid Extract, oz. ss;
Acid Sulph. Aromat, drams iiss;
Elixir Simplicip, ad., oz. viii. M.

Sig. — A table«{>oonful in some water every four hours.

R. Ergot, Fluid Extract, oz. ss;

Hamamelis, Fluid Extract, drams iii;
Tinct. Hyoscyam, drams iiss;
Elixir (Jentian Co., oz. i;
A(juas ad., oz. viii. M.

Sig. — A tablespoonful in some water three times a day after meals.

Thicfure I)i()if(dis, drams iiss, may be combined with
either of these, should the indications call for it.

The action of medicinal agents should be supplemented
in severe cases by local applications. Hot water may be
injected into the vagina, and when the patient has
become deeply aniemic from loss of blood, normal salt
solution may be injected into the rectum. The best non-
operative means is the vaginal tampon. The vagina and
cervix may be tamponed with absorbent cotton after the
hot water irrigation and allowed to remain there for
twenty-four hours. During the intervals, the judicious
and thorough use of the currette is one of the best means
of promptly and safely curing many of these cases.

Local galvanization of the uterus is a therapeutic
agent worthy of the highest consideration in uterine

DISORDERS OF MENSTRUATION. 115

hemorrlingo (loppiidont upon uterine fibroids nnd chronic
nfpections of the endometrium. Faulty conditions of the
blood from niiiinnin, chlorosis, or defective hygiene, are to
receive special care. Iron, in the form of the nniridtrd
fiiicfurc, forms an excellent means for checking excessive
menstruation dependent upon marked annemia; however,
in most causes it is to be utilized only daring the mens-
trual interval. Arsenic is a most valuable hemostatic in
the menorrhagic conditions of young girls, as well as of
women nearing the menopause. At such times, if too
profiise, too frequent, or continues too long, it is best met
by administering threi^ to five drops of liquor potassse
arseuicalis three times a day. It seems to be indicated
when iron is contra-indicated, and may be given during
the time of the flow as well as during the interval. A
generally favorite prescription is known as the combination
of the sulphates.

R. Magnesia' Siilpli., dniins vi;

Qiiiniii' 8ulph., grs. xxv; ,

Ferri Sulph. Exsiccat, grs. xl;
Acid Sulph. Aroinafc. , drams iis.s;
Acjua Mentha' Pip., ad., oz. viii. M.
Sig. — A tablespoonful in a wineghi.ssof water after meals.

R. Pulv. Ferri Redact., grs. xl;
Quiniie Sulph., grs. xl;
Acid Arseniosi, grs. i;
Extract (ientian., (js. M.

Ft. pil No. yh.

Sig. — One pill after each meal.

Precocious menstruation is a regular lunar flow of
blood from the genitals every four weeks, occurring in
children below the age of puberty. As a rule, both the
external and interal genitals and the breasts are abnor-
mally developed in such children, and sometimes they show
sexual appetite. Nothing can be done for them except to
keep up their strength, and such other treatment as will
make uj} for the loss of blood, until they have reached
the proper period.

lift MEDICAL AND SURGICAL OYN.EC()L()GY.

DYSMENORRH(EA.

Dysmenorrhcea means difficult or obstructed men-
struation. It is one of the most common of the various
menstrual deranfj^ements, and manifests itself by pain,
which varies greatly as to frequency, duration, time aud
severity. It may properly be divided into the following
varieties: — The ncuvdlf/ic, the rofUfCfit ire or injUimmaiovji,
the ohstnictivc, and the mcmhrcmous. To this classifica-
tion the ovdvlan has been added by some authorities. It
differs from the others more in location than in kind, and
it can scarcely be said to deserve recognition st^parate
from the inflammatory.

Spasmodic dysmenorrhcea is a term applied to the
neuralgic form, in which there is spasm of the circular
fibres about the os internum.

Neuralgic dysmenorrhcea. This variety does not
depend upon any appreciable organic disorder of the
uterus or of its appendages. Ordinarily, on the most
careful physical exploration, no alteration in size, shape,
position, consistency, or vascularity of the pelvic organs
or structures will be noticed. The sentient nerves of the
endometrium appear to be in a state of hyi^eraisthesia — a
neuralgia in the ordinary sense of the term.

Cduscs. There are many agencies which, at times, so
alter the healthy state of the nerves as at one time will
produce a gastralgia, at another an occipital or facial
neuralgia, and similarly in neuralgic dysmenorrhooa there
is present a local neurotic state, provoked to the excita-
tion of pain by the stimulus of the physiological congestion
incident to the oncoming menstruation. The causes which
generally induce it are: The neuralgic diathesis, hysteria,
chlorosis or plethora, malaria, gout, rheumatism, luxurious
and enervating habits, and habits deteriorating the ner-
vous system.

Symptoms. It is by far the most frequent variety, and
is found oftenest in those who are subject to the various

DISORDERS OF MENSTRUATION. 117

neurotic discnses. The pain mny show itself before the
flow hns been established and disappi^ar as soon as it
comes on, or may continue with varying intensity throuj^li-
out the duration of the menstrual discharge. The pain is
located in the uterine or ovarian regions and radiates
towards the iliac, abdominal, lumbar, or sacral region, or
down the thighs. The discharge may be scanty or profuse,
and the severity of the pain seems to bo in inverse propor-
tion to the quantity of the flow. The diagnosis is made
by the exclusion of the other varieties. The pain felt in
the uterus has nothing expulsive in its character, the flow
is steady and not interrupted, no clots are discharged by
spasmodic efforts, and physical examination discovers no
obstruction. These facts will distinguish it from obstruc-
tive dysmenorrhoea. It is differentiated from the conges-
tive form by the absence of constitutional disturbance and
by its being habitual and not exceptional, by the absence
of the ordinary signs of endometritis and of ovarian and
pori-uterine inflammations.

The trcdtmcnt resolves itself into that which is appro-
priate for the time of the flow, to relieve pain, and that for
the interval, to remove the cause and prevent its repetition.
If the rheumatic or . gouty diathesis *>xists, it may be
combated by administering half dram doses of the
ammoniated tincture of guaiacum. by twenty drop doses
of the wine of colchicum, or by Ave t'^ ten grains of soda
salicylate, three times a day. In amemic and neurasthenic
cases ferriagineous and nerve tonics such as iron, nux
vomica, phosphorus, quinine, cod liver oil, malt extracts,
and the hypophosphites should be given, and the strictes*^
attention to general hygiene observed. If plethoric, a
strict plain dietary should be demanded, and administra-
tion of such purgatives and saline medicines as will favor
the portal circulation and deplete the system generally.

Malarial toxeemia should be treated by quinine and
change of residence. A sea voyage will often accomplish

118 MEDICAL AND SURGICAL GYN.ECOLOdY.

excellent rosults. Local fnrmliziition with the secondary
current in UHefu!, but often the bcBt rcHults are to be
obtaintul from the galvanic, with the positive i)ole intra-
utiirine. For relief at the menstrual pt^riod tlu^ use of
opium and cldoral should be forbidden, except under
extreme necessity. Phenacetint> in five to ten grain doses
often gives almost immediate relief. Tincture of cannabis
indica, in doses of ten to fifteen drops every four liours
while the pain is severe, is also beneficial, and should be
tried before resorting to opium or chloral. Apiol. in
five drop capsules, given three tinu^s a day for a f(^w days
before the flow is expi'cted and continued mon^ often
during the fiow, has done excellent service, especially in
the amenorrluvic forms of dysmenorriuua. Tincture of
Pulsatilla, given three times a day for at least three days
preceding the painful period, is indicated in the neurotic
types of the disease, especially in young women. Tincture
of cimicifuga. given three times a day during the whole
interval and more fre([U(uitly at the menstrual period, is
useful in the neuralgic and rheumatic forms. Viburnum
prunifolium, in the form of fluid extract, often gives good
results when administered in half dram doses for a few
(lays before the exijected period and continued during it.
This treatment may be supplemented by hot vaginal
douches and the introduction of one-fourth grain sup-
positories of extract of b(>lladonna.

Congestive or inflammatory dysmenorrhi^a. At
each menstrual period an active congestion occurs in the
mucous membrane of the Fallopian tubes and uterus, as
well as in the ovaries, and probably to a less degree in the
pelvic tissues. When any abnormal influence renders
this excessive, it naturally produces pain in the nerves
lying between the distended vessels. This excessive
hypericmia, which may result from a mechanical cause, as
a displacement of the uterus, or from a vital cause, as the
peculiar condition which we know as inflammation, gives

DISORDERS OF MENSTRUATION.

U\)

rise to n vnrioty of painful inouHtruaticu which has boeu
styled congostivo or inHammatory.

Causes. In a groat many cases inHanimation of the
uterine mueou.^ membrane is the cause of this form of
(lysmenorrluDa. The existence of disease in this part
causes perhaps little pain until aroused by menstruation.
It may result, however, from almost any i)elvic inflamma-
tion which alters the condition of the m^rves immedialely
affected by ovulation or menstruation, or from any c luse
which exaggerat(>s and prolongs the congestion excited by
ovulation. Chief among these may be mentioned general
pk>thora, exposure to cold and moisture, sudden mental
disturbance, disturbed portal circulation, displacements of
the uterus, fibroids of the uterus, areolar hyperplasia,
endometritis, pelvic cellulitis, and peritonitis.

Si/mplonis. The patient, who has previously men-
struated painlessly, is seized during a period with severe
pelvic pain, accompanied by di munition or cessation of
the discharge and considerable constitutional disturbance.
The pulse becomes full and rapid, the skin hot and dry, and
with these there is headache, nervousness and restlessness,
and occasionally rectal and vesical tenesmus. In cases in
which a local inflammation exists, when the flow begins
or before that time, the patient suffers from dull, heavy,
fixed pelvic pain, which lasts until the process is ended,
and even afterwards. If it be due to hypenemia, the
suddenness and constitutional disturbancew will mark its
difference from the neuralgic and obstructive form, and if
it be due to the influence of existing pelvic inflammation, it
will usiially be marked by jjain during the inter-menstrual
periods, by difficult locomotion, fatigue after exertion,
leucorrhoea, and such like.

Treatment. As in the neuralgic form, the source of
the trouble must be sought for and combated along the
lines laid down for the treatment of that particular form
of disease. General or local plethora must be relieved,

120 MEDICAL AND SURCUCAL (iYN/Ct'OLOGY.

(liHplntHMnoiitH and versions ovorcom(% and if niiy lociil
iiiHamination bo diHooveriMl, it should hv tlio subjoct of
trontmcnt. Should the fittnc-k bo nccidoutal nud duo to
hypi^raMnin moroly, as from oxi)OHuro to cold and nioisturo,
the patient had better be put to bed, hot applications
applied over the hypogastric and lumbar rofjfioiiK, and a
hot vaginal douche administorod every four hours. A
saline pur^e is to be ^iven, and a febrifuge mixture com-
posed of the following administered:

R. Tinct. Aconit., dram 88;

Liciuor Ammonia! Acefcatin, o/.. 188;
Spirit .'Ether, Nit., drums v;
Atjuii', ad., oz. iv. M.

Sig. — Uessertsjwonful in Home water every two liourw.
The pain may be relieved by phonacetino or by small
repeated doses of Dover's powder.

Should local inflammatory conditions be discovered to
bo the cause of the dysmenorrhfea, a small cotton tampon,
impregnated with boro-glycorido, with or without the
addition of a few drops of fluid extract of belladonna, and
inserted behind the uterus, will often give marked relief.
A five per cent, solution of ichthyol in glycerine applied
in the same way will act in a similar manner.

Local applications of heat and vaginal douches will

also act as valuable adjuvants. The internal administration

of bromide of ammonia, or of tincture of cannabis indica,

combined with liipior ammonia acotatis, spirits of ammonia

aromat and peppermint water, will have a decided soilntivo

effect, and tend to relieve the congested state.

R. Ammonia' Bromid., oz. ss;

S[)t8. Ammoniiv Aromat, oz. i ;
Li(|. Ammoniiu Acet !. i ;

Aqua> Menth. Pip., oz. viii. M. •

Sig. — Table.spoonful in some water every four hours.

Obstructive dysmenorrhoea. If after the blood has

collected in the uterine cavity any obstruction exists to

prevent its escape into and through the vagina, sijasmodic

pains are excited which often amount to uterine tenesmus,

DlSOUbEUS OF MENbTUUATiON. 121

and (irc^ very Himilar to the (WpulHivi^ paiiiH xHuirrinjjf
(luring iioriiml labor. To tliiH form of painful uumi-
struatiou tin* name obHtriuitivi^ (lyHnuMiorrluua \uxh boon
applied. The obHtruction may exist in tho corvix or os, in
the vagina, or at the vulva.

The special raiiscs of obstructive dysmenorrhcua aro
con^^enital or acciuin^d contraction of the cervical canal,
such as is found in the elongated and (lonoid infra-vaginnl
cervix, with pin-holo os, or that form arising from chronic
intlammation, especially inrtammation resulting from the
vicious use of strong caustics. Flexions of the uterus,
especially wlien the angle formed is sharp, will produce it,
more particularly when associated with version. Vaginal
stricture, either congenital or acquired, will prevent the
free escape of blood and produ<!e uterine tenesmus, and
in like manner the hymen may produce the same effect.
Sometimes a small polypus comes down to the os internum
and resting upon it, acts upon the principle of the ball
valve, and by so doing produces the worst features of
obstructive dysnienorrluua. A fibroid in the parenchyma
of the cervix, by producing tortuosity of its canal, will
cause a similar effect.

The s///«7>/o;».s are characteristic. After menstruation
has continued for some hours, and sufficient blood has
collected in the uterus to distend it, a spasmodic pain
occurs in the jK^lvis, increasing into a more or less violent
expulsive eft'ort, like the contractions attending a mis-
carriage. This, in time, causes the passage of a certain
amount of blood, the pain then ceases and the patient is
relieved, until further distension and obstruction occurs,
when the process by which the uterus empties itsel'; is
repeated. These symptoms are so marked and decided
that little difficulty will be experienced in a diagnosis, but
before a decision is arrived at, a careful physical iwamin-
ation should be made, to discover the cause and thus place
the matter beyond doubt.

122 MEDICAL AND Sl'lU;iCAL UYN-ECOLOOY.

Trcdttiiciit. Till' ln>Ht rccoj^iii/t'd trcatmciitof onlinary
cftH(^H of iu'rvi(Mil o()iiKtri(^ti()n, wlu'thcr u('([uirc(l or con-
j^i'iiital, is (lilutHtloii by incanH of j^radiiatcd dilators, or
more fonribly by iiu^aiiH of (loodi'lTH or some otluT nivrl
dilator. Wlu'ii the conHtrictioii docK not cxiKt within tlio
ciTvicMd (^anal. it in usually tlio rcKult of Homo Ht'vrro
intiammation following; tlu^ uh(^ of caustics, or of a (u»rvical
laceration, and in such (^ascs it may be found ninu'ssary to
lay opiMi the oh by cutting with a knife or wussors. Tn
order to keep the cervix or os patulous, the dilators may be
introdu<^ed from time to tinu\ but the method is painful
and often unsatisfactory. The difficulty may be overcome
by at onci> inserting a glass or aluminum intra-uteriiui
stem pessary and rt^taining it in place by means of
tampons friupiently changed, or better, by a Thomas' cup
pessary, allowing the pessary to be worn for two or three
months. The intra-uterine stem pessary is the best
method of treatment, after the canal has been straightt^ned,
for constriction arising from flexion. Obstruction, arising
from vagitml stricture or obturator hymen, may be ov(^r-
come by dilatation or incision. Polypi and submucous
fibroids in the cervix are to be at once removed.

Membranous dysmenorrhcea. This variety consists
in the exinilsion from the uterine cavity at menstrual
periods, of organized material, which is found to consist of
structures resembling the lining membrane of the uterus.
It may consist of a sac representing the triangular cavity
of the body of the uterus, with its three openings, or it
may come away piecemeal, in shreds, or as strips of
mucous membrane. When more or less complete it is
soft, comparatively tliK-k, and with many perforations, the
sites of the utricular follicles. Under the microscope the
cast is found to consist of the lining membrane of the
uterus hypertrophied in all its elements, almost exactly as
in pregnancy, lieMice it has been termed " menstrual
decidua." There are many views held as to its etiology,

DIS'.UUEUS OF MENSTRUATION.

123

l)ut the two nmin oiu>h nrc, first, tliat it \h an exfoliation of
the entire nuK^ouH membrane of the uterine body (hi(> to
irritation transniitted to it, the rt'Hult of some ovarian
(list'ase. This view is tho one most fre([ia ntly accepted.
Second, that it is an exudation, thrown out ovi^r tiio
ut(>rini^ wall, the result of endometritis, and tH)nstitutinj^
a caste of the uterine cavity.

Membranous dysmenorrho^a may be confoundi'd with
early abortion, blood casts or fibrinous moulds of the

Fn;. 3g. — A Dysmenorrhtual Membrane laid open. ■

uterus, or with exfoliation of the vaginal mucous membrane.
From the first of these, the differentiation may be accom-
plished by the progress of the case, the repetition of tho
pr- ^ess, and the caitire absence of the symptoms of
l^regnancy, wliile tiie microscope will show the absence of
villi of the chorion and of tho large irregular decidua
cells. Blood clots and vaginnl exfoliations will also be
readily recognised by the microscope.

Sij)iij>t(niiii. With the commencement of the menstrual
flow there are steady pains which iucrense as it progresses

124 MEDICAL AND SURGICAL aYN//COLt)GY.

until tlioy become violent nnd expulsive, like those of
abortion. Under these the os gradually dilates and the
membrane is forced out into the vagina. Tlu^re is
commonly a tendency to menorrhagia, which however,
soon disappears, but for some tim(^ after it has passed off
there are symptoms of endometritis and purulent and
sanguineo-purulent discharges.

Trcafnioit. The uncertainty of the i)athology of this
disorder has led to a great variety of treatment. For the
pain which attends the attack, a hypodermatic of morphia
may have to be administered, and occasionally the pain is
so severe as to demand the administration of a little
chloroform or sulphuric ether, particularly when morphia
is not well tolei-ated. Hot applications and vaginal
douches, so useful in all forms of dysmenorrluua, are also
ai)plicable here. If uterine or ovarian disease be detected,
it should bo treated in accordance with general rules.
The largest number of cases successfully treati'd has
followed repeated dilatation and curetting cf the uterus,
in conjunction with applications of chloride of zinc or
carbolic acid, and packing with iodoform gauze. This
line of treatment may alternate with galvanization, ten to
twenty milliami)en^s, the negative pole intra-uterine. All
varieties of constitutional treatment have been tried and
abandoned.

Ovarian Dysmenorrhcea. In a number of cases, by
no means small, no disordered condition of the nervous
system will be found to account for habitual dysmen-
orrlnua, and exploration of the pelvis will fail to discover
uterine or peri-uterine disorders. By a careful bimanual
examination in such cases, a globular slightly compressed
mass, abo\it the size of a walnut or small egg, will often
be found in Douglas' cul-de-sac, or or one or both sides of
the uterus, low down and in close proximity to it. These
are the ovaries, enlarged, tender, prolapsed, and revealing
a condition known as chronic ovaritis. The pain in this

DISORDERS OF MENSTRUATION.

125

form of dysmenorrlujoa precedes the flow by several days
and diminishes as it is established. It is of a dull
character, extends over the nates, down the thighs, and is
particularly liable to be accompanied by nervous mani-
festations and depression of spirits. The breasts often
sympathize, becoming painful to the touch. It must not
however be supposed that in all cases of enlarged, tender,
or prolapsed ovaries, ovarian dysmenorrhoea will be found,
nor in every case of ovarian dysmenorrhoea that the
ovaries will be found in tliis condition.

Tlie trcdtnirnf of this class of cases is perhaps the
least satisfactory of all classes of dysmenorrhcea. In a
young girl, in whom ovarian disorder has advanced only
to congestion, recovery may rapidly take place, but in a
woman further advanced hi life, and in whom chronic
enlargement of the ovaries has occurred, associated with
tenderness and prolapse, the prospects for cure are slight.
Sterility in tliese cases is the rule. It is just in .such
conditions that bad habits are to be contracted by the use
of alcohol, morphia, cldoral, or chloroform, and their
administration should be avoided as much as possible.
Hot applications, warm sitz baths, and warm soothing
vaginal injections should be employed. Internally there
is no remedy so efficacious as the bromides — tiai grains of
bromide of ammonia or soda every four hours, commenced
a few days before tlie fion' and co^itinued until its close.
For the immediate relief of pain, phenacetine, exalgine,
cannabis indica, or monobromate of camplior may be
employed. Locally, in addition to the hot applications
and douches, a boro-glyceride tampon, impregnated with a
few drops of fluid extract of belladonna and inser<^'^d behind
the uterus, soothes and relieves the local irritation and
congestion. When unmistakeable evidences of organic
ovarian disease exist, the operation for the removal of one
or both ovaries is advised as the only means of giving
relief.

126 MEDICAL AND SURGICAL GYNiECOLOGl.

In treating the subject of dysmenorrhoea, all the
Vftrioties generally indicated by autlioriti(^s have been
included, because, by the adoption of this method, a more
thorough investigation of the subject is secured, and a
recollecticn of them at the bedside will often aid in the
classification and treatment. It must not, however, be
supposed that every case of dysmenorrhoea will be sub-
jected to strict limitations, on the contrary, many, if not
most cases, give evidence of one or more disturbing
elements. As for instance, a retroversion occurring in a
weak' nervous woman with impoverished blood might
cause a dysmenorrhoea, due in part to mechanical obstruc-
tion, in part to neuralgia, in part to congestion, and,
perhaps to some extent, to a secondary endometritis. In
view of this fact, it is well to have in memory somt^ general
plan of treatment which may be resorted to in cases not
readily susceptible of classification. Hot wet or dry
applications to the abdomen and lumbar region, hot
vaginal douches, and rectal enemata have a place in the
treatment of every form. Medicated vaginal tampons and
suppositories aid in allaying congestion, in soothing the
pain, and in supporting the uterus and adnexa, and may
safely be used in almost every case. The administration
of a saline jjurgative will empty the bowels and relieve
portal or pelvic congestion; and for the relief of pain and
as a sedative to the nervous system, a judicious selection
from the drugs already referred to will oftcMi accomplish
much of the desired effect.

STERILITY. 127

CHAPTER XIII.

STERILITY, NYMPHOMANIA, VAGINISMUS,
LEUCORRH(EA.

Sterility is nnothor functioiml disorder of the uterus,
and implies an inability for impregnation during normal
reproductive life. It is sometimes coiKjcnitdl, the result
of faulty development. It is said to be cicquircd when it
arises from disease after an uncertain period of fertility.
A marriage may be unfruitful from causes pertaining to
the male or to the female. More women than men are
sterile, in the proportion of six to one. Impregnation
becomes impossible from absence or a very incomplete
development of the vagina; from atresia of the vagina,
or from an imperforate hymen. Sterility may occur from
a condition of the vulvar orifice, called vagiiusmus, in
which all attempts at coition cause extreme suffering
(dyspareunia), the sphincter vagiiiie and muscles of the
pelvic floor being, at the same time, thrown into a spas-
modic state. It may arise from inability of the semen to
enter the uterine cavity owing to atresia or stenosis of the
OS, or to flexions, displacements, or tumors of the uterus.
The vitality of the sperm may be destroyed by excessive
acidity of the vaginal mucous. There may be incapacity
for proper ovulation, which includes any condition of the
ovary which impairs the ovule, such as chronic ovaritis
and cystic degeneration; from impt^rfect development of
the ovule, the result of debilitating diseases as amemia,
scrofula, tuberculosis or syphilis. Gonorrhoea, it matters
not how contracted, is a very common cause. Sterility
may be owing to organic changes in the Fallopian tubes,
which prevents the safe passage of the ovum through
them; to pelvic peritonitis, which prevents an instinc-
tive application of the fimbrire to the ovaries; to inability,
after fecundation, to continue gestation; or, finally, to
want of physical adaptation of the parties, " sexual incom-

128 MEDICAL AND SUROICAL GYNAECOLOGY.

patability." Mnrried life may bo sterile for years, yet
when either party obtains a new companion fertility may
follow.

Treatment. While judicious treatment occasionally
gives favorable results, it often terminates in disappoi it-
ment. Success in the managt^ment of sterility depends
largely upon a correct diagnosis, and the special I'atment
of all varieties consists in the riunoval of the cause, if
practicable. In all cases of long-continued sterility, after
having thoroughly examined the female without finding
a satisfactory cause, investigation should commence with
the male. If the uterus is absent or small, less than an
inch or an inch an a half in length, all efforts to ensures
fertility would seem hopeless. An ill developed uterus
may be stimulated to growth if the patient is young and
healthy. Excessive acidity of the vagina may be overcome
by the use of alkaline waters internally, and by v .ginal
injections of weak solutions of carbonate of potash prior
to coitus.

Nymphomania. When the sexual feeling in the
female is excessive or perverted it is called nymphomania.
There is a mental perversion, attended by an uncon-
trollable sexual passion, which, in its most severe form, is
often associated with or dc^pendcnt upon certain varieties
of insanity with or without gross brain disease. Although
observed in children and octogiuiarians, it occurs most
frequently at the beginning and at the end of men-
strual life. There is the greatest perversion of the sexual
act, gratification being sought not oidy in masturbation,
but also with others of the same sex. In many instances
the disorder is a reflex manifestation arising from irrita-
tion of the genital organs, or from certain diseases of the
uterus and appendages. The exciting causes may have
their origin in the intestines, especially in the rectum,
such as by the presence of worms or hemorrhoids. Inflam-
mation of the vulva, vagina, urethra, bladder, or the

NYMPHOMANIA, VAGINISMUS, LEUCORRHCEA. 129

irritntiou of diabctio urine may give rise to it. Nymplio-
maiiin inny also result from freciueut masturbation as well
as cause it.

Treatment. The best results are obtained by moral
suasion. Occupation of the mind and free physical
exercise in the open air, early rising, cold bathing,
regularity of the bowels, a plain non-stimulating diet, and
the internal administration of the bromides, are the best
remedies. When local disease is suspected, it is to be
sought for and treated. Clitoridectomy and oorphorectomy
have been tried and have failed to effect a cure, and such
operations are indicated only when incurable disease of
the external genitals or ovaries respectively perpetuate
the condition.

Vaginismus. Vaginismus consists of hyperajsthesia
of the vulvo-vaginal orifice and neighboring parts, accom-
])anied by abnormal and painful contraction of the
muscles of the pelvic floor. It is not a disease in itself,
but a symptom of various morbid conditions of the vulva,
vagina and the surrounding parts, among which may be
mentioned urethral caruncle, erosion, inflammations or
fissures of the vulva or hymen, rectal fissures, cervical
lacerations, and uterine and ovarian displacements.

Tri'dtumit. The cause of the local irritation is to be
removed and the general health improved. Gradual
dilataticni may be practised by introducing a series of
dilators, a larger dilator being used and allowed to remain
for a longer period each succeeding day. Forcible
dilatation, under an ana^stlietic, may be practised, after
which a good sized glass or hard rubber dilator is to be
inserted and allowed to remain for several hours.

LEUC()RUH(EA.

By the term leucorrhoea is meant a " white flow," but,
in the ordinary acceptation, it is used to designate any
discharge, other than blood, coming from the genitals,

130 MEDICAL AND SURGICAL GYN/ECOLOGY.

although nt times the leucorrlioeal discharge may have a
sanious admixture. In its normal condition tlu^ genital
tract is just moist enough to be soft and well lubricated.
For a day or two after menstruation many women have a
slight increase of moisture, but any decided increase,
whether mucous, senms, or purulent, is abnormal and
constitutes in itself, if not a disease, a symptom of one,
and one often of much importance. The discharge may
come from the vulva, the vagina, the cervix, or the interior
of the uterus. It may be colorless, white, yellow, green,
red, or brown. It may be nearly as thin as water, or more
or less thick, like cream or soft cheese. Leucorrhoea may
be idioixithic or stjniptotiiafic. It is called idiopathic
when it is not traceable to any definite disease, or patho-
logical condition, or to any permanent structural anatomi-
cal lesion. It is found often in young and anaemic girls,
in those of sedentary habits, or in those whose employ-
ment compels them to remain standing upon their feet
for hours. It may be induced by anything that weaktnis
the constitution, such as protracted lactation, bodily or
mental fatigue, emotions, especially of a depressing kind,
and is often found in persons predispt)sed to uulmonary
phthisis. Like other catarrhal affections, it nay be due
to exposure, or to residence in a damp climate; or it may be
induced by local irritation, such as masturbation or
frequent coition; or it may appear in consequence of
amenorrhoea or scanty menstruation.

Si/iiipfoiiis. Apart from the discharge, which, as a
general thing, is of a whitish color as it appears at the
vulva, there are often other leading symptoms. The
patient is often auipmic, has a pale, worn, tired, or pinched
look, and a feeling of general weakness. The appetite is
poor and the digestion impaired, giving rise to flatulence
and gastralgia or enteralgia; constipation and an irritable
bladder are frequently present. Backache is a character-
istic symptom. The patient complains of a dull heavy

LEUCORUHCEA. 131

pnin over the sacrnl region, or at the tip of tlie ooccyx,
whioli may be continuous or may be brought about by
long standing or other fatigue.

Trcdtment. From the symptoms described it will be
readily seen that general and local treatmiuit must go
hand in hand. The more the condition depends on
constitutional causes, the more general must be the treat-
ment. Strict attention must be paid to general hj'^giene.
Plain substantial food that the stomacii can readily digest
must be taken, and the bowels kept open by some mild
aperient, such as a pill of aloin, strychnine and belladonna.
Tonics, particularly the ferrugineous and ni^rve tonics,
are here indicated, and an emulsion of cod liver oil is
often well borne, helping to liuild up the system. Such
inti^rnal remedi(^s as hydrastis and cimicifuga seem to
have the special virtue of checking leuchorrluua. Warm
hip or tepid general baths are to be recommended, and
night and morning a vaginal douche of hot water, followed
immediat(^ly by a warm astringent solution, may be used.
In many cases treatment carried out on these lines will
suffice to effect a cure, and is especially to be tried in
intact girls, before resorting to or suggesting a physical
examination.

Symptomatic leucorrhoea. Leucorrhom is a symptom
of numerous local diseases of the genitals, suc^h as vulvitis,
vaginitis, specific or otherwise; endometritis; metritis;
subinvolution ; erosion of the os ; lacerated cervix ; polypi ;
fibroids, or carcinoma. When even a mild leucorrlntial
discharge has resisted treatment for a considerable length
of time, or in cases in which the amount of discharge,
or its color or consistency, points to the ijresence of a local
disease, no time should be lost in making an examination,
and in treating the cause according to the pathological
conditions found to be the chief factors in the production
of the loucorrhcoa.

PART THREE.
DISEASES OF SPECIAL REGIONS.

CHAPTER XIV.

DISEASES OF THE VULVA.

Malformations. 1. Absence of the vulva. By nu
arrest of developmont in tho first mouth of foitnl life, the
external genitals and nnus may be absent, the skin covering
the region uninterruptedly. If the nnus is formed life
may be continued without the external genitals, the urine
being evacuated through the navel.

2. Hi)i)(Hi})(t(li((S. In consequence of insufficient clos-
ure in the median line, the lower wall of the urethra may
be split more or less deeply. If the defect extends very
deeply so as to divide the different sphincters of the
urethra the patient cannot retain the urine.

3. Episjxidids is characterized by a lack of union of
the upper wall of the urethra. It is generally combined
with a similar defect in the anterior wall of the bladder
(extroversion). Epispadias, like hypospadias, has been
cured by plastic operation, such as stitching together
flaps derived from the mucous membrane of the vestibule,
or by uniting two lateral denuded surfaces in front of the
open urethra.

4. The clitoris is sometimes split in two lateral halves,
with or without cleavage of the urethra. It may be
absent, or very small, or, on the other hand, as large as a
medium sized ixniis.

5. The prepuce is frequently adherent to the glans,
and in many cases this condition gives rise to reflex
neuroses and even epilepsy and nymphomania.

DISEASES OF THE VTLVA. I'iili

(). The l<tl>i<i miiioni may b(^ ahsoif, or it may bo
mnUi'itIc, each being Hplit lengthwise in two or three
flaps.

7. The hihid, nuijovd may likewise be split by longi-
tudinal ch^fts, or may extend so far back ns to reach
behind tiie anus so that there is no apparent perineum.

8. Hcmdphnxlisni. By this term is meant a congenital
malformation of the sexual organs, in which the germinal
gland of each sex (testicle in the male and ovary in the
female) is found in one and the same individual, together
with mori^ or less perfect organs belonging to both sexes.
Anatomically and clinically it may be divided into two
chief varieties, the true and the .'^/>?^•/o/^s•. or pHciulo-
hcnuiplirodinm. True hemaphrodisni may be divided into
three forms: bilaieml, in which an ovary and a testicle
are found on each side; unihiteraJ, in which an ovary or a
testicle is found on one side, and on the other both an
ovary and a testicle; and hiferal, in which an ovary is
found on one side and a testicle on the other. Fseudo-
henidphrodism is that condition in which the sc^xual
glands belong to one sex, either masculine or feminine,
while the passages leading from them, as well ns the
external parts, approach more or less the other. There
are two great varieties of this malformation, Andnuftpie,
in which a man simulates a woman both in the general
conformation and local appearance of his sexual organs;
and (jt/aitdrid, the far less frequent condition, in which a
woman simulates a man, the resemblance being confined
almost entirely to the external sexual organs. The clitoris
is elongated two or three inches and possessed of more or
less erectility, and perhaps the labia partially united so
as to have the appearance of a scrotum.

Tiie diagnosis of the sex is often difficult. A periodical
bloody discharge has even been observed to take place
from apparently normal male genitals, especially from
males suffering from hypospadias.

IJU MEDK^AL AND SUR(JICAL OYN/ECOLOOY.

Tlu* fi'caliiiciif in pnuiticnlly nil. A liyiJOHjHidino
un>tlini may bo ri>Htoro(l, n blind vaj^iiml poiu^li (doHod, but
usually nothing can ho dono to restoro the partH to tluur
normal Htato. A liyp('rtroi)Iii('d (ditoris Kliould, of courH«.%
bo romovcd.

Hernia. Two kindn of liorina find tlioir way into tho
labia majora, tlio (inferior or iiii/Kiiio-lahidl and tho
f^oxtcrior or rfajino-lahitd.

Tho in(ffii)i(>-l(ihi(il, or that kind corrospoiuling to an
inguiiud hernia in tho malo, in not uncommon. Tho
hornia comos out throujfh tho inguinal (wuuil, follows tho
round ligament, and tl(>s(U'nds into tho anterior part of tho
labium niajus. Tt may contain intestine, a portion of tho
mesentery or omentum, an ovary, the bladder, or even tho
entire uterus. It may be mistaken for a tumor of the
round ligament or a hydrocele, or for an abscess, cyst, or
tumor in the labium, but bj'^ paying att(>ntion to the
general rules laid down in tho surgery of hernia a
diagnosis may be readily made.

Trcdfrncnf. A properly fitting truss will very often
give the required relief, but the wearing of it is
occasionally uncomfortable or irksome to the patient.
This class of hornia is particularly suitable for what is
commonly known as tho radicxil opcratiou, and Bassini s
method, modified so as to apply to the female inguinal
canal, is very readily performed and gives excellent results.
In cases where the opening is large or direct, buried
silkworm sutures, uniting the conjoined tendon with the
deep i^art of Poupart's ligament, will give the necessary
and -permanent support, acting in the same manner as
silk worm sutures when buried in the aponeurosis, after
CGiliotomy, to prevent ventral hernia.

Va<lino-l(ibi(il is a much rarer form of hernia. The
escaping abdominal viscera descend in front of the uterus,
along the vagina and bladder, between them aiul the
levator ani muscle, and form a swelling at the posterior

DISEASliS OF Tllli VULVA. 135

(mhI of tli(< lahiimi tnnjiiH. It uHimlly contni h n part of
till' Hiimll iritcHtiric.

Troihticnf. It is ditfiiMilt to hold this form of luTiiia
back, but, aH it may bccomii very lar^v tho attempt h1iou1(1
be madt' with vaginal iM^HHarioH or iiitlatablc rubber ba^H.

Hydrocele cousiHts in a colhu^tion of tiuid iu that pjirt
of tho routid ligament wliic^h lies in or below tlu> iuj^uiiuil
canal. Thin Huid may be (-oiitaiiied in the proiu'SH of
peritoneum which at times surrounds the ligament outside
the internal inj^uinal ring (canal of Nuck), and in this
way may communit^ate with the ab(h)minal cavity; it
may bo in the surrounding connective tissue, or in the liga-
ment itself. Great care should be observed in making a
diagnosis of this rare malady. The sensi> of fluctuation,
with entire abseiu^e of symptoms of iiiHamnuition. tlu^
absence of resonance on percussion or other signs of
hernia, the existence of translucency, and the gradual
development of the tumor without pain or constitutioiuil
excitement, \k'ould be reasons for suspecting it.

Trciihucni. It is unsafe to inject these tumors, the
same as in the nmle, on account of the uncertainty of the
diagnosis. By open incision the diagnosis may be properly
made and appropriate treatment i)ursued. The incision
is made over tlu^ tumor iu its long axis, the sac opened
and the contents carefully examined. After the fluid has
been evacuated the wall may be touched over with strong
carbolic acid, the cavity packed with iodoform gauze and
allowe i to heal by granulation. Should the sac communi-
cate with the general peritoneal cavity, it shouUI be drawn
down and closed off by a circular catgut ligature, or by
one if the methods recommended for the radical cure of
hernia.

Haematocele of the canal of Nuck and haematoma
of the round ligament are ev(m more rare than hydrocele.
The former consists of a collection of blood within the
process of peritoneum, and the latter in the interior of the

L% MEDICAL AND SURGIC\L QYN/ECOLOOY.

round lij^amciit, nn tlu^y lit^ in tin* hiKuiiml canal. Tliry
may b(» dia^iioHi'd from intoHtiiial lu-rnia by tlic poiiitn
ri'ferrod to wluui Hpcakhig of liydrocelo, and from lirrida
of tho ovnry by its immobility and abHonce of Hensitivc-
ncHH. The trontmi'ut couHiHts in makinj^ an incision into
it, turning out tho contontH and packing with iodoform

gaU 7A\

Injuries. Tho vulva may bo tho scat of bruiHos or
wounds in conHocpKuico of a fall upon some blunt or sharp
instrument, or from blows or kicks, which, if slight, readily
respond to ordinary treatment. Sliouhl tlu^ injury bo so
localized or of such violence as to injure tho reticulated
plexus of large veins, known as tlie bulbs of tho vestibule,
on(^ of two effects will be produced. If there be corres-
ponding rupture of tho skin a free and sometimes
alarming hemorrhage will occur, known as pudenddl
lu'morrlKiyc. If the skin remains intact, the blood pouring
out into the areolar tissue surrounding tho wounded plexus
will soon form a (\oagulum, constituting a bloody tumor
which has received tho name of pmlcniUil luriiKifocch'.

Cduscs. Tho j)r<'(lisj><tsin(/ cduscs are pregnancy,
varicose condition of tho veins, and largo pelvic tumors;
the oxciting causes are muscular efforts, blows, or incised
or i)unctured wounds. In pudcMidal hemorrhage a physical
oxamiimtion will at once reveal the condition, and the
control of the How will not bo difficult if managed on the
general i)rinciplos laid down for the treatment of hem-
orrhage. The clotted blood which forms a pudendal
' ^Mnatocele may occupy the tissue of one labium or tho
ar tissue immediately surrounding tho wall of the

<ina. When a considerable sized vessel has been
raptured tho tumor may reach tho size of an orange; at
other times it is quite small, perhaps not larger than a
walnut. Care must be observed not to confound it with
abscess, pudendal hernia, inflammation of the vulvo-
vaginal glands, or oedema. The physical characteristics,

DISEASES OF THE Vl'LVA. 137

niodi^ of (l(>v(»lof)m('(it. and ratioiml hIj^iik of hucIi affcctionH
nro HO (liffcmiit from i)U(lcii(lal liu'inatorrli' that a careful
oxainiiiatioii will always scttk* tlu- [)oitit with certainty.

Xntnral ronrm' (iftrt'fnnndfioii. Should the tumor bo
left to itself, it may bo absorbed in a short time; in five
or six days it may burst and discharge; the clot may
become encysted and remain in(letinit(>ly; or it may
creatt^ suppurative inflammation and formation of an
abscess.

Trcdfnicnf. A small tumor may be let alone, or treated
V ith a cooling astrinj^ent or absorbent application. When
the tumor is large, or experiment has demonstrated that it
will not undergo absorption, it is advisable to make an
incision into it antl evacuate the cont(>nts. If bleeding
points appear they may be securcnl by forcipressur(>, and
the cavity afterwards i)acked with iodoform gauze. When
the cavity is large, or the hemorrhage abundant, buried
catgut sutun^s may bo inserted through the walls of the
tumor so as to include the veins from which the hem-
orrhage occurs. After approximation of the walls by
these ligatures, and a gauze drain introduced, super-
ficial sutures may be inserted in the marginal mucous
membrane. As soon as pus is formed, whether largo or
small, it must at once be evacuated, the cavity carefully
washed out with bicldoride SC' ition and drained with
strips of iodoform gauze.

Phlegmonous inflammation. The areolar tissue of
the labia raajora is frequeiitly the seat of inflammation
and abscess. The disease is excited by irritating vaginal
secretions, vulvitis, direct injury, ami the peculiar blood
state which results in the development of furuncles and
carbuncles.

Didf/nosis. It is usually easy to distinguish this
disease, but care must be taken to diagnose it from hernia
of the intestine or ovary, and from haimatocole. ojdema,
and vulvitis. The ordinary symptoms of inflammation

138 MEDICAL AND SURGICAL GYNAECOLOGY.

and tlu> ox(iuisit(^ sensitiveness of the swelling will servo
as a valuable aid.

Treatment. The first stag(> is best managed by cold sed-
ative and astringent applications, such as acetate of lead
and opium lotion. If suppuration is inevitable it should
be met by hot fomentations and hot bio^'loride absorbent
cotton poultic(>s. Early evacuation of the pus as possible,
is advisable, becausi^ the tissues obstinately resist natural
evacuation^ and the accumulation of pus is liktly to point
in another direction.

Cysts and abscesses of the vulvo-vaginal glands.
The long exert tory ducts of these glands, situated on each
side of the ostium vagiuiu between the vagina and the
ascending branch of the ischium, sometimes become
occluded by adhesive inflammation arising from acrid
dischargi^s, from the presence of pruritis from other
irritating causes. As a result, the secretion of these
glands is retained; they undergo great enlargement and
distension with or without preliminary formation of a
cyst; suppurative inflammation may be sot up and abscess
result.

Diajjiiosis. When cystic distension exists, the locality
of the round or ovoid mass rolling slightly under the
finger, without tenderness, will assist in making a diag-
nosis. Pudendal hernia and hydrocele of the round
ligament are two important conditions from which they
must be diagnosed. Hernia is reduceable and gives a
distinct impulse when the patient is requested to cough,
and it does not feel so elastic as in the case of cysts. Cysts
grow slowly, the percussion sound is dull, whereas the
appearance of a hernia is rather sudden and, if an
enterocele, is resonant on percussion. When inflammation
has been set up there are the usual symptoms present, the
mouth of the duct is red. and the fing(>r press(>d over the
site of the gland will discover a hard, painful, and perhaps
fluctuating tumor, about the size of a small hen's egg. It

DISEASES OF THE VULVA. 139

may bo known from plilej^inonous inflnmma^^ion of the
liibinin by its distinct globular and liniitod outlines the
t'ornuT affection bc^in^ diffuHc.

Trcdfnicitf. The cyst mav be incised within tlie free
edge of the hibiuni and, afte. vacuation of the contents,
the sac wii)ed out with tincture of iodine or a ten per cent,
solution of (chloride of .Jnc, and then i^acked with iodoform
^auze. It is desirable to remove a portion of the sac wall
after having incised the cyst. This operation, although
tedious, is certain in its results, and is the best to follow
under ordinary circumstances. The total removal of the
cyst is often a difficult and sometimes bloody operation,
and hatl bc^tter not be attmnptt^d, unless prepared for such
emergencies. Pozzi recommends, after withdrawing the
contents, to distend the sac with warm paratine, and whe.i
hardened, to dissect the whole mass out. After the
removal of the sac, by whatever method employed, the
cavity is closed by a deep row of sutures placed through
the edges of the wound and passing down through the
bottom of the cavity, and a second row placed at iialf the
depth. After insertion they are to be tied in the order in
which they were placed. When inflammation sets in, it is
to be treated in the same way as for abscess of the labia,
and as soon as fluctuation is distinct the pus should be
evacuated by a long incision, the cavity irrigated with
bichloride solution and drained with iodoform gauze.

Tumors. The vulva is subject to the formation of n
variety of tumors. The condjilonKifa acnmlnafa or
pn})iUom<d<i may be due to gonorrheal irritation, or
simply to the hypenemia and discharge from the parts
occurring during a vulvo-vaginitis or normal pregnancy.
They are found chiefly on the labia minora, or at the
posterior commissure, and may extend more or less deeply
into the vagina.

The coiKli/lomafa hit<i, occurring on the iiisidi' of the
labia maiora, on the perineum, or around the anus, are

14:0 MEDICAL AND SURGICAL GYN/ECOLOGY.

always due to syphilitic infection. The treatment of the
acuminate and pajiilloinatous varieties consists in cutting
them off witli curvt'd scissors, and touching their bases with
caustic or with the actual cauti^ry; or they may be
effectually removed by puncture with the negative electro-
lytic needle. Compresses soaked in the tincture of tliuga
occidentalis mixed with equal parts of water will, in some
cases, cause atrophy of these growths.

Liponid have their origin either in the labiiim majus
or in the mons veneris. They are rare, but when they
occur, sometimes attain large dimensions.

Mjioma, Jihronui, myxoma, and miral (/roii^fliH have
their origin ordinarily in the labium majus. Their
tendency is to grow in the direction of the least resistance,
and lience it is not unusual for them to bec^ome peduncu-
lated, and sometimes they reach as low as the knees. The
treatment of these tumors is surgical and, when operated
upon with care, is devoid of danger.

ElcplKUiti'dsiis vulv(V. This disease, seldom seen in
this country, may affect the entire vulva or only part of it.
Its location is generally on the labia majora. the clitoris,
and the nymplia\ Histologically, several varieties of
this disease occvr, but they have all one element
in common, namely, a change in the lymphatic cir-
culation, the lymph vessels being dilated and indurated
from the beginning. They have their origin from repeated
attacks of lymphangitis, which ultimately result in hyper-
plasia of the entire derma and subcutaneous connective
tissue. When inflammatory changes with new forma-
tions occur first in the papilhv*. the tumor strongly resembles
the large coalescing condylomata. The large tumors are
liable to extensive ulceration from local irritation, and the
warty forms may undiu'go malignant degeneration.

Tn'((tiii('iif. All medicinal treatment has thus far
failed; the same may be said of the galvanic current,
the only rational one being surgical.

DISEASES OF THE VULVA. 141

Lupus, sarcoma and cancer are fortunately rare. Thoy
occur usually upon the labia minora or majora and spread
thence in various directions. The prognosis of cancer,
which is usually of the epitheliomatous variety, is
unfavorable, unless seen very early and completely extir-
pated. Sarcoma presents itself as a tumor springin^j^ from
either the labia majora, the labia minora, or the clitoris,
and is diagnosed mainly by its rapid growth and soft fe(4.
In cases of difficult diagnosis, resort should always bo
made to the microscope.

Neuromata are of more frequent occurrence, and are
either situated about tlie meatus or clitoris, or at the
posterior commissure. They are usually nodules, not
larger than a pea or bean, and exquisitely sensitive to the
touch. They should be removed by thorough deep
incision with scalpel or scissors.

Varicose tumors. Such tumors may occur in the
vulva as the result of pressure from a pathological or
physiological growth in the pelvis. The distended veins
are readily recogni/.ed, and can hardly be mistaken for
any other condition. In most cases they are connected
with pregixancy, but may occur independently of it.
They may burst spontaneously and if the skin holds, a
hiematoma is formed. If the! skin breaks, a serious if not
fatal hemorrhage may follow, especially when associated
with pregnancy, at which time they are often of large size.

Uretliral caruncle. Just at the edge of the meatus
urinarius, and sometimes along its wall for some distance,
little vascular tumors develop which render the c^anal very
irritable. They consist of hypertrophied papillfi\ are
extremely vascular, and are richly supplied with nerve
filaments, facts which account for two corresponding
clinical observations, nanu^ly, that they bleed very freely
and readily, and that they are almost as sensitive to the
touch as a neuroma.

142 MEDICAL AND SURGICAL GYNECOLOGY.

Sijmf)foms. Tho patient complains of pain, accom-
paniod often with hemorrhage during sexual inti^rcourse,
in passing urine, in walking, or by contact of the clothing.
Inspection shows at the meatus a florid vascular growth,
varying in size from that of a cherry stone to that of a
pigeon's egg. Sometimes, instead of one, quite a number
may be found of small size extending around the meatiis.
Care must be taken not to confound it with prolapsus
urc^thne.

Treatment. In single large caruncles an almost posi-
tive promise of relief may be held out from its removal by
means of the thermo-cautery. When a number of small
fungous growths surround the meatus and extend up the
urethra, cure is extremely difficult, as after their removal
the morbid process rapidly produces more. When the
urethra has been invaded it should be thoroughly stretched
and the growths brought into view, when they may be
removed by scissors, or scraped from their attachments by
a curette, after which their bases should be touched by
the thfmo-cautery. Special attention should be paid to
any disordered condition of the urine or disease of the
bladder. The nervous hyperi^sthesia engendered during
the growth of these tumors is apt to continue, and an
irritable condition of the urethra and neck of the bladder
are likely to follow for some time after their removal,
hence it is well to notify the patient of these probabilities.

Urethval venous (iiKjionia is a disease affecting the
urethro-vaginal tubercle, and occasionally the urethro-
vaginal wall. It sometimes attains a large size and pro-
jects between the labia. Absence of sensitiveness will
diagnose it from urethral caruncle, which it closely
resembles in apptmrance, but the treatmtnit is Identical
with that condition.

Prolapsus urethrse. This accident consists, when
acute, of prolapse of the urethral mucous membrane
alone, but if it is of long standing there will be in ad-

DISEASES OP THE VULVA. 143

(litiou n i^roliferntion of tho uuderlyinpf coniioctivo tissue.
It is not nil uncommon condition, and may exist for some
time without symptoms, but usually it creates difficult and
painful micturition, pruritis vuIvjb and leucorrhceal dis-
charge. It may be confounded with urethral caruncle
and venous angioma, but can be recognis(ul by remember-
ing that it produces a projection which completely
encircles the meatus, while the former do so only in part.
Neither pain nor hemorrhage can be depeniled upon for
diagnosis, as prolapse may develop such symptoms very
dcicidedly.

Treat me nf. Acute cases may be treated by replacing
the protruding mass, and by the subsequent application
of hot wati>r, by rest in bed ani^ by efforts to previ^nt
rectal and vesical tenesmus during the evacuation of these
organs. Tannic acid, or other astringent bougies, may
be introdiiced into tiie urethra. These means failing,
recourse may be had to linear cauterization of the pro-
lapsed membrane by means of the thermo-cautery. Ex-
cision of the redundant tissue is frequently necessary and.
after removal witli the knife or scissors, the urethral
mucous miMubrane should be stitched to the margin of
the oritice with tine sutures.

VULVITIS.

Vulvitis is the name applied to inflammation of tho
skin and mucous membrane covering the vulva. It
appears in three different forms, simple, pHrident, and
follienlar. To this chissiflcation there has been added by
some, the i>lil<>(/iii(>ii(ms, venereal, and (/aiijirenoKs forms.

Simple vulvitis is by far the most common form of
inflammation. It is usually produced l)y the irritation of
acrid vaginal discharges, by the pn^sence of pediculi, or
by pruritis. The secretions from the inflamed surfaces
are usually of a serous, non-purulent character. The
diaf/nosis is made by the red eroded appearance of the

144 MEDICAL AND SURGICAL GYNECOLOGY.

vulva, which often exttmds down to the anus and to both
nates, especially in stout women.

Purulent vulvitis. This variety of the aft'ectiou may
be either a non-specific form or a true gonorrluea. It may
result from simple vulvitis, specific or simple vagiuitis»
uncleanliness, friction from exorcise, erui)tive disorders,
onanism, chemical irritants, or excessive venery.

Difupiosis. The parts are red, swoHon, hot, and at
first dry, but soon a free flow of pus takes place whicli
bathes the whole surface. In addition to thes'? signs of
active inflammation, superficial ulcers will be found
scattered over the parts att't^cted, and at times th>> inflam-
mation will extend to the submucous and subcutaneous
connective tissue, producing abscesses { ph!<'<))it()Hoiis
vulvitis), and in rare cases patches of membrane will be
seen adhering to them {(liplithcritic vulvitis). The glands
of Bartholin may be involved, leading to suppuration and
tlie formation of abscess. At times tlu' meatus uriiiarius
becomes affected, prodncing a reddish margin around it,
accompanied by* painful micturition, and a sensaticni of
heat and s(;alding. The pus which is discharged, ^^speci-
ally when specific, gives forth a disagrec^able odor, and
is exceedingly irritating when brought into contact with
other parts.

Follicular vulvitis. By this form of vulvitis is meant
inflammation of the muciparous, sebaceous, and piliferous
glands. In ordinary purulent vulvitis these, as component
parts of the diseased membrane, are implicated in the
morbid action, but sometimes the glands alone are
affected by disease, when the name follicular vulvitis or
vulvar folliculitis has boon applied. The causes are about
the same as those of purulent vulvitis, and the general
symptoms those of local inflammation, but it is diagnosed
by the peculiar appearance it gives to the vulva, the labia
majora and minora being studded with small round red
protuberances, from the size of a millet seed to that of a

DISEASES OF THE VULVA.

145

hemp seed. Ofton n hnir comoH out from tho middle of
one of these elevatiouB, and from the opeuiufj; n drop of pus
may be pressed out. As a rule the inflamed follicle
bursts, and shrivels up, but exceptionally the disease ends
in induration and the production of small hard nodules,

DifKjnosis. The signs and symptoms are usually clear
enough, nevertheless it is sometimes difficult to distinguish
one variety from the other. It is especially important,
but often impossible, to
determine whether the in-
flammation present be of a
gonorrluual nature or not.
Th^^ history of the case is
generally wanting or mis-
leading, but the following
features may be looked
upon as important, not
only in making a diagnosis
of gonorrhuial vulvitis, but
of gonorrlnual infection in
organs beyonil : A purulent
discharge in the absence
of ulceration, erosion, or
malignant disease, associ-
ated with inflammation of
the urethral orifice, and
two bright red spots mark-
ing the orifice of the ducts of Bartholin's glands (macula
gonorrlueica); warty condylomata complicated with folli-
cular vaginitis; salpingo-perimetritis; sudden development
of infiammatory disea.se of the genital organs in a newly
married woman, which injunvs her healtli to a degree out
of all proportion to tlie local condition; habitual aborti(m;
sterility acquired after the birth of one child; ophthalmia
neonatorum; and especially the detection of the gono-
coccus.

Fin. 40. — FoUiciil.ir Vulvitis.

146 MEDICAL AND SURdlOAL OYN;ECOLOGY.

Trndniciif. Propliylaxis consists in scrupulous ch^nn-
liiicss niid in tlio prcvt' itioii m\d removal of cvt^ry cftusc
liki^ly to pro(luct> it. In schools and institutions, it is of
jjjrcat importance that tach person should have her own
basin and towel. Sponges, as far as possible, are to be
avoided; certainly they shoidd not bo used in common.
In acute vulvitis the paiient slumld bo confintHl to bed
and the diet of a li^bt unstimulating character. She
shoulil sit for Hftel^n miiiuti's in a warm hip bath, to
which has boon added bi carbonate of soda or permang-
anate of potash, and after this a compress wet with liquor
jjlumbi subacetatis dilute, or a solution of boric acid
(2 per cent), or of salicy'ic acid (1 to (i(XX)). appli(5d
frecpiently. In tlu^ mon^ chronic form, astringent and
antiseptic applications will also he requin^d, such as
solutions of acetate of lead and opium, tannin, carbolic
acid (1 to (>0), sulphate of copper (1 per cent), corrosive
sublimate (1 to .'{aX)).

In chronic cases, particularly in the intertrigo of fat
women, dusting powdt^rs will bo found useful:

R. Boric acid, zinc oxid., aa. drams ii ;
Pulv. aiiiyii, drama iv ;
Pulv. rad. iridis Horeiitiiui', oz. i. M.

Ointments are indispensable in some cases, especially
when the surface has to be protected;

R. Zinc oxid., drams ii ;
Carbolic acid, dram ss ;
Va.seliii alb., oz. ii. M.

If there be much local irritation, thymol (2 per cent),
or cocaine (5 per cent), may be added.

In follicular vulvitis the pustules should be opened
and the parts fomented with an antiseptic compress. In
acute inflammation of Bartholin's glands, a warm sub-
limate compress should be constantly applii^d and, as soon
as the absci^ss shows any tendency to point, it should be
freely opened, well washed out and draininl with iodoform
gauze.

DISEASES OP THE VULVA. 147

There is a vnrioty of vulvitis wliieh 1ms boon styled
(/(iHjircnoux. It bogins on the vulva as a white blister
which soon changt^H to an uleer; it nc^xt asHumeH a
diphtheritica aspect and becomes gangrenous. It is a disease,
however, almost entirt^ly confined to children.

Eruptive diseases. The skin and mucous membrane
making up the vulva may, like the same structures in
other parts, be affected by eruptive disorders of various
kinds. Tln^ following will include thosc^ most commonly
met with:

rnir{(/(> presents large scattered pai>ules, very irrita-
ing, and generally have their apices bereft of cuticle.

Liclirn shows more numerous papules resting upon a

thickened and somewhat indurated cutaneous base. For

such conditions the use of one of the following formuhe

often proves very serviceable :

R. Menthol, flrams ii ;
01. OlivH', dniins iv ;
Chloroform, (hum i ;
Lunoliiii, oz. ii. M.

Ft. ungueiitiim.

R. Acid Salicyl, dram s« ;
(Jreosote, gtt. xl ;
(ilycerini Amyli, oz. ili ;
Ltinoliiii, o/. i. M.

Ft. uiif^uentum.

Eczema producers a red heated surface, covered with
little vesicles which, breaking down, give forth a serous
fluid. Sometimes there are successive crops of vesicles,
and in many cases of diabetes and vesico-vaginal fistula ;
this affection constitutes an exceedingly annoying and
even painful complication. In the acute stage, cold or
warm compresses and subacetate of lead lotions are
generally all that is needed. When the discharge is
profuse and watery the surface should be powdered. In
more chronic cases Hebra's unguentum diachylum, white
precipitate ointment (grs. xx. to oz.), or the following,
will often prove very serviceable:

148; MEDIdAL AND SUimiCJAL GYN^ECOLOOY.

11. Boric acid, drain i ; '

I Mil I lib. acot. , {ffH. X ;
BiHtuiitli. .siibiiit, dram i ;
VaHcliii alb., oz. i. M.

Ft. iiiif,'iioiit.

The vulvn mny also bn tho scat of acnr, cri/thona, aiul
n'ifsijK'his, but as thc^Hc diHi-asi^H ottVr nothing piHuiliar in
this region tlioy aro to bo treated tho samo as in otht^r
parts.

Herpes pro(iciiit(i lis iH a mild inflammatory aff'oction,
consisting, as it doos in other parts, of vosiolos, or a group
of vesicles upon an inflamed base, their appoaraneo being
preceded by a burning and it(!hing sensation. Tho
vesicles soon rupture and form scabs or shallow ulcers,
each the size of a single vc^sicle. Sonu^tinu^s it is accom-
panied with much (inlema of the vulva and may lead to
enlarg(^ment of one or more of the inguinal glands. It may
be confounded with a cihancre in tho erosive stage, but
that has a deep, dull rod, ooj^jpory color, and its floor is
smooth and shiny, without the small granulations foend
in herpes. This disease is also apt to be confounded with
exr/ema, but tho latter has a tendency to spread at the
edgi^s, herpc^s appearing in successive crops. In tho early
stage a cooling sedative lotion will give much rolicsf, and
tho following ointment may be applied:

R. Menthol, drum i ;
01. Olivii', drams iii ;
Bismutli. Hubiiit, drams ii ;
Lanolihi, o/. ii. M.

Ft. unguent.

Pruritis Vulvae. This affection consists in irritability
of the nerves supplying the vulva which induces tho
most intense itching, and desire to scratch and rub the
parts. At first tho irritability and tendency to scratch
aro slight and give little annoyance, but tho disorder is
aggravated by the counter-irritation which it demands for
its relief. Tho itching is so extreme that it irresistibly
drives tho patient to scratch herself, anil by constant

DISEA8EH OF THE VULVA.

14'.)

ropctition the nkin boromcs torulor, its iutvor HPnHitiv(>,
cxcorintioiiH and intlnmiiuitory coiiditioiis follow, all of
which conirihuti' to the morbid condilioii. The misery
produced ill Hiu^h (mihch cannot be I'xa^^erated; tlu' i)atient
Ih tormented night and day, WKrioty be(!omeH dintaHti^ful to
lier. and nhe j^ivoH way to dcHpondency and di^jn^Hsion.
The itt^iing iH j^enernlly intermittc^nt, in some (rawos
<)c(Mirrinj^ at nij^ht, and in others only at ct^rtain periods
of tlu^ day. It is not always confined to the vulvn,
the irritation often (extending up the vagina, to tlu^ anus,
and down th(^ thighs. Tlu^ pn^disposing causes nn\
uterine, vaginal or urethral disease; pregnancy; liabits of
indolence, luxury or vi(u^; unch^aidiness; or over-exercise
in one of sedentary habits. In nearly ev(^ry instance of
pruritis one of the following conditions will b(* found to
exist as i\\v ap[)arent cause at U^ast: (/ontact of irritating
dlst^harges, such as from acute and chronic tMidometritis
and vaginitis, from the discharge of cancer, from incon-
tinence of urine, or from diabetes; local intiammation,
as vulvitis, urethritis, or vaginitis; local irritation, as
eruptions of the vulva, animal parasites, f)nanism, vt^geta-
tions oTi th(> vulva, or vascular urethral c^aruncles. How-
ever produced, very soon secondary influences arisiiig from
excoriations, ulcerations, increased discharges, the result
of scratching, superadd themselves as auxiliary agents
and keep up the disorder. ■

Trcdfimmt. The first effort must be made to discover
the disease of which the pruritis is a symptom, and
remove it by appropriate means. But this alone will not
be sufficient, for, while eradication of the mischief is being
attempted, palliative means must be vigorously adopted
for the sake of i^resent relief. Perfect cleanliness should
be secured by means of three or four sitz baths daily and
the vagina syringed with pure or medicated water. The
irritated surfaces should be protected by unctious sub-
stances or inert powders, such as bismuth or zinc oxide,

lt«!

150 MEliU'AL ANU SUKOICAL UYNJiCULOUy.

combiiiod with lycoiKMlium or stureh. In cnm^ tlio (IIh-

clmr^c* conu'H from tht^ utc^ruH, uftcr a thorough viij^iiiul

(louflic, tlu' ii|t|)('r (>ii(l oF tlu' vaj^iiui slh)ul(l hv tanipoiu'il

with cotton luoiHtt'iu'd witli ii wt>ak Huj^arof lead or horairic;

Holutioii. If it is thci roHuit of a hx^al iiitiaininatioii it

Hhould bo trt^atod as olHowliorc rcoomiiuMidw! for such

conditions. Tcnipo'-ary ndi(^f (^an be obtained by covering

the parts with a lotion composed of the following:

R. Plumb, licet., (Irainn Ihh ;
Afitl Carbolic, dram i ;
Tiii(!t. Opii, o/. i ;
A(iii!i' ad., oz. xvi. M.

R. Hydra;;, bichlor., grs. xvi ;
Tiiict. Opii, oz. i ;
Atjuji' ad., oz. xvi. M.

Relief may also be obtained by a strong solution of

bromide of potash, or by painting the parts several times a

day with glycerine mixed with chloroform or acid hydro-

vjyan. dil. (1 to 8), or with morphim^ (3 grs. to the oz.), or

at longer intervals with a ten per cent acpieous solution of

cootane. Ointments often give markc^d relief, such as:

R. Chloral. Camphor, aa., drum i;
Vawolin alb., oz. ii. M.

R. Aciid hydrocyan. dil., ilrams ii;
I'lumbi acet., grs. xl ;
Olei cacao, oz. ii. M.

R. Acid Tannic, dram ss;
Kxt. Belladonna', grs. x ;
Va.'ielin, oz. ii. M.

Hyperaesthesia of the vulva consists in an excessive
sensibility of the nerves supplying the mucous membrane
of some portion of the vulva. Sometimes it is confined
to the vestibule, at others to one labium majus, at others to
the meatus, while at other times they may all be simul-
taneously affected. It is not a true neuralgia, but an
abnormal sensitiveness of the nerves. There is no inflam-
matory action and examination reveals nothing; the
slightest friction, however, excites pain and nervousness
and any degree of pressure is absolutely intolerable. The

DISEASliS (IF Tllli VULVA. 151

(liHonlcr is comparatively rare and the trcatniout of it
moHt iinsatisfactory. even coinijlctc {l^Htnictiou of tlio
mucous uicmhrani^ of the Hcusitivi^ area with caustics, or
its removal with tlu' knife, has failed to [)roduce a
pernianetit cure.

Kraurosis vulvae is a diseast' .-harai^teri/ed by a
pet^uliar atrophic shriiikiu;^ of the intt^j^umentH of the
tvxternnl genitals and perineum, ri^sultiiig in the oblitera-
tion of the normal folds. Tlu* tissues att'cu'tinl beconu*
dry, shrink, lose* their normal elasticity and become so
brittle tiuit tiu^ most (direful examiiuition may cause dei^p
fissure. Tlu* surfaci* assumes a whitish, maceratt^d, shiinn^
nppenrance. This disease does iu)t yield to any rimKul} .

Coccygodynia. UiuU^r this name are united different
and i)artially unknown patholo^^ical (H)uditions. thi> com-
mon feature of wliic^h is intense pain at the coccyx, wheiu!o
it may radiatt* into the periiuMim, hips, uterus, or bladder.
Sonu'tinu'H there are palpable diseases or deformitit^s of tlu*
coccyx, such as caries, ankyh)sis. luxation, or abnormal
length. At other times it is combined with disease of the
uterus, ovaries, or rectum, whiU> in a third class it is of a
l)ur(*ly luniralgic nature. It is usually found in women
who have borne children, but it occurs alst) in virgins. . It
often appears after ted'ous labor, accompanied by rupture
and straining of tlu muscles nnd ligaments. It may bo
due to violence from without, as from kicks, falls, or other
injuries, while sometimes it appears to be due to a reflex
neurosis. Severe pain is felt on sitting, and it may be so
great that the patient can sit only on one half ^f the
nates, near the edge of the chair, and the jjain is aggra-
vated in sitting down or getting up. The condition is
easily recognized by introducing the index fiager into the
rectum, while the thumb rests on the skin over the coccyx.
The slightest movement causes severe pain and f ometimes
it may be possible to feel the diseased coiulition of the
bone.

152 MEDKiAL AND SURGICAL GYN.ECOLOGY.

Trcdfmnit. B(>foro any plan of troatmi^nt is adopted
care nuist bo tnki'ii to discovc^r wlicthcr the disorder is
secondary to uterine diseas(> or anal Hssure. Ifsnt^h should
be the easi% thi' primary disordt^rs and not thi^ir results
shoidd receive attention. If the disease be primary,
blisteriiij^. hypodermatic injections of morphia and the
persistent use of the galvanic current will often effect a cure.
While they are bein^ employed, tliree grain iodoform rectal
suppositories may be used, together with general treat-
ment to improve the nervous system. Sliouhl these means
do no good, resort must be had to one of the radical
methods for cure. The first operation consists in making
an incision down upon the coccyx, lifting the exposed
extremity of this bone, and then with a pair of scissors
severing the muscles. It has been recommended to
perform the operation subcutaneously, with an ordinary
tenotomy knife, but it is by no means so easy a matter as
one would suppose, besides, open incision clears up any
doubt there may be in the diagnosis and, if found
necessary, leads to the performance of the second method,
which consists of the complete severance of all attach-
ments, and the removal of the whole coccj^x, by a pair of
bone forceps, or by disarticulation with the kni'le.

CHAPTER XV.

LESIONS OF THE PELVIC FLOOR.

The pelvic floor, also known by the somewlnit in-
definite name of perineum, comprises the tissues which
together occupy the space between the bones of the jielvic
i)utlet. It is composed of a pair of broad thin muscles
(levatores ani), which are the chief support of tlu^ pelvic
viscera, and an arrangement of fascise and muscles, the
components of which act as accessories. Until very

LESIONS OF THE PELVIC FLOOR. 15,'j

rooontly tho porinoum was considoriHl ns n thick wcdjifo-
slinpcd body, (K^sigiuiti'd as tlio "poriiical body," wliicli,
acting as an inverted koyntone of an arch, 'nati^ialiy
aided in the support of the uterus. It is now more
accurately regarded as a movefible centre of attachment
for the muscles and pelvic fascia; which enti^r into the
formation of tlie pelvic floor, as w(dl as for tlu' attachmc^it
of the lower portion of the rectum and vagina. By a
study of its anatomy and the resiilt produced by the more
or less complete laceration of it, its functions can be more
readily estimated. Briefly, it may be said to assist in
sustaining the anti^rior wall of the rectum, preventing a
prolapse of this canal, which, should it occur, would havi^
a tendency to drag down the upper vaginal concavity and
destroy the equilibrium of the uterus. In the same way
it assists in sustaining the posterior vaginal wall which
otherwise would allow of a rectocele. The anterior
vaginal wall, and with it the bladder, is in part supported
by the posterior vaginal wall, and a sagging of this would
tend to the production of a cystocele. If affords by its
presence in the act of defecation counter-pressure, by
which the focal mass is turned br, "kward to follow the
curve of the canal, before it is ejected. The perineum
may lose its tonicity or efficiency from the following
causes : —

1. CoiistitntioiKil fcchlrncss. In girls of weak deli-
cate flbre, the pi^rineum will, without any assignable cause,
be found incapable of performing.; its functions. Such
cases are not commondy met with, but when they occur,
the examining finger reveals not only abnormal relaxation
of the perineum, but of the vaginal walls as well.

2. Fcchlcnci^s. flic result of proloiij/cd orcr (listciisioii.
When a prolapsed uterus remains for a long time betwinui
the labia, the perineum, by over distension, loses its
power, and, after restoration of the uterus, remains per-
manently enfeebled. This condition is likewise produced

154 MEDICAL AND SURGICAL GYNAECOLOGY.

by the proHcnco of largo fibrous polypi, or by the wearing
of Inrgo globular pessaries.

3. Siihinroliifioii. During utero-gostation the perineum
undergoes physiological hypertrophy, which continues
until delivery. Involution may fail to take place, and it
will thus remain large, lax, and wanting in contractile
power. Subinvolution often affects the vagina and
perineum simultaneously, and, as a result, the anterior
vaginal wall and bladder sag downward for want of
support, and the posterior vaginal wall and rectum pro-
trude over the ineffectual perineal barrier.

•4. Senile atrophi/. Complete uterine jirolapse is by
no means rare in old women. As the decadence of
advancing years shows itself, the perineum, hitherto
strong, becomes inefficient and inactive.

5. Ldcevdtion. Injuries due to the passage! of the
child during labor are exceedingly common, and a large
proportion of female diseases take their origin thus.
Rupture of the perineum furnishes one of the most fruit-
ful sources for the absorption of septic elements; and
thousands of women suffer throughout their lives from
uterine displacements, (nigorg(Mnents. an<l vesical and
rectal prolapse, from injuries intiicted upon it during
parturition.

Presented thus to the intelligent obstetrician who has
familiarized himself with the anatomy and physiology of
the perineum, it is difficult to understand how there can
be any doubt of the propriety of early closure of a rup-
tured perineum, for should the operation prove a success,
the gain to the patient will be great; if it prove a failure,
no evil will have been done.

From what has been said it will be readily understood
that certain diseases, disordturs, or conditions are apt to bo
associated with, or to be the direct outcome of lesions of
the pelvic tloor. They may bo thus enumerated:—

LESIONS OF THE PELVIC FLOOR.

155

1. Prolapse of the vagina. When the tono of the wall
of the vagina 1ms boon impaired and it ijonches into its
own canal, so as to fall downward toward the vulva, the
condition is called prolapsus. From a study of the
anatomical relations, it will be readily seen that prolapse
of the vagina, without simultaneous displacement of one
or more of its surrounding viscera, must be considered as
exceedingly rare, and that it must of necessity be asso-
ciated, to some extent, with rectocele, cystocele, or uterine
prolapse. Among the causes of prolajjse may be men-
tioned violent efforts of the abdominal muscles, repeated
parturition, senile atrophy,
rupture of the perineum,
previous distension by tu-
mors, and subinvolution of
the vagina and perineum.
The displacements may be
of two forms, acute, or
that form which comes on
as a r<'s-':ll of violent effort,
which, with great sudden-
ness, forces the contents of
the abdomen down upon
the pelvic viscera, and is
generally accompanied by
sudden descent of the uter-
us. The ordinary or chronic
form is that which, by slow
and steady action of one

or more of the causes enumerated, little by little forces
the folds of the vagina downward, toward or through
the vulva.

2. Ci/storele, or prolapse of the bladder, consists of
descent of the bladder toward the vulva, so as to impinge
upon the vaginal wall. When the anterior wall of the
vagina ceases to afford the required support, tlu^ bladder

^^^iiff

Fig. 41. — Cystocele and Rectocele.

ir)() MEDICAL AND SURCJICAL GYNECOLOGY.

descends and forms n siiihII poucli in the vagina, wliitth
gradually increases until it forms a de(!ided tumor and
protrudes between the labia. Residual urine retained in
this sjjecies of diverticulum decomposes, cystitis nud
vesical catarrh are established, all of which further annoy
the patient by the new set of symptoms pnxhiced.

3. Rccforcic, or prolapse of the rectum, occurs in a
similar manner, and the pouch thus formed soon becomes
filled with fecal matter. The feces becoming hard, and in
consecpience irritating, create mucous inflammation and
discharge, accompanied by tenesmus, obstinate constipa-
tion, and hemorrhoids.

4. Eiifcrocc'lc, or prolapse of the intestine, consists in
descent of a portion of the small intestine into the pelvis,
so as to encroach upon the vaginal canal. Loops of
intestine, finding their way to the bottom of Douglas'
pouch, gradually stretch this serous prolongation and,
advancing between the rectum and vagina, push the
posterior wall of the latter before it so as to form a tumor
at the vulva.

Treatment. Should the accident have occurred sud-
deidy, reduction should at once be accomplished, and the
recurrence of displacement prevented by appropriate
means. Sudtlen cases of vaginal prolapse, cystocele or
rectocele are, however, very rarely met with, and it is
mostly those which have slowly and gradually established
themselves that demand treatment.

The methods adopted for overcoming such cases are: —

1. By the use of loral astriiigeiit^i and by the persistent
insertion of minlicated astringent tampons. These
methods will often restore the tone of the vaginal walls
and bring about a complete cure, but they can only be
effectual in slight cases; in those of graver character they
will prove iusuflicient.

2. By st(pf)lewentai'j) unpports. Numberless forms of
special supports have been invented for the purpose of

LESIONS OF THE PELVIC FLOOR. 157

ntfording relief, witli more or less success. The vaginal
pessary does little or no good here. In many cases no
pessary which rests upon the walls of the vagina can be
retained within the distended canal; in others none can
be found capable of resisting the downward pressure;
while in all, increase of dilatation and atony is affected
by them. In some cases an exception will be found to
this rule in Cuttc^r's cup jjessary, or some similar instru-
ment, supiiorted by an external attachment. Gehrung's
pessary, while it does not cure cystocele, gives much
comfort to the jsatient, and may obviat(^ the necessity for
oi)eration, when such is considered inadvisable.

ii. By sHiujIcdl procedures. Of these there are three,
any one of which may prove effectual. If a ruptured
p(^rineum seems to produce the want of support, peri-
neorrhaphy may be all that will be necessary. Should
this not be sufficient, colporrhaphy should be performed
on the anterior or posterior vaginal wall, as one or the
other seems most at fault, and should tlu^ condition be
still furtlua* aggravated, an anterior colporrhaphy and
posterior colpo-pi^inciorrhaphy may be resorted to, to
retain the prolapsed structures.

Colporrhaphy or elytrorrhaphy is an operation re-
sorted to with the idea of constricting the vagina so as to
diminish its calibre and, by this means, remove the
traction exerted by its fall upon the rectum, blackler and
uterus.

Anterior colporrhaphy. Hims' iii, "khL The patient
is placed in the dorsal position, and the knees sei)arated
by a Clover's crutch. A vulsellum is inserteid into
the anterior lip of the cervix; a tenaculum hooked
into the mucous membran(> of the anterior wall of the
vagina, just below the urc^thra, and a Sims' large speculum
introduced. Two tenacula an- next hooked in near the
lateral sulci, and the amount of tissue to be removed is
estimated by approximating them. By making a snip

158 MEDICAL AND SURGICAL GYNiECOLOGY.

with n pair of scissors on encli side, the grontost width of
tlio surfnco to bo denuded inny be thus marked out. The
whf)ie surface to be pared is put on the stretch and, with a
pair of scissors curved on the flat, a strip of mucous
membrane, about one-third of an inch wide, is raised in
the form of the letter "V," the apex being just below the
ur(>thrn. the arms passing up on each side so as to
includi^ within them the amount of redundant tissue.

Fit;. 42. — Clover's Crutch.

Tlie two extremities of the arms pass back laterally as far
as the cervix, and by a removal of additional strips of
mucous membrane at right angles to the extremities of
the arms, they are made to approximate each other in
front of the cervix. Commencing at the apex of the
triangle, catgut or silkworm sutures are passed beneath
the denuded surface on one side, and then crossed over
and passed beneath the denuded surface on the other side.
After insertion the lateral denuded surfaces are approxi-
mated and the ligatures tied, care being taken in this, as
well as in all similar operations, not to draw the sutures
too tight lest they cut their way out.

Hrujar makes his denuded surface in the form of a
lozenge or rough ellipse, with the long diameter in the
long axis of the vagina, and advises the excision of all the
redundant anterior wall. Closure of the wound may be

LESIONS OF THE PELVIC FLOOR.

15<)

carried out by through niid through sutiiros of silkworm
passed beneath the denuded surfaces, or by means of
deep and superficial layers of iuterruptt^d sutures, or by
two or more layers of superimposed continuous sutures.

Stoltz''s iiif'f/tod consists in making a circular denuda-
tion, embracing the larger portion of the prolapsed vaginal
wall, and then passing a thick silk suture, witli a needle
at either end, just outside the edge of the wound, begin-
ning at the point nearest the cervix and emerging on either
side just below the meatus. The stitches are not entirely
buried, but are made to emerge and enter again at short
intervals, and when the denuded portion has been pushed
up they are crossed and carefully tied.

Lcfo rPs opcrntion
consists in dcniuding an
elongated quadrangular
surface on the anterior
and ijosterior surfaces of
the prolajjsed vaginal
walls, and then uniting
them by sutures, replac-
ing the uterus as the
sutures are tied. It is
obvious that this oper-
ation can only be select-
ed for patients of ad-
vanced age, or for those
who have ceased to men-
struate.

Posterior colporrha-
phy consists in the de-
nudation of an elliptical surface on the posterior wall,
similar to that described, but it is seldom resorted to
alone, When indicated, it is generally combined with
perineorrhaphy, forming the operation known as colpo-
perineorrhaphy.

Fic. 43. — Stoltz's operation for cystocle and
Hegar's operation for rectocele.

Kit) MEDICAL AND SURGICAL OYN^COLOCiY.

PERINEORRHAPHY.

By this term is monnt rostorntioii of tho porinoum.
Tliis oporntivo procodurc is not limited to tlu> euro of
Incoratioii tho rosult of parturition, but is npproprinto to
tho restorntiou of n porinoum which has k)st its power
and functions from any of tho causes previously men-
tioned, and when porformt^l for such is to be conducted
upon exactly the same principles as those which apply
to the operation for laceration,

Varieties of laceration. In its simplest form tho
ln(H^ration extends through the mucous mombraiio of the
vagina, the integument, and tho junction of the bulbo-
cavernosus with the transversus perinei muscles, as well
as through a few fibres of the levator ani and correspond-
ing fascia?. It may be more extensive, and prolonged I
backwards, so as to involve tho structures as far as tlie
sphincter. Those forms have boon designated as hicom-
})l('f<' rupture. Tho rupture may extend througli the
sphincter ani, to which the i -.mo complete 7'upt\irc has
been given; or it may extend still farther and involve
more or less the recto-vaginal septum. Instead of any of
tlu>so, the laceration may be a subcutaneous separation of
i\\v, muscles of tho pelvic floor, at, or near their junction in
tho median lino. The evils resulting from partial rupture
are by no means insignificant, but they are more tolerable
than those which follow complete rupture. When the
sphincter ani is torn through, and still more markedly when
the rectal wall is ruptured, incontinence of feces and rectal
gasc^s occur to such an extent as to embitter the life of tho
patient.

The consequences of rupture of the perineum may
thus be presented: Subinvolution of the vagina, prolapsus
vaginio with cystocele or rectocele, prolapsus uteri, incon-
tinence of feces and prolapsus recti. It is the oi^inion of
many that a laceration which does sever the sphincter
may unite witiiout surgical treatment, but it is doubtful

LESIONS OF THE PELVIC FLOOR.

1<)1

if comploto rostorntion ever occurs by iinmcdinto union.
Repair is occnsionnlly effected by grnnulation, and often
is very efficient, but never perfect, on account of th(^
tendency to formation of unnatural adhesions, cicatricial
bands, and cicatricial tissues, with the consequent con-
tractions, retractions, d'stortions and indurations.

Operation for incomplete rupture. The patient is
placed on the operating table in the dorsal position, the
legs being held apart by Clover's crutch. The first
part of the operation
consists in denuding
the surfaces to be
united, the extent to
which this should
be carried on de-
pending upon the
extent of injury, and
tlu^ amount of pro-
lajjse of the vaginal
wall. A point is
marked on each
side as high as the
denudation should
extend, the seat of
the highest caruncu-
la myrtiformis often
serving as a good
guide. Grasping the
tissue at one point
with a pair of tissue
forceps, scissors are
made to remove a

strip, at the junction of the skin and mucous membrane,
from this point to a corresponding one on the op-
l)osito side. In a similar manner a strip higher up is
removed, and so on until a sufficient surface has been

Fi<;. 44. — Operation for Incomplete laceration of the
perineum. Denntlation completed, and sutures
in the recto-vaginal septum introduced.

162

MEDICAL AND SUIUilCAL tlYN/ECOLCKlY.

(ItMiudi'd. The (liHtnnco to which tliiH should b(^ oarric^l
up will dopiMid upon tho oxteiit mid ttluiractcr of thu
injury. If thero is no prolapso of th(^ pelvic floor, or of the
posterior vnginnl wall, it will suffice to denude the surface
as far as the original laceration only, otherwise it may be
necessary to carry the denudation high up on the vaginal
wall.

H('morrli(i(/(' can generally be controlled by si)onges
and hot water. If there is any decided spurting it may

be checked by a
light pinch with
hemoBtatic forceps,
or by the temporary
introduction of a
ligature until the
I jiiLlMBiili'L " °°W 11- sutures are intro-

r M?m^-. ir M / duced and tied, when

all hemorrhage will
then be brought
under control. Com-
mencing in the up-
per angles of the
denuded surface
which point toward,
or lie in the lateral
sulci, sutures are in-
serted on each side.
After these have been placed, a silkworm suture, threaded
on a good sized, full-curved needle, is inserted through
the skin, at the poinl where denudation was first started,
and passed outward deep into the tissues. It is then
curved round in the tissues in front of the rectum, then
deep into the tissues on the other side, and made to emerge
at a point corresponding to the one where it was entered.
If there is any difficulty in making the needle follow this
extensive curve, it may be brought out in the median line

Fig. 45.— Operation for lacer.ition of the perineum and
sphincter ani. Denudation complete.

LESIONS OF THE PELVIC FLOOR. 163

nnd ro-iiiftortod. Tho noxt suturo is inserted in tho snmo
way, about tlircc-ci^litlis of an inc^li ncunT the anus, and so
on with tho third and fourtli, until thi^ posti^rior anglo of
tho wound has boon roachod. Tho catgut suti'-os first
introducod within tho vagina aro now tied and cut short.
Noxt in ordor, tho first silkworm sutun* is brought up,
and, when tiod, unitos tlio highest points of tho lateral
odgos of tho denuded surface, and now forms tho now
posterior c jmmissure. Tho remaining sutures aro next
tied in ordor, and the wound drossod with borated
iodoform powder and with strips of iodoform gauze laid
over tho vaginal and perineal sutures, after which a pad
and " T " bandage aro applied. It will probably bo
necessary to cathotorizo the patient every six hours for a
d"y or two, after that slu> usually can pass tho urine
voluntarily. On tho second evening a mild laxative may
bo given and a soap and water enema the next morning,
after which the bowels should be moved daily with an
enema. Tho external sutures may be removed on the
ninth day and tho patient allowed up at the end of two
weeks.

Operation for complete laceration. The two varieties,
laceration of the sxjhincter ani alone, and tliat involving
the recto-vaginal septum as well, may conveniently bo
considered together. If the bowel be not injured above
an inch and a half from the sphincter, one operation will
suffice, but if it extends far up, it is better to close it by a
primary operation, consisting of vivifying its edges and
uniting them. When tho sijhincter ani has been ruptured,
the severed ends are drawn outward and backward by the
retraction of the muscles, until they lie on either side
nearly on a line with tho posterior walls of the rectum,
and are often easily recognised by a pitting or depression
at these points. Tho process of denudation should bo
begun by seizing the end of the musck^ on one side, and
with scissors exciso a strip of tissue, so as to free the torn

164

MEDK'AL AND SUR(HOAL (lYN-ECOLOOY.

cud of tlu' muHcl(>. From tlioro it in to bo cnrriod forwnrd
and inward across the brid^'c formed by tlie recto-vaginal
Hcptum, cutting away all cicatric^ial tissue fouiul in it,
after which the denudation is to be continued down the
opposite side, so as to expose the torn end of the sphinct(^r
there. After this, the denudation is carried upward upon

each side to the poiiit
where the laceration be-
^an, or even higher, if
there is much relaxation
of the rectal and vaginal
walls. At this stage of
the vivifying there are
two broad denuded sur-
faces, one on each sid(\
connected by an isthmus
formed by the rt^cto-vag-
inal septum. When the
recto- vaghial wall has
been iir. olved for a short
distanct^ catgut sutures
ar(^ to be insi'rted from
the rectal side, tlu^ lugh-
est one first, and, by

F'r<;. 46.— Complete laceration iif perineum extend- <■ i c

ing into recto vagin.\l septum. Denudation meailS ot them, Carcrully
complete, and recto-vaginal sutures inserted. , .

coaptate their denuded
surfaces. Care must in every case be taken to properly
unite the denuded ends of the sphincter. For this
purpose a silkworm suture or braided silk is to be inserted
a quarter of an inch behind and inside the end of the
retracted muscle, and carried under the denuded surfaces
parallel to the repaired rent in the septum, so as to unite
the innermost fibres. A second suture is inserted at tlu^
outer end of the broken sphincter and carried around
parallel to the first, after which both are tied. A silkworm
suture is next entered at the highest lateral point of the

LESIONS OF THE PELVIC FLOOR.

K)")

(UMMuliitioii, wlirn^ tlic iM^w rommiHHiirc is to Im^ formed,
and carried around after tlu> inaiiiicr dcHtTihcd for iiicom-

^p.rr^

'P^'t^rf/;

'.>--<i

Fl<;. 47. — DiaKrnin of operation for
simple rupture.

Fig. 48.— Operation for complete
rupture.

ploto laceration, after which the remaiiid(T of the operation
is to be tinished in the manner already described.

Flap-splitting operation. The operation referred to
is tlmt introduced by Lnwson Tait, and recommended
after him by Saenger. After the patient has been placed
in the lithotomy position, the left index finger of the
operator is introduced into the rectum, a blade of a pair
of sharp-pointed scissors is inserted in the median line of
the perineum, where the cicatricial tissue meets the skin,
and is made to cut to the left in a curved line along this
margin, to the upper border of the perineal cicatrix. The
scissors are again inserted in the median line and made to
cut to the right, so that when complete the incision assumes
a "U" shape. The upper vaginal tlap is then drawn
upward, in front of the vestibule, by means of tissue
forceps, and the lower rectal flap downward, by similar

166

MEDICAL AND SURGICAL GYN/ECOLOGY.

menus, increasing, if necessary, th's '>ow formed quadri-
laternl surface by splitting the septum farther up. A
curved needle, pushed through the skin, outside the
wound, at the anterior end of one incision, is made to pass
under the cut surface, and is so directed that it will pass
through, or just in front of the commissure formed by the
two flaps and emerge through the skin on the other side
at a point corresponding to the point of entrance. A
similar suture is inserted half an inch farther back, and
made to travere t the tissues of the rectal flap lower down.

Vn:. 49.— Flap-spHitiiig operaiicii for in-
complete l.icer.-ilion of the Derineiini.
Lines of incision.

I''n;. 50. - Flap-spliltinj; opei,.iion (ot
complete laceration of the perineum.
Lines of incision.

One or two more are similarly inserted farther back,
according to the size of the denuded surface. The first
ligature is then tightened, aft?r <-hit the remainder.
Instead of passing the sutujes through the skin, Tait
recommends their being passed ju.-st within the edge of
the wound. The almost inevitable puckering of the
vagintd flap is corrected, by short interrupted catgut
sutures passed froi- one mucous surface to the other,
through its w'ole w.'dth.

LE.IIONS OF THE PELVIC FLOOR.

167

In complete laceration, tlio scissors are made to enter
the n '^o-vaginal septum forming the isthmus and, after
splitting it and making the anterior incisions, the scissors
are re-entered, and an outward and backward incision is
made on each side, so as to reach and denude the retracted
ends of the sphincter ani. The rent in the septum, if any,
together with the margins of the spliincter, are ai)proxi-
mated in tlie same manner as already described, after
which the sutures are introduced precisely as in the
incomplete form.

COLPO-PERINEORRHAPHY.

Hegar's operation. Incomplete rupture. As the
name implies, there are two parts to the operation, that
which narrows the vagina,
and that which api)roximates
the muscular fibres. Th
former is entirely intra- ^^^^U•j:^?x^-i'
vaginal, the latter partly
vaginal and partly perineal.
On each side, at points, h, c,
(Fig. 52), corresponding to
the original commissure,
^lie mucous membrane is
caught up and nicked.
High up on the posterior
vaginal wall, above the rec-
tocele curve, a, a similar
mark is n\ade and the three
points united by lateral
linear incisions. Tiie apex
of the tr'-^ngle is seized, and
the flap dissected down to
the base of the triangle, he,

which forms the margin of the laceration, and there cut
oflF. Dee « buried catgut sutures, alterna' ing with super-
ficial ones, 1, 2, 3, 4, 5, 6, 7, 8, 9, passing through tl^e

;. 5''.— Flnp-spliieinp o|)eration foi l.icer.-iled
perineum — Appearance of wound and in-
trtxUictioii of sutures.

168

MEDICAL AND SURGICAL (lYN.ECOLOGY.

tlie niargitiK of the domulwl surface, are iiisertt^d
from above downward, whieli, wlieu tied, uuitt^, f<(. A
silkworm suture is carried up under tlie wound, from a

point a short distance from
the median line, //, to a point
near the closed lino, /, and
down to the corresponding
point on the other side. The
second suture is inserted
midway between the first
and tlu^ point, c, brought out
on the edge of the denuded
surface at, h, reinserted on
the other side at, /, and
brought out through the
skin at a point correspond-
ing to its entrance. The
last suture is inserted near,
c, brought out at, k, rein-
serted at, ,/, and brought out
through the skin near, /).
After being tied, a few su-
perficial sutures may be in-
serted to ensure coaptation.
Complete laceration. A
point is taken n* r, in the
median line, an inch ril:ove.

Fig. ,s2.— Heg.ir's Colpo-p.-rineorrhaphy : sii- f, (Fig. 53 \ the UJ>per pjillt

Hires s, 7, and g slant tlownwaril toward the . ' , . '

entrance, and are hronglit mil about a quar- in tllC Tent lU tho VCCtO-

terofan inch from the median line ; />', the , _ 1 1 rn

triangle shown in .( having heen closed, the vaginal Wall. 1 WO otlierS,

perineal sutures are inserted — lo, alllniried; i i i i i i

II .anc 12, partly free-all in a slanting O, aild, O, locatcd at tlie loWCr

end of the labia, at points
where we desire the new commissure to be, are next marked
out. Commencing at, .r, a curved incision is mad(> along
the line, xnh, and then curved downward, along the line,
hdy to, (/, tho point indicating tho torn end of the sphincter.

LESIONS OF THE PELVIC FLOOR.

IC/.)

KlG. 53. — Hegar's operation for complete
laceration of the perineum.

A similar incision is next mnde on tlu' otlu^r side ; the
points, (/, and, c, are carefully denuded and made to
communicate with each other by carrying the ilenudation
across the recto-vaginal septum, removing nil cicatricial
tissue there. The surface thus mapped out is finally
denuded. Sutures are inserted from side to side, under
the whole raw surface
represented by, .rmu.
Next the sutures in the
recto-vaginal wall, if
any are required, are
inserted, followed by
those for coaptating the
sphinctei', after the
manner already de-
scribed. Next the
lines, ma, and, nh, are
brought together by
deep catgut suturo^s, reaching half way under the raw
surface, and fairtlier coaptated by superficial ones. Finally
four or five silkworm sutures are placed rather superficially
on the perineal surface.

Emmet's operation. The top of the rectocelo, li, is
caught up with n tenaculum, and other tenacula are
inserted at the highest caruncula myrtiformis on each
side, T, Tl, (Fig. 54), while a fourth is inserted at the
median line, H, in front of tlie anus. By drawing in
divergent directions on all four tenacula at the same
time, a rhomboidal part of the mucous membrane of the
vagina is put moderately on the stretch, with two triangu-
lar-like Hurfaces, apex upward, extending outward and
upward in the lateral sulci of the vagina. The mucous
membrane is now removed from the "M" shapi'd space,
particular care being taken to go deep enough into th(>
sulci. The insertion of the sutures is begun at the upp(>r
angle of one side, passing them from the outside towards

170

MEDICAL AND SURGICAL GYNiECOLOGY,

the nicdinn lino, not strniglit norosH, but first downwards
and inwards to the centre of tlio donndcd surface, and
tlien upwards and outwards through tlK> tongue of tlu^
ct^ntral dap. A series of four or five of these sutures are
passed and at once tied. Having completed one triangle,
and the other treated in the same way. a roughly quadri-
lateral raw surface will still De found to be left. A full-
curved needle, threaded with silkworm, or silk, is entered
through the skin, at the upper and outer angle of the
wound, near the point, T, and made to enter laterally

Kl(i. 54. — Kmniet's colpo-periiieorrhaphy.
Deniul.ilion complete, anil sutures
inserted in left triangle.

Kui. 55.- -Sutures in both lateral tri.ingles
tied, leaving quadrilateral denuded
surface with sutures inserted.

deep into the tissues, after which it is curved up under
the raw surface to the tongue of the flap, under the tip of
which it is passed. The needle is next made to traverse
a similar course and emerge through the skin at a
point, Tt. on the o])posite side. This is sometimes called
the "crown stitcli.'" Half an inch nearer the anus another
suture is inserted, and made to travel under the denuded

DISEASES OF THE VAGINA. 171

surfnco lower down, after which n third nnd fourth, if
necessary, are placed in the same order. Tlu' tirst suture
is then drawn up and tied, the effect of which is to bring,
T, T 1, R, together and form a new commissure by
reuniting the upper angles of the original lacerated sur-
faces, and interposing between them the crest of the
rectocele. The remaining sutures are tied in order, and,
if necessary, a few coaptation sutures inserted.

Emmet's operation for complete laceration is somewhat
similar to the method described as Hegar's, and thus a
separate description is scarcely recpiired.

CHAPTER XVI.

DISEASES OF THE VAGINA.
MALFORMATIONS OF THE HYMEN.

The hymen is a small crescentic membrane which
separates the vulvar cleft from the vaginal canal, and may
be considered as the portal to the vagina. There are
many conformations of the hymeneal membrane all of
which may be perfectly normal and physiological (Fig. 8).

Absence of the hymen. The hymen may be entirely
wanting, or only a trace of it may be present, even though
the genital organs are perfectly normal, but such a con-
dition is exceedingly rare.

Atresia hymenalis, or imperforate hymen is a
malformation in which the hymen forms an imperforate
diaphragm. Tliis condition prevents mucous, cast-off
epithelial cells and menstrual blood from passing away by
the natural channel, and permits of its accumulation above
it. In childhood no bad effects will be notice^', except in
rare instances arising from accumuhition of mucous. After
puberty, the constant repetition of the nu-nstrual period
causes an .iccumulatiou of blood in the vagina {luvmnto-
colpos), which, by reason of absorption of the serum,

172

MEDICAL AND SURGICAL (JYN.ECOLOGY.

sliriuknge of the corpuscles, niul ndmixture of the mucous,
bc'coincK converted into a thick, dark browu, tarry mass.
Tlie j^'irl pcwsi'ssed of sucli an abnormality has the
symptoms of nu^nstruation evi^ry montii, but no blood is
scon. The increase of menstrual blood cnust^s pnin, which
becomes aggravated each month, and with it occurs the
formation of a tumor gradually growing in size from
below, upward. If the symptoms of menstruation have
persisted for several months, probably enough blood will
have accumulated to distend fully the vagina, and to

cause a bulging of the imperforate
hymen. The cervix may next
become dilated and distended, the
two forming one globular mass, on
the top of which may be felt the
undilated body of the uterus. The
body of the uterus itself may take
part in the dilatation {luvnudo-
mctra), so that on making a
bimanual examination there will
be found, lying between the vulva
and the hypogastric region, a
globular, tense, very slightly fluc-
tuating body, corresponding in
outline to the distended uterus, a wave of fluctuation
being transmitted from the fundus uteri to the i^rotruding
surface at the vaginal orifice. The Fallopian tubes may,
in their turn, form large tumors, filled with blood
{li(T'ni(if<>s(i1j)iii,r), the blood contained in them being not
always pressed out from the uterus, but coming sometimes
from the mucous membrane of the tubes themselves.

A (litujnosis can very easily be made, when the
history, symptoms and subjective signs are taken into
consideration. The tumor formed may nearly fill the
pelvic cavity and, by pressure, produce vesical and ri'ctal
symi)toms. It may form n tumor in the perineal region.

KlG. 56.

-Atresia of the vaginal
outlet.

DISEASES OF THE VAGINA. 17)5

ns Inrgo ns n fcutnl hoad, which finttons out the frenulum,
and is continuous witli the skin on tlie distended periucnini
nnd Inbin ot the vulvn, in front of which will be found tiie
meatus. The dangers arising from such a condition are
self evident. Spontaneous rupture through the hymen is
very rare, hence, if left alone, it may lead to rupture of
the vagina, uterus, or tubes, and even operative inter-
ference is not without its dangers.

Trcdtmcni. When tlu^ tumor is small and confined to
the vagina, a crucial incision, or one made by cutting
along the insertion of the liymen. is to be made, the cavity
irrigated with a warm alkaline solution, such as soda
bicarbonate, or lic^uor potassje, and subseciuently with a
1 to 2(XX) sublimate solution. To prevcait septic absorp-
tion, the cut margins may be touched over with the
thermo-cautery, and some strips of iodoform gauze intro-
duced to allow for free drainage. When the accumulated
mass occupies the uterus, the dangc^rs arising are those of
rupture of the tubes and sepsis. To avoid the former,
the utmf)st delicacy in manipulation must be observed,
and no attempt at rapid evacuation made by pressure on
the tumor or otherwise. To avoid the latter a large opening
should be matle and the accumulated fluid carefully
washed away, the cavity irrigated and free drainage
established. If luematosalpinx can be made out before
operation, it is best to remove the distended tubciS first,
together with the ovaries. The subsecpient treatment
will consist in irrigation with antiseptic solutions and in
maintaining free drainage until involution has been well
established.

MALFORMATIONS OF THE VAGINA.

Atresia and Stenosis. The term (itva^id signifies an
imperforate condition, and in its strict import is limited
to complete closure of nil aperture or canal. Any
obliteration or occlusion so extreme as to remove the case
from the class of strictures, and yet is not complete, is

174

MEDICAL AND SURGICAL OYN/EC!()LOOY.

stylod stenosis. Somo authoritioa uso tlu> term iitrcaia to
si^tiity both conditions, marking the divisions by the
terms complete and incomptete.

The vagina, in fojtal lift?, is created from the approxi-
mation and amalgamation of the MuUerian ducts ujion
the median line, and to arrest of developmcmt of these
joarts a great variety of congenital malformations are
attributable. There may bo no trace of the vaginal caiml,
the ducts of Muller seeming to have failed entirely to

develop; there may be a distinct
fibrous cord marking the site which
it should have occupied, somo slight
devoloijment appearing to hav(^ oc-
curred; development may exist for
some distance up the canal, failure
having taken place above; or one
duct may have developed in part
above and another below, giving two
cul-de-sacs, separated from each other
by impervious tissue. Not rarely
the whole canal is ill developed, and
the hymen guarding its outlet a
closed unyielding membrane — a con-
dition often combined with an infantile uterus. The
vagina may be divided by a more or less complete
longitudinal partition into two halves, eacli of which
corresponds to one Mullerian duct — a condition often
combined with double uterus. Double vagina may be
combined witli atresia on one or both sides, and if one
side is pervious, the condition may be overlooked for a
long time. While congenital defective development is
one of the frecpiont causes of atresia and stenosis, it may
occur as a result of injury from mechani(!al, chemical, or
pathological agencies. A vagina once fully developed
may close entirely from adhesions of its walls, or its
calibre may be diminished by absolute removal of its

Fit;. 57- — Extern.al appearance
of (loulile vagina. «, /',
v.^gillaI orifices.

DISEASES OF THE VAGINA. 175

coinpoiuMit Htru(!tuniH in consoquonco of Hloughin^ pro-
duced by impaired vitality, by prolonged or difficult labor,
by chemical agencies locally applied, or by syphilitic or
other extensive ulceration.

Hi/nii>f()nii<. T\w condition will demonstrate its ex-
istence oidy by incapacitating tlu^ vaginal canal for the
p(vrff)rmance of its functions. Should it occur in ont> too
old, or too young, to rec^uire such funtitions from the
vagina, it may attract no notice. Amenorrluua alone, or
combined with those symptoms of retained menstrual
blood already describcnl when spi^aking of imperforate
hymen, or inability to perform the act of coition, will
probably first bring tlu> sufferer under notice. On making
a physical examination, the entrance of the finger into, or
up the vagina, will b(^ found difficult or impossible. In-
vestigation will prove that it is not due to vaginismus, or
udhesion of the labia. The introdut^tion of a sound into
the bladder, and the finger into the rectum, may discover
the canal running up as a fibrous cord, or no tracer of it
whatever may be found. DoubU> vagina can generally be
very readily made out, but when there is atresia on one
side the diagnosis may not be so easy. In this there will
be a menstrual discharge from the open side and retention
in the other half, ff)rming a luiMuatocolpos or hiumatometra.
From UK're occlusion of tlu^ vagina there is no imnu'diate
or direct derangemc^nt, but in those cases where ther(> is
retention and accumulation of menstrual blooil in the
portion of the canal above the stricture, or in the uterus,
the danger assumes the same proportions, or even greater
than in imperfon.te hymen.

Trcatincnt. The possibility of removing tlu^ abnormal
state will depend upon the extent and completeness of the
obliteration, or upon tlu^ destruction of tissue. General
uarrowni^ss, due to arrest of development, may be success-
fully treated by the introduction of graduated dilators,
anil the treatment kept up until it has reached the normal

176 MEDICAL AND SURGICAL GYNMJOLOGY.

size. Whou ntrosin occurs from tho pr(>Hoiic(> of a mem-
brnue nbovo tlir hymon {scj)(i(iu rctro-liijinciKflc). it is to
bo trimtod on the snmo principles ns for ntresia of the
hymeii.

If, in complete congenital closure or absence of tho
vagina, the uterus be found to be absent also, no attempt
should be made to make a vagina, as it is hardly justifiable
to expose the patient to the dangers of operation mi^t^ly in
the hop(^ of forming an organ of copulation, besides the
artificially formed vagina is apt to close again. The
situation is entirely different when there is a uterus, with
attempts at menstruation or retention of the menstrual
flow. Under such circumstances operative interference is
imperative. The patient is placed in the dorsal position
and the legs elevated by Clover's crutch. A transverse
incision is made midway between the urethra and anus.
The operator works his way slowly and very carefully up
between the bladder and rectum, insinuating his way with
fingers and closed blunt scissors, keepiiig at the same time
a metal catheter in the bladder. The left forefinger in
the rectum will locate the position of the cervix and in-
dicate tho direction in which the operator must work to
reach it. After reaching tho cul-de-sac and the cervix
exposed, tho opening is stretched, accumulations removed
if present, observing tho same care as heretofore expressed,
and the parts carefully irrigated. A few strips of iodo-
form gauze may be introduced into the fornices, after
which a hollow glass tube covered with gauze, and jiropor-
tionate in size to the new formed vagina, is inserted and
held in position by a "T" bandage. Tho tube should be
worn for a month at least, during which it should be taken
out daily and the parts irrigated. Subsequently tho plug
should be worn for an hour each day during a whole year.
If absence of tho vagina is combined with absence of tho
uterus, but active ovaries present, they should be extir-
pated.

DISEASES OF THE VAGINA. 177

In floublo vngiiin, If tlio w^ptuni inti'rfi^rcs witli coition,
it may bo Hi)lit U^nf^thwise and the marj^ins touclu'd with
tlio tliornio-cautory. DoubU^ vagina, with unihitcral or
bilateral atresia and retention of the inenHtrual fluid, may
bo mistaki^n for luematocele, or a uterine myoma, unless
the history of the case is carefully taken into consideration.
Unilateral atresia may b(^ treated by introducin?^ a
sinnnilum into the open half, and openinj^ into i\\" otlur
by means of scissors or thermo-cautery. In double atresia
one side may be opened first, as in atresia of the single
vagina, and afterwards the septum incised.

Faulty communications. As a result of arn-st of
development other conditions are sonii'times met with.
There may be complete atresia, or absence of any opening
on the cutaneous surface leading into the intestinal or
uro-genital canal, while under the skin is found a common
cloaca, into which open the bladder, vagina and rectum.
In other cases the vagina and urethra apparently open
into the rectum, being cases of persistent cloaca. The
partition between the rectum and the uro-geiutal sinus
may have been formed, but tlu^ urethra seems to opt'n into
the vagiim -a condition die to persistent uro-genital sinus.

VAGINITIS.

Vaginitis is the word commonly used to (h^signate
inflammation of the vagina, but some autliors, however,
have substituted the word colpitis or cli/trifis.

Under this term is comprised so many different con-
ditions that it is necessary to admit certain divisions
and subdivisions of the subject. Thus the intensity of
the symptoms and the length of timi^ which the disease
lasts, classifies it as (irufc or chronic. It is called prinnrrif
when it appears first in the vagina; accotuUtrji when the
inflammation invades the organ from another part.

Taking the chief features of the disease into consider-
ation, vagiiiitia may be classified as simple, yonorrlujcal,

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178 MEDICAL AND SURGICAL GYNAECOLOGY.

and (jranular, and to this clnssificntion may be added the
(iplithous. cfjsfic, adhcsivo, vesicular, and onphysonah.ns,
as forming less important varieties.

^tiolofjy. Any intluence which injures the vaginal
epithelium, such as long continued friction from foreign
bodies, or chemically irritating secretions or injecta,
diminishes the resisting power of the vfiginal mucous
membrane. If accompanied by lack of drainage, and t \
consequent accumulation of secretions, bacteria multipl;y,
infection follows, and vaginitis results. Among the
prcdisjiosinji causes may be mentioned anaemia; chlorosis;
constipation; any of those causes which tend to produce
unhealthy conditions of the skin; pregnancy; abdominal
tumors, or other conditions which tend to produce pelvic
congestion. Masturbation; pin worms; pessaries; tam-
pons; chemical irritants; retained secretions; pathological
secretions from the uterus, urethra, or vulva, or infection
introduced from without, such as gonorrhoeal pus, may be
enumerated among the exciting causes. The exanthemata
are held accountable for a small share of the cases.

PathoUnjij. In the acute stage of simple vaginitis,
hyperffimia and enlargement of the papilliB take place,
with small celled infiltration of the epithelial structure.
The epithelium on the summits of the papillfc is shed, but
between them it is thickened. The discharge in .some
cases is thin and slightly acid; in others it is alkaline and
thick; in others purulent. In the chronic form the
deeper layers of the membrane become infiltrated, with
loss of epithelium in some places, giving rise to ulceration.
When caused by chemical irritants, such as strong solu-
tions of iodine, a sort of vesication may oc^ur, with
exfoliation of large layers of epithelial tissue having the
appearance of a false membraiu>. In the gonorrhoml
variety the changes are similar to those mentioi'^d, but
more pronounced. The papilhe are larger and more
vascular, the vestibule and inner surfaces of the labia

DISEASES OF THE VAGINA. 179

participnto in those clmugos, while the discharge from tlie
first is muco-puruhMit. Later the discharge becomes
thinner and more distinctly purulent, and may give rise
to infection of the urethra, vulva, and vulvo-vaginal
glands.

Graanlar vaginilis differs chiefly by the more jjro-
nounced enlargement of the papilhe and by more extensive
exfoliation of the epithelium covering tliem, causing the
surface to resemble a mass of granulations.

Adhesive V(i<)iiiitis is a disease of childnni and old
people. In them the prtpillffi are smaller and the epithelial
layer thinner. The inflammation is usually found more
in patches, the secretion scanty, the surface smoother, and
often ecchymotic ia spots. The opposed surfaces tend to
agglutinate, and by this means the lumen of the fornices,
or even of the whole vagina may become obliterated.

Cystic or follicfdnr raf/iuitis consists of an inflamma-
tion in the follicles occasionally situated about the vaginal
fornices, causing the retention of their contents and the
formation of small cysts.

Aplitliovs viujinHis arises from a development of the
oidiurn albicans on the congested or more or less eroded
vaginal surfaces, giving rise to whitish patches.

Vesicular raijinitis gives rise to round vesicles situattnl
on inflamed areas, which, after bursting, leave sharply
defined raw surfaces about the size of split peas.

Emphjisemaions va(jinitis is an inflammation of the
vagina characterized by the development of fluid and gas
in the small spaces and canals of the connective tissue and
lymphatics at the upper end of the vagina. They project
like little bladders on a raised hyperannic base, produce
a crackling sensation when felt, and collapse when punc-
tured. Pregnancy favors the development of this form.

Sympfonis. Acute vaginitis is indicated first by a dull
pain in the pelvic region, and a sensation of heat and ful-
ness in the vagina, accompanied by a slight rise of tern-

180 MEDICAL AND SURGICAL ftYN^COLOGY.

perature and a feeling of malaise. There is a discharge
which is at first scanty, but rapidly increases in amount,
and often possesses a disagreeable odor. Micturition and
defecation become painful, conditions which may soon be
followed by severe urethral and vesical symptoms, such as
frequent urination accompanied by burning pain and
vesical tenesmus. Urethral and vesical symptoms indicate
with fair certainty thnt the causative agency is one of
gonorrhoea, particularly if accompanied by pain or tender-
ness in the inguinal region. Digital examination shows
the vaginal orifice to be sensitive, the canal hot and
swollen, and at a later period roughened. If the urethra
be involved, it will be found thickened and tender, and
pressure along its course may cause a drop of pus to exude
from the meatus. Pus from this quarter is said to be con-
clusive evidence of gonorrhoea also, as gonococci thrive
best upon its mucous membrane. If the bladder becomes
infected, pressure on the vaginal wall will reveal the fact
by the marked increase in the pain produced. Inspection
will show the vulva acutely inflamed and covered with a
muco-purulent or purulent discharge.

The symptoms of chronic vaginitis are similar, but
less pronounced. In some cases symptoms of importance
are absent altogether, and nothing, except a leucorrlux3al
discharge, calls the patient's attention to her condition.
It may follow the acute stage, but more often is, from the
first, a subacute or chronic process, such, ivT instance, as
that form which develops in consequence of discharges
from the direction of the uterus, or as the result of senile
changes. The more acrid and abundant the discharges
become, the more likely will they produce vulvitis and
pruritus. Touch and sight reveal the rouglunied surfaces
and, if of the gonorrluwal form, vegetations are not
uncommon. With the symptoms described, a vaginitis
should not be confounded with any other lesion, but it is
not always easy to distinguish one form of vaginitis from

DISEASES OP THE VAGINA. 181

auotluT. The presence of the gonococcuH may establish
the presence of one form, but its absence is not adecpiate
proof of the absence of such infection. Corroborative
evidence in its favor is found, however, in other directions,
the prominent points of which have already been related
when speakinj^ of vulvitis.

Treafnicnf. Simple acute vaginitis is readily controlled
and cured by keeping the patient at rest, by freeing the
bowels with mild cathartics, and by the copious use of
douches, consisting of a strong aqueous solution of boric
acid, borax, or of bicarbonate of soda, at a temperature
of 105° to 110° F., every four hours, the vagina being
stretched by means of a wire speculum to permit of its
application to every part. If the tenderness is so groat as
to exclude the use of such an instrument, a soft cutheter
may be used, aided by hot alkaline fomentations applied
to the external genitals. If there is a suspicion that it is
of a gonorrhaml type, or in cases in which the simple form
does not readily yield, the fluid used for douching should
contain instead of alkalies, bichloride of mercury 1 to
5(XX). If the disease shows a tendency to become chronic,
more energetic local measures become necessary. Through
a Sims' speculum, the vaginal walls are to be carefully
cleansed with green soap and warm water, then wiped
over thoroughly with a solution ol bichloride 1 to 1000,
followed by another washing of warm water. After
cari'fully drying with absorbent cotton, the vagina is to
be lightly packed with plain or borated absorbent cotton,
or the surfaces kept apart by tht introduction of three or
four thicknesses of gauze. This treatment should be
repeated daily, until the disease is conquered. In the
chronic form, the same careful cleansing is to be carried
out but, instead of the bichloride, the entire surface is to
be painted with a Hve per cent, solution of nitrate of
silver, after which gauze is to be inserted as before and
allowed to remain for twenty four hours. This treatment

182 MEDICAL AND SURGICAL, GYN/ECOLOGY.

should bo given every three or four days, and in the
intervals warm borax douches niglit and morning. Treat-
ment by dry powder, such as ecpial parts of bismuth and
chalk, or tannin and chalk, and kept in places by a cotton
tampon, often proves serviceable when there is a tendency
for the discharge to linger. The powder and tampon
should be removed every day, the old powder being
douched out just before the treatment is repented. Sup-
positories of tannni, oxide of zinc, or acetate of lead may
be similarly used, with equally good results. In the
senile and vesicular forms, mild antiseptic douches are
indicated, supplemented by strips of lint smeared with a
two per cent, carbolized oxide of zinc ointment and
introduced within the vagina.

Neoplasms. Cysts are rather frequently found in the
vagina of adults or, as congenital formations, in new born
children. They are usually single, globular or oblong, and
for the most part sessile, but may become pedunculated.
They vary in size from that of a pea to a goose egg,
but may, exceptionally, reach the size of a foetal head at
full term. The contents may bo serous, yellowish,
purulent, or thick and chocolate colored. Those cysts
may have different origins. They may be formed by con-
densation of the peri-vaginal connective tissue around an
extravasation of blood, or they may be simple retention
cysts. Remains of an ununited du3t of MuUer or of the
canals of Grartner may give rise to them. If small they
may not give rise to any symptoms, but are discovered
accidentally during delivery, or an examination. They
may be diagnosed from a cystocole or rectocelo by the
introduction of a catheter into the bladder, or the tinger
into the rectum.

The treatment consists in making an incision over the
tumor and enucleating the entire cyst wall, if possible.
When unable to do this, removal of as much of the cyst

DISEASES OF THE VAGINA. 183

wall as possible is to bo accomplisluMl and the remainder
caiiteri7A>(l and packed with iodoform j^aiize.

Fi'hronid ((ltd Jiln'(,mi/())ii<i arv rare. Their most com-
mon Hcni is in the upper jiart of the anterior vaginal wall.
Orifjcinally they are globular, sessile tumors, but when
their weight increases they have a tendency to become
pedunculated, and may even protrude through the vulva.
When they are small they are easily diagnosed by their
elastic hardness, but when large they may be mistaken for
a uterine pedunculated fibroid. If, however, the os can
be reached, it will be undilated and no pedicle will bo
found passing through it.

Treahmmt. If sessile, it may be removed by making
an incision over its longest diameter and, after enucleating
it, the cavity closed by rows of superficial raid deep catgut
sutures. If pedunculated, the pedicle may be secured by
ligature and the mass cut away.

Mhcoks polypi are very rare. In shape and structure
they are similar to the mucous or glandular jjolypi found
in the cervical canal.

Prinud'i/ cfcrhwdKi is also fl rare disease. As a rule
it is secondary, either propagated by continuity from
neighboring organs, or appearing as metastatic deposits
from carcinoma in remote parts. As a primary affection
it occurs in the form of epithelioma and submucous
carcinoma. Epithelioma usually begins as a circum-
scribed projecting nodule on the posterior wall of the
vagina, which soon breaks down on the surface and
assumes the form of a raised, ulcerating, cauliflower-like
mass, with everted edges. The submucous or diffuse
variety commences as a flat area of infiltration, under the
normal vaginal membrane, which spreads along and around
the vagina, until the latter feels like a narrow opening
through a mass of hard unyielding tissue. Ulceration
and excavation sooner or later take place, with corres-
ponding softening of the parts. The sijmpfums are at

184 MEDICAL AND SURGICAL GYNAECOLOGY.

first confined to a thin irritating dischargo, wliich bi^forc^
loufr becomos ott'onsivc, bloody at times, and containinj^
Homo tissue debris. Pain, radiating from the vagina, is
soon experienced, and later t!io symptoms are those which
characterize infection of the neighboring organs. The
treatment consists in extirpating the dis(uised tissues,
whenever possible, and thorougldy cauterizing the wound.
When it is no longer possible to remove ail the tissue, the
surface may be curetted, and a solution of ''orric chloride
applied once a week, if it is tolerated that ot*^^en. Astrin-
gent and antiseptic douches will help to diminish hemor-
rhage, destroy the odor, and prevent septic absorption.

CHAPTEB XVII.

GENITAL FISTULA.

Genital fistulae are abnormal avenues for fecal or
urinary discharge, by moans of which some portion of the
intestine or urinary tract communicates with the genital
tract.

Fecal fistulse are formed by a communication bet ween
the rectum or the small intestine, and the uterus, vagina,
or bladder.

Urinary fistulae are formed by the bladder discharging
into tho uterus or vagina; by an opening from the urethra
into the vagina; or by a ureter emptying into the uterus
oi vagina. They have been designated as vesico-vaginal,
urethra - vmjinal, vesica - uterine, vesica - utera - vaginal,
utera-vag inal, nretero-uterine. and uretera-vesica-vaijinal.

Vesico-vaginal fistula is a communication between
the bladder and vagina, and is by far the most common
form. These tistuhe may originate from protracted labors,
in which the bladder has boon compressed between the
head of the child and the symphysis pubis sufficiently

GENITAL FISTULA. 185

long to produco n locnlizod nocrosis, niul tbo necrotic
tissue thus formed, coming nwny after a period of a few
days, establishes the fistulous tract. They may also arise
from direct injury to the tissues from the use of forceps,
or from injury sustained during surgical oj)erations in the
neighborhood of the bladder, particularly hysterectomy.
Other agencies may create them, such as pessaries, stono
in the bladder, or the presence of other foreign bodies.
The vaginal walls may be perforated by cancer, or by
syphilitic or other ulcers, or by the formation of an abscess
in the parietal tissues. Lastly, certain diseases, producing
deficiency of nutrition, may cause localized sloughing of
the vaginal walls.

Sijmptoms. The chief symptom is indicai3d by a more
or less constant dribbling of urine from the vagina, accom-
panied by a disagreeable ammoniacal odor. By the
passage of this irritating excrementitious material through
a canal and over tissues not intended by nature to tolerate
it, inflammatory action, pruritus, eruptions and excessive
irritability are produced, and the vagina sometimes becomes
covered with urinary concretions, and the vulva and thighs
red and excoriated. If the fistulous orifice be a large one,
even a superficial examination by touch will reveal the
nature and extent of the lesion, but the opening may be
so small, or so hidden behind the projecting cicatrix, that
it cannot be discovered. For their detection a Sims'
speculum should be employed, with the patient in the
genu-pectoral position, injecting at the same time, if
necessary, an infusion of India ink, cochineal, madder,
indigo, or plain milk.

Treatment. A fresh fistula, even if of considerable
size, may be much diminished, and sometimes closed
altogether, by the use of warm vaginal douches, and by the
internal administration of drugs to render the urine
normal, such as salol, or benzoic or phosphoric acid, or
benzoato of ammonia. When a fistula has been discovered

1H(> MKDUIAL AND STHdlCAL (iYNECOLOOY.

soon after parturition, it hIiouKi bi- treated by such
nil thods, as it is too early to resort to suture. The once
favorite inetliod of treating all varieties of these Hstuhe by
cauterization has now, very deservedly, faHeii into disuse
under the inHuenee of improved surj^ieal methods.

Closure by siitinw <(f the Hcaf of tlw Jhfiiln. This is
the most reliable and satisfactory of all methods. The
best time for operating is eight or nine weeks after con-
finement, at a period when the patient has regained her
constitutional vigor, for in no operation in surgery is this
more vigorously demanded. The pvcporotorii tt'catnicnt
consists in the use of the same nu'asures as have just been
mentioned, namely, warm vaginal douches, the adminis-
tration of drugs to render the urine unirritating, and the
careful removal of incrustations. If cicatricial bands
exist they are from time to time to be cut with a knife or
scissors, and the vagina stretched by tht> introduction of a
Bo7AHnan's dilator.

trims' opcrotion. This operation may be divided into
three parts; paring the edges of the fistula; passing the
sutures; and apjjroxi mating and coaptating the denuded
surfaces. The patient is placed in Sims' position and a
large broad-bladed speculum introduced into the vagina.
The (.'dges of the fistula are caught up witli a tenaculum
and, with scissors, the edges pared all round, to the extent
of producing a raw edge one-third of an inch wide, and
bevelled from the vesical mucous membrane outward to
the vagina, care being taken not to imijlicate the former
in the incision. Two sorts of sutures should be used in
approximating the denuded margins, silkworm for the
deep, and fine silk for the superficial stitches. Beginning
at the most remote portion, a slightly curved needle is
entered half an inch from the edge of the incision and
brought out on the denuded surface, just under, but not
including the edge of the vesical mucous membrane.
After drawing the suture partly through, the needle is

GENITAL, nSTUL.E.

LS7

iiitroducu^d jigaiii into tlu* raw Hurfnn^ ()i)i)()Hiti'. jiiKt uudor
the vosic^nl ituk^ouh iiuMnbraiic, mid n\ndv to ciiuTj^c lialf
an inch from the edge of the wound. The otlier .sutun^s,
tivo or six to the inch, are iiiiroduced similiarly, and one
at, or just beyond each angle of the wound. The sutures
are then brought together and tied .snugly, approximating
the tissues without strangulation, after wliich the margins
may be mor(> carefully coaptated by sup(^rficial sutures.
Tho ends of the sutures having been cut ott*, a loose
iodoform gauze pack is placed in the vagina. A self-
retaining catheter, preferably of soft rubber, may bo
introduced, after carefully washing out the bladder. Many
surgeons prefer to trust to frequent catheterization for a

Fig. 58 — Operation for vesico vagiii.il fistula, denuclalion complete, and sutures in place.

few days, believing that the constant presence of the
catheter keeps up continued vesical tenesmus and lessens
the chances for immediate union. If the vaginal pack
bc^comos wet or soiled, it should be removed, otherwise it
may be left in place for two days, when it should be taken
away, antl the vagina allowed to remain empty.

When the operation was first perfected by Sinii,
silver wire, introduced by silk carriers, was used ex-

188 MEDICAL AND SURGICAL GYN.ECOLOGY.

cluHivoly, but it in found tlint Hilkworm servoH oqunlly
an W(^ll.

Tivo ofluT <>f)cr<itions Jiro gouorully doHcribcHl for tho
closure of vesico-vagiunl tistuhe, namely, Simon's and
Bozemau's, but as they dittVr mostly in the matter of
technique, and in tho method of procedure, it is not
(!onsi(lere(l necessary to describe the various stejjs.

There is a y/ff;;-.s7>///////// (>j)('f((fi<)n, known as Blazius'
method, and recently rem wed by Lawson Tait and others.
No tissue is cut away, but an incision is made parallel to
tho vaginal and vesical mucous membrane, on tho white
lino of the cicatrix, to the depth of three-eighths of an
inch. The vesical and vaginal flaps thus formed are
separated and, in the cleft formed, a vircular suture is
introduced, which, when drawn up, approximates the raw
surfaces all around.

Urethro-vaginal. In this variety the wall of the
.septum being very thin, the denudation must be extended
over the nearest part of the vagina and the edges brought
together from side to side over r. metal catheter. If the
tension is great, it may be relieved by n. cing an incision
on each side parallel to the line of union.

Vesico-uterine. From its anatomical relations, fistulous
communication can only take place between the bladder
and uterus at the cervix, except under rather rare circum-
stances. These fistulte are produced in the same manner
as vesico-vaginal fistuloe, and form small round holes
opening through the anterior lij, of the cervix. It, too,
may be diagnosed by injecting milk or colored fluid into
the bladder. Sometimes a probe can be brought from the
bladder, through the fistula, into the cervical canal.

Trenhncnt. This kind of fistula has an unusual
tendency to spontaneous healing, and efforts of nature in
this direction may be aided by cauterization. If that
does not succeed it may be closed by operative i^rocedure.
After having split the cervix in the median line, so as to

GENITAL FISTULiE. 189

ronch the fistulous trnct, and denuding its surfaces,
sutures nro introduced through the uterine and vesical
walls, after wliich tlu^ incision in the cervix is closed the
same as in tracludorrhaphy.

Vesico-utero-vaginal. In this variety the fistulous
tract i)asses from the bladder through the anterior lip of
the cervix and ends in the vagina. They are subdivided
into superficial and deep, according to whether tlu^re is
partial or comi^lete sloughing of the anterior cervical lip.
In the superficial form, good results may be obtained by
simple denudation and suture, but the deep are rarely
amenable to treatment by this metnod, and it is generally
necessary to bring the posterior lip of the cervix in
apposition with the vaginal edge of the fistula, and stitch
the two together. The os uteri therefoi-^ will open directly
into the bladder. This operation has been termed vesico-
hijiitcro-alcisis.

Uretero-vaginal. A uretero-vaginal fistula is situated
on the anterior wall of the vagina, a little below and
outside of the vaginal portion of the uterus, and is formed
between the ureter and vagina. The causes are, difficult
parturition, perforation of a pelvic abscess, prolonged use
of pessaries, and vaginal and abdominal hysterectomy.

Difu/nosis. By placing the patient in the dorsal
position and exposing the vaginal vault, the fistulous
opening may, with a little patience, be found, though it
be only the size of a pinhead, or smaller. With a probe
or ureteral cathoter, it is usually possible to enter the
ureter for some distance and see the urine coming out
drop by drop. A catheter or sound passed into the
bladder will reveal the absence of the probe there. Milk
introduced through the urethra will not escape through
the fistula. Cystoscopic examination will positively clear
up the diagnosis. With the ureteral catheters introduced
no urine will come from the catheter on the affected side,
while on the opposite side it will issue drop by drop.

Ill

l^R) MEDIOAL AND SURGICAL GYNitCOLOGY.

Trrdtmrnt. All uretoro-vnginni fistulre should bo
operated upon ns soon as circumstnucos will permit, on
account of the great liability of the kidney to become
infected. Three operations are available, closure of the
fistula, implantation of the ureter into the bladder, and
nephrectomy.

1. An elliptic incision is made around the fistula, the
ureter exposed, and a sound passed into its orifice. After
freeing the ureter for about one third of an inch, an
opening is made into the bladder, just above the end of
the ureter, and, after removing the sound, the free end of
the ureter is turned into this opening and ludd there by
two or three fine sutures passing through the vesical and
ureteral walls, but sufficiently superficial as not to
encroach upon the lumen of the ureter. The vaginal
incision is then closed carefully.

2. If a vesico- vaginal fistula does not already exist, one
is made by the excision of an oval flap around the ureteral
oijening. The end of a very fine gum elastic catheter is
then passed into the renal end of the ureter, and the other
end into the urethra by way of the fistulous opening in
the bladder. The geuu-pectoral position is now assumed
and the edges of the fistula denuded. A series of fine
sutures are passed through the flaps, at right angles to the
ureter, and tied. The catheter must remain in position
for at least eight days, and the bladder kept empty for a
portion of that time by a self retaining catheter or by
frequent catheterization.

3. Implantation of the ureter in the bladder. (Uretero-
cystostomy). After opeidng the abdomen, the ureter is
dissected out low down, and an opening made in the
posterior wall of the bladder by cuttmg down on closed
forceps introduced through the ureiiira. A flexible
catheter is introduced into the ureter and pulled out
through thxC urethra. The ureter is then fastened to the
wall of the bladder by fine sutures, after which the flaps

GENITAL FISTULA,

191

of peritoneum are mnde to cover over aud close off the
point of entrance, fine silk sutures being also introduced
for that purpose. If there is difficulty in selecting the
proper point for oijoning into the bladder, it may be
partially filled with boric acid solution, which is at once
to be evacuated after the point has been selected. Finally
a self-retaining soft rubber catheter is to be inserted
through the urethra by the side of the ureteral catheter,
after which the abdominal wound is closed.

Uretero-uterine fistula. In this variety the urine
flows from the oh, as in the vesico-uterine, but the
mt^thods adopted to ditt'erentiate between vesico-vaginal
and uretero-vaginal and vesico-uterine will be sufficient to
make a diagnosis. This form of fistula is exceedingly
rare, and if abdominal implantation cannot be performed,
relief may be obtained by turning the cervix into the
bladder, by artificial closure of the vagina (colpo-cloisis),
or by excision of the corresponding kidney (iie])hrectomy).

Indirect methods for the relief of urinary fistulae
have been devised. They consist in the closure of the
genital canal, at a point below the site of the fistula, so
that the portion of the vagina above becomes a part of the
bladder, menstruation, if present, taking place into this
viscus. Three varieties have been devised : — Antero-
posterior closure of the vulva (episio-cU^isis) ; complete
vulvar closure with the formation of an artificial recto-
vaginal fistula; and the obliteration of the vaginal canal
transversely (colpo-cleisis). The two former have proved
so unsatisfactory that tliey have been jiractically aban-
doned.

Colpo-clcisifi. In performing colpo-cleisis care should
be taken to preserve as much of the depth of the vagina
as possible, and theriifore closure should not be made at a
lower point than necessary. A ring of mucous membrane
is marked out on the vaginal wall, and with a sound in
the bladder, the anterior surface is denuded, and with the

192 MEDICAL AND SURGICAL GYNECOLOGY.

finger in the rectum, the posterior surface. Sutures are
passed by means of two short half-curved stout needles,
one at each end, the anterior needle being passed from
above downward, under the denuded surface of the vesico-
vaginal wall, and the posterior needle similarly, under the
denuded surface of the recto-vaginal wall, and, after all
are inserted, they are carefully tied.

FECAL FISTULA.

|j;| Fecal fistulse are abnormal avenues for the escape of

the contents of the small or laige intestine, either by the
vagina or by the bladder. Implication of the small
intestine is comparatively rare, and that of the bladder
extremely sp. The fistulous communication may take
place between the rectum and vulva, recto-hihuil; between
the rectum and the vagina, recto-vagimd; or between the
ileum or sigmoid flexure and the vagina, ilco-vaginal, or
entero-vaginal.

The size of the opening varies. It may bo so small as
to be found with difficulty, or large enough to admit a
fiiger. It may be situated anywhere between the intestine
and vagina, but it is most commonly found either immedi-
ately above the sphincter ani or at the fornix. The causes
of fecal fistulae are in many respects similar io those
determining urinary fistulje, but the most common by far
is child-birth. The symptoms are plain. The escape
of flatus and, when the bowels are loose, of their fecal
matter through the vagina, readily indicates the condition,
but when the fistula is very small there may be some
difiiculty in locating it. Distension of the rectum with
water will often bring the opening into sight.

Treatment. Many small fecal fistula? have a decided
tendency to close naturally, and this happy result should
be facilitated by scrupulous cleanliness, sitz baths, rectal
and vaginal injections, laxatives, and by an occasional
light cauterization.

GENITAL FISTULyE. 193

Rccto-lahial fistula is best treated as a fistula in nno.
If the labial opening be near the rectum it may be cut
through, the fistulous tract curetted or denuded, and either
packed with gauze, leaving it to heal by granulation, or
the surfaces brought together with deep sutures, to heal
by immediate union.

Many operations have been devised for the cure of
recto-vaginal fistulse: —

1. Emmefs operation consists in splitting the perineal
body up to the fistula, cutting its wall away, and uniting
the same as in complete rupture of the perineum.

2. The fiap-splittiiKj mctJiod described for the cure of
vesico-vaginal fistula often gives good results when the
opening is small.

3. Make a broad denudation on the vaginal side and
extending from the sound tissue deep down into the
fistula. De<ip and superficial sutures are passed from
side to side.

4. Make a vertical incision in the median line, extend-
ing half an inch above and below the fistula, and dissect
the vaginal from the rectal wall on each side, for a
distance of half an inch. Unite the edges of the rectum
by a continuous buried catgut suture inserted from the
vaginal side, and afterwards the vaginal flaps by silkworm
or chromic catgut.

Ent<'ro-va(/inal fistula', when the opening is lateral,
may be closed by denudation and suture like other fecal
fistuljB. In the case of raxjinal anus no attempt at closure
must be made until it is ascertained that the lower part of
the bowel is pervious.

In ilro-vaginal fisfuhv, and in fistulous openings
bv>tween the bladder and intestine, the oidy plan of treat-
ment is to open the abdomen, find the fistulous tract,
sever the adherent intestine if possible, and, by means of
Lembert sutures, close the openings in both viscus.

194 MEDICAL AND SURGICAL GYNiECOLOGY,

CHAPTER XVIII.

DISEASES OF THE URETHRA AND BLADDER.

Malformations of the urethra. Tlio urethra may be
entirely absent, due chiefly to arrest in development of
the vagina at a point where it should form the main
portion of the posterior wall of the urethra.

The lower and anterior portion of the virethra may
be absent (hyi)ospadias).

Airesia of the urethra is a comparatively common
affection. There are two forms mentioned: one is produced
by imperfect development of the vaginal process, or of
both the clitoral and vaginal segments, the urethra being
open up to the bladder and there closed. The second form
occurs when the clitoral and vaginal processes are both
defective. In such cases there is no trace of a urethra,
except an imperfect vaginal wall, which extends obliquely
dowiuvaid and closes the bladder. The symptoms which
aris* from malformation of the urethra are incontinence
of ur* in the one cla.ss of cases, and retention in the
other. vV'hen the urethra is deficient in part, and the
bladder perforate, urine constantly escapes. Atresia of
the urethra and the consequent retention of urine
causes hydrops of the bladder, ureters, and kidneys.
Distention of these organs occurs in utcro, and such
malformed children are usually born dead, or die soon
after birth. The evil effects of this malformation is
sometimes naturally obviated by the occurrence of another
developmental anomaly — fistula of the urachus and escape
of the urine from the umbilicus. In making a diagnosis
of these di^formities, reliance cannot be placed on objective
symptoms alone, and a physical examination of the parts
becomes necessary. The general relative appearance of
the external organs must be observed, aidetl by attempts
at passing a sound into the bladder and by the intro-

DISEASES OF THE URETHRA AND HLADDER. 195

ductioii of the finger into tlu> rectum find, if possible, into
the vnginn.

Atresia of the urethra can only be cured by operation.
When there is entire absence of the urethra with the
existence of vesical fissure, or when there is persistence of
the sinus-uro-genitalis with partially developed urethra,
the production of an artificial oanal has been suggested.

Malformations of Kxe bladder follow the general rule,
and are thus in most instances due to some defect in the
normal process of development. Fissure is the most
frequent and prominent anomaly. It consists in partial
or complete absence of the anterior vesical wall, and is
usually accompanied by malformations of other organs.
It may be a simple fissure of the lower part of the
bladder, with an opening about three quarters of an inch
in breadth. A higher grade is that in which the fissure is
near the umbilicus, the lower part of the pelvic cavity and
the [)ubic symphysis being closed, and the lower part of
thi bladder, urethra, and external genitals normal. The
hir,hest grade {crsfrofilii/) is that in which the whole
anterior wall of tlu^ bladder seems absent, the inferior
abdominal region much shorter than normal, and the
umbilicus nearer the base of the pelvis. The abdominal
walls are divided, and the resultant fissure is filled up by
the bladder wall. The mucous membrane is puffed out
and red, and graduallj' merges into the skin of the
abdomen. On each side of the lower portion of the everted
bladder are situated the orifices of tlu' ureters. As a rule
the urethra is absent, and the clitoris is either divided, or
there may remain but a trace of it, or it may be entirely
absent.

Double bladder may be considered as extremely rare.
In such cases the double allantois, instead of forming one
passage, forms two, with a ureter opening into each.
Various explanations have been offered to account for the
malformation; some attribute it to defect in the allantois

196 MEDICAL AND SURGIC.T. QYHMCOLr.i.

at an early period in embryonic life, some to a failure of
the pubic bones to unite; some to atresia of the urethra,
followed by over distension, the distended organ pushing
aside tirst the recti muscles, later the cartilaginous pubic
bones, and finally bursting,

Trcdtmcnt. In t}ie severer form no plan offers any
relief except a plastic oper^iion, find this is often only
palliative. Even under the most favorable circumstances
not much more can be done than to diminish the annoy-
ance which comes from the flow of urine over the
surrounding external surfaces. The operation which has
given most satisfaction consists in dissecting a flap
from the central part of the abdominal wall, immediately
above the fissure, and large enough to close in the bladder
completely. After vivifying the edges of the bladder
wall, the abdominal flap is turned down and the edges
stitched to it. A lateral flap is next taken from each
groin, and brought together with their raw surfaces in
contact with the raw surfaces of the central flap, and
stitched to it.

Irritable urethra. A case will occasionally be met
with, in which will be found pain and tenderness of the
urethra, frequent desire to urinate, and pain in doing so,
while a careful examination will fail to find any lesion.
It very commoidy follows catarrh of the bladder, or it
may be the result of exposure to cold, or of some
temporary or accidental irritation of the bladder. It may
be very effectually treated by dilating the whole urethral
canal with dressing forceps, or some form of dilator, the
operation being repeated several times. An application
of equal parts of carbolic acid and glycerine to the whole
canal will materially aid in effecting a cure, although
urination will be painful for several days after.

Urethritis. Urethritis is of three varieties, acute,
chronic, and gonorrha'Ml. Acute urethritis, though not a
very frequent disease, is a very distressing one, and often

DISEASES OP THE URETHRA AND BLADDER.

1U7

difficult to relieve. In mnny cases it will be found to
depend upon a speoific cause, yet, like vaginitis, it is
sometimes uitfioult to mark the difference. Simple
urethritis comes on g/adually, and is often preceded
by symptoms of uterine or vesical disease, while the
gonorrh(Bal variety comes on rather abruptly, and is
preceded or attended by acute vaginitis and vulvitis. In
both varieties there is painful urination, and a sharp,
scalding sensation produced by the urine passing over the
tender surface. The desire to urinate is not so frequent,
or so urgent, as in cystitis, and in some cases the urine is
retained for a long time, dread of pain on the part of the
patient causing retention. During or immediately after
micturition, in some cases, a few drops of blood escape,
which may be recognized by its being exuded separately,
and not intimately mixed with the urine, as is usually the
case in hemorrhage from other portions of the urinary
tract. Examination will show the meatus swollen, red-
dened, and the urethral mucous membrane somewhat
prolajjsed. The urethra is felt as a firm, tender cord, and,
by pressure from above downward, a purulent fluid can be
pressed from the meatus, in which, if the gonocoecus is
found, reveals the nature of the urethritis.

Cystitis, a disease apt to be confounded with urethritis,
may be differentiated by using the catheter, and with-
drawing the urine direct from the bladder for the purpose
of examination. In the female, gonorrhoeal urethritis
frequently passes into the chronic stage, in which there
are no subjective symptoms, the diagnosis depending
wholly upon physical examination. A drop of thin milky
pus may be obtained by pressure upon the urethra from
behind forward, and the endoscope reveals the usual
appearances of inflammation.

The treatment, whether specific or otherwise, is con-
ducted on the same general plan. It consists essentially
in rest, a mild diet, the use of alkaline drinks, hot vaginal

lyS MEDICAL AND SURGICAL OYN.EC()^OaY.

(loroln'H, warm sitz biiths uiul saiiim l(ixntivi\s. Much
boiiufit inny bo derived from doucOiin^ tho urothrn with
water as hot as can be borne. When the more acute
syniiytomiH have subsideil, injections of sulpliate of zinc
(1 to 509y, or of nitrnto of silver (1 to 4000), repeated four
to six times u day, will often prove useful. The injection
may be made with an ordinary uri^thral syringe, a pipette,
or a reflux catheter specially adapted for urethral irriga-
tion. In subacute or chronic cases, great benefit may be
deriv(>d from douching the urethra two or three times a
day, with hot water followed by the use of some astringent
solution, while internally, oil of santal wood in ten minim
capsules, or salol in five grain doses, may be administered.

Granular erosion. This very troublesome, but fortu-
nately rare affection may result from urethritis, or it
may appear without any previous disease. The mucous
membrane is found covered with young, imperfectly
developed epithelium, the papillre hypertrophied and
extremely sensitive, giving rise to most excruciating pain
during micturition, and afterwards keeping up a most
distressing tenesmus. In the treatment, mild measures
do not accomplish much. The best results will follow
dilatation of the urethra and painting the mucous mem-
brane with a solution of nitrate of silver, a dram to the
ounce, or of carbolic acid dissolved in glycerine.

Strictures of the urethra are far less frequent in the
female than in the male. They are for the most part
acquired, narrowing being extremely rare. The causes of
cicatrical contraction are chronic urethritis, most fre-
quently gonorrhcBal; injuries during childbirth, or other
forms of traumatism; caustic apjilications; and ulcers of
syphilitic or t\iberculous origin. The most satisfactory
method of treatment is by gradual dilatation, as practised
in stricture of the male urethra, by means of dilators,
similar to those used for dilating the urethra for diagnostic
purposes. -, ■

DISEASES OF THE URETHRA AND BLADDER. HM)

Prolapse of the urethral mucous membrane, ure-
thral caruncle and venous angioma hnvo nlnmdy boon
consiclorod wlion six^akiiij^ of (lisonsoH of tho vulvn,
(Ohap. XTV).

Urethrocele cousists of a PAOoulntion of tho middle
portion of tho urothrr. It is formod, most fnuiuontly, by n
bagging of tho inforior wall, tho ujipor wall (h^viating
little, if at all, from its normal ijosition. Tho symptoms
are, for tho most part, due directly or indirectly to the
retention of a certain amount of urine in the sac. The
residual urine becomes ammoniacal by decomposition, and
finally jjurulont. The sac wall becomes inflamed and
eroded, followed by general urethritis and perhaps cystitis.
The sacculation is susceptible to the touch and ocular
inspection, and when the pouch is large it protrudes from
tho vulva.

Trcdfmcnt. If the sac be of the diverticular variety,
with little urethritis, it may be wholly excised and the
resulting fistula closed by suture. In the presence of
much urethritis the sac should be left unclosed, to
facilitate drainage and the use of remedial applications.
After the parts have been restored to a comparatively
health}' condition, the fistula may then be closed.

Irritable bladder. Under this heading may be grouped
those conditions, either extrinsic or intrinsic to the
bladder, which are not sufficient to induce organic disease,
but which keep it in a constant state of irritability. The
symptoms are such as to lead to a diagnosis of cystitis,
but a careful examination shows the bladder to be normal,
and we are forced to ascribe the symptoms to simple
irritation of the peripheral nerves, either from direct or
reflex causes. Probably tho most painful form of irrit;»ble
bladder is that following plastic or abdominal operations.
Following coeliotomy, the urine is genqrally of high
specific gravity, has a heavy sediment, consisting usually
of amorphous urates and phosphatic crystals, and is

200 MEIJICAL AN1> SURGICAL CIYN.ECOLOGY.

cupjiblo of prodiu^iiig gn^nt vcsic-iil irritability. Afti^r
Huch optirntioiiH too, tho uriiio is frcHiuoiitly diminiHluHl in
(pinntity, ho ns to HUggost tho poHsibility of noi^hritis or
obHtruction of one or both uretorH, n condition cnijabio of
aggrnvating tho bladder already irritated by tho heavily
charged urine. Irritability of the bladder will often be
found to be prt^sent as a reilex manifestation, in diseases of
the appendages, in dislocation of the bladder, in urethral
caruncle, in i)rolai)se of the rectum or of tho uterus, and it
often accompanies hysteria or other severe emotional
disturbances. The diagnosis can only be settled by
making a chemical and microscopical examination of the
urine; the former reveals nothing abnormal, the latter
a field laden with amorphous urates or phosphatic
crystals.

CYSTITIS.

Cystitis in the female is of frequent occurrence. It
may be either (trut(^ or chronie, local or (/cncral, and may
vary also greatly in intensity and duration, lasting from a
few days to many weeks The most frequent cause is the
introduction of septic matter into the bladder by means
of catheters, bougies, or other instruments. Cystitis,
caused by extension of an inflammatory process, is a
frequent result of vaginitis or urethritis, particularly of
the gonorrluDal type. Mechanical injuries, retention and
decomposition of urine, local chemical irritants, calculi
and foreign bodies, are all potent causes of vesical
inflammation. In the early stage of acute cystitis the
mucous membrane is red and congested, but otherwise
normal. Later the walls of the bladder become thickened
and the mucous surface covered with pus, fibrin, and
exfoliated epithelium, with, occasionally, small bleeding
areas, where the epithelium has become detached. In tho
chronic form the dangers are still more noticeable; the
muscular and fibrous coats are greatly hypertrophied, the
bladder cavity much decreased by the thickening and

DISEASES OP THE URETJIRA AND HLADDEIl.

201

coiitraetioii of its wall, nml tho normal folds staiul out as
promituMit rid^os, and may cvcmi assiuiu> a polypoid form.
HtMiiorrlia^os occur into the mucous mtMiibranc and
appear as dark occliymotic spots, wliich latc^r cliango to
slate color from partial absorption. As a rule when,
cystitis arises from habitual over-distiMision, the bladdi^r
walls nrv thin and parohmi^nt-like. In these cases thii
diphtheritic and croupous type of intlammation is most
likely to occur. The entire mucous membrane becomes
extensively involved, and is covered with a layer of
Kbrous material, or false membrants which may be thrown
off as a complete cast of the bladder. In more severe
cases of diphtheritic cystitis, the membrane is composed,
not oidy of necrotic mucous membrane*, but also of the
muscular coat. In some cases the diphtlu^ritic process
becomes locali/Anl and deep erosions or ragged ulcers
result.

The urine is usually intensely alkaline and heavily
laden with mucous and urinary salts, especially the
phosphatic, and are often dt^posited as tine incrus-
tations on tlie ulcerated areas. Microscopically, there
will be found a large number of leucocytes, or red
corpuscles, pavement epithelium, isolated, or in clumps,
and often large numbers of crystals of triple phosphates.
As a result of the hypertrophic thickening of the bladder
walls, the vesical orifices of the ureters may be partially
occluded, and dilatation of the ureters, pyonephrosis or
hydronephrosis may result.

Symptoms. The symptoms will vary according to the
cause, extent, severity and stage of the inflammatory
affection. In the acute stage, pain, often severe, is felt
above and behind the pubes, and radiating into the groin
and down the thirhs. The desire to void urine is almost
constant, and the act is attended by s-harp lacinating i ain
at the base of the bladder. Follovang urination there is
usually a sensation as though a few drops of urine yet

202 MEDICAL AND SUUOICAL GYN.ECIOUHIY.

romniiK^tl, ii (^(uiditiori soinor^'U^H so urj^iMit an to <'(iuho tlio
pationt to remain for liourH on tlio ohainbor. Thoro in
often n dull pnin in tho pcrin(>um, and proHHuro over the
pubos will incrri'aso tho i)ain or tenderneHH tlu^re. Fre-
quency of micturition iH an invariable .^ymptom, tlu^
frecpuMicy deijendin^ upon the dej^nn^ or Hta^e of intlam-
mation. Hematuria is not uncommon in tlu» early wtage,
and at times there appearH to be little less than pure
blood voided; but as tho process becomes older it entirely
disappears. In the acute form, the (piantity of urine
passed may be normal, or slightly incn^ased, tho color
unchanged, and possessing feeble acid reaction. After
standing a few hours it becomes alkaline, and precipitates
a diffuse sediment containing mucous, pus, and blood, in
greater or less amounts. Sometimes the urine becomes
ammoniacal and extensively offensive. The attack is
often ushered in by a chill, followed by a rise of tempera-
ture, which soon subsides, but in more severe septic or
diphtheritic cases, tlu^ symptoms from tho onset indicate
a very gravis condition. The patient falls into a typhoid
state, with dry tongue, headache, vomiting, subsultus
and delirium. Urination is sometimes obstructed by
fragments of membrane, causing over-distention, or the
ureters may be obstructed, producing total suppression
and death from uraemia. In chronic cystitis, the symp-
toms referable to the organ itself, and its contents, are
similar to those described, but of a milder type. Tho
urine contains pus, mucous, and exfoliated epithelium in
large amount. On standing, it precipitates an extremely
tenacious sediment, is neutral or alkaline in reaction,
and sometimes fetid. A careful examination with the
endoscoije will reveal the evidences of inflammation and
! j; the pathological changes present.

Treatment. Especially important is the prophylaxis
of vesical inflammation. A large proportion of cases arise
from the introduction of pyogenic organisms into the

UlSliASES OF THE UUETHUA AND ULADDlilt. 20,3

l)la(l(lor, honco too much cnro cannot be oxerciHtnl in
clonnHinj:? and Htorilizin^ all inHtrumt>ntH uhihI for (examina-
tion or tri'atmcnt. Tho first (^HHiMitial in rent i.. bed until
the acuto HymptoniH have HubsicU'd. The diet should bi^
.instimulatin^; Huid and Hemi-fluid foods, such as milk,
eggs, and light broths, are most suitable. Saliiu^ laxatives
should be admiiiistered, and cnre tnkou to keep the large
intestine free from fecal accumulation. Warm vaginal
douches and em^mata nre very soothing, and hot sitz
baths, with hot local compresses, will relieve thc! tenesmus
and V(esical fulness. To allay the fever, and to render the
urine unirritating when acid, the admiidstration of the
following mixture will be found usef d, osijocially when
combined with copious alkaline draughts:

R. PottvHS. Citrat., oz. h.«;
Spts. yEther Nit. , oz. i ;
Tiiict. Aconit., drains iss;
Atiuii' ad., oz. viii. M.

Sig. — Tablewpooiiful in some water every four hourw.
When the urine is alkaline it may be rendered acid *>y
the administration of benzoate of ammonia, in tei- grain
doses, every three or four hours. Salol is particularly
useful in ammoniaeal decomposition, giving five to *ni
grains every four to six hours. The same may be said of
boric acid, in ten to tifteen grain doses. To control jjain,
opium, belladonna, hyoscyamus, or chloral may be used
with caution, and when prescribed should be given by the
rectum. The first three mentioned are best administered
in the form of suppositories, while chloral gives the best
results when dissolved in two or three ounces of starch
water, and administered as an enema. One of the most
suitable preparations of opium to be given by the mouth,
is Dover's powder, but bromide of soda, in twenty grain
doses, and repeated every four to six hours, often acts
more kindly for the relief of pain and tenesmus. Cannabis
indica will often subdue the pain quite as effectually as
opium, and with less injurious after effects. Irrigation

204 MEDICAL AND SUliGICJAL GYN.ECOi^OGY.

of the bladder may be resorted to when the acute
symptoms Imve subsided, or earlier if it is of septic origin.
The most useful solutions for that purpose are three per
cent, boracie acid, one-tenth to one-half per cent, nitrate
of silver, ono-tenth to one-third per cent, permanganate
of potash, one-half per cent, creolin, or one to ten
thousand bichloride.

In chronic (cystitis special attention must be paid to
the general health, opium is to be avoided if possible, the
bromides or cannabis indica being used instead to relieve
tenesmus. Alkaline reaction of the urine should be cor-
rected as in the acute stage and, if the urine be purulent,
benzoic acid will be found of most service. Of the balsamic
preparations there is none better than pure oil of santal-
wood, administered in ten minim capsules every four
hours. The treatment consists mainly in local measures,
in the form of vesical irrigation by means of some simple
form of irrigator. The quantity to be injected at one
time must depend upon the character of the solution and
the degree of vesical irritability ; in some cases an ounce
is all that will be retained. The maximum volume shovdd
rarely exceed two to four ounc^^s. the process being
repeated several times until the bladder is thoroughly
cleansed. The temperature of the tluid should be from
UX)° to 105° F., and the irrigating process repeated twice
daily. Besides the solutions already mentioned, other
remedies have been found very serviceable, such as
salicylate of soda, a dram to the pint; methylene blue,
one to two grains to the ounce, especially in purulent
cases; ichthyol in water, one-half to one per cent., especi-
ally in gonorrhceal cystitis. In rebellious cases a two per
cent, solution of rescicin may be employed. Iodoform,
in the form of an emulsion (iodoform fifty parts, glycerine
forty parts, mucilage of acacia ten parts), has been highly
recommended, from two drams to an ounce being injected
once a day. When treatment fails and the pathological

DISEASES OF THE URETHRA AND BLADDER. 205

procoss j^rows worHo, it may be nooessnry to Hocuro
coustaut drainage of tlie bladder by means of dilatation of
the urethra, by tlie formation of a vesico-vaginal fistula,
or by the use of a self-retaining catheter. The most
satisfactory method for draining the bladder is by the
formation of a vesico-vaginal fistula.

KmmcVi^ operation. A sound is first passed into the
bladder, and the vesico-vaginal wall steadied with a
tenaculum and incised, after which a pair of uiunt-pointed
scissors is entered and the opening tmlarged. To prevent
the fistula from closing, the vesical and vaginal mucous
mi^mbrane should be stitched together. Instead of the
knife or scissors, the Paquelin cautery may be used.

Vesical Calculi. Stone in the bladder is a far less
common ilfection in the female than in the male. They
are oftener of the phosphatic variety, roughened areas of
the bladder wall being liable to become encrusted, and
serve as the starting point for calculous formation. The
stone usually lies free in the cavity; rarely it is encap-
suled. When suspected the diagnosis can readily be made
by the sound, by a cystoscopic examination, bj' digital
exploration through the urethra, or by conjoined abdom-
inal and vaginal palpation.

Treatment. Calculi may be removed by way of the
urethra, or by vpgiiml or suprapubic cystotomy. Small
calculi may be removed through the urethra, after dilata-
tion by n ^>ans of slender forceps. Larger, friable stones
may be crushed with a lithotrite, and the debris washed
out through a ^ "ethral speculum. When cystotomy is
required, the vaginal operation is generally preferred as
the simplest and safest.

Foreign bodies introduced by accident, or intentionally,
may be found in the urethra or bladder. The diagnosis
may be made in the same way as in calculus, and their
removal may be accomplished through the urethra.

20(i MEDICAL AND SURGICAL GYNECOLOGY.

Neoplasms of the female bladder are of infrequent
occurrence. They include papillomxi, mijxomd., jibvomd,
mijoma, sarcoma, cpitlu'lioma, and carcinoma. The most
constant symptom of vesical neoplasm is hematuria.
Growths at ^' 3 vesical neck give rise to frequent and
painful urination, and may interrupt the flow of urine at
micturition, or cause retention. As a rule cystitis sooner
or later results, followed by urethritis and pyelo-nephritis.
An examination of the urine will show it to contain pus,
blood, mucous, epithelial scales, neoplastic shreds and
phosphates. The diagnosis is made by conjoined abdom-
inal and vaginal manipulation, by the cystoscope, or by
direct examination through a speculum.

Treatment. Many small growths which are peduncu-
lated, may be twisted off and removed through the urethra.
If the tumors be sessile and spread out over the mucous
surface it is best to resort to the curette. If the hemoi-
rhage is free, or persistent, the bladder may be irrigated
with hot water, and the vagina tightly packed with gauze.
If the tumor be too large for removal through the urethra,
vaginal cystotomy should be performed. If the tumor be
malignant, it may be curetted and lightly cauterized,
which will have the effect of greatly alleviating the
patient's suffering. If the urination be painful and a high
grade of cystitis present, the vaginal incision should be
left open to allow for free drainage.

Diseases of the ureters. The ureters are liable to
ascending diseases from the bladder, to secondary involve-
ment, or to descending diseases from the kidney, or to
diseases which begins primarily in the ureter itself. One
or both ureters may be affected. A serious att'ection of
both ureters is incompatible with long life, as sooner or
later .secondary changes occur in the kidneys. As a result
of ureteritis, of whatever form, the ureter of the affected
side becomes enlarged and may be palpated through the
antero-lp.teral wall of the vagina in its upper third, where

DISEASES OF THE UTERUS — MALFORMATIONS. 207

it gives to the finger the sensation of n rigid cord, or the
feel of n round lead pencil. It is extremely sensitive upon
pressure, and when so compressed produces a strong desire
to urinate. An enlarged ureter can readily be felt by the
rectum, from the broad ligament up as far as the pelvic
brim. Further examination may be made, and much
information derived, from the use of cystoscopy and the
ureteral catheter and probes.

The treatment should consist in curing the cause
which produces the ureteritis; co-existing cystitis should
be managed in the usual way, morbid urinary conditions
corrected and the urine rendered antiseptic by salol. Fre-
quent vesical douches and high rectal enemata of warm
water should be employed. With the use of Kelly's spec-
ulum *\\e ..i-eteral injections may be repeated, at suitable
intervals, provided the operator has acquired the necessary
technique for the introduction of those instruments.

CHAPTER XIX.

DISEASES OF THE UTERUS.
MALFORMATIONS.

All the important anomalies of the uterus result from
arrest of development, and the nature of these anomalies
depends, in a great part, upon the time at which the
development was arrested. By bearing in mind the
history of the normal development of the uterus, the many
abnormal forms will be more readily understood. If the
arrest of development occurs at a very early period, there
will be simply a rudimentary bundle of muscle to indicate
its situation, and in extraordinary cases there may be
entire ab.senco of the organ. If there is arrest of f sion
of Muller's ducts before the twelfth week, a more or less

208 MEDICAL AND SURGICAL GYNiECOLOGY.

duplex uterus must result. If there is arrest of fusion in
the two cnnnls after the twelfth week, a bicornate or sep-
tate uterus will result. If the disturbance of development

occurs at a later period,
the uterus will retain a
fwtal or infantile form,
without longitudinal sej)-
aration or distinct indi-
cation of the duplex man-
ner of its formation.

For convenience of de-
scription, malformations
can thus be divided into
those due to arrest of de-
velopment during the
first half of intra-uterine
life; and those due to
arrest of development
after the first half of
intra-uterine life.

Malformations from
^ , arrest of development

FiG.sg. — Development of the genito-iirinary tr.-ict .

in the feniale.—w, «, kidneys ; e, i; ureters ; during the firSt half Of

a, their orifices ii] the bladder ; 711, 7u, WolfTian

bodies; {?,?, their efferent ducts; /,/», their mtra-Utenne life. Ah-

openings into the urethra ; ^, ^'i ovaries ; »i,i>i,

ducts of Muller ; 0, their common orifice ; 7', SCUCC OV VlKUIHCIlldVll ('('-

iiro-genital sinus ; i/r, urachus ; c, clitoris. 1 ,• 11 1

velopmcnt oj the uterus.
Complete absence of the uterus is an extremely rare
occurrence, but rudimentary development is not un-
common. There may be a small, solid, muscular body,
without a cavity, or a partial excavation, or it may consist
of a membranous sac. The vagina is usually absent, or
consists of a shallow depression. Usually the tubes and
ovaries are ill developed, and menstruation absent, but in
cases where they are developed, periodical activity
occurs in them, which, being unrelieved, causes much
suffering.

DISEASES OF THE UTERUS — MALFORMATIONS.

20<)

Uterus unicornis results from nn arrest of development,
or from failure to appear, on the part of one of Muller's
ducts. The developed side is situated entirely on one side

Fit;. 60. — Uterus unicornis with rudimentary horn. LH, left horn ; RH, right
rudimentiiry horn ; I.o, .ind Ro, left and right ovary ; l< Lr, and R Lr, left and
right rouiui ligament ; LT, and RT, left and right tnhe.

There is

of the axis of the pelvic cavity, and it inclines quite
strongly towards the corresponding pelvic wall
no uterine fiiiidns.
the uterine body end-
ing in a cone-shaped
projection, in which
is inserted the Fallo-
pian tube.

Uterus hicornis
and uterus didelplnjs
result from the want
of union of Muller's
ducts immediately
below those portions
which normally forir
the Fallopian tubes.
The want of union
may be confined to
the neighborhood of
the tubes, leaving a
slight depression in
the fundus, or it may extend lower down, dividing a large
part of the uterus.

Kit;. 61. — Didelphic Uterus and Divided Vagina : a,
right segment ; /', left segment ; c, rf, right ovary
and round ligament ; /, e, left ovarj; and roiuid liga-
ment ; g, j, left cervix and vagina ; k\ vaginal
septum ; //, /, right cervix and vagina.

210

MEDICAL AND SURGICAL GYNAECOLOGY.

Fig. 62.— Uleriis Duplex.

UtcruH <luph:r. The double uterus results from n
wnnt of union of Muller's ducts ns far as the vagina.

in consequence of which
two uteri have developed.
One Fallopian tube is
attached to each uterus,
and the vagina and cer-
vix may, or may not be
double.

Uterus septus, or two-
chambered uterus, arises
from an imperfect union
of Muller's ducts. The
uterus is of normal shape,
but the septum has not been obliterated. The vagina is
apt to be similarly divided. When the septum lias been
partially absorbed it is called nterus suhseptus.

The diagnosis of these de-
formities usually requires the
aid of an anaesthetic. With
the thumb in the vagina, and
the finger in the rectum, the
structures between them may
be palpated, especially if the
uterus is drawn down with a
vulsellum, toward the vaginal
outlet. A sound introduced
into the uterine cavity will
also aid materially in arriving
at a correct conclusion. In
such cases treatment is of no
avail, except as far as reliev-
ing painful or distressing
symptoms. Where there is absence or rudimentary
development of the uterus, removal of the ovaric^s may be
demanded in order to secure relief.

Fk;. 63. — Twci-chambered uterus.

DISEASES OF THE UTERUS — MALFORMATIONS.

211

Atresia uteri. Just as has been shown that the hymen
or vagina may be closed, the uterine canal itself, although
more rarely, may be the site of atresia. The mucous
membrane of the vagina may cover the whole vaginal
portion, without forming any external os, or the cervix may
form one uninterrupted muscular mass without bore. In
such cases the vaginal portion may be well developed, or
totally absent. In a bicornate uterus, one horn may be
closed. Whenever the genital canal is closed, the symp-
toms due to retention, such as amenorrhoja, painful
menstrual disturbances, and the
formation of a tumor will be
present, hence tin; remarks
made upon the symptoms,
diagnosis, and treatment of
atresia of the hymen and
vagina are applicable to atresia
uteri. When the atresia is
situated in the uterus, however,
the vagina can be exposed to
its full extent and, in so doing,
the uterus will be found to form
a round elastic tumor above it.

Dicujnosis. In pregnancy there will probably be a
history of menstruation, and there will be present some of
the well known signs. A fibroid forms a hard, nodular
tumor, and often causes menorrhagia. Hematocele
appears suddeidy, forms a broader mass, which pushes the
uterus forward, and with these there will be a history,
possibly, of previous menstruation. If the uterus is
double the atresia is found much more frequently on the
right side. In such cases the tumor will form in one
uterus, while the other may perform the menstrual
function quite normally.

Treatment. If the uterus is single, an opening should
be made through the cervix with a trocar, or blunt-pointed

Fk;. 64. -Atresia of ihe cervix uteri.

212 MEDUJAL AND SURGICAL OYNiECOLOGY.

forceps, ftiid (Milarged if uocessnry, and the contents
evacuated witli the same care as already described wlien
speaking of the treatm(^nt of atresia of the hymen, after
which the uterine cavity must be irrigatt^d with an anti-
sejjtic solution, and somc^ strips of iodoform gauze loosely
inserted, and brought out through tlie now formed os.
Later on the interior of the uterus may be curetted to
combat endometritis and to hasten involution.

If the accumulation is found in one half of a double
uterus it is still an advantage to enter, if possibh\ tlirough
the cervix; but often there is no choice, and the tumor
must be punctured at its lowest point in the vagina. If
the swelling cannot be reached from the vagina, cceliotomy
should be performed, and the affected horn or whole uterus
removed.

Arrest of development during the second half of
intra- uterine life. Fetal and infantile uterus. Some
adult women have a uterus which corresponds in size to
the uterus of a fcotus toward the end of pregnancy, or that
of a young chihl. Other organs may be normal, but often
the condition is combined with other abnormalities,
especially of the ovaries.

Pul)escent or con(/enitally atrophic uterus is one
characterized by its small weight, often not exceeding an
ounce, but the cervix and body have abo' t the same
length. Sometimes the body of the uteras is well
developed, but the cervix is small, pointed, or conical. In
exceptional instances, the whole vaginal portion may bo
lacking, while the rest of the vaginal apparatus is well
developed. In those cases the vagina i^asses directly into
the uterine cavity by a small constricted canal. Anteflex-
ion of the uterus is often congenital, and simply a contin-
uation of the shape of the uterus found in the fa3tus and
in young children. The uterus may congenital ly bend to
one side, the two Mullerian ducts not having kept pace
with one another.

DISEASES OF THE UTERUS— INJURIES.

213

CHAPTER XX.

DISEASES OE THE UTERUS CONTINUED.
INJURIES.

On account of its position, tlui unimpro^unted utoriis
is littlo exposed to iujurios from without, but is frequoritly
the Hoat of injuries produced through t lo vagina. In
gyn.'Dcological operations the uterus m occasionally
wounded. Some uteri are so soft that they are easily
penetrated by the sound or dull wire curette. When
strict antiseptic precaution have been observed, and in-
jection of an irritating tluid omitted, no evil consequence
will probably follow a small puncture of the uterus. If
there is prolapse of the intestine, cceliotomy should bo
performed, the intestine drawn up and the opening closed
in the uterus.

Laceratio.i of the cervix. By far the most common
injury to the uterus is that sustained by the cervix during
child-birth, when it may be
ruptured, or lacerated. The
important pathological bearings
of this accident upon disorders
of the uterus have been appre-
ciated only of late years. The
credit of having recognised the
significance of the lesion, and
of having furnished a safe and
efficient means for cure, belong
to Dr. T. A. Emmet.

Ctuiscff. The rapid forcing of the presenting part of
the child through an imperfectly dilated cervix, brought
about by early riipture of the membranes, or unusually
severe and protracted expulsive efforts, is the cause, in a
large proportion of instances, of laceration. More or less
important parts in the causation of this injury are played

Fig. 65.— Unilateral laceration of the
cervix.

211

MEDICAL AND 8UR(tICAL OYN.ECOLOOY.

by rigidity, faulty {lovolopmctit, cystic disonHc, cicatricijil

iiidunitiou. and liyporplaHia of the corvix. The uimkillcd

U80 of obstetric forceps may also be a cause of tln^ accidiMit.
Lacerations are called pdrtial whiui the tear in the

canal do(»s not reach the mucous membrane of the vagiim;

complete, wlien the whol(> thickness of tlu^ cervix is torn.

Complete laceration may be uniUiteral, hiUitenil, or

stcUdte.

Bihiferal lacerations are by far the most common, and

they almost always extend from side to side, rarely from

before backward.

Unihiievdl lacerations may occur in any part of the

cervix, but are more common on the left side, owing, it is

said, to the frequency of the
first position of the vertex.

Stelldte lacerations, while
sometimes not deep, are
often of considerable extent.
In regard to frecjuency, it
may be said that but few
women confined at full term

Fig. 66.-Bilaterall.-.ceration of the cervix, wilh CSCapC withoUt SUStaiuiug
ever.ionoflhecervical,nucousn,eml,rane. ^^j^^^ j^^.^^^, ^^ ^j^^ ^^^^j^^

be it ever so slight, but the proportion of rents likely to
produce pathological symptoms, may be put down as
somewhat less than fifty per cent.

After laceration, the torn surfaces, bathed in the lochia,
rarely unite, and in that condition will act as a source of
irritation, jirevent p r involution of the uterus, and
will eventually indue enlargement and thickening of the
uterine tissues. In some cases the flaps become enor-
mously hypertrophied by the formation of new connective
tissue, so as to resemble small fibroid tumors, and have
been mistaken for such. Relaxed ligaments with uterine
displacement — especially when it is associated with a
lacerated perineum— and congested ovaries and tubes, in

jfiiim

mm^!il'!l!l^l^*"

-((//)(/, i*ff'j^B

\ 1

DIHEASES OF THE UTERUS— IIJJUUIES.

215

tlu'ir turn, follow. OccnHiomilly imtJirc H(>t'ins to inak«^ uii

effort to rc^pair tlui hKu^rntioii by tlu^ t'orinntioii of a hirgo

amount of granulation tissui^ tilling up tho angloH of tho

rent. Ill process of time this granulation tissui^ becomes

converted into a hard dense cicatrix, compressing terminal

nerve Hlaments, a condition thouglit by many to be the

cause of the reflex symptoms so commonly met with in

long standing cases. When the lacerated cervix does not

cicatrize, the separated lips evert, the mucous membrane

lining the cavity is rolled out (ectropion), its epithelium

is gradually rubbed off, and a hyperplasia of cysts and

papilhu take place, giving rise

to a profuse, discolored, glairy

discharge. This hyperjbmic

a n d hyperlastic condition

often extends ujjward to, and

often beyond the internal os,

and cervical and corporeal

endometritis result, so that

menorrhagia may be present.

Attention has been calhid to

the frec^uency with which

epithelioma of the cervix has

been found in conjunction

with laceration, and it is

undoubtedly a fact that a very large proportion of such

cases are preceded by such traumatism.

Symptoms. Tho symptoms which attract the attention
of the patient will probably be a dull pain in the back,
sacrum, and lumbar regions; bearing down or dragging
in the pelvis; pain in the ovarian regions, hips and thighs;
leucorrhoea; menorrhagia; and occasionally sterility, or
habitual miscarriages. Accompanying these there will
generally be found progressive loss of health, and a most
decided state of anaemia. Neuroses of the eyes, head,
stomach, and bowels are also frequently met with; to

Fig. 67. — Multiple stellate laceration of
cervix.

21() MEDICAL AND SUUOICAL <lYN.ECOL()GY.

which hyHtc'^-icnl Hymptoms may ovon bd mldiHl. On
pnHHiii^ the Hiig(^r into i\w vagina, tho hicoration in oawily
ro(M)gni/-('(l. In tho angh'H of tho ront hanlonod tinHUo is
foit, i)roHHuro upon whicli product^H [)fiin, wlii(!h ofton
rndinti^H into tho pt^lvis and down tho thighs. Tlio Hurfnco
may fool rough and granuhir from tho largo follioloH, or
volvoty and soft from orosion. Kxamination by spocuilum
dooH not givo mu<Oi information, furthor than to bring into
view tho granular or orodod Hurfaco, tho whito or yollowish
dlHchargo with whicih it is covorod, and tho hyportrophiod
condition of tho cervical flaps.

Indications for trachelorrhaphy. Tho moro oxistonco
of a lacc^ration does not call for radical operation. Tho
indications for that moasuro depend entirely upon tho
depth of tho rent, tlu^ degree of oversion and amount of
orosion and hyporijlasia of tho torn lips; tho intensity of
tho symptoms depending upon it, and by tin* improbability
of these .symptoms b(ung permanently cured by other than
radical treatment. The treatment of laceration immedi-
ately after their occurrence has boon strongly advocated
by some, but such a procedure has not gained in favor
with the majority of obstetricians, owing to the difficulty
in estimating tho extent of laceration, the relation of the
parts, and the ability to bring them together properly.

Prcliminarji frcafmcnt. Some have thought it advis-
able to cure orosion. when present, before operating, but
such a procedure does not seem necessary. If there is
extensive cystic degeneration, it may be treated for a
time by local applications, but generally both these
conditions can be managed at tho time of operation.
Preparatory curettage of the uterine cavity has also been
advised when endometritis exists, but this too is un-
necessary as it can be done just as effectually before
beginning the denuding process.

The operation of trachelorrhaphy may be performed
by placing the patient in the dorsal position, the legs

DISEASES OP THE UTER'JS— IN.Il'KIES. 217

elovnt(Ml, mid kepi in poHition by Clovcr'H crutch, nrul n

Sims" brofid-bliKlccl Hpcciilum itiHcrtcd. A very convciiii'iit

Hpcculurn for that niid other opi nitioiiH on tlie utcruH,

when the pnti(Mit is in tlic dorHnl i)o.sition. in oi.o known

(iH Fidc^bohl's. It is HO curved at the junction of the

haiuUe jind the blade that it will not slip out. and. by

HUH[)ending a HufficicMit weight to the handle, the neceHsary

retraction is made on the perineum, and the necessity for

an assistant to hold the si)eculum df)ne away with. Sumo

prefer oijcratinj^ in Sims" position, claiming that it ^ives

much mon> room for manipidation

and for the piissage of the needles.

However the choiv'^e of position and

speculum is largely .^ matter of <»du-

cation and habit. Th > best needles

to employ are heavy triangular or

bayonet-pointed, straiglit. or curved

Slightly at tlie point (Emmet's). The

suture material is a matter of in- p, -„ vii m- .^ „i,.n,

rlG. 00. — Kdebonl s speculum.

difference: silver wire, silkworm, silk

and catgut are all used, If the perineum is to bo closed
at the same time, it is best to use some material which
will be absorbed in the course of eight or ten days, such
as chromic catgut. Unless contraindicated from some
good cause, it would be preferable to use catgut under
all circumstances, as most patients have a great dread
of what they look upon as another operation for the
removal of the stitches.

After deciding upon the amount of denudation neces-
sary, the edge of one lip is seized with a tenaculum, and a
Hap raised from the surrounding tissue with scissors or
scalpel, the cutting process being continued until tlie
angle is reached, where it may be necessary to go (piite
deeply to remove all the cicatricial tissue. After the
angle has been passed, denudation is made in a similar
manner on the other lip, and completed by uniting it with

218

MEDK^AL AND SURGICAL GYN.flOOLOOY.

the previous incision. If n second laceration exists on the
opposite side, it is to be denuded in the same way. Some
use a peculiar pair of scissors devised by Skene and known
as " hawk-bill " scissors, wliich denude the margins and
take out th(> cicatrix at one and the same time. Hemor-
rhage can usually be controlled by hot water, but if very
troublesome a stitch may at once be jjassed through both
lips of the cervix, above the angle, and tied so as to com-
press the circular artery. The sutures are next introduced,
the first being passed through the upper angle of the rent,
and each successive one through the whole depth of each

Fir,, fig. — Surfaces Jenuded and sutures passed.

Fk;. 70— Same with sutures lied.

lip, until all the sutures needed for that side have been
inserted. Next the sutures on the opposite side are
similarly inserted, if the denudation has been bilateral,
after which they are tied, the highest one first. A sound
is next introduced into the cervix, to mrke sure that it is
sufficiently patulous. After flushing and drying the
vagina, it may be lightly packed with strips of iodoform
gauze.

DISEASES OF THE UTERUS — METRITIS. 211)

CHAPTER XXI.

DISEASES OF THE UTERUS CONTINUED.
METRITIS.

According to the etymology of the word, metritis
means iriHnmnintion of the uterus, but tlie classitiontion of
the various patliolo^ical conditions included under that
heading is not so easily disposed of. When considered
according to the progress of the disease, it is designated
by the terms acute and rhrouic ; when classifi(^d according
to location, it is divided inio cervical rw\ corporeal: when
looked at from r^a etiological standpoint, it is designated
by the terms pucrperah post-puerperdl, <ionorrh(ral,
exanthematous. and traumatic; or when from a patho-
logical standpoint, (jrannlar. fuiajous, and ulcerating.

For convenience of description the various forms of
endometritis may be classified as follows:

1. Acute metritis and acute endometritis.

2. Chronic cervical endometritis.

3. Chronic corporeal endometritis.

4. Chronic metritis, or subinvolution and sclerosis.

ACUTE ENDOMETRITIS AND ACUTE METRITIS.

By the term ; :ute endometritis i.s meant acute in-
flammation of the endometrium, and by the term acute
metritis, inflammation of the walls of the uterus, but as
inflammation of the endometrium can scarcely occur
without the uterine walls participating to some extenc. nor
can inflammation of the walls occur v .thout participation
of the mucosa, the description of the two. as distinct
diseases, would be usel(>ss. at least from any other *han a
pathological standpoint. When the inflammation affects
the mucous membrane more than the walls, it is termed
endometritis; when it produces extensive changes in the
walls, it is called metritis.

220 MEDICAL AND SURdUUL (lYN. ECOLOGY.

(^(iiixcs. Tlu' luost poti'ut fuiisf )lriH(^s from bnctorinl
invasion from iafccti'd Imiuls and instruments (luring
parturition, abortions, operations and examinations: during
uterine and vaginal douches; from retained deoidua after
abortion: or from invasion of the gonococcus. Infc^etion
may arise seeomhtrily from foreign bodies K'ft in the
uterus or vagina, such as stem pessaries, tents and tampons.
Violent congestion of the uterus, such as occurs in acute
suppression of menstruation, and the prolonged conges-
tions growing out of flexions and versions, are prominent
factors in these lesions. Retained menses, arising from
stenosis, catching cold, and other influences, such as over-
exertion, excessive coitus, or traumatism, acting during
the menstrual congestion, increase the natural hyperaMnic
condition to such an extent as to interfere with its natural
subsidence, and tend to engorgement and inflammation.
Specific germs of the exanthemata appear to be capable of
inducing mild inflammatory changes upon the mucous
membrane of the entire uterus, seeming to act upon it as
upon other mucous tracts (the conjiinctivfv for instance
during measles), and in a similar manner tend to disappear
with the subsidence of the disease.

Pafholoc/ii. In acute endometritis the extent of the
lesion will de})en(l upon the virulence and activity of the
infecting element, and will vary from a mild injection of
the endometrium to a deep and wide spread inflltration
with the products of inflammation. The material found
bathing the infected surfaces will also depend upon the
same influence, being in mild cases merely a muco-
purulent fluid, in others purulent, or even bloody. The
normal red color of the endometrium is dee[)ened propor-
tionately, and may he almost livid: the mucous membrane
is thickened, softened, even pulpy at times, and easily torn
from its attachments. The interglandular spaces show an
increase of round cells, which, in extreme cases, are so
abundant as to give the whole surface the appearance of

DISEASES OF THE I'TERUS— METRITIS. 221

granulation tissue. The epithelium is iutiltrated, and even
destroyed in certain places, and the cilia in general may
be said to have shared a like fate. The implication of the
muscular coat (metritis) is slight, except in some cases of
gonorrhceai infection. There is swelling of the muscular
fibres, increase of cell formation in the interspaces, and
infiltration with a serous or sero-purulent tiuid, by which
the uterus becomes more or less enlarged. Minute
extravasations of blood are apt to be found in spots,
particularly near the mucous membrane.

Sijiujdoiiis. In the simple form they may be compar-
atively insignificant. There will be a sense of fulness in
the pelvis, more or less pronounced, if there be arrest of
the menstrual tlow. accompanied by fret^uent micturition
and rectal tenesmus. In more severe cases the symptoms
are more decided. There will be dull deep seated pelvic
pain, backache, and aching down the thighs, increased by
motion or by the evacuation of the bladder and bowels.
Slight febrile reaction will also be present. In septic
cases a chill, more or less pronounced, ushers in the general
disturbance, accompanied by a rapid and decided rise of
temperature. Should the intlamnuition extend to the
peritoneal covering (perimetritis), the phenomena of local
peritonitis will be directly added; if it extend through the
Fallopian tubes the evidence of salpingitis will appear,
and from either of these general peritonitis may arise, or
other extreme symptoms indicative of general septic
absorption.

The chief physical signs are tenderness over the pubes,
and tenderness of the uterus, elicited by bimanual and
vaginal pressure. The cervix will be found patulous,
softer, larger, and redder than natural, particularly about
the external os, and exuding from it a tough, glairy,
opacpie secretion. When the uterine walls are afflicted,
particularly in septic iuHammation, the entire organ is
enlarged and softened, and then' will be noticed flowing

222 MEDICAL AND SURGICAL GYXJICOLOGY.

from the os a thick, ichorous, bloody discharge, which
may have the odor of decomposition.

Fro(iiiosis. Ill the simple form life is rare'y en-
dangered, but in the septic forms it commonly is, either
through general peritonitis, or from general septic infec-
tion. The integrity of the organ is always tnidangered to
an extent proportionate to the severity of the inflammation;
slight, if any, in the milder forms. I»ut decidedly pro-
nounced in the graver ones. The dangers result in part
from the chronic changes in the uterus itself, and in part
from the implication of the adnexa.

JJidtinosis. In the non-pregnant uterus this lesion is
indicated by tenderness of the organ, and by discharge
from the cervix, taken in conjunction with the comparative
suddenness of an attack developed in connection with an
acute suppression of menstruation, with a prior vaginitis,
or with some such cause as an operation upon the cervix,
or the introduction of a sound. After a ortioii or labor
it is commonly indicated by a chill, followed by rise of
temperature, and temporary arrest of the lochia, with its
subsequent reappearance, and on reappearance often has
an odor of decomposition. The organ soon becomes
tender and subsequently loses its firmness. Such cases
may be confounded with typhoid or malarial fevers. If
malarial, quinine will control it absolutely ; if typhoid,
differences in the rise and fall of temperature will assist
in making a diagnosis. In all cases when in doubt, it is
wiser to assume the presence of septic infection. Local-
ized mastitis is another source of error, but a careful
examination of the breasts will readily correct that.

Tre^diucnt. From what has been said of the etiology
of the disease, it will be readily understood that the treat-
ment will vary according to the nature of the case. The
milder forms are best treated by rest in bed, purgations
by means of salines, by mild febrifuge treatment, and by
hot vaginal douches supplemented by hot fomentations,

DISEASES OF THE ITERUS — METRITIS. 223

and counter irritation over the abdomen. If there is no
serious objection to physical examination, local depletion
may be accomplished by free scarification of the cervix,
followed by a warm vaginal douche. As soon as the more
acute symptoms have subsided, boro-glyceride tampons
may be i^laced against the cervix daily. When it arises
as a result of vaginitis, particularly that form met with in
gonorrhoeal infection, it will probably be necessary to
irrigate the uterine cavity with a solution of bichloride
(1 to 3000), dilating the cervix sufficiently for that
purpose, if it is not already patulous. In the septic forms
prompt and energetic measures are demanded. If the
result of negligence in failing to keep up proper aseptic
precautions during operations or examinations, the cavity
of the uterus should be freely irrigated with bichloride
solution and packed with iodoform gauze. Should a
wound exist, the lips had better be separated and kept
apart by strips of the same material. Should the case be
one of septic inflammation following abortion or labor,
radical surgical measures should be promptly applied.
The cavity of the uterus should be curetted, all debris
scraped away, and the uterus fully and tirmly packed with
gauze. The vagina must then be packed loosely, tirst
around the cervix and then down to the introitus. The
packing of the vagina should be removed at the end
of twenty four hours and warm stt^rile douches given. At
the end of forty eight hours the uterine packing may be
removed and, if no fever be present, the cavity of the
uterus need not again be entered, but if the temperature
is still elevated the cavity should be irrigated and fresh
gauze inserted. Even though the case appears desperate,
the cleansing and draining should be continued, for not
unfrequently it yields in the end. The gravest surgical
perplexity arises in connection with further operative
procedure. The removal of the infected uterus, either
through the vagina or by cu;liotomy. offers the surest

224 MEDICAL AND SURGICAL GYNJICOLOGY.

relief, could the nhock of so grnve an operntiou be
controlled. Patients infected with a general sepsis rarely
withstand any grave abdominal, or even pelvic operation,
and although many successful cases have been reported,
it is still looked upon by many as justifiable only under
desperate conditions.

Stimulated by the success of serum therapy in
diphtheria and in a few other infectious diseases, effort
has recently been made to procure a serum that will be
antagonistic to streptococci and antidotal to the products of
their activity. This form of medication bids fair, thus far,
to be of great service in puerperal infection. Few reports
have yet been published regarding the use of the serum
antitoxine, but those that have been, serve to prove that in
cases of infection due to poisoning by the streptococcus
alone, the streptococci antitoxine, when used early, is a
curative agent of great value, but in mild cases of infection
in which, besides the streptococcus, the colon bacillus, the
bacillus fetidus, the staphylococcus, the bacillus pyocyaneus,
and other micro-organisms are found, this antitoxine has
little or no beneficial effects.

si ENDoL'iiKvicrr:

Endocervicitis is recognized oy various synonyms,
such as cervical endometritis, cervicitis, cervical catarrh,
trachelitis, and erosion of the cervix. Inflammation
of the cervix exists independently of like lesions in
the body of the uterus, its position exposing it to
disease to a far greater extent than the deeper portions
of the organ, and as such requires separate consideration.
In acute processes, especially those derived from gonorrhcBa
and septic infection, the two parts of the organ are so often
involved together, that it seems unnecessary to consider
the lesions of the two separately. The appearance pre-
sented by the cervix in acute inflammation has already
been referred to. The mucous membrane of the canal is

DISEASES OF THE I'TERrs— METRITIS. 225

swollen niid softened, nud its cavity filled with a viscid
muco-puruleiit secretion. The appearance presented by
the deeper portion of the cervix is also, in all respects,
similar to that met with in the body of the uterus. This
does not apply, however, to the chronic forms of the
disease; the inflammation being of a lower grade of
intensity, more strictly confines itself to the cervix, without
involving the d(H>per parts of the uterus.

Cdiiscs. Chronic endometritis may arise from a variety
of causes. Impoverishment of the blood from chlorosis or
some other form of malnutrition, producing lowered
vitality, strongly predisposes to the disease. Infection
from the vagina, such as from gonorrheeal or purulent
vaginitis, from the entrance of foreign bodies or septic
germs into the vagina, from examinations, operations,
coitus, masturbation, pessaries, and vaginal douches, may
infect the cervix directly. Laceration of the cervix is by
far the most frequent cause, and along with it may be
mentioned displacements of the uterus, opt^rations upon
the cervix, strong local treatment, and attempts at abortion.
P(itliol<Kjij. Endocervicitis is cliara(^terized by hyp«r-
femia, thickening of the cervical mucous membrane, and
hypersecretion of the glands. The mucous may be
unaltered, or it may be thicker than normal and excessive
in quantity. If the congestion is long continued,
exfoliation of the epithelium progresses faster than
its replacement by the development of new cells, so
that the membrane becomes covered with young epithe-
lium, giving it a reddish color (si niplc erosion). This
disturbance not only involves the mucous membrane
of the canal, but extends outward from the os, about
half the thickness of the walls of the cervix, giving
rise to the condition once described as ulceration. As the
process advances the mucous membrane becomes thick-
ened by proliferation of the areolar tissue, so that it
becomes too large for the surface which it covers, and is

226

MEDICAL AND SURGICAL GYNAECOLOGY.

thus thrown into a multitude of minute folds, rugosities
or wrinkles. To this condition the name papillary erosion
has been given, as the small folds look like papillee. The
glandular pockets formed by these folds reach down to
and between some of the bundles of muscular fibres.
These pockets, as well as mouths of the glands, may
become closed and filled with secretion, forming cysts
of all sizes up to that of a pea, and give rise to that
condition called follicular erosion. When the hyper-
plasia is extensive, the thickened mucous m.nnbrane

Fig. 71. ^Erosion of the cervix, — a, ^.simple papillary erosion ; c, follicular slightly enlarged.

pverfills the cervical cavity, dilates the external os and
rolls out into view, giving the cervix the appearance as if
the vaginal portion were partly clothed with cylindrical
epithelium. This condition is called eversion or ectropion.
When the structures are more actively affected, or to a
greater depth, other changes are produced. The mucous
membrane throws out largo projecting folds which may or

DISEASES OF THE TTERUS— METRITIS. 227

may not develop into mucous polypi or polypoid masses.
The occluded and cystic pockets and Nabothian glands may
project on the surface, and, if numerous, may occupy half
the thickness of the cervical walls, and produce a condition
known as cystic ((('(/('ucrotioH. As a result of these
changes all of the glandular structure may be finally
destroyed, and sclerosis, resembling senile atrophy, result.

Sijmphms. When mild, and of short duration, the
case may be free from all symptoms except a vaginal
discharge. This discharge, however, is in some degree
characteristic; it is not continuous, nor. in the absence of
vaginal implications, abundant. It is viscid and jelly-like,
and transparent, opaque, or yellowish according to the
amount of purulent admixture. In the presence of
cervical laceration, it is mixed with a un^re muco-purulcnt
discharge, and is at the same time more constant. In
deeper seated implication of the cervix there will be, in
addition to the discharge, dull lumbo-sacral pain, and,
perhaps, reflex nervous symptoms. On making a digital
examination, a softened ring is felt around the os, and, if
extensive cystic degeneration with eversion exists, the
cervix will be felt enlarged, soft, and elastic, with perhaps
isolated distended follicles, like buried shot under the
surface.

Laceration of the cervix, with extensive erosion, may
simulate carcinoma, but by examining under the micro-
scope a small strip removed by the knife, it can be readily
differentiated. A profuse serous and blood-stained
leucorrhoea is almost always characteristic of cervical
carcinoma, and so are the hard exuberant cauliflower
excrescences springing from the vaginal aspect of the
everted cervix.

Treatment. As the disease consists mostly of an
inflammatory degeneration of the cervical mucous mem-
brane, efforts should be directed to produce an alterative
influence uix)n that membrane; and as it is often associated

228 MEDICAL AND SURGICAL GYNJICOLOOY.

with H depraved condition of the system, further efforts
must be made to iitt'ect favorably the general health.
Every function of the body should be regulated by
proper nu'unH, and vegetable tonics, mineral acids, and
preparations of iron administereil, and daily exercise and
good healthy nourishing food provided for. Particular
attention should be paid to the proper regulation of the
bowels, for which a ferrugineous tonic with a cathartic
may be prescribed, as in the following: —

R. Magiiewiif Sul|thati.M, oz. ii ;
Ferii Sulphatis, mn. xvi ;
Acid Sulphurio, Hil., dram i ;
Tinct. (ieiit. Co., oz. i ;
Elixir Siniplici.s, ad., oz. xvi. M.

Sip. — Two tablespoonsful in half a tumbler of ice water each morning.

R. Hodii' et I'otass. Tart., oz. ii ;
V^ini ferri amari, U.S.I), oz. ii ;
Afid Tartaric, dramis iii ;
Eli.xir Simplicis, oz. iv ;
A<iii!e ad., oz. xvi. M.

Sig. — Two tablesiKJOMsfuI in half a tumbler of water each morning on
rising.

Locally the source of irritation must be remove'' and
the ett'ects counteracted by mild antis(^ptic and astringent
applications. Endometritis and vaginitis, if present,
should be treated, and uterine displacements corrected.
Of local applications, the most important is the vaginal
douche. The water may contain permanganate of potash
(1 to ;}OUU). carbolic acid (1 to 100), or bichloride (1 to
5000), when for antiseptic purposes; and if required for
an astringent effect, sulphate of zinc, three grains to the
ounce, sulphate of copper, two grains to the ounce, or
acetate of lead, five grains to the ounce. Vaginal tam-
pons, saturated with boro-glyceride, or glycerite of tannin,
or a ten per cent, solution of ichthyol, may be introduced
by the patient every night, and removed the next morning
before taking the douche.

Local applications, such as a ten per cent, solution of
sulphate of copper, or crude pyroligneous acid, may be

DisKAsiis OF Tin: iTuin's mktkitis. 229

made tliroiij^h a Hpcculum. twice r tl>r(H> times weekly.
In Home eaw^H the applic-ntioii. once in a wiu'k or ten (lays,
of strong ('arlM)lie acid, or tincture of iodine, or of the two
mixed in ecjual parts, seems serviceabh*. follow(>d at once
by the api)lication of a horo-Kly('cri(h' tampon. In all
cases the os should be w«^ll dilated, the mucous wiiu'd
away, and the application made frei^ly to the tMitire cervical
cavity and to the vaj^inal portion, by means of an api)li-
cator, or by for(H«[)s wrapju'd with cotton. When the
cervix is much indurat(*d and studd(^d with retention cysts,
Kcaritication is very useful. It acts by depletion and
allows the escape of tl)e inspissated mucous. The punc-
ture should be permitted to bleed a little, but if the
hemorrhage is too free it may be checked by absorbent
cotton Hrmly pressed against the cervix. Subseiiuently
tincture of iodine, or carbolic acid, should be applied, and
a small boro-glyceride or ichthyol tampon placed under
the cervix to maintain the antiseptic and alterative
acoion.

In cystic degeneration, the cysts must be laid open, and
carbolic acid or tincture of iodine applied. In very
chronic cases, where there is extensive degeneration of the
mucous membrane, it has been recommended to destroy it
by means of strong caustics or escharotics. but their use
is dangerous, it being impossible at times to limit their
action, and. besides, they are likely to [jroduce cicatricial
contraction. When glandular tissue is to be destroyed,
the most efficient way of doing so is by excision of the
mucous membrane, after the manner recommended by
Schroeder.

CHRONIC" CORPOREAL ENDOMETRITIS.

Like the cervix, the body of the uterus is liable to
chronic inflammation of its lining mucous membrane.

Causes. It may follow at once upon an attack of
acute endometritis, or metritis; or it may be brought about
by causes which delay or disturb involution after abortion

Wiiil

l(;f
1/ 1

^v^inuy wt.,t;:;,';;l,,r':;;rf ''" °"™ -<-«•

"vantm, „„,| „„„,, j,;^,,. "''''"'''' «'™™i« o( el,e cervix
'- -"ori,,,, „„,„„,;,• „'^.„^:''';'""»i in.,.rf„r,.„co wm,'

•x'lii'vo,! to bo pr«l,,,J„ '^"'™"" »"'! <l.-bilitv arc.

"f 'I- -™lo.m..ri„ ™r" """'' "■"""'. ""'I '.yi-rpta
J (ithohxni To f 1, , ,

■ '-woll™ „;„, ,„f, "" ""kec ..,e tho muoo„« „™br„„e
"'tl. Lore „„d „„.„, I J,,"'"; " ^emblos cjuinco jolly

muscular coat participates i,^ ,7 " "* """'' """ ">e

projections „„„ depr"^ „, J"'^'"'"'' P"'-"'inK alternate
go«.t.e8„„yb,„./'« These projections or fu„.
or they „„y b, veritable poly"" ""'?"'' "'o^'"""! form.
In other cases small cysts'T 1^7'''' ™ P""»"o"l»ted.
bodies met with in the ™'""'''"« »mewl,„t similar

"rophyofthemuco mlh:™!- "" f™^"'' ^•''«"
« smooth and glfetenin^.""";, ''",?"""'• "-surface
"troph.c changes, is thin am '""''" '"•'' oxtonsive

MicroscoDienI „ »»'' tr»"«P»rent.

three forms l^^L::Z^t """"™'"'- Presents i„
'" o- "nd the s„me';X: T'"''' "' "" "■»""•«"

Jn the infcrsfifi'n/ f i

transformed into cicatr IT , '"'"Klandular tissue is
«h.nds, causing thet™ "r; iTn?''''"'' """"'"^^ "-
obLteration. I„ other'^„ "i thev"""""""^ """P'*

P'aces they are converted into

DISKASIiS <)!' THK UTERI'S - MKTUITIS. 231

cysts, in number proporti()iiat(> to the doj^rrnof connective
tissue development. In extreme cases, of lon^ durntion,
the inu(H)us m(>mV)rane becomes atroi)liied. and is converted
into n thin hiyer of s(^h>rosed connective tissue. Embedded
in this sch^rotii! tissue, lien- and th(<re are cyst cavities,
the remains of constric^ti^l and (h'^i'iierated glands.

Thi^re are two forms of th(^ j/hnidnhn' varii^ty. one in
whicli the glands are incr(>ased in their dimensions
{hjipct'ivophic): and another in whi(Oi there is actual
increase in the ({uantity of gland tissue (hijitcrpldstir).
In the former, the utricular glands no longer appear as a
series of straight tubes, but are twisted, elongated and
arranged spirally. In the second form there is not only
increase in the number of the glands, but they are dis-
torted, and here and there present lateral prolongations or
diverticulre.

Chronic poli/poi'tl endometritis is a combinn*'on of the
interstitial and glandular varieties, with marked cystic
formation, together with great increase of the vessels, both
in number and in dimensions, and an increase of the
interglandular structure. In some cases the whole
mucous membrane is thickened, in others only portions,
while in others the glands are chiefly affected and project
as polypoid masses. The great increase in vascularity
accounts for the clinjcal behaviour of this variety, menor-
rhagia being the st. "iing symptomatic feature. In con-
nection with this la.st form of endometri'Js. there is a
variety resulting from the retention of portions of the
decidua. after abortion chiefly, but occasionally after labor
at term, cvdowfirififi deciihuilis. The retained tissue
presents itself as projectionr. from the general surface of
the mucous membrane, and is soft and easily detached.
Microscopically, it is diff'erentiated by the presence of
degenerated decidual tissue surrounded by a mass of
small cells. Clinically it presents symptoms of the
polypoid form by the profuse menstrual flow.

232 MEDICAL AND SURGICAL GYN.13COLOGY.

Symptoms. The Hymptoms of (nidometritis vary to a
great extent, according to whether the case be a severe one
or not. They may scarcely attract attention, or they may
be so pronounced as to render life a burden. Mcnovrhdf/id
is by far tlie most common symptom. The flow may be
profuse and clotted, persisting at times longer than
normal, and at others contini:i'\tr during the larger part of
the intermenstrual i^eriod. particularly in the fungous or
Ijolypoid form.

LoucnrrlKrd is nearly always present between the
periods, although in old cases it may be so sliglit as not to
attract the patient's attention; after sclerosis of the
mucous membrane has resulted it may be absent altogether.
The discharge consists of a thin clear mucous, or muco-pus.
As it appears at the vulva it is rnilky white, creamy, or
greenish in color, owing to its having mingled with
cervical and vaginal discharges. When mixed with
blood it acquires a pink, brown, or smoky tint.

Pain of some kind is rarely absent. Lumbo-sacral
pain is a prominent feature, and it may radiate down the
thighs. Dull, persistent, deep seated pelvic pain is also
present, extending i^erhaps to the perineum. If the
organ is enlarged and anteverted there will be frequent
micturition and vesical distress; if retroverted there will
be mechanical constipation, with pain along the sciatic
nerves. Unusual or prolonged exercise, especially jolting
over roiigh surfaces, increases the pain. To the local
discomforts, neuralgic pains may be added, such as
occipital, intercostal, lumbo-abdominal. and facial neural-
gias; coccygodynia. gastralgia. meteorism. and similar
reflex symptoms may also be prestMit.

Sfcnlifi/ is a common accompaniment, owing to the
several obstacles to impregnation, and to proper decidual
growth. Sometimes the ovum does not reach the uterus,
or it may be destroyed by the secretion, or by forming
no attachment to the endometrium.

li Li

DISEASES OP THE UTERUS— METRITIS. 233

Phi/sical sifpis. Palpation shows nothinj^ but a
symmetrical enlargement of the utjrus. Generally it is
tender on pressure, particularly when the cervix is touched.
In th'3 absence of complicating diseases of the adnexn, of
the utero-sacral lig' .lents, or of the peritoneul surround-
ings, the uterus i& .reely movable. The introduction of
the uterin"^ sound is ordinarily, though not invariably,
attended by pain, and in most cases a sensitive spot is met
with at the internal os. The canal may measure from
three to four inches in length, but the sound conveys
little information as to the state of the endometrium, unless
it be by the induction of bleeding in the decidual or other
hemorrhagic forms.

Didf/nosis. Pregnancy has been mentioned as a con-
dition with which the lesion may be confounded, but a
proper examination and consideration of the signs and
symptoms will readily determine which condition is
present. It may be mistaken for commencing fibroid
disease. If tlie disease be interstitial, and more particu-
larly if it be subperitoneal, conjoined vaginal and rectal
examination will reveal inequalities on the outer surface.
If the growth be wholly submucous, it may be detected by
the introduction of the sound. The hemorrhagic: form
may be confounded with abortion, but the early history
and a careful examination of the discharges will suffice for
differentiation. The diagnosis of certain forms of corporeal
and cervical inflammatory lesions from carcinoma is a
matter of pressing urgency, for, to be of any service,
diagnosis must be made early. Here the free use of the
sharp curette and a careful microscopic examination of
the scrapings will assist materially in clearing up the
difficulty, and should never be omitted in doubtful cases.

Pro(j)i(>sis is usually favorable as far as life is concerned.
Taken early, all forms yield readily, but after extensive
changes have taken place permanent cure is uncertain.
Of all forms, polypoid is the most obstinate, and it also is

284 MEDICAL AND SURGICAL GYN^C()Lf)GY.

tho form which appears to tend most frequently to
carcinomatous degeneration. Every form tends towards
the induction of intlammation of the adnexa and
peritoneum.

Trcahneid. Cases witli profuse menorrhagia, unac-
companied by tumors or diseases in the adnexa, pelvic
peritoneum, or connective tissue, but with considerable
thickening of tho mucous membrane; fungous endome-
tritis, and in general all cases that have resisted long
continued local treatment, should be submitted to thorough
intra-uterine curettage. After completing the operation,
it may be considered advisable to touch the surface over
with strong carbolic acid, or tincture of iodine, or iodized
phenol, and to pack the cavity lightly with strips of iodoform
gauze. Subsequently the treatment should be along the
lines already enunciated in conjunction with the treatment
of acute metritis. Subsequently, an effort must be made
to keep up the free drainage through the cervix already
established, which maj'^ be done by occasionally passing a
dilator and introducing a few strips of gauze into the
cervical canal. Boro-glyceride or ichthyol tampons may
be inserted by the pAtient once a day, and allowed to
remain for twelve hours. After their removal, the vagina
shovtld be douched with hot water, and again before rein-
sertion of the tami^on. If the disease does not seem to
yield, thorou'^h curetting had better be repeated, and in
the intervals, when dilating the os, the endometrium may
be lightly touched over with a twenty five per cent, solution
of ichthyol, or with stronger preparations, if thought
advisable, such as tincture of iodine, carbolic acid, or a
twenty five per cent, solution of chloride of zinc. Success
in treatment will largely di^pend upon a removal of the
conditions which cause and perpetuate the disease.
Retroversion, retroflexion, and prolapse of the uterus may
need correction. Inflammation of the cervix, ovaries, or
of the tissues surrounding the uterus should be treated.

DISEASES OF THE UTEKUS—METRITIS. 235

Special cnre slioukl bo tnken at each monstrual poriod; a
few (lays spe^iit in binl will often do much to check monor-
rhagia or dysmenorrhcea, should one or the other bo
present. Throughout the whole intermenstrual jjoriod
the mode of living should be one of extreme (luietudo,
both mental and physical.

CHRONIC METRITIS.

To this condition the synonyms chronic parenchy-
matous metritis; (ircolar luipcrpldsid; and suhinrolntion
and sclerosis have been applied.

Etiologi/. Chronic metritis may result from three
entirely different pathological states: — First, from inter-
ference, from any cause, with retrograde metamorphosis
of the puerperal uterus after abortion or labor at term,
such as puerperal metritis, retained secundines, septic
innoculation, laceration of the cervix, over-exertion after
confinement, or suppression of milk. Acute diseases
occurring during the period of involution have a similar
effect. Second, from congestion long kept up by mechan-
ical causes, such as displacements, pelvic tumors, and
chronic diseases of the pelvic or abdominal viscera; or from
congestion indirectly produced by sedentary habits com-
bined with constipation, by laborious occupations kept
up during the menstrual period, or by long standing
cardiac disease. Thirdly, from a formative irritation, or
a state of hypernutrition excited by endometritis.

Pdtholoiii/. After joarturition the muscular fibres
undergo fatty degeneration, by which the organ rapidly
dimiidshes in size, so that, at the end of the eighth week, the
uterus will have returned to its normal state. Untoward
influences may retard or check this process, and the uterus
will accordingly remain large, fiabby, and softer than
natural. As a result there is hypont'mia, serous infiltra-
tion, and a large increase of embrj'^onic elements. Later
an increase of adult connective tissue between the bundles

236 MEDICAL AND SURGICAL GYNiECOLOGY.

of muscular fibres arises, wliich in time compresses the
blood vessels, and leads to uterine aujemia with atrophy
of the muscular tissues. The uterus becomes harder than
natural, and remains for a long time enlarged, but in time
begins to diminish in size as a result of contraction of the
connective tissue, and in a few cases becomes smaller
than normal.

During each menstrual period the uterus, being to
some extent an erectile organ, is enlarged and distended
with blood. If from some cause it does not return to its
normal intermenstrual quiescent state, chronic congestion
with hypergenesis of its tissues will follow, and, as a result,
the organ will increase in size month after month, until
the circulation becomes finally constricted, and in a
hardened state the uterus will remain enlarged until
after the menopause.

Displacements of the uterus at first result in passive
congestion. Fibroids keep up constant nervous irritation
that induces hyperemia. Cardiac disease and abdominal
tumors interfere with the return of blood through the
vena cava and jjroduce blood stasis, any of which, when
continued for a length of time, will induce hypergenesis
of connective tissue in the uterine walls.

Course and termination. The length of time which
the condition may last is very uncertain. After the
connective tissue has once become thoroughly affected it
rarely returns to its original condition. The extent of the
enlargement of the cervix, the result of areolar hyperplasia,
is sometimes very great, equaling in size, at times, a small
orange.

Sifniptoms. After labor or abortion, the first symi^tom
may be a return of the discharge soon after the patient
gets up, or the menses may return abundantly in three or
four months, while the child is still nursing, or there may
be complete menorrhagia. It is not to be forgotten,
though, that some women menstruate regularly throughout

DISEASES OP THE UTERUS — METRITIS. 237

the whole period of lactation. In all cases, after the
disease has been well established, there will be a dull
dragging pain through the pelvis, much increased by
locomotion; pain on defecation or coition; and painful
menstruation, commencing several days before the flow
appears and lasting during the whole period. There is
often noticed pain in the inammce before and during men-
struation; darkening of the areolre of the breasts, if
lactation is not present; nervous disturbances; and rectal
and vesical tenesmus. As felt bimanually the uterus, in
the earlier stage of subinvolution, is enlarged, but more in
its long diameter than in its transverse; is slightly softened,
somewhat tender, and probably situated low down in the
pelvis. The cervix is more or less enlarged and softer
than normal. The os is purplish in color, and firm, unless
cervical endometritis is present. In cases of long standing,
the uterine tenderness diminishes, the walls become hard,
the cervix paler in color, and, as sclerosis supervenes, the
body becomes somewhat flattened. It might be mistaken
for pregnancy in the early stages, but the early symptoms
of that condition are entirely wanting.

Treatincnt. The sooner treatment is adopted the
better, before the stage of induration is accomplished.
Cases discovered a few weeks after delivery or abortion
should be again put to bed and perfect quietude insisted
upon. Any causes which may have been etiological factors,
such as retroversion or retained secundines, should be
removed. Hot vaginal douches three times a day are
decidedly beneficial. Internally, fluid extract of ergot
given alone, in half dram doses, three times a day, or
combined with fluid extract of hydrastis, in ten drop doses,
will have a decided elt'ect in promoting involution. Two
or three drams of blood may be removed from the cervix
by scarification, three times a week, and a tampon saturated
with boro-glyceride placed against the cervix and allowed
to remain for twelve hours.

238

MEDICAL AND SURGICAL GYNiECOLOGY.

In the enrly stages of menstrual subinvolution, uterine
displncement, or other onuses which keep up the menstrual
congestion, should be corrected. During each menstrual
period perfect quiet, with rest in bed, should be enjoined.
During the stage of infiltration both forms yieUl readily
to treatment. The appropriate measures to be adopted
for such are cleansing the uterine cavity, removing
exuberant and diseased tissue^ and
checking its reproduction by airect
applications, aided by enforced deple-
tion and efficient draJnage — the methods
for which are identicf 1 with that already
enunciated in conjunction with the
t 1 / / ' / treatment of endometritis. The appli-
cation, twice a week, of fifty to sixty
milliamperes of the galvanic current,
with the negative poh^ intra-uterine,

Fig. 72 — Amputation of the cervix with ilouhle flaps. W, sectional view, showing lines of
incision for formation of ttapa and method of suture ; B, front view of cervix, operation
complete.

will soften the uterus and promote absorption. Pelvic
massage will also stimulate the circulation and promote
absorption.

Operative interference is often of much advantage for
the purpose of removing redundant tissue, and to alter
the circulation and the nutrition of the uterus. If the
cervix is lacerated, trachelorrhaphy should be performed.
Where there is decided circumferential enlargement of
the cervix and the canal dilated, a wedge-shaped piece
may bo cut out of one or both sides, and the surfaces

DISEASES OF THE UTERUS— ACQUIRED ATRESIA. 239

brought togotlior ns in trncholorrlmpliy. When this
tnilnrgoment takes the shnpo of an elongation as well as
thickening, amputation should be i)erformed.

Schfoedei'^s met hod for ampntdtion of the cervix. By
means of lateral incisions convert the cervix into anterior
and posterior lips; next remove the anterior lip by two
transverse incisions — one on the vaginal and the other on
the cervical side— by cutting upwards towards the supra-
vaginal portion of the cervix until the incisions meet each
other high up in the cervical tissue. The two flaps thus
formed are stitched together. A similar operation is next
performed on the posterior lip.

CHAPTER XXII.

DISEASES OF THE UTERUS CONTINUED.
ACQUIRED ATRESIA. STENOSIS. HYPERTROPHY.

Besides the result of a congenital defect, the uterus
may become closed later in life, producing a condition
know as (lequired (dresid. This condition may bo brought
about by adhesions forming after child-birth or abortion,
or by cauterization with strong caustics or the actual
cautery. Sometimes it is simply due to old age, especially
when the patient suffers from prolapse. As a result of
acquired closure, there may be hematometra or pyometra;
the treatment for which consists in overcoming the atresia
by puncture, and subsequent evacuation of tlie contents of
the uterus, after the manner previously described.

Stenosis of the cervix is an abnormal narrowing
occurring in some part of the cervical canal. It is most
common at the exti^rnal os, wlu^re the opening may be
found so small as not to admit the finest uterine sound
(pin-hole os). Less frequently it is found at the internal
OS, while sometimes the whole cervical canal is involved

240 MEDICAL AND SURGICAL GYNECOLOGY.

in the stonosis. In acquired stenosis the prominent
symptom is obstructive dysmenorrhcxia, produced by the
difficulty whicli the menstrual flow meets with in passing
through the cervix. If not relieved it may give rise to
chronic endometritis and chronic metritis.

Ti'catment. At one time all sorts of metrotomes and
scissors, for the purpose of overcoming the obstruction,
were in use, but these have now been abandoned as
unnecessary. With tht^ patient under an anjesthetic, the
cervical canal is entered by means of a fine dilator (Hanks')
and the process of dilatation proceeded with. When
sufficiently dilated, a glass or hard rubber stem pessary is
inserted into the cervical canal and retained there for
two or three months.

Hypertrophy of the uterus. An increased size of the
uterus is commonly due to subinvolution or chronic
metritis, but it may be also due to simple hypertrophy,
independent of inflammatory action. General hypertrophy
is a very exceptional condition, the cervix being the part
usually affected.

Hypertrophy of the oervix is divided into infra-vaginal
and supra-vaginal.

I)}fr(t-r:<((ji)i(d luj'pcrtropliii consists in an increase in
the size of the vaginal portion of the uterus. If congenital,
the enlargement takes place chiefly or exclusively from
above downwards, resulting in an elongated cervix. If
acquired, the cervix is not only elongated, but thickened,
and is frequently thicker near the end than at the base.

Treatment. Slight degrees of elongation may be suc-
cessfully treated by dilatation, which enlarges the os and
shortens the canal. If it is more extensive, amputation of
the cervix may be called for.

Snpra-Vdfiindl lii/pertrophy consists in the increase,
especially elongation, of that portion of the cervix situated
above the utero-vaginal junction. This condition is due
to prolapse of the vagina, while the body of the uterus

DISEASES OP THE UTERUS— DISPLACEMENTS. 241

romnins in plnco, tho prolapsod vn^iiin pulling down tho
oorvix nnd thus olongnting it. The symptoms nri'^ thoso
of prolfqjso of tho vngiim, with perhaps tho npponranco of
ft hyportrophiod corvix at tho vulva.

Trratmcnt. In the lesser degrees the uterus may be
pushed up, and the cervix supported by a cup-shaped
pessary attached to an abdominal .belt. In more serious
conditions recourse must be had to operation. Simple
amputation of the cervix may be sufficient; if not, recourse
may be had to supra-vaginal amputation of the cervix, an
operation is reality similar to amputation of the cervix
already described, only the incisions are made higher up.

Schroedcr^s mcihod for siqird-raf/iiuil (imputation.
An incision is made through the mucous membrane at the
utero-vaginal junction, and the cervix separated carefully
all around, for some distance up. A ligature is passed on
each side, around the uterine arteries, to control them, as
in the operation for vaginal hysterectomy. The anterior
vaginal wall is next cut through, and the anterior vaginal
mucous membrane stitched to the mucous membrane of
the cervical canal. The posterior wall is next severed
and the posterior vaginal mucous membrane stitched in a
similar way, thus uniting the mucous membrane of the
cervical canal all around to the vaginal wall.

Hc<j(ir''s operation differs from Schroeder's in that tho
excised piece forms a cone, tho length of which may bo an
inch to an inch and a half above the utero-vaginal junction.

CHAPTP]R XXIII.

DISEASES OF THE UTERUS CONTINUED.
DISPLACEMENTS.

Even in perfectly normal conditions the uterus is
liable to vary greatly in its relations to the pelvic cavity
in which it lies. These relations are modified by its own

242 MEDICAL AND SURGICAL GYNECOLOGY.

functioiml nctivitieH, as woll ns by tlu^ distontioTi niul
ovacuation of the adjacent viscera. With this wido range
of physiological mobility, it is kept in place by the
surrounding connective tissue, by folds of peritoneum as
it is reflected over its walls, and by special ligaments, all
of which have alreatly been described in an earlier
chapter. When it fails to retain its eciuilibrium, either by
excessive movement beyond its normal rangt*, or by losing
the power to recover its normal relations, its displacement
becomes pathological.

Cldstiijicdfioii. Five kinds of displacements are recog-
nized: — Version, or displacement involving a change in
the axis of the uterus. Flexion, or deformity involving an
increase or alteration in the normal slight anterior curve
of the uterine axis. Prolapse, or displacement of the
uterus in the axis of the pelvic outlet. Torsion, or twisting
of the uterus on its long axis. Inversion, or sinking of
the upper part of the uterus into its own cavity, or com-
pletely down through its canal, into tlie vagina.

ANTEVERSION.

The uterus is said to be anteverted when its position
is so changed from the normal one that the fundus
apiJroaches the symphysis pubis, and the cervix points
towards the upper portion of the sacrum. The cause of
anteversion of the iiterus is usually an increased weight of
the organ, produced by subinvolution, hypertrophy,
fibroid tumors of the anterior wall — conditions generally
accompanied by relaxation of the ligaments and supports,
which permit the anteverted uterus to sink down into the
cavity of the pelvis.

Symptoms. From pressure of the uterus upon the
bladder, there will be frequent desire to urinate. In the
erect position, there will be a bearing down sensation, and
on attempting to walk, an uncomfortable dragging feeling.
By digital examination, the body and fundus of the uterus

DISEASES OF THE I'TEKUS- DISPLACEMENTS.

248

will bo found close to the sytni)hyHiH pubiB, touching it, or
(^ven bolow it, nnd tlui cervix pointinjjf towards the middle
or upper portion of the sncrnl excnvntiou.

Trcatnioif. As in mnny cnses the displncements
depend upon subinvolution or iiyperphisin, the first
attempts at treatment must be for the restoration of the
organ to its normal size, after which it will likely return
to its normal position without further interference. It
would be useless to attempt the introduction of any
instrument for the mechanical support of the organ,
without such previous treatment, and, as the symptoms
are genc^rally relieved after the
condition which produced them /''

has been overcome, the large
number of pessaries once found in
the instrument shops have now
disappeared, as being wholly un-
necessary in the treatment of this
deformity. There is one pessary,
Grehrung's, which is still held in
favor for anteversion. It is double-
horseshoe shaped, and is inserted
bj' slipping it sideways into the
vagina, and then turned so that
both bars rest between the sym-
physis pubis and the anterior aspect of the uterus.
Operative measures of various kinds, such as fixation of
the cervix to thvi anter'or wall of the vagina, and shorten-
ing of the anterior vaginal wall, have been proposed and
carried out, but they have not been received with much
favor.

ANTEFLEXION.

Anteflexion is an exaggeration of the normal anterior
curve of the uterus. The body of the uterus may be bent
down upon the cervix, or the cervix may be bent upwards
towards the body.

Fk;. 73. -CJehruiig's pessary.

244 MEDICAL AND SUROICAL OYN,EC()L()GY.

(htU)iCH. (■(ni<i<'nif((l. In oarly lif(5 tlio normal aiito-
floxioii of tli(^ utcTUH i8 very pronounced. Ah puberty
approaohoH, tho body of tho organ dc^vt'lops very decidedly,
and tends to become more erect. In Homo, however, as
puberty approacheH, such erection of the organ fails to
occur, and antefioxion is tlu^ result Failure of the genital
organs to dtwelop synimetrically, or as fast as the pelvis
<l'.'veiops, favors the formation of autetlexion. The short
sacro-uterine ligaments draw the upper portion of the
cervix backward, while the short, ill-developed vagina
holds the lower end of the cervix forward, as in tho
normal condition in young children. The cervix is thus
bent forward into the vaginal axis and, accordingly, is
apt to be elongated, conical, and with stenosis of the os,
while the ill-developed fundus is forced over the bladder
by downward pressure.

Changes in the uterus. Inflammatory changes in the
uterine walls, or their relaxation, or atrophy of tho tissues
at the internal os, favor exaggerations of the normal
anteflexion.

ClKDKjes in the liyaments. Shortening of the sacro-
uterine ligaments may take place from contraction follow-
ing parametritis posterior, or from peritoneal inflammation
about them. When such occurs the ligaments drag the
upper i)art of the cervix toward the hollow of the sacrum,
while the body of tho uterus becomes bent in an exagger-
ated degree by the superincumbent structures.

Sifjnijicance. In unmarried and sterile women ante-
flexion is by far the most common form of displacement.
The views held concerning this condition have of late
been changed materially, and the exaggerated ideas once
held of the cliiiical importance of anteflexion have been
almost entirely abandoned. Recent investigations have
shown that, in minor degrees, antofloxions are practically
of no importance, neither causing pain nor preventing
conception; and when of a more marked character they

DISEASES OP THE UTEUU8 — DISPLACEMENTS. 215

produce only two possible' hnd results, imniely, dysmeiior-
rlnvn mid sti^rility.

Si/inpfoniH. As 1ms been explaiiu'd, tlit* symptoms nro
not very marked. Aside f n m dysmenorrluim and sterility,
ftii uiioomi)li(;nted fiexioti produces no symptoms. CVr-
tnin complications mny. however, be present, which,
even in tlie minor degrees of tlexion, may produce
symptoms such as chronic catarrh of the uterine mucous
membrane and spasmodic contraction of the circular
fibres at the internal os. The first may produce congestive
dysmeuorrhom; the second the obstructive or neuralgic
variety. Digital examination will tind the cervix well
back in the pelvis, and pointing forward almost in the axis
of tlu^ vagina. Tlu^ angle of flexion can easily be felt, the
cervix lying under, and the body of the uterus over, the
finger. By bimanual and rectal examination, it is possible
to determine the condition of the ligaments and the extent
of adhesions, if any. The sound often gives material help
in determining the exact position of the fundus, and to
facilitate its introduction, it may have to be bent pretty
sharply towards the point. There is a condition known
as anteflexion with retroversion, in which, from child-
birth, debility, or other causes, the uterine ligaments have
become relaxed, and allow retroversion to take place after
flexion has become permanent. In such cases the ante-
flexed uterus falls into retroversion in Douglas' cul-de-sac.

Treatment. The minor degrees of anteflexion require
no treatment. Catarrh of the endometrium, engorgement
of the uterus, congestion of the ov ries and tubes, if
present, should be treated on accepted principles. Para-
metritis posterior, and adhesions from recent peritoneal
inflammation, are benefitted by vaginal tampons. To
overcome the two ijrominent symptoms, dysmenorrhcwa
and sterility, stenosis of the os nust be overcome, the
flexion straightened, and the canal kept open. This can
best be done by dilatation of the cervix, under an

246 MEDICAL AND SURGICAL GYN/ECOLOGY.

nric'cstluitio, niul if no inflnmmntory condition exists to
contrnindicuti' it, by the HnbHixj^ucnt introduction of a
glass stem pessary, to be worn for two or thro(^ nonths. It
may be held in position for the first few days by a gauzt>
taniijon, and subsequently by a Thomas cup pessary. If,
from satisfactory reasons, it is deemed advisable to intro-
duce the glass stem, repeated dilatation with Hanks',
or other small dilators, may be employed at the home of
the patient. In old cases, with well pronounced endom-
etritis, accompanied by rigidity of the uterus and dys-
menorrluiea, thorough dilatation of th*? cervix, curettage
and cauterization of the endometrium should be first
performed. The use of pessaries of any kind whatever
have been abandoned, the best results b(ung obtained
from mechanical treatment. Should impregnation occur,
a complete cure may with certainty be promised.

RETROVERSION AND RETROFLEXION.

The uterus is said to be retroverted when the body
of the organ is turned backward. According to the degree
to which the tilting is carried, the os points downward,
or forward against the symphysis, and the fundus turns
upward, or backward towards the sarrura. Retroi'u .Tion
is that displacement in which the body of the uterus is
bent backward, the cervix remaining in its normal position.
As in most cases of retroflexion some degree of retro-
version is present, the os will change its direction also,
and in well marked cases, the fundus will be found lying
in the lowest part of Douglas" pouch, and the os looking
toward the lower margin of the symphysis.

Causes. When the utero-sacral ligaments are relaxed,
the cervix is liable to be carried too far forward, and the
fundus is then likely to fall backward. When the round
ligaments are relaxed and fail in their function of keepiirg
the fundus directed forward, retroversion is favored.
Along with changes in these ligaments, there is apt to be

DISEASES OF THE ITERUS— DISPLACEMENTS.

247

rclnxntion of the broad ligaments, and of tho structures
whicli enter into the formation of the floor of the pelvis,
the result of over-distention, subinvolution, or laceration.
If the bladder and rectum are proialJS(^d to some extent,
as they are apt to be under such circumstances, the
subinvoluted uterus, having lost much of its support,
descends somewhat into the pelvis, and a backward tilting
of its bo( V is the
inevitable result.
Changes in the
uterus, causing in-
duration of the
uterine tissue, and
destruction of its
normal flexibility,
such as that pro-
duced by subinvo-
lution, chronic me-
tritis, and tumors in
the walls, render
that organ liable to
be affected by the
influences that press
the fundus back-
wards, and it will thus suffer retroversion. It may occur
as a result of a strain, or fall, or other jar to the body,
especially if the accident occurred at a time when the
fundus was tilted backward by a distended bladder, and,
remaining in that iiosition, is pressed into a persistent
state of retroversion or retroflexion by the superincumbent
pressure. Habitual over-distention of the bladder will
keep the fundus directed towards the promontory of the
sacrum, and a permanent retroversion will thus be
acquired. A permanent backward displacement is, in
some cases, the result of peritonitis leading to adhesions
that bind the posterior surfaces of the uterus to the

Fig. 74. — Anteflexion with -etroposition.

248 MEDKJAL AND SURGICAL GYNECOLOGY.

rectum nnd to the posterior wall of the pelvis. Backward
displacements may arise from congenital defects, or from
subsequent want of symn'etrical development between the
pelvis and genital organs. Congenital shortening of the
sacro-uterine ligaments, combined with retarded develop-
ment of the vagina, will draw the cervix forward, and
hold the fundus backward.

Sijmpfoms. Of all the displacements, retroversion and
retroflexion are the most common. When the displace-
ment has persisted for some time, the patient will
complain of a bearing down or sinking sensation in the
pelvis during standing or walking; and pain in the lower
I)art of the sacrum and coccyx, perhaps extending down
the back of the thighs along the course of the sciatic
nerves. Sterility, leucorrhoea and profuse menstruation
are often prominent symptoms. If the ovaries are pro-
lapsed, the pain will be more acute. The function of the
rectum may be disturbed, preventing an easy escape of its
contents, or causing frequent desire for defecation, accom-
paaied by mucous dejections. Reflex symptoms are often
present, characterized by hemicrania, frontal and occipital
headache, intercostal neuralgia, gastralgia, nausea and
vomiting, or there may be a general depressed nervous
condition. The examining finger will find the body of
the uterus horizontal, or tijiped backward, more or less,
into the excavation of the sacrum, with the cervix pointing
upward, toward the anterior wall of the vagina, in retro-
version; or in the axis of the vagina, with an angle at the
junction of the cervix and body, in retroflexion.

Bimanual palpation will show the body absent from its
natural position, and the use of the probe will indicate the
direction of the uterine canal. If the ovaries and tubes
are prolapsed, they will be found lying on either side, or
immediately behind the body of the uterus.

TreatmoHt. The treatment consists in the restoration
of the displaced organ to its normal position, and its

DISEASES OF THE UTERUS — DISPLACEMENTS. 249

rotontiou there. Elevation of the retro-displaced uterus
may be aeeoinplished by the fingers, posture, and instru-
ments. The usual method is to put the patient in Sims'
position, insert the index and middle fingers of the right
hand into the vagina, and press the body upward, nhvr
which the index fiugin* is passed in front of the cervix and
pushes that part backwards, while the middle finger
remains in tlu^ posterior pouch. If this method fails,
particularly wlu^n the case is one of impaction, the patient
may be put in the genu-pectoral position, and. after
admitting air into the vagina by means of a Sims'
speculum, efforts are made, by the aid of a depressor or
cotton on a holder introduced into the riictum, to dislodge
the fundus from the sacral excavation. If these manual
and postural methods fail, the reposition may be attempted,
with the patient in the dorsal or Sims" position, by means
of a large blunt sound or Sims' or Emmet's repositor.
The uterus having been replaced, it should at once be
retained in its normal position by a properly fitting
support, or. if considered inadvisable to use such, by
tampons, or gauze packing inserted behind the uterus.
It may not be possible to (completely restore the uterus at
the first attempt, in which case the attemi^ts are to be
repeated at suitable intervals, the advantage gained at
each attempt being kept up by the insertion of tampons.
Pessaries. There is mujh diversity of opinion on the
use of pessaries generally, but, notwithstanding the pro-
gress made in treatment of displacements through surgical
aid, pessaries seem to be, to some extent, a necessary evil.
As has already been stated, in anterior displacements
pessaries are but little used; and in prolapse, especially
when there is (h'scent of the vaginal walls, it has been
shown, when speaking of rectocele and cystocele, that they
cannot be well retained, and hence ari^ of little or no
benefit. In retrofiexion tlu'y are still found to be of much
UBe, but to obtain beneficial results, two indispensable

250

MEDICAL AND SURGICAL GYN/ECOLOGY.

conditions miiHt bo observed:— First, that the uterus
sliould bi' returned to its norinfil position; second, tlint
the pessary should bo properly fitted, and should, without
injury or discomfort to tho wearer, retain the uterus in its
normal position.

Varieties. The cardinal principle upon which most
pessaries for retro-displacements are
constructed is that of leverage, first
introduced by Dr. Hodge. It acts on
the principle of the pushing down of a
short anterior lever, and the consociuent
Fig. 7s-Hodge pessary, tilting upward of a loiig postorior lever,
and all pessaries for rotro-displatiomonts, with few excep-
tions, are based on this idea. The instrument devised by
Hodge is of equal width at both extremities, and with two
curves. Albert Smith modified this form by narrowing
and pointing the lower extremity, in order to enable it to
rest upon the symphysis — an innovation which has proved

Fi<;. 76— Allien Smith
Pess.nry.

Fig. 77 — Thom.as' retroflexion
pessary.

a permanent one — and nearly all pessaries are constructed
after that plan. According to the length and width of tho
vagina, the depth and width of the postorior vaginal
pouch, the firmness or relaxation of the postorior vaginal
wall and ijorineum, the pessary will have to be broader,
longer, or more or less curved. If there is retroflexion,
with considerable relaxation of the posterior vaginal wall
and uterine ligaments, a pessary with a sharp postorior
curve will usually be required. For this form of displace-
ment Dr. Thomas has added a bulbous enlargement on

DISEASES OF THE UTERUS— DISPLACEMENTS. 251

the posterior crossbar, wlioreby the body of the uterus is
prevented from tipping mid biuidiiig backwards.

C()iifr<i-{nilic(ifi(nis. All imrnovabhi, iioii-replaceabie
uterus is always an absolute contra-indication to the use
of a pessary, whethc^r the cause be recent or remote. So
also is the presence of fibroid or ovarian tumors.

Tm^crtion. The patient being placed on the back-
some prefer Sims' position — a suitable pessary is selected,
and smeared with some unguent. The anterior cross-bar
is taken between the index finger and thumb of the right
hand, and the pessary held vertically, while the index
finger of the left hand is made to draw back the perineum.
The pessary is now passed between the vulva, through the
introitus vagiiue, and, as it is about to impinge ; 'jon the
cervix, the index finger retaining th(^ perineum is passed
inward, and catching the posterior bar. draws it downward
and backward under the os. The right hand continues to
push the pessary onward, and at the same time rotates it
from the vertical to the horizontal position. 'The anterior
bar must then be depressed downward and backward to
settle the pessary in its place, and while so doing the left
finger should make sure tliat the cervix is in its proper
place.

A pessary properly fitted should produce neither pain
nor discomfort, but sometimes, after it has been worn for
a few months, abrasions are formed by pressure, and tlu>y
may even become imbedded -n the vaginal walls. In this
way urinary and rectal fistulje have been formed. After
introduction, it is well to allow the patient to walk about,
to make certain that it gives no discomfort, aftc^r which
she should be re-examined to ascertain that the pessary
remains in position. The patient should be advised to
take a tepid vaginal douche every day and to return from
time to tim(> for i-xamination.

When tlu^ fundus and body of the uterus are adherent
from inflammatory adhesions, or cicatricial contractions,

252 MEI>1C!AL AND SURGICAL GYNAECOLOGY.

attempts to roplncci the ori^nn will usunlly fail, and an
effort must then be nmdv to softi^n and gradually detach
or stretch tluMU. This may be done by careful bimanual
and rectal rnaiiiijulation, by uterine massage, and by
vaginal pa(^king with tampons or gauze, with the patient
in the genu-pectoral position.

Opcrativr treatment. When a pessary fails to cure
the displacement, or when the uterus cannot be held in
place, an operation may be performed to accomplish this
purpose.

Extra-peritoneal shortening of the round ligaments.
Ale. r (UK lev'' s oiienitlon. This consists in making an
incision over the external inguinal ring on each side,
dissecting out, picking up, and drawing out the round
ligaments, until the fundus points towards tlie anterior
abdominal wall. Tlie ligaments are then ma(h^ fast in the
wound by buried sutures, which pass through the pillars
of the ring and th(^ ligament, after which the redundant
part is cut off, and the external wound closed.

Intra-peritoneal shortening of the round ligaments.
Wi/lie''s method. After opening up the abdominal cavity,
the round ligaments are brought into view and denuded
on their inner surfaces. Each round ligament is then
doubled on itself, and the loop retained in position by the
introduction of ligatures, after which the abdominal
wound is closed.

Vaginal fixation. Vaginal hysteropexy. With the
patient in the dorsal position, and an Edebohls" speculum
inserted, a median incision is made in the anterior
vaginal wall, from the neck of the bladder to the cervix,
after which the bladder is carefully separated from the
uterus and vagina as far as the peritoneal reflection. The
anterior surface of the replaced uterus if; drawn freely
forward by means of bullet forceps, and stitclied to the
incision in the anterior vaginal wall. This operation hau
now been practically abandoned.

DISEASES OF THE L'TERUS — DISPLACEMENTS. 253

Ventral fixation. Abdominal hysteropexy. Tliif*
mc^thod consiKts in opc^niug tlic nbdoiuiiml cnvity. nnd
suturing the body of the uterus to th(3 nnterior abdomiuul
wnli. This operntiou has^ proved very satisfactory, both as
to its performance and results, and the only serious
objection which can be raised to it is the influence
which it will have on pregnancy and labor. From care-
fully prepan (1 statistics, it has been shown that women
subjected to this operation are less apt than others to
become pregnant; that pregnancy and labor are, as a rule,
uncomplicated. Inertia uteri is, however, not infrequently
met with, and serious or insuperable objections to labor
may be produced if the fundus and nnterior wall of the
uterus are imprisoned below the point of attachment
between the uterus and abdominal wall.

Various methods have been (U^vised for introduction of
the sutures, to avoid difficulties arising during pregiumcy
and labor. Kcllij',^ method consists in suturing the uterus
at th(3 junction of the fundus and posterior wall, to the
abdominal wall, with buried silk sutures. In this
techniqu"^ the sutures which suspend tho uterus embrace
only the peritoneal coat of the abdominal wall, and are
introduced superficially through the uterus. OUhlumaen
sews the cornua to the abdominal wall by means of silk-
wo m gut buried at the aponeurosis, the anterior rather
than the posterior surface of the fuiulus being included in
the sutures. Leopold uses silk sutures passed through
the entire thickni'ss of the abdominal wall, one at each
cornu, and tlu^ third between them. The sutures are
passed through the anterior rather than the posterior
surface of the fundus, and to ensure firm attachment the
peritoneum of the fundus is scraped oft*. Aft(^r fixation
the abdominal wound is closed in the usual way.

Latero-versions and latero-flexions are cuther con-
genital or acquired. In either case they occur through
shortening of the broad ligament on the side towards

254

MEDICAL AND SURGICAL OYNJICOLOGY.

which the body tips. The only renl importance of theso
displncomonts, particularly floxions, is the production of
sterility. The diagnosis can be readily mad(> by bimanual
examination and by the sound. No treatment, unless that
of persistent taniponading of the vagina to stretch the
contracted ligament, offers any reasonable chance for
success.

PROLAPSUS.

Prolapsus is a displacement of the uterus in tlie axis
of the pelvic outlet. Three degrees liavo been described.
In the first degree there is simple ilescent in the axis of
the pelvic outlet, the cervix touches the tloor of the pelvis,

Fig. 78. — Procidentia uteri.

the fundus is pi oportionately below its normal level, and
the uterine axis slightly inclined backwards. Neither the
bladder, rectum, nor the vagina is necessarily involved.
In the second degree, the external os approaches the
vaginal orifice, the body of the uterus is retroverted and
lies in the sacral excavation, and usually the anterior
vaginal wall, together with the posterior wall of the
bladder, accompanies, if it does not precede the prolapse.
In the third degree, the cervix protrudes from the vulva

riSEASliS OF THE I'TEKUS — IJISFLACEMENT.S. 255

moro or loss (i)r<)('i<l<'uti(i), evoii to tlio extent of the
ciitiro extrusion of the uterus. The anterior vnginal wftll
and posterior wall of the bladder, down to the meatus
urinarius, protrude from the pelvic cavity, and in a very
large proportion of cases the posterior vaginal wall and
the anterior wall of the rectum are prolapsed to the same
extent.

Causes. Of the indirect causes, laceration, over-
distention, or subinvolution of the perineum after
parturition is the prime element in the weakening of the
pelvic floor that eventuates in displacements of the jjelvic
contents. Varying conditions of the vaginal walls arising
from over distention or lack of tonicity, and relaxation of
the ligaments persisting for some time after parturition,
increase as well as facilitate the tendency to descent.
Absorption of adipose tissue, such as that which occurs in
those suffering from wasting disease, also lessens the
natural support and renders its desc«Mit more easy.
Among the conditions which operate more dirt^ctly may
be mentioned enlargement of the uterus. If. after partu-
rition involution is not complete, or if the organ is hypor-
trophied as a result of chronic metritis, or enlarged from
development of neoplasms in its walls, the increase in its
weight, favored by some of the indirect causes mentioned,
is almost certain to end in prolapse. One of the most
common causes is frequent parturition. A large majority
of cases of prolapse occur in women who, after one or more
severe child-births, are unable to remain at rest for a
sufficient l(Migtli of time to allow the pelvic organs to
regain their normal tone.

(Jomplicafio)is. In extreme cases, not only has the
uterus descended, but the bladder and rectum will b(^ found
displaced, and the ovaries will have descended into the
pelvic cavity to the depth of Douglas' pouch. In its
descent a chronic metritis may take place, by which the
walls are thickened and indurated, and the endometrium

256 MEDICAL AND SURGICAL OYNJICOLOGY.

oxpaiidod ftiul vnscular. Ouo of tlui most comiiK m oom-
plicintioiiH is Incorntioii niid ovorsion of the lips of tlui
cervix, and often accompanied by a lacerated perineum.
Hypertrophy of the cervix in also a common occurrence,
in consequence of the irritation produced by the laceration.
When prolapse is compU>t(i the vaginal walls b(>come
smooth, dry, and are deprived of their rugosities, and in
cases of long standing the epithelium in places takes on
the appearance of the epidermis. Imperfect evacuation
of the distended bladder leads eventually to cystitis, and
the rectum may be the seat of irritation and of undue
accumulation of fecal matter.

Sijtnptoiiis. In cases which develop gratlually tlu^n;
may be no decided symptoms at first, but .soon ba(!ka(^ho
and a bearing down, dragging sensation about the vulva,
with a disagreeable feeling of weakness or want of support,
is noticeable. Difficult urijiation and defecation, find
even the symptoms of cystitis, are often prominent. The
diagnosis of prolapse of the uterus is excteedingly easy.
The examining finger will readily determine that the
cervix is lower in the pelvic cavity than it should be, or
that it is protruding through the vulva. Bimanual exam-
ination will indicate that the fundus is absent from its
normal position, and eitluT retroverted, or low down, at or
near the pelvic outlet. Accompanying prolapse in th(«
second degree will be found cystocele, and in the third
degree both cystocele and rectocelo.

Tri'dtmcnt. The treatment of prolapse is either palli-
ative or radical. Minor degrees of recent origin may be
treated by astringent injections and by tampons inserted
into the vagina in the genu-pectoral position, and later by
the ins(>rtion of a retroversion pessary. In the more
advanced degrees of prolapse, mechanical and palliative
means will be found of doubtful benefit, but treatment by
means of them may be made when operations are inad-
missable. A large soft rubber ring, or pessaries inflated

DISEASES OF THE I'TEKUS - DISPLACEMENTS. 257

w'ifli Jiir, or mado of (Onstifi \vir(\ will sonu'timos rctniii i\ui
uterus ill tlu^ p(>lvis by (listciidiuj^ i\\v uppcT part of tlii^
vagina. In most cases of (Hinipli'tc prolapst', it is necessary
to use n supporter composed of a c,v\ and stem pressing
against the vaginal portion of tlu> uterus and fastened
billow to an abdominal belt. The wearing of it is, however,
often very annoying and fre([Uontly causes excoriations
and ulcerations.

()j)('i'(ifir(' fi-c(if)iiciil. This consists in applying m(>thods
for the diminution of the size of th(^ uterus, for
restoring the tone of the utt>rine ligaments, and for the
repair of the uterine supports. Tliese may be accomplished
by amputation of the cervix if it is much hypertrophied;
by repair of a laceration in it; and by thorough curettage;
all of which can b(^ completed at one sitting, aftl^r whicrh
the liganuuits will probably regain their tonicity. The
round ligaments may be made at once to renitw their
support by Alexander's operation for shortening them,
already describ(>d.

INVERSION OF THE UTERUS.

By inversion is meapt a more or loss complete turn-
ing inside out of the body of the uterus. There may be
simply a folding in of tlu^ fundus, or a projection of the
fundus through the dilated cervix, or a complete inversion
of both uterus and cervix.

Inversion comes under observation at three different
periods: Immediately after the occurrence of the accident,
or that form appearing during or immediately after child-
birth; second, about six weeks after labor; and third, that
which occurs after a lengthened period, often many years.
Leaving out the first form, which belongs more to the
subject of obstetrics, two classifications may be made:
Inversion (liirhu/ inroinfioiinnd inversion ((ff<'r involnfion.

The predisposing causes are, an enlarged uterus and
a relaxation or an inability on the part of some portion of

258

MEDICAL AND SUIKHC'AI GYNECOLOGY.

Fig. 79— Incomplete Fk;. 80 —Complete
inversion of inversion of

t\w utcriin' wall to (U)iitnutt, hucIi rh oxists nt tho plno,(4ital
Hit(^ nftor labor, or at tlu^ phwv of orij^in of a hohhIK' iiitra-
utoriiio tibro-myoma. When hucIi (toiulitioiiH exist,
umiHual utorino coutraotioii may tako i>lac(% by which the
weaki'iied area is depressed and inverted, and the first

sta^e of inversion is initiated.
Subsequently a species of peri-
staltic movement, proceeding
from above downwards, is set
up in the uterine muscular
coats, until inversion becomes
nion^ or less complete.

Sijnipfomn. The chief symp-
tom for which n patient pre-
sents herself, is repeated hem-
orrhage, which may already
have undermined the constitution by its frequent recur-
rence or profuseness. To this symptom are added leucor-
rh(ua, dragging pains, and diffiv ulty in walking. Physical
examination will reveal tlu^ peculiar condition
present. When involution has not taken jilace,
or is not complete, the peritoneal cup formed
by the depressed fundus contains all, or a large
portion of the uterine appendages, and may
also contain loops of intestine. The inverted
uterine body projects into the vagina as a
large soft, more or less spongy mass, upon
which ran be discovered small depressions
corresponding to the orij,in of the Fallopian
tubes, and from the surface of which blood
seems to slowly ooze. Inversion after invo-
lution has neither intestine nor uti^rine appen-
dages in the cup. except the ends of the
Fallopian tubes and the ovarian ligaments.
The inverted body is firm, pear-shaped, and hangs
out of the cervix like a fibroid polypus. The mucous

Fk;. 8i~I'olvpus
simiiKitini; com-
plete inversion of
uterus.

DISEASES OP THE UTERUS — DISPLACEMENTS.

259

nuMnhmiio roH<imbh<H ^ramilntion tissiu*, mid from it
lu'inorrhago tnkoH plmus but not to such an ^^\tont as in
tlio proviouH form.

I)i(((/n<>sin. Prolapse of the uterus and hyiMirtrophy
of the cervix might be mistaken for inversion. In tht^
former the os is found in its normal place, through whicli
the sound readily enters, and the tumor is broader above
than below, the reverse being the case when invc^rsion is
present. A fibroid polypus with a h rge pedicle might
cause an error in diagnosis. In inversion the uterus is
darker and softer than a fibroid, and the
sound introduced between the body and
cervix discovers no opening into the
uterine cavity. A fibroid can be slightly
twisted on its long axis without twisting
the cervix; in the case of inversion this
cannot be done. With a fibroid, biman-
ual and rectal examination reveals the
fundus of the uterus at, or near its
proper place. In inversion there is an
abisence of the fundus, and a cup-shaped
depression occupies its plac(\

Trcdfmnit. Inversion should, if pos-
sible, be reduced as soon as recognised.
The methods for reduction are mtmiud, iustrioncntdl, and
opcrdtive.

Manual. The fingers of one hand, formed so as to
make a cone, are inserted into tlie vagina and the tip of
the cone pressed against the summit of the inverted uterus,
or alternately against one uterine cornu and then the
other, while the other hand exerts counter-pressure, or
with the fingers attempts to dilate the ring through the
abdominal wall.

Emmet describes a method of reduction in the follow-
ing way : The hand is passed into the vagina, and,
with the fingers and thumb encircling the portion of the

Ki<i. 83.--Kil)rous [jolypus.

260 MEDICAL AND SURGICAL ftYN/ECOLOGY.

body olosi' to tlio st^at o^ inversion, the fundus is allowi^d
to rest in tlio palm of the hand. This portion of the body
is firmly grasped, pushinl upward, and the fingers immedi-
ately separated to tluur utmost; at tlu^ same time the
other hand is employed over the abdomen in the attempt
to roll out tlu> parts forming the ring, by sliding the
abdominal parit^tes over its edge. This manoeuvre is
repeated and continued. At length, as the diameter of the
uterine cervix and os is increased by lateral dilatation
with the outspread fingers, the long diameter of the body
of the uterus b( -oLies shortened and tiie degree of inver-
sion proportionately lessened. After the body has
advanced well v/ithin th'> cervix, steady Qjjward pressure
upon the fundus is applied by the tips of all the fingers
brought together.

Iiistrumciital. Ingenious minds have devised instru-
iTients by which a steady pressure can bv effected upon the
inverted fundus, while counter- pressure is exercised upon
the cervical ring. By the use of i ich instrumenl,s re-
position of the organ lins been effected in less than twenty
four hours. A more sim])le method consists in packing
the vagina witli gar.ze in such a manner that the fundus
will be pressed upward, in tlie direction of the axis of the
superior s':rait, whih' the dihited wall of the vagina
makes traction upon the c(>rvix.

Opcvdtivc. Tlie only operative measures for thc^ reduc-
tion of the inverted uterus is that proposed and carried
oat first by Dr. Tliomas. It (;onsists in opiming tlie
abdomiiml cavity, stretching the ring witli a kind of glove
stretcher, while the hr..".'' iiitroduced into the vagina forces
the fundu,; throu.;h the rii\g. and up into its normal plawi.
Should efforts by this method fail, resort nmy be luul at
once to hysterectcnny to relit^ve the distressing as well as
dangero\is condition. Amputation of the inverted uterus,
preferab by the elastic ligature, is aLso recommended
v.heT other less radical methods hav^ failed.

DISEASES OF THE UTERUS — BEN'IGN NEOPLASMS. 261

CHAPTP]R XXIV.

DISEASES OF THE UTERUS CONTINUED.
HENKiN NEOPLASMS.

Cysts in the cervical canal are of common occur-
rence and arc erroneously called ovules (>f Nabotli. Like
cipher cysts lined with epithelium, ihey orij^inate from
glandular formation, and are thus a species of adenoma.
The contents are li([ui(l. semi-li(|uid, or form a jelly-like
mass. The tit'atment consists in opening them, and
touching the interior with tincture of iodine.

Myxoma. Glandular polypus. All so cnlled polypoid
tumors of a jelly-likt^ consistency, and half translucent to
the naked eye. appear under the microscope to be made
up mainly of myxomatous tissue. They are found most
fre(piently in the cervix, and are usually sessile at first, but
have a tendency to become pedunculated nnd protriulo
through the os as bluish or purplish red lobules. The
symptoms which usually attract attention are leucorrluna
and luunorrhage, and. on examination, a small iumor will,
perhaps, be seen i^rotruding through the o.s. The treat-
ment consists in removal with the curette if intra-uterine,
and in torsion if cervical.

FIBROMATA.

To those tumors of the uterus which have the .same
structure as the uterus itself, the names ol Jihroiud, mi/oma,
Jihvoiis fiitHO" find Jihi'oids li::ve been given, and from the
fact that tlu^y are generallj^ of the mix(>d variety, com-
posed of muscle fibres and fibrous conniM'tivi' tissue, the
corresponding terms inj/o-Jihi'oiiKi or Jihro-DiijonKi have
been applied. They are usually benign, that is to say.
incapable^ of becoming g(>neral and infecting t'u' org.'inism.
but they are not .so harmless as the older ...thors con-

262

MI5I)K!AL AND SURGICAL GYNECOLOGY.

;. 83. — Interstitial
fibroids.

Fit;. 84. — Subserous
and su))Miucous
fibroid.

siderod tliom to be. Tlio knowlwlgo of tlio orijjin of these
tumors is still very imperfect. Klobs asserts that they
have tlieir origin in n pro-
liferation of the connective
tissue and muscular layers
of certain vessels. Another
authority asserts that they
ar(> due to a round cell found
alonj^ the capillaries, which
by growth obliterates them ;
the cells then become fusi-
form and produce nodules, y

The tumor may consist of
one mass, or of several dis-
tinct masses, developed side by side, and enclosed in a
single capsule, or many tumors with individual capsules
may be scattered throughout the uterine walls. They
vary in size from a tumor the size of a pea to a growth of
immense proportions. The majority have their origin in
the body of th3 uterus and most often are situated in the
posterior wall; least frequently they spring from the
cervix. They are classified according to the relation
which the tumor bears to the uterine tissues.

The iiifcrsfiti'dl develop within the uterine walls, and
are surrounded on all sides by iterine muscular tissue.

The finh-miic(>ut^ develop imme(\ately o** just below the
mucous membrane, and project into the uterine cavity
without becoming pendulous <^sv'.s'.s'/A').

The poli/itoid have their origin under the mucous
membrane, on the surface of the muscular wall, from
which they project more and more, as they grow, until
they bec(^me i>endulous.

The sKb-pcrifoncdJ or siih-scrous develop upon, or near
the external surface, under the peritoneum, and either
project upon the suiface, or become pedunculated.

DISEASES OF THE I'TEUrS- BENIGN NEOPLASMS. 2{)li

Th(i I'litrd-liutnuciiloiis. nn iiuportaiit sub-vuricty,
develop in the thickness of the broad ligament.

Htrnctun'. To the naked ey(^ thesi' tumors are eoni-
posed of dense tissue, shiny, or rosy whit(\ elastic, giving
a very clenu surface on section, and, when examined under
the microscope, exhibit varying i)roportions of connective
tissue and muscle Hbre irregularly intt'rwoven. Their
vascular supply is relatively scant, but they are apt to be

FiLi. 85 — Large pedunculated fibroid of uterus, i, cervical canal ; 2, 2, ovaries; 3, liliroid ;
4, fundus of uterus, (Krom the pathologic.1l lalxiratory, (Jueen's University.)

surrounded by vascular and hypertrophic uterine walls.
In tumors of considerable size, large arteries are sometimes
found under the peritoneum, or in the capsule, and wIumi
such n condition exists the peripheral veins arc> sometimes
th(> size of tlu' jugular, and adherent on all sides to the
muscular bundU^s which hold them wide ()i)en. WIumi
this arrangement is well marked and the tumor hollowed
out by vascular lacunu3 due to dilatation of the capillaries,

264

MEDICAL AND SURGICAL UYN/EC(lLOGY.

tliere exists what Vircliow calls '• tolcaii,i^i('('tatic myoma."
or " myomn caveriiosum,'' the portion degciierated resem-

FlG. 86. — Kil)ro-cyslic tumor of uterus. i. Incision in wall of l?.rge cyst, i, a. Interior of
cyst. 3. Small cyst. 4. lUerine cavity. 5. Multiple fil ro-myom.T. (>. "undus of
uterus. (From the pathological lalioratory, Queen's University.)

bliiig a sponge soaked in blood. Polypoid tumors some-
times contain large blood vessels, but when removed the

DISEASES OF THE UTERUS — BENIGN NEOPLASMS. 265

contractility of tlio walls usunlly brings about rapid
hsemostasis.

AUerdtioa <ind (legcywrdtion. At the mcniopauso most
of the fibromata undergo a progressive induration and
diminution in volume, and in such a state often persist
without causing any morbid reaction. Very rarely they
undergo calcification by a deposition of carbonate of lime.
During sexual activity they may undergo changes depen-
dent upon physiological processes. During pregnancy a
marked increase in size is sometimes noticed, due princi-
pally to changes in the circulation causing cedema of the
growth. CEdema occurring in tumors existing in a non-
pregnant uterus is frequently the forerunner of gangrene.
Fatty degeneration is very rare, and where suppuration
exists, it is for the most part the outcome of gangrene.

Cystic derfeneratiofi is a peculiar process of liquefac-
tion characterized by a primary serous infiltration and
associated with myxomatous softening of the growth,
accompanied by an oedeniatous swelling of the connective
tissue, followed by more or less disintegration. When
advanced, these changes result in the formation of spaces
tilled with linid, the walls of which are formed by the non-
disintegrated portion of the tumor. At first the muscular
bundles prevent the formation of large cavities, and give
to the cyst wall a peculiar uneven appearance, like the
columnse of the heart. Subsequently, however, tliese also
become disintegrated and large spaces are formed.

The contained fluid varies in color, from a pale amber
to a dark brown, the changes in color being due to
extravasation of blood. The fluid, as a usual thing,
coagulates spontaneously, and chemical and microscopic^al
examinations show it to contain serum-albumen and
fibrin, with more or less mucin, blood, and detritus from
degenerated tissue.

Etiolo()i). Although much attention has been paid to
the causation of these neoplasms it must be admitted that

266 MEDICAL AND SURGICAL GYNAECOLOGY.

little or nothing is known. No single cause assigned has
been proved with reasonable certainty.

H]imptows. Small subserous tumors sometimes exist
without causing any .symptoms. Hemorrhage, either
monorrhagia or metrorrhagia, is common to nearly all the
fibromata. In the polypoid and submucous varieties it is
the most noticeable symptom. In the interstitial variety
it is less frequent, while in the exclusively subserous it is
very often absent. More or less profuse leucorrhoea, and
intermittent watery discharges are also present in the
majority of patients. A symptom of equal importance is
pain, at times of an intermittent character, and most
intense during menstruation. It may arise from painful
uterine contractions due to the presence of polypoid
tumors, or to retention of secretions; from pressure of a
polypoid or submucous growth at or near the internal os;
or it may be due to pressure upon the surrounding pelvic
tissues, or upon the bladder, rectum, or sciatic or gluteal
nerves. Pressure on the rectum may cause obstinate
constipation; pressure upon the bladder, vesical disturb-
ances; and on the ureters, retention of urine in the pelvis
of the kidney, with subsequent renal changes. Pregnancy
is not infrequent, and should it occur the tumors are apt
to grow more rapidly, but after partiirition they may
comijletely disappear.

Course. Fibromata in most cases run a benign course.
They grow slowly and seldom cause death directly. As
has been already stated, they often undergo progressive
induration and diminution after the menopause. If
polypoid thoy may be expelled by the vagina. Multiple,
interstitial, or submucou.s tumors may attain a great mzQ,
but when a large number start simultaneously, intermediate
pressure tends to cut off the blood supply and arrest
growth. Submucous and interstitial tumors may become
gangrenous, followed by suppuration, and when such a

DISEASES OF THE UTERUS — BENIGN NEOPLASMS. 267

course is pursued death may follow from peritonitis,
septioasmia, or pyremia.

I)i<((/)iosis. Single interstitial, submucous, and poly-
poid fibroids, if of moderate size, may be mistaken for
pregnancy, retained menses (luematomotra), malignant
disease, or subinvolution. A fibroid uterus is harder to
the feel than in pregnancy, and the os, although some-
times slightly dilated, is not softened or deepened in color,
and there is absence of the familiar signs of pregnancy.
A large polyjjoid growth often dilates the cervix, and may
be felt presenting at the os. In ha^raatometra the retained
discharges give the uterine walls a tense elastic or fluctu-
ating feel, and, on examination, the internal or external os
will be found impermeable, and perhaps the menses will
have never appeared. In malignant disease, tlu^ age of
the patient will assist in making the diagnosis. The
peculiar offensive discharge is characteristic, and if in
doubt curetting and examination with the microscope will
make the condition clear.

Subinvolution generally produces cervical, as well as
corporeal enlargement, the body is flatter, the antero-
posterior diameter being not so much increased as when
fibroids are present. Interstitial multiple tumors cause
the uterus to enlarge more or less irregularly, and make
the canal to become so tortuous that n probe can with
diflficulty be passed, or even not at all. When the tumors
are near the outer surface, the probe may enter readily the
full length of the canal, but bimanual examination will
disclose the hardened projections on the outer surface of
the uterus.

Retro-uterine hematocele and ha?mHtoma may be differ-
entiated by bimanual examination and by tlu> use of the
sound. In such cas(^s the uterus will likely be found in
front of. or at one side of the tumor, or it may be pushed
up behind the pubes, where it can be moved indep«>ndeiitly
of the mass. A small subserous tumor, if pedunculated.

268 MEDICAL AND SURGICAL GYNECOLOGY.

may bo miHtnkcMi for a diHoasod ovary. Tho formor is
usually tinner to the touch than Ih tlu^ ovary, lias a
smoother surface, and is not siMxsitive on bimanual
pressure, and the pedicle may be palpated. A tumor
partially extruded from the os may be mistaken for cancer,
especially when the former is gangrenous. In both cases
there is profuse vaginal discharge, but witli care tho
cervix may be shown to surround the protruding mass.
Fibro-myomata of the pelvic variety may resemble pelvic
exudations, but if the tumors are not adherent they can
be displaced by the examining fingers. They do not
encroach so closely upon the pelvic wall, and are generally
harder to the touch. Intra-lignmentouH fibroids are dis-
tinguished by their close connection with the uterus, and
their unyielding feel to the touch Cervical fibroids are
usually easily recognised by the protuberance in the lip
affected, and the fiattened appearance of tho opposite lip.

Treatment. This may be divided into pdlUdiivc and
r(uliv(d; or mc.dicdl and nunjicdl. It may be stated at tho
beginning, that a serious operation should never be under-
taken just because a woman has a fibro-myomatous tumor,
the growth must in some manner menace life or health,
and not be amenable to other treatment. It may also be
stated that all medical treatment is absolutely ui.;?les8 in
pedunculated subserous tumors.

The hypodermatic use of crffot has, in some cases,
caused a cessation of growth in interstitial tumors, and
even their extrusion, and is therefore applicable for the
treatment of such growths, as well as the submucous
variety. The effect of ergot is to cause comprestJon of
the blood vessels, by producing more or less marked
contraction of the muscular structure of the tumor. The
drug should be used in the form of ergotine, from one to
two grains being injected into the fleshy part of the thighs
or buttocks twice daily, the dose being governed largely
by the uterine pain produced. Instead of hypodermatic

DISEASES OF THE UTERUS— BENION NEOPLASMS. 269

inj(>ctions, dram doses of fluid extract of ergot, or two
grain capsules of ergotiue may bo given by the moutli
three times daily, or if it disagrees with the stomach, it
may be mixed with four ounces of water, and administered
by the rectum. Fluid extract of hydrastis, in half dram
doses, may also be used with benefit, but the chief
advantages from its use lie only in the effect it has in
checking hemorrhage. The bromides and iodides, arsenic,
mercurials, and such like, do not possess any positive
therapeutic value.

Among recent remedies (jdhxinism plays an important
part, especially the method introduced by Apostol; The
method of application,'and the benefits to bo derived from
this class of treatment, has already been referred to when
speaking of the practical application of electric currents.

Subperitoneal tumors, tilling the pelvis and causing
much distress, can at times be dislodged by pressure
upwards through the vagina, with the patient in the genu-
pectoral position. Hemorrhage may be treated by dilata-
tion of the cervix, repeated curettage, and subseciuent
application of tincture of iodine, or carbolic acid to the
endometrium.

Beside the administration of ergot to diminish the
blood supply, an operation for li<j(dure of the uterine
nrterios, for a similar purpose, is recommended as giving
beneficial effects on many tumors, the peduncalated and
subperitoneal excepted. With the patient in the dorsal
position an incision is made on either side of the cervix,
and the connective tissue pushed away until the uterine
artery can be felt pulsating. A pedicle needle, armed
with a ligature and guarded by the finger, is passed from
behind forwards through the broad ligament, above the
artery, and after the withdrawal of the needle, the ligature
is tied. The artery on the opposite side is tied in the
same way, care being observed in each case to avoid the
ureters.

270 MEDICAL AND SURGICAL OYNJICOLOOY.

Ooplinrcctomif. It lins been stnted that at tlu^ iiuiiio-
pnuse, uterine tumors may undergo retrograde* cliangc^s,
and that the symptoms produced by them may gradually
disappear, when menstruation has ceased. With this end
in view, oophorectomy is frequ(uitly performed to bring
about the menopause prematurely and, if the case has
been properly selected, will likely produce the desired
effect.

Large tumors, those which are soft or cedematous, pure
submucous growths, subserous ones with broad bases,
tibro-cystic growths, or those which produce painful
pressure symptoms, should not be treated by this
operation. Cervical fibroids are not amenable to palli-
ative treatment, and should be removed. When peduncu-
lated and small, they may be twisted off; if large, and the
pedicle thick, the mucous membrane may be incised all
around close to the cervix, and the remainder of the
pedicle cut through, after which the mucous membrane is
stitched over so as to close in the stump. When sessile
or distinctly submucous, the capsule should be incised
and the tumor enucleated. After trimming the margins,
the raw surfaces are coaptated by deep sutures. If unable
to do this, or if there is troublesome hemorrhage, the bed
of the tumor, and the vagina as well, should be packed
with iodoform gauze. Intra-uterine polypi, smaller than
a child's head, may be removed in the same way as the
cervical, the cervix having been previously dilated to such
an extent as will permit the extraction of the tumor. In
cases where the attachment of the pedicle is high up, or
difficult to reach, or where there is fear of hemorrhage, a
pair of light forceps may be clamped on the pedicle at its
attachment to the uterine wall, and the pedicle cut through
with scissors. The forceps, carefully surrounded with
gauze, are allowed to remain in situ for some hours, when
they may be removed.

DISEASES OF THE UTERUS — BENKiN NEOPLASMS. 271

The nature of further operations for utoriuo fibromntu
will vnry ncconliug to tho situntiou niul nttnchmout of tho
tumorH. Tlioy may bo thus clnssifiod: 1. iiimjAc myomrc-
tornij, or romovnl of the tumor without any of the uterine
tissue by excision or enucleation. 2. Hysto'cctoniij, tot((l
or pdi'ildl, or removal of more or less of the uterine tissue
with the tumor.

Myomectomy. When it is jw^sible to remove the
tumor from the uterus without destroying the organ, it
should be done. The operation is called myomectomy,
and is suitable for all subserous growths, and for such
interstitial ones as can be enucleated without entering the
uterine cavity.

The (ibdomiiKil incision. The operation for opening
the abdominal cavity has been known by various terms,
(jastrotoniy, \ap<ir(itomy, and (ihdominal section, but
lately the term ecvliotomy has been introduced, which,
while more fully expressing the meaning to be conveyed,
is classically correct. The incision should be made in the
line of the linea alba, between the umbilicus aiid symphysis.
After incising the skin and adipose tissue, the aponeurosis
is reached, i nd after carefully dividing this structure the
recti muscles are brought into view. These are next
separated in the median line, exposing the subserous
areolar tissue. After cutting through it, and the peritoneum
brought into view, the latter is picked up between two pairs
of forceps and incised with the point of a scalpel. It is
best to make the first opening not more than two and a
half inches long, as subsequently it may be enlarged,
should circumstances demand it. Care must be taken not
to incise too lo>^^ lest the prevesical space be opened or the
bladder wounded.

After the abdominal incision is complete the libro-
myomatous uterus is brought up, if necessary, partially
or wholly through the wound. If there be danger of
copious hemorrhage, an elastic ligature may be placed

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272 MEDICAL AND SURGICAL GYNECOLOGY.

around the uterus and broad ligaments, below the tumor
or tumors to bo removed. When the pedicle is large its
capsule may be incised a short distance from the uterus,
its fibrous tissue enucleated, and the capsule sutured over
the base firmly enough to check all oozing. In some
cases it is easier to cut the pedicle wedge-shaped, with the
thin edge extending up to, or into the uterine wall, and
sew up the flaps that are left with deep and superficial
rows of sutures. A subserous Lumor without a pedicle
may be enucleated and its bed sewed up in a similar
manner.

Closure of the (ihdominal incision. Strict attention
should always be paid to the proper closing of the wound
in the abdominal parietes. The methods vary much, but
they all aim chiefly at avoiding the subsequent occurrence
of ventral hernia. Three loading principles should be
observed in order that good results may follow. The
apposition of the raw surfaces sh./.M be as broad as
possible. Each divided structure should be placed and
kept opposite its fellow, peritoneum with peritoneum,
muscle with muscle, fascia with fascia, fat with fp.t. The
sutures should not bo removed too early. The material
used for suturing may be divided into absorbable and
non-absorbablo agents, the chief among the former being
catgut and kangaroo tendon, and among the latter, silk-
worm gut and silk.

Methods. Suture in mass or through find through
suture. For this class of suture either silk-worm or silk
may bo used, but the former is tho one almost universally
adopted. The needle is inserted into the skin at the
upper angle of tho wound, about throe quarters of an inch
from tho margin of the incision, and, as it passes through
each layer — fascia, muscle and peritoneum — they are
separately picked up, so as to make certain of their being
included in the suture. The needle is carried through on
the opposite side in reverse order. The sutures are placed

DISEASES OP THE UTERUS— BENIGN NEOPLASMS. 273

about throe to tho hicli, and, after nil nro inserted, the ends
,Tro gathered up so as to bring the wound together care-
fully, and are then tied. Some operators make the sutures
include only the structures overlying the peritoneum, the
latter being left intact.

Buried or tiei- suture. For this purpose catgut or
kangaroo tendon is used. By means of a continuous
suture tho peritoneum is first closed. Next the muscular
layer is drawn together, next the fascial layer, and finally
the skin.

Comhined method. By this is meant the combination
of suture in mass and of the buried suture. When the
through and through sutures are being inserted a few
silk-worm sutures are passed through the aponeurosis
only, and when tied, are left as buried sutures.

Hysterectomy. By hysterectomy is meant partial or
total removal of the uterus. It is termed complete when
the cervix as well as the body has been removed; partial
when the cervix has been left. Some surgeons speak of
the operation as total htjstereetomij, even when the cervi'c
is left behind. Another division is made into extra-
peritoneal and intra-peritoneal, according as the pedicle
is treated outside or inside the peritoneal cavity.

Indications for operation. Mere bulk may of itself
bo a sufficient reason. Rapid growth or the development
of cysts in soft cedomatous tumors ; suppuration and
sloughing; excessive metrorrhagia which every palliative
measure fails to check; pressure on adjacent viscera pro-
ducing obstruction; uncontrollable pain; the presence
of abundant ascitic fluid, are all clear indications for
operation.

Besides tho instruments commonly used in coeliotomy,
special large forceps should be provided to clamp on large
vascular areas ; also two trustv^orthy clamps for the
constriction of the pedicle, and I'or tho latter purpose
Koeberle's serre-nonud, or Tait's modification of it, is

274

MEDICAL AND SURGICAL GYNECOLOGY.

probably the most efficient. The Trendelenborg is the
position most often used. After the abdominnl cavity lias
been opened, information is obtained as to the size,
position, relations and possible adhesions. By moans of
a large vulsellum, or myoma screws, the tumor is brought
up into the wound, and ligature of the broad ligament
proceeded with. When the tumor is well drawn up, these
ligaments will be put on the stretch. Eacl broad ligament

Fig. 87.— Application of ligatures in ablalion of the fibroid uterus.

is tied and divided, after placing pressure forceps on the
uterine sides, outside the ovaries and tubes. If the
ligameiits are very broad, two or even three successive
applications of the forceps, each below the previous one,
and as many ligatures, may be necessary. The tumor
being delivered as fully as its attachments to the vagina
and the lower portion of the broad ligament will permit,
the bladder is pushed well down under the pubes in front,
and sponges are packed in behind to keep the intestines
out of the way.

It must now be decided in what way the pedicle is to
be treated, whether extra-peritoneal or intra-peritonenl.

Extrn-peritoncdl treatment of the pedicle. The wire
of the serre-ncjeud is passed around the pedicle, care
always being taken to avoid the bladder, and, when drawn

DISEASES OF THE UTERUS — BENION NEOPLASMS. 27o

uiJ, tho free ond is made fast to tho movonble pin and ?is
mucli constriction made, by turning tlio thumb screw, as
will arrest the circulation to its fullest extcuit without
cutting. Pedicle skewers are inserted across the incision,
either parallel or crucially, just above the wire, and the
tumor removed close to them, leaving only enough tissue
to give firm hold. In placing the serre-nooud, it should
be so arranged that the constricted wire will be well within
the parietal wound, and the handle so that it will lie over
the pubic region. There are other modes of constriction
besides the wire, such as the elastic ligature, and tho
clamp, but the method described seems to be the favorite
one. The parietal incision is closed in the usual way
as far down as the pedicle, tho lowest stitches being
inserted so as to draw the tissues closely around
it. The use of styptics, such at, icrchloride of iron
or the actual cautery, to the stump is x-ecommended by
some for their charring effects. Subsequently the wound
is dressed in the usual way. The whole stump above the
wire is removed in course of time by pressure necrosis,
but it is not necessary to allow the wire to remain for that
length of time, but may be removed as soon as the new
adhesions are sufficiently strong. Afti'r tlu pedicle
separates, a deep granulating excavation is left, which
rapidly fills up even with the skin.

Intrd-pcriiom'dl trcxdmod of fh'.> pedicle. The opera-
tion in its first stages is similar to that already described.
If there is fear of hemorrhage an elastic ligature, or wire
clamp, may be placed temporarily around the cervix, but
this procedure is scarcely necessary when the uterine
arteries have been controlled by the broad ligament liga-
tures. With the same precautions observed for tln^ care
of the surrounding structures as already described, an
incision is made a little above the attachment of the
bladder, and a corresponding incision behind, by which a
cup-shaped cavity is cut out and the tumor removed.

276 MEDICAL AND SURGICAL GYNECOLOGY.

Tho cavity thus formed in the cervix is now closed by
buried cntgut sutures, and by a separate row of silk to
unite the peritoneum. The abdominal incision is then
completely closed.

Complete hysterectomy. After ligature of the broad
ligaments according to the manner described, another and
lower deligation of them is carried out, great care being
observed not to include the ureters. The peritoneum is
next divided all around the cervix, below the constricting
ligature, if one has been used, avoiding carefully the
bladder in front and the rectum behind. An opening is
made on the top of the vagina, the point being indicated
by the insertion of a probe into that canal, and with a few
strokes of the scissors the division is completed as close as
possible to the cervix. After securing the few bleeding
points, the anterior and posterior flaps are united by a
continuous catgut or silk ligature. After carefully cleans-
ing out the peritoneal cavity, the parietal incision is
closed; should necessity demand it, drainage may be
established through the vagina. The vagina should next
be loosely packed with iodoform gauze and changed daily
after the second day.

CHAPTER XXV.

DISEASES OF THE UTERUS CONTINUED.

MALIGNANT NEOPLASMS.
CANCER OF THE UTERUS.

This disease occurs most frequently between the
ages of forty and fifty, although earlier periods of life are
not exempt. It was formerly thought that cancer was
limited to the cervix, but later experience has shown that
cancer of the body, although not so frequent as cervical
cancer, is not rare.

DISEASES OF THE UTERUS— MALIGNANT NEOPLASMS. 277

Cancer of the cervix. Tho gront predisposition of
the cervix to the development of cancer hns been noticed
by all observers. More than one tliird of nil cases of
cancer in women occur in the cervices of inultipane, and
the frequency is explained by the fact that iho cervix is so
often subjected to irritation, laceration, ero.^'ion, and
infection.

Pdtholofi/i. From a clinical point of view, and when
seen at the start, and before the primitive aspects of the
part have been altered by their spread to adjacent struc-
tures, four classes may be distinguished.

1. PapiUarij. (Superficial cancer of the cervix, vege-
tative or cauliflower cancer.) This form begins on the
vaginal portion of the cervix, and may for a long time be
limited to it. Often it starts from cylindrical epithelium
which ha;i invaded the external surface. It may take on
a fungous appearance, the os and healthy lip being hidden
beneath it, and for a long time may show no tendency to
spread. Sooner or later, however, it attacks the cul-de-sac
and passes on to the peri-uterine tissues; or the extension
may take place along the cervical canal.

2. NoduJar. (Parenchymatous cancer, cancerous
nodosities, circumscribed or infiltrated cancer.) This
form starts as one or several nodules in the mucous
membrane of t'' j cervix, on either the external or internal
surfaces, witl ^-eration only late in the disease. In this
form the whole organ soon becomes involved, as well as the
adjacent tissues.

3. Cancer of the cdvifi/. (Boring or eating cancer).
This form develops first in the cervical mucous membrane
by an infiltration which soon ulcerates and causes the
slow destruction of the part by erosion, and there are
cases of this kind where the cervix becomes a mere shell.
The body of the uterus is early involved, then the peri-
uterine connective tissue, and the vagina last or not at all.

278

MEDICAL AND SURGICAL GYNAECOLOGY.

4. Vdffi'ndl This is far moro oommon tlinu the otliors.
It begins in the postorior cul-de-sac and invades equally
the cervix and the adjacent j)ortion8 of the vagina, i^ro-
ducing extensive ulceration.

Histologically the three kinds most often found are: —

1. Pavemenf cjiitlicliormt (sciuamous epithelioma) is
that variety often found in the superficial forms — papillary
and vaginal. In the variety called lohnhdcd, cellular
masses lie between the bundles of muscular fibres. In the
tubulated, anastomosing cylinders, stuffed full of epithelial
cells, penetrate between the muscular trabecular.

2. Ctjiindn'cal epithet iomd is usually the form which
begins in the cervix and spreads along its cavity, and
resembles that of the uterine body. It begins by a

typical glandular proliferation
(adenoma), and ends as an
atypical proliferation ( malig-
nant adenoma), which is simply
an epithelioma.

3. Carcmomd or atijpirrd
epdiielioma is not clearly dis-
tinguished from certain forms of
tubulated pavement epithelioma.
It is characterized by poly-
morphism of its cells which
correspond to those of the al-
veolar wall, or to those of the gland ; also by their
disjoosition in masses within the alveoli, the walls of which
are formed by anastomosing bands of connective tissue.
When the fibrous stroma is small in amount, and the
cells are swollen and predominant, t' e tumor is called
enceplKiloid; when hard and dry it is called sct'ri-lius.

Extension. At an advanced period of the disease, the
characteristics peculiar to each form are lost in the
destruction caused by its extension. Extension to the
vagina may be found at the outset. It may occur rapidly

88. - Cylindrical epithelioma of
ihe cervix.

DISEASES OF THL UTERUS — MALIGNANT NEOPLASMS. 279

in the pnpillr.ry form, and may oven ronch the vulvn. The
body of the organ is very soon involved in the case of
tumors of the cervical cavity, and, in the nodular form,
it may bo infected from the first. The pelvic connective
tissue may be invaded from the cul-de-sac, the cervix, or the
fundus, by which the uterus becomes imprisoned, as if set
in plaster of Paris, and the broad ligaments bocome thick-
ened and shortened. The ureters, instead of being pushed
aside, become assimilated by the neoplasm, and ulceration
and fistuhe may re-
suit; or they maybe-
come compressed
producing hydro-
nephrosis and allied
conditions of the kid-
ney. The rectum is
seldom involved, ex-
cept in far advanced
cases, when the vagina
may be found open-
ing both into the
bladder and rectum.
The peritoneum re-
sists the ingrowth by
the production of
adhesions, and is seldom opened. The ovaries and
Fallopian tubes may all become affected, and, lastly, there
may be metastases to distant organs, as the liver, kidneys,
stomach, and lungs.

Symptoms. The onset of the disease is insidious, and
may exist for some time while the patient preserves every
appearance of health. The earliest symptoms are in no
way characteristic. The attention h. often first attracted
by a small loss of blood at other than the regular periods,
or appearing at variable times after the menopause,
especially after some exertion, or after coitus. Leucorrhoea,

Fig. 89 — Epithelioma aflecting both lipsof Ltrvix, vagina
and bladder.

280 MEDICAL AND SURGICAL GYNAECOLOGY.

without nny spocinl < hnractoristics npponrs. to^othor with
somo diffuse pelvic pniii. Such Hymptoms sliouid always
excite suspicion in one who has passed for some time the
climateric period, and a local examination insisted upon.
Digital exploration recognizes the induration, or the
papillary and ulcerated condition. The speculum tlemon-
Etrates the livid aspect of the tumor, the yellowish surface
of the ulceration and the fungous vegetations if present.

As the disease advances, hemorrhages become more
frequent. The vaginal discharge becomes reddish and
has a peculiar, characteristic, as well as disgusting odor,
and so abundant and acrid that it causes distressing
erythema of the thighs and pruritus of the vulva. The
local pain now becomes more or less severe, with radiation
of it in different directions. By digital examination the
vaginal pouches may be found invaded, the uterus more
or less fixed by extension of the morbid processes, and the
cervix changed by the advancing disease.

The third stage, or that known as the cancerous
cachexia, is indicated by digestive disturbances, anorexia,
constipation, and by the skin assuming a peculiar pale
yellow tint, and by becoming harsh and dry. At this time
there may be present cystitis, intolerable neuralgia,
phlegmasia dolens, and genital fistuhe, while local exam-
ination will reveal wide extension to the adjacent parts.
Successive attacks of subacute unumia may co-exist with
these, or the urremia becoming chronic, the patient
gradually sinks into a semi-comatose condition, and
quietly dies. Peritonitis, by extension or perforation,
may bring about speedy termination, or septicemia,
especially in neglected cases, may alone be the immediate
cause of death.

Diagnosis. In this disease, perhaps mon* than in any
other, the necessity for early diagnosis is imperative to be
of much benefit. The early stage can never be dijignosi'd
with certainty without microscopical examiuRtion of an

DISEASES OP THE UTERUS— MALIGNANT NEOPLASMS. 281

excised piece from the suspected part. As already stated,
when speaking of endocervicitis, it may resemble follicular
erosion, but it differs from it in having scmewliKt elevated
and indurated edges. The :'aw surface in both conditions
may bleed with equal readiness, but if papillary projec-
tions are already present, in cancer they break down
much more readily. It may be mistaken for a submucous
fibro-myoma protruding from the os, but if carefully
examined, a healthy ring of cervical tissue will be found
encircling the neoplasm.

When the disease begins in the cervical canal, early
diagnosis may be extremely difficult. It may have made
considerable progress, and yet there may be nothing
abnormal in appearance. The chief clinical distinction
between beginning cancer and endocervicitis will be found
in the fact that the discharge in the latter condition
always retains its mucous consistency, while in cancer the
discharge is mostly of a watery consistency, and has an
offensive odor. A nodule may be suspected to be malig-
naTit if it is hard and protuberant, the exterior of a bluish
color, and the patient over thirty five years of age.
Advanced stages of cancer of any part of the cervix are
readily diagnosed by the symptoms already mentioned,
but in such instances it is usually impossible to recognize
from what part of the cervix it originated.

The proijuosis is not very good, even with operative
interference. Could the disease be discovered in its
earliest stages, total extirpation might give better results
than they usually do. When the pelvic connective tissue
or lymphatics are invaded, or the entire thickness of the
cervix involved, a p' rmanent cure cannot be held out.

Treatment. Treatment of cancer may be divided into
railirdl and jHiUiative.

Radical. Radical operation, to be successful, pre-
supposes conditions which will allow of the total removal
of all disease. There must be complete absence of exten-

282 MEDICAL AND SURGICAL GYNECOLOGY.

sion to any surrounding organ or gland, to tho ijoritonotim,
broad ligament, bladder, rectum or vagina. The utoruH
must bo freely movable nnd unassociated with severe
pelvic pains. When these conditions exist operation
should at once be proceeded with.

Hij/h (imput<itioti of the cervix by one of the methods
described when speaking ol liypertrophy of the cervix is
recommended, and has been frequently performed, but the
operation is not upheld now as being the best, because
independent cancerous nodules in the body of the uterus
have been observed, and second, the operation, when
properly performed, is just as difficult and nearly as
serious as complete extirpation.

Vaginal hysterectomy. Colpo-hysterectomy. The
patient is placed in the dorsal position, and the knees kept
apart and the thighs flexed on the pelvis by means of
Clover's crutch. A large Edebohls' speculum is inserted
into the vagina, and by means of scissors and a sharp
curette, exuberant tissue is cut or scraped away. The
uterus being next curetted, and the interior packed with
a little iodoform gauze, the cervix is closed with a few
sutures. After again thoroughly cleansing the vagina
and fornices, a strong vulsellum is introduced into the
lips of the cervix and the uferus drawn down. Except
when the cervix can be brought outside the vulva, lateral
retraction will be of advantage to give the operator more
room and light. A pair of scissors is made to cut through
the mucous membrane around the cervix, at a distance
well clear of the disease. By means of the finger, or by
the handle of a scalpel, or by closed blunt-pointed scissors,
the mucous membrane is elevated from the cervix all
around, the uterus being drawn forward and backward to
facilitate the manipulations. In front great care mus' be
observed not to open into the bladder, and if there is any
doubt, the introduction of a sound through the urethra
will serve as an excellent guide. When the mucous

DISEASES OF THE UTERUS — MALIGNANT NEOPLASMS. 283

mombrnno has been rnisod from the cervix as high ns the
pcritonoum, that mombrano is perforated behind and in
front, and a few layers of gauze, secured at one end by
means of a ligature, pushed into Douglas' cul-de-sac, to
keep the bowels out of the way. The uterus is next well
drawn down and the division and closure of the blood
vessels of the broad ligament proceeded with. For this
purpose a variety of plans have been devised, but the

Fig. go — Vaj'inal hysterectomy by ligature.

principal ones may be described under two headings, by
h'gfitii7'es, and by chimps.

Bji lujatnrc. The material for ligature may bo either
good reliable catgut or silk. A pedicle needle armed with
the ligature, and guided by the index finger, is introduced
behind the broad ligament, close to the uterus, and passed
through and made to emerge in front of the ligament as
high ui) above the uterine artery as possible. Another
ligature is oassed in the same way on the opposite .'•ide,
and, after being carefully tied, those portions of the broad

284 MEDICAL AND SURGICAL GYNAECOLOGY.

ligaments included within the ligatures are divided. The
uterus may now be pulled still farther down. If the first
ligatures have not secured enough of the broad ligaments
to bring the body of the uterus fairly into view, others may
be placed on each side higher up. The uterus being now
drawn weJl down, the tubes and ovaries may be felt. A
ligature is passed over the infundibulo-pelvic ligament,
and after being carefully tied, is divided. The corre-
sponding ligament on the other side will then be very
readily ligated, and, after division, the uterus will be free.

If there is much difficulty in bringing the tubes and
ovaries into reach they may be left behind, the last liga-
ture passing over the tubes, as they lie in the free margins
of the broad ligaments. If the tops of the broad ligaments
are beyond easy reach of the finger, or the uterus consider-
ably enlarged, inversion of the fundus, either in front, or
behind through the opening in Douglas' cul-de-sac, will
always bring them within reach. After removal of the
uterus the gauze packing is withdrawn, and steps taken
for the management of the vaginal wound, for which
various methods have been adopted. The broad ligament
stumps may be drawn down with bullet forceps into the
vagina, and a full-curved needle introduced through them
on either side, entering anteriorly through the vagino-
peritoneal margin, and emerging posteriorly in the same
manner, and the ligature tied. The opening in the
vaginal wall is now closed with a few sutures. Some
surgeons recommend that simply the peritoneum should
be sutured to tiie vagina, others that the vagina alone
should be sutured, while others leave all the structures to
fall into apposition and unite as best they can. The
vagina may now be packed with iodoform gauze. When
the vaginal wound has been left open, a few strips of gauze
should be put in the slit, particularly when drainage is
necessary.

DISEASES OF THE UTERUS — MALIGNANT NEOPLASMS. 285

IVic clamp method. The first steps in this method are
the same as have already been described. The peritoneum
is opened in front and behind, and if it be convenient to
do so at this stage of the operation, may be attached to
the margins of the vagina. A clamp is now placed on the
base of the broad ligaments, one on either side, and the
ligaments divided close to the uterus. The uterus is now
drawn lower down, and the remaining part of the ligaments

Fig. 91.— Vaginal hysterectomy with clamps.

included in a second pair of clamps, and also divided.
The handles of the forceps are securely tied to prevent
them from springing open, and wrapped with gauze, after
which the vagina is lightly packed as before. The clamps
are allowed to remain in place for thirty six to forty eight
hours, after which they may be removed. Instead of
incising the mucous membrane around the cervix, the
thormo-cautery is sometimes used, and as the uterus is

286 MEDICAL AND SURGICAL GYNECOLOGY.

being separated from the bladder, the tip of tbo caut(^ry
knife is kept almost constantly in close contact with the
uterus. By this method the operation practically becomes
a bloodless one.

Abdominal hysterectomy is at times performed for
cancer of the cervix, the advantage claimed for it being
that more of the broad ligament can be removed, and by
this means it is possible to get farther away from the
disease. A combination of the two methods, vagino-
abdominal hysterectomy, is also now performed, the upper
portion of the uterus being freed by abdominal incision,
and the lower portion through the vagina.

Sacrnl hysterectomy. Kraske's operation for cancer
of the rectum has been adapted to the removal of a
cancerous uterus, but the operation has not received much,
if any encouragement.

Palliative treatment. When the disease has pro-
gressed to such an extent as to make radical treatment
inadvisable, only palliative treatment is left. Among the
various remedies and forms of treatment, curettage, with
subsequent cauterization by means of the thermo-cautery,
is one of the best. Another efficient treatment consists in
packing the crater formed after curettage with a fifty-per-
cent solution of chloride of zinc, the vagina and bladder
being protected by gauze moistened with a solution of
bicarbonate of soda. If there is a tendency to hemorrhage
after the removal of the slough, or practically at any time,
it may be checked by vaginal tamponade, either alone or
combined with some styptic, such as perchloride of iron.
Local antiseptic treatment must be constantly kept up.
Injection of a one-per-cent solution of creolin is valuable
both as a heemostatic and antiseptic. Peroxide of hydrogen,
or a weak solution of permanganate of potash, has a
decided cleansing and deodorizing effect. Equal parts of
iodoform and charcoal will relieve pain and counteract the
objectionable odor. Suppositories made from chloral and

DISEASES OP THE UTERUS— MALIGNANT NEOPLASMS. 287

tannin (an. gr. xv.) will relievo pain, lessen hemorrhage,
and counteract the offensive odor.

Narcotics will invariably become necessary at some
time during the course of the malady, and it has been
claimed that when opium is freely used, the progress of
the disease is to some extent retarded. So far no drug
has been found that will cure cancer, although from time
to time new specifics have been praised. Condurango
bark, chian turpentine, methyl blue, have all enjoyed a
short lived celebrity. Not much more can be done than
to sustain the general health as far as possible, and treat
complications ns they arise.

CANCER OF THE CORPUS UTERI.

Modern means of investigation have shown that
primary cancer of the body of the uterus is not so rare as
was once thought. Two varieties may be distinguished,
epithclionui and adeno-carcinoma or malignant adenoma.

Epithelioma occurs as a diffuse growth of villi through-
out the whole uterine cavity, and consists of an atypical
development of epithelial cells of different sizes. It has
little tendency to involve the mucous membrane of the
cervix, but the uterine wall, little by little, is eroded and
destroyed, and the interior of the uterus converted into
an ulcerated cavity.

Adeno-carcinoma occurs as an isolated fungoid growth
with a large or small base, and at times has the form of a
polypus. Histologically the tumors are corajjosed of
anastomosing tubules filled with cells. The first layer of
cells implanted on the wall is regularly cylindrical, and
the successive layers are formed by polyhedral cells which
are, at times, of the pavement variety. The interior of
tiie mass also contains alveoli, lined with one or two
layers of epithelial cells, as well as cavities containing
mucous and free cells. At a later period, in both varieties,
metastatic nodules form in various parts of the parenchyma,

288

MEDICAL AND SURGICAL GYNJICOLOGY.

and even under the peritoneum, forming protective ad-
hesions and metastatic noduh^s there. Frequently tht>se
metastatic nodules are found superficially in the vagina,
and deeply in the ovaries and tubes.

Symptoms. Hemorrhage is the primary symptom, and,
as in cancer of the cervix, it is usually accompanied by a
serous discharge, of a reddish color and disagreeable odor,
and with this there is often a discharge of small shreds of
tissue from the broken down parts of the fungosities.
Symptoms of uterine inflammation are often noticeable,

Fig. 92. — Medullary cancer of body of uterus.

but, as the disease becomes more advanced, the pain takes
on a paroxysmal character which is remarkable and also
pathognomonic. These crises have none of the character-
istics of colic, and are peculiar from their appearance, at
almost regular hours, once or twice a day. Bimanual
examination shows the organ to be increased in volume.
It remains movable for a long time, but finally becomes
imprisoned by adhesions. The cervix is found free from
disease, but often is much softened a:.id partly open.

DISEASES OF THE UTERUS — MALIGNANT NEOPLASMS. 289

The sound rovonls nii increase in the capacity of the
uterus, and the presence of irreguhir masses. The general
health fails as the neoplasm develops and terminates in
cachexia.

DifUfiiosis. In the early stages this may be very
difficult. The hemorrhage, the serous dischar?^e, the in-
crease in the volume of the uterus, itnd the results of
intra-uterine exploration, constitute the clinical elements
of the case, while the microscopical examination of por-
tions removed by the curette clearly differentiates between
cancer and metritis without malignant neoplasm, or be-
tween carcinoma and sarcoma.

Treatment. When seen sufficiently early the only treat-
ment is total eradication of the uterus by hysterectomy.

SARCOMA.

Sarcoma is a comparatively rare form of malignant
disease of the uterus. It may occur at any period of the
sexual life of the woman over twenty years of age, but is
most often fouad just before, or just after the menopause.
There are three well defired forms of sarcoma.

Fibro-sarcoma. This form occurs in tumors or
masses, and has a striking resemblance in growth and
structure to fibro-myomata. Like them they occur as
submucous, interstitial, or subserous tumors, and have
their origin also in the parenchyma of the uterus, but
instead of being limited by a loose capsule, it is, as a
distinctive characteristic, deeply rooted. The vast weight
of authority is in favor of the view that they are malignant
transformations or degenerations of the ordinary fibro-
myomata. Histologically they show a proliferation of
round, and in places fusiform cells, more or less replacing
the normal tissues of the uterine wall. When they have
a pedicle it is apt to be fibrous, intimating that it has
come from a degenerated fibro-muscular polypus. They
give rise sometimes to metastatic growths in distant parts

2iK) MEDICAL AND SURGICAL GYNAECOLOGY.

of the body, but show little tendency to disintegration or
trnnsformntion. Occasionnlly cystic degeneration takos
place, giving rise to cif^to-sarrom'i.

Diffuse sarcoma. SarcomH of the endoraetriu~n closely
resembles the typical form of carcinoma of the sau e
structure. The term is used to desigiiate a new growth
proceeding from the connective tissue of the uterine
mucous membrane, consisting mostly of small closely
packed round cells, though sometimes spindle-shaped, and
producing soft villous or lobulated tumors of an encepha-
loid aspect. The tissue does not break down as readily as
that of epithelioma, but is apt to fill the uterus and
present at the cervix. The uterine walls are gradually
invaded, and become a mere shell filled with the encepha-
loid mass. This form is found most frequently in young
women.

There is a rare variety, mah'tpuint (Iccichioma (sarcoma
uteri deciduo-cellulare). Many authorities dispute this
variety of sarcoma as a particular form, considering it
simply a mixed sarcoma. It is developed soon after
parturition or abortion in the placental remains or
decidua, and is composed of polymorphous decidual cells,
and giant cells embedded in connective tissue.

Sarcoma botryoides, or grape-like sarcoma (papillary
sarcoma of the cervix) is a variety which appears in the
c'?rvix, and as such is characterized by its grape-like form.
Clinically, it is extremely malignant. Tire mass is soft in
consistence, and grows to a large size, often filling the
vagina. The disease spreads along the mucous membrane
into the uterus, and to the vagina, and finally invades the
pelvic connective tissue and peritoneum.

Symptoms and course. All forms run a more rapid
course than the corresjionding carcinomata after the
symptoms first attract attention. Fibro-sarcoma gives
rise at first to the same symptoms as fibro-myoma, and it
is stated that when a tumor, previously existing as a fibro-

DISEASES OP THE UTERUS— MALIGNANT NEOPLASMS. 29J

myoma, begir s to grow Rt th > me^iopnusc, it is uiulorgo-
iiig sarcomntouH trnasfonimtion. Wlioii post-climateric
growth occurs, two symptoms soon appear. One is jjain,
owing to tension or invasion of the peri-uterine connective
tissue, the other is marked deterioration in the general
?'ealth. If the neoplasm has developed from a submucous
fibro-myoma, there will be severe hemorrhage, and pain
from the efforts of the uterus to expel the tumor. As it
advances in growth, in addition to occasional violent
hemorrhage, it may cause a sanious hydrorrhcua, and the
discharge will sooner or later take on an ott'ensive odor.
Owing to the intense anjemia, sapra^nia, and marasmus,
death is readily produced. Death may occur from peri-
tonitis, intestinal obstruction, or from pressure on the
ureters. In the diffuse form the symptoms are not dis-
tinguishable from carcinoma affecting the same structures.

Diagnosis. With the exception of the rare form,
sarcoma botryoides, it cannot positively be diagnosed
without microscopical examination. The clinical symp-
toms must be carefully observed, and in this there are two
points desiTving special attention; first, the rapid growth,
at or about the menopause, of a tumor previously known
to exist; and second, a more marked ansemia and deterior-
ation of health than is ever found associated with the
same stage of growth of a benign tumor.

The treatment is, as in other forms of malignant
neoplasms, palliative or radical. If the uterus is movable,
and there is no metastasis or invasion of the vagina, total
extirpation of the uterus is at once to be undertaken.

292 MEDICAL AND SURGICAL OYN.ECOLOOY.

CHAl'TER XXVI.

DISEASES OF THE FALLOPIAN lUBES.

Malformations. Tlu^ ubes show a numbor of devolop-
mentai anomalies, but thoy arc of little importance except
in the study of the etiology of tubal gestation. Accessory
fimbriated extremities are not uncommon. There may be
an accessory uterine orifice, or the whole duct of the tube
may be duplicated. In connection with imperfect develop-
ment of the whole sexual apparatus, the tubes may also
be non-developed; they may possess an abnormally small
calibre; they may be without any lumen; or they may bo
entirely absent. On the other hand, the tubes may show
an abnormally great development, with corresponding
patency of the canals. They may be congenitally displaced
backward and downward into Douglas' pouch, or they
may be wound in a spiral, or abnormally contorted.

SALPINGITIS AND ITS COMPLICATIONS.

The important position taken by inflammation of the
uterine appendages has but recently been generally
admitted. To thoroughly understand the close association
of inflammation of one organ with that of the other, the
common embryonic origin of the uterus and tubes, and
the close association of the ovaries, must be borne in
mind. The various coats of the tubes and ovaries are
continuous with each other, a fact which explains the
possibility of ascending salpingitis following endometritis,
just as ascending pyelitis may follow chronic cystitis.
The ovary, which is connected with the tube by the tubo-
ovarian ligament, and almost in direct contact with the
ampulla, may also be easily infected by continuity. In
addition, these organs are intimately bound together by
important vascular and lymphatic vessels, so it may be
said that there is scarcely ever a salpingitis unaccompanied
by ovaritis, or an ovaritis uncomplicated by salpingitis.

r EASES OF THE FALLOPIAN TUBES.

293

Non-cystic salpingitis.

Cystic snlijingitis.

Salpingitis and its results may be studied from n
clinicni nn<l anntomicnl standpoinl. under the following
classification : —

(<i. Acute catarrhal.
h. Acute purulent.
('. Chronic parencliymatous.
( Pachysalpingitis. )

(a. Hydrosalpinx.

-. h. Pyosalpinx.

{('. Hematosalpinx.

Acute catarrhal and purulent salpingitis. The chief
causes of salpingitis are intlammatory conditions of the
uteriis, gonorrlueal infection, puerperal infection following
parturition or abortion, and contamination from surgical
exploration or interference.

P(ifli<)J<>(/i/. In the acute caiarrhal form the tube is
swollen cylindrically, from about the size of the little finger
to that of the thumb, and owing to its lower border being
attached to the broad ligament, becomes more tortuous.
The lesions are especially marked in the mucous coat,
being thickened, infiltrated with round ct^Us, and moistened
with abundant mucous secretion. The normal folds are
swollen, and covered with lateral newly formed vegeta-
tions. In places they are agglutinated, enclosing spaces
between them, giving the appearance of glandular forma-
tion. The epithelial cells, as a rule, maintain their
integrity, and the fibro-muscular coat is but slightly
affected, there being only a hyperplasia of its substance.
The fimbriated extremity is at first jjatulous, but later the
fimbrire become contracted and folded up. The uterine
ostium generally remains patulous, through which the
excess of mucous is discharged. In some cases a few
drops of mucous escape through an uncljsed fimbriated
extremity, giving rise to a slight localized peritonitis.

In piirnhmt sdlpini/i'tis there will be evidences of
extensive inflammation. The tubes are swollen, twisted

294 MEDICAL AND SURGICAL GYNJICOLOOY.

and tortuous, and tho fimbria so ngglutinatod as to close
tho abdominal orifice. On section it is found to be filled
witli a creamy pus, the cavity often resembling a string of
beads owing to contraction. The pus can or.sily bo
evacuated through the uterine cavity, as the ostium
internum is not occluded like the ostium abdominale.
The mucous membrane is of a grayish tint, and under the
microscope a transverse section shows thick reduplications,
forming a system of primary and secondary folds enclosing
irregular cavities that look like glands. This thickening is
duo to the infiltration of migratory cells in the connective
tissue. The ciliated cells are destroyed, and the epithelial
cells are changed in shape. The whole thickness of tho
wall is also infiltrated with round migratory cells, and the
blood vessels are dilated. In the beginning the disease is
usually confined to one side, but if left unchecked, is apt
to affect the other. Usually some exudate appears on the
serous surface, forming adhesions with tho surrounding
surfaces, but the greatest amount of localized peritonitis
and adhesion is set up by an occasional exudation of pus
from the abdominal end, which, when frequently repeated,
has the effect of agglutinating the pelvic organs, omentum,
and intestines into a matted mass. Accumulations of pus
or serum b(^tween the adhesions are occasionally found,
sometimes displacing the uterus laterally or forward.

Iiif('rstiti<(l sal])ifi(/itis represents an advanced stage of
the purulent form. Both tubes will be found involved,
and the lesions, instead of being limited for the most part
to the mucous membrane, include the whole thickness of
the walls, so that they become thickened, hardened, and
purplish in color. Sometimes the induration is general;
at times it is more marked in places, giving the tube a
peculiar nodular appearance. The mucous membrane is
dark blue in color; the villi are enlarged, united, and in
Ijart destroyed by small celled infiltration. False glands
and cystic spaces are thus produced at some distance

DISEASES OF THE FALLOl'IAN TUBES.

295

below the surface. The externnl orifice is nlwnys obliter-
fttod, but the uterine orifice in more or h^ss pervious. The
mesosnipinx may be expanded by the enhirged tube, or it
mny be folded up by adhesions, or infiltrated by infiain-
matory products. The ovary, which often preserves its
integrity in the catarrhal form, is usually affected. It
is generally displaced,
fixed by adhesions in
DoughiH' pouch, or to
the sides of the pelvis,
or it may suppurate
independent of t h e
tube. The peritoneal
adhesions, which may
also involve the omen-
tum and intestines, are
dense and strong, and
are sometimes so firm
that they cannot be
broken up without

laceration of the peritoneal surfaces, or even of the walls
of the viscera. Organized bands may extend between the
surfaces in all directions, so as to make it difficult at times
to determine the relations of the parts after the abdomen
has been opened.

. Symptoms. As acute salpingitis usually occurs in
patients already exhibiting symptoms of endometritis, it
is difficult to decide with precision to which lesion the
symptoms are due. Pain situated in the neighborhood of
the appendage, or in the lumbar region, and radiating
upward to the epigastrium and downward to the thigh, is
generally present. A bimanual examination elicits tender-
ness and fulness on one side of the uterus, and some pain
when that organ is moved or displaced by the fingf r.
Leucorrhoea is present to a greater or loss extent, and
when the menstrual flow appears it is usually very pro-

FlG. 93. — Salpingitis with pelvic peritonitis and ad-
hesions posterior to the uterus.

2% MEDICAL, AND SURGICAL OYN^EC'^UHIY.

fuHo. Gonrrnl conHtitutioiinl HymptorriH mny npprnr, Huch
RH n fooling of mnhiiHo, noumlgio pniiis Hcnttorod ovor tho
body, and n Blight rino of tompornturo and pulso. Shoulf.
muooiiH oscnpo tiirougli tlio outor opening, tlu^ro will bo nn
oxncorbntion of tho HymptoniH, charactiTizod by incroawc^d
pain in the iliac region, local tympanites, nausea and
perhaps vomiting, and other symptoms of a mild form of
local peritonitis.

When the salpingitis is of the purulent form the
symptoms may be similar to those just described, but they
are likely to be morci pronounced in character, and slower
in subsiding. Should gonorrluBal pus make its escape
through the outer ostium, the peritonitis may not be much
more severe than that already described, but when the
case is one of mixed infection, an extensive pelvic i)eri-
tonitis will be set up, accompanied by great tympanites,
high temperature, rapid pulse, extensive pelvic pain and
tenderness, and as a result, there will be an abundant
peritoneal and cellular effusion which becomes hard and
solid, like plaster of Paris, and which may partly or
entirely fill the pelvis. The symptoms may last for a few
days, and after confinement to bed for a few weeks, the
patient may, as far as her symptoms are concerned, entirely
recover for a few weeks, months, or even years. Sooner
or later, however, perhaps after some unusual exertion or
exposure to cold, more particularly at the menstrual period,
a recurrent attack of peritonitis will make its appearance
with the same suddenness as before. In many cases the
symptoms do not subside entirely, but remain in a semi-
quiescent state, the patient suffering more or less from the
milder form of symptoms in the intervals. When the
attack results from direct infection during abortion or
operative procedure, the symptoms of a general ii ''ection
will probably predominate, indicated by chills, high pulse,
exaceroation of fever, the temperature rising and falling
three or four degrees once or twice daily, being highest in

. DISEASES OF THE FALLOPIAN TUBES. 2V)7

most cases in tho afternoon or enrly evening. Other
symptoniH of a general peritonitiH m/iy rapidly follow,
8U(rli as abdominal diHtt*nHion, labored riiHpiration, a wt^ak
thready pulwe, piirniHti^nt vomiting, and cold clammy
perspiration, all indicating that death is near.

A vaginal <\xamination will reveal an enlarged and
tend uterus surrounded by highly sensitive infiltrated
tisE'i' % in which a hard mass may or may not be found.
In severe cases abdominal palpation may reveal a tender
exudate extending from the enlarged uterus, but when tho
symptoms have been mild, there may be nothing but deep-
seated tenderness.

The symptoms of interstitial salpingitis are those of
an ailment which has extended over a considerable length
of time, with more or less severe attacks of pelvic inflam-
mation occurring at varying intervals. There may be a
history of but a single attack of pelvic peritonitis, but
that is exceedingly rare. There will more likely be a
history of recurrent attacks, with intervals of good health,
or of semi-invalidism. during wliich the patient is in-
capacitated by pain or discomfort from the ordinary duties
of life. Between the attacks the symptoms of endometritis
are seldom absent. There will likely bo a burning pain in
one or both iliac regions, radiating into the lumbar, gluteal
or sciatic regions. Painful micturition and defecation,
dysmenorrhoea and intermitteni or constant leucor-
rho3a are often present. In the earlier stage, when pus is
present, there is apt to be an afternoon rise of temperature,
possibly a degree or two, but after the disease has lasted
for a length of time, and septic influences disappear, the
temperature will probably remain normal throughout the
day. Along with these symptoms there may be those of
a general nervous disturbance, such as nausea, indigestion,
neurasthenia and hysteria. A bimanual examination will
reveal an enlarged, hard, tender mass behind or beside
the uterus, with more or less immobility of that organ, or

298 MEDICAL AND SURGICAL GYNJICOLOGY.

the uterus may be fixed in one side of the pelvis by bands
of adhesions, and surrounded by a thickened and hard
mass. The discharge issuing from the cervix may be
thick tenacious mucous or muco-pus. Tlie uterus itself
will bo found in a condition of subinvolution, or of chronic
metritis.

Prognosis. Catarrhal salpingitis frer^uently ends in
restoration of the tubes to a practically normal condition.
When the disease, however, has existed once, it is apt to be
reproduced by the accompanying endometritis; or a puru-
lent salpingitis may be established. Purulent salpingitis
may endanger life, owing to the eocape of pus through the
ostium abdominale and the consequent local or general
peritonitis or abscess formation. There is, as a rule,
sterility, or a strong tendency to the occurrence of
ectopic gestation. Interstitial salpingitis usually con-
demns the patient to more or less chronic invalidism. In
some cases it involves all the dangers of pyosalpinx, while
in others there may bo a gradual improvement of both the
local and general symptoms, a recovery from septic con-
ditions, and a final restoration to comparative good health.

Treatment. As the disease is asually an extension of
endometritis; much may be done to prevent its occurrence.
Acute metritis following labor, abortion, or operation,
should, as soon as dip^nosed, be treated on thoroughly
active and antiseptic principles, and the same advice is
applicable in cases of gonorrhoeal infection. It may be
necessary to curette the uterus, after which it may be
touched over with strong carbolic acid, and the antiseptic
treatment subsequently k» pt up by vaginal or intra-uterine
douches. The treatment of catarrhal salping' tis is identical
with that of endometritis. Absolute rest in bed is neces-
sary, and measures taken to relieve congestion, and favor
drainage of the uterus and tubes. Hot fomentations
should be continually applied over the abdomen and vulva,
and a hot water bag beneath the lumbar region. A sharp

DISEASES OF THE FALLOPIAN TUBES. 299

saline cnthnrtic, such as sulphate of magnesia or soda,
Rocholle salts or phosphate of soda, should be at once
administered, and repeated suC jiently often to keep the
bowels relaxed, and in the intervals a mild febrifuge
mixture may be prescribed. If much pain is present it
may be relieved by phenacetine, Dover's powder, or small
doses of morphine, or by the introduction of an anodyne
into the vagina or rectum by means of a suppository.
Warm vaginal douches should be administered every four
to six hours, while the patient lies on her back upon a bed-
bath. As the acute stages are subsiding the fomentations
may be withdrawn, and the lower abdomen painted over
with tincture of iodine. The douches are, however, to be
continued, the temperature of the water being gradually
elevated to the maximum degree which the patient can
endure without much discomfort.

The same treatment is applicable to purulent salpingitis
at the outset, with the addition of intra-uterine douches
every eight to twelve hours, if the os will permit the
entrance of the instrument. In case that it will not, it may
be advisable to dilate the cervix for that purpose. When
severe peritoneal symptoms are present, vaginal and intra-
uterine douches, and all manipulations likely to interfere
with absolute rest, should be avoided until they have
subsided. If there is dee'ded rise of temperature, especi-
ally when intermittent, quinine, in five grain capsules,
will act better than any other fe^ ifuge treatment. After
the subsidence of the symptoms of an attack, prophylatic
treatment should be continued, and every effort made to
prevent the recurrence. For this purpose the patient
should avoid all worry, excitement, fatigue, or over-work,
resting, if possible, for a few hours every day. Antiseptic
vaginal douches and mild counter-irritation over the
abdomen should be continued, and during the menstrual
period she should remain in bed. Drainage through the
uterus should be encouraged and kept up, and for this

300 MEDICAL AND SURGICAL GYNECOLOGY.

purpose the cervix should be dilated once or twice a week,
and the uterine cavity touched over with some mild but
efficient antise^ tic, such as a twenty-five-per-cent solution
of ichthyol in glycerine. After each treatment the vaginal
vault may be painted with tincture of iodine, a tampon of
cotton aaturated with boro-glyceride placed against the
cervix, and the vagina lightly packed with gauze.

When the case has become chronic, and there is but
little tenderness, and no signs of pus in the pelvis,
electricity and pelvic massage have been praised, as
favoring the absorption of the exudate, but in view of the
difficulty there exists in making a diagnosis, such treat-
ment must of necessity be surrounded by great dangers.

If all therapeutic measures fail, after a sufficient delay
recourse must be had to the radical operation of salpingo-
oophorectomy. It is preferable to delay operation until
the subsidence of an acute attack, but when the severity
of the symptoms are such as to lead to the conviction that
a purulent salpingitis is immediately endangering life, no
delay should be made, but radical measures resorted to at
once, for the removal of the adnexa and possibly of the
uterus. Salpingo-oophorectomy is also indicated in inter-
stitial salpingitis, if the patient suffers much pain, and
has repeated attacks of pelvic peritonitis.

Salpingo-oophorectomy. The appendages may be
removed through the abdominal walls or through the
vagina.

1. Abdominal sdlpingo-oophorectomy . The abdominal
incision is made in the median line sufficiently large to
allow the entrance of two fingers. The first and middle
fingers are introduced into the abdominal cavity, the
omentum and intestines pushed up, and the fundus of the
uterus sought for. Passing the fingers outward along the
tube to the ovary, they are both lifted up between the fingers
through the abdominal wound. If there are adhesions
they are cautiously separated, relying on the sense of

DISEASES OF THE FALLOPIAN TUBES. 301

touch nlone. If the points of adhesions are difficult to
overcome, they may be lifted into the wound and separated
there, or it may be necessary to enlarge the incision, so as
to make the whole pelvis accessible to the eyes and hands.
When the tube and ovary are lifted up, a pedicle needle,
threaded with a strong silk or catgut ligature, is pushed
from the front backward through the broad ligament, a
half to three quarters of an inch under the ovary. After
removal of the needle, the ligature is brought up over the
tube, close to the uterus, and tied tightly, after which the
endp passed below the ovary, and sufficiently far away
fron ,o allow for u pedicl , and again tied tightly. By
this means the tube, ovary, and the included broad liga-
ment are tied off, and may now be removed with a pair of
scissors, taking care to take away all of the ovary, and as
much as possible of the tube, while on the other hand
sufficient pedicle should be left to prevent the ligature
from slipping. After carefully walohing the stump to
make certain that the vessels are securely tied, the surface
may be smeared with a little iodoform, or aristol, the liga-
ture cut short, and the pedicle allowed to sink down into
its normal jjosition.

As to the treatment of the appendages of the other side,
there is much difference of opinion ; some authorities
recommend their removal even if they are healthy, because
they will very likely become affected later, while others
recommend that an effort should be made to save them,
even if found to be slightly diseased, particularly where
offspring is much desired. If both appendages must be
removed, it is rJmost as well to remove the uterus too.
This organ is often the source of the infection, and besides,
after the removal of the appendages it is useless, and may
be the cause or source of a new infection.

Besults. ^n a very large percentage the operation
brings on the menopause at once, or after a few months.
When menstruatio.i continues, it may be due to the in-

302 MEDICAL AND SURGICAL GYNJICOLOGY.

complete removal of the appendages, to irritation of the
stump, to disease of the uterus, or to the law of " persis-
tence of habit." As a rule there is a discharge of blood
for several days following operation, which is accounted
for by the congestion caused by the ligatures. The sexual
appetite may remain unchanged, increased, diminished, or
may disappear altogether. In a considerable number of
cases melancholia has developed. Even if the mental
disturbance does not go so far as insanity, despondency
and irritability are qui(;e frequently observed.

Vaginal salpingo-oophorectomy presents the advan-
tage that there is less shock, and less risk of causing a
hernia, but it has the disadvantage that the field of
operation is narrow and deep seated. When the diagnosis
is uncertain, and when there are adhesions to intestine or
omentum, it is much more difficult to cope with these
difficulties through the vaginal route than by abdominal
incision.

The vagina is opened by anterior or posterior colpo-
tomy, or by both, and if more room is necessary, an
incision in the median line may be carried from the
posterior transverse incision as far down as the bottom of
Douglas' pouch. The fingers are gradually worked up
until they pass through the peritoneum. Adhesions may
be now carefully broken up, after which the appendages
can be brought down and ligated. The vaginal wound
may be ligated in cases where there has been no local
infection, otherwise it is best to lightly fill the wound with
iodoform gauze, and subsequently the vagina.

Pyosalpinx signifies an accumulation of pus in a
closed or cystic Fallopian tube. It is merely a tube, the
walls of which show interstitial inflammation, with the
abdominal opening obliterated by agglutination and firm
adhesions of the fimbriae, and probably the uterine opening
also obliterated by inflammatory thickening, or by torsion
of the tube. The closure of the openings permits of the

DISEASES OP THE FALLOPIAN TUBES. 308

retention of secretions and exudations within the tube,
and, as a result, it undergoes enlargement and distension
from the presence of its contents. The greatei enlarge-
ments occur as the result of closure of both ends of the
tube, the lessor are found in conjunction with a free
uterine end, the contents of the tube having some oppor-
tunity for escape into the uterus. The escape is either a
constant leakage, or an intermittent discharge, brought on
by direct contraction of the tube, or by indirect pressure.

Pyosalpinx is generally unilateral, but may be bilateral.
In the commonest form there is a general enlargement
of the tube, club-shaped at the outer end, and tapering
gradually towards the uterus, or more or less convoluted.
The diameter of such tubes may reacli an inch or more.
When there is an absence of constrictions, it may assume
the appearance of a pear-shaped cyst, and attain the size
of a normal uterus; rarely it may reach the dimensions of
a foetal head. The pus contained in the sac is often
mixed with blood, serum, or mucous, which accounts for
such collection not presenting the active tendencies of
collections of pure pus witnessed elsewhere. Collections
of pus in a tube will often remain relatively quiescent for
considerable periods of time, and may suffer partial
absorption and inspissation, appearing ultimately as a
pultaceous mass. The tendency, however, is for escape,
the direction being most often along the canal to the
uterus. Next in frequency, it tends to escape through
the abdominal end of the tube, and least frequently by a
combination of stretching and degeneration an opening
may be made througa the tube wall.

When the contents escape through the uterus, the
tendency of the tube is to refill, and thus alternately
emptying and refilling, the condition may exist for a long
time, either ending in atrophy of the tube, or in permanent
closure and the formation of a complete pus sac. Leakage
from the abdominal end is not uncommon, each escape

304 MEDICAL AND SURGICAL GYNECOLOGY.

being nccompnnied and followed, ns has already been
stated, by the phenomena of local peritonitis proportionate
to the amount and specific virulence of the fluid.
Leakage through the wall of the tube is less common, but
should it occur at the upper and posterior surface, the
favorite situation, there would be discharge of the tube
contents into the general peritoneal cavity, accompanied
by all the dangers which pertain to such an accident.
The opening may occur on the under surface of the tube,
between the layers of the broad ligament, through which
the pus reaches the subperitoneal cellular tissue, where
its further incapsulation is largely provided for. Fortu-
nately most cases of pyosalpinx beget such an amount of
local peritonitis about them as will ensure strong pro-
tecting peritoneal adhesions, and the occasional leakages
only add to, and extend the adhesions, so that even though
secondary foci of pus develop outside the tube, they are
again held in check. It is in this way that pelvic abscesses
are formed, and the further consideration of pus collections,
originating in pyosalpinx, will be considered under that
heading.

Hydrosalpinx. Hydrosalpinx is a cystic enlargement
of the tube, in which the general outlines and dimensions
of the organ are in the main similar to those found in
pyosalpinx. It is usually an advanced stage of pyo-
salpinx, and represents a practical destruction of the tube,
The walls are attenuated and may be so thin in places as
to be translucent. The contents are serous, not puru-
lent, and in many cases as limpid as water. It is found as
a bilateral rather than a unilateral disease, and is rarely
without the association of strong well organized adhesions.
It is free from the aggressive action which characterizes
pyosalpinx. It tends rather to quiescence, sometimes to
intermittent discharges through the canal into the uterus,
and ultimately to absorption and general atrophy, more
particularly of the outer parts of the tubes.

DISEASES OF THE FALLOPIAN TUBES. ilOo

Haematosalpinx. Liko pyosalpinx, lianiintoHnlpinx
Ims itH sont in tho ampulln, and hns similar dimoiisions
and form. Leaving aside that form already mentioned
when speaking of atresia of tho genital tract, there are
two chief varieties.

The first and most frequent is apoplexy of the tube,
a condition which may occur in the coarse of a catarrhal
inflammation, or during an irregular menstruation affected
by fatigue, cold, or pelvic or uterine congestion. The
tube is about the size of the middle finger, the contents
fluid blood and retained in the tube by closure of
the abdominal opening which has occurred at some
prior inflammation. The lesion is usually only temporary,
the blood is reabsorbed, and the symptoms gradually
subside.

The second variety represents a graver condition.
There will probably be extreme dilatation of the tube, and
an extremely thickened and infiltrated wall. On opening
the tube it will be found filled with a syrupy, chocolate
colored blood, or more often with a clearer liquid formed
of a watery fluid and blood. Clots may form in layers on
the walls, or in little fibrous masses lying free in the cavity.
Various explanations have been offered as to their produc-
tion. First, that there is originally disease of the inner
surfaces of the tube, and from this a true hemorrhage
occurs at each menstrual epoch. This blood coagulates,
filling the ampulla. A second hemorrhage occurs with
coagulation of its blood around tho original clot. This
process is repeated time and again, until largo masses are
produced, which in time soften in the centre, and lead to
the conversion of the entire mass into a collection of blood
debris. The second explanation is that it follows a
pyosalpinx or hydrosalpinx, as tho result of traumatism,
or twisting of tho pedicle or inner end of the tube. Tho
third explanation presupposes a tubal pregnancy arrested
in its development by the death of the foetus.

306

MEDICAL AND SURGICAL GYNECOLOGY.

Tubo-ovarian abscess. When the inflnmmntory
process extends to the peritoneum in cases of chronic
salpingitis, it is sure to involve the ovary. The first effect
will be thickening of the capsule, which in turn prevents
the rupture of the ripe ovarian follicle. The tension pro-
duced gives rise to considerable disturbance and pain, and,
as the enlarged follicles cannot discharge their contents,
it necessarily follows that an ovary which has long been
the seat of peri-oophoritis will be largely converted into

Fig. 94— Pyosalpinx and ovarian abscess.

cystic spaces (cystic ovaritis), two or more of which may
become confluent, and form a cyst the size of a walnut.
As such p cyst enlarges, it not unfrequently comes in con-
tact with a dilated pus-containing ampulla, and by mutual
contact adhesions form and absorption takes place between
their walls, and the cyst becoming infected, a tubo-ovarian
abscess is the result.

Atrophy of the tube may result from the destructive
action of pelvic suppuration. After a partial atrophy of
the walls by cystic degeneration, a rupture and discharge
of the contents may be followed by cicatricial contraction
and partial obliteration. Traces of mucous membrane
and muscular fibre may remain, but the chief part consists

DISEASES OF THE FALLOPIAN TUBES. )}07

of conuoctive tissue bo contracted as to rooemblo a fibrous
cord.

Symptoms. Tho clinical picture does not materially
differ from those drawn of non-cystic salpingitis. Tlu^re
are the same pains, and the same menstrual disorders. At
times there may be a sudden flow of a certain purulent,
serous, or bloody fluid following an attack of colicy pains,
occurring at irregular intervals of a month or six months.
Unless there is leakage, or rupture into the abdominal
cavity, no marked constitutional symptoms may be present,
and it is possible for a woman to carry about with her two
sacs filled with pus, without any serious phenomena, or
even seeming to suffer from their presence. Between the
initial period of formation and the final period of inflam-
mation of surrounding parts, and efforts at spontaneous
evacuation, pyosalpinx passes through a torpid and latent
phase, during which the rational symptoms seem to be
exactly similar to those of chronic salpingitis, and the
physical signs in no wise different from those of hydro-
salpinx and hsematosalpinx.

Two groups of symptoms are really characteristic; the
pain which directs attention to the uterine appendages,
and the local examination which results in the finding of
a tumor at one or both sides of the uterus. Physical
examination should be undertaken with the utmost care,
as serious and even fatal accidents have been caused by
too rough handling of a pyosalpinx. By bimanual exam-
ination, a pear-shaped body can be made out, extending
from the side of the uterus, and connected to it by a
slender pedicle which can scarcely be reached. When the
tumor is bilateral, it gives the sensation as if " a wallet
had been thrown over the uterus, saddle-bag fashion."
Fluctuation is rarely felt, but pain is always caused by the
examination. Sometimes the tumor falls down into
Douglas' pouch, giving in that region the sensation of the
presence of an elastic or fluctuating globular mass, incor-

308 MEDICAL AND SURGICAL OYNiECOLOQY.

porntod with th(i i)OHtorior Hurfnce of the utorus. It is
UHimlly purulimt, and is at first frots but grndunlly bc^comos
so ndluToiit to the surrounding parts tlmt it is trnns-
formod into n voritnblo pelvic nbscess which cannot bo
enucleated.

Diagnosis. Appendicitis is distinguished by the high
position of the exudate, by the seat of the pain being
abdominal rather than pelvic, and radiating towards the
umbilicus, rather than into the hips, or down the thighs.
The attack is generally attended by disorders of the
stomach or bowels, and with much greater tendency to
nausea and vomiting, and there are usually absent those
symptoms specially referable to the genital organs.

Pyosalpinx is to be suspected, if the dilatation of the
oviduct follow gonorrhcBal or puerperal infection, and if the
tumor be closely adherent. Pyosalpinx is frequently, and
hydrosalpinx usually double, while hjematosalpinx is
unilateral. While the tumor is still movable it may be
mistaken for a small ovarian cyst, and especially for an
intra-ligamentous cyst. The latter however is soft, fills
the ligament flush with the uterus, and is thus without a
pedicle. A parovarian cyst is softer, and has no traceable
connection with the uterus, and no adhesions. The
differential diagnosis from tubal pregnancy is often
difficult during the early months, but there will be the
absence of those characteristic symptoms to be referred tr>
later on. It may be mistaken for a '- dunculated intra-
peritoneal fibroid, but a fibroid is ^' a, insensitive, and
can easily be traced to the uterine wall, while the adnexa
may possibly be palpated on either side.

Treatment. As soon as the diagnosis of a cyst of the
tube is established, salpingo-oophorectomy must be per-
formed. As said before, operative interference should not
be undertaken during an acute attack, but if it be of so
serious a nature as to threaten general peritonitis, or if

PELVIC INFLAMMATION. 30.)

there bo (Ijiuger of rupture of the pyosnlpinx, thoughtH of
delay muHt not be entertained, ns operative interference in
the only way to Have the patient's life.

CHAPTER XXVII.

PELVIC INFLAMMATION.

Much confusion has existed for a long time in the
classitication and complete understanding of diffuse in-
flammations of the pelvis, and, as a result, a variety of
names has appeared in the literature of pelvic inflamma-
tion, intended to represent the conditions which, under
varying circumstances, seem predominant. The intimate
relations existing between the Fallopian tubes, ovaries,
peritoneum, cellular tissue, and lymphatics, compels an
almost constant intermingling of the lesions of inflamma-
tion affecting them, and consequently under the heading
"pelvic inflammation," recent authorities are disposed to
include all those inflammatory diseases which involve
these structures, treating them as if a single disease. As
hos already been pointed out, a pyosalpinx rarely exists
except it is complicated by pelvic peritonitis, and in all
probability by pelvic cellulitis, and the abscesses which
form are usually the result of more advanced stages of
those conditions.

There are, however, two forms of inflammation occur-
ring within the pelvis, which, from a clinical standpoint
at least, deserve separate consideration, and the phrase
"pelvic inflammation," as here used, is to bo understood
to include the two affections, pelvic cellulitis and pelvic
peritonitis. Inflammation of the several viscera contained
in the female pelvis are described under their severol
headings, and will only be referred to as far as they are
concerned in the pathological processes that lead to the
two diseases just named.

310 MEUU'AL AN'l) SUIUMCAL OYN^COLOOV.

PELVK! CELLULITIS.

Pelvic cellulitis, hIho known by tlu^ Hyiioiiyms para-
mrfn'fis niid prri-nfrrinc phliu/mon, is an iaHammatiou of
the pi^lvio connective tisHue. Such inflnmmation may be
pfimdrji or scrouildrif, tliat is, it may originate in the
connective tiwHue itself, or in one of the neighboring
structures, and reach the connective tissue by extension.

The primary form, or that which will now be con-
sidered, is an acute infective disease, and differs in no
respect from acute inflammation of the connective tissue
in any otlier part of tlie body. Chronic pelvic cellulitis is
always a secondary affection complicating inflammation
of some other part.

Etiology. Primary pelvic cellulitis is always a result
of septic infection. Its most common source is the
absorption of septic matter owing to laceration of the
cervix uteri, or of the upper part of the vagina, during
labor. Other sources of infection are the various
surgical manipulations practised on the vagina and cervix.
The lymphatics are the channels by which the poison is
conveyed to the connective tissue, hence there is always a
certain amount of lymphangitis associated with cellulitis.
It is highly probable that the lymphatic glands are also
generally implicated, particularly the lumbar which re-
ceives the lymphatics from the broad ligament and body
of the uterus, and the hyjjogastric or pelvic glands which
roceive the lymphatics from the cervix and upper part of
the vagina, and as such have been described as pelvic
lyinplimufitis.

Pelvic cellulitis occurs with or without formation of
pus. In tlie latter case there is an exudation of coagulable
lymijh with oedema into the tissue of the infected area,
which at first produces increase of '^ulk without manifest
alteration of consistence. Very soon the inflamed tissue
becomes stiff and indurated, and, at a later stage, seems as

PELVIC INFLAMMATION. 311

hard nn cartiln>^i\ Tliiw iiiHnmmatory cxiulntioti may
gradually uiidorj^o absorption, and oviuitunlly diHappoar,
or it may trrminato in wiippuration, with the formation of
a p(>lvic! abHC(*H8. Usually thoro in a Hin^^ltt abHcoHH cavity,
but ocoaHionally ntivural an* formod.

Symptoms. Polvic cellulitis is often ushered in by a
chill or rigor. In puerperal cases this usually occurs on
the second or third day aft(>r dtlivery, but it may be later.
In non-puerperal cases it seldom exceeds a day or two.
The tempiTature rises, and the pulse becomes (quickened.
Severe pain is peldom present, unless the inflammation
extends to the neighboring peritoneum. When suppura-
tion has occurred, the most marked symptom is progres-
sive emaciation, associated with pallo •, or a peculiar
sallowness of the skin. There is complete anorexia and
the bowels are usually constipated, though occasionally
there is diarrlioja.

In the early stages, local examination does not give
much information. After the lapse of several days, the
exudation in the tissue of the affected area becomes
densely hard. When the infection has occurred at the
upper part of the vagina, or through the cervix, the latter
loses its normal mobility, and the supra-vaginal ti-ssues on
the affected side are tender, p.vd more or less hard and
unyielding. It is seldom that both sides of the pelvis are
uniformly affected. In the majority of cases the inflam-
mation spreads laterally along the base of the broad
ligament, and then passes toi ward to the tissues beneath
the reflection of peritoneum on the anterior abdominal
wall, and the induration produced there takes the form of
a broad band lying along the upper border of the inner
portion of Poupart's ligament. Sometimes the exudation
spreads upward and outward from above Poupart's liga-
ment into the iliac fo.ssa, interfering with the action of
the psoas and iliacus muscles, and causing the patient to
keep the thighs flexed. In some instances the inflamma-

312 MEDICAL AND SURGICAL GYNAECOLOGY.

tion passes bnckwnrcl instead of forward, producing an
exudation in the tissues of the utero-sacral ligament, in
the tissues surrounding the rectum, and in those beneath
the peritoneum lining the posterior pelvic wall. ^\' hen
the body of the uterus is tlu^ starting point of the cellulitis,
and the broad ligament the seat of the exudation, bimanual
examination will reveal a hard, smooth, flattened, slightly
movable tumor by the side of the uterus, and inseparable
from it.

Pelvic abscess. When a pelvic abscess forms, the
situation of the abscess, and the position where it may be
expected to point, will u ipend upon the direction in which
the inflammatory exudation has extended. When the
inflammation is seated in the tissues at the base of the
broad ligament, and passes forward, forming an area of
induration above Poupart's ligament, the presence of
suppuration is manifested by oedema in the skin over the
indurated area which pits on pressure; by the signs of
deep seated fluctuation, and by the eventual pointing of
the abscess a little above Poupart's ligament. When the
inflammation extenc s backward, and suppuration occurs,
the abscess is formed beneath the peritoneum covering
the back of the pelvis, and, as free access is difficult,
burrowin is almost inevitable. Extension into the iliac
fossa and the loin is more particularly apt to take place
when the posterior pelvic wall is the seat of an abscess,
the abscess pointing either at the iliac crest or above it.
Sometimes the pus leaves the pelvis by the sciatic notch,
and follows the course of the gluteal vessels. In other
instances it may make its appearance in ScarpaV *^riangle.
Pelvic abscesses may, though very rarely, discharge them-
selves into the rectum, vagina, or even the bladder. The
usual time for an abscess to point is from the seventh
to the twelfth week.

Diagnosis. Pelvic cellulitis may bo mistaken for
hoematoma of the broad ligament, or a fibroma of the

PELVIC INFLAMMATION. 313

uterus. The history of the case, nnd the fibHonce of symp-
toms of severe ilhiess will, as a rule, serve sufficiently to
distinguish a luismatoma from an inflammatory condition.
Hrematoma occurs suddenly, either from rupture of a
pregnant tube, or of a varicose vein in the broad ligament.
In either case the onset is usually marked by sudden pain
and faintuess, and usually also by an attack of vomiting.
In the case of rupture of a pregnant tube, one or two
menstrual periods will have been missed, and attacks of
pain will have occurred in the lower part of the abdomen,
generally at one side, with slight irregular hemorrhages
from the uterus. It must not be forgotten, however, that
a h.'i3matoma may become infected and undergo suppura-
tion, when the symptoms will be similar to those of pelvic
abscess due to cellulitis. In regard Lo myoma, no great
difficulty should arise, unless developed laterally between
the layers of the broad ligament, and complicated by an
attack of localized peritonitis. The mobility of the ".ervix,
and the absence of pain and tenderness, as well as the
absence of the constitutional symptoms attending cellulitis,
should readily diagnose it from the latter condition.

Prognosis. Except in those severe forms in which
cellulitis forms only a part of a general septic process of
the most acute and fatal type, the disease usually termi-
nates in recovery. As soon as th- fever subsides the
exudation begins to undergo absorption, and will have
entirely disappeared in a few weeks. Should the fever
not subside in the course of five or six weeks, suppuration
has probably occurred, and the duration and progress of
the illness will then largely depend on the direction ii \i
the pus may take in its efforts to reach the surface. In
the large majority of cases the abscess will point above
Poupart's ligament, where it can be opened. These cases
almost invariably do well. In the rarer cases, where
suppuration occurs at the back of the pelvis, the pus is
longer in reaching the surface, and is apt to burrow.

314 MEDICAL AND SUROICAL GYNJICOLOGY.

Such cnHoa often Inst a long timo nnd are very trying upon
tlio pntiont.

Treatment. Romomboring that this diHoaso which
pr()(hic(^H Huch wi(h> sprimd destruction, and ofton danger-
ous and oviMi fatal results, has its origin in septic infection,
the neces^:ity for strict asepsis, or surgical cleanliness,
becomes fully apparent. If freedom from infection could
be ensured to every parturient woman, and a similar free-
dom extended to every woman who is submitted to vagiual
examination and manipulation, pelvic cellulitis, as a
primary affection, would entirely disappear. It is doubt-
ful whether, when once an attack of pelvic cellulitis has
been initiated, it is possible to modify to any great (^xt(^nt
the course of the disease, hence strict care should be tak^^n
not to do harm by meddlesonn^ interf(5rence or frequtnit
examinations.

The state of the bowels should receive the most careful
attention, and a regular course of aperient medicine should
be kept up. A mild febrifuge mixture, containing liquor
ammonije acetatis, or citrate of potash, may be admin-
istered. The tendency to emaciation calls for generous
dietary, and the X)fttient's appetite should be tempted by
every means available. When induration and pain are
felt in the pelvis, hot fomentations kept in place by a
bandage, or hot water bottles, should be applied to the
lower abdomen. Vaginal douches of hot water should
be administered frecpiently, after which a boro-glyceride
tampon, or one saturattnl with a ten-per-cent. solution of
ichthyol in glycerine may be inserted in the vaginal
fornix. When there are evidences ot suppuration, ([uinine
may be administered, and, if necessary, the system sup-
ported by stimulants. The abscess should be opened as
soon as fluctuation is detected, or there is the faintest
indication of pointing, and treated on general principles.
The point for incision, whether intra-vaginal or external,
must depend largely uj)on the direction which the abscess

PELVIC INFLAMMATION. 315

HoottiH to bo tiiking, and the dogroo of pointing in that
direction.

(^lironio prlvic oollulitiH doos not oxist an nn indopon-
dont (Uhc^uho, or nn a sociuol to tlu^ Jicntc^ form, but it occurs
occjiHioruvUy fiH a Hc^condary rosuit of purulent HalpingitiH.
It oidy involves tlu^ parts immc^diati^ly contiguous to tlio
intlanu>d structures, and never gives rise to the broad
band of induration in the lower part of the abdomen so
common in the primary affection.

PELVIC PERITONITIS.

Pelvic peritonitis, also known by the synonyms peri-
mctrHis, peri-i^dlpiiuiitis, and pcri'-ooplioritis, is an in-
flammation of that portion of the peritonc^um situated
within the pelvis. It is much more common than pelvic
cellulitis. In a large majority of cases, if not in all, it is
an infective process, due either to the presence of micro-
organism or to their chemical products.

Etiology. Pelvic peritonitis, as now understood,
probably never occurs otherwise tlum as a result or com-
plication of some preexisting disease within the pelvis.
Not infre(iuently, however, it is the first indication of the
presence of such disease, for the symptoms of peritonitis
are for the most part acute, and of a character to compel
attention, whereas those of the original disease are often
so slight as to be scarcely noticeable.

Sdtpiiif/ifis (did its ('omplicdiions. In the vast majority
of cases pelvic peritonitis is the result of inflammation of
t'nC Fallopian tubes. The methods of infection of the
p(4vic pi^ritoneum, by means of the tubes, and the effects
produced, immediate and remote, have already boon con-
sidered when speaking of salpingitis.

New (jrowfliH. Peritonitis may result from twisting of
the pedicle of an ovarian tumor, or by the presence of any
new growth in the pelvis, and it is in this way in
ordinary cystic disease adhesions are formed.

316 MEDICAL AND SURGICAL GYNAECOLOGY.

SepticAvmid. When septic infection of a severe type
follows abortion, parturition, or surgical manipulations,
giving rise to diffuse septic infection of the pelvis, the
pelvic peritoneum will also be involved.

Pelvic cellulitis. Pelvic peritonitis may result from
the spread of the inflammatory process from the pelvic
connective tissue, more particularly when it is attemled
by suppuration.

Disease of the vermiform (ijypewlix is not to be for-
gotten. Occasionally the appendix is found lying within
the pelvis, and, when investigating a case of pelvic
peritonitis, it is well to remember that it may arise from
disease of that organ.

Pathology. The earliest change produced in the
peritoneum is hyperemia, with cloudy swelling of the
endothelium. The membrane loses its normal, smooth,
shiny appearance, and becomes dull, dry, and slightly
roughened. Plastic lymph is then poured out on the
surface, which leads to rapid formation of adhesions be-
tween the adjacent surfaces. In addition to the lymph
effused, there is also an eft'usion of serum which tends to
accumulate, principally in Douglas' pouch, but it also
tends to form collections of fluid in different parts of the
pelvis, where spaces intervene between the adhesions.
One of the earliest results of the adhesive process is to
roof in the contents of the pelvis from that of the general
peritoneum. The intra-i^eritoneal collections of serum
are absorbed, but the adhesions formed continue for a long
time, and many of them become permanent, with the
result of producing more or less serious interference with
the functions of the vise ^^a involved. When the disease
causing the peritonitis is purulent, the peritonitis is also
apt to be purulent, and as a result, instead of accumulations
of serum amongst the adhesions, collections of pus are
' irmed — intra-peritoneal abscess.

PELVIC INFLAMMATION. 317

Symptoms. An attack is characterized by pain in the
lower part of the abdomen, sudden in the onset, and at
first severe in character. There is rise of temperature,
rapidity of pulse, and intestinal disturbance, indicated by
vomiting and local or general distension. After the acute
pain has subsided, movements of the body are painful,
owing to the tenderness of the inflamed parts. There is
usually constipation, and pain preceding defecation and
during micturition. In subacute and chronic cases, pain
in the back, and inability to undergo physical exertion,
are the most common and may be the only symptoms,
while trifling causes, such as slight over exertion or ex-
posure to cold readily provoke localized acute attacks.
Such recurrent attacks are especially apt to occur when
the chronic pelvic peritonitis is kept alive by the presence
of pelvic suppuration, and serves as a better guide to the
diagnosis of pus in the pelvis than does the temperature.
In course of time, patients become ill and emaciated, and
entirely incapacitated for work of any kind, and may even
become invalided.

During an acute attack of pelvic peritonitis the patient
lies on the back, usually with the knees drawn up. The
lower part of the abdomen is extremely tender to the
touch, and the walls over the area affected more or less
rigid. On vaginal examination, the parts at this stage
will be too sensitive to allow of a satisfactory investiga-
tion. In there be any depression in the vaginal vault, it
will be central and not lateral, owing to the filling up of
Douglas' pouch. There may be tenderness and a sense of
resistance on pressing the fingers upwards into one or
both lateral fornicos, but it will not be possible to map
out any definite swelling until the acute symptoms have
subsided. After this has occurred, a careful bimanual
examination will probably reveal an inflamed Fallopian
tube as a fixed, irregular, tender, sausage-shaped swelling,
and gradually increasing in size as it extends outwards

318 MEDICAL AND SURGICAL GYN/ECOLOGY.

from tho uterine cornu. As the patient recovers from the
immediate effects of the attack, the hardness of tho
peritoneum gradually disappears, and tho outline of the
adherent appendage more readily made out.

Diagnosis. Pelvic cellulitis. Pelvic cellulitis is a
much rarer disease than pelvic peritonitis. Its origin is
exclusively septic, never gonoiTlioeal or tubercular, and is
essentially a disease of the puerperium, or one following
surgical manipulation. Cellulitis, when uncomplicated,
is unattended by pain, or at any rate by severe pain. In
both diseases there is swelling in the lateral regions of the
pelvis, but in cellulitis the swelling is usually unilateral,
smooth, uniform, attended with fixation of the vaginal
vault, and of stony hardness. In peritonitis it is more apt
to be bilateral than unilateral, and instead of being smooth
and of uniform consistence, is irregular in outline and
unequal in consistence. In cellulitis the cervix is apt to
be surrounded by a hard thick collar, in which it is
immovably set, whilst in peritonitis it is not present, and
the impairment of mobility of the cervix is never so com-
plete. In cellulitis the rectum will often be felt surrounded
wholly, or partially, by a belt of exudation of ston; hard-
ness, fixing the coats of the bowel at that pa.t, and
narrowing the cavity of the canal. In peritonitis en-
largement will be in Douglas' pouch, and will bo less
hard, and will not affect the mobility of tho walls of the
bowols to the same extent. When cellulitis has its seat
in the broad ligament, bimanual examination will reveal
a smooth, hard, flattened tumor by tho side of and
continuous with the margin of the uterus. This tumor can
be moved backward and forward within certain limits.
The swelling caused by the inflamed and adherent
appendages in pelvic peritonitis is, on the contrary, of
irregular contour, and is not continuous with the uterus,
but on a plane behind it, and quite fixed.

PELVIC INFLAMMATION. 319

Pelvic ho'imttocele. The diagnosis will largely dopond
upon tho clinical history. As pelvic hremntocele, in n
majority of cases, is a complication of tubal pregnancy,
there will usually be a history of early pregnancy, and of
a sudden attack of pain accompanied by great faintness.
The patient will have a blanched appearance, or that of
shock. The effusion is at first fluid, but soon acquires a
doughy consistence, and later becomes diminished in bulk
and harder.

Prognosis. The prognosis in pelvic peritonitis is
much less favorable than in pelvic cellulitis. The mor-
tality is higher, and the after effects in those who recover
are apt to be much more troublesome. The damage done
to the uterus, ovaries, and tubes during an attack fre-
quently produces sterility. Displacements of the uterus
are apt to follow, together with the symptoms induced by
such conditions, and the normal action of the bowels are
apt to be disturbed.

Treatment. Preventative. Inasmuch as the large
majority of non-purulent cases of pelvic peritonitis is duo
to gonorrhoeal salpingitis, care should be taken to
destroy gonorrhceal infection as soon as discovered, and
before it has gone beyond the reach of local applications.
Strict attention to surgical cleanliness in every form of
manipulation will often prevent the occurrence of salpin-
gitis, the forerunner of pelvic peritonitis. In those who
have once been the subject of pelvic peritonitis, it is im-
portant to avoid such causes as are likely to provoke a
relapse, such as exposure to cold during the menstrual
period, over exertion, prolonged standing, and inattention
to the bowels.

The medicnl treatment consists in very much tho same
measures as those recommended for the relief of pelvic
cellulitis. Pain being a most distressing symptom must
be relieved by small doses of morphia, and the tendency
to the formation of scybala prevented by the careful use

320 MEDICAL AND SURGICAL GY> ECOLOGY.

of onomatn. Sliould tho stnto of tho pulso indicate it,
stimulants in tho form of brandy or whiskey should bo
given in defined and measured doses, and the effects care-
fully watched. Tendency to collapse should bo mot by
the application of hot water bottles, and by hypodermatic
injections of strychnia.

Surgicdl measures, when necessary, are best deferred
until the acute symj^toms have subsided, and until an
opportunity has been afforded of making a thorough
bimanual examination and arriving at a correct diagnosis.
If it is a first attack, and the symptoms such as to lead to
the diagnosis of non-purulent inflammation of the appen-
dages, operative interference should not for a moment be
recommended. If, on the other hand, the patient has had
several attacks previously, and the swelling has attained
such dimensions as to make it fairly certain that pus is
present, nothing but tho operative measures advised when
speaking of salpingitis will be of any avail.

CHAPTER XXVIII.

DISEASES OF THE OVARIES.

Malformations. One or both ovaries may be con-
genitally absent but such a condition is very rare. When
it does exist, it is generally only a part of a complete want
of genital development manifested by the parts makiiig
up the vulva, vagina, and uterus. More common than
absence is rudimentary development, in which tho ovaries
may or may not contain Graafian follicles. Tho gland
itself may bo of nearly normal size and in a normal
situation, but the gland contents, the Graafian follicles
and ovules may be absent. Such conditions may be
found in connection with a normal uterus, but most
commonly thoy are found associated with arrest of

DISEASES <»F THE OVARIES- DISPLACEMENTS. li'll

(lovolopinont of timt orgnii. A dinf^aosis in suoli cnsos is
extremely difficult, but the condition may be presumed
when the ovnries cannot be palpated bimanually, com-
bined with want of development in the other genital
organs, with absence of the usual signs of the menstrual
crisis, and with lack of general constitutional vigor and
development.

The ovaries of now-born children may be twice their
normal size, a condition which may be due to uniform
enlargement of its constituent parts, or to fo)tal inflamma-
tion resulting in a preponderance of connective tissue,
and a partial or total disappearance of the (xraafian
follicles. Accessory ovaries immediately joining the
normal ovary, and included usually within the same
peritoneal investment, have been found. The ovary may
likewise be constricted so that it consists of twoi)ractically
independent parts. A true supernumerary ovary, far
removed in station from its fellow, is extremely rare.

DISPLACEMENTS.

Congenital displacements of the ovaries are very rare.
In the early embryo they are situated, like the testicles, in
close relation with the kidneys, but soon after birth they
are found to occupy a position in the true pelvis. Only
in extremely rare instances have ovaries been found re-
tained in their original relations with the kidneys.

Congenital inguinal hernia of the ovary is also rare,
but when it occurs, it is generally due to deficient develop-
ment of the round ligament, by which the ovary, tube, and
sometimes one horn of the uterus, are pulled through the
canal of Nuck. There are usually no symptoms until
menstruation sets in, when there may be much disturbance
of that function. The only treatment consists in extirpa-
tion.

Acquired displacements of the ovaries are not un-
common. Any influence which increases their weight, or

322 MEDICAL AND SURGICAL GYNiECOLOOY.

drnwH upon thorn directly, or nets upon tliom by trnction,
mny cauKo tlicm to lonvo their position, nnd Honu^times to
such an extent ns to pnss out of the pelvis in the form of n
hernia.

Cduscs. Displacement of the ovaries may be brought
about by any causes which will increase their weight; such
as inrtnmmatiou, hypertrophy, or cystic degeneration.
They may be a(!ted upon by contraction of effused lymph
resulting from pelvic peritonitis, or by contraction of the
ovarian ligaments drawing them out of place. It may be
brought about by displacements of the uterus, more par-
ticularly retroversion and retroflexion, or by insufficient
support from below, especially when it is the outcome of
a weakened or ruptured perineum.

Displacements may bo subdivided into intra-pelvic
and extra-pelvic, according to whether the ovary is found
within, or outside the pelvis.

Intra-pelvic displacement, or prolapse of the ovary,
is a common disease, and one of considerable practical
importance. When the ovary becomes displaced it sinks
backward, downward, and inward, first upon the retro-
ovarian shelves, and next into Douglas' pouch, describing
in its descent an arc of a circle.

Symptoms. The symptoms will vary according to the
causes which have induced the displacement, and to
the possibility of its return to its normal position.
Ovaries prolapsed behind the uterus manifest themselves
by more or less severe, or constant pain in the lower part
of the back, usually referred to the sacral or rectal region,
and intensified by the passage of hardened feces or by the
act of coition. There is a further sensation of dragging
or bearing down, and when the ovary is adherent these
symptoms are usually aggravated.

The (iimjnosis is usually made by vaginal examination.
Tile prolapsed ovary can readily be touched in its abnor-
mal position, giving a peculiar sensation of faintness and

DISEASES OP THE OVARIES— DISPLACEMENTS. 323

nauHOft wluui prossod upon. It mi^ht bi^ iniHtakeii for a
swollon tube, but tho latter is more sausa^e-HhapiHl. A
small podunoulatod fibroid in hardor and not stMisitive,
while scybala may be indented or crushed without much
pain, and may be removed by enemata or cathartics.

Tr<'((tm<'iit. The treatment consists in replacing the
ovary, if it is movable, by digital manipulation, or by
posture in the genu-pectoral position, and, after replace-
ment, its return to the pelvic cavity prevented by some
suitable support, suoh as a Thomas' retroflexion pessary,
or astringent balls or tampons of cotton packed behind
the cervix. If a retro-displacement of the uterus exists,
the reposition of that organ, together with the ovaries, and
its retention by a suitable pessary will usually suffice. If
the ovary is adherent it will be necessary first to endeavor
to stretch and break up adhesions. This may be done by
pelvic massage, and by packing the posterior fornix of the
vagina, while in the genu-pectoral position, with cotton
balls, the first few inserted being i opregnated with boro-
glycoride,or a ten-per-cent solution rf ichthyol in glycerine.
If these measures fail recourse may be had to radical
methods. If there are no adhesions and the uterus is
freely movable, Alexander's operation may be performed;
if otherwise coeliotomy .must be undertaken in order that
the adhesions may be broken up, after which the uterus
should be retained in place by ventral fixation.

Extra-pelvic displacement, or hernia of the ovary.
The ovary p.ay pass through the same openings as other
herniee, bxc all but two forms are exceedingly rare.

Irufuinal. The passage of the ovary into or through
the inguinal canal can only occur when the tube and
infundibulo-peivic ligament are unusually relaxed and
elongated. When such a condition exists hernia may be
produced by a fall or similar violence, and the ovary, in its
abnormal place, may become inflamed, or undergo cystic
or cancerous degeneration.

324 MEDICAL AND 8UROICAL OYN JICOLOOY.

Tlic ilidj/iiosla niny bc^ nmdi^ by tlu^ prc^Hoiicc^ of a tumor
ill tho inj^uinul region oorrtiHpoiidiiig in Hhnpi^ to that of
tho ovary, nnd producing a peculiar sickening Honsation
when prcHHcd ui)on. Bimanual examination revoals
abHcnco of tho ovary from the pelvis and tilting of the
corresponding uti-rine cornu to that side, while backward
and forward movement of the uterus causes the tumor to
move.

The hernia may be reduced by taxis, and held back by
the application of a suitable truss. Herniotomy may be
necessary to relieve the imprisoned ovary, and wIumi per-
formed may be followed up by a radical operation to
securer permanent results, or by extirpation of the ovary
if it is found to be diseased.

Criit'id. The ovary may make its way through the
crural ring into the crural canal. Tho same symptoms
and treatment are applicable in this variety as in the
former.

HYPER-EMIA AND H<EMATOMA.

Hyperaemia of the ovaries occurs to a considerable
extent during each menstrual period, and often just pre-
vious to, and during coition, but should liyperiBmia be
kept up for any length of time, or is frequently repeated,
it will result in persistent dilatation of tho vessels, and
some serous effusion into the stroma; and in more stwore
cases hemorrhage into the Graafian follicles may take
place. The hemorrhage may bo confined to one follicle,
or it may occur in many. When thoro are many follicles
aifooted, rupture of their septa may take place, producing
luTBmato —1. of a size varying from a pea to a walnut, or
even Ir

^ iiage into the stroma is apt to assume the form

o jrous minute extravasations. The blood may bo

cc /lotely absorbed, or remain as a coagulnm, or as a
mass of tarry fiuid. The fluid part may be absorbed
altogether, leaving a granular pigment, or tho solid parts

DISEASES OF THE OVAKIES—HYI'ER^MIA. .'^25

limy b(> abHorbinl, ho that only a cyHt HlU'd vvitli Hcrouw
tluid riMnaiiis, or Huppuration may Hot in. An oxti^nHive
litMiiorrha^o may causo rupturo of tlio ovary, and the
bh)od pouring into tho poritonoal cavity or ponotrating
between the two layerH of the broad ligament, will form a
htematocelo.

Kfiolof/jf. It may be due to anything which will
produce venouH staaiH, such as maHturbation, venereal
excesses, uterine displacements, and sedentery habits, or
it may arise from causes which produce a disordered
condition of the blood, such as severe burns, phosphorus
poisoning, scurvy, typhoid fever, or septicsemia.

Hijmi)f()ms. A patient affected with hypeniMnia of the
ovary is likely to suffer from menorrhagia, and accom-
panying it there will bo pain in the region of the ovaries
am extending down the ti ighs- and sometimes neuralgia
of t. e breasts. Hemorrhage into the ovary may take place
without giving rise to any symptoms. If the collection
is large, it causes severe pain, and even nausea and vomit-
ing, and on examination the ovary will bo found enlarged.
Hyperemia and luematoma may be diagnosed, if, in a
healthy person, one or both ovaries suddenly become
enlarged and tender without fever. In those who have
been affected with blood dissolution, luematoma may be
inferred if the patient is seized with ovarian pain, and a
movable tumor can be felt in the pel. "?.

Tvcdtmenf, In hyperemia, rest in bed is demanded;
but to be complete, physiological rest must bo secured as
well. The general health should be improved, suitable
tonics administered, and the bowels properly regu-
lated. Some form of local treatment for tho purpose of
reducing general hyperremia should be instituted, such as
occasional counter-irritation over tho lower abdomen by
moons of tincture of iodine or blisters, by hot vaginal
douches, and by the use of ichthyol or boro-glycoride
tampons. Later the patient may be allowed to return to

326 MEDICAL AN1» SURGICAL GYNECOLOGY.

out door oxorciso, still keeping up the local and general
treatment, but rest in bed must be insisted upon during
each menstrual period. Should an acute attack occur
at any time, the patient sliould at once be put to bed,
an ice bag placed over the hypogastric region, and a dose
of morphia administered to relieve the pain. If the
ovaries have suffered in structure, the result ot prolonged
hypera^mia, or from repeated attacks, they should be
removed.

OOPHORITIS.

Oophoritis, or inflammation of the ovary may be
either acute or chronic.

;ute oophoritis. The inflammation may bogin on
the surface, 'pcri-oophorifis; in the anterior, intcrstitidl
oophoritis; in the follicles, /o///c«/(^ir oophoritis; or in the
stroma, intor-follicnl<ir oophoritis. As a rule both organs
are involved.

Etiology. Acute oophoritis is infrequently found
out.jide the puerperal state. It may, however, be ca\ised
by hyperemia and luBmatomaj or by any of the causes
mentioned as liable to produce that condition; or by a
sudden suppression of the menstrual flow. It may follow
minor operations, such as the use ol' the .sound, incision of
the cervix, or trachelorrhaphy. From proximity of the
ovary to the abdominal end of the tube, inflammation of
the latter necessitates an almost constant implication of
the ovary, peri-oophoritis being here the first form pre-
sented. Oophoritis may however occur quite indepen-
dently of salpingitis. The lymphatics leading from the
ovary connect in the meshes of the broad ligament with
those coming from the upper part of the uterus, and it is
thus easy for pathogenic germs to reach the ovary through
those channels and infect them, without the presence of
salpingitis. Interstitial oophoritis is the form here pre-
sented.

DISEASES OF THE OVARIES— OOPHORITIS. 1327

Wlietlior the initial lesion begins within or without the
organ, the results will generally be the same, for by trans-
mission through the lymphatics outside implication will
extend to the interior, and inside implication to the
exterior. When the disease begi- •? as a peri-oophoritis
the surface will be found covered th a serous, plastic, or
purulent exudation, in accordance with the grade of in-
flammatory action present. The ovary wJl be enlarged,
and in the plastic and serous types, the cortex will be more
or less infiltrated with small round cells, similar to inflam-
matory processes in other organs. If the type of inflam-
mation be purulent, pus cells will predominate. Beginning
as an interstitial process, the same elements pervade the
organ, the predominance of the simpler inflammatory
elements, or those indicative of suppuration, being gov-
erned by the presence or absence of septic elements. The
Graafian follicles in all cases suffer changes kindred to
those going on around them. There is turbidity of the
liquor folliculi, with softening and disintegration of the
membrana granulosa, and the ovum.

Course. In the absence of purulent infiltration, it
may terminate in resolution, or in connective tissue
sclerosis leading to atrophy, or the follicles may be con-
verted into cysts, the cva and the membrana granulosa
undergoing fatty degeneration. Purulent infiltrati(m
leads tO the development of abscesses, coalescence of which
may convert the ovary into a complete pun sac, nothing
remaining but the tunica albuginea. These pus sacs may
become encysted, but the rule is, a continuance of suppur-
ation until the pus makes its way through the tunic, when
the course will be similar to escape of pus from the tube.

Sytnpfoms. Often the symptoms are masked by those
of the disease which produced it. The ovarian region
will be the seat of a burning pain radiating down to the
knee, and tc the bladder and rectutn, and occasionally
there will be reflex pain in the breast, and not infrequently

328

MEDICAL AND SURGICAL GYNECOLOGY.

nausea and vomiting. By bimanual examination it is
possible to feel the ovary enlarged and exceedingly tender
to the touch. When an ovarian abscess has formed, it
will give rise to symptoms similar to the formation of pus
elsewhere, and when felt, a sensation of fluctuation may
possibly be made out. It is seldom possible to make a
certain diagnosis. An inflamed tube or a pyosalpinx is
sausage-shaped when palpated, an inflamed ovary or
ovarian abscess is round. Pelvic abscess is situated lower
down and is absolutely immovable.

h'ui. 95.— Ovary with many dropsical follicles CLeopold).

Ti'catntciif. The patient must be kept quiet in bed,
with an ice bag over the affected side, and the bowels kept
relaxed by means of saline aperients. Pain is to be
combated by means of morphia in some form. If the
symptoms point to tlie presence of pus, it is to bo removed
either by abdominal or vaginal oophorectomy.

Chronic oophoritis represents certain changes brought
about in the ovary the result of repeated attacks of
congestion or of acute inflammation, or it may be a
chronic process from the beginning. The common changes
which occur are (itrophy and cystic dc(jeneration. Atrophy

DISEASES OF THE DVARIES— OOPHORITIS. 32*.)

is most mnrkocl in conjunction witli adliosions. which, by
compn^ssin^ the ovnry, iiicreuso tiic sch'rotic changes
in'Uiccd by the acute interstitial form. The whole organ
may bo converted into a small mass of connective tissue,
with almost entire disappearance of distinct formation.
In the ci/sh'c form the albuginea is thickened, and the
organ filled with cysts intermixed with comparatively
normal follicles. The cysts are transformed follicles with
thickened walls surrounded by indurated tissue, the ova
and membrana granulosa having undergoiu* fatty degener-
ation and absorption, leaving merely limpid Huid. In
other cases the cysts may contain a gelatinous or colloid
material. Some of these cysts may be so large as to
involve the whole ovary.

Kfiolofji/. Chronic oophoritis is much more common
than the acute form, and is often the result of, or follows
acute iuHammation. A displaced ovary strongly pro-
dispo.ses to it. It is most frequently due to puerperal or
gonorrhceal infection, while venereal excesses, masturba-
tion, the abuse of alcohol, and syphilis are strong factors
in its production.

Sipfiptoms. The symptoms are often masked by sur-
rounding inflammation. The patient compLiins of pain in
one iliac fossa, or if both ovaries are affected, as is often
the case, in both fossjB, the pain often extending to the
rectum, bladder, hips, and down to the knees. The pain
is increased at the approach of the menstrual period and
during coitus, especially if the ovary is prolapsed. Stand-
ing or walking for even a short time gives great fatigue.
Menstruation is often irregular and profuse, but in the
atrophic form there may be amenorrhcea. Leucorrhooa is
a common accompaniment, and often the digestive and
nervous system suffer to a greater or less extent. ( )n ex-
amination it is extremely difficult to say whether a mass
felt through the roof of the vagina is an ovary or tube.

330 MEDICAL AND SURGICAL GYNiECOLOGY.

Sometimes the enlarged and prolapsed ovary can be made
out by its globular form and extreme tenderness.

Treatment. The management of chronic oophoritis
coincides in most respects with that described for chronic
salpingitis, and when the case has been seen early, treat-
ment may be of great benefit, but when degenerative
changes have taken place to any marked extent, it will be
readily understood that no immediate benefit can be de-
rived. A displaced ovary, or retroverted uterus should be
restored to its normal position and retained there. Hot
vaginal douches and medicated tampons often give much
relief from pain, and absorption of inflammatory material
may be promoted by painting the vaginal vault with tinc-
ture of iodine. Notwithstanding local and general treat-
ment, carried out methodically and persistently, in many
cases nothing short of an operation for the removal of the
diseased structures will be of benefit, and should be
recommended before the patient's health commences to
break down from the continued strain on the nervous
system.

CHAPTER XXIX.

DISEASES OF THE OVARIES CONTINUED.

NEOPLASMS.

From a histogenitic point of view tumors of the
ovaries have been divided into neoplasms of connective
tissue origin, and epithelial neoplasms. The first group,
desmoid tumors, includes fihromata, sarcomata, and
myxomata, all of rare occurrence. The second group,
epithelial tumors, includes cystomata, carcinomata or
alveolar epitheliomata, and adenomata or mucoid epithe-
liomata.

For convenience of study, and from a clinical stand-
point, they are most conveniently divided into cystic and
solid growths. The cystic tumors include simple, pro-

DISEASES OF THE OVARIES— NEOPLASMS. 331

liferatiiu/, (Irrnioid, and hrodd ligiimont cysfs. The solid
tumors nre Jihroniatd, sarcoimita, and aircinomdta, all
comparativoly rare.

OYSTS OF THE OVARY.

Cysts may originate in any part of the tubo-ovarinn
structure; in tlio cortical, medullary, or parenchymatous
structure of the ovary; in its inferior border or hilura; in
the structures between the tube and ovary in which are
found the remains of the Wolffian body, known as the
organ of Rosenmuller, or the parovarian structure; or in
the hydatid of Morgani, the obliterated remains of the
canal of Gartner. Cysts may also develop in the folds of
the broad ligament, and then are known as brodd li(j<i-
mciit r/y.s'/.s. The cysts may bo nnilociildr with limpid
contents, or muUiloculdr with varying contents, some
clear and limpid, others thick and viscid, or discolored
with admixture of blood.

From an anatomical standpoint it is important to dis-
tinguish cystic growths according to the size which they
attain. Some of moderate dimensions may be well toler-
ated or give rise to troubles, which, though painful, do
not threaten existence. Others, on the contrary, increase
in size with the greatest rapidity from the moment their
development has been started.

Small cysts may be subdivided into: — 1. Snidll rosidudl
cysts coming from Morgani's hydatid, or the horizontal
canal of the parovarium. 2. Follivnldr. 3. Cysis of tlic
corpus lutcum. 4. Tubo-ovdvian cysts.

Large cysts may be subdivided into:— 1, Gldndnldr
prolifcrdting. 2. Popillary prolifci'dtiny. 3. Dermoid.
4. Parovdridn.

1. Small residual cysts. In uterine fibromata and
ovarian tumors at the start, there are found either on the
broad ligament or on the tubes, small transparent vesicles,
but are of no surgical interest. They are of three kinds: —

332

MEDICAL AND SURGICAL GYNECOLOGY.

i. Cjl^t of the hijddtid of Mor(jffni. Attached to the
fimbrinted end of the Fnllopian tube there is generally
found a cyst varying from the size of a pea to that of a
cherry, transparent, and covered with a single layer of
endothelium. This hydatid is the remains of the extremity
of the canal of MuUer.

ii. Siipra-fnhdl ri/sf is no larger than the preceding
and has the same appearance and structure. It is probably
a micro-cyst of the broad ligament which has s'ipped
under the serous membrane, and worked its way up to this
unusual position.

iii. MicA'o-cysts of the broad lujament. Some of the.^e
are suspended from Rosenmuller's organ, and some are

Fig. 96. — niagr.ini of the structures in and adjacent to the broad ligament. (I)oraii.)
t. Framework of the parenchyma of the ovary, seat of a simple or glandular nuiltilucular
cyst, I a. 2. Tissue of hilum, with, 3, papillomatous cyst. 4. Hroad ligament cyst. 5.
A similar cyst al>ove tube, but not connected with it. 6. A similar cyst developed close
to 7, ovarian fimliri;p of tube. 8. The hydatid of Morgagni. 9. Cyst developed from
the horizontal tube of parovarium ; cysts 4, 5, 6 and 8 are always lined internally with
a single layer of epithelium. 10. The parovarium. 11. A small cyst developed from
a vertical tube. 12. The duct of Gartner, often persists in the adult as a fibrous cord.
13. Tract of that duct in the uterine wall.

free and of undetermined origin. Only those which
originate from the vertical tubes of the parovarium have
ciliated epithelium, and are likely to subsequently develop
into papillary growths.

DISEASES OF THE OVARIES — NEOPLASMS. 333

2. Follicular cysts. Hydrops of the Granfinn folliolos
wns long coiisidorod the only or chief onuse of Inrgo
ovarian cysts. From failure to rupture owing to some
morbid cause, particularly inflammation of the appendages,
the follicles may form cysts from the size of a hemp seed
to that of a walnut (cystic ovaritis). There may be ex-
ceptionally an agglomeration of several of these sacs,
causing the ovary to become as large as the fist or a foetal
head (Rokitansl^ifs tumor).

3. Cysts of the corpus luteum. This cyst, when first
described, was believed to be a corpus luteum of pregnancy
transformed into a cyst, but microscopical examination of
the walls will show the bud-like papilla* characteristic of
the corpus luteum. The recognition of this prevents their
being confused with follicular cysts, or with suppurative
ovaritis. They are generally no larger than a walnut, but
cases have been described in which they have attained
the size of an orange.

4. Tubo-ovarian cysts. The presence of an ovarian
cyst not infrequently results in the formation of a tubo-
ovarian cyst tlirough its proximity to a distended tube.
A dilated follicle or small cyst may rupture into a dis-
tended tube with which it is in contact and adherent, and
form one sac. They do not usually attain to a large size.
The uterine opening of the Fallopian tube may remain
pervious and as the fluid increases it passes into the
uterus.

Large cysts. Proliferating cysts are also called myxoid
cystomata in opposition to dermoid cystomata, because
their inner surface resembles a mucous membrane. The
term "proliferating" has been given them because they
produce new cysts or papillary growths from their inner
surface. There are two varieties, (fUmdnUir and ptipllUo'jj.

1, Proliferating glandular cystoma has a wall com-
posed of the same structures as found in follicular cysts
and similar external epithelium, but the internal epithe-

334 MEDICAL AND SURGICAL GYNyGCOLOGY.

Hum undergoes a remarkable proliferation which results
in the development of gland-liko growths. This epithe-
lium is polymorphous, but the long columnar is the
predominant variety. It is stratified and forms pouches,
which are at first placed regularly side by side, and are
about the same size, but in consequence of the continued
proliferation they become closed, thus forming a secondary
cyst in the wall of the primary cyst. When the secondary
cyst is formed, the same process of proliferation is re-
peated, so that continually one generation of cysts is

Fio. 97. — Small imillilociilar cyst. (Museuiu of the College of Physicians and Surgeons.)

formed in tlio wall of another. With the production of
new cavities, a r(>duction in their number takes place by
the absorption of the partition which separates them. By
this continued proliferation of epithelial cells, formation
of new cysts, and absorption of their walls, very large
tumors are formed, in which, as a rule, one cyst pre-
dominates, with a greater or smaller number of secondary
cysts in its wall. These cysts are therefore always multi-
locular from a pathological standpoint, although they may
be considered unilocular from a surgical one. This variety
of tumor is by far the most common, and may reach an
enormous size. The outer layer of the wall corresponds to
the albuginea, is smooth and dense in texture, and pearly-
grey or white in color. The inner layer furnishes the

DISEASES OP THE OVARIES — NEOPLASMS.

335

connective tissue, and together with the epithelium enters
into the composition of the secondary cysts. It is of a
reddish color, slightly uneven, and velvety like the inside
of the stomach. From the outer layer may grow small
excrescences covered with short columnar epithelium. As
a rule they have a pedicle.

Contents. In very small new-formed cysts, the tumor
may be one solid mass of cells, but as a rule the contents

'.1^ ''©*

:°:9©r^

Fig. g8. — Microscopic examination of fluid from ovarian tumors. A. Epithelial cells.
H. Oil globules. C. Fine granular matter. D. Crystals of cholesterin. E. Gran-
ular cell. F. Blood corpuscles. G. H. Pus cells, i. Inflammatory globule", of
Gluge.

become more fluid as the cysts grow. The fluid in com-
mon ovarian cysts is of a grey, yellow, or brown color. It
may be limpid as pure water, or filled with solid bodies as
not even to be translucent. Usually it is more or less
viscid. Its specific gravity will therefore vary much, but

336

MEDICAL AND SURGICAL OYNiECOLOQY.

itrt reaction is always alkaline. Generally ovarian fluid
does not coagulate Hpontaneously, but by bein^ boiled the
oont(>nts are more or less completely turned into a solid
mass. It possesses a remarkable degree of resistance to
decomposition, formed elements being sometimes preserved
in it for weeks. As a rule, ovarian fluid is full of a variety
of formed elements, red blood corpuscles, epithelial cells,
nuclei, pigment granules, finely granular globular bodies
like lymph corpuscles or colorless blood corpuscles, pus
corpuscles, spindle-shaped cells, and crystals of cholesterin
and of indican.

2. Proliferating papillary cystoma is not nearly so
common as the glandular, being found in only one out of

fit;. 99.— Papillomatous ovarian cyst. (Museum of the College of I'lij'sicians anil Surgeons.)

ten ovariotomies, nor does it acquire such large dimen-
sions. Tlu^y contain a comparatively small number of
secondary cysts. From their inside spring dendritic or
cauliflower-shaped growths, called papilloraata, whicli may
entirely fill the secondary cyst in which they grow and
break tlirough its walls into a neighboring cyst; or they
may perforate the wall of the primary cyst and cover the
outside of the ovary and neighboring parts. They may

DISEASES OP THE OVARIES— NEOPLASMS. iiiil

ovon pcnotrato tho uterus, blnddor, roctum, or otlu^r visoorn,
HO ns to form oiui masH with tlicm. The paijilla' nm^(> in
ni/iO from that of a poa to that of a small oraiij^fc. They
aro Hossih^ or pt'(hinoulatt'(l, and may bo white, dark red.
or black. Tho interior of a papillary cyst is usually lined
with ciliated epithelium, and the contained fluid not viscid
or colloid, but of more watery consistency. This kind of
tumor is often bilateral, and its development is much
slower than that of the glandular variety. It is ()ft(Mi nr-
compani(^d by ascites.

Mixed proliferating cysts. In one and the same cyst
some cavities may be of the glantlular typ(% others of tlie
papillary, indi(^ating that there is no radical diU'ercMice
between the two varieties, the glandular variety being
built up of the epithelial walls which center into the forma-
tion of the ovaries, the papillary from its conn(>ctive tissue
mainly.

Origin of proliferating cysts. There is still a con-
siderable divt^rsity of opinion in regard to tln^ origin of
these cysts. Microscopical examination has shown that
both the glandular and tlu^ papillary variety may devi^lop
from a (Jrnatian follicle. Another sources may be the
germinal epithelium, which in some ovaries, even of
adults, forms pouches extending into the stroma of the
ovary. Some claim that the papillary cystomata are de-
veloped from remnants of the Wolffian body growing into
the ovary from the hilum. The source of the glandular
variety is by some thought to be a degeneration of the
tunica intima of the arteries in the ovary.

3. Dermoid cysts. These cysts vary greatly from any
already described. The internal surface is covered with a
nu'.mbrane which looks like skin and has a similar struc-
ture. Upon the surface of the derma are papilk-e, anil
hairs are inserted into hair follicles occasionally provided
with a sebac(H)Us gland. The hairs, whether inv or im-
planted, are long, and tawny in color, agglutinated

338

MEDICAL AND SURGICAL QYNJJCOLOOY.

to^(>tlu«r by Hc^mcoous mnttor nnd somotimos rolK^d into
littlo ImiIIh. Sebum n^Hembliii^ tlu< V(*rnix caH'Hwa, jMirtly
tillH tlu' cavity, and ofton forniH Hmall iHolatod niaHHCH. It
is sonu'timivs oily in consiHtoncy, and contains many
(4)itliolial c(*11m, (rholi^Hterin crystals, and fatty acids. T(H<th

and bones have been
found in these cysts.
The bones are in-
sorted in tlie wall,
and are more or loss
covered by the der-
mic layer. Thoyare
irregular in shape,
usually flat, and
formed of compact
tissue. Cartilage is
sometimes present
in small patches.
Tho teeth project
into tho cavity, and
are often loosely in-
serted into alveoli
lormed of bony de-
bris. As many as
one hundred teeth
have been found in
one cyst. Unstriped
muscle fibres have
been found in the

Fn;. loo.— Dermoid cyst, sliowiiiK pl.ites of bones and dermic laVOr. CaSOS
large qll.^ntities of long tawny hair.

are quoted where
striated muscle fibre and nerves distributed to the teeth,
have been found. A most remarkable case is reported
where the cyst, besides skin, hair, and teeth, contained a
body which resembled an eye, with a species of convex
cornea, and epithelium like that of the retina. There was

DISEASES OP THE OVARIES— NEOPLASMS. I}|}U

also n mucous momhrano similar to that of tl'.^ intostiii^H
and stomach, and cncophah)id ucrvi^ substatico.

Oviijin. Tho (lucstiou of the origin of ('crmoid cysts
is one of tho most obscure points in gtMiend pathoh)gy.
Various theories have been put forth. It has been
ascribed to extra-uterine pregnancy, to diptogenesis by
fojtal inclusion, and to parthenogenesis duo to a pro-
liferation of germinating epithelial cells. The theory of
impaction, accortling to Pozzi, is, on the whole, the most
satisfactory. According to this view, during intra-uterino
existonee certain portions of the blastoderm become im-
pacted by pressure within the tissues, and develop there
later, giving rise to an irregular formation of the normal
tissues. The outer surface of a dermoid cyst is, as a rule,
of a dull gray, or greenish color, with orange or ochre
colored patches. They are small, or of nu'dium si/e,
rarely exceeding in size an adult head. Commoidy but one
ovary is affected, but two or three cysts may develop in
tlu^ same ovary. A dermoid cyst may form adhesions and
ruptuni into another organ, or on the surface of tlu^ body.
Tf it opcMis into tlu^ bladder, hairs may be elimiimted with
thi^ uriiu>i. A dermoid cyst in one ovary may be combined
with a proliferating myxoid cystoma in the other.

Etiology of ovarian cysts. Little or nothing is known
about the circumstances which cause their development.
They are met with at all ages. Simple cysts have been
found in the ovary at birth. Even in young chikln^n
multilocular cystomata have been found. Commonly
however, they appear during the period of greatest sexual
activity. Single women are proportionately more liable
to the disease than married.

4. Broad ligament cysts. Broad ligament, or, as
they are sometimes called, parovarian cysts, are net in
reality cysts of tho ovary, being anatomically s(^parate
from it, but are best described in connection with tho
latter, being surgically and clinically closely connected to

340

MEDICAL AND SURGICAL GYNAECOLOGY.

thorn. Broad lignmoiit cysts nro much rarer thnii ovarian
cysts, and. as a rule, arc monocystic. Commonly they do
not oxcood the size of a pregnant uterus at six months
gestation, out exceptionally they may become enormous.
As a rule, the wall is so thin as to be translucent, but in
exceptional cases, the cyst may look like a uterine growth,

on account of the thick
layer of involuntary
muscle fibres. The wall
is composed of peri-
toneum, a layer of
connective tissue con-
taining muscle fibres,
and but few blood
vessels, the absence of
which gives it its white
color. Its internal
surface is smooth, or
wrinkled, but has no
glandular formation,
and is covered \\ith a
single layer of epithe-
lium. The fluid is normally watery, nearly colorless, and
alkaline or neutral. It does not coagulate spontaneously,
nor to any extent by heat before adding an acid. Papillary
and dermoid cysts may also develop in t le broad liga-
ment. As a rule cysts of the broad ligam >nt are sessile,
but sometimes the ligament forms a pedicle. They are
found during the period of sexual maturity; they grow very
slowly, do not impair the health, and give rise to no
symptoms except such as are produced by their bulk.

The pedicle. Whatever the origin of ovarian cysts,
ther(^ is one important point in their surgical history, the
presence or absence of a pedicle. Ovarian cysts as a rule
rise up into the abdomen, and are connected with the
uterus by means of a pedicle. In some cases the develop-

[•'k;. ioi.- Unilocul.ir cyst. (Museum of the College
of Pliysici.ans aiu\ Surgeons.)

DISEASES OF THE OVAKIES — NEOPLASMS. Ml

merit tnkes plncc downwnrd, so thnt the cyst is sitiiiitod
betwecni the layers of the broad ligament, more or less
close up to the uterus, and accordingly has no pedicle.
The pedicle may be long or short, thick or thin, broad or
narrow. It always contains the ligament of the ovary, and
part of the broad ligament, and, as the tumor grows, the
Fallopian tube is drawn in so as to form part of it, and is
as a rule both elongated and thickened. The arteries may
become as large as the radial and the veins the size of the
finger. Besides these structures, lymphatics, nerves, in-
voluntary muscle fibres and connective tissue, all forming
a bundle covered by a peritoneal sheath, enter into its
formation.

Accidents and complications. 1. Torsion of the pedicle.
When the pedicle is long and thin, the tumor from some
cause may rotate on its axis. Sudden torsion may lead
to gangrene and fatal peritonitis. If it develops slowly, it
will cause rodema and hypencmia of the wall, hemorrhage
into the wall and cavity, or suppuration. If the torsion
continues the whole pedicle may be se\ red. Torsion of
the pedicle may involve the intestine and cause its
occlusion; on the other hand it may effect a cure, by
causing atrophy from diminished blood supply.

2. Adhesions. So long as the wall is covered with its
epithelium it slides freely over the surfaces with which it
comes in contact, but when the epitheihim is rubbed off",
or covered by inflammatory exudation, adhesions to the
surrounding structures or organs are easily fornunl.

3. Ascites. An accumulation of ascitic fiuid some-
times accompanies an ovarian cyst, especially the prolifer-
ating papillary variety.

4. Ilemorrhcuje. Blood, arising from erosion of the
vessels, ulceration of the walls, or torsion of the pedicle,
may be poured into the cystic cavity, imparting to the
fluid a dark red or bn-iwn color.

842 MEDICAL AND SURGICAL GYNECOLOGY.

Suppuration. Tlie wall of a cyHt may booomo inflamed
and tlio contonts chanj^od to pus. Tho suppuration may
W" duo to torsion of tlio pedicle, to puncture of the cyst, or
to puerperal infection.

(). liupfnrc. The cyst may rupture and pour its con-
tents into the abdominal cavity, when the fluid, if unirrita-
ting, may become absorbed. Bloody, ichorous, or purulent
fluid, and the contents of dermoid cysts cause more or less
violent peritonitis, and very likely death. Rupture may
also occur into the intestine, stomach, vagina, bladder, or
Falloijian tube, or through the abdominal wall, especially
at the umbilicus.

7. C((lrijic(iti(>n (ind ossifwatioii may take place to such
proportions that the whole tumor may be changed into a
hard shell.

8. Cdtircrnus (Icf/rnrrafiou. Proliferating glandular
cystoraata and dermoid cysts may become malignant and
implicate neighboring organs, and with the formation of
metastatic deposits elsewhere.

Symptoms. The onset is characterized by vague dis-
turbances which do not differ from those described under
uterine symptoms. They are at first reflex troubles due
to congestion and stretching of the appendages, later
come symptoms due to pressure on the rectum and bladder,
but the latter are often absent. Following these occurs the
period of tumefaction, when the abdomen becomes more
or less distended, and the general health aff'ected.

Two stages in the development of cystic tumors can bo
recogni'/AMl. In the first stage the tumor is small, is
hiddiui in the pelvis, and recognized only by bimanual
palpation. In the second stage the tumor has become
abdominal and may be felt through the walls.

Pelvic sUujc. As Boon as the tumor has attained three
or four times the size of a normal ovary, it falls into Douglas'
cul-de-.sac. Bimanual examination will determine its
presence, and its situation and connections, as well as its

DISEASES OF THE OVARIES— NEOPLASMS. 343

ovarian nature. It is usually hard, bocause of the small
size and great tension of the capsule. When it has a well
defined pedicle it is very movable. When included in the
broad ligament it seems to be one with the uterus, but
careful examination will reveal a slight groove between
them. Tumors limited to the size of the fist or ftwtal
head will probably remain permanently in the pelvis,
otherwise they will ascend into the abdominal cavity.

A Inlom hud shu/c. By palpation a well defined spherical
tumor is felt above and laterally, but leas marked below.
Irregular shape or protuberances generally indicate a
polycystic tumor. Fluctuation may be felt, the degree
deixniding upon the size of the tumor and the elasticity
and thickness of its walls. Percussion over the tumor
gives dulness. Bimanual palpation reveals the uterus
anteverted, lying just in front of the pubes, and pushed
slightly to the opposite side from the cyst. The cervix is
drawn upward and not easily within reach. In some cases
the uterus ir.ay be pushed downward, and in cysts of the
broad ligament it may be pushed completely to one side.
The sound .sometimes will show decided elongation of the
uterine cavity.

When the cysts have grown to a large size the abdom-
inal walls will be thinned out, fluctuation will be more
readily made out, while towards tht? s'do^ solid masses are
often found. Percussion elicits flatness over an irregular
spherical area, convex above, and separated from the region
of hepatic dulness by a zone of resonance. Pressure on
the aorta and crural arteries may cause vascular souflles.

Menstrual disorders are rather rare. Menorrhagia is
often very extensive in follicular cysts of the ovary.
Sterility is an unavoidable result when both ovaries are
att'ected, but a unilateral ovarian cyst sometimes compli-
cates pregnancy. Pressure upon the bladder often pro-
duces incontinence of urine, and upon the rectum
constipation. When the tumor reaches very high in the

JUJ: MEUICAL AND SURGICAL GYNAECOLOGY.

jibdomon, tlio inovemonts of tho dinplira^m tnny be
st^riously ombarmssod, onusing dyspiuun aiul cyanoHis.

Sooner or later tlie gt^ioral health becomes rapidly im-
l)aired, caused by (ioinpression of the various portifjus of
the digestive apparatus, joined with a reflex dyspepsia
observed in the course of all utero-ovarian diseases. Com-
pression of the ureters, though it may not for a long time
cause albumenuria, does cause serious uropoietic disturb-
ances, and adds to the malnutrition of the system. Pres-
sure upon other organs, causing pain and sleeplessness, act
in the same way by adding to the general enfeeblement.
'Vhen combined these conditions produce an appearance
of ill health and distress to which Spencer Wells has
given the name " fascies ovariana."

Pro(/no!-fis. "When ovarian tumors," writes Spencer
Wells, "attain such a size that the general health is
affected, the length of life granted to the patient will
probably not exceed two years, and these two years
usually consist of serious trouble, even of torture and-
despair," However, in some rare cases, the course of the
disease may be very slow. Unilocular broad ligament
cysts may rupture into the peritoneum several times in
succession, with quite a long respite after each rupture.
On the other hand, proliferous cyst"), after remaining
quiescent for a long time, may suddenly take a rapid
course. An absolute or relative spontaneous cure is not
an impossibility. Intra-peritoneal rupture often brings
about the cure of broad ligament cysts. Gradual torsion of
the pedicle may, exceptionally, cause atrophy. Death is
the ordinary result of cystic development, unless there be
surgical interference. Marasmus, peritonitis, and embolus
are the three causes of death. Ascites, although not
necessarily fatal, is an unfavorable occurrence.

Papillary cysts tend towards malignancy, and wluni so
diagnosc^d, should always make the prognosis very guardinl.
(ilandular cysts may also undergo cancerous degeneration.

DISEASES OF THE OVARIES — NEOPLASMS. 345

Oortnlu clinical symptoms, indicated by sudden develop-
ment of n tumor which has already existed for some
time, rapid emaciation and cachexia, multiple adhesions,
especially in the pelvis, redema of the lower limbs and
abdominal walls out of all proportion to the size of the
tumor and the amount of ascites present, leave no doubt
in such cases.

Diagnosis. 1. In the pelvic stage. In the early
stages of ovarian cysts, it is difficult to distinguish them
from other tumors situated by the side of the uterus. A
sessile cyst of the broad ligament might be simulated by
a ccUulifis or saljnngitis, but a remembrance of the
previous symptoms, and the course of the disease, will
prevent error. A small pelvic hfematocele shows fluctua-
tion at first, but does not give tlie sensation of an en-
capsuled tumor, while the manner of its appearance is
entirely different.

K.t'tra-ii ferine pregnancy in tlie beginning has few
distinctive symptoms, except those of amenorrluea and
congestion of the genital mucous membrane. Later it is
characterized by special signs which will be referred to in
a subsecpient chapter.

Retrojlexion of the gravid nterus will be suspected
when the signs of early pregnancy are present.

2. In the abdominal stage. Pregnancy. Error in
such a case is a very serious one, and is mo' *^ likely to be
committed when there is hydramnios, for then it is diffi-
cult to palpate the fcBtus or hear the fojtal heart sounds.
It must not be forgotten that amenorrhcua, swelling of tlie
breasts, and imaginative sensations of fcutal movements,
produced by borborygmus, may exist in a case of ovarian
tumor. The diagnosis will be settled only by the rercep-
tion of f(Dtal movement, the hearing of the heart sounds,
the identification of foetal parts, contraction of tht^ gravid
uterus, ballottement, and toward the end of pregnancy en-
gagement of the fttital parts.

340

MEDICAL AND SURGICAL GYNAECOLOGY.

Ascites. Ascites mny simulate a large cyst. In
effusion of fluid within the pelvic cavity, the abdomen is
more bpread out, less acuminated, and on percussion flat-
ness is found in the dependent portions, and tympanites on
the uppermost surface of the dome. In a position of
lateral decubitus, the fluid gravitates to the side and iliac
fossa, while the tympanitic note appears on the opposite
side, where it did not previously exist. This displacement
of the fluid is very characteristic. In cases where ascites
has rapidly developed in connection with an ovarian

Fig.

102. — The sh.ided portion shows the are.i of dulness.
A. Ascites. B. Ovarian tumor.

tumor, much difficulty may be experienced in making a
diagnosis, but the rapid increase in the size of the
abdomen, oedema of the lower limbs, decline of the general
health, and the absence of a previously existent tu.nor, will
assist in making a correct diagnosis. Another sign to be
looked for is mobility of the uterus, which is present in
ascites and absent in large cysts. Finally the condition
of the heart and liver should not be overlooked, disease of
either of which often gives rise to ascites.

^uhcrcnldv and cancerous peritonitis. In the first
named there will be signs of intestinal or pulmonary

DISEASES OF THE OVARIES —NEOPLASMS. 'Ml

tuberculosis, and irregularities in the siuipe of the abdomen
duo to nieteorism interfered with by adhesions. In th(^
case of cancer there will be tiie presence of irreguh'ir
masses in the mesentery and neighboring parts, togetln^r
with rapid cachexia. Puncture may be of service in
establishing a tliagnosis, but at the present day it is usually
omitted. Even when done with the greatest precaution it
is by no means a harmless operation. It may bo followed
by (effusion of tiuid into the abdominal cavity and fatal
peritonitis; or by suppuration of the cyst; or by grave
lunnorrhage from wounding a blood vessel in tli'' abdominal
wall; or an o^ i^rlying portion of intestine may be punc-
tured. If the tumor be of the papillary form, there may
be escape of vegetations into the abdominal cavity, and
conse(|Ucuit infection of the peritoneum. If none of
these accidents happen, the puncture is apt to set up in-
tlammatory adhesions, which, if extensive, or of long stand-
ing, may complicate the removal of the tumor subsequently.

Uterine Jihroids. Uterine fibroids, particularly fibro-
cystic ones, may simulate ovarian cystomata, but a careful
examination under an anjcsthetic, takiui in consideration
with the history and symptoms of fibroids, will generally
make the diagnosis easy.

H(vm<itometr(i may be recognized by its situation and
special etiology.

Vesicdl distension has been the source of numberless
errors, but may be avoided by the employment of a
catheter before proceeding to examine.

Renul tumors, hydronephrosis, and hyddtidiform ei/sfs
have also given rise to mistakes. In such cases the
diagnosis may be made by ascertaining whether the tumor
is fixed in the hypochondrium, and free inferiorly, per-
mitting the hand to be passed beneath it quite far above
the pubes; and also by ascertaining whether the intes-
tines, especially the colon, are interposed between the
tumor and the abdominal wall. Tumors of the liver,

348 MEDICAL AND SURGICAL GYNECOLOGY.

spleen, mesentery, omentum, and echinococcus, may also
give rise to error, which sometimes can only to bo cleared up
by coeliotomy. Tumors of the abdominal wall, phantom
tumors, tympanites associated with partial contraction of
the abdominal muscles, or superabundance of fat in any
particular spot, may give rise to difficulty in making a
diagnosis, particularly in hysterical patients, but the
difficulty may be overcome by examination under an
an.nesthetic.

Treatment. It is scarcely necessary at the present
day to reiterate the statement made by all writers, that
there is only one form of treatment for ovarian cysts, and
that is extirpation.

McdiciiKil treatment. Electrolytic puncture, injections
of iodine and other astringents into the cyst are now
regarded as malpractice. It is only a few years since it
was the frequent practice to tap the cyst several times
before its removal, a proceeding which has been aban-
doned by all who recognize its dangers. There may be
circumstances under which it may be impossible to per-
form ovariotomy on account of the objections of the
patient or of the friends; or where the presence of cancer,
extreme weakness, or grave vLsceral complications would
render an operation inevitably fatal. In such cases tap-
ping may be resorted to, to relieve immediate symptoms.

OVARIOTOMY.

Ephraim McDowell, of Kentucky, was the first to do
an ovariotomy for ovarian cyst, in 180^). The pedicle was
left in the abdomen, and a cure followed. Subsequent to
this there were isolated cases of bold operations which
found no imitators. In America, in 1844, W. L. Altlee
commenced a remarkable series of operations which, in
1871, reached the number of two hundred and forty six.
Ovariotomy can be said to have been thoroughly estab-
lished in America after the year 1865. In England,

DISEASES OF THE OVARIES — NEOPLASJIS. M\)

bi^twooii 1852 niul 185(), Bnkor Brown oporatod iiiiio timcH.
In tho yenr 1858 commoncod the remnrknblo cnrcor of
Spcucor Wells, nud which wns kept up nlinoat to the time
of his death, when he had well passed the thousand. The
next prominent figure in ovariotomy is tliat of Thomas
Keith, of Edinburgh, who performed his first operation in
1,862. On the Continent, the names of Koeberle, Schroeder,
Billroth, Martin, and others, are honorably associated with
the operation. The introduction of antisepsis into the
field of surgery introduced a new phase of existence for
the operation. Ovariotomy has now passed from the
hands of a few eminent specialists into those of surgeons
all over the civilized world. In every capital, city, or town,
there are surgeons who, with honor to their art and credit
to themselves, successfully perform the operation which,
half a century ago, was condemned by the leaders of
surgery as being little removed from murder.

The operation. The patient having been prepared
according to the general directions given in an early
chapter, she is placed upon the back on the operating
table. The incision is made in the middle line, between
the pubes and the umbilicus, after the manner already
described. On reaching the peritoneum it will be found
to vary in thickness. It may be thinned by distension, or
thickened by constant irritation or inflammation. When
there has been much inflammation, the peritoneum may be
a thick highly vascular tissue, which bleeds freely on
division. The incision is made in that structure long
enough to admit of the extraction of the collapsed and
empty cyst without using force. If the tumor is unusually
large, or the adhesions abundant or very dense, it may be
subsequently enlarged to suit the conditions present.

Emptying and delivery of the cyst. Whatever be the
condition prefcent, it is always best to begin by emptying
the cyst, and the best mode in the large majority of cases
is by tapping. For a cyst of small size Wells' small cyst

.*}50

MEDldAL AND SURGICAL OYN^ECOLOdY,

trocar, nnd for n Inr^o ono Tnit's iuHtrunumt with blunt
conical point, may bo used. To prcvont tlio t\scapc of
Huid at the side of the trocar, a flat sponj^o wrapped
around the point of introduction will suffice. After the
trocar has entered the cyst cavity and the walls become
fiaccid, large forceps are mad(^ to grasp the cyst wall and
pull it steadily but gently out of the wound, keeping the
pnrii^tes of the tumor in easy contact with the abdominal
parietes. A flat sponge placed between the cyst and tlu^
parietes may be useful in preventing the escape of fluid
into the abdominal cavity. Secondary cysts may b(*
emptied without removing the cannula from the main
(!yst. but whiles this is boing done, tlu^ flngiTs inside the
abdomini should make certain that the trocar is not pushed
through the main cyst wall. As the cyst is withdrawn
the trocar opening is pulled ovt^r the edge of the wound,
and as soon as it is clear of the abdominal opening, a fold
of the (!yst wall above and below is caught in strong for-
ceps. The trocar is now removed, and if the sac has not
been emptied sufficnently for its total withdrawal, it may
be incised betwet'n forceps, permitting the cyst contents
to run down into the ovariotomy pad.

Adhesions. If, after emptying the cyst as compU^tely
as possible, adhesions prevent its biding delivered, the im-
pcjrtant step of separating them is to be begun. For
separating very soft, tine, and recent adhesions, a sjjonge
may be used, the adherent structure being, so to speak,
sponged away from the tumor. Adhesions of firmer con-
sistency may be dealt with in various ways. If compara-
tively recent they may be peeled off with the fingers. If
the adhesions are old, fibrous, and thick, they may be sur-
rounded by ligatures and divided. During the separation
of adhesions the walls of any of the hollow viscera may be
torn. Such laceration must of course be immediately
closed by suitable sutures. If at any point the connection
to the bowel or bladder is so intimate that complete separ-

DISEASES OF THE OVARIES— NEOPLASMS.

H51

ntion Houms dnnj^erouH to the integrity of the orjjjau, thou
a thin layer of the ndhorent portion of the cyst wnil must
be cut off and left behind.

Tfcdtmt'ut of the pvtUclc. The pedicle has been sub-
jected to almost every conceivable surgical treatment.
" It has been tied (Mitire, tied in sections, been twisted oft',
burnt off, crushed off, cut S([uaro off. cut off' in Haps, left
inside, left outside, and has been made to slough oft'." —
(Bland Sutton.)

The extra-peritoneal treatment by the clamp is now
permanently abolished, and needs no description. The
silk ligature is now almost universally used for securing
the pedicle, although strong coarse catgut is used by some

Fig. 103. — Ligation of pedicle in three sections.

surgeons. After fully exposing the pedicle, and estimating
its size and the position of the blood vessels, a pedicle
needle, threaded with stout silk, is passed through the
centre, taking care to avoid all vessels. After dividing
the silk into two equal parts, the needle is unthreaded
and withdrawn. Each division of the ligature, after
interlocking it with the other, is tied over its own half of
the pedicle, and then returned and tied over the opposite
half.

352 MKDUIAL AND 8lIR(4It!AL «YNiK(!OL()<»Y.

WIhmi tho ixnliclo in vory brond it mny nuiuiro li^nt.ion
ill MoctioiiH. TliiH mny bo dono by puHHiu^ tlu* pi'diclt^
iuhhHo, annod with tin oxtra lon^ nilk li^iituro, tlirou^h
tho pedioh) ono third distnut from tlio mnr^iii. Tho loop
i!\U8 formed in cnught on ono tiii^or und tlio iuhkUo Htill
throudod withdrawn, and rooutorod midway botwooa tho
last point of ontrancii and tlio oppoHito margin. Tlio
podicUo neodUi in again withdrawn and th(^ loo^w arranged
HO that thoy will bo of oqual hingth. Tho ligature in
divided at tho loops, and after interlocking one with the
other, each ligature is separately tied so as to include its

own section. The ends of the outer
ligatures may be reversed and tied
around tho opposite sides of tho
pedicle. A favorite method for so-
curing tho pedicle is that known
I'Ki. io4.-staffordshire knot, as tho "Staffordshire knot." The

pedicle noodle, armed with a silk
ligature, is passed through the pedicle and then with-
drawn, so as to leave a loop on tho distal side. This loop
is then drawn over the tumor, and one of the free ends
drawn through it, so that one end is above while the other
is under tho retracted loop. Both ends being seized in
tho hand, they are drawn through tho pedicle until com-
plete constriction is made.

The pedicle secured, it may now bo divided at a
distance from the ligature sufficient to prevent it slipping,
and the stump allowed to drop back into tho pelvic cavity.
The peritoneal cavity, if necessary, is to bo carefully
cleansed, taking care not to overdo it. A sponge on a
holder is left in contact with tho stump of tho pedicle
until the parietal sutures are introduced, after which it
may bo withdrawn, and if it indicates that no hemorrhage
is going on, the abdominal wound can be closed.

Accidents durhu) operation. Mishaps, such as the
escape of fluid into the cavity, hemorrhage, or injury to

DISEASES OF THE OVARIES -NEOPLASMS. 352}

tlu^ viHC(^ni, may occur during tlu^ most. Himplt^ ovnriotoiuios,
and tlu^y nro eHptH'-ially fro(iuciit in dilHcult cnsos. It is
nocoHHiiry tlu^n^foro for ovory surgoon, to \w suo(H^HHful, to
bo nbhs promptly and (>fHci(mtly, to deal with hucIi
acuiidiuits, and without such knowUHlge no surgoon shouUl
undcrtako an ovariotomy.

Broad ligament cysts, as a ruhi, grow away from the
ligament, pushing aside the ovary and tube, and o-^ca-
sionally tht^y exhibit a well marked pedicle. Sometimes,
however, they may grown downward, widely separating the
layers of the broad ligament, and stretching out the tube
and ovary over their walls. Adhesions are rare, but spon-
taneous rupturt^ is not infrequent. These cysts wen^ onco
r(Mnoved by tapping or aspiration, and their innocuous
luiture and slowness to rt^till are great inducements to use
that kind of treatment, but since it has been discovered
that some of them are papillary growths, and the radical
operation in most cases easy and safe, extirpation is pre-
ferred. Thiur removal, when there is a pedicle, is to be
a<;complish('(l the same as in ovarian tumors.

In some rare cases, when the cyst grows between tlie
layers of the broad ligament, removal may be attended
with considerable difficulty. Here there is no pedicle,
and the base of the cyst lies deep in the pelvis. The
growth in these cases must be dissected out between the
layers of the ligament. Beginning on the side next the
uterus the jieritoneal investment is opened, and the wall
of the cyst exposed. The finger pushed into the cellular
tissue separates the cyst from the ligament, bleeding
vessels being caught up by forceps. Step by step the
process is continued until the cyst is completely enucleated
from its bed. The two flaps representing the layers of the
broad ligament may, according as seems best at the time,
bo left untouched, or united by suturing; or after ligation
in section, its upper portion may be cut .way and the
peritoneal structures turned in and sutured.

354 MEDICAL AND SURGICAL GYNECOLOGY.

Incomplete operations. Tlio presence of Hrm general
ndhesious of nu intrn-lignnieiitous cyst which will not
permit of its being enucleated without extreme shock and
loss of blood, or the sudden collapse of the patient in the
middle of the operation, may determine the surgeon to
ccmclude it without total removal, or as rapidly as possible.
In such cases the cyst may be emptied, and after beiii^;
drawn up into the wound, as much of the sac as possible
may be excised, and the remaining portion sutured in the
lower angle of the wound and drained by gauze pnc';iiig.
The method of .- raining by an openiiig through the vagina
presents many advantages, especially in the c;ase of sup-
puratii\g cysts firml)' adherent to the floor of the pelvis.

SOLID TUMORS OF THE OVARY.

Under this heading is included Jihroma, sdrcorna,
and cjn'th: lioma or ctu'ciuoiiui.

Fibroma. Fibroids of the ovary are rare. They do
not form circumscribed new growths like flbroids cf the
uterus, but seem rather to be a kind of fibroid degener-
ation of the organ, and so uniformly hypertrophied that
its shape and relations are not .xltored. As a usual thing
they are small, not larg(^r than a hen's egg or an orange,
but they may n^ach largCi proportions. They are hard in
ct)usistency and have a mammillaied surface. They
usually have a pedicle, and are free from adhesions be-
cause of the .ascites which they produce. They may
become cystic, due to dilatation of the lymph spaces in tlie
connective tissue — the so called (/codes— and filled with a
coagulable serous fluid.

Siimj)f<)ms. The symptom which usually first attracts
notice is ascites, caused by the excessive mobility of the
tumor. When this symptom is absent, the tumor may
escf^pe notice, or may accidentally be discovered by
ptteiiiion being drawn . i the patient, owing to menstrual
disturbances. li is alraost impossible to diagnose it from

DISEASES OF THE OVARIES— NEOPLASMS. 355 i

1' ;.

a pedu ^ulntod fibroid of tho uterus. Tlie trontmont con-
sists in its removal by vaginal or abdominal hysterectomy.
Sarcoma. This neoplasm is of rare occurrence. It
may be primary, or it may develop secondarily in an
ovarian cystoma, and is often bilateral. It forms a pink
tumor, ranging in size from that of a smjdl orange to that

of an adult head. It is globular or oval, has a smooth ii,

surface, and of varying consistency according to structure. ji

Spindle-celled sarcoma is the most common variety, but

round celled and mixed celled sarcomata are also found. fi

From a clinical point of view <^hese tumors are of great
malignauviy, and the symptom^: are ihose of a rapidly

developing malignant tumor. Ascites . .. ^ i

is always present and cachexia rapidly , ^(^j^^ '^^C^^'^ ^

appears, features which distinguish it 0f^^ ^<^B>^\k -- [

from fibroma. ^"^T^^, ,^ f

Epithelioma or carcinoma. If '^^^JfcTv^^^^ ®
secondary cancerous degiMieration of ^^^l^^'^ ** ''^ ^■^
cysts is excluded, primary cancer of ^i^r^-^^^v^
the ovary is very rare. It may affect
the young as well as the old, and is '''"=• i"5- Spin.iie-ceiie,i s.-»r-

•' '^ coma of the ov.iry.

apt to be bilateral. Two principal

anatomical forms are described; one, a diffuse infiltratifui
of the ovary, originating in the (epithelium of the follieU'.s
of Pfiuger's ducts; the other a superficial !li>velo[)ment
from germ epithelium. In the former, the ovary retains
its shape fo^^^ a long time, with the exception that its
surface becomes nodular. It may attain the size of an
adult head, and as it increases in size the pedicle and
broad ligam nt become infiltrat(>d. In the latter variety
a dendritic growth appears on the surface of the ovary,
whieli, in the later stage cannot be distinguished from
papilloma of the ovary.

Ascitic fli. 'd, possibly tinged with blood, is character-
istic of this disease, and the other symptoms will be
similar to those of sarcoma. The diagnosis is based upon

..<!»> i

■i/.^

:'■?

356 MEDICAL AND SUROICAL GYNECOLOGY.

tho blo(Hl tinged ascites, infiltrntion of tho broad ligament,
upon the existence of nodules about the rocto-uteri)io
cul-de-sai-. and upon the rapidly appearing cachexia.
When seen early, tho treatment consists of performing
oophorectomy; later the treatment can only be palliative.

CHAPTER XXX.

ECTOPIC GESTATION.

By this term is generally understood development
of the impregnated ovum outside the normal uterine
cavity. No entirely satisfactory conclusions have yet
been reached regarding the cause of this form of preg-
nancy. The chief difficulty lies in the fact that it has not
yet been determined at what point of the female genital
tract normal impregnation of the ovum takes place, and
until this question is settled, the primary question,
whether extra-uterine fcBtation is an abnormal ectopic
impiegnation, or is simply a detained impregnated ovum,
must remain unanswered.

Etiuluiji). It is claimed by many that the seat of
coalescence of the male and female elements is normally
in the Fallopian tubes, and if such be admitted, it can
readily be seen how a variety of causes m _, operate to
detain the ovum in the tube. The most frequer . condi-
tions named as tending to bring about ectopic gesf.ition.
are : — Adhesions of the ovaries and tubes, the rt suit jf
peri-salpingitis; loss of ciliated epithelium; ttoxioii of ^he
tubes; dilatations and diverticula; constrictions from in-
flammatory changes; and polypi of the tube, closing its
lumen like a ball valve. Uiitil recently it was the common
belief that the ovum might, after fecundation, develop
primarily in tho tube, within a Graafian follicle, or in the
peritoneal cavity. Modern research, and the advantages
for observation which early cceliotomy has given in such

ECTOPIC GESTATION. 357

cases, hnve chnngocl to a considerable extent the views
once held. At the present time the weight of opinion
leans towards accepting two primary forms of ectopic
gestation, the tubal and ovarian, although niany able
writers assert that all ectopic gestations are originally
tubal.

C](iss{Jic((fion. Ectopic gestation may be divided into
2)rini((rij and scvondary forms. The primary form may
be thus classified: —

id, Tubo-uterine or interstitial.
6. Isthmial.
c. Ampullar.
2. Ovarfan

In tubal pregnancy when the fertilized ovum vlevelops
out near the fimbriated extremity it is called (impulhir;
when at the inner portion of the tube it is called isthmUd;
and when in that part of the tube which traverses the
uterine walls, it is designated interstitial or tuho-uterine.

Tlie secondary forms of ectopic gestation are derived
from the primary. The tubo-uterine or interstitial may
rux)ture into the uterus and be followed immediately by
expulsion of the fijutus, or it may go on to full term and
be delivered in the natural way. It is more likely, how-
ever, to rupture into the abdominal cavity, or into the
broad ligament. In the isthmial form, the rupture occurs
into the abdominal cavity, giving rise to a secondary
abdominal pregnancy; or into the broad ligament, forming
extra-peritoneal broad ligament pregnancy. The ampullar
form of tubal pregnancy gives rise to secondary tubo-
ovarian. abdominal, or broad ligament pregnancy. The
ovarian form gives rise to tubo-ovarian, or abdominal
pregnancy. The secondary forms thus derived from the
primary may be classified as follows: —

(I. Uterine.
1. Interstitial. { h. Broad ligament,
e. Abdominal.

358 MEDICAL AND SURGICAL GYN-ECOLOGY.

a. Tubo-ovariaii.
2. Ampullnr. \ h. Abdominal.

ii. latlitnial.
i. Ovarian.

Broad ligament.

(1: Abdominal.

I). Broad ligamont.

(I. Abdominal.
b. Tubo-ovarian.

Tubal pregnancy. In the first week after fecundation
the tube begins to thicken, which is mostly due to ex-
cessive vascularization, and not, as in the case of the
pregnant uterus, to any great increase in its tissue elements.
As pregnancy progresses, the wall of the tube becomes
thinnod and stretched, until in some cases it appears as a
thin transparent membrane, composed only of an attenu-
ated stratum of muscle covered with peritoneum. The
dovelopraeat of the fcetal membranes is the same as in
intra-uteriiie pregnancy, except that the placenta is largely
foital in its origin. During the first four to six weeks, the
abdotninal ostium of the tube becomes hermetically sealed.
Ui'til the foetal membranes are well formed, the chorionic
villi have but a feeble hold upon their points of attach-
ment, and may be easily separated. Should this occur
during the first two or three weeks of pregnancy, it will
probably give rise to no serious di.scomfort, but, if later,
the accompanying hemorrhage may cause rupture of the
tube, followed by death of the motlier.

If the ovum continues to grow, the point of attachment
of the placenta is one of great importance to the mother.
If it is implanted in the upper wall of the tube, she is in
constant peril, for rupture means almost certain death
from hemorrhage, there being no counter-pressure to con-
trol the lacerated or detached placenta. If implanted on
the floor of the tube the chances for rupture are decreased,
and when rupture occurs the dangers from hemorrhage are
diminished, owing to the placenta being pushed downward
against the resisting pelvic floor. Occasionally the ovum

ECTOPIC tlESTATlON. 359

is lightly attnclu'd in tlu^ finipulUir oxtnMiiity of the tubo,
aiul is extruded into tlio nbdoiniiml caxity without rupture
of the tubal wall. This extrusion is known as fiilxti
abortion.

Tubo-uterine, or interstitial gestation. In this typo
the museular fibres of the uterus undc^r^othe same changes
as in normal pregnancy. Rupture is almost inevitable,
but it does not occur as early as in the tubal form. The
foetus occasionally escapes into the uterus, to be at once
expelled, or to go on to full term. Rupture however in
this case most frequently occurs into the abdominal cavity,
followed by profuse hemorrhage, wliich u.sually terminates
the patient's life.

Rupture of the sac. Tlie time at which this may occur
depends uj)on the location of the placenta, and to a certain
extent upon the attachment. In tubal pregnancy, primary
rupture occurs usually between the second and four-
teenth weeks. The rupture is owing to thinning of the
walls of the tube beyond their limits of elasticity by
hemorrhage or by gradual enlargement of the embryo; or
it may occur as the result of traumatism. If the patient
survives the primary rupture, the foetus may continue to
develop, either burrowing down between the layers of the
broad ligament or extending upward into the peritoneal
cavity. The blood, if poured out into the peritoneal cavity,
will usually be absorbed: if the hemorrhage occurs between
the layers of the broad ligament, it constitutes an extra-
peritoneal pelvic hematocele. After the twelfth week the
sac is liable to secondary rupture at any time up to term,
and here again the situation of the placenta is of the same
im])ortance in the prognosis as in the primary ru^iture.

The foetus. The question as to the possibility of life
for the foetus is influenced by the location of the pla'UMita.
In the tubal variety, the most favorabh* attachment of the
placenta is on the floor of the Fallopiat' tubii, ns there may
be slight if any disturbance of the fiBtal circulation if the

.%0 MEDICAL AND SURGICAL GYNJICOLOGY.

rupture be in the superior wnll, and the child may thus ^o
on to full term. In ectopic gestation, even should the
child be delivered alive, it is often deformed, puny, and
rarely survives more than a day or two. Should the
mother survive rupture, and the embryo die, it may be
completely absorbed as it lies in the abdominal cavity, up to
the second month; after that it either undergoes mnniniiji-
cation, calcijicdtioii, or is converted into adipocere, or it
decompoiics.

Mummification is similar to that change which bodies
undergo in a dry atmosphere. The tluid constituents are
absorbed, and the soft tissues become leathery, or parch-
ment like. In other cases the fatty elements are converted
into adipocere. Either the mummified or the adipocere
foetus may become partially or wholly calcified, and is then
known as a lithopedian. The foetal mass may remain for
a long time in the abdominal cavity, but should pyogenic
organisms gain access to the sac from a neighboring organ,
the fcBtus will be converted into a putrid mass which may
be discharged into the rectum, vagina, or bladder.

Symptoms. All the symptoms of normal pregnancy
may, though not always, be present. In some cases, in-
stead of amenorrhoea there will be profuse metrorrhagia
with expulsion of some bits of decidua. This symptom is
not to be confounded with membranous dysmonorrluBa,
already referred to when sjieaking of that disorder. Pain
is variable, in some cases it is almost constant, and in otluM's
abs(>nt. When present before rupture it may be sharp
and lancinating, or a dull heavy aching. Changes occmr
in the external genitals similar to those in normal preg-
nancy, together with softening of the cervix. On exam-
ination, the Fallopian tube of one side will be found
enlarged, and, if far advanced, will be forced from its
normal position. ShouUl pregnancy have advanccnl to the
tliird or fourth month, a tumor with a well defintul area of
dullness on the anterior abdominal wall may be made out

ECTOPIC (IKSTATION. 861

by percussion. By va^innl oxniniiuitioii tlu^ tumor will bo
found Intornl, unci jit one side of tlie uterus with u sulcus
between them.

Rupture. The symptoms of rupture are very pro-
nounced. A patient in prmMously good health, complain-
ing^ only of some mild form of disturbance, and possibly
with some of the earlier symptoms of prej:;nuncy, is
suddenly seized with severe lancinating, cutting, or
agonizing abdominal pain. If the hemorrhage is extensive,
she may fall almost as unconscious as if struck a blow.
Soon tliere are the usual symptoms of severe intc^rnal
hemorrhage, indicated by a rapid or almost imperceptible
pulse, quickened jerking respiration, air hunger, vertigo,
nausea and vomiting, and dimness of vision. These
symptoms soon merge into those of profound slioc!k, the
extremities becoming cold and clammy, tlu^ skin pal(% the
conjunctiva; pearly, and the face drawn. Death may
follow at once, or it may be delayed for a day, or even
longer. In some cas<^s the hemorrhage ceases for some
time, to begin some days later and then prove rapidly
fatal.

When rupture occurs into the broad ligar nt the
initial attacik is similar, but the subseciuent symptoms are
not so urgent, and the hemorrlmge will soon cease from
its own pressure. Should tlu> embryo die there may be
no further trouble, but often the fditus continu(^s to
develop, and sooner or later a secondary rupture occurs.

In those rare cases which go on to full term, labor like
pains, closely resembling normal labor, come on, and may
continue for hours, or even days, and then c 5ase. During
this time escape of blood, and of portions of the decidua
occur in a majority of cases.

When the patient survives rupture the sharp labor like
pains subside, the breasts diminish, the tumor decreases
rapidly in size, and she may regain her health in time,

ii62 MEDICAL AND SURGICAL QYNiECOLOGY.

absorption, or one of tlio othor changes tlint rondor the
fcEtnl body innocuous, taking place.

Diagnosis. A careful review of the cliiucal history
will often lead to a suspitaon of the condition. A multi-
para, who, perhaps, has not borne any children for some
years, and probably has had in the meantime an attack
of salpingitis and pelvic peritonitis, develops the early
symptoms of pregnancy. There will be more or less
dull ovarian pain, which continues until it terminates in
the paroxysms of ruptuns and which, if not fatal, is
followed by marked auiemia. A bimanual examination,
taken in conjunction with this clinical history, will point
certainly to the nature of the pregnancy.

A rctrovcrfcd j/rdvid uterus may give rise to mislead-
ing symptoms, but a careful vaginal and rectal palpation
will make out the eidarged fundus.

Ovarian tumors and cnlarficmoit of tlic Falloju'an,
tubes associated with intra-uterine pregnancy, may lead
to error, but the fever which accompanies pyosalpinx in
the majority of cases will mark the difference. If it be
impossible to arrive at adefinito conclusion, it is justifiable
to recommend exploratory coeliotomy. The ru])fure of a
p}jOsali)in.r may be mistaken for a ruptured tube, but
when such occurs, the clinical history is entirely different,
the pulse is not so rapid, the temperature rises rapidly and
steadily, the patient does not present such marked symp-
toms of loss of blood, but shows early signs of sepsis. It
can scarcely be expected to differentiate between the tubal,
ovarian, and the secondary abdominal form, when anato-
mists fail to agree concerning them when the abdomen is
opened.

Treatment. Before rupture. The electrical treat-
ment, once so much advocated, has fallen into disrepute
on account of the uncertainty of terminating fcetal life,
and its dangers to the mother. Nevertheless, as stated
before, when speaking of the practical application of

EOTOI'IC GESTATION. .%3

electric curroritH, its use mny bo couHidorod justifiable
when the pntic^it is far removed from skilled hands, or
when the patient positively refuses to submit to cdBliotomy.
Should this procedure be decided upon, the transmission
of the faradic current is accomplished by passing one
pole into the rectum or vagina as far as tlu^ site of the
ovum, and placing the other on the abdominal wall over
the ovary. The full force of a one-celled battery is turned
on for a period varying from five to ten minutes. The
treatment should be continued daily for one or two weeks.

Injections of solutions into the sac, such as half a
grain of morphia, for the purpose of destroying the foetus,
have also been tried and advocated.

Undoubtedly when a diagnosis has beeii made previous
to rupture, the proper course to pursue is the removal of
the atfected tube. Cases with a history suggestive of
ectopic gestation, and a mass lateral to the uterus detecttHl
by vaginal examination, should be operated upon without
hesitation. A proportion of such cases may prove to be
pyosalpinx or hydrosalpinx, but the error is not a serious
one, as in either instance operation is indicated.

A f finir of rupture. If the patient is seen at the time
of, or imnunliately afttM* rupture, the obstetrician must
exercise much judgment in arriving at a decision. Should
examination make certain that hemorrhage has occurred
into the broad ligament, the method of treatment should
be an expectant one, the possibility being that the
hemorrhage will soon cease, if it has not already done so.
Should examination reveal free fluid in the cul-de-sac, and
there are no signs of improvement in the patient's condi-
tion, intra-peritoneal rupture has doubtless occurred. In
such a case operation is indicated, provided there is
sufficient vitality left for it to be undertaken with any
degree of success. In any case attention should bo
directed towards arresting the hemorrhage, overcoming
the shock, and sustaining the patient. Injection.:} of

364

MEDICAL AND SUKOICAL OYNiECOLOOY.

strychnino niul brnndy may bo pfiven hypodormationlly,
and infuHJoii of normal Halt Holutioi injocti'd into the radial
artery or pectoral region, if tiie necessary appliances are at
hand, or if not, into the rectum in the form of an enema.

Ojwrdfion. After opening the abdomen clots should
be turned out as rapidly as possible, and the ovarian and
uterine arteries caught either with forceps or the fingers.
If while clearing the pelvis fresh blood wells up, the
bleeding points must be exposed, and hjemostatic forceps
applied. Having controlled active hemorrhage, the rest of
the operation, if pregnancy has advanced as far only
as the first or second months, may consist merely of
salpingo-oophorectomy. If. however, gestation has further
advanced, attempts at removal of the placenta are ex-
ceedingly hazardous, and the hemorrhage following its
dislodgement may defy oontrol. No means further than
those necessary to save life at the time of the operation
should bo undertaken, and consequently the best course to
pursue in such cases is to check the hemorrhage, cut the
cord close to its placental origin, and leave the placenta
undisturbed, to be removed by absorption or by subsequent
operation. Drainage should not be employed as it in-
creases the danger of sepsis.

After rupture. Should there be a history of previous
rupture occurring at the first or second months after
gestation, operation should not be performed unless the
foetus has ccntinued to grow. If the life of the foetus has
not been destroyed at the time of rupture, the operation
should be performed as soon as the patient has recovered
from the primary rupture. As the dangers of operation
greatly increase as the pregnancy advances on account of
the development of the placenta, the earliest date possible
should be selected. If the ijregnancy is in the early
weeks, the operation may be no more difficult than
salpingo-oophorectomy for hydrosalpinx, and is somewhat
similarly ijerformed. If pregnancy has further advanced.

PELVIC H/EMATOCELE. 3()5

and ndlu'Hioiis Imvo fornuMl botwcnni tlw pfostntiou hao iiiid
tin* ndjdoi^iit viHc-cirii. or if it in a broad li^ainoiit i^ostatioii
with tUv placHMita firmly implanted on tlu^ polvic fioor, tho
opi^ration bccomoH nxciHMlin^ly difficult. Tho adhosions
should be disHeetod off' oarefully, bleeding pointH ligated,
and the Hac enucleated in the ordinary way.

Kvdcudtlon of the ija^tdtlon Xdc fln'oiKjIi flic ViKjiiKt.
After carefully examining tlui mawH and deciding upon
the most accessible point for evacuation, usually in tho
fornix, a pair of blunt-pointed forceps are thrust into the
sac, and with the blades opened are partially withdrawn
whih^ the sac is being steadied from above. The embryonic
debris is evacuated with the finger inserted through tho
opening, after whicih the sac may be washed out with a
weak solution of bichloride, and afterwards packed with
gauze.

CHAPTER XXXI.

PELVIC HyEMATOCELE AND PELVIC H/EMATOMA.

The mere effusion of blood (intra-pelvic hemorrhage)
into the pelvic cavity should not be confounded with
hajmatocele, the term pelvic luumatocele being reserved for
encysted collections of blood. When tlm blood effused
and so encapsulod lies within the i)eritoneal cavity, it is
termed intra-pcritoneul Itwrnatocclc, or simply pelvic,
h(t'm<itocelc. When tho blood is spread out below the
serous membrane, within the broad ligaments, it is called
cxtrd-pcritoncdl luenuitoei'le or simply [wlcie hcrinatonid..

PELVIC HEMATOCELE.

Etiology. The effusion of blood into the pelvic cavity
may arise from tho tubes at tho regular menstrual period,
the hemorrhage taking place from its distal end, and
generally presupposes the existence of salpingitis. In
such a case the amount effused may bo comparatively

IMAGE EVALUATION
TEST TARGET (MT-3)

f/.

1.0

I.I

1.25

1^ iilM

■ 40

Z2
2.0

R III! 1.6

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36()

MEDICAL AND SURGICAL OYNiECOLOGY.

small, and may undergo absorption, or may become
eTioapsuled from inflammatory adhesions. Subsequent
tubal hemorrhages may increase the size until the
hiematocelo may attain considerable proportions. The
most common origin is recognized by all to be the early
rupture of an extra-uterine pregnancy, and by some it is
stated to be the only one. Other causes are assigned, such
as rupture of varicosities of the utero-ovarian plexus,
disorders of ovulation, abortions in connection with
peritoneal adhesions, hematosalpinx or ovarian hwrnatoma,

atresia of the cervix or vagina,
and the rapid evacuation of
the uterus for hjematometra.

The tumor is usually situated
in Douglas' cul-de-sac. At the
outset the blood is liquid and
for.ns a sort of lake, but the
cyst, however, is rapidly formed,
a..d is then entirely separated
from the mass of intestines.
In this way it is often difficult
to distinguish the arch formed
by the new membranes from
an uplifted peritoneum. The uterus ia pushed towards the
sympliysis .^nd the sac is adherent in front to its posterior
wall, and to the agglutinated intestines which lie upon it.
The sac contains a mass of coagulated, or syrupy stMni-
liquid blood, according to the length of time the lesion
has existed. Even in cases where there is reason to
suspect tubal pregnancy as the cause, it is not usual to
find any piece of the fcBtus, as it usually disintegrates and
is absorbed.

Symptoms. The appearance of hematocele is usually
associated with symptoms characteristic of its production,
such as those connected v/ith the uterine appendages, or
ectopic gestation. It is seldom that the effusion of blood

Kic. io6. — Retro-uterine haimatocele.
U. Uterus. R. Rectum. A. Blood-
clot.

PELVIC H HEMATOCELE. 367

is noc ushered in by some decided disturbance. In the
most severe cases, there mny bo those which have been
mentioned as cliaracterizing ruptured tubal pregnancy.
In less severe cases there may only be local pain, and a
sensation of weakness, accompanied by an increase in the
size of the abdomen; or the oozing of blood may be so
insidious that the syra^)toms may be imperceptible. On
making . iginal examination, a iluctuating tumor will
be felt in i-ouglas' cul-de-sac which pushes the uterus
upward so that the cervix is reached with difficulty, and
when felt is found flattened against the pubes. By
bimanual examination, the uterus can be outlined and
seems to be incased in the mass which fills, or more than
fills the pelvis.

The course of the disease is essentially chronic, but
successive attacks at times occur. In the most favorable
cases, the patient is unable to walk for many months, and
is exposed to repeated attacks of peritonitis, during which
the tumor is subjected to change of size, and finally dim-
inishes by degrees. Instead of this the tumor may remain
for an indefinite period, with but little change in the
syrupy chocolate colored contents. Suppurative inflam-
mation may set in, and the mass may be converted into an
abscess cavity, which increases its size and softness. Per-
foration into the abdominal cavity is rare, but perforation
may take place into the rectum, by which the whole mass
may become evacuated and complete recovery follow.

Diagnosis. The sudden appearance of a retro-uterine
tumor coinciding with the phenomena of internal hemor-
rhage is almost pathognomonic. It might be mistaken
for a ruptured pyosalpinx or a retrovertod gravid uterus,
I'Ut the diagnosis of these conditions has already been
referred to in the chapter on ectopic gestation. Ovarian
cysts and uterine fibromata have nothing in common with
hematocele, their manner of appearance and course are
entirely different.

368 MEDICAL AND SURGICAL GYNJICOLOGY.

Treatment. Active interference is justified only by tl\e
appearance of accidents which may endanger the life of the
patient. If seen at once, absolute rest in bed is demanded,
and ice may be applied over the lower abdominal region.
Antisepsis of the vagina is to be attended to, to avoid all
danger of infection through that channel. It is best to
leave the disease to itself, so long as it follovrs a regular
and progressive course towards absorption. Should such
not occur within a moderate limit, or the ])atient'8 life is
threatened by compression or inflammatory phenomena,
rapid evacuation of the cyst becomes obligatory.

Incision is preferable to puncture, and the site of the
incision is to be determined by the protrusion of the
tumor. If it projects plainly into the posterior cul-de-sac,
it should be opened through the vagina. By the use of
retractors the field of operation is enlarged as much as
possible, and an incision is made following the axis of the
tumor, care being taken not to injure the ureter by going
too far forward in the lateral forviix. The finger in the
rectum will serve as a guide in avoiding the intestine.
After reaching the %iterior of the cyst, the opening may
be enlarged and the contents carefully evacuated with the
fingers, or by antiseptic injections. After clearing out the
cavity, it may bt> loosely filled with strips of iodoform
gauze, which will prevent further hemorrhage and
complete the process of disinfection. The strips may be
allowed to remain for forty eight hours. When removed
the irrigation mny be renewed, and drainage kept up by
strips of gauze inserted into the opening in the cyst cavity,
and by a few pieces inserted loosely into the vagina.

Cildiotomy has given good results. The walls of the
cyst, if possible, are to be fixed to the abdominal parietes
by caieful suturing, and the margins protected with pads
of iodoform gauze. The cyst wall is then incised, emptied
of its contents, and packed with gauze. Such fixation of
the walls is often impossible, in which case the intestines

PELVIC HEMATOMA. 369

aro to bo cnrofully tucked away, and the gonoral abdominal
cavity thoroughly walled off with several thiokiiessc^K of
iodoform gauze. When this has been carefully and
accurately done, an incision may be made into the sac,
and the contents removed by means of sponges. The cyst
cavity may be then packed with iodoform gauze, and the
occlusion pads previously inserted allowed to remain
in Situ until sufficient peritoneal adhesions have formed
around them to permanently wall off the peritoneal cavity,
and with it the intestines, from infection. By this means
also capillary drainage is established, and the broken
down material of the cyst cavity removed. In course of
time the gauze is gradually withdrawn, preserving careful
antisepsis, and a smaller quantity reinserted each time
until the cavity is completely filled up by granulation.

PELVIC HEMATOMA.

The effusion of blood into the connective tissue of the
pelvis has also been designated by the term thrombus of
the brodd liijoment.

Etiology. It may be produced by the influence of
pregnancy, or by rupture of a utero-ovarian varicocele.
The immediate attack is usually the result of overwork or
sexual excesses during pregnancy or the menstrual period.

Pdthology. The blood may form a circumscribed
tumor between the folds of the broad ligament, which not
being a closed cavity, but communicating with the pelvic
cellular tissue, permits the escape of blood, if abundant,
into the latter, and the effusion then is directed toward the
vagina and rectum. The tumor is usually of medium
size, varying from the size of the fist to that of a man's
head. The locality is decidedly lateral, and the contents
similar to that described v>^ben speaking of intra-peritoneal
hajmatocele.

Symptoms. It usually occurs in women who are
apparently in a healthy condition. Sharp pain in the

370 MEDIO\L AND SURGICAL GYNiECOLOGY.

nbdomon marks the onset, accompanied by a tendency to
syncope. Symptoms of decided ansemia, and troubit r. due
to compression of the bladder are manifested, witli swel-
ling and tenderness of the abdomen. By bimanual exam-
ination, a tumor soft and pasty in consistence is felt in the
broad ligament, and not in Douglas' cul-de-sac. The
uterus is situated upon its internal surface and more or
less pushed aside, but it can be distinctly outlined on
every side. As for the other symptoms, they are the same
as those given for intra-peritoneal hematocele.

Treatment. Expectant treatment is the rule. If the
gravity of the symptoms calls for interference, vaginal in-
cision may be dangerous owing to the possibility of
wounding the uterine artery or the ureter. In such cases,
coeliotomy may be performed, with evacuation and drainage
as described for intra-peritoneal lu^matocele.

It may be evacuated by a combined operation of
coeliotomy and drainage through the vagina. After open-
ing the abdoiainal cavity and protecting it after the
mannev already described, the sac is carefully incised and
the contexts removed. Gruided by the lingers of one
hand in the vagina, an opening is made through into that
canal. The sac is then loosely packed with strips of iodo-
form gauze, the ends being brought out through the
/' vaginal opening, and drainage established by that route.

The edges in the upper opening in the sac are then in-
verted and drawn together by a continuous catgut suture
and protected by gauze. The management of the gauze
within the peritoneal cavity will be the same as already
described.

GENITAL TUBERCULOSIS. 371

CHAPTER XXXII.

GENITAL TUBERCULOSIS.

Tuberculosis of the female genitals, although long
known, has only recently attracted special attention. It
was previously known only as a concomitant of advanced
phthisis, and it was not until coeliotomy demonstrated its
frequent occurrence, either alone or in combination with
tubercular peritonitis, that its clinical importance began
to be appreciated. It may involve any or all of tlie
various parts of the genital tract, though some portions
are more frequently affected than others, the order of
frequency being the tubes, uterus, ovaries, vagina, cervix,
and vulva.

Etiology. Tuberculosis of the genital tract may bo
either primarif or scconddry. Primary inoculation may
occur when the patient has been much in the company of
one suffering from tuberculosis. The clothes, a sound, or
the fingers of a physician may carry the germ. Cohabita-
tion with a person who has either genital or pulmonary
tuberculosis is a well authenticated cause in many
instances. The puerperal state has a large share in
primary infection, but whether infection can come through
the semen, the saliva, or the blood of a scratch, is a
disputed point.

Secondary genital tuberculosis is that which is devel-
oped ill the coarse of tubercular degeneration of other
organs, especially the lungs. In the great majority of
cases, genital tuberculosis is secondary and metastatic, the
infection taking place by way of the peritoneal cavity and
the lymph channels, from the abdominal viscera, or
through the general circulation from distant organs, or
by auto-inoculation from the secretions.

Vulva. Vulvar tuberculosis is the least common, and
is often unassociated with tuberculosis of other portions
of the genital tract, being due either to blood infection or

372 MEDICAL AND SURGICAL GYNiECOLOGY.

to direct infoction. Tlui tubtTouIous ulciern may attain a
couHidorablo sizo and are usually Hhallow. Tluur marj^iiis
aro irregular, sharply out. slightly raised above tlie general
surface, and of a more or less granular appearances

Vagina. Vaginal tuberculosis is much mor(^ frequent,
and while it may bo primary, it is usually secondary to
tubrtrculosis affecting the higher portions of the genital
traci It occurs in the form of miliary tubercles, never
larger than millet seeds, and which in time undergo
caseation and break down, producing tuberculous ulcera-
tion. The ulcers thus formed are irregular in outline,
their margins sharply cut and perpendicular, the base
shallow, studded by granulations of varying size and color,
and covered by a layer of caseous material. These ulcers
by extension may jierforate the walls upon which they are
situated and lead to the formation of fistul{T3. It is gen-
erally limited to the posterior wall of the vagina, and does
not ordinarily extend below the upper third, circumstances
which are explained by the fact that infection generally
takes place by secretions from the tuberculous uterus or
tubes.

Uterus. Tuberculosis of the uterus is not a rare affec-
tion. It is generally associated with tuberculosis of the
tubes from which it has usually originated, and is fre-
quently secontlary to phthisis, or occurs as a part of a
general infection. It is nearly always limited to the
corpus uteri. When tuberculosis of the cervix occurs, it
is usually without any involvement of the body, and
appears eitluT in the form of miliary tubercles, or of tuber-
culous uka>ration, or as a combination of both forms. It
is at first limited to the endometrium, but later the
muscular coat becomes involved. The formation of the
miliary tubercles occurs just beneath the epithelium of the
endometrium, and may or may not be combined with in-
flammatory changes. The appearance of the tubercles,
and of ^he ulcerations resulting from them, does not differ

(lENlTAL TUBliUCULOSIS.

373

t'HHriitinlly from that obsorvcd in tuln'rculoHis of other
inu(H)iis miMnbrfines.

In (rhroiiic ditt'uHo tulwrculosiH, tho iiiti'rior of tho body
of tlie uterus in filled with casoouK matorial which forms a
lay(>r ovct its inner surface. On H(Ta[)inK it off tiie sub-
jacent tissue is seen ja^^ed and irregular, and stuchled
with tubenies in all stag<?s of development, from the
typical grayish semi-transparent nodule, to the irregularly
shaped ulcer. As the disease progreasfiS, tubercles are
gradually formed in the muscular coat, which accordingly
undergoes hypertrophy, and leads to a consitlerable on-

r. I.

»•,(>.

Fig. 107. — Primary tuberculosis of the tubes ami ov.iries, posterior view. ( Kotscfiau.)
r.o. KiRbt ov.iry, enclosiiiK laseous m.-isses ev.ncuated by the tearinu apart of iulliesions.
r.t. KiKhl lube, ililateil and .i<lh'ireiu to iliuui, havini; fornieil part of llie w.ill of a
tuberculous abscess. Mie left ovary, tube, Lo. an<l l.t., and endonietriutn, c, .ire also
tuberculous.

largement of the uterus. By obliteration or clogging up
of the cervical canal, it may lead to the formation of a
pyomc^tra.

Tubes. The Fallopian tubes are far more frequently
affected by tuberculosis than any other portion of the
genital tract, and in the great majority of cases either the
uterus, or the ovaries, or both, are likewise affected. In
most cases it is secondary to tuberculosis elsewhere,
although in a considerable number of cases they are the
seat of the primary form.

ii74 MEDICAL AND SUKOICAL GYNiECOLOOY.

Tubonnilosis of the tubes may oocur in two forniH.
Miliari/ fiihcrriilosis, in which 11 o tubes present the
fjfenernl charncteristics of miliary tuberculosis of other
mucous membranes, and chronic diffuse tuhcrcnh^iis,
which corresptmds to the like named process in the uterus,
and is the form familiar to all under the name cuscons
2)us ti(l)rs.

In advanced cases the tube is greatly enlarged, and if
the peritoneum is involved, its external surface is studded
with tubercles in various stages of development. It is
densely adherent to the surrounding structures, and in
some cases i^resenta an almost stony hardness. In most
instances the fimbriated extremity is occluded, but when
patulous caseous material will be found protruding from
it. On section the lumen is found more or le.ss dilated
and filled with typical yellowish caseous material, which
varies greatly in consistency, sometimes being fluid, some-
times it forms a soft mass, and occasionally is dry and
solid or even calcified. The normal appearance of the
mucosa has disappeared, and i>resents a ragged, ulcerated
sui face over which are strewn tubercles in all stages of
development.

A third form of tuberculosis of the tube has been
described, chronic jihroid tuhcrcnlosis. It differs from
the others in the excessive formation of fibrous tissue in
and between the tubercles.

Ovary. Tuberculosis of the ovary is comparatively
rare, and when seen is usually found in combination with
other forms. The process may be limited to the surface
of the ovary, or it may invade the entire organ. Macros-
copically it appears in the form of miliary tubercles,
caseous masses, or tubercular abscesses.

Symptoms. No period of life is exempt from genital
tuberculosis, but the period in which its occurrence is
most frequent is that of the greatest sexual activity. The
early symptoms are often not very clear, or so masked by

GENITAL TUBERCULOSIS. ^75

thoHd of tlip primary affection that, the involvoincMit of tlio
^onitals is not Huspocted. When it occurH in tlui vulvu
and vagina, it gives rise to symptoms oommon to all
ulcerative processes, and in these instances simple inspec-
tion is fre(piently all that will be reipiired, but a positive
diagnosis can be made only by the microscope.

Tuberculous ulceration of tli<i cervix may show itst^lf
by profuse hemorrhage, and in that way may be mistaken
for carcinoma. In cases in which the uterus is affected
there is usually a very profuse leucorrluBa, which in some
instances consists of a mixture of the caseous material
and the ordinary secretions. The uterus will be found
enlarged, and there will bo associated with it menstrual
disturbances.

The symptoms produced in tuberculous disease of the
ovaries and tubes <,re in most instances overlooked in the
generul condition, and even no symptoms at all may be
present. When the process is limited to the tubes and
ovaries, the symptoms will vary from those of a simple
salpingitis to those of the most severe form of pelvic
abscess, and in spite of careful examination nothing will
be found to indicate the tuberculous nature of the affec-
tion. Amenorrhoea is not necessarily an accompaniment,
but if it occurs it is usually due to the coexisting phthisis.

Diagnosis. From the clinical history afforded, it be-
comes evident that prior to the discovery of the tubercle
bacillus a positive diagnosis of genital tuberculosis could
not be made.

Tuberculosis of the vulva and vagina may be con-
founded with (jr(tni(l(ir inujiniUs. When the frequency
of the latter is compared with the rarity of the former, it
is in itself almost sufficient for a diagnosis; but when one
considers that when tuberculosis of the vagina occurs it
is in phthisical women, and that granular vaginitis is
frequently associated with pregnancy or gonorrluea, a
mistake should not occur. Tuberculosis should also be

.37(5 MUDKiAL AND SUIUlKiAL (lYNiECOUKJY.

(liii^iioHod from Uw pdpiihir and ulcrntfin' si/plu'lidrs,
which may bt< doiio by thti hiHtorv by th(i rutins abHuace
of pain, and by thci total disappi^aianco of tho lattor uiidiir
antiKyi)hiliti-.; trcvitiiKMit.

JlcrfX'fic cniitlions about thc^ vulva oocnir as Hinall
cysts tilled with cKwir fluid, aiid usually appcmr about tho
monstrual period, and disappear soon after. Ihinl and
.so/7 cliancrcs may be diagnosed by tho history, by tlu^
appearance of the patient, and by their well known
characteristics.

Tuberculous ulceration of the cervix nay be diat^nosed
from ('(irrinonid by the aid of the microscope. In tuber-
culosis of the uterus, and in all cases where there is the
slightest suspicion of genital tuberculosis, the vaginal and
uterine secretions should be inspected with the greatest
care for tubercle bacilli. Tho diagnosis of tuberculous
disease of the tubes and ovaries is more difficult than that
of tuberculous disease of the uterus, for the reason that
their secretion is not so readily obtained for examination,
and it is doubtful if, when the disease is limited to these
organs, a i^sitive diagnosis can bo made.

Diagnosis. Primary tuborciilosis of the genitals is
always to be regarded as a serious affection, as it always
presents the possibility, as do other foci of tuberculosis, of
a general infection, with its uniformly fatal termination.
Tuberculosis of the tubes and ovaries tends to the produc-
tion of tubercular peritonitis, or it may go on to the for-
mation of an abscess in them. The results of operative
treatment have been quite satisfactory. If the tuberculosis
is limited to the tubes and ovaries, the prognosis after
removal will hardly be more grave than if they wore re-
moved for tho usual inflammatory affections.

Treatment. Remembering the sources of primary in-
fection, the necessity for prophylaxis becomes apparent.
Possible infection by physician or attendant should be
carefully guarded against. Persons afflicted with genital

TUBERCULOSIS OF THE PElilTONEUM. 377

tuborculofliH, wliotlior mnlo or ft^innlo, should \hi improHHod
with thl^ dnngorH of infection by coitus. The trtiiitiiKitit
will vary nccordiiig ns different portions of the genital
tract are affected, and whether the affection is primary or
secondary.

Ulcers of the vagina and vulva may be made to dis-
appear by the application to tliem of tincture of iodine,
iodoform, or la(;tic acid. If a tuberculous ulcer of the
cervix is recognised, and fails to respond to conservative
treatment, it should at once be amputated. If the process
is limited to the uterus, it should be curetted and iodoform
suppositories inserted. If there is the slightest recurrence
of the infection, the uterus should be removed by vaginal
hysterectomy, and in such cases it is best to remove tlio
tubt>s and ovaries as well.

The question as to the removal of the tubes and ovaries
when they are the sent of tuberculosis, is a difficult one.
As primary tuberculosis is rarely diagnosed, the propriety
of their removal is seldom faced, but when discovered in
cases of coeliotomy undertaken for other causes, there
should be no hesitation as to the propriety of their
removal. In advanced or decided cases of pulmonary
phthisis, there should be no thought of operating. In
cases associated with tuberculous peritonitis, there need
be no hesitation to perform ca3liotomy and remove the
tubes and ovaries, and uterus as well, unless the general
condition of the patient is altogether unfavorable.

CHAPTER XXXIII.

TUBERCULOSIS OF THE PERITONEUM.

In connection with miliary and chronic pulmonary
tuberculosis, it is not uncommon to find the peritoneum
studded with small gray granulations, and they ai'e
constantly present too on the serous surfaces of tuber-

378 MEDICAL AND SURGICAL GYNiECOLOGY.

culous ulcers of the intestines. Apart from these con-
ditions the membrane is often the seat of extensive
tuberculous disease, which occurs in the following forms: —

Acute miliarij tuberculosis, with sero-fibrinous or
bloody exudation.

Chronic tuberculosis, cliaracterized by larger growths,
which tend to caseate and ulcerate, leading to perforation.
The exudate is jjurulent or sero-purulent, and is often
sacculated.

Clironic fibroid tuberculosis, which may be subacu'e
from the onset, or which may represent the final stage of
the acute form. The tubercles are hard and pigmented,
there is little or no exudation, and the serous surfaces are
matted together Vy adhesion.

Tubercular peritonitis occurs at all ages, and is
common in children associated with intestinal and mesen-
teric disease. The incidence is most frequent between
the ages of twenty and forty.

Symptoms. The process may be latent and not cause a
single symptom, the condition being accidentally met with
during ccBliotomy for some other lesion. Sometimes the
onset is so sudden and violent that a diagnosis of enteritis
or hernia is made. Many cases set in acutely with fever,
abdominal tenderness, and the symptoms of ordinary
acute peritonitis. Cases with slow onset, abdominal
tenderness, tympanites, and low continuous fever, resemble
typhoid fever very closely. Ascites is frequent, but the
eft'usion is rarely large, and is sometimes hemorrhagic.
Tympanites is generally present, particularly in the more
acute cases. Fever is also a marked symptom in acute
cases, and the temperature may reach 104° F. In many
cases it is slight, and in the more chronic cases subnormal
temperatures are common. Associated with this, there is
usually abdominal pain, imperfect digestion, loss of flesh,
emaciation, sometimes diarrhoea, and occasion.olly pigmen-
tation of the skin, resembling at times that of Addison's

TUBERCULOSIS OF THE PERITONEUM. 379

disease. A striking peculiarity of tuberculous peritonitis
is the frequency with which the condition simulates, or is
associated with tumor, and is to be remembered when
making a diagnosis of abdominal and pelvic tumors.

Orncntdl tumors may form from the puckering and
rolling up of this membrane until it forms an elongated
firm mass, attached to the tranverse colon and lying across
the upper part of the abdomen.

Sdcculdtrd cxmUi.fion may occur, in which the effusion
is limited and confined by adhesions between the coils of
intestines, the parietal peritoneum, the mesentery, and the
abdominal or pelvic organs. This encysted exudate is
most common in the middle zone, and has frequently been
mistaken for an ovarian tumor. It mfiy occupy the entire
anterior portion of the peritoneum, or there may be a
more limited saccular exudate on one side or the other.
It may be completely within the pelvis proper, associated
with tuberculous disease of the Fallopian tubes. In
rarer cases the tumor may be due co the great retraction
or thickening of the intestinal coils. Not only the small
intestine, but the entire bowel, from the duodenum to the
rectum, has been found forming such a hard nodular tumor.

Mesenteric glcmds occasionally form very large tumor
like masses, but they are more commonly found in
children than in adults.

Diagnosis. The prodromata, the gradual onset, the
progressive development, suggest the tuberculous nature
of the disease. The presence of extensive induration
about the Fallopian tubes, not traceable to labor, abortion
or gonorrhoea, and of tuberculous disease elsewhere in the
system, aid materially in differentiating it from peritonitis
due to ordinary salpingitis or appendicitis.

Mali</nant peritonitis is seldom encapsuled, and is
more often connected with a tumor or characteristic
enlargement of an organ, has less extensive acute attacks,
and runs a more rapid course. When tuberculous peri-

380 MEDICAL AND SURGICAL GYNECOLOGY.

tonitis progresses more rapidly, the charncteiistic symp-
toms of it will prevent it being confounded with malignant
disease.

Encysted tuberculous peritonitis may, as has been
said, be mistaken for an ovarian in mar. In addition to
the local signs of ovarian tumor already mentioned, the
presence of salpingitis, the induration of the sacro-uterine
folds as felt by the finger introduced into the rectum, the
slow development and other signs and symptoms of tuber-
culosis, will serve to distinguish it. An ovarian tumor
with pelvic adhesions presents severe increasing pelvic
symptoms, with proportionately less general depression,
loss of health and emaciation than tuberculosis.

Treatment. The treatment in general consists in that
which belongs to tuberculosis elsewhere. Attacks of
peritonitic pain should also be treated on the general
principles laid down for peritonitis occurring under other
circumstances. Bismuth and salol, the digestive ferments,
and a carefully regulated diet may be required for gastro-
intestinal irritability and impaired digestion. Constipa-
tion or diarrhoea should be combated by appropriate
treatment. Counter-irritation over the abdomen by tinc-
ture of iodine, and later by gentle pelvic massage, may be
employed. Encysted peritonitis shouhl be relieved by
lappi/ig, or by a short abdominal incision and the in-
Kufiiation into the sac of a small quantity of iodoform.
Drainage is seldom necessary, unless adhesions have been
separated that leave oozing surfaces.

PART FOUR.
DISEASES OF THE FEMALE BREAST.

CHAPTER XXXIV

ANATOMY. THE NIPPLES. NEUROSES. MASTITIS.
MAMMARY ABSCESS. CYSTS.

For a proper consideration of the various affections
of the mammary gland, it is essential that there should be
a knowledge of its anatomical position, its structure, and
its physiological functions. Into these it is impossible to
go here, but a few points regarding its blood vessels and
lymphatic channels will not be out of place.

The breast receives nearly its entire arterial supply
from the thoracic branches of the axillary, namely: — The
acromio-thoracic, the long thoracic, and the external
mammary arteries, all entering the gland from *^^he upper
and outer aspect. Branches are sent to the sternal side of
the gland by the perforating and intercostal branches of
the internal mammary artery. The venous blood returns
througli the veins accompanying the arterial vessels.

The lymphatics of the breast consist of two sets, an
axillary and a mediastinal. These are further subdivided
into superficial and deep sets. The main lymphatic
channels pass either superficially, or deeply, from the
upper and outer portion of the gland, the former over, the
latter in the fascia which covers the pectoralis major
muscle. The majority of these lymphatics bend around
the pectoral muscle and ontt^r the glands there; others pass
directly to the glands about the axillary artery. Still
others, belonging to the superficial set, pass upward and
outward, joining first with the lymphatics of the arm
before entering the glands about the axillary vessels. The

382 MEDICAL AND SURGICAL GYNiECOLOGy.

mediastinal set of lymphatics, consisting of a superficial
and deep set, drain the sternal side oi: the gland, particu-
larly the upper and inner quadrant. T!iey pass into the
glands of the anterior mediastinum by perforating the
intercostal spaces, those on the right side joining usuully
with the lymphatics from the convex surface of the liver.
A knowledge of the lymphatic distribution is important,
particularly in carcinoma, as it explains the common
infection of the axilla, and the rarer infection of the
mediastinum and liver which may occur in this disease.

Malformations or deformities of the breast are very
rare and of no practical importance.

Diseases of the nipple. Apart from inflammatory
disturbances, the nipple is rarely affected by disease.

Inflammation may be excited by any irritation, but it
is seldom found except during lactation, either early in
its course, or when lactation is unduly prolonged. The
alternate wetting and drying associated with nursing the
child, is the exciting factor. In the mi.der cases the
nipple and surrounding areola are ; fected only. In
severe and neglected cases the process -ay involve the
neighboring skin and underlying fascia, or even the gland
itself. This extension is due to the Assuring which opens
up the lymph tracts to the entrance of pyogenic micro-
cocci. These micrococci, which are commonly present in
the skin and mouth secretions, enter and excite lymphan-
gitis, and by spreading deeply may set up mastitis,
either of which may terminate in mammary abscess. In
the milder cases the nipple and areola become red and
swollen, then fissured, leaving small ulcers, constituting
what is commonly termed cracked nipples. Pain is
always present, usually smarting in character, and inten-
sified during the nursing of the infant. In severe cases
the ulceration may extend deeply, leading to considerable
destruction of the nipple substance. ..

DISEASES OF THE BREAST— NEUROSES. i^83

Tr'catment. In the milder cases thorough cleanliness
is all that is usually required. Washing the breasts with
warm boracic acid lotions, and thorough drying after
nursing, v/ill accomplish this. When fissures appear, a
breast shield should be worn when the child is nursing,
and in the intervals an astringent lotion, such as the
glycerolo of tannic acid, used. In severe cases the use of
the breast will have to be abandoned, the ulcers touched
with a caustic, such as the solid stick of silver nitrate, oud
the breast compressed with a firm bandage after the appli-
cation of a belladonna ointment or lotion, or bettor still,
perhaps, the oleato of atropine in two-per-cent strength.

Neuroses of the breast are not unfrequently found in
young unmarried women. As a rule the condition is most
marked at, or about the menstrual periods. This affection
is qi 'te a common manifestation in hysterical women.
The features usually noted are a peculiar sensitiveness in
the gland, at times amounting to pain, neuralgic in
character, and usur^ly localized, but may shoot to the arm
or shoulder. On examination no departure from the
normal can be detectv3d. It is important to examine the
breasts carefully for tumor nodiles and to exclude these
as causal agents.

The treatment of these neurotic conditions must be
directed to the general health of the patient, no attention
being paid to the breasts; in fact attention should be
directed entirely away from them, as local treatment
usually intensifies the trouble.

Inflammation of the breast. (Mammitis, mastitis,
mammary abscess.) Inflammatory conditions of the
breast may be either acute or chronic, but the vast
majority of such must be placed in the former category.

Acute mastitis may follow traumatism, but most
commonly it is found during the first weeks of lactation,
or late in its course, being due to the extension of infective
material from cracked nipples. It may also be found in

384 MEDICAL AND SURGICAL GYNJICOLOOY.

infaris shortly after birth, duo to attempts of the nurse
or mother to break the "nipple strings;" ov at puberty,
owing usually to some trauma or irritation of the then
sensitive breasts. All cases of acute mastiffs, not directly
traumatic, are due to the entry of infective bacteria, par-
ticularly the pyogenic micrococci, of which staphylococci,
pyogenes aureus and albus, play the chief part. Cold,
inefficient emptying of the breasts, irritation from the
clothing or other slight trauma, and prolonged lactation are
factors predisposing to infection. Infection, though com-
monly of local origin through the milk ducts or lymph
channels, may at times take place by way of the blood
current.

The symptoms are at first a sense of fulness and
discomfort, followed by swelling of the breasts and ten-
derness, often localized at first to a single lobule or group
of lobules. Pain is present, sharp and lancinating, and
often shooting to the axilla. The skin next becomes tense,
red, and indurated. Constitutional disturbances are
manifested by slight chill with subsequent fever. The
inflammation may terminate in resolution, or it may pass
on to suppuration and the formation of an abscess.

Mammary abscess. When the inflammation termi-
nates in pus formation, the parts, usually localized to a
group of lobules, become tense, boggy, and fluctuation
appears. In true mastitis pus forms in the gland, but pus
may form either over or under the gland. Superficial
abscess formation may mean no involvement of the gland
tissue, but frequently it is but a forerunner, or rather a
concomitant of abscess formation in the gland itself,
Pus formation beneath the gland is commonly due to the
direct passage of infective pyogenic bacteria to the lymph
tracts in that situation, the gland itself being only occa-
sionally involved. In such cases the inflammatory process
is behind the gland, and when pus forms the gland is
pushed forward and floats, as it were, upon it. Pointing

DISEASES OF THE BREAST- -MASTITIS. 385

of the abscess usually takes place at the lower margin of
the breast.

Trcdttnciit. The treatment of mastitis at p'jrioda other
than lactation, consists in keeping the gland at perfect
rest. This is best secured by bandaging with firm com-
pression the affected breast, and at the same time fixing
the arm to the chest. The bowels should be opened by a
sharp saline purgative, and kept acting freely. Tonics
should also be given. Locally, soothing astringent lotions,
as lead and opium wash, should be applied to the breast.
If the inflammation tends to pass on to pus formation,
these lotions should be replaced by hot fomentations, or
by aseptic poultices, such as linseed meal boiled in carbolic
water (1 to 80) . When pus forms it must be freely opened.

Mastitis during lactation always shows a great tendency
to proceed to abscess formation. During lactation, if
mastitis develops, the child should be withdrawn from the
breast, and distension relieved either by gentle stroking,
or by the proper use of the breast pump. The breasts
must also be placed at perfect rest by firm bandaging, and
other points attended to according to the manner already
described. If pus forms it must be evacuated at once.

In opening an abscess in the breast the incision should
always be made in a line radiating from the nipple, thus
avoiding the milk ducts. The opening should be freely
made, the abscess cavity irrigated and packed with a
little iodoform gauze, and the skin incision partly
approximated. When the abscess is behind the gland,
the incision should be made where the abscess tends to
point, that is at the lower border of the gland. After
evacuation of the pus the cavity should be thoroughly
irrigated and drained as before. A rubber drainage tube
may be sufficient for such cases, as the dependent position
affords in itself good drainage.

Chronic mastitis. (Interstitial mastitis.) Chronic in-
duration of the breast is a proliferative inflammation of

386 MEUICAL AND SUUQIOAL GYN/ECOLOGY.

some of its lobulos. It may be due to various onuses, nutl
there are differont varieties. It may bo found arisinji^ Jato
during lactation, or more commonly in married women
after the menopause. In both these conditions it may
be mistaken for carcinoma, and 't is well to remember
that 8' me ^f such cases do terminaio in carcinomitous for-
mation. Besides those commoner conditions, we may have
a chronic mastitis set up by continued irritation of the
clothing. Tuhercnlosis and syphilis at times attack the
breast, usually taking the clinical form of chronic mastitis.
Either of these conditions may lead to the formation of
chronic or cold abscess of the breast. Abscess formation
is at times found in connection with chronic mastitis
occurring late in lactation.

In chronic mastitis there is an extensive proliferation
of the connective tissue cells, and to a slighter extent of
the epithelium of the gland alveoli, with a slight leucocytic
infiltration. The connective tissue cells develop into
adult fibrous tissue, and by their contraction load to in-
duration, and to occasional adhesion of the skin and
retraction of the nipple. The gland acini are also pressed
upon and gradually destroyed. In some parts small re-
tention cysts may be formed by the obliteration of the
ducts.

The disease is first noticed as a circumscribed indura-
tion in the breast, moving only with the breast tissue, and
affecting but one or two lobules at first. The affected
area is tender on pressure. Pain, if present, follows the
distribution of the intercostal nerves. The indurated area
is commonly wedge-shaped, with apex toward the nipple,
and gradually increases in size. The induration has not
the stony hardness of scirrhus, nor does it become adherent
to underlying structures. The axillary glands are at times
somewhat enlarged, but never indurated. The skin over
the area of induration may become somewhat dimpled,
and the nipple retracted, owing to the contraction of the

DIUEASES OF THF BRii.\ST — CYSTS. 387

nowr rormod fibrous tissue, ^n n cnso wlicro tho din^nosis
botwoen this affection and scirrhus is doubtful, thoro
should bo no hesitation in making an exploratory incision,
for in this, as in the case of scirrhus, early operation is
the only hope for eradication of the disease.

Trcdtment. Tonics and good food are indicated in
most cases of chronic mastitis. Potassium iodide may
also be administered, and is essential in syphilitic cases.
Locally, various preparations may be made use of, such as
a two-per-cent oloate of mercury or iodide of potassium
ointment, or belladonna plaster. When used they should be
applied with firm pressure, and the treatment continued
for some weeks. If pus forms it must of course be im-
mediately evacuated and the cavity irrigated and drained.
In cases persisting for months, and in tubercular mastitis,
amputation of the breast is called for, as long continued
cases, if left alone, are apt to become malignant.

Simple cysts. Cysts may occur in nearly all forms of
tumor of the breast, the common cysts being found in
connection with adenomata of the breasts, but the cysts to
be now considered are those apart from such tumor forma-
tion. Of the simple cysts there are two classes: —

1. Serous cysts, due to distension of lymph spaces in
the connective tissue stroma. They contain a torous fluid
and seldom reach a large size.

2. Retention cysts, of which there are several varieties.
(a) The large duct cysts. (/>) Small duct cysts or gland-
ular cj'sts. (c) Involution cysts.

The duct cyst is due to blocking of one of the larger
milk ducts, leading to distension of the duct. Occurring
during lactation, such blocking leads to milk cysts or
galatocele. The smaller duct cysts are usually multiple,
and are due to dilatation of smaller ducts and gland
alveoli, from blocking of the lobular ducts. These cysts
contain a yellow, or a brownish yellow mucoid fluid. The
third class, or involution cysts, are of very small size, and

388

MEDICAL AND SURGICAL QYN-ECOLOGY.

occur in oldorly pooplo, or as a result of chronic inaHtitis.
Thoy nro of no importnnco. Homorrhago may occur into
any of those varieties, forming a nemorrhagic cyst.

Serous cysts and duct cysts give rise to the same
symptoms, and are found most often between the ages of
thirty and forty years. They appear as rounded or ovoid
swellings, situated usually in the centre of the gland, have
an elastic feel, are freely movable, and do not lead to skin
adhesion. Galatocele or milk retention cysts occur during
lactation, and are filled with a milky fluid changed by
absorption and inspissation.

The treatment consists in laying open the cysts and
removing the contents. In serous cysts the cavity may be
allowed to granidate up from the bottom. In other forms
it will usually be necessary to dissect out the cyst wall, or
to remove the effected zone entire. In such cases the
wound may be sutured and treated as an ordinary incision.

CHAPTER XXXV.

DISEASES OF THE FEMALE BREAST CONTINUED.

NEOPLASMS.
Tumors of the breast constitute the largest class of
affections of this organ. Various classifications are given
in the larger text books, but the following is here put
forward as resting upor a fairly accurate pathological and
clinical basis. Tumors of the breasts may be: — 1. Simple
OT innocent ; 2. Mdlignant. I'his classification must be
further subdivided as follows: —

1. Benign, innocent, or histioid tumors made up of: —
a. Tissues resembl/ng the fully developed
connective tisswes, as fibroma, lipoma,
-o I chondroma, etc.

/>. Tissues resemblinj;^ the more specialized
connective tissuen, as angioma, neuroma,
etc.

DISEASES OP THE BREAST - -NEOPLASMS.

389

Common
Hiiuplo
tumor.

Usunl

sarcomatous

tumor.

V. Tissues coriHistiug of opitholial olcmc^nts
nirnnged fairly typically in alvooli, with
distinct lumon, and a stroma of fully
developed connective tissue, as adtuioma
and its subvarieties, adeno-fibronm, cyst-
ndonomn, and papillary cysts.

2. Mdlifjiuirit tumors made up of : —

Ui. Tissues of the nature of class, e, in simple
tumors, in which the stroma is not fully
developed, but embryonic, that is con-
sisting of young forms of connective
tissue, adeno-sarcoma and its sub-class
sero-cystic .sarcoma. The distinction
between class, r, and this one is often
more pathological than clinical.

b. Tissues made up entirely of embryonic,
that is to say, young forms of connective
tissue. Sarcoma (pure).

('. Tissues made up of glandular epithelium
arranged atypically in alveoli, by a con-
nective tissue stroma, and without base-
ment membrane. Carcinoma.

Of all cases of tumor of the breasts, including cystic
tumors, over eighty per cent are carcinomatous, and about
three per cent sarcomatous, either pure sarcomata or
adeno-sarcomata. Thus malignant tumors constitute
about eighty five per cent of all breast tumors. ( )f the
remainder, . adenomata or their subvarieties constitute
nearly the entire percentage.

The simple tumors, fibroma, lipoma, angioma, and
adenoma are rare, with the exception of the last named,
end as they do not differ from similar tumors situated
in other regions, it will not be necessary to refer to them
further here.

Adenomata. These tumors are made up of epithelial
cell elements, spheroidal or cubical in shape, arranged
in olveoli with a distinct lumen and a limiting base-
ment membrane, by a fibrous connective tissue stroma.

390

MEDICAL AND SUROICAL GYNiECOLoaY.

Puro ndiMiomnta closoly rof«niblo tho true glniul Hhhuo
itwlf, (liffiiring howovor in tho niraloHS nrnmgomoiit of ti
nlvooli, niul thd nbsenco of tho propor ducts. In the pure
form ndciiomatn nn^ rnns commonly wo find in Huch
growtiiH a coiiHidiiniblo nmount of fibrous stroma, (jonsti-
tuting Jihro-ddciKnud, tho couimon simple tumor of the
bronst. Other modifications in structure of the adenoma
are found constituting further subvarioties. Some of tho
glandular alveoli may dilate, and their lumen become
filled with a serous, mucous, or more rarely, a milk-like
fluid, at times somewhat dark in color. These dilated
alveoli may themselves etdargi^ greatly, or more commonly
neighboring dilated alveoli run together forming smaller
or larger cysts, and constituting tho cijstic (tdcnomata of
the breast. Into these cystic spaces prolif^^rous ingrowths
of the cystic wall.-}, consisting of tho frame work of connec-
tive tissue covered with the epithelial lining of the cyst
wall, may occur. These ingrowths constitute tho pvo-
lifcroHs nuimmdrj) cysts, or piipilldvy cystonuifd of the
breast, and are analogous to the papillary cysts of tho
ovary. Cystic adenomata constitute about eighty five per
cent of the various cystic formations in the breast. In
some adenomatous formations the stroma, instead of btdng
of a type of fully developed connective tissue, contains more
or loss embryonic or young connective tissue. These are
the adeno-sarcomdUi of the breast. At times the epithe-
lial lining of the alveoli of the tumor takes on an
atypical course, breaking through the basement membrane,
forming atypical alveoli. This is a cdrcinomaious change
and though it occurs but rarely, its possibility should
always be borno in mind.

Adenomd and jibro-ddenoma may bo considered to-
gether. These tumors are found nearly always between
the ago of puberty and thirty five years, being most com-
mon between seventeen and twenty seven. They occur as
a rule in otherwise healthy women. The tumor appears as

DISEASES OP THE BREAST— NEOPLASMS.

391

jiHlowly growing iukIuIcs commonly in the uppc'r linlf of tlio
^land; it in frot^ly movablo, (unuimsrribod. and roundt^l,
and at times lobulatwl. The noduU'H foci firm, and
may vary in si/.o from a poa upwardH; commonly tl'.cy
reach tlic sizo of a wjvlnut, but con.sidi^rably lHr^l^r growths
may be found. The nkin \h rarely involv(>d, and if ho,
only by direct presHure. The growth may become^ more
rapid during pregnancy _

or lactation. Pain in the iflss^xvK v,v

nodule i* seldon. '^om- '^^M^^f^f^J^Uv'^

;"SF--*a8

Vui. io8. — Fibro-atlenonia of the breast. The
glandular tissue is l).-\<lly developed, and is
mingled with nnich filirous tissue.

plained of, but tii«ro may
be uneasinesH oi slight
tendernesB in neurotic
patients. Shooting pains
through the breast are
not an infrequent symp-
tom, but the axillary
glands are not involved.

Cijstic (idenomd usually
occurs at a somewhat later

period than tibro-adenoma, being most common between
thirty and thirty five years, though not wholly confined
to that period. The tumor grows larger than the simple
adenoma, which they resemble clinically, at times reaching
one or two pounds. Their later appearance, larger size,
their frequent irregularity of surface, and the demonstra-
tion of points of fluctuation, are diagnostic features.
Many of the cysts are so tense that fluctuation may be
most difficult to make out.

The papilldry cysts present the same general features
as the cystic tumors. Often the cysts are so filled with
ingrowths that clinically these tumors are solid, and they
may even appear, on superficial examination when re-
moved, to be solid fibro-adenomata.

Cystic adenomata do not invade the breast tissue, but
pressure may lend to atrophy. The skin may be involved

392

MEDICAL AND SURGICAl GYNiECOLOGY.

by pressure of a largo tumor, but it is never infiltrated.
The glands are not involved except there bo some accom-
panying inflammation, when they may be slightly enlarged
and tender.

The treatment of all varieties of adenomatous tumors is
excision. Whon they involve but a small portion of the
gland structure, as in most cases of simple adenoma and

Fig. 109. — Proliferous cyM adenoma— «, termination of an acinus; h and c, the tissus lie
tween the .-icini taking on incrc.->sed Rrowth and pushing into and dilating the acini into
cysts. (Billroth.)

early cystic trouble, the growth cpn be excised without
injuring the secxetive function of the breast. The skin
incision in such cases should radiate from the nipple,
avoiding the ducts, and should cut to the capsule, when
the growth may bo either enucleated or dissected away
with its capsule. Enucleation is advisable in simple cases,
while if cystic change occurs, the latter procedure should
be employed. When the tumor is large, or involves the
gland tissue extensively, the breast must be amputated.

DISEASES OF THE BREAST — NEOPLASMS. 393

Recurrence after complete removal does not take place.
Further nodules may occasionally appear, but these will
have developed from now foci.

Sarcoma and adeno-sarcoma. About three per cent
of the tumors of the breast are sarcomata, and the majority
of them belong to the mixed variety, adeno-sarcoma, the
remainder being derived from the connective tissue with-
out change in the epithelial elements. Sarcomata begin
most commonly between the ages of thirty and forty, and
attack chiefly the central area of the gland. Ac first
they appear as small, slightly lobulated, freely movable
growths, and early it is impossible to differentiate them
from adeno-fibromata. The growth, however, is much more
rapid, advancing as much in weeks as the simple tumor
does in months. The growth soon becomes large, less
movable, and often somewhat adherent to the surrounding
parts. It is also more elastic, softer, and of more unequni
consistence than a simple tumor. In an adeno-sarcoma
the glandular part may undergo the same changes as occur
in simple tumors, and cysts roa;y thus be formed. Cystic
sarcomata rapidly enlarge, and hemorrhage very frequently
takes place into the cysts. As a rule, sarcomata of the
breast are, until late in their course, distinctly encapsuled.
Later they infiltrate the gland structure and involve the
skin, which becomes first blueish, and its veins dilated.
Later the skin becomes dusky red, and ulcerates, owing
both to pressure and infiltration, After ulceration the
tumor may protrude as a bleeding fungoid mass. The
axillary glands are seldom involved, as dissemination
occurs by way of the blood current. SeccJary growths
are most common in the lungs, and when they occur, are
always of the nature of pure sarcomata, even though the
primary growth be an adeno-sarooma.

Treatment. In the early stages the treatment does not
differ from that of adeno-fibroma. Later amputation of
the breast with free and wide extirpation of the surround-

31)4

MEDICAL AND SURGICAL GYNAECOLOGY.

ing skin, is essential. With early excision recurren(!e is
uncommon, but when the tumor is large, recurrence not
infrequently may occur locally, or there may be a genciral
dissemination of the growth. Local recurrences shouhl bo
freely removed. The prognosis after free excision is fairly
good, as about two thirds of the cases show no return. If
left alone the tumor has always a fatal issue, due to ex-
haustion from ulcerative discharges, or from continued
hemorrhage, or to general dissemination, or to the
cachexia which appears late in the disease.

Carcinoma. Carcinomata, or cancers, comprise the
vast majority of new growths in the breast, making up
over eighty per cent of the tumor formations in this
situation. As compared with neoplasms elsewhere, it also
forms a large percentage, comprising seventeen per cent
in the extensive series collected by Roger Williams. In
tlie female, the breast and uterus aie the usual seats of
carcinomatous formations.

Carcinoma may attack the breast in all its varieties,
but spheroidal-celled carcinoma is by far the most common,
comprising from ninety seven to ninety nine per cent of
such formations. All forms of spheroidal-celled carcinoma
may be found — sci'rrhiis, enccphaloid, and culloiti— hut
scirrlius is the most common form. S<)U(inioi(s-e('ll('(l car-
cinoma or epithelioma may attack the skin surface subse-
quent to a continued intractable eczema — the so termed
Paget's disease. This is very rare, at least in this section.
Colmmiar-celled carcinoma, originates from the ducts of
the breast, comprising the villous or duct cancer.

The spheroidal-celled carcinoma originates from the
gland structure itself, and its varieties, scirrhus, encepha-
loid, and colloid, are differences only in the amount and
character of the epithelium as compared with the stroma.
The larger the number of epithelial cells, compared with
the stroma, the softer will be the growth, and the more
malignant its character; the more embryonic in character

DISEASES OF THE BREAST —NEOPLASMS.

395

the epithelial cells, the more rapidly will they tend to
disHoniinate. Colloid cancer consists of a colloid degen-
eration of the epithelium of scirrhus or encephaloid,
a degeneration which lessens their malignancy very
materially.

In the causation of cancer of the breast there are the
same factors which appear to predispose to it elsewhere.
A family history of the disease is occasionally obtained.

[ /

I If,, no.— Section of a breast with scirrhus carcinoma. The growth infiltrates the fat, and
has caused retraction of the nipple.

Cases have been frequently recorded as fol]v)wing some
traumatism. Long continued irritation, particularly when
accompanied by proliferative (chronic) inflammation, as
in chronic mastitis, is the most important predisposing
causal factor. In the breast, as elsewhere, the actual
causal agent of this distressing affection has not been
found.

Carcinoma is most frequently found towards the
periphery of the gland, particularly in the upper and
outer quadrant of the organ. No part is however free
from attack. It is most common in women over forty, and
more especially about the menopause. The vast majority
of cases are found between thirty six and fifty two years,
but cases are at times found in younger, and not in-
frequently in more elderly women. The softer, or en-
cephaloid variety, is more apt to occur in younger patients,

31M)

MEDICAL AhD SURGICAL GYNiECOLOGY.

than scirrhua. As sciirhus is by far tlie most common
form found, it alono will be completely described.

Scirrhus usually commences as a small rounded firm
lump, which is at first movable, and commonly painless.
Its early growth is slow, but later it becomes hard,
nodular and less movable, or moving only with the entire
breast. The outlines of the growth are ill defined,
merging into surrounding mammary tissues and fat. Later
the tumor approaches the skin, causing dimpling, and then

puckering, while later still

the skin becomes densely
adherent, and finally may
ulcerate. This involve-
ment of the skin differs
considerably from that of
sarcoma or adenoma, for
while in them the skin is
first stretched and thinned
by pressure before ad-
hesion and ulceration oc-
cur, in cancer there is
puckering due to contraction of the newly formed fibrous
stroma in the invaded fibrous septa stretching from the
skin to the fascia covering the gland. The tumor sooner
or later, by downward extension, becomes adherent to the
pectoral muscle, and is then quite fixed. Later it may
infiltrate the muscle fibre, and even pass through the
intercostal spaces to the pleura.

The nipple commonly becomes retracted, the retraction
usually commencing somewhat sooner than the skin
dimpling. This retraction is due to the contraction of tlie
fibrous wulls of the milk ducts from invasion of their
walls by the growth. The retraction is a true one, not
like that occasionally seen in other tumor formations,
where the nipple lies buried by the tumor mass. It is to
be remembered that retraction of the nipple is not always

Fig. III. — Scirrhus carcinoma of the breast.

DISEASES OF THE BREAST — NEOPLASMS. 397

present, and further that it is often a late sign. At times
a milky fluid can be expressed from the nipple, but this
symptom may also be present in adenoma.

Pain is absent in the early stages of growth, but later
becomes manifest, at first slight and stinging, but later
more severe sharp and cutting, and often shooting to the
axilla. This pain is almost constantly complained of, but
in rare cases entire absence of pain may be noted.

Ths axillary glands are affected early in the disease by
extension to them, through the lymphatics, of epithelial
cells from the breast nodule. These glands become en-
larged and tender, and though at first not palpable, later
appear as shoty nodules. The glands along the lower
border of the great pectoral muscle are first involved, and
later those about the axillary vessels and brachial plexus.
Owing to pressure on the axillary veins, oedema of the arm*
often follows, while pressure on the nerv( .^ will cause
severe neuralgic pain along their course. From the axillary
glands there may be extension to thoee above the clavicle.
In such cases the disease is usually considered to be
beyond operative interference. At times extension occurs
to the glands of the anterior mediastinum, and on the
right side, to the liver. General dissemination may occur
in the bones or viscera. In all cases of cancer of the
breast, a careful examination should always be made of
the axillary, supraclavicular, and anterior mediastinal
glands, and of the lungs and liver.

After adhesion of the tumor to the skin, little nodules
may develop there; and it, in its turn, will become red,
glazed and finally break down at some point. The skin all
about the ulcerated and adherent portion becomes puck-
ered and drawn towards it. In the ulcerated portions, a
protruding fungus rarely *orms; more commonly there
may be an ulcer with raised, everted, stony hard margins,
and a rough irregular sloughing base, which bleeds
readily. By the time the skin has ulcerated and the

398 MEDICAL AND SURGICAL GYNJICOLOGY.

axillary glands have become enlarged, there will be develop-
ment of the cancerous cachexia. Death may be dne to
exhaustion from hemorrhage and local discharge, from
general dissemination of the growth, or from involvement
of a vital organ, or to some secondary infection or com-
plication.

Some exceptions should be made to these general state-
ments regarding scirrhus. In some rare cases the growth
may not begin as a localized nodule, but affects, as a
diffused growth, almost the entire breast. In some cases
known as atrophic or withering scirrhus found at times in
quite old women, the growth shows great shrinking and
density, and is of slow formation. This growth has not so
much tendency tc invade the glands, but general dissem-
ination may occur.

Cases of scirrhus of the breast, when untreated, have
an average course of thirty months; many cases do not
run more than eighteen months, while others may be pro-
longed for three or four years.

Encephaloid carcinoma is very rare, and runs a much
more rapid clinical course than scirrhus, a few weeks to
about fifteen months being the limit. It occurs as a !*ule
in younger patients, grows more rapidly, forming a large
tumor in a few months. It soon involves the skin and
glands, and rapidly disseminates in the internal organs or
bones. Occasionally it attacks both breasts at the same
time, and is then most rapidly fatal.

Colloid carcinoma is a carcinoma in which the
epithelial cells are undergoing colloid degeneration.
Such cancers are of slow growth, do not involve the glands
until late, and when removed have much less tendency to
recur than the other varieties. It is in fact much less
malignant.

Duct carcinoma or columnar-celled carcinoma origi-
nate s from the epithelium of the lactiferous ducts. The
gro\» th is thus found in the centre of the g'ind. Growth,

DISEASES OF THE BREAST NEOPLASMS. 3<.M)

ns ft rule, is quite slow, the nipple is only occasionally re-
tracted. The axillary glands are involved but rather late
in its course. The growth, if left alone, reaches to and
involves the skin, leading to ulceration and the protrusion
of a fungous mass. When this form of carcinoma is freely
removed the tendency toward recurrence is slight.

Treatment and prognosis. In all cases at all amen-
able to treatment, there is but one method that can be
advised, and that is early and wide excision of the disease.
This will include amputation of the breasv and t)ie re-
moval of the axillary glands and pectoral fascia. This
operation of excision of the breast, with clearing out of
the axilla, is in itself not free from danger, but ranks as a
major operation, with a death rate of from three to ten per
cent. Needless to say the earlier and more radical the
operation, the better will be the result, so that operation
should always be undertaken as soon as a diagnosis has
been made. The common, early diagnostic signs of scirrhus
may be summarized as follows: — An ill defined, hard, and
usually painful lump, occurring in the periphery of the
gland, in a woman about the menopause, moving only with
the breast tissue, causing somewhat later retraction of the
nipple and dimpling of the skin, with early involvement
of the axillary glands, will prove to be scirrhus. All of
these features are of course not constantly found.

Dennis says: "The earlier the disease can be detected
and operated upon, the better the prognosis as regards
recurrence, and in a large number of cases the disease can
be diagnosticated at a time before glandular infection has
taken place; and if the tumor can be removed within six
months from its incipiency, and the axillaiy glands and
fatty tissue can be dissecti^l out, and likewise the pectoral
fascia and the peri-mammary and para-mammary areolar
tissue, the prognosis will yiekl brilliant results."

Wide infiltration of the skin, extensive adhesion to the
pectoral muscle or to the thoracic parietes, very large

400 MEDICAL AND SURGKUL GYNJICOLOGY.

axillary glands or enlarged mediastinal glands, or involve-
ment of the supraclavicular glands, all tend to contra-
indicate operation with the hope of giving permanent
relief, but even in such, excituon of the breast and axillary
glands may at times be undertaken for the relief of the
local symptoms, and the prolongation of life.

In undertaking an operation for the eradication
of this disease, no partial one should be performed.
The rule must be, excise wide of all affected tissues,
remembering that there is an area of affected tissue out-
side those portions visibly affected. In all cases it is
necessary, too, to open up the axilla and eradicate the
glands and axillary fat. Further it is advisable in all
cases to remove the fascia covering the pectoralis major,
for it is in this fascia that the lymphatics lie which trans-
port the epithelial cells from the primary growth to their
secondarj^ seats of growth in the axilla. If the pectoralis
major muscle be involved superficially, the muscle must
be completely excised. One should not cut into the
tumor and then use the same knife, without careful
sterilization, to make further incisions. It is the epithe-
lial cells of the growth from which growth occurs, and
the opening up of the tumor and after use of the knife
might transfer these cells to the wound surface, where,
under favorable conditions, they would grow, reproducing
the carcinoma.

Recurrence of the growth after operation is the great-
est danger in carcinoma, and this danger is the greater
the later the operation is undertaken, or when the skin is
involved, or there is marked glandular involvement.
Dennis, carrying out his principles of early operation and
wide removal of the breast and lymph tracts, has had a
series of brilliant results. In his first series he had forty
three per cent of permanent recoveries after the three year
limit, with recurrence, either local, in glands, or in bones
or viscera, in the remainder. In his last series of cases he

DISEASES OP THE BREAST— NEOPLASMS.

401

lins had one death, two local recurrences, and ten perman-
ent recoveries, two cases have not yet reached the limit
but are yet free from recurrence. No partial op-ration'
can claim these results, but it is well perhaps to remember
that these cases were, at least, moderately early in their
course. With partial or late operation, recurrence is the
rule, usually within a few months, either in the scar, in
the axilla, or internally. When possible, all recurrences
should be immediately excised, as removal holds out the
only hope.

ihmhhi

INDEX.

Abdomen, examination of, 86
Abdominal hysterectomy, 273

pref,'nancy, S")?
Abortion, tubal, ,'<;")!>
AbHcesH, tubo-ovarian, 300

intraperitoneal, 316

pelvif3, 312

Abscess of vulvo- vaginal trlands,

138 *'

Absorbent cotton, ,52
Acne of vulva, 147
Aflonoma of breast, 389
Adeno-cur<rin()mu of uterus, 287
Adono-sarcoma of breast, 3!)(), 393
Adiposcere in e(;t()piegestation,36()
Ala vesportilionis, 13
Albumen water, 97
AI(!oliol in aiiii'sthesia, (57
Allis' inlialer, (i(i

Aloes, therapeutic use of, 88, 1 10
Alum, tlierupeutic use of, 81, 92
Amcnorrhoa, 1(17

after oopliore;!tomy, 108

an.emia and chlorosis in, 108

causes of, 108

definition of, 107

delayed puberty, l(t7

diai^nosis of, 1(»9

prinuiry, 107

primary permanent, 107

primary temporary, 107

secondary, 108

symptoms of, 108

treatnuiut of, 102, 109
Ammonium cliloride, 89
Anniulla, 28

Amyl nitrite in ana-sthesia, 68
Amt'sthetics, 62

a.c.e. mixture, 64

administration of, 64

Allis' inhaler, 66

choice of, 63

chloroform for, 66

closed etherization, 6.">

Clover's inhaler, 66

Anit'sthetics, ether for, 65

Eemarch's inhaler, 66

examination under, 7(i

niortality from, 62

open etli(!ri/.ati()n. 6.'>

Ormsby's inhaler, 66
Anal fascia, 36
Anal region, .38
Anatomy of |)elvic organs, 16

of breast, 380
Andro{;yno, 133
Angioma, urethral, 142
Anode, 101
Antellexion of uterus, 243

causes of, 244

symptoms of, 24r>

treatment of, 245
Antoversion of uterus, 242

causes of, 242

ofrerative measures for, 243

symptoms of, 242

treatment of, 243
Antisepsis, 43
Apiol, no, I IT)
Appendi(;itis, diagnosis from pelvic;

inflannnation, 316
Areolar hyperplasia of uterus, 235
Aristol, 92

Arsenic, therapeutic use of, II 1 1,")
Ascites, diagnosis from ovarian

cyst, 346
Ase))sis, 43, 45
Atresia of vagina, 127

of uterus, 21 1, 23!(
Axillary glands, anatomy of, 380

in cancer of breast, 397

Bacillus coli commurn's, 43
Bacteria, pyogenic, 41
Balsam I'eru, 92
Bandages, 52
Bartholin's glands, 19
inflammation of, 146
Bassini's ojHsratioii, 134
Baths, hot, local, sitz, 90

404

INDEX.

BiittoricH, Kivlviiiiic, fiiriuli( , 101
Boef ten after o|KMati()iiH, i(7
Bollmionim, !»'i, llH, 125
Bladdor, anatomy of, 32
nal(!uli of, 205

oystoHcopicr oxaminatioii of, H">
digital (ixamiiiatioii of, H3
(loiil)le, 111")
exploration of, S3
exMtrophy of, IHr)
HBHine of, lJir>
foreiffn ImdicH in, 205
intlamniation of, 2(HI
injectionn into, 1>3
lif^aments of, 32
tnulforniabiotiH of, 195
neoplasms of, 200
ojHJiiings into, 32
jKJsition for oystoHcopy, 85
relations of, 32
trif^one of, 32
Blazius'o|ieration for vesico- vaginal

fistula, IS8
Boranic aoi<l, 45, 54, 92
Boring cancer of uterus, 277
Bozeman's operation for vesico-
vaginal fistula, IMS
Bre^vst, anatomy of, 3S1
blood supply of, 380
diseases of, 381
diseases of the nip[)le, 382
lymphatics of, 380
malformations of, 382
nerves of, 381
neuroses of, 383
Breast, inflammation of, 383
abscess of, 384
acute mastitis, 383
chronic mastitis, 385
cysts of, 387
Breast, neoplasms of, 388
adeno-sarcoma of, 394
adenoma of, 389
civrcinoma of, 394
classificaticn of, 388
colloid carcinoma of, 398
cystic adenoma of, 390
cystic sarcoma of, 393
encephaloid carcinoma of, 398
fibro-adenoma of, 390
papillary cystoma of, 390
proliferous cysts of, 300
sarcoma of, 393
scirrlius of, 396

Broad ligament, cysts of, 339

contents of, 340

incomplete o|K3ration in, 354

removal of, 353

unilo(;ular, 340
Broad ligament, thrombus of, 36fi

C'alcification in ectopic gestation,

3(iO
Calcium chloride, 89
Cahuilus of bladtler, 205
Calomel, 88
Canal of Nuck, 2(5
Cancer, etl'ects onmenstruaMon, 108
Cannabis indica, 89, 118
(Jantharides, 91
(Jarbolic acid, 44, 92, 124, 146
('arcinoma of bladder, 206

of cervix uteri. 278

encephaloid, of uterus, 278

of ovary, 355
Carcinoma of breast. 394

colloid, 398

columnar-(!elle<l, 398

duct, 398

encephaloid, 398

scirrhus, 396

prognosis of, 399

spheroidal-celled, .394

squamous-celled, .394

treatment of, 399
Caruncle, urethral, 142
Caruncuhi myrtiformis, 21
Cascara sag!'ada, 88
Catheter, Kelly's ureteral, 85

Mott's double current, 93
Cathode, 101
Cauliflower cancer, 277
(Jervical canal, dilatation of, 81

stenosis of, 103
Cervix, amputation of, 238, 282
('ervix, cancer of, 277

amputation of cervix for, 282

causes of, 1:77

diagnosis of, 280

extension of, 278

hysterectomy for, 282, 286

jwilliative treatment for, 286

pathology of, 277

symptoms of, 279

treatment of, 281

varieties of, 277
Cervix, congenital auresia of, 211

INDEX.

405

Cervix, cyHtM of, '_'«!

cyntio doj^oiienitioii of, "J-J?
ectropion of, 22ti
(/'ervix, oronioii of, •2'24, 22U
follicular, 2'.>»
papilliiry, 220
Himple, 225
Cervix, lacoriitioti of, 213

8arconiii of, 290
Chloroform, adiniiiiHtration of, 66
syinptoniM of dfinger in, 67
treatment of dangerous synip-
tomw, 67
Chloral hydrate, 1 18
Chlorosis and anainia, 108, 112,

116, 130
Cimicifiiga, 110, 117, 131
Clitoris, anatomy of, 18
malformations of, 132
Clitorideotomy, 129
Cocaine, 92
Cocjcygodynia, 1.")!
Coccyx, excision of, 152
Cci'liotomy, 271

abdominal incision in, 271
closure of abdominal incision in.

272
for genital tubercidosis, 377
for pelvic ha-matocele, .368
methods of suture in, 272
Clover's crutch, 1,)8

inhaler, 66
Cold, application of, 90
Colloid carcinoma, 398
Colpitis, 177
Colpo-cleisis, 191
Colpo-perineorrhaphy, 167
Colporrhaphy, 157
anterior, 157
Hegar's method, 158
Lefort's operation, 159
position for, 159
Sims' method, 157
Stoltz's method, 159
Commissures, 17, 18
Condylomata of vulva, 139
Connective tissue of pelvis, ,36
Constipation, jiost operative, 98
Copper sulphate, 92, 146
Corpus cavernosum, 18
Corpus luteum, 31
Corrosive sublimate, 44
Corpus uteri, cancer of, 287
diagnosis of, 288

Corpus uteri, cancer of, treatment,
289

varieties of, 287
Cracked nipples, 382
('urettoM, 83, 94
Curetting, 94
Cystitis, 201

a(nite, 200

causes of, 200

chronic, 200

Emmet's button-hole oiKsration

for, 205
operative treatment for, 205
pathology of, 200
symptoms of, 201
treatment of, 202, 204
Cystocele, 155

causes of, 1,55, 256
complication?, of, 156
treatment of, 1;.;!, 171
Cysto-sarcoma of bre.st, 3!)3

of uterus, 29(t
Cystoscope, 85, 189
Cysts of the breast, .387
retention, 387
serous, 387
treatment of, 388
Cysts of cervical canal, 261
of vagina, 182
of vulvo-vaginal glands, 1.38
Cysts of ovary, 331
dermoid, 337
follicular, .3.S1

glandular proliferating, 333
papillary proliferating, 336
parovarian, .339
supra-tubal, 332
tubo-ovarian, 331

Depressor, vaginal, 79

Diabetes, effects on menstruation,

108
Diagnotfis in general, 68
Dietary, post operative, 97
Digitalis. 68, 112
Dilators, uterine, 82

Ellinger's, 82

glass, 129

(ioodelKe, 82

Hanks', 82

VVylie's, 82
Diplococcus pneumoniie, 42
Discus proliferus, 30

INDEX.

Diseusf of special rej^ioiiH, 132
Disiiifc^ction, (^liomiciil, 44

of Held of opei'iitioii, 47

of hands, 4")
Dorsal position, 76
Douthes, 90, 91

iiitra-tifceriiie, 93
Douglas' potu^h, 34
Drainage, iodoform gauze for, 53

nietliods for, r)3

reasons for, '}'3

tubes, 53
Dressings, 51

preparation of, 52
Dj'snienorrho'a, 1 1'l
Dysmenorrhd'a, e,,'igeHtive or in-
Hanimatory, 118

causes of, 119

definition of, 118

iliagnosis of, 1 19

symptoms of, 1 19

tieatment of, 120
Dysnienorrhiea, ineuibraiious, 122

character of disiiharge in, 122

chfira(!ter of pain in, 123

curetting in, 124

diagnosis of, from early abortion,
123

dilatation of cervix for, 124

galvanization for, 1(13, 124

menstrual decidua in, 122

microscopical examination in,
122

pathology of, 122

symptoms of, 123

treatment of, 124
Dysmenorrliu'a, neuralgic. iKi

causes of, 1 1(5

definition of, IKi

symptoms of, 1 17

treatment of, 1 17

use of drugs in, 1 17
Dysmenorrhd'a, obstru('tive, 120

causes of, 121

character of pain in, 12!

dihitation of cervix in, 122

flexions as a cause, 121

pin-iiole OS as a cause, 121

poh ,.>! and fibroids as causes,
121 .

symptoms ot, 121

treatment of, 122

use of stem pessary i!i, 122
DysineiiorrlKt'a, ovarian, 124

I)ysmenorrh(pa, ovarian, causes of,
124
dironic ovaritis in, 124
prolapse of ovary in, 124
treatment of, 124
Dj'smenorrhd'a, treatment of mixed

form, 126
Dyspareunia, 73, 127

Ectopic gestation, 35(1

abdominal, 358

ampullar, 357

changes in fatus after death in,
360

classification, 357

diagnosis of, 362

etiology of, 356

evai.aation of gestation sac
through vagina, 356

interstitial, 357

life of foetus in, 359

operation for, 364

primary, 357

rupture of sa(! in, 357, 361

secondary, 357

symjjtoms of, 360

tubal, 358

treatment of, at time of rupture,
363

treatment of, before ru[)ture,362
Fctropion of cervix uteri, 215, 226
Kczcnia of vulva, 147

diagnosis from herpes, 148
Electricity, a|>i)li(;ation of, 100

articles necessary for, 101

faradic, or indirect current, 102

galvanic, or direct current, 101
Electrodes, lOl

Apostoli's, 101

bipolar, 101

Engelman's, 101

large and small, 102

Martin's, 101

thera|ieutic ett'ectsof, 103
Elepliantiasis of vulva, 140
Elytritis, 177
Elytrorrhajjhy, 157
Enuiiet's button -hole oj)eration, 205

operation for fecal fistula, 193

perineorrhaphy, 1()9

tiachelorrhaphy needles, 217
Encephaloid carcinonui, 398
Endocervicitis, 224

INDEX.

407

Kndocervioiti.s, cdiise.f of, •J.'J.'t
cystic (legenenitioii in, 227
cliagii(),si.>< of, 227
eversion or ectio|)ioii in, 22(i
folliciilfir eroHion in, 22(5
lociil jippliuatioiis for, 228
opyrutive treatment for, 229
I)apilliiiy erosion in, 226
patholof^y of, 22o
symptoms of, 227
treatment of, 227
Ehflometritis, acute, 219

associated with metritis, 219,221
causes of, 220
diajrnosis of, 222
follow inir abortion or labor, 222
hysterectomy for, 223
pathology of, 220
prognosis of, 222
septic infection in, 222
streptococcus antitoxine in, 224
symiitonis of, 221
treatment of, 223
treatment of septic form, 223
Eulometritis, chronic corporeal,
229
causes of, 230
diagnosis of, 233
glandular, 230
interstitial, 230
pathology of, 230
I)hysical signs of, 233
I)rognosis of, 233
symptoms of, 232
treatment of, 104, llf), 234
Endometritis decidualis, 231
Endoscope, .Skene's, 83
Enterocele, lot!
causes of, Irili
formation of, 153, 155
treatment of, 156, 171
Epispadias, 132
Episio-cleisis, 191
E|)ithelioma of bladder, 206
of breast, 394
of ovary, 354
of uterus, 278, 287
atypical, of cervix, 278
cylindrical, of cervix, 278
pavement, of cervix, 278
Hcjuamous, of cervix, 278
Erect position for physical exam-
ination, 76
Ergot, tiierapeutic use of, 88, 113

Eruptive diseases of vulva, 147
Eryt.'iema of vulva, 147
Er^'sipelas of vulva, 147
Esmarch's inhaler, (>"
Etiology of diseases of women, 57
airest of development, 57
bacteria] a(;tion, 57
congenital doticiencies, 57
constitutional defects, 59
education, 60
infectious diseases, 61
operative causes, 62
sexual exhaustion, 61
Ether, ad'.iinistration of, 65
danger.ri of, 66

treatment of dangerous symp-
toms, 67
Examination, form for recording,

69
Examination of natient, (»8

abnormal varieties of menstrua-
tion in, 72, 74
history of patient 'n, 70
menstrual history in, 70
obstetric history in, 72
physical examination, 75
tumors and swellings in, 74
urinary and intestinal symjitoms
in, 75
Examination, methods of, 77
bimanual, 78
digital, 77
instrumental, 78
rectal, 78
vaginal, 77
visual, 77
Examination, position for, 7G
dorsal, 76
erect, 76

genu-pectoral, 76
Sims', 76

Treiidelenlwrg, 76
Exanthenmta, etl'ects of, 61, 112
Exstrophy of bladder, 195
Extra-peritoneal ha'inatocele, 365
Extra-uterine pregnancy, 365

Fallopian tubes, 28
ampulla of, 28
developuient of, 14
diseases of, 292
fimbria' of, 28
limbria ovurica of, 28

408

INDEX.

Fallopian tubes, infundibulutn of,
28

isthmus of, 28

malformations of, 292

ostium abdominale of, 28

ostium internum of, 28

structure of, 29
Fallopian tubes, inflammation of,
292

acute catarrhal, 293

acute purulent, 293

atrophy of, 306

hydrosalpinx, 304

interstitial salpingitis, 294

prognosis of, 298

pyosalpinx, 302

salpingo-oophorectomy for, 300

symptoms of, 295

treatment of, 299

tubo-ovarian abscess, 306
Faradism, 102
Fascia, anal, 36

deep perineal, 38

ischio-rectal, 36

obturator, 36

[»elvic, 36

perineal, 38

rectovesical, 36
Fibro-adenoma of breast, 390
Fibro-myoma of uterus, 261
Fibro-sarcoma of uterus, 289
Fibroids of uterus, 261

alterations and degenerations in,
265

course of, 266
■ diagnosis of, 267, 347

etiology of, 265

hysterectomy for, 271

ligature of uterine arteries for,
269

myomectomy for, 271

oophorectomy for, 270

structure of, 263

trf itment of, 105, 268

UP J of ergjt in, 268

varieties of, 262
Fibroma of bladder, 206

of ovary, 354

of vagina, 183

of vulva, 140
Fistula, fecal, 192

causes of, 192

operative relief for, 193

situation of, 192

Fistula, fecal, symptoms of, 192

treatment of, 192

varieties of, 192
Fistula, genital, 184

causes of, 184

definition of, 184

varieties of, 184
Fistula, urethrovaginal, 188
Fistula, uretero-vaginal, 189

causes of, 189

ca'liotomy for, 190

cystoscopic examination in, 189

implantation of ureter for, 190

situa*^ion of, 189

vaginal operations for, 190
Fistula, urinary, indirect methods

for relief of, 191
Fistula vesicouterine, 188

diagnosis of, 188

location of, 188

treatment of, 188
Fistula, vesi CO- utero- vaginal, 189
Fistula, vesico- vaginal, 184

Blazius' o{)eration for, 188

Bozeman's o{)eration for, 188

causes of, 184

detection of, 185

location of, 184

Simon's oj)eration for, 188

Sims' operation for, 186

Tait's operation for, 188
Follicular oophoritis, 326
Form for case taking, 69
Fossa navicularis, 18
Fourchette, 18
Frenum clitoridis, 18
Functional diseases, 107

Galvanism, 101

thera{>eutic effects of, 102
(ialvanometer, 101
Gastrotomy, 2V1
Gauzes, 52

(Jehrung's j)essary, 240
(Jenital cord, 14
Genital fistulaj, 184
(ienital folds, 15
Genital tubercle, 15
(ienital tuberculosis, 371

diagnosis of, 375

etiology of, 371

of ovaries, 374

primary, 371

INDEX.

409

Oenital tuberculosis, proytiosis of,
376
secondary, 371
symptoms of, 374
treatment of, 376
of tubes, 373
of uterus, 372
of vagina, 372
of vulva, 371
Genitals, development of, 12

anatomy of, 16
Genu-pectoral position, 76
(terminal spot, 31
(Jerminal vesicle, 31
Olands, axillary, anatomy of, 380

in cancer of breas^, 397
Glans clitoridis, 18
Glycerine, 91
Gonococcus, 42
Gonorrhtta, 127
Gonorrhreal vulvitis, 145
diagnosis of, 145
treatment of, 146
Goodell's dilator, 82
Gossypium, 89

Gout, effects on menstruation, 116
(iuaiacum, 110, 117
Gynandria, 133
Gynecological techni(|ue, 40

Hands, disinfection of, 45
Hank's dilator, 82
Hamamelis, 89, 113
Hiumatocele of canal of Nuck, 135
pelvic, 365

pudendal, 136
Hiematocolpos, 171, 175

dangers from, 172

mode of formation of, 171

symptoms of, 172

treatment o*^, 173
Hajmatoma of ovaries, 324

pelvic, 369

of round ligament, 135
Hiematometra, 172, 175

dangers from, 172

definition of, 172

diagnosis from ovarian cyst, 347

mode of formation, 172

symptoms of, 172

treatment of, 173
Ha'matosalpinx, 172, 305

diagnosis of, 308

HjL'mat()8aii)inx, sym[)toms of, 307
treatment of, 308
varieties of, 305
Heat, external application of, 90
Hemaphrodism, 133
androgyne, 133
gynanclria, 133
treatment of, 134
true and spurious, 133
Hemorrhage, post operative, 99
symptoms of, 99
treatment of, 99
Hemorrhage, pudendal, 136
Hernia, inguino-labial, 134
diagnosis of, 134
radical operation for, 134
situation of, 134
treatment of, 134
Hernia, vaginolabial, 134
method of production, 134
situation of, 134
treatment of, 134
Hernia, vulvar, 134

varieties of, 134
Hegar's anterior colporrhaphy, 158
colpo-perineorrhaphy, 167
method of amputation of cervix,
241
Herjies progenitalif, 148
diagnosis from chancre, 148
diagnosis from eczema, 148
treatment of, 148
Hydatid of Morgagni, cysts of, 331
Hydrastis Canadensis, 89, 131
Hydrocele, 135

diagnosis from hernia, 135
situation of, 135
treatment of, 135
Hydronephrosis, diagnosis from

ovarian cysts, 347
Hygiene, general, 87
Hydrosalpinx, 304
diagnosis of, 308
pathology of, 304
symptoms of, 307
treatment of, 308
Hymen, absence of, 171

anatomy of, 21
Hymen, atresia of, 171
dangers arising from, 173
diagnosis of, 172
hicmatocolpos from, 171
ha'inatometra from, 172
hivmatosalpinx from, 172

410

INuEX.

Hymen, atresia of, symptoms of,
172

treatment of, 173
Hymen, imperforate, 171

malformations of, 171

varietiep of, 20, 171
Hyijenimia of ovary, 324
Hypentsthesia of vulva, 150

pathology of, loO

treatment of, 151
Hyijertrophy of uterus, 240
Hysterectomy, abdominal, 273

complete, 276

extra-peritoneal treatment of the
stump in, 274

indications for, 273

intra-peritoneal treatment of the
stump in, 275

partial, 273

varieties of, 273
Hysterectomj', vaginal, 286

by clamps, 285

by ligatures, 283
Hysterectomy sacral, 286
Hysteropexy abdominal, 253

vaginal, 2o2

Ichthyol, 91, 92
Infundibulum, 28
Injuries of vulva, 136
Instruments, list of, 55

for cii'liotoniy, 55

for dilatation of cervix and cur-
etting, 56

for operations outside of hospi-
tals, 56

for trachelorrhaphy, 56

for perineorrhaphy, 55

for vaginal hysterectomy, 55
Interfollicular oophoritis, 326
Interstitial oophoritis, 326
Intra-ligamentous fibroma of uter-
us, 262
Intra-{)eritoneal hfumatocele, 365
Introductory, 9
Inversion of uterus, 257

causes of, 258

diagnosis of, 258

instrumental treatment of, 260

manual treatment of, 259

operative treatment of, 260

symptoms of, 258

varieties of, ' '7 - - .

Iodine, 90, 92

Iron, thera|jeutic use of, 110, 117

in amenorrhua, 110

in monorrhagia, 115

in metrorrhagia, 115

in neuralgic dysmenorrhd-a, 117
Iodoform gauze, prejMiration of, 52

powder, 54
Irrigating fluids, 53

normal salt solution, 54

selection of, 54

temperature of, 54
Irrigation during operations, 53

of bladder, 93

of uterus, 93

Kangaroo tendon, 51
Kelly's method for examination of
bladder, 85
for ureteral catheterization, 85
Koeberle's serre-nu-ud, 273
Kraske's operation for hysterec-
tomy, 286
Kraurosis vulvit;, 151

Labarracque's solution, 46
Labia majora, structure of, 17
Labia minora, structure of, 18
Laparotomy, 271
Lefort's oi)eration for prolapse of

vagina, 159
Leucorrhd'a, 72, 129

appearance of discharge, 130

etiology, 130

idiopathic, 130

symptoms of, 130

symptomatic, 130

treatment of, 131
Lichen of vulva, 147
Ligaments, broad, 25

of bladder, 32

ischio-perineal, 38

ovarian, 13, 29

perineal, 38 -

round, 25

sacro-sciatic, 16

sacr. iterine, 25

triangular, 38

uterine, 24 -^

vesico-uterine, 24, 32 '

Ligatures, choice of, 48
Liquor folliculi, 30

INDEX.

411

Lithoijedian, 360
Lupus of vulva, 141
Lyniphutice of breast, 380
Lvsol, 92

Magnesia sulphate, 88

Malaria, effects on menstruation.

108, 112, 116
Malformations of bladder, 195
of breast, 382
of hymen, 171
of ovaries, 320
of tubes, 292
oi urethra, 194
of Uu'M-us, 207
of vagina, 173
of vulva, 1.32
Malignant deciduoma, 290

peritonitis, 379
Mammary abscess, ,384

cysts, 390
Manganese binoxide. 111
Mastitis, acute, 383
l)athology of, 384
symptoms of, 383
treatment of, 38")
Mastitis, chronic, 385
interstitial, 385
pathology of, 386
treatment of, 387
Meatus urinarius, 18, 31
Membrana granulosa, .30
Menopause, 72, 113
Menorrhagia and metrorrhagia, 1 12
action of eigot, digitalis, ham-

amelis and hydrastis in, 11
action of iron and arsenic in,

112, 115
causes of, 112
curetting for, 114
definition of, 1 12
galvanization for, 104, 115
treatment of, 113
use of hot water in, 114
use of tampons in, 114
Menstrual decidua, 122
Menstruation, 70
abnormal varieties of, 72
age of commencement of, 71
atteiu'ant symptoms of, 71
daily amount of discharge, 71
delayed, 107, 109
disorders of, 107

Menstruation, duration of flow, 71
precocious, 115
rhythm of flow, 71
vicarious. 111
Mercury bichloride, 44, 91, 146
Mesosalpinx, 13
Mesovarium, 13
Metritis, acute, 219
exanthematous, 219
fungous, 219
granular, 219
gonorrheal, 219
traumatic, 219
post-puerperal, 219
puerperal, 219
ulcerating, 219
Metritis, chronic, 235
etiology of, 235
pathology of, 235
symptoms of, 236
synonyms of, 235
treatment of, 237
Metritis, chronic endometritis, 229
Metrorrhagia, 112
Micrococcus lanceolatus, 42
Milk, post-operative use of, 97

peptonized, 97
Mineral waters, use of, 88
Mens Veneris, structure of, 17
Morphia, post operative use of, 98
Mullerian ducts, 13
Muscle, bulbo-cavernosus, 38
coccygeus, 37
compressor urethra', 31, 39
constrictor vagina-, 19, 39
erector clitoridis, .38
ischio-cavernosus, 38
levator ani, 34, 37
transversus perinei, deep, 39
transversus i)erinei, superficial,

39
sphincter ani, .34
sphincter vagina-, .34, 38

Mummification inectopicirestation
360

Myo-fibroma of uterus, 261

Myoma of bladder, 206

of uterus, 261

of vulva, 140
Myomectomy, 271

N.
Nabothian glands, 23, 227
Naphthol, 45

412

INDEX.

Neoplasms of bladder, 206

of breast, 3MH

of uterus, benign, 2(51

of uterus, malignant, 276

of vagina, 182
Neuralgia, ovarian, 105

{)elvic, 105
Neuralgic dysmenorrhd'a, 116
Neuroma of vulva, 141
Neuroses of breast, 383
Nipple, diseases of, 382

fissures of, 382

inflammation of, 382
Nuok, caiuil of, 26, 135
Nux vomica, 117
Nymphif, 18
Nymphonumia, 128

causes of, 128

definition of, 128

treatment of, 128

Obstetric history of patient, 72
Obturator pouch, 35
Oophorectomy, 125, 300, 302
Oophoritis, acute, 326

course of, 327

etiology of, 326

symptoms of, 327

treatment of, 328
Oophoritis, chronic, 328

etiology of, 329

symptoms of, 329

treatment of, 105, 330
Operating suits, 45
Organs cf generation, 17
Ormsby inhaler, 66
Ostium abdominale, 28

internum, 28
Ovarian cysts, 331

abdominal stage of, 343

accidents and complications in,
341

diagnosis of, 345

pedicle in, 341

pelvic stage of, 342

prognosis of, 344

treatment of, 348
Ovaries, at. ,ihy of, 328

cystic degeneration of, 328
Ovaries, cysts of, 331

classification of, 331

etiology of, 339
Ovaries, dermoid cysts of, 337

Ovaries, dermoid cysts of, contents
of, 338

mode of origin of, 339
Ovaries, development of, 13

anatomy of, 29

structure of, 29
Ovaries, diseases of, 320
Ovaries, dis{)lacements of, 321

acijuired, 321

congenital, 321
Ovaries, liy[)eriemia and hajmatoma
of, 324

etiology of, 325

symptoms of, 325

treatment of, 325
Ovaries, malformations of , 320

neoplasms of, 330
Ovariotomy, 348

accidents during, 352

delivery of cyst in, 349

for broad ligament cysts, 353

history of, 349

incomplete operation in, .i54

methods of operating in, 359
Ovary, cysts of the corpus luteum,
333

cyst of the hvdatid of Morgagni,
332

follicular cysts of, 333

hirge cysts of, 333

microcysts of broad ligament,
332

small residual cysts of, 331

supra-tubal cysts, 332

tubo-ovarian cysts, 333
Ovary, hernia of, 323

varieties of, 323

radical oi)eration for, 324
Ovary, prolapse of, 322

causes ot, 322

diagnosis of, 323

symi)toms of, 323

treatment of, 323
Ovary, jnoliferating glandular
cysts of, 333

(contents of, 335

formation of, 334

origin of, 337
Ovary, proliferating papillary cysts
of, 336

contents of, 335

formation of, 336

origin of, 337
Ovary, tuberculosis of, 374

INDEX.

418

Ovary, solid tumors of, 354

carcinoma, 3").")

epithelioma, 3r)5

fibroma, S'>i

treatment of, 355
Ovum, structure of, 39

Paget's disease, 394

Papillary cystoma of breast, 390

Pupdloma of bladder, 2(J(5

of vulva, 139
Parametritis, 104, 310
Parametrium, 25, 36
Parasites, cause of pruritus, 149
Para-uterine pouch, 35
Para-vesical pouch, 35
Parenchymatous cancer of uterus.

277
Parenchymatous metritis, 235
Paroophoron, 25, 31
Parovarium, 13, 25, 31

cysts of, 339
Patient, i)reparation of, for opera-
tion, 46
Pedicle in ovarian cysts, 351

ligature of, 351
Pelvic abscess, 312
extension of, 312
situation of, 312
treatment of, 312
Pelvic diaphragm, 37
functions of, 37
muscles of, 37
Pelvic floor, anatomy of, 36, 153
functions of, 1.53
lesions of, 1,52, 171
Pelvic floor, causes of weakness of,
153
constitutional, 153
laceration, 154
over distension, 153
senile atrophy, 154
subinvolution, 1,54
Pelvic Hoor, conditions associated
with lesions of, 154
cystocele, 155
enterocele, 156
prolai)se of vagina, 155
rectocele, 156
Pelvic floor, treatment of lesions
of, 1,56
colporrhaphy in, 157, 1.59
local astringents in, 156

Pelvic floor, treatment of lesions
of, perineorrhaphv in, 160
supplementary suppoits in, 156
suigieal methods in, 157, 171
tampons in, 156
Pelvic hii-matocele, 365
causes of, 366
Cd'liotomy for, 3().S
diagnosis of, 367
formation of, 366
symptoms of, 36(i
termination of, 367
treatment of, 36.S
Pelvic ha-matoma, 3(i9
etiology of, 369
pathology of, 3(59
symptoms of, 370
treatment of, 370
Pelvic inflammation, 309
Pelvic lymphangitis, 31(»
Pelvic peritonitis, 128, 315
diagnosis of, 318
etiology of, 315

intraperitoneal abscess in 316
pathology of, 316 '

prognosis of, 319
treiitment of, 319
Pelvic peritoneum, .35
Perimetritis, 104, 315
Perineal body, 39, 153
fascia, 38
ligaments, 38
muscles, 38, 1,52
region, 38
Perineorrhapliy, 160

for complete rupture, 163
control of hemorrhage in, 16''
denudation in, 161
Emmet's operation, 169
Hegar's operation, 167
for incomplete rupture, 161
for rui)ture of recto-v;iginal sep-
tum, 164

sutuitJi^ in, 162

Tait's operation, 165
Perineum, craise of loss of power
of, 153

laceration, 154

ovei' destension, 153

senile atrophy, 1.54

subinvolution, 154
Perineum, laceration of, 160

effects of, 160

varieties of, 160

414

INDEX.

Perineum, results of loss of power
of, ISf)

cystocele, l^H

eufcerocele, ITHS

prolapse of viiffina.. 155

rectocele, 155
Perineum, blood supply of, 40

functions of, 153

nerve supply of, 40

structure of, S9
Perioophoritis, 315, 326
Perisalinngitis, 315
Peritoneum, pelvic, 35
Peritonitis, tubercular, 346

diagnosis from ovarian cysts, 346
Peri-uterine phlegmon, 310
Permanganate gauze, 52
Phenacetine, 1 18
Phenol, 92
Phlegmonous inflammation of

vulva, 137
Phosphorus, 117
Plastic operations, post-operative

treatment of, 100
Plethora, effects on menstruation,

1(»S, 116 I

Plumbi acetatis, 01, 146
Pole changers, 1(H
Poles of battery, 101
Polypoid flbromaof uterus, 262, 270
Polypus, uterine, 261

vaginal, 183
Post-o{jerative treatment, 96
Potassium permanganate, 45, 111,

146
Powder for dressings, 54
Pregnancy, extia-uterine, 356

abdominal, 357

ovarian, 357

tubal, 357
Prepuce, 18
Procidentia uteri, 255
I'rolapsus urethra', 142
Prolapsus uteri, 254

causes of, 255

complications of, 255

symptoms of, 256

treatment of, 256
Pruritus vulvio, 148

causes of, 149

clinical appearance of, 148

[Mithology of, 149

symptoms of, 149

treatment of, 149

Puberty, delayed, 107
Pudendal hn'matocele, 136
Puflendal hemorrhage, 136
Pulsatilla, 110, 118
Purgatives, 87
Pyii-mia, 41
Pyosalpinx, 302

definition of, 302

diagnosis of, 308

l)atiiology of, 303

symptoms of, 307

termination of, 304

treatment of, 308

Rectocele, 156

mode of formation, 153, 155, 256

complications of, 156

treatment of, 156, 171
Recto-uterine j)ouch, 35
Rectum, structure of, 34

muscles of, 34

relations of, 34
Retro-ovarian shelves, 35
Resolvents, 90

Restlessness after oi»eration, 98
Retroversion and retroflexion of
uterus, 246

causes of, 246

operative treatment for, 252

shortening round ligaments for,
252

symptoms of, 246

treatment of, 249

use of pessaries in, 249

vaginal fixation for, 252

ventral fixation for, 253
Rheophores, 101
Rheostats, 101

Rheumatism, effects on menstrua-
tion, 116
Rosenmuller's organ, 13, 21

Salicylates, 110
Salicylic acid, 45, 146
Salpingitis, 292

acute catarrhal, 293

acute jHirulent, 293

interstitial, 294

prognosis of, 298

salpingo-oophorectomy for, 300

symptoms of, 295

treatment of, 104, 298

INDEX.

415

Salpiiifro-oophorectomy, 3()0
abdominal, IM)
vaginal, 302
Salt solution, normal, 54
Sapni'inia, 41
Saifjonia botryoideM, 290
Sarcoma of breast, Hm
of ovary, 355

uteri ileciduo-cellulare, 290
Sarcoma of uterus, 289
diagnosis of, 291
symptoms and course of, 290
treatment of, 291
varieties of, 2S9
Sarcoma of vulva, 141
Schroeder's method for amputation

of cervix, 239, 241
Scirrhus of breast, 396
adhesion of skin in, 396
axillary glands, infection in,

397
axillary glands, removal in, 400
pathology of, 39G
retraction of nipple in, 396
treatment of, 400
Sedatives, 88
Septicemia, 41
Sepsis, 41
Serre-n(vud, Koeberle's, 273

Tait's. 273
Serum therapy in septic endome-
tritis, 224
Sex, diagnosis of, 133
Sexual incompatability, 127
Shock, post-operative, 99
Silk sutures, 48
Silkworm gut, 49
Silver nitrate, 92
Simon's operation for vesico- vaginal

fistula, 188
Simpson's sound, 80
Sims' anterior colporrhaphy, 157
operation for vesico- vaginal fistu-
la, 186
Skene's endoscope, 83
glands, 32

hawk-bill scissors, 218
Speculum, Burrage's, 93
bivalve, 79
dack-bill, 79
Edebohl's, 217
Ferguson's, 78
vaginal, 78
Sponges, 62

Sponges, bleeching of, 52
gauze, 53
marine, 52
Staflfordshire knot, 352
Staphylococcus citreus, 41
epidermidis ulbus, 41
pyogenes albus, 41
pyogenes aureus, 42
Steriliziition, 43
of catgut, 49
of catgut chromicized, 51
of dressings, 51
by dry heat, 43
of field of o{)eration, 47
fractional, 44
of hands, 45
of instruments, 48
of irrigating fluids, 54 , '■■', '
of kangaroo tendon, 51
Kronig's method of, for catgut,

49 ^

by moist heat, 44
of normal salt solution, 54
of o{)erating trays, 48
of silk, 48
of silkworm gut, 49
of 8{)onges, 52
by steam, 44
of water, 54
Sterility, 125
ac(juired, 127
causes of, 127
congeniuil, 127
definition of, 127
treatment of, 128
Stenosis of cervix, 259 ^

Stolti' method for anterior colpor-
rhaphy, 159
Streptococcus antitoxin in septic

endometritis, 224
Streptococcus pyogenes, 42
Stryhnine in amesthesia, 68

post-operative use of, 96
Subinvolution and sclerosis of

uterus, 235
Submucous fibroma of uterus
262

Subperitoneal fibroma of uterus.

262
Sutures in ca-liotomy, 272

buried, 273

in mass, 272

tier, 273

through and through, 272

41()

INDEX.

Tait'H opoiiitioii for vewco-vaj^iiml
fistiilii, ISH

|)orine()rrtiii|>liy, 165

Herre-iiii'iitl, 'iT-H
TiiiiHK)i>H, !t2
Taiiiiic acid, Stl, 14(i
Te(,'l)ni(|ue, gynucoloj^icuil, 40
Telaiigieotatii! inyoma, 'J()4
Therapeutics, gyiiiicological, 8(i

hygiene, general, 87

purgatives, 87

resolvents, 90

sedatives, 88

special gyna-cological drugs, 88

tonics, 88
Therapeutics, local, 90

applications to uterus, 92

counter-irritation, 91

curetting, 94

electric currents, 100

external applications, 90

internal applications, 90

intra-uterine injections, 93

{lelvic massage, 9()

vesical injections, 93
Tiierapeutics, post-operative, 96
Thiersch's solution, 54
Thirst, treatnient of, after cu'lio-

tomy, 97
Thomas' cup pessary, 246
Thrombus of broad ligament, 367
Tonics, 88
Toxaniiia, 41
Tracheitis, 224
Trachelorrhaphy, 216

indications for, 216

ligatures for, 217

nietiiods for operating, 217

needles for, 217
Trendelenberg position, 76
Tiiatigular ligament, 38
Tub; I pregnancy, 358
Tube, .;trophy of, 306
Tuberculo'^is, etiects on menstrua-
tion, iM8, 112
Tuberculosis, genital, 371
Tuberculosis of peritoneum, 377

diagnosis of, 379

treatment of, 380

symptoms of, 378

varieties of, 378
Tubes, inHanmiation of, 292

tuberculosis of, 373

Tubo-ovariaii abscess, 306
Tumors of breast, 388

of ovaiy, 330

(if uterus, 261, 276

of vagina, 182

of vulva, 139, 143
Tunica albuginea, 30

fibrosa, 30

propria, 30
Tui'pentine, 91
Tympanites after ojieration, 98

Urachus, 14
Ureteral catheter, 85

searcher, 85
Ureteritis, 206
Uret-ero cystoscojjy, 190
Ureters, catheterization of, 85

diseases of, 206

relations of, 33
Urethra, anatomy of, 31
Urethra, atresia of, 194

causes of, 194

surgical treatment of, 195

symptoms of, 194

varieties of, 194
Urethra, dif'efises of, 141, 194
Urethra, granular erosion of, 198

appearance of urethra in, 198

treatment of, 198
Urethra, irritable, 196

causes of, 196

definition of, 196

treatment of, 196
Urethra, malformations of, 194

causes of, 194
Urethra, prolapse of, 142, 199

diagnosis of, 143

treatment of, 143
Urethra, stricture of, 198

causes of, 198

treatment of, 198
Urethrtd caruncle, 141, 199

situation of, 141

structure of, 141

8ym[)tom8 and appearance of, 142

treatment of, 142
Urethral dilator, 84

speculum and obturator, 84
Urethral venous angioma, 142, 199

diagnosis of, 142
Urethritis, 196

acute, 196

INDEX.

417

UrefchritiH, chronic, l)»7
(lefitijtioii of, I'Hi
(liatfnoHiM of, 107
Konoriho'ul, I4r,, ISO, H)7
H.VtnptoniH of, 197
treiitiiiciit of, 1!»S
Urethiocclo, |j)il

(!oinpli(;iU.ioiis of, i!))»
foriimlioii of, l!><j
HyniptoinH of, IJ«>
treatment of, MM»
Urinary fintulic, IH4
Urinary oifranw, anatomy of, 31
Uro-geiiittil rej-ion, 88
Urogenital MinnK, 14
Uterine dreHHing fon;ei)8, 81

sound, 80
Utero-abdominnl pouch, 3;">
UteruH, anatomy of, 21
Uterus, atresia of, accjuired, iJSO
Uterus, atresia of, congenital, 211
diagnosis of, 21 1
definition of, 21 1
sym|»toms produced by, 171, 172.

211
treatment of, 211
Uterus, applications to, 92
blood supply of., 27
cancer of, 276
Uterr cancer of body, 287
syi .ptoms and diagnosis of, 288
treatment of, 289
varieties of, 287
Uterus, cancer of cervix, 277
abdominal hysteiectomy for, 282
palliative treatment for, 28(5
pathology of, 277
radical treatment for, 281
symptoms of, 279
vaginal hysterectomy for, 282
Uterus, diseases of, 207
Uterus, displacements of, 241
anteflexion, 24,3
anteversion, 242
inversion, 257
latero-flexions, 25,3
laiero-versions, 2.'53
retroversion and retroflexioi. 246
Uterus, examination of, 81
Uterus, fibroid tumors of, 261
diagnosis of, 267
degenerations in, 265
etiology of, 265
hysterectomy for, 273

Uterus, fibroid tumors of, intor
stitial, 2(i2
intraligamentous, 2(i3
myomectomy for, 271
Dophoreitomy for, 270
polypoid, 262
structure of, 263
submucous, 2(i2
subjwritonoal, 262
Uterus, glandular polypus of, 261
Uterus, hypertrophy of, 240
Uterus, intlanunation of, 219
acute endometritis, 219
a<'ute metritis, 219
chronic corporeal endometritis.

229
chronic endocervicitis, 224
Uterus, injuries of, 213
Uterus, accidental puncture of, 213

treatment of, 213
Uterus, lacuration of cervix, 213
causes of, 213
digital examination in, 216
examination by speculum in, 216
o{)er:itive treatment for, 216
pathological changes in, 214
symptoms of, 215
varieties of, 213
Uterus, ligaments of, 24
Uterus, malformations of, 207
absence of, 208
bicornis, 209
causes of, 207
congenitally atrophic, 212
diagnosis of, 210
didelpliys, 210
frt'tal, 212
infantile, 212
septus, 210
subseptus, 210
unicornis, 209
Uterus, nerve su|)ply of, 27
neopiafmo of, 261
position of, 24
Uterus, sarcoma of, 289
diagnosis of, 291
diflusfc, 290
fibro-sarcoma, 289
sarcoma botryoiden, 290
symptoms of, 290
treatment of, 291
Uterus, sclerosis of, 2.35
stenosis of, 239
structure of, 23

418

INDEX.

UteruM, nubinvolution of, 103, 235

HiipiKirtin^ npiMvratii8 of, 24
Uttiru8, tuboruuioHiH of, 372

Vagina, anatomy of, 19
^^agina, uppliRutionH to, 91

arreHt of developnioiit of, 174
V'agiiia, atresia and HteiioHi8 of, 173

<!au8e8 of, 174

complete and incomplete, 174

(lutinition of, 174

oHects of. 17r)

physical examination in, 17r>

surgical nietho<ls for relief of, 176

Hyirptoms of, 17«'»

treatment of, 175
Vagina, blotnl supply of, 21
Vagina, carcinoma of, I S3, 27S

pathology of, 1S3

symptoms and treatment of, 183
Vagina, cyats of, 182

diagnosiH of, 182

patTiology of, 182

treatment of, 1 82
Vagina, development of, 14, 174

diseaHes of, 171

double, 17.'»

tibroma of, 183

fornicet* of, 19

malformations of, 173

mucous ])olypi of. 183

neopla.sms of, 182

ocdu.sion of, 175
Vagina, prolapse of, 155

acute, 155

causes of, 15.5

chronic!, 155

methods of production of, 153,
155

treatment of, 156, 171
Vagina, structure of, 21

tuberculosis of, 372
Vaginal fixation of uterus, 262
Vaginal hysterectomy, 282

by clamps, 285

by ligatures, 283
Vaginal hyatero{)exy.
Vaginismus, 129

causes of, 129

definition of, 1.

treatment of, 12s»
Vaginitis, 177

acute, 177

Vaginitis, adhesive, 179

aphthous, 179

(jlironic!, 180

cystic, 179

definition of, 177

diagnosis of, 180

emphysematous, 179

etiology of, 178

gcmorrlKi-al, 145, 178, 180

granular, 179

pathology of, 178

primary, 177

secondary, 177, 179

simple, 178

symptoms of, 179

treatment of, 181

varieties of, 177

vesicular, 179
Varicose tumors of vulva, 141
VegeUitive cancer, 277
Ventral fixation of uterus, 2,53
Vesical calculus, 205
Vesico-hystero-cleisis, 189
Vestibule, 18

formation of, 15
Vestibulo-vaginul glands, 18
Viburninn pnmifolium, 89, 118
Vitelline membrane, 'M
VitelluH, 31

Vomiting, |K)8t-o|)erative, 100
Vulsellum, 81
Vulva, 17

development of, 15

diseases of, 132
Vulva, eruptive diseases of, 147

acne, 148

eczema, 147

erysiiielas, 148

erythema, 148

herjws progeni talis, 148

lichen, 147

prurigo, 147
Vulva, Tuematocele of, 1.35

hii'matoma of, 135

hernia of, 134

hydrocele of, 135

hy{)era'stlieaia of, 150

inrtammation of, 143

kraurosis of, 151
Vulva, malformations of, 132

absence of, 132

absence of labia in, 133

absence of clitoris in, 132

adherent prepuce in, 132

INDEX.

419

Vulvn, iimlfortniitioriH of, enisiwi-
fliafl, 132
hemaphrodiHrn, 1.S2
hyjHWfMMlias, i;J2
Vulva, plih^jrrnonous inflammation
of, 137
pruritus of, 148
pudendal lia-niatocelo, I3(J
pudendal lieniorrliago, !36
tuberculosis of, 371
Vi iva, tumors of, 1.39
condylomata, I3«>
<ilci)lmMti,isiM, 140
fibromata, 14(1
liponiata, 140
inyomatu, 140
myxomata, 140
neuromata, 141
papillomata, 13!)
r>rolapsuM uretlira-, 142
urethral earunele, 141
urethral venon.s ani'lonui, 142
Vulvitis. 143
clasHifioatii of, 143
diai,'nosis ol 14,')
diphtheritic, 144
follicidar, 144

\ ulvitis, gangrenous, 147

gonorrh<i"al, 145

{ihlogmonous, 144

purulent, 144

simple, 143

symptoms of, 144

trwitment of, 1 46
Vulvo-vaginal glands, 19
Vulvo- vaginal glands, abscess of,

cysts of, 1.38

Water, warm, use of, 113, 118, 124

12.'5, 126
Water, sterile, 54

thera{)eutic effects of, 90, 91
Whites, 129
White line, .36
Wolffian body, 12
Wolffian ducts, 12
Wylie's dilator, 82

Zona pellupida, 30
Zinc chloride, 124
Zinc sulphatf;, 91