Class lliiifld Book. K CopyrigiitN . COPYRIGHT DEPOSIT. A TEXT-BOOK OF GYNECOLOGY EDITED BY CHARLES A. L. REED, A. M.. M. D. President of the American Medical Association 11900-1901 ) ; Gynecologist and Clinical Lecturer on Surgical Diseases ofAWfomen at the Cincinnati Hospital ; Fellow of the American Association! of Obstetricians and Gynecologists ; Fellow of the British Gynecological Society ; Corresponding Member of the National Academy of Medicine of Peru, etc.* ILLUSTRATED BY R. /. HOPKINS NEW YORK D. APPLETON AND COMPANY 1901 A THE LIBRARY OF CONGRESS, Two Copies Received APR. 4 1901 Copyright entry CLASS ^XXc. N». COPY 8. Copyright, 1901 By D. APPLETON AND COMPANY r TO R. C. STOCKTOX REED, M. D., LL. D. FORMER PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS IN THE CINCINNATI COLLEGE OF MEDICINE AND SURGERY THE LABOR OF THE EDITOR IX THE PREPARATION OF THIS WORK IS DEDICATED AS AN EXPRESSION OF FILIAL AFFECTION PKEFACE In the preparation of this work there has been held in view the three following special objects, viz.: 1. The formulation of a Text-Bool- which shall serve as a working manual far practitioners and students, and which shall embrace the best approved developments of gynecology, including those of later date than are. or can be, included in a work of similar magnitude by a single author. For this purpose assignment of topics was made to a considerable number of writers, but only to those who have acquired reputation in connection with the subjects upon which they were asked to write. This division of labour, giving to each writer a relatively small amount of work, insured a careful preparation of copy in the shortest possible time, and the issuance of a strictly up-to-date volume. 2. The co-operation of the various departments of medical science in their synthetic relation to gynecology. For this purpose contributions were invited from several writers who are not gynecologists in the strict sense of the term. Thus the various topics upon pathology were given to pathologists, while those relating to bacteriology, dermatology, neurology, hygiene, etc.. were assigned with similar appropriateness. As a consequence a single chap- ter, in some instances, is based upon contributions from several writers, while the whole has been rendered consecutive, systematic, and homo- geneous by the Editor. The work is not, therefore, in any sense a mere aggregation of monographs. 3. The specific recognition of the work of investigators and oper- ators in gynecology and correlated departments. For this purpose invitations to contribute to the work were limited to those who had already contributed something to science. As a con- sequence writers were asked to treat their respective topics not only in a general way. but freely to express their individual views relative to the same. V yi A TEXT-BOOK OF GYNECOLOGY The Editor has rendered into the third person all references by the different writers to their own work. In this way and by reference to the table of contents, the reader is enabled to determine the authorship of each particular paragraph. The Editor feels a special sense of obligation to the contributors to the volume, whose clear and lucid comprehension of his objects and design and whose scholarly contributions have done much to lessen his task. The work of illustration has been in the hands of Mr. E. J. Hop- kins, whose previous special studies in anatomy as applied to art, and whose almost intuitive comprehension of the task, combined with ex- cellent technical skill on his part, has enabled him to add materially to the value of the book. Dr. Kenneth W. Millican, Assistant Editor of the New York Medi- cal Journal, has kindly seen the pages through print, and it is to his vigilance, industry and scholarly supervision, that the Editor is in- debted for the elimination of errors, which would have, otherwise, escaped detection. To Miss Georgia A. H. Isaminger, secretary to the Editor, acknowl- edgments are due for efficient service in transcribing and arranging manuscript. To the Publishers, the highest praise must be given for cordial co-operation at every stage of the work. Chakles A. L. Reed, Editor. Cincinnati, Ohio. CONTKIBUTORS J. W. Ballantyne, M. D.. F. R. C. P. E, F. R. R. Lecturer on Midwifery and Gynecology, School of the Royal Colleges. Edin- burgh. Scotland. J. H. Carstens, M. P. Professor of Obstetrics and Clinical Gynecology in the Detroit College of Medicine. Detroit, Mich. Murdoch Cameron, A. M., M. D.. F. R. C. S. Eegius Professor of Midwifery in the University of Glasgow. Glasgow, Scotland. Henry C. Coe. M. P.. M. R. C. S. Professor of Gynecology in the University of Bellevue Medical College. New York, X. Y. John G. Clark. M. A.. M. P. Professor of Gynecology in the University of Pennsylvania. Philadel- phia, Pa. F. X. Percoi. A. M., M. P. Clinical Professor of Diseases of the Nervous System in Jefferson Medical College. Philadelphia, Pa. Walter B. Dorsett, M. D. Professor of Obstetrics and Clinical Gynecology in the Beaumont Medical College. St. Louis, Mo. L. H. Punning, M. P. Professor of the Diseases of Women in the Medical College of Indiana. Indianapolis, Ind. Frank P. Foster, M. P.. LL. P. Editor of the New York Medical Journal. Xew York. X. Y. Samuel G. Gant, M. P. Professor of Rectal Surgery in the Xew York Post-Graduate Medical School. New York, X. Y. Hobart Amory Hare, M. A., M. P. Professor of Therapeutics in Jefferson Medical College. Philadelphia. Pa. Malcolm L. Harris. A. M., M. P. Professor of Surgery in the Chicago Polyclinic. Chicago. 111. Maximilian Herzog, B. S., M. P. Professor of Pathology in the Chicago Polyclinic. Chicago. 111. R. J. Hopkins, B. S. Artist. Xew York, X. Y. Joseph Tabor Johnson, A. M.. M. P. Professor of Gynecology and Abdominal Surgery in the University of Georgetown. Washington, D. C. vii viii A TEXT-BOOK OF GYNECOLOGY Wyatt G. Johnston, M. D., F. R. C. S. Professor of Bacteriology and Pathology in McGill College and University. Montreal, Canada. Matthew D. Mann, A. M., M. D. Professor of Gynecology in the Medical Department of the University of Buffalo. Buffalo, N. Y. Thomas Charles Martin, B. S., M. D. Professor of Pathology and Rectal Diseases in the College of Physicians and Surgeons. Cleveland, Ohio. Lewis S. McMurtry, M. D., LL. D. Professor of Gynecology and Abdominal Surgery in the Hospital Medical College. Louisville, Ky. Dan Millikin, M. D., LL. D. Former Professor of Materia Medica and Therapeutics in the Miami Medical College of Cincinnati. Hamilton, Ohio. Henry P. Newman, M. A., M. D. Professor of Gynecology in the College of Physicians and Surgeons of Chi- cago. Chicago, 111. William Warren Potter, A. M., M. D. Secretary of the American Association of Obstetricians and Gynecologists, and Editor of the Buffalo Medical Journal. Buffalo, N. Y. A. Ravogli, M. D., LL. D. Professor of Dermatology in the University of Cincinnati. Cincinnati. Ohio. Charles A. L. Eeed, A. M., M. D. Gynecologist and Clinical Lecturer on Surgical Diseases of Women at the Cincinnati Hospital. Cincinnati, Ohio. Hunter Robb. A. M., M. D. Professor of Gynecology in the Medical Department of the Western Reserve University. Cleveland, Ohio. James F. W. Ross, M. D., L. R. C. P.. England. Lecturer on Clinical Gynecology in the University of Toronto. Toronto, Canada. A. W. Mayo Robson, F. R. C. S. Professor of Surgery in the Yorkshire College of the Victoria University. Leeds, England. J. L. Rothrock, A. M., M. D. instructor in Pathology in the University of Minnesota. St. Paul, Minn. W. Japp Sinclair, M. A., M. D.. F. R. C. S. Professor of Obstetrics and Gynecology in Owen's College, Victoria Uni- versity. Manchester, England. Horace J. Whitacre, B. S., M. D. Lecturer on Clinical Surgery and Demonstrator of Pathology in the Univer- sity of Cincinnati. Cincinnati, Ohio. E. Gustave Zinke, M. D. Professor of Obstetrics and Clinical Midwifery in the University of Cincin- nati. Cincinnati, Ohio. CONTENTS Gynecology defined . Historical resume Gynecology as a specialty Nomenclature of gynecology Radicalism and conservatism in gynecology CHAPTER I PROLEGOMENA PAGE . Reed 1 1 2 . Foster 3 ovnecologv . . Reed 4 CHAPTER II GENERAL ETIOLOGY OF DISEASES OF Prevalence Causes Civilization . Education Personal habits . Occupation . Diseases Copulation . Prevention of concept Criminal abortion Childbirth . The social evil WOMEN Reed CHAPTER III GENERAL PATHOLOGY OF THE FEMALE GENERATIVE ORGANS Local pathology conforms to general pathologic laws Peculiarities depending- upon differentiated functions Menstruation ........ Ovulation in its relation to pathologic states Gestation in its relation to pathologic states The poise of the uterus and its variations . Bacterial origin of inflammatory diseases of the femal Tuberculosis ........ Syphilis ......... Trophic changes . Xeoplasms . Herzog genitalia . 12 12 12 13 13 15 15 17 17 17 18 A TEXT-BOOK OF GYNECOLOGY CHAPTER IV GENERAL THERAPEUTICS OF GYNECOLOGY General medication Serum therapy Local medication Balneotherapy . Suggestion Electricity Massage Reed PAGE 20 21 22 22 23 23 24 CHAPTER V THE GYNECOLOGICAL ARMAMENTARIUM The gynecological armamentarium . . . . . . Root) 27 CHAPTER VI DIAGNOSIS Definition and scope . Indications and contraindications for vaginal examination The gynecologic examination . Physical examination The armamentarium The examination itself Inspection of the external genitals Digital examination Bimanual examination Rectal exploration .... Examination under anaesthesia Auscultation, percussion, and general palpation of the ab domen .... Regions of the abdomen . Instrumental examination {a) The speculum (&■) The sound . (c) The dilator . (d) The curette . (e) The aspirator Examination of the secretions — Urines, faeces, menstrual fluid . Examination of the blood Examination of the nervous system Reed 29 „ 30 Potter . 30 31 , 31 , 33 , 34 3 35 5 37 , 39 ' 40 55 40 Reed 41 „ 42 Potter . 42 j? 45 45 ?j 46 „ 47 Reed 47 55 49 49 CHAPTER VII SEPSIS Sepsis defined .... The bacteria of sepsis Local sepsis ..... Symptoms, pathology, treatment General sepsis Symptoms, pathology, treatment Reed 50 50 55 56 57 58 Xll A TEXT-BOOK OF GYNECOLOGY Ether in its relation to bodily temperature Choice of anaesthetics in children . Bromide of ethyl .... Ether and its administration Mixed vapours and their administration Chloroform and its administration Management of accident in anaesthesia Anaesthetic mixtures Central anaesthesia by cocaine General anaesthesia by alcohol General anaesthesia by hypnosis Local anaesthesia Hare Reed PAGE 89 91 91 92 93 94 95 98 97 97 98 CHAPTER XII ABDOMINAL SECTION Terminology Reed . . 99 Preliminary treatment of the patient ....... . . 100 The evils of hypercatharsis ........ . 101 Examination of the urines . „ . . 102 Instruments Robb . . 103 Location of the incision ....... Reed . . 103 Direction and varieties . „ . 105 The incision itself „ . . 107 Closure „ . 109 Drainage ............. . 114 CHAPTER XIII THE EXTERNAL ORGANS OF GENERATION IN WOMEN Definitions Reed . . 117 Development . . . . . . . . . „ . .117 Malformations of — (a) Vulva ' . . . Ballantyne . 118 (6) Vagina ., .126 The hymen Reed . . 131 Malformations of the hymen Ballantyne . 131 CHAPTER XIV INJURIES OF THE EXTERNAL GENITAL ORGANS Injuries from — (a) External violence Dorsett . 135 (6) Parturition . ., 130 (c) Sexual intercourse ,. 136 Pudendal hematocele Reed 136 Injuries of the vagina V 139 Rupture .... „ 139 Urinary fistulae Ross 139 Vesico-vaginal fistulae „ 139 Sims's operation . Reed 144 A TEXT-BOOK OF GYNECOLOGY CHAPTER IV GENERAL THERAPEUTICS OF GYNECOLOGY General medication Serum therapy Local medication Balneotherapy . Suggestion Electricity Massage Reed PAGE 20 21 22 22 23 23 24 CHAPTER V THE GYNECOLOGICAL ARMAMENTARIUM The gynecological armamentarium ...... Root) 27 CHAPTER VI DIAGNOSIS Definition and scope . ..... Indications and contraindications for vaginal examination The gynecologic examination . Physical examination The armamentarium The examination itself . Inspection of the external genitals Digital examination Bimanual examination Rectal exploration .... Examination under anaesthesia Auscultation, percussion, and general palpation of the ab domen .... Regions of the abdomen . Instrumental examination (a) The speculum (fr) The sound . (c) The dilator . (d) The curette . (e) The aspirator Examination of the secretions — Urines, fasces, menstrual fluid . Examination of the blood Examination of the nervous system Reed Potter Reed Potter Reed 29 30 30 31 31 33 34 35 37 39 40 40 41 42 42 45 45 46 47 47 49 49 CHAPTER VII SEPSIS Sepsis defined .... The bacteria of sepsis Local sepsis ..... Symptoms, pathology, treatment General sepsis ..... Symptoms, pathology, treatment Reed 50 50 55 50 57 58 CONTENTS XI CHAPTER VIII ANTISEPSIS Antiseptic provisions of Natui Sterilization Mechanical means Heat .... Germicidal agents The nurse The room The patient Instruments and dressings Sutures and ligatures Post-operative antisepsis The surgeon Hand sterilization . Gloves .... Reed PAGE 60 60 61 61 63 63 64 66 66 67 68 69 69 70 Definition Pathology Causes Symptoms Diagnosis . Treatment Prophylactic Restorative CHAPTER IX SHOCK Reed 72 72 72 73 74 74 74 CHAPTER X HEMORRHAGE AND HEMOSTASIS Hemorrhage Symptoms . Diagnosis Treatment of hemoi Hemostasis Styptics Heat . Pressure Angiotripsy Electric hemostasis Ligatures base Reed Newman Reed 78 78 79 79 79 79 80 80 81 83 86 CHAPTER XI ANAESTHESIA AND ANAESTHETICS IN GYNECOLOGY Definition Hare Anaesthetic agents .......... Race and temperament in the selection of an anaesthetic . „ Indications and contraindications for the use of chloroform and ether 87 87 88 xu A TEXT-BOOK OF GYNECOLOGY Ether in its relation to bodily temperature Choice of anaesthetics in children Bromide of ethyl Ether and its administration Mixed vapours and their administration Chloroform and its administration Management of accident in anaesthesia Anaesthetic mixtures Central anaesthesia by cocaine General anaesthesia by alcohol General anaesthesia by hypnosis Local anaesthesia Hare Reed PAGE 89 91 91 92 93 94 95 98 97 97 CHAPTER XII ABDOMINAL SECTION Terminology Reed 99 Preliminary treatment of the patient •? 100 The evils of hypercatharsis „ 101 Examination of the urines ,, 102 Instruments .... . Rol)b 103 Location of the incision . Reed 103 Direction and varieties 55 105 The incision itself . . . 55 107 Closure 55 109 Drainage ..... 55 114 CHAPTER XIII THE EXTERNAL ORGANS OF GENERATION IN WOMEN Definitions Reed . .117 Development ............ • 117 Malformations of — (a) Vulva " Ballantyne . 118 (b) Vagina „ .126 The hymen Reed . . 131 Malformations of the hymen Ballantyne ■ 131 CHAPTER XIV INJURIES OF THE EXTERNAL GENITAL ORGANS Injuries from — (a) External violence . Dorsett . 135 (&) Parturition . „ 13G (c) Sexual intercourse j. 136 Pudendal hematocele Reed 136 Injuries of the vagina v 139 Rupture .... 5? 139 Urinary fistulas Ross 139 Vesico-vaginal fistulae . 55 139 Sims's operation . Reed 144 I ^ CONTENTS xm Vesicovaginal fistula?— Ross's operation Reed's operation After-treatment , Utero-vaginal fistula? Treatment Recto-vaginal fistula? Causes . Operation (Mayo Robson's Ross Mayo Robson PAGE 145 146 148 151 151 152 152 153 CHAPTER XV INJURIES OF THE EXTERNAL GENITAL ORGANS— ( Contill lied ) Rape TT. Johnson Objective evidences ........ •> Local condition ........ „ Injuries on other parts ....... „ Condition of clothing „■ Schedule for examination „ Indecent assault „ Prolapse -, Injuries of perineum, vagina ....... „ Uterus .........:. „ 156 15G 157 158 158 159 160 161 162 162 CHAPTER XVI INFECTIONS OF THE EXTERNAL GENITAL ORGANS Bacteriology of the external genital organs Mixed infections Gonorrhoea .... Tuberculosis .... Erysipelas .... Erysipelas and puerperal infection Diphtheria .... Aphtha? ..... Aerogenous infection Bilharzia ..... Chancroid ..... Reed Whitacre Reed R a cor/1 i 163 165 166 171 177 178 179 179 180 180 181 CHAPTER XVII DISEASES OF THE SKIN OF THE FEMALE GENITALS Intertrigo . Erythema . (Edema Eczema Folliculitis Herpes progenitalis Pruritus vulva? Pathology Causes Ravogli . 191 ., 194 ?? 195 „ 196 ,, 198 ., 200 „ 202 Reed 203 Ravogli . 204 XIV A TEXT-BOOK OF GYNECOLOGY Pruritus vulvae — Treatment Ravogli Surgical treatment Reed Parasitic affections ......... Ravogli Atrophy (kraurosis) „ Vulval adhesions Reed CHAPTER XVIII HYPERTROPHIC AND HYPERPLASTIC DISEASES OF THE PUDENDAL ORGANS Herzog Hypertrophy of the clitoris Condylomata Treatment Elephantiasis Polypi Treatment Ravogli Herzog CHAPTER XIX NEOPLASMS OF THE EXTERNAL GENITAL ORGANS Benign neoplasms of the pudendum Varices Fibromyomata Pure myomata Myxomata . Lipomata Enchondromata . Cysts Benign neoplasms of the vagina Cysts Fibromata .... Treatment of benign neoplasms Malignant neoplasms of the pudendum Carcinomata Sarcomata Melano-carcinomata Malignant neoplasms of the vagina Sarcomata Carcinomata Treatment Clitoridectomy Extirpation of the vagina Palliative treatment . Herzog Rothroek Reed Herzog Rothrock Reed CHAPTER XX DISPLACEMENT OF THE VAGINA The vagina Varieties of displacements Cystocele .... Reetocele .... Urethrocele Colporrhaphy f Reed CONTENTS XV CHAPTER XXI THE VULVOVAGINAL GLAND PAGE Anatomy Rothrock . 243 Gonorrhoea! infections . „ 244 Abscess ........... „ 245 Cysts . 247 Carcinoma .......... „ 249 CHAPTER XXII THE PELVIC FLOOR AND ITS INJURIES The pelvic floor .... The " pelvic diaphragm " Injuries ...... Laceration of the perineum Restorations of the pelvic floor Immediate operation Instruments . ... Operations for incomplete lacerations Superficial Emmet's operation Reed's method of suturing Modifications .... Operations for complete laceration Tait's operation .... Modifications .... Repair of deep injuries of the pelvic floor Harris's operation . CHAPTER XXIII CLASSIFICATION Malformations of the uterus Ball ant yne Embryonic „ Foetal Postnatal „ Absence „ Uterus unicornis „ Foetal, infantile, pubescent „ Uterus septus ......... „ Uterus bicornis „ Duplex uterus - Minor malformations Reed Treatment . „ Stomatoplasty „ Ret >d 250 j> 253 55 253 Dorsett . 253 Reed 258 „ 258 Robb 259 Reed 260 55 260 5" 260 263 , 265 . 267 , 267 , 269 , 271 , 272 274 274 274 275 276 276 277 277 278 278 279 280 281 CHAPTER XXIV DISPLACEMENTS OF THE UTERUS Normal position of the uterus . . . . . . Reed . . 284 Displacements in general „ . . 285 Varieties, causes, pathology „ . . 285 Treatment Mann . . 288 B XVI A TEXT-BOOK OF GYNECOLOGY Retro-displacements Symptoms and diagnosis Treatment Massage Pessaries Surgical ..... Shortening the round ligament; Alexander's vaginal operation; fixation operations Anterior abdominal cuneohysterectomy . Anterior displacements ..... Prolapsus ....... Inversion ....... peration Reed Mann Reed 55 Herzoy Reed CHAPTER XXV PARTURIENT INJURIES AND FOREIGN BODIES OF THE UTERUS Parturient injuries . Rupture . Laceration of the cervix . Trachelorrhaphy Instruments Vesico-uterine fistulse Reed's operation Nonparturient injuries Wounds from external causes Foreign bodies Reed Rooo Ross Reed CHAPTER XXVI INFECTIONS OF THE UTERUS The uterus .... The endometrium The secretion of the uterine cavity The myometrium Bacteria of the uterus Infections ..... Endometritis and metritis Pathology Causes Symptoms Diagnosis Treatment Topical Curettage Instruments McMu Reed Sinclair Reed Rolib CHAPTER XXVII infections of the uterus — {Continued) Specific — Gonococcous infection Streptococcous infection Reed 2Tt2 376 CONTEXTS xvn Specific — page Tuberculosis infection Whitacre . 384 Syphilitic infection Reed . .391 Echinococcous infection ......... . . 393 CHAPTER XXVIII NEOPLASMS OF THE UTERUS Neoplasms of the uterus in general . Herzog . . 396 Benign neoplasms Fibroin yomata .... Causes, pathology, history . Secondary degenerations ... - . 390 . 396 396-397 . 399 Diagnosis .... McMurtry . 402 Complicating pregnancy Treatment .... " . 403 . 404 Medicinal and electrical „ . 404 Surgical .... ,, . 404 Indications . . . . . Ross . 405 Myomectomy Supravaginal hysterectomy . 407 . 410 Panhysterectomy .. . 415 Reed's operation Reed . 417 Vaginal myomotomy Extirpation of polypi Dunning . 420 . 424 CHAPTER XXIX NEOPLASMS OF THE UTERUS — (CO)lti )l lied) Malignant neoplasms Syncytioma malignum Pathology Histology Causes Symptoms . Treatment Adenoma . Symptoms Diagnosis Treatment Sarcoma Pathology Histology Symptoms . Causes Treatment Carcinoma Pathology Histology Causes . Symptoms . Pregnancy as a complication Reed 42(5 Herzog . 426 ,. 427 427 Recti 42 S ?> 428 .. 429 Herzog . 429 Reed 431 „ 431 ,. 431 Herzog . 432 „ 432 „ -133 Reed 435 V 436 436 Her.zog . 437 „ 438 „ 439 Reed 440 >3 442 443 XV111 A TEXT-BOOK OF GYNECOLOGY Carcinoma — Palliative treatment Carstens Radical treatment Reed Vaginal hysterectomy Newman Instruments ......... Robb Abdomino-vaginal panhysterectomy .... Carstens Extended operation Reed Byrne's operation of electro -hysterectomy . . . ,, Results of hysterectomy ........ PAGE 444 447 447 448 453 453 456 458 CHAPTER XXX CESAREAN SECTION AND ITS MODIFICATIONS Definition . . . . . . . . . . Cameron Historical resume „ Preparations .......... „ Position of child and placenta . . . ". . . „ The operation „ Sanger's method ......... „ Porro's modifications 460 460 465 465 466 470 471 CHAPTER XXXI MALFORMATIONS AND DISPLACEMENTS OF THE FALLOPIAN TUBES Absence and defective development .... Supernumerary and accessory tubes .... Accessory ostia ......... Displacements . . . . . . . . intyne . 473 „ . 474 55 . 474 }J . 477 CHAPTER XXXII NEOPLASMS OF THE FALLOPIAN TUBES Benign neoplasms Papillomata Cystomata . Lipomata Fibromyomata Malignant neoplasms Carcinomata Sarcomata Reed 478 478 480 480 481 481 481 482 CHAPTER XXXIII INFECTIONS AND INFLAMMATION OF THE FALLOPIAN TUBES Infections in general ...... Bacteria of the Fallopian tubes in health . Bacteria of the Fallopian tubes in disease Relations of infections to inflammation of the tubes Catarrhal salpingitis Morbid histology of salpingitis Acute Chronic .... Hydrosalpinx .... Reed Sinclair Clark 483 484 484 487 489 489 489 491 495 CONTENTS xix Hematosalpinx Clark Pyosalpinx Symptoms and diagnosis of salpingitis Robb PAGE 499 499 501 CHAPTER XXXIV INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES Infections by — Gonococcus Reed Streptococcus Bacillus tuberculosis Bacillus coli communis Pneumococcus Staphylococcus Saprophytes Septic vibrion Actinomyces WMtacre Reed 512 516 519 528 529 530 530 531 531 CHAPTER XXXV TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES The natural course and termination of inflammatory dis- eases of the Fallopian tubes Clark . . 532 Hygienic treatment Coe . . 535 Medicinal treatment ,. . . 536 Local treatment „ . 537 Massage . . 538 Electricity Reed . . 539 Drainage ............. . . 540 Vaginal incision ......... . . 541 Inguinal or inguino-vaginal . 542 Abdominal and abdominovaginal ...... . . 544 Rectal puncture ,. . . 546 Aspiration „ . . 546 Conservative operations on the tubes Coe . . 54(3 Radical treatment Reed . . 549 Salpingectomy . 549 Tait's operation ........... . . 551 Modifications of Tait's operation ...... . . 553 Abdominal panhysterectomy ....... . . 554 Doyen's operation ........... . . 556 Modifications, indications, and limitations ..... . . 557 CHAPTER XXXVI MALFORMATIONS AND DISPLACEMENTS OF THE OVARIES Malformations BaUantyne Absence ..... Rudimentary development Accessory ovaries .... Coexistence of ovaries and testicles 560 560 560 561 562 XX A TEXT-BOOK OF GYNECOLOGY Displacements of the ovary . .... . . . Reed Decensus and prolapsus „ Hernia PAGE 563 563 564 CHAPTER XXXVII INFECTIONS AND INFLAMMATIONS OF THE OVARIES Classification Hypersemia . . . Acute inflammation Chronic inflammation Bacteria of the ovaries Individual infections Streptococcous infection Gronococcous infection Pneumococcous infection Bacillus coli communis infections Tubercular infections . . . Whitacre 567 Reed 567 j? 568 Whitacre 569 Sinclair 570 j? 571 Reed 571 !) 574 „ 574 JJ 575 Whitacre 575 CHAPTER XXXVIII TREATMENT OF INFECTIONS OF THE OVARIES Preliminary consideration Natural terminations Palliative treatment Conservative treatment Radical treatment Oophorectomy Unilateral Effects : primary, secondary Reed 579 „ 579 >' 581 •? 582 ,, 584 J. T. Johnson 584 Reed 585 586 Atrophy Cirrhosis Hypertrophy CHAPTER XXXIX TROPHIC DISEASES OF THE OVARIES Coe . 592 Whitacre . 593 Coe . 594 CHAPTER XL NEOPLASMS OF THE OVARIES Small benign cysts . Follicular cysts Cysts of the corpus luteum Tubo-ovarian cysts Neoplastic cysts Proliferation cysts Dermoid cysts . Solid tumours . Fibroids Calcified tumours Hematoma Rothrock . 597 ,, . 598 ?> . 599 „ . 601 „ . 602 'j . 602 5J . 611 ,, . 614 ,, . 614 Reed . 615 Coe . 618 CONTENTS xxi PARE Malignant neoplasms Rothroek . 619 Carcinoma .......... „ 619 Sarcoma „ 622 Endothelioma 624 CHAPTER XLI NEOPLASMS OF THE OVARIES (ConthUIC(l) Complications . Symptomatology Diagnosis . Treatment . Ovariotomy History Indications . Technique After-treatment . Incomplete ovariotomy Ovariotomy during pregnancy Reed 627 ?j 632 633 637 J. T. Johnson 638 638 639 639 645 Reed 646 647 CHAPTER XLII ECTOPIC PREGNANCY Historical resume Definition . Etiology Classification Course and termination Histology . Symptomatology Diagnosis . Treatment McMurtry 649 Herzog . 650 >j 650 652 654 ,, 656 McMurtry 660 662 664 CHAPTER XLIII NEOPLASMS OF THE BROAD LIGAMENT The broad ligament .... Varieties of neoplasms Cysts (parovarian) .... Origin History Causes Symptoms, complications, diagnosis Treatment ..... Hall-Hawkins operation . Hydrocele of the long ligament Fibroma and myoma Symptoms, diagnosis, treatment Dermoids Solid tumours of the round ligament Pelvic varicocele, aneurismal varix, phlebolithiasi Carcinoma, sarcoma ..... Reed Zinke Reed Zinke Reed Zinke 669 669 670 671 671 674 674 675 676 677 677 679 681 681 682 XX11 A TEXT-BOOK OP GYNECOLOGY CHAPTER XLIV INFECTIONS OF THE BROAD LIGAMENT AND OF THE PELVIC PERITONEUM Infections of the broad ligament . Reed 688 Pyogenic ....... „ 688 Pelvic abscess — treatment .... „ 689 Syphilitic infection „ 690 Tuberculous infection . Whit acre 691 Tubercular peritonitis ,, 692 CHAPTER XLV MENSTRUATION Normal menstruation Millikin . 699 Time of appearance . . . . . . . . „ . .701 Menstrual cycle . . . . . . . . . „ . • 704 Quantity of discharge ., 704 Character of discharge „ 705 The inducing cause of menstruation ..... „ 706 The role of the uterus „ 708 The role of the Fallopian tubes . 709 The role of the ovaries ........ „ . . 709 The hygiene of menstruation . . . . . . . „ . .712 Millikin CHAPTER XLVI THE DISORDERS OF MENSTRUATION Menorrhagia ...... General systemic causes Local causative diseases above the pelvis Pelvic causes Treatment Metrorrhagia Amenorrhcea Treatment Retention of the menses Dysmenorrhcea Intermenstrual pain Vicarious menstruation The menopause CHAPTER XLVII THE FEMALE URINARY APPARATUS Physical examination Harris Catheterization of the ureters » Pawlik-Kelly method „ Use of the uretercysto scope ....... „ Harris's urine segregator ....... „ Anomalies of the kidneys ....... „ Number „ Location ........... Form n 714 714 714 715 716 719 720 721 723 725 734 735 738 744 746 746 747 747 749 749 750 751 CONTENTS xxm Movable kidney Etiology Pathologic anatomy Symptomatology Treatment . Anomalies of the ureters Strictures of the ureters Nephrocytosis . Nephrydrosis Pathologic changes Symptomatology Diagnosis Treatment Harris PAGE 752 753 755 757 759 760 760 762 762 763 765 765 766 CHAPTER XLVIII THE FEMALE URINARY APPARATUS- Renal infections Symptomatology and diagnosis Treatment Tuberculosis of the kidneys Pathologic changes Symptoms and diagnosis Treatment Renal calculi Pathology Symptoms and diagnosis Prognosis . , . Treatment . Tumours of the kidney . Pathology Symptoms and diagnosis Treatment Operations on the kidneys Nephropexy Nephrotomy Nephrectomy {Continued) . Harris . . 768 „ 770 ,, 772 „ 772 M 773 „ 774 „ 775 „ 776 ,. 778 15 778 „ 778 ,, 780 „ 780 ., 781 ,, 785 „ 787 „ 787 „ 788 „ 788 » 789 CHAPTER XLIX THE FEMALE URINARY APPARATUS — {Continued) Cystitis Etiology .... Bacteriology Pathologic changes Symptomatology and diagnosis Treatment .... Hyperemia .... Treatment .... Foreign bodies in the bladder . Treatment .... irris 790 790 791 792 793 794 795 5J 796 796 „ 798 XXIV A TEXT-BOOK OF GYNECOLOGY Tumours of the bladder . . Harris Symptomatology and diagnosis )j Treatment 55 Urethral caruncle 55 Treatment 55 Carcinoma of the urethra 55 Treatment 55 Sarcoma of the urethra . 55 Diverticula of the urethra ., Treatment }) Stricture of the urethra . ,, Prolapse of the urethra . 5' Treatment ,, Foreign bodies in the urethra 55 Dilatation of the urethra ,, The urachus Reed Vesico-umbilical fistula . 5J Treatment „ Cysts of the urachus . . » CHAPTER L THE RECTUM Malformations . . . ■ Reed Examination Martin Displacements ... .... Reed General etiology of rectal diseases Gant Relation to intra-pelvic disease in women Martin CHAPTER LI INFECTIONS OF THE RECTUM Inflammation Gant Periproctitis . . . . ' 55 Gonorrhoea . . Reed Syphilis Gant Tuberculosis .... „ Surgical conditions resulting from i nfections „ Anal ulcer or fissure . Martin Ulceration of the rectum . 55 Fistulse .... „ Stricture Gant CHAPTER LII NEOPLASMS OF THE RECTUM Adenoma Gant Lipoma Fibroma 55 Papilloma ...... Angioma Terratoma ..... J) • CONTENTS xxv Retention cysts Myoma Enchondroma Malignant growths . Operations . Divulsion Proctotomy . Curettage Colostomy . Excision Hemorrhoids Injection Whitehead's operation Ligature Clamp-and-cautery Gant PAGE 844 844 844 844 846 840 846 846 846 847 848 851 852 852 853 CHAPTER LIU PELVIC DISEASES AND NERVOUS AFFECTIONS Neurasthenia Dercitm . . 856 Symptoms „ 856 Conclusion . „ 860 Hysteria „ . . 860 Symptoms „ 860 Pathology . 862 Conclusions .......... „ . . 864 Operations for the neuroses „ 864 Nervous symptoms of pelvic disorders „ 865 A TEXT-BOOK OF GYNECOLOGY CHAPTER I PROLEGOMENA Gynecology — Historical resume — Gynecology as a specialty — Nomenclature of gynecology — Radicalism and conservatism of gynecology. Gynecology. — This word (derived from ywr/, a woman, and Aoyos, understanding) implies, etymologically, the study or understanding of woman; but in its applied, modern sense, it means a consideration of the names, causes, prevention, symptoms, diagnosis, pathology, and treatment, of diseases peculiar to women. Historical Resume. — The evidence revealed by numerous papyri establishes beyond doubt that the ancient Egyptian physicians under- stood somewhat of the diseases of women, and that there were practi- tioners who devoted themselves especially to their treatment. The Mosaic writings reveal keen intelligence of the menstrual and repro- ductive functions; and the Talmud records the operation which subse- quently became known as the Cesarean. The Greeks, deriving their knowledge from the Egyptians, improved upon their inheritance, and, with the writings of Hippocrates, marked the beginning of gynecology in the sense of a systematic treatise on the diseases of women. Inflam- mations, the disorders of menstruation, and uterine displacements, here occur for the first time in recorded science. The writers of the next live hundred years simply elaborated upon the teachings of the great master. The speculum vaginae and the speculum ani were described by Galen, Avhile vaginal examinations by the digital method were practised long before that epoch. In the third century b. c, Soranus wrote a book on the uterus and pudendum. Aetius, Paul of JEgina, and other writers, show active and intelligent attention to divers diseases of women, including sterility. The speculum, duck-bill and multivalvu- lar, was in use, as were the uterine sound and uterine dilators. These instruments, and a knowledge of their use, however, seem to have dropped into oblivion during the long night of the Middle Ages. It was not until 1761 that Astruc, of the medical faculty of Paris, reinvented the speculum which he describes in his writing, but which passed with- out attracting the general attention of the profession. In 1801 Eeca- 2 1 2 A TEXT-BOOK OF GYNECOLOGY mier introduced his really practicable instrument by that name, an event which marked the revival of the long-lost gynecologic art. From this date progress has been rapid. In 1809 Ephraim McDowell, of Kentucky, did the first ovariotomy, an event which marked the begin- ning of intrapelvic gynecologic surgery. Uterine depletion by leeches (Guilbert); the use of the uterine sound (Lair); topical intrauterine and intravaginal treatment (Melier); the curette (Becamier); uterine pathology (Simpson); inflammation of the uterus (Bennet); anaesthesia (Wells-Simpson); the rediscovery of the univalve speculum (Sims); operation for vesico-vaginal fistulas (Sims); oophorectomy (Battey); pathology and operative treatment of the Fallopian tubes (Tait); infection of the upper genitalia (Noeg- gerath); perineorrhaphy (Emmet); antisepsis (Lister); and hemostasis (Koeberle), are among the more striking events which have character- ized the evolution of modern surgical gynecology. During this period it has been a constant beneficiary of the general development in the medical sciences. Many other names are entitled to be recorded upon a scroll more complete than is consistent with the limitations of this work. The aggregate result of such developments as are herein indi- cated comprises what is known as modern gynecology. It is obvious at a glance that the great steps that have been taken in the development of this department of medical science have been almost exclusively sur- gical; and with them, more conspicuously than any other names, must stand associated those of Marion Sims, Lister, and Lawson Tait. It must be admitted that the tendency to exclude rational therapy, in its broader and more general as well as in its local and special sense, from consideration in connection with the treatment of diseases pecul- iar to women, is an evil. The fact should be held in constant view, that gynecology is an integral and thoroughly correlated department of medical science. The gynecologist should, therefore, be grounded, not alone theoretically, but by years of actual practice, in all that per- tains to the most advanced state of the healing art, considered in its broadest sense. He should, moreover, keep himself in constant touch with medical science in the various phases of its evolution. Gynecology as a Specialty. — It is a fundamental law that progress is due to the gradual evolution of heterogeneity. This process is exem- plified, not alone in the various phases of organic life, but in complex social organisms. The medical profession, considered as a constituent element of the social fabric, is subservient to the same law. Special aptitudes and special knowledge lead to correspondingly special occu- pations. This comes as a result, not alone of the tastes and predilec- tions of the individual, but of the discrimination of those who become Iris patrons. It follows, therefore, that those who would assume to be specialists in any department of medical practice, but who are un- qualified for the responsibilities which they invoke, sooner or later must fail. Specialism in medicine has an ethical basis which can not be ignored. These facts render the segregation of medical science PROLEGOMENA 3 in its practical application inevitable. There is no practitioner but knows and does some things better than he knows and does others, and he is to that extent a specialist. If, however, he were to concentrate his attention exclusively upon those things which he knows best and to ignore those things of which he knows least, his intelligence would move only upon convergent lines. This is indeed the inherent mis- chievous tendency of specialism, and one which the gynecologist, as other specialists, should never cease to resist. The sphere of the gyne- cologist's labours has already resulted in a broadening of his activ- ities. His constant experience with intraperitoneal conditions has resulted in his expansion into an abdominal surgeon, a fact recog- nised, not alone by the general consensus of the profession, but, spe- cifically, by the creation in medical schools of professorships of " gyne- cology and abdominal surgery," or of " abdominal and pelvic surgery." Nomenclature of Gynecology. — One of the chief embarrassments in the evolution of a science is an indetermined and essentially de- fective terminology. Words are but symbols, and each word, to prop- erly fulfil its office, should be easily and definitely translatable in the mind into that for which it stands. In this way alone can language subserve, in the highest degree, its legitimate function as a medium for conveying ideas from one person to another. The language of medi- cine, says Dr. Frank P. Foster, is by no means free from the defective neologisms that are to be found in the contemporary literature of the other sciences. That they are more abundant in the writings of gyne- cologists than in other medical writings he is not prepared to admit. He considers that their formation is for the most part to be attributed to the rage for designating diseases, operations, and the like, by single words. Their defects generally consist (a) in joining a Latin word to a Greek word to make a compound; (b) in adding a Greek termina- tion to a Latin word; (c) in reversing the proper order of the terms of a compound; or (d) in retaining an aspirate which any classical Greek writer would have suppressed. The following are examples of these forms of error: (a) " rectocolporrhaphy," made up of one Latin and two Greek words; (b) " annexitis," borrowed from the annex- ite of the French; (c) " hydronephrosis," instead of " nephydrosis " ; (d) " anhydrous " for " anydrous." Most of these defectively formed words have, however, established themselves firmly in the favour of the multitude, and it would be foolish to seek to root them out at this late day; nevertheless, by pointing out their deficiencies one may hope to moderate, in some degree, the further coining of objectionable terms. Far more to be regretted than these errors of coinage, is the perverted meaning often attached to well-known words, as when we say " differ- entiate " for " distinguish," or speak of " single " and " double castra- tion "; but even such perversions, however much they may offend the fastidious, throw no real obstacle in the student's way. The same can not be said, however, of the fancy that some authors have shown for dividing retroversion of the uterus, for example, into arbitrary " de- 4 A TEXT-BOOK OP GYNECOLOGY grees." The need of the day, long since emphasized by Jonathan Hutchinson, is for the legitimate employment of well-understood words, preferably those that are short, easily remembered, and so far as possible in the vernacular. Radicalism and Conservatism in Gynecology. — The essentially sur- gical character of modern development in gynecology has led to some abuses that are the necessary incidents of all surgical evolution. The operations of tenotomy in orthopaedics, of tonsilotomy, and of the divi- sion of the recti muscles for the cure of strabismus, were followed imme- diately after their introduction, respectively, by indiscriminate applica- tion that resulted in damage to many patients. Other examples could be cited. In gynecology each new advance has been characterized by similar experiences. The use of the sound, of pessaries, and of caustics, was in each instance attended with early abuses. Emmet's operation for the repair of the lacerated cervix was followed by its needless per- formance in many cases. Oophorectomy and the more comprehensive operations upon the uterine adnexa were followed, immediately after their introduction, by efforts to relieve by their means conditions to which, in the light of subsequent experience, they were not adapted. These abuses, if such they can be designated, are to be construed rather as evidences of conscientious efforts on the part of the profession to determine the remedial value of surgical expedients. Reactionary in- fluences can be relied upon to correct these tendencies. The actuating motive in gynecology, as in other departments of medical and surgical practice, is to preserve in a safe or entire state, or to protect from unne- cessary loss, waste, or injury, the various organs or structures that are the seat of disease. Any departure from this criterion must be attended with danger. From this point of view, conservatism in gynecology is to be commended. It should be remembered, however, that even reac- tionary tendencies may go to dangerous extremes. This is sometimes exemplified in an effort to conserve an organ at the expense of the general health of the patient. On this point it is well to be governed by the rule tersely enunciated by S. C. Gordon (Philadelphia Medical Journal, August 19, 1899) that " conservative gynecology demands saving health rather than diseased and useless organs." All the splendid achievements of modern surgery, however, have been made in violation of the other equally legitimate definition of " conservatism " — namely: " Disposed to retain and maintain what is established, as institutions, customs, and the like; opposed to innova- tion and change; in an extreme and unfavourable sense opposed to progress." In view of the fact that the term conservatism of neces- sity carries with it the meaning expressed in the last as well as in the first definition, its introduction into the literature of gynecology is to be considered unfortunate. The life-saving impulse of the medical profession, and the yet unrelieved necessities of afflicted humanity, join in a demand for every innovation that will increase the efficiency of the healing art. CHAPTER II GENERAL ETIOLOGY OF DISEASES OF WOMEN Prevalence — Causes: Civilization; education; personal habits; occupation; dis- eases; copulation; prevention of conception; criminal abortion; childbirth; the social evil. There is a prevailing impression that the diseases peculiar to women are increasing relatively to the population. There exist no data upon which such an affirmation can be based. The impression probably depends for its existence upon the fact that such diseases are now better understood and more generally treated than formerly. Evidence is not wanting to indicate that the Anglo-Saxon woman is not degen- erating. Bowditch has made some interesting observations on the physique of women, as follows: Of over 1,100, he found that the average height was 158.76 centimetres (5 feet 3^ inches). Sargent, in nearly 1,900 observations, the ages of the women ranging from sixteen to twent\ r -six, found the average slightly higher. Galton, in 770 measure- ments of English women from twenty-three to fifty-one years of age, also found a higher average — a difference due in part, no doubt, to the younger age of a number of the American subjects. In 1,105 subjects in ordinary indoor clothing Bowditch found the average weight to be 56.56 kilogrammes (125 pounds). These observations, compared with 276 by Galton, show that the average weight is a little greater among Americans. It would seem that while the tallest English women sur- passed the tallest American women in height, the heaviest American women exceeded the heaviest English women in weight. Specific ob- servation of this systematic character, however, is not necessary to im- press the intelligent traveller with the generally satisfactory physique of the women of England and America. It is true that many defective specimens are found, and these come with relatively greater proportion under the observation of the physician. But no one can fail to be impressed with the fact that they comprise a distinct minority of the masses. The improvement in the physique of women has been very noticeable since the sentiment for athletics has supplanted that for the cloister, and since outdoor exercises have taken the place of those seden- tary habits which, but a few decades ago, were considered the proper affectations of refinement. With that other and vastly larger class of people, who are not at liberty to choose their occupations, there has been a distinct improvement in physical estate. Improved habitations, 6 A TEXT-BOOK OF GYNECOLOGY better hygiene, more humane regulation of occupation, more rational methods of education, and, with all, a more general diffusion of pros- perity, are responsible for this improvement. It is a source of regret that this more or less optimistic view must be tempered by a frank recognition of yet existing evils which, to a certain extent, retard the progressive improvement of womankind, and are largely responsible for the diseases which, in the aggregate, comprise the subject of this volume. Civilization. — The assumption has been made, and in some quarters entertained, that civilization, in the aggregate, exercises a deteriorating influence upon woman; that it develops her mind and brain and nervous system at the expense of other elements of her physical organism. There is no doubt that between the women of aboriginal peoples and those who belong to the civilized races there are certain physical dif- ferences, some of which tend to the production of sexual diseases in the latter. The reproductive function can be taken as an index. Sav- age women, as a rule, have but little difficulty in childbed, because they have large pelves and bear children with small heads. Accidents in childbirth, however, do occur among these primitive peoples with gen- erally fatal results. Currier (Medical Netus, 1891), who has studied the physical and sexual condition of the North American Indians, says: " that pelvic disease has not been treated among Indians does not prove that it does not exist." The fact that Indian women are very generally the victims of venereal diseases establishes upon a firm basis the pre- sumption that they must suffer from the remoter physical consequences of those diseases. Menstrual habits among many of the Indian tribes may well serve as an example to civilized women. The Mosaic rule that women during this period shall be put apart for seven days is observed in practice by these lowly people, who never heard of the records of Leviticus. Napheys, confirmed by Holder (American Journal of Ob- stetrics, 1392), says that " it is an inviolable rule among all these tribes for the women, when having their monthly sickness, to drop all work, absent themselves from their lodges, and remain in perfect rest as long as the discharge continues. " Measurements made by Holder indicate that the average height of the Indian woman is 5 feet 3-| inches; chest, 32| inches; waist, 29f^- inches; hips, 34-ff inches. The measure- ments of the perfect form of the civilized woman are given as follows: Height, 5 feet 5 inches; bust measure, 32 inches; waist, 26J inches; hips, 35 inches. It would not seem from this comparison that civilization is producing the disastrous results with which it is accredited. On the contrary, there are many evidences of an improvement in the physique of women of the civilized type, in which improvement the genital organs are no doubt participating. Education. — Education of the conventional type has been held re- sponsible for many of the ills peculiar to women. This criticism had much more point and force a few decades ago when, the convent, with its seclusion and sedentary habits, determined the character of GENERAL ETIOLOGY OF DISEASES OF WOMEN 7 women's education. The present, however, may be designated as the ra- tional epoch in women's education — one in which they receive the max- imum of physical, mental, and moral benefit with the minimum of in- jury. The most hopeful feature of the present regime is the tendency on the part of educators to study and regard the capacities and require- ments of the individual pupil. Eecognition is given to the primary bio- logic law of the antagonism between growth and genesis; and the effort is made in all advanced institutions of learning to adjust the curricula to the needs of the growing girl at different periods of her life. The doctrines of Froebel and Pestalozzi have relieved educational methods of much of their subjectivity, with the result that more attention is given to the education of the muscular system and the special senses; the book has largely yielded to the laboratory, and the cloister to the open volume of Xature. Potter (New York Medical Journal, 1891), recognis- ing some of the yet remaining defects of the educational system, sug- gests that for girls between twelve and sixteen, study hours or school work be restricted to four hours daily; that during each catamenial pe- riod the recitation room should be avoided; that during this period girls should indulge in much mental and bodily repose; and that during the school period especially, which is also the period of most active growth, girls should be provided with an abundance of wholesome food and be instructed in the most careful dietetic habits, special stress being laid upon a full morning meal. The dress should be constructed with ref- erence to relieving the waist line of all weight and pressure. He lays great stress upon the rule that no girl should enter a boarding school where the building is more than two stories high, and that stair climb- ing, at this developmental period of life, should be reduced to the minimum. Sir J. Crichton Browne urges that there are sexual brain differences between men and women which militate against the latter in higher education. While he admits that there are no trustworthy data for the estimation of the normal brain weight of healthy natives of Great Britain, he bases his conclusions upon the study of the brain of insane subjects, with the result that he finds the average excess of male over female brain weight to be 4.5 ounces, or, if allowance is made for the difference in bodilv height, the excess of the male over the female brain weight is reduced to 1.05 ounces. Sir James Browne asserts that the posterior brain development is greater in woman, that the convolu- tions have a similar pattern, and that her left brain weighs relatively less than her right; but there is a marked difference in the distribution of the blood to the brain in the two sexes, and from these observations the conclusion is drawn that women are not fitted for the same educa- tional tasks as are men. The whole argument is misleading, first, from the fact that the observations were made upon the brains of insane peo- ple; next, that they were not sufficiently numerous to justify a general conclusion; and, finally, that the results of higher education among women show that they improve physically as well as mentally, rather than deteriorate, under its influence. The last statement is confirmed 8 A TEXT-BOOK OF GYNECOLOGY by Dr. Mary Dixon Jones, who, as a former principal of a young ladies' seminary, and latterly a successful practitioner with an extensive clien- tele among women, asserts that menstrual disturbances are of rare occur- rence, and that symptoms referable to the pelvis are but seldom com- plained of among young women students. The after life of such stu- dents indicates as good an average state of health and as high a degree of fecundity as among any other class. It is not apparent why intellec- tual occupation during the period of pubescence should interfere with sexual growth any more among girls than among boys. Personal Habits. — That personal habits have much to do in the causation of pelvic diseases can not be denied. Habitual errors of diet resulting in constipation; general physical inactivity inducing slug- gishness of the splanchnic circulation; and habits of dress seriously constricting the waist and imposing weight upon the pelvic viscera, are all to be taken into account. The corset, however, as an article of dress is not to be unqualifiedly condemned; on the contrary, if loosely applied, it serves as a protection rather than otherwise to the underlying viscera. More serious criticism should be directed to the deficiencies of dress of the neck, shoulders, arms, and legs. The influence of cold upon these more or less extensive areas can not but have a tendency to produce internal engorgements. Habits of outdoor exercise, now more or less prevalent, evince a hopeful tendency in the hygiene of women. Equestrian exercise, the bicycle, and golf, are all calculated to improve the physique of those who temperately participate in them. While this is true, it should not be forgotten that excessive activity in these, as in other wholesome sports, may be provocative of damage. Occupation. — The modern extension of woman's activities has brought with it more or less of a penalty in the form of genital diseases induced by her occupations. It was not to be expected that women could adjust themselves without damage to labours which, through generations, had been arranged for men; nor could it have been ex- pected that the several vocations could be at once so remodelled as to suit them to women's physical capacities. Clerking in stores, with its long hours of uninterrupted standing, employment in offices that were not provided with proper lavatory facilities, work in factories with im- perfect ventilation, and the carrying of heavy burdens, are among the examples which illustrate the influence of occupation as a cause of pel- vic disease in women. The peasant women of continental Europe work side by side with the men in nearly all occupations, and they are espe- cially given to carrying heavy burdens upon the head, as is true of the American negro in the South. All these classes furnish examples of uterine displacements — especially procidentia and its attendant evils. The relative robustness of the European peasant women is largely a fic- tion. The modern household has many features that have etiological bearings upon this class of diseases. The thoughtless construction of houses, carrying with it the necessity of excessive stair climbing; the totally unnecessarily great weight of household utensils that must be GENERAL ETIOLOGY OF DISEASES OF WOMEN 9 handled b} T women; and the performance of overhead tasks, many of them unnecessary, are causes to be taken into account. The sewing machine, while a great mercy to womankind in general, is, by its abuse, a fruitful source of mischief to those whom it was designed to benefit. Diseases. — Aside from gonorrhoea and syphilis, mentioned in an- other paragraph, other diseases are provocative of genital disorders in women. Miiller, of Munich (C entralblatt fur Gyndkologie, 1890), has reported several cases in which miscarriages were induced by la grippe. The influence of the same disease upon the genital organs is noted by the same author, who finds that in a large number of cases it provokes either metrorrhagia, menorrhagia, or aggravation of sexual diseases already existing. Erysipelas may result in bacterial invasion and con- sequent suppuration within the pelvis and in puerperal fever. Neuras- thenia, a distinctly constitutional state, may occasion symptoms which Goodell appropriately designated as nerve counterfeits of genital dis- eases. Engorgements of the liver, from whatever cause arising, may produce disturbance of the portal circulation to a degree that will induce passive congestion of the pelvic viscera. Constipation is a fre- quent cause of functional disturbance of the ovaries and uterus. Copulation. — The sexual relation fulfils the meaning implied in the creation of two sexes. It is distinctly a physiologic function, yet errors in its establishment and practice frequently cause injury and disease in women. Coition, done abruptly for the first time, particularly if attempted by a male organ disproportionately large, may produce lac- erations and dangerous hemorrhage. A penis of inordinate length may penetrate a woman so far as to exercise undue violence upon the uterus and adnexa, and thereby sooner or later induce disease of those organs. If practised too frequently, or in the absence of inclination on the part of the woman, or if repeatedly completed by the man before an orgasm is experienced by the woman, it sooner or later becomes a mere source of mechanical irritation to the latter. Prostitutes suffer greatly in consequence of the nonamatory character of their sexual relations, although in such cases the constant possibility of infection as a com- plicating causative factor must be held in mind. Coitus reservatus when indulged in by the female has a tendency to increase to an abnormal degree the turgescence of the organs. Van de Warker made a critical study of forty-two women of the once notorious Oneida community, which seemed to have been organized chiefly with reference to the practice of coitus reservatus, especially by the male, but under condi- tions of promiscuity. He found no greater prevalence of sexual disease there than elsewhere, nor was he able to find diseased conditions which he could attribute to the sexual habits of the community. Sexual anaesthesia, of frequent occurrence in women, is a cause of unhappiness and physical injury. Sexual perversions are to be considered in the light of both cause and consequence of genital disease. Masturbation is often caused by a pre-existing local irritation of the vagina or puden- dum, or by adhesions of the clitoris to the prepuce, and it as frequently 10 A TEXT-BOOK OF GYNECOLOGY causes similar disturbances. It is highly probable that there is no form of sexual perversion that is not associated with more or less congestion of the genital organs which remains after the act, whatever it may be, is completed. Prevention of Conception. — Malthus formulated a doctrine which assumed to justify the limitation of families by the prevention of con- ception. Practices having this object in view have been known since Onan spilled his seed upon the ground. Many accessory practices, how- ever, have come into vogue in modern times, none of which are destitute of serious consequences. The use of the vaginal douche immediately after intercourse, the use of a sponge within the vagina for absorbing the semen, the " womb caps/' condoms, are all damaging expedients. If it is granted that their local physical effects are not deleterious, the fact still remains that their employment implies a psychic state inim- ical to the perfectly normal performance of the copulative act. Coitus reservatus is generally more damaging to the male than to the female. Criminal Abortion. — There has been no time within the known his- tory of the human race when women have not sought to avoid mater- nity. The induction of abortion as a means of limiting reproduction was known and practised by the Egyptians, the Greeks, and the Eomans. Although certain social theorists have enunciated the prin- ciple of justifiable foeticide, it remains an unproved assumption that the practice is more prevalent to-day than in previous periods. That it is prevalent to-day, however, there is no denying; nor can the dele- terious results of the practice upon the reproductive organs of women be ignored. Infections induced in this way, when not fatal, almost always destroy fecundity and render relief by surgical means im- perative. Childbirth. — Many of the injuries and diseases of women have their origin in childbirth. The relatively large cranial development of chil- dren borne by civilized women, rather than any other one circumstance, tends to increase the difficulties and dangers of parturition. Infec- tion occurring in childbed, resulting in puerperal fever, or in infection of the endometrium or the Fallopian tubes, is yet of too common occurrence, although it is encountered with less frequency since the bacterial character of puerperal infections has become better under- stood. The recent great improvement in the obstetric art has already resulted in the practical disappearance of vesico-vaginal fistula and in the diminished frequency of both cervical and perineal lacerations. These conditions, however, are yet encountered as the demonstrable results of parturition. The Social Evil. — The social evil has long been recognised as re- sponsible for many of the physical infirmities of women. This evil, which has existed from the remotest antiquity and which will continue to exist as long as the race survives, is a necessary incident of social organization. It is properly recognised by all sociologists as an in- evitable feature of social evolution. In dealing with it, therefore, it GENERAL ETIOLOGY OF DISEASES OF WOMEN H is important at the outset to recognise it as an abiding fact rather than as an evanescent theory. In what way, therefore, does it exercise a deleterious physical influence upon society at large? The answer is that it works its mischief by the dissemination of the two great vene- real diseases, syphilis and gonorrhoea. Syphilis causes disease of the genital organs of women chiefly from the fact that it is communicated, for the most part, in the act of inter- course, and that the primary sore manifests itself in the genitalia. This, as a rule, is not an especially serious matter, although it may lead to the graver constitutional complications characteristic of the disease. In its hereditary form it is liable to manifest itself in defective develop- ments and in temperamental deficiencies, both of which may be mani- fested in defective functional capacity of the genital organs. The manifestations of this disease in relation to the different organs will be considered in their appropriate places in this work. Gonorrhoea, more than any other one disease, is responsible for those complications in women which are destructive of her reproductive ca- pacity, which produce organic disintegrations, and which demand sur- gical interference for their relief or cure. Before Noeggerath demon- strated that the gonococcus (see Microccocus gonorrhoea? under Sepsis) was the essential infectious element in the vast majority of intrapelvic suppurations, tubal and otherwise (see Pyosalpinx), gonorrhoea was looked upon as a local and comparatively trivial affection, involving the vagina and external genitalia. Since that time, however, the medical profession has come to recognise it as the most dangerous disease of frequent occurrence with which woman is afflicted, cancer, of course, being excepted. This assertion finds ample confirmation in the etiology and pathology of inflammatory diseases of women as presented in sub- sequent chapters. The social evil being recognised as a fixed and inevitable fact, and the dissemination through it of venereal disease being so destructive to women, it is the manifest duty of society to subject prostitution to the most rigorous supervision. The medical profession owes it to itself, and to the humane objects to which it stands consecrated, to use its influence to secure the legal regulation of that evil which society has proved itself unable to suppress. CHAPTER III GENERAL PATHOLOGY OF THE FEMALE GENERATIVE ORGANS Local pathology conforms to general pathologic laws — Peculiarities depending upon differentiated functions — Menstruation — Ovulation and gestation in their relation to pathologic states — The poise of the uterus and its variation — Bac- terial origin of inflammatory diseases of the female genitalia — Tuberculosis — Syphilis — Trophic changes — Neoplasms. Local Pathology conforms to General Pathologic Laws. — The gen- eral pathology of the female organs of generation in many respects does not differ from the general morbid anatomy and physiology of other parts of the body. Simple and specific inflammations, local bacterial infections, benign and malignant tumours, hypertrophy and atrophy, degenerations and other secondary changes, complications, and sequelae, follow the same pathologic laws and types as are observed elsewhere in the organism. There may be minor differences, but these variations do not involve any fundamental change in principle. Of such slight devia- tions from the ordinary there may be mentioned unusual degrees of glandular hypertrophy, often developing after slight inflammatory irri- tation, such as we find, for instance, in the mucous membrane of the uterus. There are tumours, ordinarily very malignant in type, which in some parts of the female genitalia — the ovary, for example — may exist for a long time without involving neighbouring structures or giving rise to metastases. On the other hand, tumours histologically of a benign type may produce purely mechanical disturbances by their rapid growth, location, or otherwise, which may endanger or even take the life of the patient. There are, however, also quite a number of morbid phenomena and conditions to which the female only is subject, and which must be studied from a strictly specialistic standpoint, with- out, of course, losing sight of the great general principles of pathology. Peculiarities depending upon Differentiated Functions. — The fe- male genitalia in the human race perform such specific and well-differ- entiated physiologic functions that we should expect to find in them disturbances unknown elsewhere. Such is the case; for the functions of menstruation, ovulation, and pregnancy, are often disturbed in their exercise by underlying abnormal changes which call for particular attention. Menstruation in its Relation to Pathologic States. — Menstruation brings about a cycle of profound though transitory changes in the 12 GENERAL PATHOLOGY OF FEMALE GENERATIVE ORGANS 13 uterus. Congestion to a degree which anywhere else in the body would be abnormal, and actual hemorrhage, would, of course, be pathologic in any other organ but the female genitalia. It was formerly gen- erally held that the uterus in menstruation shed its whole mucous membrane, this being regenerated from what little remained of the glandular epithelium. Herzog, who has carefully examined several menstruating uteri obtained by operation from living subjects and not post-mortem, agrees with Mandl, Westphalen, Gebhard, and others, who within the last few years have maintained that the uterus does not shed its mucous membrane in menstruation, but only loses some of the surface epithelium. It being conceded that this view is cor- rect, there are then still present during and shortly after menstrua- tion some small patches of mucous membrane denuded of surface epi- thelium. This condition certainly favours bacterial invasion whenever microbes are present, and a locus minoris resistentice is thus created periodically in the female which does not exist in the male. Morbid subjective symptoms, the disturbances of beginning menstruation, dys- menorrhea, menorrhagia, amenorrhcea, and vicarious menstruation, are phases of pathologic phenomena necessarily peculiar to the female, and that are considered in detail in the section on Menstruation. We thus find that the function of menstruation may and does carry with it to the female, dangers and pathologic conditions from which the male is exempt. Ovulation in its Relation to Pathologic States. — We likewise find the same to be true with reference to ovulation. In it the physiologic processes and the accompanying tissue changes are of a type which may be well called quasi-pathologic. Paradoxical as it may appear, it may be well said that nowhere in the body do we have a physiologic process with such typical pathologic features as are found in ovulation. When a Graafian follicle has become mature and has approached the surface of the ovary there occurs at the time of ovulation a break in the continuity of the ovarian tissue, a rupture, accompanied by a hemor- rhage, which may be more or less extensive. The gap so formed is in the normal course of events closed by the formation of cicatricial tissue, derived from connective-tissue elements. Herzog, who has studied the normal and pathologic anatomy of the corpus luteum, agrees with Clark (Archiv fur Anatomie und Physiologie, 1898) , who has recently reaffirmed the view that the lutein cells are not epithelial cells derived from the zona granulosa, but connective-tissue elements derived from the theca interna folliculi. The processes of rupture, hemorrhage, and cicatri- cial-tissue formation, are, with this single exception, entirely patho- logic. (We will here neglect uterine menstrual hemorrhage, which is of a different character altogether.) In the ovary we find them as normal features of a purely physiologic process. It is obvious how easily these quasi-pathologic processes may overstep their physiologic limits and lead to truly morbid conditions, such as, for instance, marked cicatri- cial contractions with general premature atrophy of the ovary. Dan- 14 A TEXT-BOOK OF GYNECOLOGY gers of ovulation to the female organism are also to be looked for in another direction. The normal living cells of the organism all pos- sess more or less the power to resist bacterial invasion. In ovulation, however, we have, formed in the female organism right in the perito- neal cavity, a blood coagulum, a focus, not consisting of living cells, but of a dead culture medium, which at the body temperature is so notoriously favourable to the development of pathogenic micro-organ- isms. It has been said above that menstruation, in consequence of slight denudation of the uterine mucous membrane, creates here a locus minoris resistentice for bacterial invasion. This is true in a still higher degree with reference to the formation of the blood coagu- lum in an open cavity of the ovary. Herzog, in studying the histology and bacteriology of a number of cases of ovarian abscess, was struck by the observation that in the large majority of cases one is able to dem- onstrate that the abscess wall contains elements of the corpus luteum. In other words, these abscesses represent an infection of the corpus- luteum cavity with pus formation (empyema of the corpus-luteum cav- ity). The proliferative processes in the normal adult body, as a rule, do not lead to the formation of newly organized tissues. They only sub- stitute tissue elements which in the cycle of metabolic changes have become senile, undergo dissolution, or are shed, as the case may be, and have to be replaced by younger elements. In the ovary, during sexual activity, with the ripening of the Graa- fian follicle we have constantly a process of real new tissue formation which, as a rule, stops only during pregnancy, but which may even then persist (Herzog: Superfoetation in the Human Kace. Chicago Medical Recorder, vol. xv, 1898). It is not improbable that the normal new tissue formation as found in the ovary in connection with the maturing follicle, stands in a certain relation as a predisposing, or even sometimes causative, factor in the development of neoplasms so frequently found in this organ. This view is here given in spite of the well-known fact that most neoplasms of the ovary are very likely of stromatogenous and not of ovulogenous origin. Among the neoplasms of the ovary, to be considered more in detail later, there is one of a most unique patho- logic histogenesis — namely, the dermoid cyst or embryoma ovarii. Her- zog strongly indorses the view so ably advocated by Wilms that these neoplasms are always of ovulogenous origin, not merely derivatives of ectodermal inclusions, and that they represent an attempt at patho- genesis. Gestation in its Relation to Pathologic States. — The most impor- tant physiologic function of the female genital organs, gestation, leads to numerous pathologic conditions and complications. Most of these lie outside of the scope of this work, but a number of them properly fall within the domain of gynecology. Minor congenital anomalies of a type which in other parts of the organism throughout lifetime may be void of any practical moment, when found in connection with female genital organs may become of the greatest pathological impor- GENERAL PATHOLOGY OF FEMALE GENERATIVE ORGANS 15 tance. Some reference has already been made to this point when speaking of menstruation in the presence of a congenital obstacle to the catamenial flow. Of still greater practical bearing are those con- genital anomalies which become responsible for ectopic pregnancy. The etiology of the most frequent form of gestation of this kind — namely, tubal pregnancy — is as yet a good deal contested and obscure-. Herzog is of the opinion that in a large percentage, if not even in a majority, of cases, congenital anomalies are indeed the cause of ectopic gestation. Several cases have been reported in which there is left no doubt as to an etiology of this kind. (Henrotin and Herzog: Anomalies du Canal de Miiller comme cause des grossesses ectopiques. Revue de gynecologie et de chirurgie abdominale, Paris, 1898. — Very Early Rup- ture in an Ectopic Gestation in a Tubal Diverticulum. New York Medical Journal, 1899.) Pregnancy also furnishes the substratum of a peculiar kind of neo- plasm found in the female, the syncytioma malignum. These tumours, developing during or shortly after pregnancy, are derived from foetal structures — namely, the chorion epithelium, comprising the layer of Langhans and the syncytium. In some way or other these foetal ecto- dermal structures acquire the properties of a malignant tumour, develop parasitic properties, invade the parental structure, primarily the sexual organs, and form distant metastases. In this manner embryonic tis- sues may become the starting point of a malignant tumour which ulti- mately destroys the life of the maternal organism. Here we have again an example of a pathologic event directly dependent upon a function of the female organs of generation, an occurrence which is of course impossible in the male. The Poise of the Uterus and its Variations. — Among the peculiar- ities of the female sexual organs must be mentioned the delicate man- ner in which the uterus is balanced and held in position by the gen- eral arrangement of the parts in the female pelvis, in connection with a complicated ligamentary apparatus. It is very obvious why such a complicated arrangement should be necessary, when we consider the changes of position and size which the fruit bearer has to go through during the sexual life of the female. The delicacy of balance neces- sary from physiologic reasons becomes a fruitful source of morbid states. A very important and voluminous chapter in the pathology of the female sexual organs is that on the malpositions of the uterus. Of course, these malpositions are usually not of a primary nature; they are, as a rule, subsequent to other morbid changes. But these morbid changes per se are often very insignificant, and a long train of patho- logic sjmiptoms and conditions is only brought about in consequence of the changed position of the womb, its sequelae, and complications. (See Uterine Displacements.) Bacterial Origin of Inflammatory Diseases of the Female Genitalia. — If we now, from the standpoint of nosology, consider the general pathology of the female organs of generation, inflammatory diseases 16 A TEXT-BOOK OF GYNECOLOGY first command our attention. After bacteriology had solved quite a number of questions with reference to general and local infections and inflammatory conditions in various parts of the organism, it was hoped, and firmly believed, that this youngest branch of pathology would also speedily contribute much toward showing us the true etiology of the great variety of inflammatory diseases of the female genitalia. The ana- tomic arrangement of the latter makes it a priori very probable that bacterial invasion plays a predominating role as a causative factor in all classes of inflammatory diseases. Doderlein, commenting upon this point with reference to such affections of the uterus, says: " Above any site in the body, the uterus seems to be the place favouring bacterial invasion and colonization. The open connection between the uterus, the vagina, and the outside world; the many chances for transport of germs which are so obvious, particularly during sexual life; stagnating secretions protected against desiccation and kept at a brood-oven tem- perature — all these factors unite to a priori impress us how well adapted the interior of the genitalia is for bacterial invasion and diseases de- pendent upon them." (See Sepsis.) Yet it has been found that, in spite of all these apparently favour- able factors, the internal genital organs of the healthy woman are not easily reached by pathogenic bacteria, and are, as a rule, sterile. The vulva, according to the unanimous verdict of all investigators, is fre- quently the seat of pathogenic bacteria, particularly the ubiquitous ordinary pyogenic micro-organisms. The vagina, however, in healthy women contains pathogenic bacteria only in a small number of the cases examined under the proper precautionary measures to avoid contamination. It, on the other hand, in healthy women always har- bours a great many nonpathogenic bacteria. Yet, fully virulent patho- genic microbes, introduced experimentally as has been done by Bumm, Menge, Kronig, Doderlein, and others, are speedily killed in the healthy vagina. Clinical and other experience has abundantly shown that the vagina under certain conditions loses its protective power of " self -purification." Particularly is this the case in parturition and immediately after delivery. A large percentage of septic inflammatory diseases of the female genitalia may be traced back to infection in par- turition. Such septic infection may, of course, also be easily induced in the nonpuerperal state by unclean instruments passed into the uterus. We know that malpositions or tumours of the uterus are responsible for hyperplastic inflammatory reactions of the endometrium. Deep lacerations of the cervix so frequently occurring in parturition, even without a manifest septic infection, may lead later on to chronic in- flammatory changes of the uterine mucous membrane. In other cases of endometritis we miss every tangible anatomic cause, and for an attempt at explanation we must turn to such flimsy causative factors as nutritional and circulatory disturbances of unknown origin — tropho- neurotic or vasomotor disturbances. It is, however, easy to understand GENERAL PATHOLOGY OF FEMALE GENERATIVE ORGANS 17 that in the tissues of the female organs of generation there may be established frequently, without the aid of bacteria, the initial stages of inflammatory processes arising directly out of a plus of the physiologic functions. Congestion and stasis, or, in other words, dilatation of ves- sels and diminution of the velocity of the current, which are among the first steps in the train of inflammatory changes, are normally found in ovulation, menstruation, and pregnancy. The inflammatory diseases of the tubes and ovaries are often of very obscure origin, just like those of the uterus. This is particularly true of the ovary. In it we meet profound pathologic changes of this type, which baffle every attempt to get at their true cause as effectually as they resist all therapeutic measures. In such inflammations of the ovary we find cases with grave vessel changes, a pathologic process which has recently been described under the designation of angeiodys- trophia ovarii (Bulius and Kretschmer). Tuberculosis of the female genital organs, which may be a primary or a secondary process, is by no means so rare as was formerly believed. Some parts of the female genitalia are invaded frequently by the tubercle bacillus. Among these must be mentioned preferably the tube. It has been found that many cases of salpingitis, formerly be- lieved to be simply septic in character, are really mixed infections in which the tubercle bacillus is present. Even the ovary, formerly held to be practically free from tuberculosis, is not at all immune but is oc- casionally infected. In the uterine mucous membrane we find tuber- culosis in the acute miliary, the interstitial, and the ulcerative variety. Tuberculosis of the muscular coat seems to be rare, yet Herzog has seen a case in which the whole muscularis was literally studded with tuber- cles. (See Tuberculosis of the Various Organs.) Syphilis of the Female Genitalia. — Syphilitic manifestations of a primary, secondary, or tertiary type, are frequently found in the puden- dal organs, but very little is known about syphilis of the internal geni- tal organs except the occasional localization of the primary sore on the portio or cervix. Herzog, who has studied the vascular changes of syphilis (A Contribution to the Histopathology of Syphilis: Chicago Medical Recorder, vol. xiv, 1899), is of the opinion that certain cases of chronic oophoritis, in which no other causation can be obtained, and which present certain vessel changes very characteristic though not pathognomonic of syphilis, may be due to either the acquired or the congenital form of this affection. Trophic Changes. — Eeference has frequently been made to hyper- trophies occurring in the female genitalia. Just as we find a peculiar liability to hypertrophy in these parts, so do we meet atrophic processes, some of which have so far baffled all endeavours to solve their etiology, as is, for instance, the case in the atrophic condition known as kraurosis vulva?. (See Cutaneous Diseases of the Vulva.) Of course all normal physiologic senile changes must be excluded from the consideration of morbid atrophies, the most interesting of which are those of the uterus. 3 18 A TEXT-BOOK OF GYNECOLOGY Normal, transitory lactative hyperinvolution may lead to permanent premature atrophy. This may also be brought about by a number of general infectious diseases, abnormal blood states (leucaemia), or metabolic affections (diabetes). Profound puerperal infection is the most common cause of partial or total atrophy of the uterus, and this may lead to grave local and general disturbances. (Bacon and Herzog: Fatal Perforation of a Uterus Partially Atrophied Post-partum. Amer- ican Journal of Obstetrics, 1899.) Neoplastic Changes. — The true intrinsic etiology of tumour forma- tion in the female genital organs is as obscure to us in these parts as it is elsewhere in the organism. We know, of course, that the female genitalia are in an unusually high degree liable to become the seat of neoplasms. No part of these organs is free from tumour formation, and all types are met with. Three classes of new growth stand out most prominently. The horrible frequency of carcinoma of the uterus is a fact only too well known, not only to the profession, but even to the laity. While diseases of the mamma have been left out of our considera- tion entirely, it perhaps deserves mention here that these accessor}- sexual organs of the female likewise belong to those organs which most frequently develop carcinoma. The second class of tumours which show a great predilection for the female genitalia is formed by the fibro- myomata. Attempts have been made to explain their frequent devel- opment in the uterine muscularis upon the ground that the structure, from its physiologic changes in pregnancy, has an intrinsic tendency toward the new formation of muscle tissue. But this seeming explana- tion disregards the fact that while we have in pregnancy an enor- mous increase in the bulk of the muscularis, it is one, as is now con- ceded, winch does not depend upon an increase in the number of the component muscle cells, but only upon an increase in their size. The third class of neoplasms occupying a very prominent place in the pathology of the female organs of generation, is the cysto-adenomata of the ovary. It has been previously mentioned what physiologic reasons may possibly stand in some causal nexus to the frequency of neoplastic formations in the ovary. In the cysto-adenomata of the ovary we have epithelial neoplasms which differ greatly in some respects from ade- nomata found elsewhere. The latter, as a rule, have a great tendency to become malignant and to change into true carcinomata. This tendency in the cysto-adenoma of the ovary is rare. (Henrotin and Herzog: Carcinoma Developing in Primarily Nonmalignant Cysto- adenoma of the Ovary. Chicago Medical Recorder, vol. xvii, 1899.) Here we have an extensive epithelial proliferation, which in other parts of the body is almost sure to lead to carcinoma, but which in the ovary does not seem to carry with it any great danger of developing malig- nancy. Not only are these cysto-adenomata very common, but they also often occur in women advanced in life, and they may exist for years and decades without ever changing their benign type. Pathologic pro- GENERAL PATHOLOGY OF FEMALE GENERATIVE ORGANS 10 cesses almost unknown in other parts of the body, bnt fairly often seen in the female in connection with benign epithelial neoplasms, are the implantation metastases of papillomatous adenomata of the ovary. These metastases are, as a rule, entirely void of true malignant features, and they generally disappear after the removal of the main tumour. Another fact worth remembering in connection with the peculiar- ities of the pathology of the female genitalia, is the comparative fre- quency of neoplasms, particularly of a sarcomatous type, in the female infant and child. In closing the foregoing considerations, it should be said that they do not pretend to furnish a full and exhaustive general description of all the pathologic phases and problems encountered in connection with the female genital organs. What has been attempted, is to give to the student of this department of medicine an idea of the special points of view and the particular physiological considerations from which the pathology of the genital system of the woman must be ap- proached, which are considered in detail in various chapters of this book. CHAPTER IY GENERAL THERAPEUTICS OF GYNECOLOGY General medication — Serum therapy — Local medication — Balneotherapy — Sugges- tion — Electricity — Massage. General Medication. — The lines along which modern gynecology has developed have been so distinctly surgical that relatively less attention has been given to the question of therapeutics. The error involved in this tendency is shown by the fact that the female genera- tive organs are in close vascular, nervous, and tissue, connection with the general system, of which they are as distinctly integral parts as are the eye, the ears, or other organs of special functions. They are capable of influencing and of being influenced by systemic states; and they are therefore, to a certain extent, amenable to therapeutic agencies. The medical aspect of gynecology is entitled to studious consideration. The deterioration of the blood, as manifested in the various anaemias, often finds expression in disturbance of the menstrual function; neu- rotic states not infrequently cause painful coition and dysmenorrhea, while hepatic disturbances produce pelvic hyperemias. It is appar- ent, therefore, that any therapy which will relieve the initial disturb- ance, will, to that degree, cure its results. This conception of the relation of the functional integrity of the genital organs to systemic states or to other anatomically remote diseases, must be the key to the intelligent employment of remedial agencies. Thus, a simple laxative may relieve ovarian tenderness, an active cholagogue may cure a con- gested uterus, and a course of iron and arsenic may become the most potent remedy for certain functional menstrual deficiencies. That remedies given by the stomach exercise in any important degree an elective action upon the nonpregnant uterus or its adnexa, is open to doubt. Ergot and the bromides, for example, given as rem- edies for uterine hyperplasia, have disappointed expectation. Laxa- tive agents, however, such as aloes and myrrh, which affect the lower alimentary canal, modify the functional activity of the generative organs by attracting an additional volume of circulation to the pelvis. The most valuable general remedy in the treatment of the diseases of women, is rest. This should be looked upon just as if it were a mate- rial agency, duly catalogued, and described in the materia medica. Eest in this sense implies not only physical repose, but, so far as possible, cessation from functional activity. To realize its full bene- 20 GENERAL THERAPEUTICS OF GYNECOLOGY 21 fit, the marital relations of the patient should be for the time discon- tinued, and the patient herself should go to bed. That kind of rest which patients are prone to take by donning a loose gown and lounging here and there about the house, engaging in one activity after another, amounts practically to no rest at all. The practitioner will do well always to explain in minutest detail just what he means by rest when he prescribes it. In many of the minor acute inflammations, noninfec- tious in character, this remed}^ is alone sufficient to cure. Serum Therapy. — The treatment of gynecologic conditions by animal extracts was introduced by Jouin in 1895, and advocated in America by Polk (Medical News, January 11, 1899). The treatment of diseases of the uterus and adnexa by these agents is under advisement. Cures of amenorrhoea due to obesity are reported as resulting from their use. Polk has advocated the administration of thyroid extract for the cure of uterine fibroids, and has reported cases which seem to be im- proved by the remedy. The treatment seems to be based upon the well- known reciprocal trophic relationship existing between the uterus and the thyroid gland. This relationship has been emphasized by Freund {GentraTblatt fur Gynakohgie), who finds that swelling of the thyroid merely from congestion is always present in pregnancy, and also during menstruation. Wherever there is energetic or persistent irritation in- volving the uterine muscles, it will cause a persistent swelling of the thyroid. That this trophic impulse is derived from the uterus rather than from its adnexa, is shown by the fact that ovarian tumours and tubal dropsy do not cause enlargement of the thyroid, except when in rare instances they encroach upon and irritate the uterine muscle. These observations are in accord with those previously made by J. Fischer, who affirms and demonstrates not only the influence of the uterus upon the thyroid, but also that of the thyroid upon the uterus. YTomen with goitre generally suffer with menorrhagia and metrorrhagia; extirpation of the thyroid is followed by genital atrophy. Myxcedema in women is generally associated with amen- orrhoea. In cretins, there is a diminution and often an entire loss of sexual power. Menstrual disturbances are among the earliest symp- toms of exophthalmic goitre. These facts, long since established in America by Jenks, indicate beyond question the relationship existing between these two organs. It would seem that an extract made from the thyroid gland of the sheep and ingested into the human system exercises to some degree a modifying influence upon the uterus, its nutrition, and functions. The extent and exact character of this influence remain yet to be determined. Ovarian extract is given with the object of stimulating ovarian activity and of increasing the sexual appetite. Favourable reports of its use have been made, but whether the alleged results are due to physical or psychic influence remains to be determined. Protonuclein, locally applied, is unquestionably a valuable antistreptococcic agent, and reports are abundant indicating that it exercises a salutary influence over the nutrient activities. 22 A TEXT-BOOK OF GYNECOLOGY Local Medication. — Local medication consists in the application of remedies directly to the part involved. This method of treatment is of great importance in many of the diseases which will hereafter be con- sidered. The application of escharotics to an inital syphlitic sore and the topical use of an antiseptic solution in the treatment of vaginal gon- orrhoea, are examples in point. Among the remedies thus employed for antiseptic purposes, the chief are mercuric bichloride, carbolic acid, lysol, creolin, and potassium permanganate. Among the local astrin- gents may be mentioned the salts of lead, zinc, and even iron. Boric adid is a favourite with many practitioners, while tannin is the vegetable salt of greatest importance in this class of cases. The action of astringents, all of which are to a certain extent antiseptic and ger- micidal, is to influence the circulation of the capillaries upon the tissues to which they are applied. They are frequently of question- able value, and always of less value than those agencies which have a more powerful influence in destroying the micro-organisms upon which depend practically all of the inflammatory diseases in the mucous and cutaneous areas. Hydrastinine, a comparatively new alkaloid, de- rived from the hydrastis canadensis, has been found by Falk to be a valuable astringent, when used in ten-per-cent solution locally, for the treatment of uterine hemorrhage. Sedative lotions and emollient applications are frequently demanded to relieve local distress in the external genitalia. Topical applications, having for their object the drainage of the pel- vis by exosmosis, should be employed in practically all cases of acute in- flammation, of chronic engorgement, or of persistent exudation within the pelvis. This treatment is made effective by virtue of the hygroscopic properties of glycerine. This agent has such powerful attraction for water that it abstracts it from any underlying tissue to the surface of which it is applied. This subject will be treated more in detail in connection with pelvic inflammations. Balneotherapy. — In no department of medical practice has the use of water proved of more value than in the management of intrapelvic diseases of women. Emmet, many years ago, pointed out the value of the vaginal douche and demonstrated its rationale — the water at a tem- perature varying from 105° F. to 120° F. is applied with the patient lying on her back, and continued for a period of twenty minutes at each seance. As has been demonstrated by Emmet, the primary influ- ence of the heat thus applied is to dilate the capillaries and to invite an increased supply of blood to the parts. In the course of ten min- utes, however, the secondary effect of the heat is realized. This is characterized by blanching of the parts, a contraction of the capil- laries, and a marked diminution in the volume of the local circula- tion. This treatment should be repeated at least twice daily. The results are invariably a marked amelioration of local engorgements, particularly when treatment is associated with rest and drainage by osmosis. Engelmann, of Kreuznach, has found general bathing GENERAL THERAPEUTICS OF GYNECOLOGY 23 Tinder scientific supervision to be a remedy of great value. Asso- ciated with friction, it acts on the same principle as a counterirri- tant, attracting a considerable volume of the circulation to the surface, thereby relieving splanchnic congestions, and. by stimulating the nerv- ous system, becomes an active promoter of absorption. In this way it becomes valuable as a remedy for chronic exudates, adhesions, neo- plasms, and in the treatment of amenorrhcea due to obesity. It is contraindicated in acute inflammatory conditions. Engelmann says that an efficacious bath ought to contain from four to six pounds of common salt or sea salt, and also from two to five pints of mother lye to four hundred pints of water. The temperature of the bath should not exceed 95° F., and its duration should not exceed half an hour. The influence of such a bath is to calm the pulse and respiration and to induce sleep, which should always be encouraged. The better time for taking such a bath, therefore, is just before bedtime. Suggestion. — Suggestion as a therapeutic agent has been in vogue since the Pastaphori of Egypt practised it in the form of a " temple sleep," and ever since the healing by words was recorded in the Mosaic writings, or in the pages of the Zend-Avesta. It is based upon the influence of mental upon physical states, and while it has never re- ceived specific recognition as a distinct agency in gynecologic thera- peutics, it is nevertheless a remedy of unconscious daily application by every tactful practitioner. That uterine and other genital disturb- ances exercise a perturbing influence upon the mind is a matter of constant observation; and that the mind diverted from the seat of dis- comfort, or thoroughly impressed with the thought of and confidence in the recovery, thereby stimulates the organism in the direction of health, is a fact long known and practised by the profession. Suggestion may be carried not only to the unconsciousness of pain due to local physical disturbances, but to the degree of anaesthesia in parts that are not the seat of disease. So powerful is this agency that operations may be, and have been, performed painlessly under the hypnosis thus induced. An agent of such power should be subjected to more critical study than has yet been accorded it by the profession. (See Anaesthesia.) Electricity. — Electricity, in the form of faradism, is a remedy of some value when adminstered in such a way as to bring the nervous and muscular systems under its influence, when it acts as a promoter of metabolism and an important stimulant to the nutrient functions. Ad- ministered locally, under antiseptic precautions, with the negative pole in the uterus and the other upon the surface of the abdomen, it has been found to act as a stimulant in restoring the functional tone of that organ. With one pole in the vagina and another in the groin it has been found to relieve neuralgic conditions within the pelvis. Favour- able reports have been made of its use in catarrhal endometritis. There is no doubt that, judiciously applied, it promotes the growth of the undeveloped uterus, for which purpose the intrauterine electrode should be the negative one and that placed over the abdomen or over 24 A TEXT-BOOK OF GYNECOLOGY the sacrum should be the positive one. It has been found to promote the absorption of effused products in the pelvis, but it must be recog- nised as a dangerous remedy in this class of cases, for the reason that it is practically impossible in many of them to determine when the exudation does or does not depend upon purulent infection, in the presence of which electricity should not be used. Electricity in the form of a strong current causes chemical decomposition of the tissues by the process of electrolysis, by which the acid elements are attracted to the positive pole and the basic elements are attracted to the negative pole. It was the application of this principle that induced Apostoli,. of Paris, in 1884, to attempt the disintegration and absorption of uter- ine fibroids by the use of strong electric currents. He began by using 100, which he finally increased to 250 milliamperes, the strength of the current being accurately measured by a galvanometer. While, in many cases, this treatment temporarily arrested hemorrhage and diminished the size of the growth, its general results have not been accepted as satisfactory by the profession. It proved to be painful, causing, in many instances, deep eschars on the abdominal surface, intractable peritoneal adhesions, infections of the tumour, septicaemia, and, in some cases, death. Massage. — Massage is one of the most primitive of remedies, and is utilized by many aboriginal peoples. Stanley found it in use among the hordes of Africa; Stevenson found it in use among the Navajos; it was a remedy among the ancient Chinese and the Hindoos; and it was employed by the Greeks and Eomans. Hippocrates mentioned its use in diseases of the joints. In the great renaissance it appeared first in France, whence it spread to other European countries. Billroth, Es- march, von Mosetig, Thiersch, von Bergmann, von Mosengil, and others recommended it highly, first in diseased conditions of the extremities, and finally as a therapeutic measure in diseases of the internal organs. In the form of general massage it is a valuable remedy for the pro- motion of metabolism and elimination, especially in cases of the neu- rotic type. In these cases, judiciously applied, it tranquillizes the nerv- ous system, induces sleep, and, by virtue of its quality as a form of pas- sive exercise, it promotes nutrition. It is of special value as an adjunct to the " rest cure." For the realization of its greatest benefits it must be given scientifically, for the details of which the reader is referred to the various manuals on the subject. Massage is contraindicated in all febrile states and in the presence of acute inflammation. Dr. G-eorge H. Taylor has devised a method called by him vibratory massage, which is utilized by means of specially devised apparatus. The method shows great ingenuity and a scientific conception of the subject, and de- serves the most careful consideration. (See New York Medical Jour- nal, April 2, 1892.) Abdominal massage consists in the manipulation of the abdominal wall, and through it of the abdominal organs, for the purpose of pro- moting functional activity of the latter. As ordinarily employed, the GENERAL THERAPEUTICS OF GYNECOLOGY 25 patient is placed in the recumbent posture with the abdominal walls flexed, when with the hand the abdomen is kneaded. This general exercise is supplemented by manipulations beginning in the right iliac fossse and extending upward to the hepatic flexure of the colon, thence across to the splenic flexure, and thence downward to the sigmoid, the object being to stimulate the colon to activity. As a substitute for a manual manipulation of the abdomen, Sahli places a cannon ball on the relaxed abdominal wall and rolls it around in various directions, and Ivanhoff has suggested a substitute in the form of a hollow wooden or celluloid globe, partially filled with shot. A shot-bag has been simi- larly used with excellent results. AYhen any one of these substitutes is used, its application should be concluded by rolling it repeatedly over the track of the colon from the caecum to the sigmoid. Abdominal massage, to be most effective, should be given half an hour before breakfast and repeated half an hour after breakfast. By its employ- ment the contents of the abdominal canal are moved onward, the portal circulation is accelerated, the lymphatics are given a fresh impetus, absorption and assimilation are promoted, the production of gas is diminished and its expulsion facilitated, and the splanchnic sym- pathetics are stimulated, while all the nutrient functions participate in the benefit. Pelvic massage has been popularized chiefly through the influence of Thure Brandt. It consists in the manipulation of the pelvic organs by the bimanual method with the object of correcting displacements, of curing old adhesions, of effecting the resorption of old exudates, of stretching shortened ligaments, and of reducing hyperplasias. The patient to whom it is to be applied is given a preliminary treatment of mild laxatives to unload the rectum, and boroglyceride tampons in the vagina to lessen pelvic engorgements. The patient is placed in the dorsal position with her knees well flexed; the vagina is thoroughly cleansed; the operator inserts the index finger of his "handy" hand, thoroughly oiled, into the vagina, passing it well up behind the cervix; the other hand is placed over the suprapubic region. At this juncture, and before any special manipulations are undertaken, a careful biman- ual examination of the pelvis should be made, a precaution which should be observed at the beginning of each seance. If points of recent engorgement or of especially acute sensitiveness are discovered the operator should desist. If, however, no such contraindications are found, it is prescribed, as the first movement of the massage, to press the external hand over and behind the fundus of the uterus, while slight downward traction is exerted by the tip of the intravaginal finger, the object being in all movements to ..draw the uterus gently toward the symphysis pubis. The ovaries are treated, when discover- able, by subjecting them to a similar range of mobility. Special move- ments are suggested by the particular conditions that may be discov- ered. A seance should not last over ten minutes, and the force to be employed, both in amount and direction, must be determined at the 26 A TEXT-BOOK OF GYNECOLOGY time by the conditions encountered and by the judgment of the oper- ator. After massage a boroglyceride tampon is inserted, and if the manipulations have been at all painful the patient should remain in a state of repose for several hours. The dangers inherent in this method of treatment are so many that it has been largely abandoned by those who formerly employed it, while, on theoretic grounds, it has been perhaps too unqualifiedly condemned by those who have never tried it. Its chief danger consists in the fact that the exact diagnosis of intra- pelvic conditions is extremely difficult, and that consequently massage is liable to be employed with fatal results in conditions in which it is contraindicated. Among the accepted, but sometimes not recognisable, contraindications to the use of pelvic massage, are acute inflammatory processes; the presence of dilated Fallopian tubes; ovarian enlarge- ments; cystic degeneration in either the ovaries or the parovarium; and, above all, the presence of pus in the pelvis. (See Diagnosis of Pyo- salpinx.) CHAPTER V THE GYNECOLOGICAL ARMAMENTARIUM The more modern principles of treating wounds have led to marked modifications in the surgeon's armamentarium, and in no part, per- haps, has the change been so pronounced as in the kind of instruments used in operative work. The day of instruments with elaborately carved wooden and ivory handles is past, and complicated trocars and tubular needles no longer have a place in our instrument cases. The present tendency is to simplify their construction as much as possible and to use no greater variety than is absolutely necessary. The choice of instruments must necessarily vary with the predilections and train- ing of the individual operator. Certain main principles, however, should always be kept in mind. The surgeon need not encumber him- self with such instruments as are seldom needed, or with a multitude of so-called " surgical conveniences " and " automatic appliances." He should, however, always provide himself with a liberal supply of the instruments in common use, in order to be prepared for emergencies. None should be retained which do not permit of easy sterilization. Knives should have smooth metal handles, and handle and blade should be in one piece. Instruments with grooves, depressions, and notches, are to be avoided. Good hemostatic forceps with smooth blades can now be obtained, and are just as effectual as the old ones with grooved faces. All scissors, forceps, needle holders, and the like, should have simple articulations, so that the different parts are readily separable. An instrument with permanent joints can not be kept surgically clean, and should therefore not be tolerated. With our present methods of sterilization, instruments made of steel do not suffer as they did for- merly, and if properly cared for should not rust. Mckel plating has been proved to be not so valuable as was at first hoped, for, since instru- ments which are subjected to constant wear have soon to be replated, they would prove somewhat expensive. For those instruments which are but rarely used, however, nickel plating is advantageous, since it protects them from the action of the air. Instruments made of aluminum have been recommended, but they are undesirable for the following reasons: (1) They are too expensive; (2) they are too soft; (3) they will not stand repeated sterilization. In a hospital, one nurse or assistant should be given the full charge of the instruments, being held responsible for their proper sterilization and preservation. In private practice the surgeon must give the in- 27 28 A TEXT-BOOK OF GYNECOLOGY struments his personal attention; and even in hospitals he will do well to watch closely the assistant to whom they are intrusted, in order to be sure that the constant careful attention which is absolutely neces- sary is being paid to them. It is important to write out lists of instruments that are used in the different operations and to keep them where they can be easily consulted on each operation day, so that none which will be needed will be forgotten. Those lists should be divided into two parts, the first containing instruments which are sure to be required; the second, those that may possibly be needed under certain circumstances; they should therefore be prepared, although they may be set aside until they are called for. (For special lists of instruments, see the different operations.) CHAPTER VI DIAGNOSIS Definition and scope — Indications and contraindications for vaginal examination — The gynecological examination : Physical; the armamentarium ; the examina- tion itself; inspection of the external genitals; digital examination; bimanual examination; rectal exploration ; examination under anaesthesia; examination of the abdomen ; regions of the abdomen ; instrumental examination by (a) the speculum, (b) the sound, (c) the dilator, (d) the curette, (e) the aspirator — Examination of the secretions — Urine — Faeces — Menstrual discharge — The nervous system. The diagnosis of a gynecologic case consists in determining the character and location not only of the local disease, but of any asso- ciated pathologic states. The destructive character of many of the infections diseases and of both the benign and malignant neoplasms in women, and the essentially insidious onset of many of these condi- tions, render prompt examination and early diagnosis necessary for the welfare of the patient. This fact will be emphasized in discussing the diagnosis of individual diseases. To the end that diagnosis may be made early, it is the duty of the practitioner to impress upon his cli- entele the importance of this step, and that it may be made accurately, it is essential that he should take the broadest possible survey of the patient and make the most critical investigation of even suggestive departures from health. It is better, in an effort to avoid a narrow investigation of simply the conditions complained of, to leave the examination of the genital state until all essential facts in the patient's general history have been ascertained. To this end systematic inquiry should first be made relative to the patient's age, hereditary influences, menstrual and marital histories, previous diseases, and present com- plaints. While these interrogatories are being made and answered the physician should cultivate the habit of carefully noting the patient's appearance, with special reference to her nutrition, her nerve poise, and her temperamental characteristics. The pulse should be counted, the tongue should be inspected; in short, a general survey of the pa- tient should be made before strictly pelvic conditions are either in- quired into or examined. All of the facts thus gleaned should be re- corded and held in mind during the progress of the physical examina- tion, which should embrace the following steps: (a) The gynecological examination, including, if necessary, an ex- ploration of the bladder and rectum and inspection and palpation of the abdomen. 29 30 A TEXT-BOOK OF GYNECOLOGY (b) Special physical examination, including, according to the indi- cations of the case, inspection of the throat and upper air-passages, percussion and auscultation of the heart and lungs, ophthalmoscopic examination, etc. (c) Examination of the secretions — e. g., the urine, faeces, menstrual flow, and perspiration. (d) Examination of the blood. (e) Examination of the nervous system, with special reference to the determination of sensory and motor disturbances. Indications and Contraindications for Vaginal Examination. — In cases of girls and unmarried women a vaginal examination, either digi- tal or instrumental, should be undertaken only in the presence of posi- tive indications. Youth and virginity should always be looked upon as contraindications for such an exploration, unless in the presence of more than counterbalancing reasons: such, for instance, as the pres- ence of all the menstrual phenomena, the flow excepted, suggesting the possible retention of the menstrual fluid; or in the presence of an offensive discharge associated with remoter pelvic symptoms; or to investigate the origin of a persistent hemorrhage. There are numerous other conditions the importance of which will occur to the practitioner. It should be set down as a rule to which there are but few exceptions, that the examination of young girls in particular, and of many unmar- ried women of the nervous type, should be undertaken only under anaes- thesia. In this way alone can they be protected from a serious moral shock and more or less physical discomfort. When the examination is being made great care should be taken to preserve as far as possible all virginal conditions; but this consideration ought not to obtain to the point of defeating thoroughness of exploration in the presence of manifest necessity. In married women less hesitancy should be manifested in under- taking an examination, although even in such cases it should not be done for trivial reasons. When, however, there are either pudendal, vaginal, or high pelvic symptoms of an obscure character and suffi- ciently severe to justify treatment at all, the practitioner owes it both to himself and his patient to insist upon an examination. Any failure to take this stand is liable to be disastrous to both parties. In women past the menopause, all symptoms of a pelvic character should be regarded with suspicion and inquired into with promptness and precision. This is especially true in the presence of hemorrhage at or about the period of the change of life — a symptom which is nearly always an evidence of malignant disease. (See Menopause.) The Gynecological Examination. — It is as important in all gyneco- logical procedures to establish accuracy of diagnosis as in any other department of medicine. The responsibility of the gynecologist is not second in this respect to that of his confreres in the other branches of medical or surgical science. The foundation of correct diagnosis lies in the thoroughness of the DIAGNOSIS 31 examination, and to this end every known means must be invoked in discovering the real seat of the malady and the character of its possible complications. At the initial consultation a complete history of the patient's con- dition should be obtained and accurately recorded. For this purpose it will be convenient to have a book so bound as to contain one hundred histories, and so ruled and spaced that additional entries may be made at subsequent dates. It is a good -plan to have the history blanks printed in sheets that may be filed temporarily and be bound after an adequate number have been filled. The form of the blank can be devised by each physician according to his own preferences, hence it is only necessary here to call attention to the essential points of the record. These are — after entering the name, age, social condition, address, and other preliminary data — to record the family history as bearing on heredity; the menstrual history; the number of children borne and the character of the labours; mis- carriages and their sequela?; condition of bowels and bladder as to func- tion; all pelvic phenomena that are abnormal; and, finally, every fact pertaining to the special condition for which the consultation is sought* After the physical examination has been made, all lesions, growths, or abnormities should be carefully entered, and the treatment advised or instituted, set forth in detail. Each physician, as he becomes impressed with the value that attaches to accuracy, will record all data shown by experience to be important. The foregoing are merely suggestive, and are, moreover, such as may not. in any case, be omitted. Physical Examination. — After having made and recorded an oral examination of the patient, the next step involves a physical investiga- tion by inspection, palpation, and pelvic exploration. The events under consideration in these pages are made applicable to office con- sultations, hence details are given adapted to that environment. Suit- able rooms are requisite, and should number three or more, en suite — one a reception room, another a consulting room, and a third solely used for the examination. In this last there should be running water, hot and cold, and a toilet room adjoining is well-nigh a necessity. The examining and toilet rooms should be presided over by a comely woman, trained as an office assistant. She need not necessarily be a nurse, but she should be a trustworthy woman competent to hold a speculum and intelligent in all that pertains to gynecological work. The armamentarium should consist of a table, specula, dressing forceps and tenacula, douche apparatus, absorbent cotton and antisep- tic wool, sounds and applicators, lubricant, protective or pad, sheet, and gown. The table should be strong and should stand solidly on its four legs. It should be capable of extension to enable the patient to lie in the horizontal position, reasons for which will be considered pres- ently. It need not necessarily be an expensive or complicated affair, but should be equipped with foot rests, a thin mattress, and pillows. 32 A TEXT-BOOK OF GYNECOLOGY An assortment of Sims's specula are essential, and one or two good bivalves will be convenient. Every successful gynecologist knows the value of the Sims specu- lum, and every one who expects to practise the specialty must of neces- sity make himself familiar with its uses. The objection often made to it is that a competent person is required to hold it. If the beginner can not employ such a person, then he must provide himself with one of the so-called self-retaining Sims instruments. Potter prefers the Emmet self-retaining attachment for this purpose. It is the simplest and can be held easily by the patient, who will grasp a piece of rubber tubing passed through the fenestrum of the buttock blade. Sounds and applicators are included in the office outfit, but it is proper to remark that they seldom will be needed. The indiscriminate use of the sound has proved harmful to many women, and should never be used by unskilful hands. Nevertheless it will occasionally be serviceable as an aid to diagnosis, hence is included in the list. Applicators, too, will rarely be employed. We need not enter into a discussion of the propriety of topical applications to the endometrium, but it will suffice to say that as a routine it is of doubtful propriety. Occasionally, however, such treatment is needful, hence the instru- ments must be at hand. The selection of a proper lubricant is a matter of considerable im- portance. A^aseline is in common use, but it is not easily removed from the hands. Dudley (Diseases of Women, second edition, Lea Brothers & Co., 1900) prefers glycerine, which is cleanly, sterile, but expensive. Some are partial to glymol, certainly an excellent agent. Potter recommends alboline in collapsible tubes, which is thus kept germ free, is cheap, and efficient. The so-called Kelly pad, really a device of Joseph Price, is a con- venient protective, but it, too, is expensive, and besides is difficult to keep clean. A piece of rubber sheeting will answer every purpose, pro- vided that it is rolled at the sides and back to prevent backflow of water. A douche apparatus should be at command for all office examina- tions or treatment. It should consist of a reservoir that will hold at least a gallon of sterilized water, with rubber tubing attached to a vaginal douche nozzle with backflow arrangement, and the tubing should be equipped with a gate or cut-off. Before examination the woman should be divested of unnecessary clothing, such as corsets and superfluous skirts, then placed upon the table in the dorsal posture, with feet in the foot rests, and the pad or protective properly adjusted to prevent wetting or soiling the clothing. After covering her with a sheet, the douche may be administered. This should consist of an appropriate quantity of sterilized water at a temperature of about 115° F. If there is suspicion of infection, the douche should be rendered antiseptic by the addition of bichloride of mercury sufficient to make a solution of 1 to 2,000. DIAGNOSIS 33 Fig. 1. — " The woman is now placed upon the table, usually in the dorsal position." — Potter. The Examination. — The preparation of the patient may be made by the office assistant, who, as we have said, should be a competent woman. She shonld ar- range the clothing of the patient, administer the donche, and, if need be, give an enema to nnload the rectum. This latter is important if there is constipation, as a distend- ed lower bowel may mis- lead in diagnosis. Such a condition not only dis- places the pelvic viscera, but it may be mistaken for a tumour, new growth, or retroverted uterus. Af- ter these preliminaries the patient is ready for the examination proper, which, it is almost needless to add, in these days of asepsis, should be conducted with the utmost aseptic care. The examiner himself should prepare his hands as carefully as if he were about to conduct an abdominal section or other important surgical operation. His lavatory should be supplied with the best of soap. A number of nail brushes, too, should be at hand, and of these there is none better, or indeed so good, as those made of vegetable fibre. They are cheap, durable, and can be kept clean. We have already alluded to the administration of the douche, which should invariably precede the examination unless for some special rea- son it becomes necessary to inspect the uterine, vaginal, and vulvar fields, to study their secretions or exudates with a view to deter- mine their character, in the expectation that they may furnish an important aid to diag- nosis. But when it is used, particular care must be paid at the conclusion of the ex- amination to the dis- infection of the douche nozzle as well as of the hands of the physician and assistant and of all else that comes in contact with the patient. With these preliminaries the woman is now placed upon the table, usually in the dorsal position (Fig. 1), as already indicated; or, accord- ing to the requirements of the case or the preference of the operator, 4 Fig. 2.— " . . . Or, according to the requirements of the case, or the preferences of the operator, she is placed in the left lateral prone, better known as Sims's posture." — Potter (page 34). 34: A TEXT-BOOK OF GYNECOLOGY Fig. 3. — " . . . Which is better appreciated if studied from the foot of the table." — Potter. she is placed in the left lateral prone, better known as Sims's, posture (Fig. 2), which is better appreciated if studied from the foot of the table (Fig. 3). Occasionally it will become necessary to employ the knee- chest posture (Fig. 4), and sometimes a woman should be examined while she is standing (Fig. 5). Upon mounting the table, the woman should sit upon the end of it, which should be properly covered with protective and aseptic towels. A pillow should be provided for her head, but, as she is to lie flat upon her back, the shoulders should not be ele- vated by the pillow. A sheet or other proper covering should be spread upon her lap while she is yet sitting on the end of the table. She is now assisted to lie down, the nurse taking hold of her feet and placing her heels in the stirrups, which should be placed as close together as possible and which have been drawn out to receive them. The thighs thus become flexed, the abdominal mus- cles relaxed, and the knees Avidely separated. In a first examination it will often become necessary to assure the patient that she is neither to be hurt nor exposed, after which the covering may be parted and adjusted around the vulva, which is ready for inspection. Inspection of the External Genitals. — It becomes necessary, espe- cially with a strange patient, at a first examination to inspect the vulvar field with care. This is done, not only for diagnostic reasons, but for safety. A physician may become infected from a venereal sore, even on the person of an inno- cent woman, unless the presence of such a le- sion is detected before- hand. To be forewarned is to be forearmed. In the investigation of such a case, abrasions of the hand, and especially of the examining finger, should be painted with collodion. Having determined the nature of the secre- tions of the parts, and having carefully inspected the hymeneal orifice, noting whether the hymen has been ruptured, the examiner should next look carefully for the evidences of parturition — such as lacerations, cicatrices, and the Fig. 4, -" Occasionally it will become necessary to em- ploy the knee-chest posture." — Potter. DIAGNOSIS 35 like — and then he may look for tumours, urethral caruncles, vulvitis, urethritis, eruptions, ulcerations, cystocele, rectocele, inflammations of Bartholin's and Skene's glands, oedema, and pruritus. The rectum should be explored with reference to hemorrhoids, fissure, fistula in ano, pimvorms, and any anomaly of anatomic configuration. The clitoris should be examined with reference to any enlargement or an adherent prepuce. The vulvar orifice, if capacious or gaping, gives token at least of marital relations, whereas the virgin vulvar orifice is small, com- pact, with a more or less perfect hymen. The absence, however, of the hymen is not considered evidence of unchastity — a fact that should always be kept uppermost in the mind of the gynecologist, especially in the commencement of his practice. The condition of the labia minora should also be noted. When these are long, flab- by, and pendulous in contour, it is prob- able that the woman is a masturbator. This condition of the minor labia, it is quite true, might arise from other causes, but this is the most probable explanation of it. While inspection is usually limited to the region and for the purposes named, it may be carried upward to include the surface of the abdomen, whereby enlarge- ment or imperfection of contour may be discovered. Inspection of the interior of the vagina through the speculum, and of the rectum by a similar instrument, does not come within the limit of this section, but will be described under its appropriate head. Digital Examination. — By far the most important method of investigation is the examination by the fingers and hands. The tactile sense is so acute, and may be so highly educated, as to supersede or take the place of every other method, provided one were limited to a single means of obtaining information. It becomes of the first importance, therefore, that it shall be employed intelligently, systematically, and thoroughly. We shall not enter into an argument as to whether the right or left index finger is the better for this investigation, but shall con- tent ourselves with saying that while the specialist will frequently prefer the left, and most of such at least will be ambidextrous, the general practitioner will usually employ his right finger or fingers for the digital examination. An advantage in using the left finger is that it leaves the right hand free for instrumental use and for bimanual examination. Again, it preserves the right hand from the clanger Fig. 5.—". . . Sometimes a woman should be examined while she is standing." — Potter (page 34). 36 A TEXT-BOOK OF GYNECOLOGY of becoming an infection carrier, which is perhaps a matter of con- siderable moment in dispensary or hospital work. Sometimes it will be useful to employ two fingers in the investigation, but this will be rather the exception than the rule, limited to the capacious vagina and the short index finger. Two fingers in a narrow vagina are, to say the least, painful; but, as the index finger is sometimes short and the diagnostic reach can be increased perhaps half an inch by the con- joined use of the index and ring fingers, this expedient occasionally becomes not only justifiable but useful. There is nothing that indicates greater gynecological skill than the tactful employment of the digital examination. The clumsy, hasty, and rough manner, in which it is sometimes used, is to be strongly condemned. On the other hand, it should be employed with the great- est delicacy, but at the same time with thoroughness, precision, and aptitude. Every gynecologist should avail himself of every oppor- tunity to educate his finger tips; indeed, they should be brought to that degree of tactile perfection that a reasonable degree of accuracy in diagnosis can be obtained, in the majority of cases, without an appeal to instrumental aid. The digital examination becomes available and applicable in the horizontal, dorso-sacral, latero-prone, genu-pectoral, and standing, postures. But its chief application is in the dorsal or dorso-sacral postures. Finally, the index finger occasionally becomes of great usefulness in everting the anus by pressure through the vagina upon its posterior wall. In this manner the examiner will often detect with ease and precision rectal or anal faults that otherwise might re- main obscure. It remains for us to give the technique of the digital examination. To begin with, let us repeat, the toilet of the hands, and especially of the index finger to be employed, should be most carefully made. Thor- ough washing with soap and warm water and scrubbing with the nail brush should precede the lubrication. Then the finger tip, palmar surface downward, should be carefully passed into the vagina against its posterior wall, the fingers of the other hand being used to separate the labia and to slightly distend the vulvar orifice. In this manner it will note, first, the condition of the perineum, its rigidity or laxness, its integrity or imperfectness; secondly, the condition of the rectum, whether it contains faeces or is empty; thirdly, the relation of the coccyx to the pelvic outlet; and fourthly, the capaciousness or narrowness of the vagina. Turning now the finger upward and passing from side to side along the vagina, its lateral surfaces are explored, until finally the cervix uteri is reached. Here is an important field for investi- gation. If the cervix is soft, like the lips, a suspicion of preg- nancy will arise; if firm or hard, like the nose, such suspicion will be dispelled. The cervix and os must now be carefully examined with reference to size and form and direction of the cervix, and the pres- ence or absence of lacerations or new growths in the os. The im- portance of thoroughness with reference to this portion of the exami- DIAGNOSIS 37 nation is to be insisted upon, and an educated finger tip is essential to its completeness. Bimanual Examination. — A great advance in the diagnosis of pel- vic diseases was signalized by the introduction of the bimanual method of investigation (Fig. 6). The term may be defined as the examina- tion of the pelvic contents by the two hands, the index finger of one being in the vagina and the other placed on the abdomen above and beyond the pubes with which to make downward pressure. The finger within the vagina lifts up the organ or organs, and the finger tip of the other hand pressing downward upon the relaxed abdominal walls Fig. A great advance in the diagnosis of pelvic disease was signalized by the introduc- tion of the bimanual method of examination.'' — Pottek. engages it or them between the two. Beginning first with the bladder, its sensitiveness, distention, or emptiness, is noted. Passing upward to the uterus, its size, condition as to firmness or softness, and its posi- tion, whether in anteflexion, retroflexion, or prolapsus, is determined. Here, again, the first question upon the mind is that of possible preg- nancy. If in the digital examination a soft cervix has been felt, the inquiry as to pregnancy must be pursued bimanually, and if it is learned that the uterus is enlarged and has floating contents the sus- picion will be confirmed, and further examination should be postponed until the question is determined. It is important to deal with this sub- 38 A TEXT-BOOK OF GYNECOLOGY ject first, because, in case pregnancy exists, it stands in the way of any further pelvic exploration lest abortion be induced. An exception to this rule would be when tumours or new growths coexisted with sup- posed pregnancy or complicated each other in an already diagnosticated condition. Then, if there is some technical point to determine, the bimanual examination may be cautiously further pursued. Displacements of the uterus are most easily and certainly diag- nosticated by means of the bimanual examination. The normal posi- tion of the uterus, it will be remembered, is one of moderate ante- flexion, in which a line drawn through its long axis appears at the umbilicus; with the fundus, however, lying farther forward, compress- ing the bladder and impinging on the pubes, the uterine body will be easily engaged and mapped out between the two hands. It will, how- ever, require some experience to distinguish between anteversion and anteflexion — all of which will be properly set forth by another writer under its appropriate head. Eetrodisplacement of the uterus may also be determined by feeling the fundus resting against the rectum in the sacral excavation, and by its absence from its appointed place as ascer- tained by pressure of the external hand. The cervix, too, in retrover- sion, will be carried upward and forward toward the pubic arch, thus resting the entire organ horizontally across the pelvis at right angles to the normal direction of the vagina. Here, again, some nicety of touch, which a little experience may soon acquire, is required to de- termine between retroversion and retroflexion. Prolapse of the uterus is more easily determined, since the index finger will come in contact with the cervix just within the vulvar orifice, or a little higher up, according to its degree. Procidentia will readily be discovered upon inspection, since the organ in whole or in part protrudes from the vagina. One of the most important functions of the bimanual is to ascer- tain the condition of the tubes and ovaries. An experienced examiner will readily discover whether the tubes are enlarged, pulpy, and soft or hardened, and whether the ovaries are unduly tender and sensitive, enlarged or atrophied, displaced, or the seat of new growths. An en- larged pulpy tube, sausagelike in shape, is suggestive of hydrosalpinx or pyosalpinx. At any rate, it means a diseased condition, which an accurate history combined with careful bimanual palpation will usually distinguish. The broad ligaments should also be carefully inter- rogated as to whether new growths lurk within their folds and if they properly support the uterus and adnexa. Adhesions, too, should be sought for, and if found, Avili of necessity influence further investiga- tion and treatment. If the uterus and its appendages are tender, bound down by adhesions, or if there is an abscess or pus tube, great caution must be exercised in pursuing further investigation. It would be in- excusable to rupture such a pus container, or to set up further inflam- matory processes by the use of force in the bimanual, or through a re- sort to instrumentation. DIAGNOSIS 39 It will be readily understood from the foregoing that the proper exercise of the bimanual in order to attain its greatest possibilities re- quires an experience that only long practice can give; hence, the be- ginner should never miss the opportunity of employing it under the supervision of a competent instructor. Only in this way can he learn either to bring the organs properly within reach, or to appreciate what he feels between his hands. At the outset he will often be foiled in his efforts by the nervous- ness of the patient; this he must overcome by his tact and gentleness, always giving the impression that he is thoroughly at home in his work. If he betrays his inexperience by suddenness of movement, inex- actitude of touch, or other evidences of the novitiate, his usefulness will be limited or destroyed. Complete muscular relaxation on the part of the patient must be obtained, and great self-possession by the examiner must exist. These two factors are conditions precedent to success. It is well to remember in pursuing the bimanual method, espe- cially when it becomes necessary to make upward pressure upon the vulvar orifice in order to reach high up in the pelvic cavity, that some- times sensitive or passionate women may be incited to sexual orgasm from irritation of the clitoris; hence, contact with that organ should be avoided as far as possible. It is probable that the aggregate number of such patients is very inconsiderable, because illness, and especially disorders of the pelvic organs, diminish the tendency to sexual excite- ment arising from physical exploration of the genital tract. Its possi- bility, however, should not be forgotten. To recapitulate, the information to be derived from the bimanual method of examination may be grouped as follows: First, capacity, rigidity, and tonicity, of the vagina. Secondly, as to pregnancy, pro or con. Thirdly, the condition of the bladder and its relation to the other pelvic organs. Fourthly, the uterus, its size, position, presence or absence of tumours within its walls, and the condition of the cervix as to integrity or lacerations. Fifthly, the status of the tubes and ovaries as to size,' location, and relationship to neighbouring parts. Sixthly, the condition of the rectum as to faecal impaction or disease of any kind, such as fistula, fissure, cancer, or hemorrhoids. Seventhly, as to the presence of any abdominal or pelvic tumour, new growth, extra-uterine pregnancy, or any abnormal condition not embraced in the foregoing classification. Finally, it may be remarked that in the case of tumours the biman- ual affords opportunity to distinguish between cystic and solid growths, and, to a certain extent, between benign and malignant neoplasms. Rectal Exploration. — It remains for us to describe examination by the rectum, which oftentimes becomes an important adjunct to the 40 A TEXT-BOOK OF GYNECOLOGY examination. The index finger in the rectum will sometimes serve to clear up a doubt or detect a hitherto undiscovered condition. It will help to diagnosticate a retroverted womb or to distinguish between that displacement and a post-mural fibroid growth. Again, it will serve to locate a hitherto undiscovered ovary occupying Douglas's pouch. Still again, examination per rectum may detect disease in that organ which will explain symptoms that otherwise would have been misun- derstood. In all cases in which careful vaginal bimanual fails to dis- cover disorder adequate to explain symptoms or to suggest a diagnosis, rectal exploration should be made. This procedure is often disagree- able, if not painful, to the patient, hence, must be instituted with great delicacy and only after thorough lubrication of the examining finger as well as the anal orifice. External hemorrhoids, even if inactive, will further emphasize the importance of careful preliminaries to the ex- ploration. (See Examination of the Rectum.) Examination under Anaesthesia. — Finally, when all the ordinary means fail to overcome the nervousness of the patient, the rigidity of the abdominal muscles, or other hindrances to the thorough and intel- ligent employment of the bimanual method of examination, anaesthesia may be appealed to; indeed, with the full consent of the patient and with adequate assistance it should be resorted to as an important ele- ment in leading to correct diagnosis. Examination by this means should be carefully conducted with reference both to its advantages and its dangers. Its advantages con- sist in overcoming hypersensibilities, both mental and physical, and in eliminating involuntary muscular resistance as a barrier to successful manipulation. By this means it is possible to explore with approximate accuracy the entire peritoneal surface of the uterus, both anterior and posterior. The ovaries and Fallopian tubes can be palpated; the presence and absence of intrapelvic tumours, including cysts, myomata, nodes, etc., can be determined. The presence or absence of adhesions can often be decided. The disadvantages of anaesthesia in gyneco- logical examinations centre chiefly in the elimination of pain, which of itself possesses great diagnostic value, and is also a safeguard against injudicious and dangerous manipulation. It may be laid down as a rule, therefore, that anaesthesia for purposes of examination is dan- gerous in the presence of a degree of sensibility indicative of acute inflammation. Auscultation, Percussion, and General Palpation of the Abdomen. — Of diagnostic measures, auscultation, percussion, and palpation, can be applied to the recognition and diagnosis of pelvic and abdom- inal tumours, inflammatory residues, and diseases of the appendi- ceal region, kidneys, spleen, liver, and gastro-intestinal tract. The method of applying these aids to diagnosis will be readily suggested to the examiner. Palpation of the kidney becomes important in relation to the diagnosis of diseases of that organ, and occasionally, also, in distinguishing between abdominal tumours and movable and so-called DIAGNOSIS 41 RIGHT UPPER QUADRANT LEFT UPPER QUADRANT floating kidney. A movable kidney, which would escape the casual or indifferent observer, is often detected by a careful diagnostician. Hy- dronephrosis has been confounded with ovarian and other cysts. A detailed description of the diagnosis of kidney diseases is foreign to the purpose of this chapter, and the reader is referred to the section which deals with that subject. In examining the abdomen it is highly important, not only to hold in mind the locus of each of its contained organs, but to have an accurate conception of its regional arrangement. Regions of the Abdomen. — It has been customary heretofore to divide the abdomen anteriorly into nine different regions as a con- venient means of des- ignating either the lo- cation of symptoms or operations, or of the presumably underly- ing organs and struc- tures. This division, however, has proved unsatisfactory, because of the cumbersome- ness of its terminol- ogy, the narrowness of the areas indicated, the indefiniteness of the imaginary lines of division, and the ana- tomical variations in the location of their supposed underlying organs and structures. In accordance with the suggestion of Pro- fessor Anderson to the Anatomical Socie- ty of Great Britain (Buffalo Medical and Surgical Jour., 1893), these objections are best obviated by divid- ing the abdomen into four regions. This is done by running a line coincidently with the linea alba from the symphysis pubis to the ensi- form cartilage, and another at right angles to this at the level of the umbilicus and encircling the entire body. The median line posteriorly is indicated by the spinal column. This arrangement, which is based upon definite landmarks, and divides the abdomen into four quadrants (Fig. 7) — namely, right and left, upper and lower — will be observed in the following pages. RIGHT LEFT LOWER LOWER QUADRANT QUADRANT Fig. 7. — u This arrangement, based upon definite landmarks, divides the abdomen into four quadrants." — Reed. 42 A TEXT-BOOK OF GYNECOLOGY Instrumental Examination. — A most important adjunct to methods of diagnosis is furnished in the marvellous development of mechanical instruments and appliances. The inge- nuity of physicians and instrument makers has presented to the gynecologist an enormous collection from which to choose. The armamentarium, however, should be simple, and such instruments as are chosen should be models of per- fection. It should never be forgotten, also, that instrumentation, no matter how dexterously applied, can never be made to supplant the educated hands and finger tips. Instruments at most are supple- mentary aids to these. We may, how- ever, enumerate some of the instruments which are considered a necessity by the gynecologist. These are: (1) The specu- lum, (2) the sound or probe, (3) the dila- tor, (4) the curette, (5) the cystoscope, (6) the aspirator with exploratory needles, (7) the stethoscope, (8) the uterine dress- ing forceps, (9) the spatula or depressor, (10) the tenaculum, (11) the volsella. The Speculum as a Means of Ex- amination. — Since Sims gave to the profession the speculum which bears his name the practice of gyne- cology has become an established specialty. Without this device it is doubtful if gynecology could have been enlarged, broadened, and devel- oped into the importance which it has attained at the present day. Dr. J. Marion Sims, then residing in the city of Montgomery, Ala., was engaged between the years 1845 and 1849 in the study of the opera- tive treatment of vesico-vaginal fistula. During his investigations he accidentally discovered that if a woman was placed upon her knees and chest, upon separating the labia the air would enter the vagina and distend it to its full capacity. What was needed was an instrument to retract the perineum. This he supplied first with a spoon handle bent to the appropriate shape, and afterward, as the product of evolution, came the present speculum, which universally bears the name of Sims (Fig. 8). In the further pursuit of his investigations, and for the ap- propriate use of his speculum, a less trying posture was needed than the knee-chest. This led to further experimentation from which was evolved the semiprone, or Sims's, position. It is sometimes called the latero-prone posture, but, by whatever name it is known, its discovery and practical application are due to Marion Sims. The Sims speculum and the Sims position form the basis of the science of gynecology as at present understood and practised. Whoever, then, would attain suc- Fig. 8. — ". . . Speculum, which uni- versally bears the name of Sims." — Potter. DIAGNOSIS 43 cess in the art, mast not only familiarize himself with the principles of this instrument and its correlative posture, but he must acqure deftness in their practical application to the patients who consult him. The beginner, therefore, should address himself to the mastery of the use of the Sims speculum in the semiprone or Sims posture. The principles are simple and the obstacles to be overcome are few. It is a mistake to suppose that a long experience is necessary to attain proficiency in the use of the speculum. It is another mistake to pre- sume that a trained assistant is necessary to its advantageous employ- ment. The physician himself must be the expert; he can then easily instruct any intelligent person to hold the speculum properly. These examinations, for obvious reasons, should be conducted in the presence of a third person. A gynecologist of large practice has an office assist- ant who performs this service. A physician whose gynecological prac- tice is limited may either avail himself of some member of his house- hold in office examinations or employ the Sims-Emmet self-retaining speculum, which has already been referred to (page 32, q. v.). In making examinations at the home of the patient the aid of some mem- ber of her family may be invoked; and this brings us to make mention of home examinations. In order to make these examinations satisfactorily and to obtain adequate information from them, the same conditions must prevail as in the consulting room. The patient must be placed upon a table, the douche must be ad- ministered, and the bimanual or instrumental examination is to be proceeded with, with the same attention to detail. Whenever the attempt is made to use the bed or couch dissatisfaction will result. It is, comparatively speak- ing, little trouble to make the home examination in the proper manner. The humblest home is furnished with a four -legged table; this can be covered with blanket, sheet, and protective; the fountain syringe can be hung on a nail near by, and if an in- strumental examination is need- ful a Sims-Emmet self-retaining speculum can be employed. Or, failing in the possession of this, the ordinary Sims instrument can be used, and an assistant to hold it may be pressed into service from the household or neighbourhood. Fig. 9. — u A good bivalve like Gau\s. — Potter (page 44). 44 A TEXT-BOOK OP GYNECOLOGY Before leaving the subject of the speculum it is proper to state that the essential re- quirements for the success- ful use of the Sims instru- ment are, first, the correct position of the patient; and, secondly, the proper hold- ing of the instrument. The semiprone posture can not be described in words with sufficient clearness for a nov- ice to understand it; more- over, it is difficult to illus- trate it clearly, hence it is advised that a physician un- familiar with it should place himself under the instructions of a person who understands it thoroughly. Besides the Sims specu- lum, it is well to have at hand a good bivalve, like Miller's or Gail's (Fig. 9), which gives a good view of the cervix (Fig. 10), as well as a tri valve, the latter according to Nott's model (Fig. 11). It occasion- ally becomes necessary to examine the os or cervix uteri in the dorsal position, and these specula are well adapted to that purpose. (See Armamentarium.) In the use of the specu- lum it is sometimes desira- ble to use reflected light or the intense rays of an electric illuminator. In cases of erosion of various character, material assist- ance in diagnosis may be derived from the use of a magnifying glass, like that devised for the pur- pose by Dr. Alexander Duke, of Cheltenham (Medical Press and Circu- lar, May 15, 1900). The lens, called a hysteroscope, is so arranged on a hinge that it can be placed at an angle by the observer. By this means the light can be di- Fig. 10. Which gives a good view of the cervix." — Potter. DIAGNOSIS 45 rected with accuracy upon the parts under examination, and when used with artificial light it acts both as a condenser and a magnifier (Fig. 12). The Sound as a Means of Examination. — Formerly the sound was considered an essential part of the gynecological armamentarium, be- cause almost the first thing done after the in- troduction of the speculum was to pass the sound into the uterus. Nowadays, however, with improved methods of diagnosis, and especially through a more thorough understanding of the bimanual, the sound rarely is Deeded. Its chief purpose is to confirm the diagno- sis in doubtful cases, such as intrauterine growths and other intrapelvic abnormalities that are misleading in their character. The dangers of the sound consist in its liability to carry infection within the genital tract, and to puncture the uterine wall; the latter is, comparatively speaking, an inconsiderable danger, whereas the former is a very grave one. The sound devised by J. F. AY. Eoss (Fig. 13) is best designed to obviate all dan- gers. The sound is no longer used by the experienced gynecologist to reposit a dis- placed womb, and whenever it becomes necessary to use it as an aid to diagnosis, first, it should be made thoroughly aseptic. and then it should be dipped in pure car- bolic acid rendered liquid by the addition of five per cent of glycerine, before it is passed into the uterus. With this precaution, and with gentleness in manipulation, the sound may not do harm, and possibly it may serve to clear up a doubtful diagnosis. The probe is only a modified sound, lighter in con- struction, and much more flexible, and prac- tically is used for the same purpose. Appli- cators, either of whalebone or aluminum, are useful in carrying certain medicinal applica- tions within the uterine canal. If, however, the uterus is sensitive from inflammation, the use of the sound, probe, or applicator, is contraindicated, although in some instances where information is urgently needed a very light probe might possibly be introduced without harm. The rule should be never to pass the sound or probe unless it can be used without causing pain. The Dilator as a Means of Examination. — Dilatation -The sound de- of the uterus is accomplished by graduated bougies, by vised by J. F. metal dilators having divergent blades, by tents, or by p ' TT er^' Fig. 12. " The lens called a hysteroseope." — Potter. 46 A TEXT-BOOK OF GYNECOLOGY rubber bags to be filled with air or water. The usual method is through the medium of the hard-rubber graduated bougie or the mechanical steel dilator of Goodell (Fig. 14). The purpose of dila- tation is to make the endometrium accessible to certain therapeutic measures, either medicinal or instrumental. In a narrow, or pin-hole, os it becomes necessary to dilate the channel before using the curette or making applications to the endometrium. Where but little dilatation is required, occasionally the glove stretcher or metallic dilator can be used without an anaesthetic; but usually when it becomes necessary to em- ploy the more complicated instrument of Goodell, anaes- thesia to the surgical degree should precede its use. When the os is patulous, curettage for diagnostic purposes may be made sometimes without resorting to anaesthesia. Diagnostitial dilatation often becomes necessary for the purpose of admitting the finger into the uterine cavity. It is an operation, however, that should never be made when there is a sensitive uterus to contend with, or when the pelvic tissues have been invaded with inflammatory conditions; in other 'words, it is necessary to surround this operation with all the precautions that pertain to formidable procedures. It is not to be done in the con- sulting room and the patient allowed to make her way homeward afterward, but it should be done either in hos- pital or at home, in order that the patient may be kept entirely quiet for the next few days thereafter. This operation is to be preceded with the seizure of the an- terior lip of the cervix by the volsella, or strong tenac- ulum. The cervix is thus stretched and the dilator gradually and slowly passed into the cervical canal, the bougie with a rotary motion, the glove stretcher with a spreading of the blades in a gentle manner, just within the os, advancing a little farther and stretching again, and so on until the work is completed. The Curette as a Means of Exam- ination. — This instrument is used to ob- tain scrapings from the endometrium with a view to determine the nature of any disease that may not otherwise be ex- plained. These scrapings may be sub- mitted to examination by the microscope. If malignancy is ascer- tained, the further method of procedure is readily pointed out. If there are remains of an abortion, or an endometritis that has fol- lowed abortion, then the interior of the uterus should be thoroughly cleaned, mopped with pure carbolic acid or carbolic acid and iodine, and the organ should be packed with antiseptic gauze. The curette is often used unnecessarily, and great caution should be observed Fig. 14. — " The mechanical steel dilator of Goodell.' 1 — Potter. DIAGNOSIS 47 in its employment. The puerperal womb is easily perforated, an accident that has often happened in unskilful hands. The Cystoscope as a Means of Diagnosis. — (See Examination of the Bladder.) The Aspirator as a Means of Examination. — This instrument is sometimes appealed to when cysts or pus pockets develop along the broad ligament. In doubtful cases these sacs may be explored through the roof of the vagina, but it is generally sufficient to diagnosticate them by the usual means, and to evacuate them by surgery through the abdomen or vagina. The stethoscope is occasionally employed to ascertain the nature of abdominal diseases, especially when pregnancy is suspected. The uter- ine dressing forceps and the depressor are an essential accompaniment to the armamentarium and need no particular description. The forceps carries cotton in wiping the tract, and the depressor holds the bladder away from the field during inspection. The tenaculum and volsella are used to seize the lips of the uterus in order to draw down the organ or to steady it while the parts are being inspected and applications are being made. These instruments should be dipped in pure carbolic acid before using. Examination of the Urinary Tract. — (See Examination of the Se- cretions and Diseases of the Urinary Tract.) With this, should be asso- ciated a systematic investigation of the various parts of the body. It is well enough for convenience 7 sake to begin with the upper air-passages; nose, throat, and fauces, should be investigated, par- ticularly in cases in which there exist head or nerve symptoms, so frequently referred to as genital reflexes. A similar investigation under similar circumstances should be made of the eyes and ears. Careful auscultation and percussion of the heart and lungs should be made when there are irregularities of the former, or when the latter may be subjected to suspicion by pelvic or other symptoms suggestive of tuberculosis. It is not presumed that every practitioner is capable of making a thorough examination of each of these several organs; but any one who assumes to practise gynecology should be so thor- oughly grounded in a general knowledge of medical science that he can. with reasonable accuracy, determine departures from health in all bodily structures or functions. If it is necessary to carry an examination of any of these organs to the point of technical perfection, they can be. and should be, relegated to special practitioners for that purpose. Intrapelvic disease is a fruitful cause of perversions of practically all of the secretions. These functional disturbances, in turn, become factors in the case and need to be dealt with as such. The Urines. — In consequence of the great advance which has been made in the study of pathologic conditions of the genito-urinary tract, and in view of the fact that the urine secreted by either kidney differs from that secreted by the other, it is now important to speak, not of 48 A TEXT-BOOK OF GYNECOLOGY the urine, but of the urines, when reference is made to the secretions which accumulate in the bladder. The technique involved in securing the urine from either kidney is considered in the chapter devoted to that subject. The investigation of the blended urines, however, is still a matter of clinical importance. Care should be taken to determine their quantity, colour, and specific gravity, the presence or absence of albumin, glucose, mucus, tube casts, pus, or other morbid products. In view of the importance of xanthine and the paraxanthines in the causation of various nervous phenomena, an examination of the urine will frequently need to embrace a qualitative and quantitative deter- mination of these substances. Urea and uric acid are of clinical im- portance and need to be studied. In many cases it will be important, not only to study the urine from each kidney, but also to study each urine and the blended urines repeatedly. To insure completeness of examination it is important to follow the usual blanks available for the purpose. Faeces. — In many gynecologic cases, particularly in those associated with marked disturbances of nutrition, it is of great importance to investigate carefully the faeces. Their naked-eye characteristics should be noted, and microscopic studies should be made of various kinds of their constituents. Blood, fats, parasites, fungi, foreign bodies, mucin, ferments, hydatids, etc, are only mentioned to suggest the range of in- quiry which should be made in many of these cases. The reader is referred to Jaksch^s Clinical Diagnosis. The Menstrual Discharge. — It is often important to determine with accuracy the quality and quantity of the menstrual discharge. To determine its character the napkins should be preserved and inspected. It should be remembered, however, that the absorption of the blood by the napkin modifies to an important degree the colour of the former. If more critical examination needs to be made, some of the discharge can be mounted upon a slide and put under the microscope. If there is occasion to ascertain the quantity passed, the napkins should be care- fully weighed before and after being used. In some cases it is impor- tant to determine whether the discharge is a true menstrual flow or a lochial discharge. For this purpose the microscopic examination is essential. It may be mentioned in this connection that in the men- strual flow immediately after its onset, there occur abundant red blood- corpuscles and prismatic epithelial cells laden with fat. These are derived from the interior of the uterus. As soon as the physiologic climax of the flow has been reached, the red blood-cells diminish and the leucocytes progressively increase until the flow disappears. The fluid which passes following a parturition, is, in the absence of hemor- rhage, thinner in consistence, with less tendency to coagulate. While it abounds in red and white corpuscles from the start, it shows, also, abundant epithelium from both the uterus and vagina. Unlike men- strual fluid, the lochia, even in the absence of septicaemia, abound in microbes. DIAGNOSIS 49 The Blood. — Every practitioner should provide himself with the necessary instruments for the examination of the blood. These should include an apparatus for counting the blood-corpuscles, chromo-cytom- eter, and a hemometer. With these instruments and a good micro- scope, with which all modern practitioners are presumed to be pro- vided, it will be possible to determine the blood state of patients. This is an exceedingly important diagnostitial measure in gynecological practice. Thus a marked leucocytosis, taken in connection with other symptoms, is confirmatory of a suppuration which may be situated so remotely in the pelvis as to defy detection. 01igochroma?mia, in vary- ing degrees, may be accepted as an index of general states of nutrition; the perturbation of which may depend, in the first instance, upon ob- scure and otherwise undetectable conditions within the pelvis. Eeed has shown (American Journal of Obstetrics and Gynecology) that many perverted conditions of the blood are caused in the first instance by disease of the pelvic organs, the disturbing influence of which is exer- cised, through the intimate nerve connections, upon the hematogenetic function. When these changes and their causation are better under- stood, the diagnostic value of blood states, considered as indicative of intrapelvic disturbances, will be greatly enhanced. The Nervous System. — The intimate relation of the entire genital apparatus with the nervous system (see Xervous Complication^ in G}Tiecology) renders it important that the gynecologist should make a careful note of the actual state of the nerve functions. He should learn to appreciate nerve disturbances as much from the neurologic as from the gynecologic standpoint. Motor and sensory disturbances should be determined by "instruments of precision, while the special senses should be investigated with accuracy. Psychic states should be studied with care. Careful attention to these precautions will speedily result in reducing the now chaotic subject of " genital reflexes " to a somewhat scientific basis. CHAPTER YII SEPSIS Sepsis defined — The bacteria of sepsis — Local sepsis: Symptoms, pathology, and treatment — General sepsis : Symptoms, pathology, and treatment. Sepsis — derived from the Greek word - assistant whose patient struggles in the first stage of the anaesthetizing process is not performing his function properly. The early stage should be sufficiently prolonged to produce quietly the so-called primary anaesthesia, and the inhaler should be gradually brought nearer and nearer to the patient as the effect of the drug is momentarily increased. By this means evil dreams or delusions in the later stages are often avoided. If a patient sinks into unconsciousness under the firm mental impression that she is being choked to death, the dreams that follow are not apt to be joyful. Aside from the trou- blesome struggling later on in anaesthesia, it should be recalled that the nervous shock of such a sensation and such dreaming is a severe strain upon the patient's nervous system. An ordinary nightmare is sufficiently disturbing, but a real operation added to it, preceded by a conscious period of fright, is a terrible combination of nerve-straining elements. It is for this reason in part that physicians are continually seeing patients who, having left the surgeon's hands as " operative re- coveries," are physical wrecks. Even if ether is given properly it may produce evil effects, as already stated, and in general terms it may be considered that known idiosyn- crasies to its effects from former accidents or sequelae, acute and chronic bronchitis, nephritis in all its forms, but particularly in its acute and parenchymatous forms, and laryngeal inflammations, render chloro- form the preferable drug. In all cases in which the surgeon has control of his patients for any length of time before the operation a careful examination of the urine should be made. Not only should albumin and cysts be sought for, but several estimations of the amount of urea excreted in twenty-four hours should be made, since this will oftentimes reveal renal inadequacy or diseases which may be exaggerated by the anaesthetic and cause complications which are undesirable and dan- gerous. Again, in the presence of marked atheromatous degenerations of the arteries, of aneurism, and abdominal inflammation, chloroform is the better anaesthetic, since it lowers rather than raises blood pressure and does not cause struggling, as does ether, and, therefore, is not so apt to cause apoplexy, nor is vomiting so apt to follow its use. On the other hand, if any dilatation of the heart or degeneration of its walls and severe valvular leakage is present, then ether is the safer drug. There are operative reasons for choosing one anaesthetic in prefer- ANAESTHETICS AND ANESTHESIA IN GYNECOLOGY 91 ence to the other which are almost as important as those just given. Other things being equal, and the ansesthetizer being skilled in the use of chloroform, this drug is often superior to ether in that it does not so frequently cause vomiting, which, if severe, may be disadvantageous in abdominal operations. It must be borne in mind, however, that if proper ante-operative procedures are taken and ether is given with care and with oxygen, vomiting can often be entirely avoided, and ether is the drug of preference in the majority of cases in cool climates. Choice of Anaesthetic for Children. — There can be no doubt that in very young children ether may cause considerable bronchitis, some- times associated with such an outpouring of mucous liquid that a state approaching suffocative catarrh is developed. Chloroform, if properly given, does not do this. Not only is this true, but it is also a fact that very young children have a certain amount of immunity from the lethal effects of chloroform. There are few instances on record of death from chloroform in young children, and this fact, combined with the avoid- ance of respiratory irritation and the early struggling produced by ether, renders it wise in many instances to emplo}^ chloroform. Bromide of Ethyl — Indications and Contraindications. — The ques- tion may well be asked, Under what circumstances is it proper to use bromide of etlryl? Before answering this question, it must be recalled that this drug is even yet under a cloud, and has not reached a degree of popular favour which makes the uninitiated feel like trying it. This state of affairs depends upon several factors. In the first place, the early attempts made to introduce it into practice in this country were productive of catastrophes which frightened the surgeons using it sufficient^ to make them give up its emploj^ment, and incidentally alarmed those who had not yet attempted its use. The use of a new and untried drug followed by an accident would naturally impose upon the medical man an increased load of blame, yet the occurrence by coincidence of such accidents when the drug was first used, is no reason for condemning the drug as too unsafe to warrant its adminis- tration. The very fact that the ana?sthetizer did not know how best to give it rendered it more likely to act badly than when it was skilfully used, and in all probability the preparation of the drug employed may not have been pure. The writer has often wondered how long the use of ether or chloroform might have been delayed had the first patients placed under their influence died, a possibility by no means remote, because those patients might perchance have had hearts unfit for the use of those drugs. If, for example, Sir James Simpson's " chloroform party " had ended in a chloroform catastrophe, one or more of them never coming back to life, what an unjust blow would have been given to a most useful drug, and who would have felt like repeating the test! As a matter of fact, a certain number of deaths have been recorded as having been caused by bromide of ethyl (see page 95 for possible causes), and there can be no doubt that it is capable of causing death if badly given to a patient unfit for its use. The important questions 92 A TEXT-BOOK OF GYNECOLOGY are, whether it is safe enough to justify its common use, and whether it fulfils any indications not so well filled by ether and chloroform. The answer to botn these questions is in the affirmative. The drug has been given many thousand times without ill effects and deserves a place in the hands of the gynecological operator and obstetrician. Cer- tain perfectly proper and easily taken precautions are essential for its satisfactory use (see page 95). The indications for its employment are sufficient and numerous. The first of these is met with when we desire to employ a rapidly acting, agreeable, and fleeting anaesthetic for the performance of short operations, such as curetting and dilat- ing the uterus, and in making painful examinations. When properly given, bromide of ethyl produces anaesthesia almost as rapidly as nitrous oxide, and when it is stopped the patient returns to conscious- ness almost as speedily as when the gas is given, and without any nausea, vomiting, dizziness, or other ill effects. It lends itself, there- fore, to a large number of cases in and out of the gynecologist's office, and deserves greater use. There are two disadvantages connected with its employment — first, that there may be muscular tonic contraction or rigidity, which is annoying, and may render efforts at examination or operation difficult until it is overcome; and, secondly, that it is apt to leave a garlicky odour on the breath — two objections of compara- tively small moment, after all. The drug is not suitable for pro- longed operations. The Administration of Ether. — The anaBsthetizer, like the operator, knows that the simpler the instrument the easier the performance of the duty before him, and as a re- sult there are but two forms of ether inhalers commonly employed in the United States, and these meet the needs of the case so well that nothing else need be consid- ered. The one is the folded towel, turned into a well-made cone, stiffened, it may be, with a sheet of heavy paper or cardboard be- tween its folds, and fitted in the apex with a small, clean, and ster- ile sponge or piece of absorbent cotton, to hold the anaesthetic fluid. For this may be substituted the Allis inhaler, which is a cylin- drical or ovoid cover around a grated case, from the gratings of which layers of cotton cloth pass from side to side (Fig. 29). The air passes freely between the layers of cloth, which, being wet with ether, load the inspired air with ansesthetic vapour. If made of metal, so that it can be boiled after Fig. 29.—" The Allis inhaler, which is a cy- lindrical or ovoid cover around a grated case, from the gratings of which layers of cloth pass from side to side." — Hare. ANAESTHETICS AND ANAESTHESIA IN GYNECOLOGY 93 each use, and kept rigidly clean, this is the best inhaler on the market, because it gives plenty of ether and it permits a view of the face of the patient. Both the simple cone and the Allis inhaler can be employed when it is desired to give oxygen gas with the anaesthetic, since the gas can be delivered to the patient by means of a soft tube slipped under the edge of the cone close to the patient's nose. The Administration of Mixed Vapours for Anaesthetic Purposes. — There are several somewhat complex forms of apparatus on the market for giving ether and oxygen gas or chloroform and oxygen gas. Hare considers none satisfactory in every respect. In all forms which he has seen, the oxygen is made to bubble through the ether or the chloroform, thereby vaporizing the anaesthetic, and a mixture of oxygen gas and of the anaesthetic vapour is then conveyed through a tube to the in- haler, which is placed over the patient's nose and mouth. There are several disadvantages inseparable from this method of using this valu- able combination of therapeutic agents. The first objection is that it is impossible to increase or decrease the quantity of oxygen gas supplied to the patient without at the same time increasing or decreasing the quantity of ether or chloroform, and conversely the quantity of these agents can not be verified without the supply of oxygen. Manifestly, an inability to make suitable variations in the quantity of these various agents is distinctly disadvantageous. As an illustration of how disad- vantageous it may be, Hare mentions the fact that an eminent surgeon complained to him that a grave difficulty in the use of oxygen and ether lay in the long period of time required to get the patient under the anaesthetic. The cause of this delay was without doubt due to the fact that if large quantities of oxygen were passed through the ether with the purpose of conveying considerable amounts of the anaesthetic to the patients, the individual also received such large quantities of oxygen that a condition of physiologic apnoea, or shallow or arrested breathing, occurred through sedation of the respiratory centres. As soon as this sedation took place the patient breathed less deeply than before, or she stopped breathing entirely, and under these circum- stances took but little anaesthetic vapour into the lungs, and so passed very slowly, if at all, under its influence. In Hare's opinion, therefore, the proper way to use oxygen by inhalation, in conjunction with the anaesthetic, is to place the drum upon whatever form of inhaler the physician desires to employ, and to carry into the inhaler the oxygen gas direct from the bag, which is usually attached to the steel c}dinder containing the gas. Under these circumstances the patient receives both the anaesthetic and the oxygen, each of which can be increased in quantity, according to his needs, with the result that he can be speedily anaesthetized and yet receive all the oxygen that is necessary to prevent any of the disagreeable symptoms of anaesthetization and its disagreeable sequelae. Such a plan has the added advantage that it is simple and does not require any additional apparatus, the rubber tube from the oxygen cylinder passing under the edge of the inhaler placed 94 A TEXT-BOOK OP GYNECOLOGY upon the patient's face, and the supply of gas being governed by the stopcock on the cylinder. One of the forms of apparatus which is usually sold for the simul- taneous administration of oxygen and ether consists in an inhaler which covers the patient's nose and mouth and prevents him from getting any atmospheric air, with the result that he is forced to breathe nothing but pure oxygen, mixed with anaesthetic vapour. In order to make this still more complete, a large rubber bag is attached to the inhaler, which has no connection with the outside air, and which is inflated with each expiration of the patient and dilated with each inspi- ration. After a very few respiratory movements the patient is there- fore receiving a mixture of oxygen anaesthetic and devitalized air, the quantity of the latter increasing with each subsequent respiration. Manifestly this method has two grave objections: First, that the pa- tient is supplied with pure oxygen instead of with atmospheric air, whereas Nature provides healthy human beings with a mixture of oxy- gen and nitrogen. The other disadvantage is that the patient is con- tinually taking back into his lungs impurities which he ought to be getting rid of. That the administration of oxygen gas with ether or chloroform is a distinctly advantageous procedure can not be doubted. The pulse under both anaesthetics when the gas is given remains in good condi- tion in a majority of cases, and there are no complications or sequelae in the shape of depressions, nausea, or vomiting. Feeble circulation and respiratory disorders are much less frequently met with if oxygen is given than if it is not administered. Further than this, the progress of the patient during the anaesthetic period is usually peaceable, cyanosis being largely avoided. The Administration of Chloroform. — For the administration of chlo- roform even more apparatus has been invented than for the giving of ether. Much of it is extremely complicated, possessing this disadvan- tage in addition to others which need not be considered in the brief space devoted to this article. While it is true that many of the English anaesthetizers employ these, American physicians are usually content with much simpler apparatus. There are, practically speaking, only two chloroform inhalers that can be generally employed with advan- tage — namely, that of Esmarch and that of Lawrie. Both of these inhalers embody two essentials of every form of apparatus used for the giving of chloroform — namely, the free access of air to the patient. All the more complicated inhalers are lacking in this important char- acteristic, or depend upon valves which may get out of order. The majority of anaesthetizers in this country employ a folded napkin or one of the inhalers just named. The patient should get at least ninety per cent of air during the use of the chloroform. Great advantages in the Esmarch and Lawrie inhalers are the facts that a free supply of air is present; too much of the drug can not be poured upon the inhaler with- out escaping, so that the patient can not receive an overdose, except ANAESTHETICS AND ANAESTHESIA IN GYNECOLOGY 95 through gross negligence; and the face of the patient is readily seen. Whatever the form of inhaler used, it must never be held so tightly over the patient's face that air is cut off (Fig. 30). The Lawrie inhaler is so cheap that a new one can be used for each patient, and the thin flannel cover of the Esmarch can be boiled each time it is used, thereby insuring sterilization. AYhen chloroform is given it must be placed on the inhaler in drops, and not poured on freely as one uses ether. Finally, the anaesthetizer should re- member that the dose of the anaesthetic is not that which he pours on the inhaler so much as the amount that the patient takes into his lungs, and, therefore, that in all cases the attention of the anaesthet- izer should be centred on the respira- tion, for upon the rapidity and depth of this function does the close depend. Again, as the respiratory function is the first one to feel the depressing effects of the drug, it acts as a good index of the degree of influence. In a case where the heart is known to be diseased, this organ must, of course, be watched also. Should the respiratory action become irregular or stormy, the anaesthetizer should at once stop the anaes- thetic, since the irregularity indicates abnormal action of the drug, and the amount inhaled can not be estimated. The Administration of Bromide of Ethyl. — YYhen bromide of ethyl is given, it should be placed upon a cone or inhaler which tightly fits the face, and be pushed freely until the patient passes under its effect, which will be rapidly accomplished, as a rule. Care must be taken that the bromide of etlrylene is not used by mistake, and that the drug is kept in dark glass bottles to prevent its decomposition. In order to be sure of its purity, it is best to use the drug from hermetically sealed flasks. Management of Respiratory and Other Accidents in Anaesthesia. — Attention may be called to the use of two instruments commonly em- ployed by inexperienced anaesthetizers, which are nearly always, abused, viz., the mouth gag and tongue forceps. The mouth gag aids, rather than prevents, the falling of the tongue back into the mouth, and increases the possibility of the inhalation of saliva or other materials into the lungs; and the tongue forceps is almost invariably so con- structed that it bruises, punches, or punctures, the tongue in a manner that is anything but wise. Inexperienced anaesthetizers are very apt Fig. 30. — Esmarch's chloroform inhaler. — Hare. 96 A TEXT-BOOK OF GYNECOLOGY to believe that these two instruments should always be in their pocket, and should be frequently employed. As a matter of fact, they are very rarely, if ever, needed, and the proper manipulation of the head and jaw, and grasping the tip of the tongue with the fingers which have been covered with a towel, are quite sufficient to produce the proper position of this organ. There is a common error in the method of manipulating the head and jaw in respiratory accidents under anaesthetics. Under such cir- cumstances it is the custom to allow the patient's head to fall backward, so that the muscles in the anterior portion of the neck are in a condition of great extension, and it is thought that by maintaining this posture the glottis is widely opened so that air can readily pass in and out of the lungs. It is true that this position of the head does widely open the glottis, but at the same time it drops the soft palate down upon the dor- sum of the tongue in such a way that the patient is required to take all the air that he needs through his nasal chambers. These upper air- passages are nearly always obstructed by mucus, which has been brought out as a result of the local irritation produced by the anaes- thetic vapour. In addition, the nasal passages of many patients are partially or totally occluded by overgrowth of the mucous membrane covering the turbinated bones or by the presence of polypi, so that if any of these causes of obstruction are present it is most difficult for the patient to get air. If, on the other hand, the anaesthetizer, standing at the patient's head in his usual position, places a hand upon each side of the head and jaw in such a way that the palm of the hand covers each ear and the tip of the middle finger rests under the angle of the jaw, and then draws the head toward him, stretching the neck of the patient, and at the same time carries the head forward instead of backward, the result is that the glottis is quite as widely opened as when the head is extended upon the neck and carried backward, with the additional advantage that the soft palate is not strapped over the dorsum of the tongue, and the patient can, therefore, obtain air both through his mouth and nasal chambers. The attitude of the head under these circumstances in relation to the rest of the body, save for the fact that the patient is prone rather than erect, is that which is taken by the athlete when running. Surely no runner desiring to fill his lungs with air would tip his head far back with his chin pointed upward, but, on the other hand, would project his head' forward in such a way as to make his upper passages as patulous as possible. Anaesthetic Mixtures. — There are three anaesthetic mixtures to which reference should be made before leaving this subject. One of these is the so-called A.-C.-E. mixture, which contains alcohol, chloro- form, and ether, this combination being made with the idea of securing the anaesthetic effect by three drugs; and of combating by the alcohol and ether any tendency to cardiac depression produced by the chloro- form. Theoretically this mixture has something to recommend it, but practically the rapidity of vaporization of these three drugs is so dif- ANAESTHETICS AND ANAESTHESIA IN GYNECOLOGY 97 ferent that the patient will get first one anaesthetic and then the other, and finally the alcohol, so that in reality he does not pass under the influence of all three at once. It can not be urged that there are serious objections to this mixture, but, on the other hand, there are no material advantages in it. The same objection holds against the C.-E. mixture, which contains chloroform and ether alone. The last anaesthetic mixture which need be mentioned is Schleiclr's, which is made according to three formulas, differing, not in ingredients, but in the quantity of each ingredient, and which consists in a mixture of ether, chloroform, and petroleum ether. It is claimed by Schleich that the petroleum ether has no deleterious effects. He believes that the effect of chloroform and sulphuric ether, together with the addition of petroleum ether, prevents the disagreeable effects which are met with when chloroform or ether is given alone. While this mixture on its first appearance received considerable attention, increasing clinical ex- perience has not been favourable to its employment, and it is speed- ily dropping out of use even in the hands of those who first considered it of great value. Central Anaesthesia by Cocaine. — In 1885 spinal anaesthesia was practised by J. Leonard Corning, of New York. Turner utilizes it in the following way: A 2-per-cent solution of cocaine is sterilized by heating at 80° C, the sterilization being repeated each day for three consecutive days. This solution is thrown into the arachnoid space of the spinal cord by means of a sterilized hypodermic syringe with a long and heavy needle. To administer the injection a line is drawn from the crest of one ilium to the other. The forefinger of the left hand is placed on the spine of the vertebra immediately above the line just indicated. The detached needle of the hypodermic syringe is now inserted to the right and a little above the tip of the left forefinger, being pushed well into the spinal canal. The escape of the arachnoid fluid will indicate that the needle has entered the canal. The loaded barrel of the syringe is now attached to the needle through which the solution of cocaine is discharged slowly and without force. From 1.5 to 2 cubic centimetres of the fluid are used, the dose depending some- what upon the size of the patient. Anesthesia from the diaphragm to the toes will develop in from ten to twelve minutes; and the insensibil- ity thus induced will last from one to three hours. The cardiac dis- turbance induced by this form of anesthesia is less than that from either ether or chloroform. No fatalities have been accredited to it. A. Palmer Dudley and other American surgeons have utilized this form of central anaesthesia with success in hysterectomy and other equally severe operations. It is especially eligible in kidney complications. General Anaesthesia by Alcohol. — It is practicable to bring patients into a condition of surgical anesthesia by the administration of alco- hol. J. M. Matthews, of Louisville, frequently operates painlessly for hemorrhoids and other rectal conditions in patients who are thus " dead drunk." The alcohol should be given in doses of an ounce 98 A TEXT-BOOK OF GYNECOLOGY every few minutes until alcoholic coma is induced. It is an eligible ex- pedient in alcoholic habitues, but is liable to induce an aggravating acute gastritis with attendant vomiting in patients who are not drinkers. General Anaesthesia by Hypnosis. — The researches of Charcot, and later of the Medical School of Nancy, have established the possibil- ity of entirely destroying physical sensibility by suggestion. Reed has operated for the repair of lacerated perineum, and for pelvic abscess by vaginal drainage, in patients who had been rendered unconscious by hypnotic anaesthesia. This, however, is not to be looked upon as an agent or influence of general utility, for the reason that women are not all subjective, and for the further reason that, notwith- standing there are no reflex manifestations of pain, nor any memory of the operation, it still seems that the impression registered upon the secondary or induced consciousness provokes shock to a degree that is not realized under general anaesthesia as ordinarily practised. The subject is one pregnant with great possibilities, and should be subjected to more critical study than has yet been accorded it by the English- speaking medical profession. Local Anaesthesia. — It is sometimes desirable and even imperative to avoid the administration of general anaesthetics. Pain may be re- lieved under such circumstances by benumbing the parts with cold or with ether, or by using a subcutaneous injection of a 2-per-cent solution of cocaine. The latter remedy, however, should not be looked upon as innocuous, so far as its constitutional effects are concerned, serious cardiac and respiratory complications having ensued upon the administration of but a small quantity. CHAPTEB XII ABDOMINAL SECTION Terminology — Preliminary treatment of the patient — The evil of hypercatharsis — Examination of the urine — Instruments — Preparation of the field of operation — Location of the incision — Direction and varieties of the incision: Vertical median, transverse umbilical, transverse suprapubic, oblique ventral, inguinal, oblique subcostal, lumbo-iliac, lumbo-costal — General observations on making the incision — Closure — Immediate and complete by laminated suture — Where drainage is necessary by suture en masse — Drainage. Theee has been much discussion of the various terms which, from time to time, have been coined to designate the operation whereby the abdominal cavity is opened and its viscera made accessible for surgical purposes. Blancard, of Middleburg, Zealand, published a work nearly two hundred years ago in which he employed the word " gastrotomia " to designate " the cutting open of the abdomen and womb, as in sectio Ccesarea" The word comes from two Greek terms — namely, yaarrip, meaning belly or stomach, and TOfirj, meaning incision. The first of these terms was formerly employed in its ordinary and vulgar sense of belly. Since operations upon the stomach proper have come into vogue, the term has been narrowed in its significance, and is commonly used exclusively to designate the operation of making fistulas into that organ. Laparotomy (derived from Xairdpa, the flanks, and to/x->J [re/xvetv, to cut]; French, laparvtomie; German, Laparotomie) was, perhaps, the next coinage, and had, originally, a meaning that was entirely consist- ent with its purpose. It was employed early in the nineteenth century to designate the operations in the inguinal regions, as, for instance, for hernia and colotomy. In later years, however, with the advent of what has since become known as abdominal surgery, " laparotomy " was made to mean all operations upon the abdominal wall. This was such a manifest misapplication of the original meaning of the term that the profession has largely abandoned its use. The first revolt was emphasized by Lawson Tait, who employed in its stead the expression " abdominal section." This term, in turn, has occasioned considerable discussion. Greig Smith says that it is, perhaps, " most objectionable of all; an abdominal section," he adds, " is made L.ofC. " 100 A TEXT-BOOK OF GYNECOLOGY on a frozen cadaver with, a saw for anatomical purposes; it is not easy to understand how an evil chance led to the name being given to an incision made through part of the abdominal wall for sur- gical purposes/' This criticism must be recognised as of doubtful accuracy. The word " section " is derived from the Latin sedio, meaning simply " to cut." A statement that " section " must imply amputation or an abso- lute severance of one part from the other, is, therefore, an unjustifiable stricture. The fact remains that, by convention at least, it has come to be synonymous with incision. This has been verified through gen- erations, and for that matter centuries, in the term Csesarean section. Latterly we hear of perineal section, sagittal section, and many other equally legitimate applications of the word. The word celiotomy — ■ from the Greek /cotAia, the belly, and Ttfxvecv, to cut, and correspond- ing in significance with the French cceliotomie, the German hoilotomie and oauchsclinitt — does not materially help the situation. The word cce- liotomy was brought to the attention of the profession by the late Dr. E. P. Harris, of Philadelphia, although Dr. F. P. Foster, writing on the subject, says " this term seems to have been introduced by Davies-Colley." " Some good people/' continues Foster, " write it celiotomy; many consider it more expressive than laparotomy, but with its adoption has sprung up the curious term ' abdominal cce- liotomy,' an abdominal opening of the abdomen, as distinguished from vagina] cceliotomy. The term abdominal section answers every purpose, and seems to me preferable to both cceliotomy and lapa- rotomy." The Preliminary Treatment of the Patient. — In the absence of an emergency, such as hemorrhage, acute sepsis, or strangulation, time should be taken to prepare the patient's system for the operation. This should be done b}^ giving particular attention to the state of the secretions. Most patients, particularly those of the more chronic class, are constipated, and their systems are, as a consequence, laden with tox- ines from the hyperabsorption constantly going on from the alimen- tary canal. The condition is all the more serious because of the de- fective peristalsis which is liable to be still further weakened, if not entirely arrested, by the influence of the operation upon the sympa- thetic nervous system. It is highly important, therefore, for these two reasons, if for no other, that the bowels should be not only un- loaded, but brought to an approximately normal standard of activity. This is best done by giving the patient a small dose (one sixtieth of a grain) of strychnine with salol (three grains) three times daily associ- ated with a persistent course of salines. For the latter purpose the magnesium sulphate, the sodium sulphate, or the sodium phos- phate, may be employed, either in the form of some of the natural mineral waters, or by dissolving some of the salt in plain water. More important, perhaps, than the selection of the remedy is the manner of its administration. The best results are obtained by giving drachm ABDOMINAL SECTION 101 doses, beginning, not before, but after a meal. If the chosen remedy is continued in this way during twenty-four hours and no laxative effect is realized, it may be well to unload the bowels of their now softened contents by administering one full dose of the medicament, given this time on an empty stomach. The saline should not be dis- continued so soon as the bowels have been evacuated, although a little time should be given for the previously secured laxative effect to subside. The saline should then be resumed in half doses, given an hour or two after each meal. In this way it becomes mixed with the ingesta, and, by stimulating both secretion and peristalsis, prevents a return of the constipation. A constipation of long standing may thus frequently be broken up in the course of a week, often with permanent results. The Evil of Hy- percatharsis. — It is highly important to urge a word of cau- tion against the prevalent habit of purging patients ex- cessively before op- erations. It is not unusual for patients to be forced to have a dozen or more de- jections during the twelve or twenty- four hours before undergoing the or- deal of an abdominal section, and during this time they are kept upon a re- duced diet, and often during the final twelve or fifteen hours are given nothing at all to eat. It should be borne in mind that such hypercatharsis (a) weakens the pa- tient, (b) still further weakens peristalsis, (c) aggravates post-operative thirst, and (d), by draining the circulation, stimulates all of the absorb- ent functions, and thus lays the foundation for systemic sepsis in the presence of unavoidable local infection. The practice is wholly wrong and should be abandoned. Fig. 31.— "Fenton B. Turck covers the abdominal wall with a sheet of rubber dam." — Eeed (page 102). 102 A TEXT-BOOK OF GYNECOLOGY Examination of the urine is very important, as is the correction, by judicious medication, of any error that may be found in that secre- tion. The condition of the skin should equally be the object of careful investigation and treatment. This latter precaution is of greater impor- tance than is generally recognised. It is only necessary to mention that failure of the urinary function, as the result of the action of the anaes- thetic on the kidneys, is one of the most frequent fatal complications following visceral operations; and that in the presence of such a com- plication the chief hope of the patient lies in the compensatory activity of the sweat glands. It is highly important, therefore, that they be put in a state of normal activity before the operation. Baths, if necessary, with dry heat or steam and followed by friction, continued during several days, generally constitute all the treatment that is required. The digestive function should be brought to as high a state of effi- ciency as possible. Penton B. Turck covers the abdominal wall with a sheet of rubber dam (see Fig. 31). This is stretched taut, and, being translucent, does not obscure the underlying integument; the incision is made directly Fig. 32. — " The cut edges of the rubber dam are brought forward and tucked into the wound." — Eeed. through the dam just as if it were a part of the skin. After the inci- sion is completed, the cut edges of the rubber dam are drawn for- ward and are tucked into the wound, covering its margins and being retained by a clothes-pin arrangement, as shown in the drawing (Fig. 32). The rubber dam is further utilized by Turck in preventing infec- tion of the peritoneal cavity by drawing a loop of intestine to be oper- ated upon through a small hole in the rubber sheet. ABDOMINAL SECTION 103 Instruments for an Abdominal Section Aspirator. Cautery (Paquelin). Forceps : Long dressing 1 Long hemostatic 6 Medium hemostatic 3 Small hemostatic 3 Bullet 1 Rat-tooth 2 Needles, curved : Very large (No. 1) 1 Large (No. 4) 2 Intermediate (No. 3) 2 Small (No. 2) 2 Intestinal (No. 1) 2 Transfixion, right curved 1 Needles, straight 2 Needle holder 1 Retractors : Large 2 pairs Next size smaller . . 2 " Scalpels 2 Scissors : Long 1 pair Short 1 " Sound, uterine 1 Speculum, Situs's small 1 Sponge holders 4 Tenacula : Straight 1 Curved 1 Additional Instruments for Ovarian Cysts Trocars, large and small. Two Nelaton forceps. Rubber tubing. Additional Instruments for Extra-uterine Pregnancy, Hysteromyomectomy, or Supravaginal Hysterectomy, and Vaginal or Infra vaginal Hysterectomy One dozen pairs of long hemostatic forceps. Two Museux's forceps for seizing tumours. Glassware Catheters 2 Drainage tubes, assorted sizes : Straight 3 Curved 3 Flask, sterilized, to receive fluid (contents of cysts, etc.) for examination 1 Nozzles (for irrigation) 2 Preparation of the Field of Operation. — (See Preventive Treatment of Sepsis.) Location of the Incision. — The abdominal incision is generally- located in the median line for the reason that this particular situation enables the operator to more freely handle the parts of the abdominal and pelvic cavities. This rule is adopted more particularly in the old operation of Cesarean section, and in the more recent procedure of ova- riotomy. In the former instance it was manifestly to the convenience of the operator to get down directly upon the uterus. In the second class of cases it vras more desirable because it enabled the surgeon to deal with either side of the pelvis with equal facility; latterly, however, the principle has gained recognition that the incision should be made directly over the organ or structure which is to be dealt with. 104 A TEXT-BOOK OP GYNECOLOGY The question of hernia resulting from the unsatisfactory restora- tion of the incised abdominal wall is also an important consideration in determining the location and character of the incision. It is generally supposed that the cut in the median line directly through the linea alba is best calculated to avoid unpleasant consequences. Of the incision in this location, it may be said that it is the easiest to make, and, by avoiding blood vessels, is least complicated with hemorrhage. It is closed with great facility, and the union which ensues is generally very satisfactory. If infection should occur, however, the approximation of the structures, however accurately made, may be destroyed, and the margin of the wound thus become retracted. This is of very serious import when the incision is a little to one side or the other of the median line, and when the separation involves the margins of the fasciae. This — i. e., separation of the fascia — is the underlying condi- tion of post-operative ventral hernia; to avoid this accident many oper- ators prefer to invade the abdominal cavity a little to one side or the other of the median line, some preferring to go as far to one side as the outer margin of the rectus muscle; some preferring to go di- rectly through the rectus ; while still others open the sheath of that muscle near the median line, pushing the muscle itself to one side and continuing the inci- sion through the middle of the under- lying layer of sheath and fascia. In this way it is contended that should one layer separate, the other layer, directly super- imposed, will exercise a greater retentive power, and thus pre- vent the development of hernia. This principle is one which is capable of adoption in many operations. It should be observed, especially in fat subjects, where, in consequence of the disuse of the abdominal muscles, or of the stretching incident to distention by fat, or from the pressure due to the presence Fig. 33. — " The incision may be made in that locality which will afford the greatest facility in dealing with the under- lying internal conditions." — Keed (page 105). ABDOMINAL SECTION 105 of deposits of adipose tissue, the structures of the abdominal wall are materially weakened. It should be remembered that an incision may- be made at any point in the abdominal wall, and that there are no blood vessels contained therein the hemorrhage from which is not readily controllable. As a rule, therefore, the incision may be made in that locality which will afford the surgeon the greatest facility in dealing with the underlying internal conditions (Fig. 33). Direction and Varieties of Incision. — While the foregoing is true, it is also true that there are distinct advantages to be gained by definitely and accurately arranging the direction of the incision into and through the abdominal wall. It is also true that, consistently with the object in view, the incision is best made (a) coincidently with the cutaneous folds, and (b) coincidently with the muscular fibres and fascial strice. This principle was enunciated by Kocher {Operative Surgery, New York, 1894), who definitely outlines the incisions to be made for vari- ous purposes, some of which come properly within the range of a work on gynecology, and are given herewith. The line of the median ab- dominal incision is, as already stated, the one most commonly employed. While it is made transversely to the normal cutaneous folds it is coin- cident with the recti muscles, a fact that conduces largely to the easy and permanent approximation of the deeper structures. The results, so far as the skin is concerned, are, however, often somewhat unfortu- nate, if from no other than an aesthetic point of view. The retraction of the skin that frequently ensues, notwithstanding the most careful approximation of the cutaneous margins, frequently results in post- operative widening of the cicatricial area. Frequently under this in- fluence the scar tissue undergoes what is spoken of as a keloid change. When, therefore, the cutaneous incision can be made transversely, the underlying layers being divided in amy direction to suit the oper- ator, but preferably in the direction of their respective strice, the result is always more satisfactory. There is nothing more striking than the difference between a scar made transversely to, and one coincidently with the cutaneous folds, the latter becoming practically imperceptible after a very few weeks, Avhile the former shows a constant tendency to increase in size and to diminish in retentive power. The Vertical Median Incision. — The incision E (Fig. 33) may be called the low vertical median incision, while that designated G (Fig. 33) is the high vertical median incision. The latter should be employed in operations upon the stomach, and in other operations in which it is desirable to reach the organs lying in the upper part of either of the upper quadrants of the abdominal cavity. A vertical in- cision (H, Fig. 33) is sometimes made in the left upper quadrant for operations upon the spleen. The incision in the median abdominal line is the best in all cases in which it is necessary to deal with both sides of the pelvis, or in those cases in which it may be uncertain as to which side of the pelvis may be the ultimate seat of operation. The median line is, as a rule, the safer locus for a general exploratory in- 106 A TEXT-BOOK OF GYNECOLOGY cision. It should always be employed in the presence of surgical condi- tions lying immediately beneath it. The Transverse Umbilical Incision. — This incision is made trans- versely at the umbilicus, and may be employed in dealing with prac- tically all conditions developing in that locality. It is the ideal in- cision in the management of umbilical hernia. As a rule, a post- operative ventral hernia, occurring in this locality, or, for that matter, at any other point above or below the umbilicus, may be safely and desirably approached through a transverse incision, while the her- nia itself should be approximated in a transverse rather than a longi- tudinal line. This line of incision is of especial importance in fat people. These patients, lying upon their backs, exercise all of the gravity which is derived from the heavy and mobile abdominal walls in a spontaneous tendency to retract from the longitudinal median line, while their equally natural tendency is to hold a transverse approxi- mation in continued apposition. The Transverse Suprapubic Incision (C, Fig. 33). — This incision should be made transversely to the median line, immediately above the pubes, in all operations in which it is desirable to approach the bladder from the outside. This occurs with frequency in gynecological practice. The Oblique Ventral Incision (A, Fig. 33). — The oblique ventral in- cision should be employed in dealing with the common iliac artery, as sometimes becomes necessary in gynecological practice; it may be used on the right side in dealing with the suppurations about the head of the colon and in appendicitis, or in surgical conditions pertaining to the pelvic bones on that side. On the left side it is the avenue of approach to the sigmoid flexure as well as to the common iliac artery. The Inguinal Incision (B, D, Fig. 33). — The inguinal incision may be made either above or below, but coincidently with, the line of Pou- part's ligament. In the former position it may be employed in inguinal hernia or to reach conditions beneath the broad ligament in order that they may be dealt with without communicating with the peritoneal cavity. Suppuration in this locality may be evacuated and drained by an incision along this line, while retroperitoneal myotomy, or, for that matter, intraligamentary cysts, may be approached by this incision, after their true character has once been determined by the incision in the median line. This incision is sometimes made below Poupart's ligament in deal- ing with femoral hernia and with conditions connected with the fem- oral artery. The Oblique Subcostal Incision (F, Fig. 33). — The oblique subcostal incision should be made from a half to three quarters of an inch be- neath the costal margins, extending from the outer margin of the rectus muscles to as far around the side as may be necessary. This operation is sometimes desirable in making explorations for the kidney — a pro- cedure which comes within the purview of this work; it is usually em- ABDOMINAL SECTION 107 ployed, however, for operations upon the gall bladder, which are not considered in this volume. The Lnmbo-iliac Incision. — This incision begins near the last costo- vertebral articulation, extending downward and forward in the direc- tion of the crest of the ilium. It may be employed in the case of ne- phrectomy, or for the complete removal of the ureter. The Lumbocostal Incision. — This incision is made from a point one to two inches to the side of the posterior median line, and carried obliquely downward, forward, and upward below the costal margin. It is employed for operations upon the kidney. General Observations on making the Incision. — Wherever the inci- sion may be located it should be made deliberately, all attempts at haste being avoided. The layers should be incised one by one. Bleed- ing points will, of course, be encountered, some localities and some patients being more vascular than others. The blood should be speed- ily wiped away by means of a bit of dry sterilized gauze, so that the structures may be kept clearly in view. The gauze thus used should be immediately thrown away. Much time is often lost in needless atten- tion to unimportant bleeding. As a rule, that bleeding which is merely capillary or venous may be left to itself, while a pulsating jet should be at once controlled by means of a hemostatic forceps. This should not be hastily applied, and should always be adjusted with care and precision. Many careless operators and assistants simply take a large Fig. 34.- u-esenting structure should be picked up by two hemostatic forceps.' 1 — Keed. bite of tissue somewhere in the neighbourhood of the bleeding point, with the object, of course, of controlling the hemorrhage. The pres- sure thus imposed upon the tissue, particularly the adipose tissue, which is found in such abundance in the abdominal wall, is liable to induce 108 A TEXT-BOOK OF GYNECOLOGY necrosis, and thus interfere with primary union. A few seconds of time should be taken to isolate more or less definitely the bleeding point, which should then be picked up accurately by the point of the hemo- static forceps. As soon as the deep fascia or the subperitoneal fat is reached, the presenting structure should be picked up by two hemostatic forceps (Fig. 34), which should be re- applied as often as may be necessary to hold the peritoneum away from the underlying viscera. The moment the peri- toneum is nicked the air rushes in and the in- testines fall away from the abdominal wall. Failure to observe this precaution sometimes re- sults in the totally un- necessary wounding of the intestines or other structures within the ab- dominal cavity. The peritoneum should be carefully incised by means of either scissors or a knife, coincidently and coextensively with the upper part of the in- cision (Fig. 35). As soon as the peri- toneum is opened, care should be taken to per- manently arrest all hem- orrhage in the abdominal incision and to remove the forceps. In the course of an operation it may be, and frequently is, neces- sary to enlarge the inci- sion; in doing so great care should be exercised to make the additional opening directly in line with the previous one, and to observe the same precautions in dealing with the incidental hemorrhage. It is better to employ a knife for this purpose rather than the scissors, which are generally so convenient, so expedient, and so generally utilized by the hurried surgeon. The scissors are objectionable, because in the act of cutting they produce a certain amount of cell destruction, which is Fig. 35.—" The peritoneum should be carefully incised . . . coincidently and coextensively with the upper part of the incision." — Eeed. ABDOMINAL SECTION 109 obviated by the keener edge of the knife. The incision having been made as large as necessary, the operation, whatever it may he, is car- ried to completion. The Closure of an Abdominal Incision. — There are various methods of closing the abdominal incision. The question of interrupted or con- tinuous suture, the question of suture material, and the question of sealing or not sealing the wound, are all to be considered: this is bet- ter done with reference to the necessity or not of maintaining drainage. The Immediate and Complete Closure of an Abdominal Incision. — When the operation has been successfully concluded, when the field of operation has remained free from infection, when hemostasis has been secured, and when there are no remaining doubts as to the safety of the internal conditions, the abdominal wound may be closed com- pletely and at once by one of the following methods: Closure by the Laminated Suture. — The ideal method of closure is by the approximation, edge to edge, of like structures; thus the peri- toneum to the peritoneum, the tranversalis fascia to the transversalis fascia, the superficial fascia to the superficial fascia, and the integu- ment to the integument, should be successively approximated. This may be done either by continuous or interrupted suture or chromicized or formalinized catgut. The kangaroo tendon and other tendinous materials have a certain vogue for this purpose, but they are not essen- tial to success. If a continuous suture is applied in each layer it ought to be supplemented by a number of interrupted sutures in the fascial layers, as these structures are more prone to retract than are the others. and they are likewise the chief retentive tis- sues of the abdominal wall. It is not safe, therefore, to trust their approximation to a sin- gle continuous suture. The application of the sutures to the various layers is largely facili- tated by drawing up. by two small volsella for- ceps, each consecutive layer into the field of operation (Fig. 36). Volsella forceps are vastly better adapted to this purpose than are those used for hemo- stasis. because they exercise no pressure, and consequently induce no cell destruction. The skin should be closed by means of intercuta- neous suture, but before starting this suture the end should be fastened Fig. 36. — " The application of the sutures to the various layers is largely facilitated by drawing up. by small volsella forceps, each consecutive layer into the Held of operation." — Reed. 110 A TEXT-BOOK OF GYNECOLOGY in such a way as to place the knot deep in the subcutaneous fat (Fig. 37) in order that its absorption may be insured. This is done by passing the needle through the subcutaneous fat from beneath, carrying it across to the other margin of the wound, and downward through the fat, bringing it out at a point corresponding to the original insertion on the other side. The suture is now tied and the short end cut close. In order to secure perfect approximation at the end of the wound, the first intercutaneous suture is passed toward the end from which the suture starts (Fig. 38). The remaining su- tures are passed in the other Fig. 37. — " The end should be fastened in such a way as to place the knot deep in the subcutaneous fat." — Reed. Fig. 38. — " The first intercutaneous su- ture is passed toward the end from which the suture starts." — Reed. direction, the margins of the skin being carefully drawn together (Fig. 39). There are connected with this last manoeuvre certain dan- gers, for instance, the unsuccessful application of the sutures, leaving a gaping point to serve as an infection atrium; or, on the other hand, if too tightly drawn after they have been inserted, the pressure itself may be destructive of the integument and may result in a necrosis, which is disastrous to primary union. After having applied the inter- cutaneous suture there may be some retraction of the subcutaneous fat, a condition which is easily remedied (Fig. 40). This is done by taking a long curved needle, inserting it an inch or less back from the line of incision, crossing the incision itself, and bringing the needle out at a corresponding distance on the other side. The needle is then rein- ABDOMINAL SECTION 111 serted through the aperture of exit, and is carried in a more or less oblique way back to the opposite side, where it is brought out half an inch distant from the point of original insertion (Fig. 41). The suture thus buried approximates the underlying fat, and in an important degree forti- fies the cutaneous approximation. It is returned in the same manner until the whole line of incision has been brought under the influence of the suture. It is then tied under the skin by inserting the needle and working its point two or three times around the strand of catgut immediately un- der the skin. The needle is then brought out on the other side and the catgut excised under traction close to the skin. The end immediately re- tracts and the whole operation will have been completed entirely beneath the integument. It is well in the majority of cases to seal the wound by adjusting over it a little sterilized gauze fixed to the surface by means of collodion, but the impossibility of sterilizing col- lodion should prevent its application directly to the margins of the wound. After the abdomen is well cleansed and dried it should be tightly bound with a cloth bandage. That in use at the Cincinnati Hospital is probably more advantageous than others, it being held firmly in place by two flaplike elongations of the back part which are brought up between the thighs and fastened to the front of the bandage (Fig. 42). Closure where Drain- age is Necessary. — In many operations it is not possible to secure com- plete hemostasis or that degree of asepsis com- patible with safety, or to control other surgical conditions to a degree that will justify the com- plete closure of the abdominal incision. Drainage must, therefore, be employed and an orifice of exit must be provided. This is sometimes Fig. 39. — " The remaining sutures are passed in the other direction, the margins of the skin being carefully drawn together." — Eeed (page 110). Fig. 40. — " After having applied the intercutaneous su- ture there may be some retraction of the subcutaneous fat, a condition which is easily remedied." — Eeed (page 110). 112 A TEXT-BOOK OF GYNECOLOGY Fig. 41. — " The needle is reinserted through the aperture of exit, and is carried in a more or less oblique way back to the opposite side." — Reed (page 111). done by making an opening in the cul-de- sac of Douglas and carrying a self -retain- ing tube out through the vagina. In other instances this will not suffice. Many opera- tors still cling to the old glass tube and pump, while in certain other instances it is necessary to pack the field of operation with gauze and bring one end of it out through the incision. The neces- sity for the latter expedient is sometimes so great as to make it neces- sary to leave open the entire wound. Under any of these circumstances it is necessary to leave a part or all of the incision open. In such cases it is not better to employ the buried animal suture, for the reason that the drainage, how- ever established or how- ever maintained, is neces- sarily a fruitful source of infection; and infection once communicated to the continuous laminated animal suture is liable to invade all of the struc- tures that may be approx- imated by it. Closure by the Suture En Masse. — To close the wound when drainage is required, the suture en masse should be em- ployed. This may con- sist of silk, silver wire or silkworm gut — the lat- ter on all accounts being preferable. The material, having been sterilized, of course, may be inserted from the skin to the peri- toneum, carried across from peritoneum to peri- Fig. 42. — " The bandage in use at the Cincinnati Hos- pital is probably more advantageous than others."— Reed (page 111). ABDOMINAL SECTION 113 s Fig. 43, -The needle < Holmes /ised \ -Reed. Dr. J. B. S. toneum and through from peritoneum to skin. For this purpose many operators prefer a straight needle, others a curved one; the most satis- factory one which the writer has encountered has been devised by Dr. J. B. S. Holmes, of Atlanta, Ga. It is a round needle bent at an angle near the point, which has a bayonet finish (Fig. 43). The needle in passing through the ab- dominal wall should be made to define an arc of a circle, so that when drawn together the intermediate structures will be brought well forward and forced into approximation (Fig. 11). In a few in- stances it may be found necessary to bring the traction to bear more specifically upon the margins of the fascia. This is accomplished by a figure-of-eight arrangement, effected as follows: The needle is in- .serted through the skin and superficial fascia, brought out into the margin of the wound, inserted into the oppo- site side just below the superficial fascia, car- ried through the peri- toneum, crossed over, inserted through the peritoneum and brought out just beneath the su- perficial fascia, crossed over to the other side, inserted through the superficial fascia, and brought out through the skin. The resulting suture is a complete figure eight, which forces into approximation the fascia which, under many circumstances, is prone to retract to a degree calculated to defeat the union (Fig. 45). The sutures having been inserted, the ends are gathered together upon either side and the entire abdomi- nal wall is drawn away from the in- testines, the perito- neal margins being forced together by properly directed traction upon all the sutures. This having been done, the ends of the sutures may be permitted to lie freely while the operator ties each one seriatim. If the material is silkworm gut the preliminary loop of the knot should be accomplished by three turns, and should be drawn together with just sufficient force to effect the approximation of the tissues, but without force enough to interfere Fig. 44. — " The needle, in passing through the abdominal wall, should be made to define the arc of a circle." — Eeed. Fig. 45. -"The resulting suture is a complete figure of eight." — Eeed. 114 A TEXT-BOOK OF GYNECOLOGY with the local nutrition of the parts. A suture that blanches the skin, under it is tied too tightly. This can not always be avoided, because the post-operative engorgement of the parts sometimes increases pres- sure to a dangerous degree. If the suture has been secured as already indicated — namely, by an extra whirl in the preliminary loop — it is totally unnecessary to apply the usual second loop for fixation. If, then, the tension should subsequently appear to be too great, the suture can be loosened. An extra suture may be inserted to secure approxima- tion at the point occupied for drainage. If applied, this suture should be left loose until after the drainage is concluded. It may be stated, as a rule, however, that this expedient is one of doubtful utility, and is not infrequently fraught with some danger. It is better, as a rule,, to leave that section of the wound which has been employed for drain- age open for spontaneous closure. Drainage. — Drainage was at one time considered more essential to success in abdominal surgery than it is at the present day. At the time when surgeons were less sure of hemostasis it was a safeguard in detect- ing internal hemorrhage, and it should yet be employed in all cases in. which the operator has any doubt about having controlled the bleed- ing. In former times, when the toilet of the peritoneum was less care- fully made than at present, drainage was essential for the escape of pus, which continued to form until limited by the self-extermination of its micro-organisms. Drainage may be practised by leaving in the abdominal wound a glass tube extending to the bottom of the pelvis. Through this tube the accumulated fluids are sucked with an appa- ratus consisting of either a syringe or a rubber bulb with a glass barrel attached to a bit of rubber tubing. The manipulation requires great care to prevent infection, the liability to which by this means consti- tutes one of the chief objections to drainage as a routine measure. In many abdominal operations in which it is desirable to promote the escape of fluid, drainage is effected by making an opening in the floor of the cul-de-sac of Douglas and inserting through that into the vagina either a small rope of gauze, or preferably a T-drainage tube. These are made of rubber after the pattern of Martin, but as found in the shops are unnecessarily expensive. Just as efficient a drainage tube can be made by taking a piece of ordinary quarter-inch drainage- tubing, eight inches long, and cutting it off oval at one end. The tube is then split for a distance of an inch and a half into two flaps; an eighth of an inch below the base of each flap a small hole is cut into each side of the tube; through each of these holes the corresponding flap is drawn by means of an ordinary hemostatic forceps; the result is the formation of a T-tube of great utility (Fig. 46). Delageniere has de- vised metal drainage tubes, but their advantages are not obvious. Gauze- has been used for drainage purposes, but it speedily becomes filled with the secretions, which it fails to conduct out of the cavity; its use, there- fore, should be limited to those cases in which the fluid expected to be taken out by it is not in excess of the absorbing capacity of the gauze to ABDOMINAL SECTION 115 be used. J. G. Clark investigated the general question of drainage in seventeen hundred abdominal sections at the Johns Hopkins Hos- pital (American Journal of Obstetrics. April, 1897). In approaching his investigations he proceeded upon the conclusions of Muscatello — Fig. 46. — " The result is the formation of a T-tube of great utility."— Reed i page 114). viz.: (1) the surface of the peritoneum is equivalent to that of the skin; (2) it has an enormous absorbing function, taking up in an hour from 3 to 8 per cent of the entire body weight; (3) under the influence of very toxic or very irritant substances an equal transudation into the peritoneal cavity may take place. Clark, from a general study of the subject as well as from these investigations, concludes that — 1. Fluids and solids may pass through the endothelial layer of the peritoneum, the fluids in many places, the solid particles only through the spaces in the diaphragm. 2. The minute solid particles are carried into the mediastinal lymph vessels and glands, and thence into the blood circulation, by which they are distributed to the abdominal organs and lymph glands. 3. Large quantities of fluids may be absorbed by the peritoneum in an astonishingly short time. 4. The leucocytes are largely the bearers of foreign bodies from the peritoneal cavity into the mediastinal lymph glands. As the result of the experimental study of infection of the perito- neum by Grawitz. it has been shown that — 1. The introduction of nonpyogenic organisms into the abdom- inal cavity, either in small or large quantity, or mixed with formed par- ticles, produces no harm. 2. Great quantities of organisms, which ordinarily produce no dis- turbance, may give rise to a general asepsis if the absorptive ability of the peritoneum is impaired. 3. The injection of pyogenic organisms into the peritoneal cavity may be quite as harmless as injection of the nonpathogenic varieties. 116 A TEXT-BOOK OF GYNECOLOGY 4. The introduction of pus-producing cocci causes a purulent peritonitis (a) if the culture fluid is difficult of absorption; (b) if there is present irritating material which destroys the tissues of the perito- neum, and thus prepares a place for the lodgment of organisms; (c) if a wound of the abdominal wall is present which forms a nidus for the infectious process. In this latter case purulent peritonitis will cer- tainly be produced. It was further found that the area drained by a tube speedily be- came limited, almost to the circumference of the tube itself; that the tube frequently acted mechanically, and thus perpetuated the peritoneal exudation; that the serum thrown off by the peritoneum acted as the best possible culture medium for germs introduced from without; and, finally, that any agents that had any possible effect upon bacteria acted as an irritant to the peritoneum, and thus defeated the purpose for which they were employed. CHAPTER XIII THE EXTERNAL ORGANS OF GENERATION IN WOMEN Names and definitions — Development — The vulva and its malformations: atresia; infantile ; double ; persistent cloaca ; persistent urogenital sinus ; epispadias in women; precocious development; individual malformations of the labia, cli- toris, and perineum; pseudo -hermaphroditism : (a) masculine, (6) feminine — The vagina and its malformations : absence ; atresia ; stenosis ; double or sep- tate — The hymen and its malformations : atresia ; double ; absence ; anomalies in (a) form, (b) structure, (c) anterior extension. The external organs of generation in women consist of the puden- dum and vagina. The pudendum embraces the structures known as the mons veneris, the labia majora, the labia minora, the clitoris and prepuce, the vestibule and fourchette, and the hymen. The word " vulva " applies to all of these external structures except the mons veneris. For convenience of classification the perineum will be con- sidered in this same group. Development of the Genital Organs. — The genital organs, whether male or female, have their embryologic origin in the Wolffian body, Midler's ducts, and the genital glands. From the Wolffian body, or the primordial kidney, there appear on the inner portion, and in the fifth and sixth months of utero-gestation, the genital glands, which subse- quently evolve into either ovaries or testicles. If, however, at the end of the third month, when differentiation of sex is manifested, the geni- tal glands develop into ovaries, the Wolffian body and canal atrophy, almost disappearing, and leave as their only remnant the organ of Ko- senmuller in the broad ligament. Midler's duct, however, persists, and from it are developed the Fallopian tubes, while the round ligament is developed from the yet persisting ligament of the Wolffian body, blend- ing, however, with Midler's ducts at the junction of the superior with the middle third. The external organs of generation are derived from the genital tubercle, which appears at about the sixth week of foetal life and reaches its maturity during the succeeding two weeks. After the development of the genital folds and at the end of the second month there is recognisable on its posterior surface a furrow extending in the direction of the cloaca and designated the genital groove. This is the beginning of sex development, the subsequent steps of which, as outlined by Pozzi, are as follows : " The genital groove does not close more in front than behind, and thus the female lacks the clitoridian 117 118 A TEXT-BOOK OF GYNECOLOGY portion of the urethra; and this canal in the adult opens at a point homologous with that where it was found in the foetus of eight weeks — a disposition which is found in the male when the proper development of the parts has been arrested (hypospadias). The corpus spongiosum of the urethra, the product of the erectilized borders of the genital furrow, is also completely developed in the male and entirely sur- rounds the canal in the pendulous portion. But in the female it aborts in the intermediate or vestibular portion, being reduced below to its two extremities extending to the bulb of the vestibule, homologue of the bulb of the male urethra, but divided by the persistent genital opening; and above, it forms the glans of the clitoris, which covers the corpora cavernosa clitoridis, homologues of the similar structures in the male penis. At the internal part of the bulb of the vestibule there are ves- tiges of a membranous organ, which reaches its full development in the male — namely, the bulb of the urethra; it is this which forms the hymen. Above, joining bulb and hymen to the clitoris and representing the ver- tical or cylindrical portion of the masculine corpus spongiosum, there is in the female a band with a vascular bundle running into it, the f rsenum masculinum vestibuli." (Medical and Surgical Gynecology, vol. ii,p. 436.) When the ducts of Mtiller coalesce by the approximation of their internal thirds they naturally form a bifurcating double tube divided at the lower extremity by a septum with two divergent ends above. As development progresses this septum disappears, leaving the rudimen- tary vagina below and the rudimentary Fallopian tubes above with no intervening uterine body. At the end of the fifth month, however, there occurs at the upper end of this rudimentary vagina a deposit of tissue, which marks the beginning of the uterus. The failure of the septum to disappear from the rudimentary vagina results in the devel- opment of a double vagina; while its disappearance from the vagina, but its failure to disappear from the uterine extremity of the rudi- mentary canal, results in the development of a double, or bicornate, uterus. (See Malformations.) Malformations of the vulva may lead at the time of birth to an erroneous declaration of the sex of the individual, and later on they may disqualify for marriage; the importance of vaginal anomalies usu- ally becomes apparent when labour is in progress; and the structural irregularities of the hymen commonly produce menstrual retention at the epoch of puberty, or interfere with the consummation of the act of coition some years afterward. Malfokmations of the Vulva The embryology of the vulva is less clearly understood than that of the uterus; it is in consequence of this that its malfor- mations have not been so completely systematized as have those that affect the uterus. When the changes which take place at the poste- rior end of the embryo in connection with the development of the THE EXTERNAL ORGANS OF GENERATION IN WOMEN 119 genital tubercle, the cloaca, and the urogenital sinus, are better known, the anomalies which arise from interference with the normal course of these changes will be more easily comprehended. The complexity of the embryogenesis of the neighbourhood of the Bauchstiel is in- creased by the occurrence of transitory structures or scaffoldings which give place in time to the permanent arrangement of parts, but which may, under certain circumstances, persist more or less completely, and thus give rise to malformations. A good instance of this permanence •of temporary scaffoldings is found in atresia ani vaginalis. Vulvar Atresia. — Complete absence of the vulva, the skin passing unbroken from the symphysis pubis to the coccyx, is a matter of tera- tological interest solely; on the other hand, apparent vulvar atresia, or atresia vulvce superficialis, has an immediate importance. On account of the existence of labial adhesions, there is an apparent absence of the vulvar cleft (Fig. 47). A small opening exists an- teriorly from, which the urine issues sometimes with considerable diffi- culty. At puberty trouble may arise through the oc- currence of hematocol- pus; but if the opening is large enough to permit the escape of the men- strual fluid, the discovery •of the anomaly is post- poned till marriage, when attempts at penetration by the husband may suc- ceed in breaking down the labial adhesions or may require to be supple- mented by the knife of the surgeon. It is note- worthy* that while this atresic condition may pre- vent coitus, it is not a complete obstacle to im- pregnation. The treat- ment is simple : some- times the labia can be torn apart, as was done by Jan (Indian Lancet, vol. vii, p. 123, 1896); at other times it may be necessary to pass a sound in at the anterior open- ing (Fig. 48), to direct it backward, and then to cut down upon it (Coop, Fig. 47. — v- On account of the existence of labial adhe- sions, there is an apparent absence of the vulvar cleft." — Ballasttyxe. 120 A TEXT-BOOK OP GYNECOLOGY American Gynecological and Obstetrical Journal, vol. vi, p. 594, 1895). When the atresia of the vulva is associated with hypertrophy of the clitoris, doubts as to the sex of the individual may arise. An anomaly closely allied to that just described consists in the existence of preputial and labial adhesions binding down the clitoris. This leads to, or is at least associated with, nervous derangements both in childhood and adult life. The freeing of the clitoris from these adhesions may be fol- lowed by the disappear- ance of symptoms, in this respect resembling the effect of circumcision in the male. Infantile Vulva. — In infancy the labia majora are less developed in comparison with the other parts, and the vul- var cleft is consequently more exposed to view; the mons also is but slightly marked, and there is an absence of hair. These infantile characters may persist in adult life. In individuals showing this persistence, there is commonly also an imperfect develop- ment of the uterus, ovaries, and mammary glands; chlorosis may be pres- ent, and the whole clinical picture may be called infantilism in woman. Double Vulva.— Only three cases (those reported by Le Cat, 1765; Suppinger, 1876; and Chiarleoni, 1894) are on record in which individ- uals, otherwise single in formation, possessed two vulvae situated side by side in the interfemoral space. In two of these there was an im- perforate condition of the anus, the rectum opening into the vulva or into the vagina. A case in which the external genital organs of both sexes were present was reported by Moostakoff in a Bulgarian journal (Meditzina, p. 32, 1894; abstract by Ballantyne in Teratologia, vol. ii, p. 234, 1895), and a similar instance (Fig. 49) has been described by Neugebauer (Monatsslirift fur Geburtsliulfe und Gynakologie, Bd. vii, p. 550, 1898). It is probable that in both these latter cases the two sets of organs were really of the same sex, one, however, being so deformed as to resemble the appearance presented by the part of the opposite sex. The corresponding malformation in the male is diphallus, or double- Fig. 48. — "It may be necessary to pass a sound in at the anterior opening."— Ballantyne (page 119). THE EXTERNAL ORGANS OF GENERATION IN WOMEN 121 penis, twenty cases of which, including one personal observation, Ballantyne and Skirving (TeratoJogia, Bd. ii, p. 92, 18-1, 255, 1895) gathered together and analyzed. Both in diphallus and in double vulva there is good reason to believe that the anomaly is truly a duplication of the lower end of the trunk — that it is, in fact, the least degree of posterior dichotomy. This view is strongly supported by the fact that in several of the cases that have been dissected there has been discovered bifidity of the lower end of the vertebral column as well as duplication of the external genital organs. Ballantyne has reported an ■•• A case in which the external crenital organs of both sexes were present." — Ballaxttxe (page 120 . instance of double genital tubercle (without any other trace of exter- nal genitals) in a foetus with exomphalos and sacral meningocele (Transactions of the Edinburgh Obstetrical Society, vol. xxiii, p. 36, 1898). Persistent Cloaca. — Under the various names of anus vulvalis, vul- var anus, atresia ani vaginalis, atresia ani vestibularis, and vulvo- vaginal anus, has been described an anomaly which is really due to the persistence of the cloacal stage of the development of the female gen- erative organs. There is no anal opening in the normal position, but fasces pass from the vagina (Fig. 50). Examination reveals an open- 122 A TEXT-BOOK OF GYNECOLOGY ing, which may be pinhole in size, in the neighbourhood of the hymen or at a slightly higher level in the vagina; this is the lower end of the rectum. J. W. Ballantyne has recently had a case brought under his notice by Dr. George Elder, in which, in a girl four months old, there were two vulvar anal openings between the posterior com- missure and the hymen; there was a dimple where the normal anus should have been. Sometimes, but rare- ly, the anomaly co- exists with a normal anal opening. It is noteworthy that in quite a number of the reported cases there was control over the motions. Under such circumstances the malformation might pass unrecognised till after marriage or the occurrence of labour. When, however, there is faecal inconti- nence, operation be- comes imperative. The time of puberty is that best suited for interference; and it is commonly rec- ommended that a probe be passed in at the vulvar end of the fistulous tract and brought out at the spot where the anus ought to be, and that the structures be- tween the director and the surface of the perineum be divided and the rectum pulled down and fixed by sutures. Buckmaster (Transac- tions of the American Gynecological Society, vol. xix, p. 275, 1894), however, advises that the rectal canal be brought down in front of the sling formed by the fibres of the levator ani muscle and fastened with- out strain; that a second operation be performed for the restoration of the perineum; and that finally the fibres of the levator ani be split so as to form a sphincter very much as has been done with the rectus muscle in gastrostomy. Persistent Urogenital Sinus. — The name hypospadias in woman has been given to the condition in which the urethra appears to open into the vagina at a higher level than is normal (Fig. 51); this is really Pig. 50. — " There is no anal opening in the normal position, but faeces pass from the vagina." — Ballantyne (page 121). THE EXTERNAL ORGANS OF GENERATION IN WOMEN 123 persistence of the urogenital sinus, for what is called the lower end of the vagina in these cases is more correctly described as the urogenital sinus. It differs from persistent cloaca in the fact that the perineum and anal opening are normally- formed and situated. There is a greater or less defect in the posterior wall of the urethra. Clinically, cases of this kind will be grouped ac- cording as there is or is not in- continence of urine. If there is no incontinence, as in the case reported by W. A. Ed- wards (American Gynecological and Obstetrical Journal, vol. vi, p. 449, 1896), the individ- ual may pass through life and even give birth to children without the anomaly being de- tected. But in the other case it will be necessary to operate, and the method of Gersuny may be adopted, as was done with success by Krajewski (Bitner, Przeglad Cliirurgicz- ny, vol. i, p. 260, 1893-'94). The urethra is dissected out up to the neck of the bladder, the slit in its posterior wall is stitched, the canal is then twisted on its long axis, and fixed in position by a series of sutures. Epispadias in Women. — In women epispadias may be met with as a part of the malformation known as extroversion of the bladder, or it may exist practically alone. To the latter condition the name is best restricted. Ballantyne (Edinburgh Hospital Reports, vol. iv, p. 249, 1896) has described a case of this kind and gathered together thirty-two others from literature. It consists, as in Dranitznr's case (Journal AhusJi., vol. viii, p. 567, 1894), in the absence of a greater or smaller part of the anterior wall of the urethra, with the division of the cli- toris into two parts, and the presence of a median groove in the region of the anterior commissure of the vulva (Fig. 52). There is no splitting of the symphysis pubis or anterior bladder wall. It has only one symptom — more or less complete urinary incontinence — and in its least marked form (clitoridian epispadias) even this may be absent. Various plastic operations, resembling those used in hypospadias, have been employed to lengthen and narrow the urethra and to restore the anterior vulvar commissure and clitoris; but success has only been occa- Fig. 51. — " The name hypospadias has been given to the condition in which the urethra appeal's to open into the vagina at a higher level than is normal." — Ballantyxe (page 122). 124 A TEXT-BOOK OF GYNECOLOGY ■ I sionally obtained, and most often the purely palliative wearing of a urinal has had to be accepted as the sole treatment practicable. Precocious Development of the Vulva. — In strong con- trast to the cases of infantile vulva are those of precocious development of it, which are occasionally met with. Girls of from two to ten years ex- hibit under these circum- stances a marked growth of pubic hair; the vulva, as in the adult, is strongly devel- oped anteriorly (de Kiche- mond, Revue mensuelles des maladies de Venfance, tome xvii, p. 74, 1899); and the mammary glands may also show hypertrophy. Physio- logically there may be early menstruation or pubertas prsecox (Hennig, CentraTblatt fur Gynakologie, Bd. xxii, p. 832, 1898), and in some in- stances (e. g., that reported by C. W. Gleaves, Medical Record, New York, November 16, 1895) there has been pre- cocious pregnancy. Malformations of the Labia, Clitoris, and Peri- neum. — The anomalies that have been described affect more or less all the structures mak- ing up the vulva, but the single parts may also be malformed. The labia minora or nymphae may be absent, or increased in number, or hypertrophied; the clitoris also may be enlarged so as to suggest doubts as to the real sex of the individual. In many of these cases of hyper- trophy there exist nervous phenomena, which are occasionally miti- gated by excision of the enlarged parts. A curious anomaly of the labia minora has recently been reported by Shoemaker {American Journal of Obstetrics, vol. xxxii, p. 216, 1895); the nymphas were unusually large, and in each there was a congenital circular perforation about half an inch in diameter, and exactly opposite each other. J. W. Ballantyne has described a case of a suspected " hermaphrodite " in which the left nympha was enlarged, p3 r ramidal, and divided into two parts by a constriction {Transactions of the Edinburgh Obstetrical Society, vol. xiii, p. 185, 1898). ■: ;. ::. . Fig. 52. — " Epispadias may be met with as part of the malformation known as extroversion of the bladder." — Ballantyne (page 123). THE EXTERNAL ORGANS OF GENERATION IN WOMEN 125 Pseudo-hermaphroditism : Masculine. — It is not out of place in a work devoted to gynecology to refer to cases of doubtful sex in which, the individual, by reason of his possession of testicles, is a male, but on account of his external organs might quite well be a woman, for such cases usually are brought to gynecologists for treatment. The anomaly most commonly met with under these circumstances is perineo-scrotal hypospadias (Fig. 53). The imperforate penis, often atrophic, re- sembles the clitoris; the ure- thra opening at the base of this rudimentary penis re- sembles the female meatus urinarius at the base of the vestibule; and the short ves- tibular canal, which may even be guarded by a hymen, simulates the vaginal orifice in a very striking fashion. Nondescent or atrophy of the testicles, enlargement of the mammary glands, and the exhibition of acquired femi- nine traits, may all combine to make the question of the sex of the hypospadia male one of the greatest difficulty. When it is added that cases have occurred in which the individual not only possessed a uterus, but also suffered every month from a san- guineous discharge from it, the discovery of the true sex only after post - mortem microscopic examination of the genital glands can be quite well understood. It must also be remembered that the testicles in such cases often show pathologic changes. In an individual described by P. Delageniere (Annates de gynecologie, tome li, p. 57, 1899), and regarded for twenty-seven years as a woman, the testicles, which were found in the inguinal regions, showed tubules surrounded by fibrous tissue, atrophied, and containing no spermatozoa. In one of the glands there were also several nodules, " adenomata of the testicle." In this case the vulva was absolutely normal, the breasts were those of a girl before puberty, and the thorax was masculine in type. The abdomen was opened, but no trace was found of uterus or Fig. 53. — " The anomaly most commonly met with is perineo-scrotal hypospadias." — Ballantyne. 126 A TEXT-BOOK OF GYNECOLOGY tubes; the atrophied testicles were removed. If such individuals are seen at the time of birth it is probably best to bring them up as boys, as Lawson Tait suggests, for male pseudo-hermaphrodites are com- moner than females, and there is less risk in bringing up a girl among boys than a boy among girls. At a later age the question of removal of the genital glands (nearly always atrophic or morbid either in structure or position) will require to be faced. C. Martin has removed the testicles from an individual brought up as a girl, with the result or sequence that the pubic hair and the breasts developed (British Medical Journal, vol. i, 189-4, p. 1361); but it is doubtful to what extent we are at liberty in these cases to remove sexual glands even when these are in all probability morbid in structure and possibly functionally inade- quate. Pseudo-hermaphroditism : Feminine. — The most common form of gynandria or feminine pseudo-hermaphroditism, is that in which superficial vulvar atresia exists' in association with hypertrophy of the clitoris. When there is also hernia of the ovaries into the labia the individual may readily be regarded as a male. In all probability, how- ever, doubts will early arise as to the true sex, and a close inspection of the parts, accompanied possibly by some slight surgical interference, will serve to make plain the matter before any harm is done. Malfokmations of the Vagixa The embryology of the vagina is better understood than that of the vulva, and the nature of its anomalies is therefore more evident. Some doubt, however, exists as to the mode of formation of the lower end of the canal and of the hymen. The general view is that the whole of the vagina above the hymen is Mullerian in origin, being produced by canalization of the fused lower ends of the two ducts of Miiller; but Berry Hart (Transactions of the Edinburgh Obstetrical Society, vol. xxii, p. 18, 1897) looks upon it as Mullerian in its upper part only, and as developed from the urogenital sinus in its lower third by the break- ing down of cells derived from the Wolffian bulbs (lower ends of the Wolffian ducts). Nageh's investigations, however, do not support Hart's conclusions, and Webster (Transactions of the American Gynecological Society, vol. xxiii, p. 446, 1898) also sums up adversely to them. Nev- ertheless the anomalies of the vagina present features not easily ac- counted for by either of the two theories of origin. Absence of the Vagina. — Cases of complete absence of the vagina, in which careful examination of the tissues lying between the rectum and the bladder reveals no trace of muscular bands, are of pathological interest solely; they occur only in connection with advanced terato- logical conditions, such as sympodia. Vaginal Atresia. — There may exist a complete or an incomplete imperforate condition of the vagina; between the bladder and rectum there may be found simply a fibro-muscular cord; in other cases the THE EXTERNAL ORGANS OF GENERATION IN WOMEN 127 vaginal canal may be present in part and imperforate in part; and in yet others there may be a membranous septum at the upper, middle, or lower, third of the vagina. When the lower third of the canal alone is present it is surmised that it is not Miillerian, but derived from the vestibular sinus; its upper boundary would be composed of the lower imperforate end of the Miillerian vagina, or (if the theory of Hart is accepted) of the persistent Wolffian bulbs. The malformed state of the vagina is commonly associated with anomalies in the other genital organs both internal and external; thus, the uterus may be ill devel- oped or absent, and the Fallopian tubes and vulva may, but not so frequently as the uterus, be defective. On the other hand, the uterus and the other genitals may be normal in structure. Sometimes it is stated that the ovaries are absent, but it must be re- marked that in cases in which the vagina and ovaries are both absent the sex of the individual can hardly be re- garded as female at all. If functionally active ovaries and uterus coexist with im- perforation of the vagina, the supervention of puberty usually leads to the retention of blood, in a more or less altered state, in the uterus (hematometra) or tubes (hematosalpinx), or in the perforate part of the vagina (hematocolpus) (Fig. 54). J. W. Ballantyne has recently seen a case (under the care of Dr. Alexander James in the Edinburgh Infirmary) in which the vagina was imper- tyne. forate in a great part of its extent, and in which the uterus was the size of a three months' preg- nancy (hematometra); the patient, a girl twenty-two years of age, had frequently recurring attacks of epistaxis, and a very remarkable fea- ture of the morbid anatomy was the presence of well-marked cervi- cal ribs. Clinically, an imperforate condition of the vagina usually begins to attract notice when the individual reaches the age of puberty. As month after month goes past without any sign of the menstrual dis- Fig. 54.— "The supervention of puberty usually leads to the retention of blood in the perforate part of the vagina (hematocolpus)."— Ballan- 128 A TEXT-BOOK OF GYNECOLOGY charge, but with all the signs associated with menstruation (pain and weight in the pelvis, headache, swelling of the breasts, epistaxis, etc.), the patient's friends bring her to a medical practitioner. It is then found that the vagina is imperforate and that there is distention in the hypogastric region, and, if the case is kept under observation, it may be noted that this swelling increases suddenly at recurring monthly periods, to diminish again slowly in the intervals. The examining finger passes into the vagina to a greater or lesser distance, accord- ing as the imperforation is high up or low down in the canal, but it never touches the cervix, and by the aid of the rectal touch, with a sound in the bladder perhaps, it can be made out whether the uterus and adnexa are present or not, and whether there is menstrual retention in the uterus and tubes or not. In other cases of vaginal atresia, the first symptoms to lead to medical intervention are those arising at the time of marriage, when coitus is found to be either impossible or incomplete and painful. In these instances the internal genital organs may be functionally quiescent, a fact which accounts for the absence of monthly suffering and for the late discovery of the vaginal anomaly. The intervention of the gynecologist in cases of imperforate vagina may be rendered necessary under two sets of circumstances — at or soon after puberty, for monthly pain and for hematometra and the symp- toms associated therewith; or at the time of marriage for dyspareunia. Under the former circumstances, the object of intervention is to reach and evacuate the retained menstrual blood; under the latter, it is mainly to establish what may be called a coitional vagina by a plastic operation. If the vaginal atresia is situated near the introitus and is localized, then a simple crucial incision will serve to set free the more or less altered blood in the upper part of the canal; the evacuation should be ■carried out without haste and strict surgical cleanliness observed. If, on the other hand, the atresia is extensive and the blood accumulation is far from the surface, very careful dissection will be needed before the cervix uteri is reached. With the sound in the bladder and a finger in the rectum, and using the handle of the knife or probe-pointed scissors, the operator will work upward toward the blood accumulation (whose position has been determined by rectal touch), will incise the sac, and endeavour, with the aid of flaps derived from the labia minora and perineum, to form a vaginal canal. Possibly in the future the method of operating recommended by P. Walton (Belgique medicate, ann. 5, p. 353, September 22, 1898) will take the place of that described above as more speedy and scarcely more dangerous. He makes an H -shaped incision between the labia minora, dissects upward, and at once opens into the peritoneal cavity (instead of avoiding it, as has been the cus- tom) through the pouch of Douglas; he then passes his 'fingers in and ascertains the condition of the uterus and adnexa; the opening in the peritoneum can then be closed with catgut sutures and the construction of the artificial vagina proceeded with. In the case operated upon by THE EXTERNAL ORGANS OF GENERATION IN WOMEN 129 Walton, five months had elapsed since the formation of the canal and menstruation had occurred regularly, although in small amount and with complete absence of suffering. The results recently obtained by posterior colpotomy for other conditions support Walton in his recom- mendation; certainly the operation is greatly shortened, and an accu- rate knowledge of the position and condition of the parts is obtained. It is doubtful to what extent the gynecologist is justified in recom- mending the creation of an artificial vagina when no menstrual suffer- ings exist, and when there is consequently no reason to suppose that functional internal organs are present, for the operation, which is not free from risk, is manifestly being undertaken solely to provide a coitional vagina. Should intervention, however, be decided upon, it will be best to dissect upward in the space between the rectum and bladder to a distance of about two inches, and then to line this in- vagination with tissue obtained from the nymphae and perineum. The cavity will require to be kept open for some time with a cone-shaped pessary. Vaginal Stenosis. — An abnormal degree of narrowness of the vagina may be met with and may affect the whole canal or only a part of it. When the stenosis is general, it probably means that we have to do with a half vagina derived from one MfOlerian duct, the other half being undeveloped, or at least imperforate. Then the condition may be asso- ciated with the uterus unicornis or bicornis (with one cornu rudimen- tary). In other cases the stenosis is annular, and consists of one or more perforated diaphragms, a condition which may have been pro- duced by adhesive colpitis in infancy or in foetal life, but which more probably represents incomplete canalization of the vaginal anlage. Dyspareunia may result at the time of marriage, or delay may occur during the second stage of labour, and the anomaly thus be brought under the notice of the gynecologist. It is usually recommended that a crucial incision be made and the ring stretched; but it will be more satisfactory to adopt the plan advocated by Yineberg (American Gyne- cological and Obstetrical Journal, vol. vi, p. 250, 1895), which consists in excision of the septum and ihe bringing together with sutures of the upper and lower margins of the annular incision thus produced. Double or Septate Vagina. — The term double vagina should in strict accuracy be applied only to those cases in which there exist two uteri and two vulvar apertures in addition to the two vagina?; such cases, as has been stated already, are exceedingly rare, and must be grouped among the double monstrosities. On the other hand, septate vagina, which is usually named c * double " vagina, is much more common. It is due to want of fusion of the two Miillerian ducts in their lower part; it is not, therefore, an anomaly by excess, but by defect, an arrested development. The septum generally runs antero-posteriorly, when, of course, the vaginae are situated laterally; rarely, as in a case reported by Fordyce (Teratologia, vol. i, p. 72, 1894). the canals lie one in front of the other and the septum is transverse. The septum may be complete 10 130 A TEXT-BOOK OF GYNECOLOGY and may extend from a point above between the two cervices (there are often two vaginal portions, indicating a double uterus) to the vulvar aperture, where it may subdivide that orifice and produce what is called a hymen biforis; on the other hand, it may exist in the upper part of the vagina alone, or in the lower part alone, or it may show a varying number of perforations. Clinically, septate vagina may give rise to no symptoms till parturi- tion occurs, when, as in a case recorded by Eanieri (Annali di ostetricia e ginecologia, xvi, p. 473, 1894), excision of the septum may be needed during the labour to prevent laceration of it, which might entail also laceration of the uterus. When, however, one or both halves of the vagina are imperforate (a not uncommon occurrence in septate vagina, Fig. 55) symptoms will arise about the time of puberty in association with the retention of blood in one or both canals (unilateral or bilateral hematocolpus). When unilateral, this condition has been called atresia vaginae lateralis. Since the retention of blood may cause pain in the back and difficulty in micturition and defe- cation, it will be neces- sary to incise (or better to excise) the sac, clear out its contents, and pack with iodoform gauze under antiseptic precautions. In all cases in which an elastic swell- ing is found in the vag- inal wall, the possibil- ity of its being an im- perforate half vagina communicating with a functionally active half uterus should be borne mind. In a case in Fig. 55. — " Both halves of the vagina are imper- forate." — Ballantyne. seen by Muret (Revue medicate de la Suisse romande, p. 280, May 20, 1895) the better devel- oped half was imperforate and the more rudimentary one was patent. Sometimes the imperforate half communicates with the patent by means of a small opening, when dysmenorrhcea may exist without com- THE EXTERNAL ORGANS OF GENERATION IN WOMEN 131 plete menstrual retention. In Fordyce's case (loc. cit.) both halves opened into the urethra. The Hymen. — This structure, which marks the dividing line be- tween the vulva and the vagina, has been carefully studied by Schaeffer in nearly two hundred foetuses. He found, without exception, that as early as the fifth month the hymen was composed of two lamellae, the inner being derived from the vagina, while the outer appeared to be the inner margin of the vulvar fold; and that coalescence of these two layers was not infrequent. On the vaginal surface of the hymen were found transverse folds, similar to those in the vagina, between which were pockets so distinct that, in the event of their occlusion, they could easily be converted into retention cysts. Irregularities in the distri- bution of these folds account for those anomalies of the hymen which are spoken of under the names of hymen crenulatus, dentatus, carinatus, falciformis, etc. On the vulvar surface of the hymen in the foetus, he found numerous folds extending from the fossa navicularis, nymphae, clitoris, and meatus. If these observations meet with suffi- cient confirmation, it may be necessary to revise accepted theories of the embryologic development of this structure. At present it is looked upon as a remnant of the cloacal appendage. In the human embryos shortly after the coalescence of Muller's ducts it manifests itself by an accumulation of epithelia on the posterior wall of the rudimen- tary vagina. Whether it develops entirety from the vulvar side or entirely from the vaginal side, or, as is more probable, in two lamellae, one from either side, is a matter of no practical importance. To the naked eye it presents the appearance of a mucous fold that in many instances is very elastic. The elasticity of this structure is so pro- nounced in a number of cases that it withstands repeated parturition. Microscopically, its surfaces are shown to be covered with flat epi- thelium on a network of fibrous elastic tissue, containing few or no muscular fibres. Capillary vessels and nerves are conducted by nu- merous papillae from the central connective tissues into the epithelial structures. Malformations of the Hymen The hymen is a developmental relic, and is, therefore, very liable to variations in form and structure. It arises from the breaking down of the tissue between the sinus urogenitalis and the lower end of the Miillerian vagina, and it is possible, as Hart asserts, that the Wolffian bulbs may contribute to its formation. In addition to the well-known part of it which forms a crescentic fold at the posterior end of the vulvar aperture, the hymen consists of a mesial band running forward toward the clitoris, and forming a collar for the meatus urinarius on the way. Attention was specially drawn to this forward extension of the hymen by Pozzi (An?iales de gynecologies tome xxi, p. 257, 1884), and J. W. Ballantyne has described the appearances presented by the mesial vestibular band in female infants (Fig. 56) (Transactions of the Edin- 132 A TEXT-BOOK OF GYNECOLOGY burgh Obstetrical Society, vol. xiii, p. 188, 1888). Anomalies may be met with, in the vestibular portion as well as in the hymen commonly so- called, and even a dis- tinct projection may exist (Fig. 57). Hymenal Atresia or Imperforation. — It is ex- tremely probable that many of the cases de- scribed as instances of imperforate hymen are really examples of atresia of the lower end of the vagina, for in some of the records the presence of a hymenal membrane hidden by the projecting vaginal sac is referred to. On the other hand, un- doubted cases of atresia hymenalis do occur. The imperforate condition of the membrane gives rise to symptoms which can scarcely be distinguished from those of atresia of the lower part of the vagina. During infancy some trouble may be caused by the retention of mucus in the canal, but it is usually not till puberty that the condition attracts notice. Every month, colicky pains recur with increasing severity; there is some difficulty with micturition and defecation, which passes off in the intermenstrual period; there may be epistaxis or vicarious hemorrhage from the bladder or bowel; but there is no discharge from the genitals. Examination of the patient at one of these epochs will reveal a fluctuating tumour projecting to a larger or smaller extent above the symphy- sis pubis, according as the condi- tion has been persisting for a longer or shorter time; and in the vulva will be seen a bulging membrane, which is the distended hymen. The 1 i EH 1 1 1 % e, • ■j i" : W HOPMte Fig. 56. — " The appearances presented by the mesial ves- tibular band in female infants." — Ballantyne (p. 131). Fig. 57. — "Even a distinct projection may exist" (section). — Ballantyne. THE EXTERNAL ORGANS OF GENERATION IN WOMEN 133 condition of hematocolpus, which has been thus produced, may be ac- companied by the accumulation of blood in the uterus also (hemato- metra). F. Neugebauer (Medycyna, vol. xxi, p. 429, 1893) has recorded an unusual case of hymenal imperforation without menstrual retention, the blood escaping through a small opening at the right side of the urethra; the hymen is described as consisting of two laminae (hymen lilamellatus), an external incomplete and an internal complete, so that it is likely that the internal one was really the lower end of the imper- forate vagina. The first step in the treatment of hymenal imperforation consists in the evacuation of the retained menstrual blood. The membrane is incised and the fluid removed under antiseptic precautions, the latter being specially necessary if the uterus and Fallopian tubes have shared in the distention. The remnants of the hymen are then excised, and the edges are brought together with sutures. The cavity is packed with iodoform gauze. The removal of the more or less altered blood should be done slowly. Double Hymen. — The cases in which two (or more) diaphragms exist near the vaginal outlet should not, perhaps, be regarded as in- stances of double hymen, but rather as examples of annular vaginal stenosis. Neither does the existence of two openings in the hymen con- stitute a double hymen in the strict sense of the words. The term ought to be left for the very rare instances, to which reference has already been made, in which two vulvae exist side by side in the inter- femoral region. Absence of the Hymen. — The hymen is rarely completely wanting except in connection with absence of all the external genitals, as in some marked forms of monstrosity; but it may be apparently absent, being hidden from view by the bulging lower end of an imperforate vagina. In the newborn infant, it is folded together and projects from the vaginal orifice as two lateral folds, which may be taken for the labia minora. In the negro infant, it is deeply seated, and may in con- sequence be thought, on casual inspection, to be absent. Anomalies in the Form of the Hymen. — Instead of its normal cres- centic form, the hymen may be circular (Fig. 56), or notched (denticu- late), or projecting (infundibuliform), or fimbriated. Instead of bound- ing one orifice it may show two openings, which may be equal in size and situated laterally (hymen septus), or unequal in size and situated irregularly (hymen bifenestratus); in rare cases there may be several openings (hymen cribriformis). J. W. Ballantyne recently met with an instance of very complete hymen septus in an unmarried woman of forty upon whom he was operating for hemorrhoids; the openings were perfectly equal in size, and the septum, which was quite fleshy, extended for some distance up the vagina; the uterus was single, as was also the upper part of the vagina. Anomalies in the Structure of the Hymen. — The hymen, especially in elderly primiparae, may be very tough and resistant; it may on this 134 A TEXT-BOOK OF GYNECOLOGY account delay the dilatation of the perineum in labour; it may even prevent the consummation of marriage, and require to be excised, as in a case seen by J. W. Ballantyne {Transactions of the Edinburgh Obstetrical Society, vol. xiv, p. 141, 1889). If it is very vascular, as well as very tough, the laceration it undergoes in coitus may cause alarming hemorrhage. Anomalies in the Anterior Extension of the Hymen (Urethral Hymen and Vestibular Band). — Gilliam has described two cases of what would seem to be a persistence of the anterior extension of the hymen, which surrounds the meatus urinarius like a collar. In one of these, that of a girl of eighteen, suffering from incontinence of urine, there was an anomalous band attached to the urethra and spreading itself over the muscles of the anterior aspect of the vulvo-vaginal junction; it was clipped, and the incontinence disappeared at once. In the other case, that of a girl of twenty-one, also suffering from urinary inconti- nence, a membrane stretched from the anterior segment of the hymen and was attached like wings to the sides and under surface of the urethra; its excision gave a cure. Gilliam (American Journal of Ob- stetrics, vol. xxxiii, p. 177, 1896) thinks that these bands set up local irritation. CHAPTEE XIV INJURIES OF THE EXTERNAL GENITAL ORGANS Injuries of the vulva from external violence, sexual intercourse, parturition — Pu- dendal hematocele — Injuries of the vagina: Rupture — Fistula?: urethrovag- inal, vesico-vaginal — Sims's operation — Ross's operation — Reed's operation — After-treatment and dangers — Atresia of upper part of urethra — Uretero- vaginal fistula? — Recto-vaginal fistula — Mayo Robson's operation. Injueies of the external organs of generation may, for convenience of study, be classified into those involving (a) the vulva, and (b) the vagina. On account of the anatomical position of the vulva, which is protected above by the mons veneris and the underlying hard and resisting symphysis pubis, the descending rami, and the inner aspect of the thighs, injuries to this structure, except when due to parturition, are necessarily rare. The vascularity of the tissues composing the vulva predisposes the structure to profuse hemorrhage, so that, should there be a solution of continuity of the skin, the loss of blood may be considerable, even amounting to syncope in weak and debilitated individuals. In considering these injuries the anatomical construction of the surrounding and underlying parts must be borne in mind. The rami of the pubis possessing a rather sharp inner edge, a blunt instrument may be used, and yet an incised wound may be the result, the blunt object forcing the overlying soft structures against the ramus. Con- tused rather than incised wounds are, however, the rule. In instances in which the skin is not divided, hemorrhage into the abundant connective tissue here found results in hematoceles of vary- ing sizes, according to the size and number of blood vessels injured. The causes of these injuries to the vulva may be considered under three headings — viz.: (a) External violence, (b) coitus, (c) parturition. External Violence. — The patient may fall astride the back of a chair, as in the case of servants engaged in cleaning windows, hanging curtains, and pictures; or in the case of the female bicyclist being thrown from the saddle and alighting on the iron frame or handle bar. Eoss, of Toronto, reports (American Journal of Obstetrics, April, 1898) a case in which a woman, while riding her wheel, was thrown from the saddle, and alighting on the sharp portion of the frame, tore the geni- talia upward as high as the erectile tissue near the clitoris, producing copious hemorrhage. Hemorrhage from the vulva may be fatal even "l35 136 A TEXT-BOOK OF GYNECOLOGY when induced by a relatively slight injury. Ford (New York Medical Journal) reports a case of hemorrhage resulting in death in a patient who, while at the theatre, in attempting to 'change her seat, fell against the iron partition between the chairs, inducing a lacerated wound, about a third of an inch in diameter, between the clitoris and the labium minus. If the injury to the deeper structures is induced by pressure against the ramus of the pubis and does not result in severing the continuity of the skin, the resulting hemorrhage takes the form of a hematocele. (See Pudendal Hematocele.) Among other wounds of the vulva are those produced in children while at play: A fall upon a picket fence; splinters of wood being forced into the labia while sliding upon the floor or down an incline; and falls from sleds while coasting, etc. Injuries to the vulva by sexual intercourse, aside from slight lacera- tions of the fourchette, are of very rare occurrence, except in cases of rape of children and of women of advanced age. In the former they are due to the tender and undeveloped soft parts, and in the latter to senile atrophy and consequent want of elasticity. These lacerations generally involve the hymen in the young and the fourchette in the aged, and extend thence in various directions. Baldy reported (American Gyne- cological Journal, 1891) a case of laceration due to first intercourse, the injury beginning at the hymen and extending upward on the vaginal aspect of the perineum. Spaeth records a case (American Journal of Obstetrics, 1890) of laceration beginning at the vulvar orifice, extending upward along the posterior wall of the vagina, causing a vesico-rectal fistula. Parturition is by far the most frequent cause of injuries to the pudenda. (See Pudendal Hematocele.) Here also the perineum suf- fers the greatest injury. Contusions of the labia, and sometimes of the vulvo-vaginal glands, are due, in the majority of instances, to a failure of the head to rotate into the conjugate diameter of the outlet of the pelvis. Not infrequently also does the careless use of the forceps cause lacerations and contusions of these parts. Treatment. — The treatment of injuries of the pudenda does not dif- fer greatly from that of like injuries inflicted elsewhere. The parts should be well shaven, washed, and antisepticized, and lacerations and incisions sewn up. If contusions only are to be dealt with, the carbolic pack is applied. This dressing is prepared in the following manner: Flakes of absorbent cotton are first saturated with a 1- or 2-per-cent solution of carbolic acid, then squeezed out almost dry and applied to the antisepticized injured part. Over this are applied flakes of dry cotton, and the whole is covered with rubber tissue or oil silk. The dressing is held in place by a properly adjusted T-bandage. A dressing thus applied will last from six to ten hours. Further treatment is given in the section relating to Pudendal Hematocele. Pudendal hematocele may be the result of a blow, a kick, or a fall; or, in the pregnant state, of varices preceding labour, the INJURIES OF THE EXTERNAL GENITAL ORGANS 137 pressure of the descending head, or the unskilful use of forceps. M. A. Tate, of Cincinnati, who has conducted a painstaking research on this subject (Lancet-Clinic, October 17, 1896), finds that it was first mentioned by Rueff, of Zurich, in 1647; in IT 31 by Kronauer, of Basle; and again, a hundred years later, by Deneaux, from which date (1830) reports of cases have been relatively more frequent. When it occurs, from whatever cause, the clot generally forms in one labium, although in certain cases its progressive accumulation results in sepa- rating the connective tissue of practically the entire pudendum. The tumour thus formed may therefore vary in size from very small to very large, Cazeaux reporting one case in which the extravasation was so extensive that it ploughed up the abdominal wall of the right side to the costal margin. Occasionally the rupture occurs in the wall of the vagina, and only reaches the vulva by an extension of the accumulation, while in other cases the hematoma is confined to the vaginal wall. Sometimes, the distention becomes so great that the skin or mucous- membrane gives way and the blood clot escapes. If the hematocele is the result of rupture of an artery, the hemorrhage resulting from the breaking down of the skin may become active, even after the clot has been in situ for a number of days. In small accumulations the clot may be absorbed; in others, where the pressure of the integument is very great, or where the contusion has been extensive and severe, gan- grene may result. In occasional cases the clot may become solidified, even to the extent of calcification. The symptoms of pudendal hemato- cele consist of swelling of the labia, with pain in the parts, which, even in the midst of the pains of labour, is generally sufficiently severe to attract the attention of the patient. The tumour increases rapidly in size and at first is usually without any change of colour in the skin,. but later becomes pinkish and bluish, and finally, when absorption is well under way, it becomes brown or bronzed in appearance. This tumour is generally at first very tense, but later, as absorption or sup- puration takes place, becomes softer and more fluctuating. Its forma- tion may be attended with some shock, corresponding in degree to the severity of the causative injury or the amount of the extravasated blood. The rarity of this complication of labour, says Sasonoff (Archives de gynecologies Xovember, 1881), will be appreciated when it is remembered that AVinckel noted only one case out of 1,600 confinements; Hecker, two cases out of IT. 2 00; Spiegelberg, three out of 3,000; and that, at the St. Petersburg Maternity, there have occurred only eight cases out of 19,396 labours. Generally, then, it may be said that this complication occurs but once in 2,3 T5 labours. The prognosis of these cases, so far as life is concerned, is favourable, and hematocele is rarely, if ever, fatal from the loss of blood, unless there is secondary rupture, when the subcutaneous extravasation becomes converted into a free hemorrhage. These injuries, however, are in many instances associated with enough superficial destruction of tissue to serve as an infection atrium, with the result that the underlying clot is 138 A TEXT-BOOK OF GYNECOLOGY very liable in the course of the next few days to become converted into a culture medium for the propagation of pyogenic bacteria. As a com- plication of labour, pudendal hematocele is looked upon by both Play- fair and Cazeaux as very serious. Tate (he. cit.) has collected cases of pudendal hematocele occurring as a complication of labour as follows: Cases. Fatal. Playfair (collected by various French authors). . Scanzoni 124 15 62 22 19 50 44 1 Deneaux 22 Barker 3 Blot 5 Winckel 6 Total 292 81 It must be remembered, however, that in explaining the mortality of 81 in a total of 292 cases from an accident intrinsically so controlla- ble as pudendal hematocele, an important percentage of these cases occurred before the inauguration of the present antiseptic regime. It is true that of these cases, but three, those reported by Barker, were recorded as having died from sepsis; but this fact does not exclude the extreme possibility that an important number of the remaining deaths occurred from the same cause. The treatment should vary a little according as the hematocele is the result of external violence or of parturition, and according to the size of the clot. If external violence is the cause, and if the clot is large, and has developed, or is developing, with rapidity, there is strong probabil- ity that it is being fed by a severed artery, under which circumstances the patient should be anaesthetized and the bleeding points found and ligated. If, however, the clot has formed slowly, and is not large, it should be treated with rest and the application of ice bags. If, after a few days, the tumour becomes red about its circumference and the pain, of a pulsating character, shows a tendency to increase, and if there is some elevation of temperature, the clot may be considered to be the seat of incipient suppuration and should be freely incised, its cav- ity thoroughly cleansed, first with the hydrogen peroxide, and next with a l-to-2,000 mercuric bichloride solution. If a hematocele occurs as a complication of labour, rather more chances should be taken to secure its absorption; as a free incision in the presence of the probably contaminated lochia may be far from an innocent procedure. It should be remembered that there exists the reciprocal danger of liberating into the vagina, or, at least, about its orifice, pathogenic bacteria that have developed in the pus of a suppurating hematocele. A pudendal hematocele in a parturient case should, therefore, be opened only in the presence of the most positive indications, after which its treatment should be conducted on lines of the most rigorous and persistent antisepsis. INJURIES OF THE EXTERNAL GENITAL ORGANS 139 Injuries to the external genital organs due to parturition, aside from pudendal hematocele which has just been considered, occur in (a) the perineum (see Pelvic Floor and its Injuries), and (&) the vagina. Of the injuries to the vagina, the chief ones are rupture and fistulae. Injuries of the Vagina. — Rupture may occur at any place, although it is more common in the posterior than in the anterior wall. Such lacerations have occurred through the vault of the vagina into Douglas's cul-de-sac and through the recto-vaginal septum. They have occurred also in the fornices, splitting up the broad ligament and causing dan- gerous hemorrhage, by severing the important blood vessels that lie upon either side of the vaginal tract. When these lacerations occur, they should be immediately cleansed, and the usually contused and roughly lacerated margins of the wound pared off and approximated by interrupted nonabsorbent sutures. Many of these lacerations pass without recognition and heal spontaneously by the formation of irregu- lar cicatrices which narrow the vagina in an irregular way, causing dyspareunia and other distressing symptoms. Rupture of the vagina is to be looked upon as a tear due to the joint influence of an expansive force and to the inelasticity of the canal. It may result in the formation of a fistula, but a rupture is to be distinguished from a fistula in the particular, that while a tear is caused as already indicated, fistula is generally the result of prolonged pressure and subsequent necrotic changes. Fistulae. — A fistula is an unnatural channel that leads from a cuta- neous or a mucous surface to another free surface, or that terminates blindly in the substance of an organ or part. The edges of such open- ings are covered with epithelium. The forms of fistula that are met with in the female genital tract are urinary and faecal. Urinary Fistula'. Fwcal Fistulce. Urethro- vaginal. Eecto-perineal. Vesico-vaginal. Eecto-vaginal. Vesico-uterine. Entero-vaginal. Uretero-vaginal. Ur etero-uterine . Urinary Fistulae (Urethro-vaginal, Vesico-vaginal). — The variety most commonly met with is the vesico-vaginal (Fig. 58). It sometimes happens that a fistula exists between the bladder and the vagina, and, at the same time, that the urethra has been partially or totally de- stroyed. A vesico-vaginal fistula may vary very much in size. At times it is so large that the mucous membrane of the bladder prolapses through it and the bladder is almost turned inside out. The mucous membrane is easily recognised by its bright-red colour. At other times the fistula is only large enough to admit a small probe. The nearer to the time at which the fistula was caused, the larger is the open- ing. The openings that are at first large gradually contract and 140 A TEXT-BOOK OF GYNECOLOGY close. It is then difficult to say how large the opening may have been originally. The cicatrix that is formed is generally thin and firm. When the urine discharges freely from the bladder after the formation of a fistula, contraction of the bladder, with thickening of its walls, Fig. 58. — " The variety most commonly met with is the vesico- vaginal." — Eeed (p. 139). ensues. The urethra may be contracted on account of its inactivity. The vagina around the edges of a fistula is sometimes firmly fixed to the bone. In this way the edges of the fistula are drawn apart. Vesico- uterine fistula are rare. They can only be recognised after the uterine canal has been opened up. Uretero-vaginal fistula are situated in the fornix vaginae. They are small and admit only of the entrance of the point of a sound. They open at the point of a small papilla or else have very sharp edges. The etiology of urinary fistulae in general must take into account the element of pressure, the duration of which, rather than the in- tensity, determines the injury. Sometimes the surgeon produces a fistulous opening for the relief of chronic cystitis, or for the removal of a stone from the bladder, or the bladder may be accidentally wounded during the performance of the operation of hysterectomy. Ulcerations of the bladder may occasionally produce perforation of the septum, and are sometimes a consequence of the presence of a vesical calculus. A pelvic abscess may open in such a way as to give rise to a urinary fistula, which may be induced also by foreign bodies, such as the long-contin- ued use of a pessary in the vagina. Injury received during labour is generally looked upon as the most frequent cause of these fistulous open- ings. Such a condition may be produced by a tear through the septum, or, as is most commonly the case, a necrosis is produced by pressure dur- INJURIES OF THE EXTERNAL GENITAL ORGANS Ul ing tedious delivery. Whatever may cause a difficult labour, may, there- fore cause a fistulous opening between the urinary and the genital tracts. It is not necessary to dwell upon these conditions, as they are well known. Cuts that will give rise to fistulous openings may occasionally be produced by the use of instruments in accomplishing delivery. Such cuts usually occur in the lower part of the vagina. The forceps is no doubt more frequently blamed for the production of fistulous openings than it should be. It is generally used in difficult labours; that is to say, those in which there is long-continued pressure on the soft parts. We may conclude, therefore, that the fistulous open- ings are due to the long-continued pressure in such cases and not to the use of the forceps. They may be due to the nonapplication of the forceps. Fistulous openings have been produced, sometimes, as a consequence of cuts made by splinters of foetal bones during the performance of the operation of craniotomy. Malignant disease frequently causes fistulous openings, not only into the bladder, but also into the rectum. Xothing can be done by surgical means to alle- viate the sufferings of these poor unfortunates, and such cases need not be considered here. A calculus is frequently formed in the vagina as a consequence of the presence of a vesico-vaginal fistula. The symptoms of urinary fistula? in general demand careful consid- eration. When a patient complains of an involuntary flow of urine, an examination should always be instituted, to ascertain the reason why such an abnormal condition exists. After labour, the patient may be discharging the urine naturally, or she may be unable to pass it, and it may be retained in the bladder, and yet, within a few days, there may be an involuntary flow of urine due to the presence of a vesico- vaginal or one of the other forms of urinary fistulas. The pressure at the time of labour produces the necrosis, and the formation of the opening is delayed for several days until the slough separates. If the opening is caused by a tear, urine will flow at once per vaginam. The symptoms vary according to the situation of the fistulous open- ing. When situated high up, the bladder fills up to the level of the fistula, if the patient is in the erect posture, and there is no leak until the urine reaches so high as to overflow. When there is a urethro- vaginal fistula, the bladder may be able to hold the urine, and yet the urine will not come out through the normal opening. The patient's clothing in these cases is not kept wet. The odour produced from the urine becomes unpleasant to the patient and friends; the skin of the adjacent parts becomes excoriated, red, and irritated. Sterility is usually produced, although there have been cases of conception re- corded. The patient feels disagreeable to herself and to others. The general health frequently becomes considerably impaired, and the pa- tient is always ready to submit to operation if any promise of relief can be given. The diagnosis must be made between these fistulas and certain con- ditions of the bladder that allow the escape of urine. One of these 142 A TEXT-BOOK OF GYNECOLOGY conditions is a paralysis of the sphincter vesicae muscle, due, fre- quently, to difficult labour, and rendering the patient unable to hold her water. It may remain in the bladder while the patient lies in the recumbent posture at night, but when she rises to the erect pos- ture it comes away and wets her clothing. The irritated appearance of the genitals, and the characteristic odour, indicate that there is a fistula. To be satisfied of this, it is a good plan to inject sterilized milk, or a coloured nonirritating fluid, into the bladder. Any fluid escaping from the bladder can then be more readily detected on ac- count of its colour. This method is one of the best in vogue. Some- times the opening can readily be detected with the finger. When the milk is being used, it is better to have the patient turned on her left side with the Sims speculum in position. All discharge must be wiped away from the vagina in order that the field to be inspected may be in a cleanly condition. As the bladder is distended, we must carefully watch the anterior vaginal wall for any oozing of the stained fluid. If no fluid comes away, we must infer that the opening is below the sphincter, or that no opening exists. If no special leak occurs during the act of micturition, we must then conclude that the leakage of urine is not due to the presence of a urinary fistula, but is due to some other cause. In considering the prognosis, it is well to bear in mind that small fistulaa sometimes heal without any surgical intervention. Many of the small fistulas, however, and all of the large ones, require operative treatment. The prognosis is not so favourable for cases in which the connective tissue of the urethro-vaginal and vesico-vaginal fold is bound down to the bony parts in the neighbourhood. If this condition is present, it is difficult to approximate the edges without great ten- sion being placed upon the stitches. Treatment. — Eecently formed fistulous openings have a tendency to close. This tendency is one of the difficulties met with in attempting to keep up free drainage from the bladder by means of an artificially produced vesico-vaginal fistula for the treatment of chronic cystitis. Such fistulous openings will often close if they are kept clean and anointed with a little vaseline or zinc ointment, and if the bladder is kept washed with boric acid or sodium biborate (3j to Oj) solution, to remove the incrustations that are liable to form at the edges of the fistula. Operations on such cases are difficult. We must be able to reach the fistulous openings, and we must be able, when we have reached them, to bring the edges carefully together with sutures. There are two positions in which the field of operation may be brought into view. One is the position on the left side with the Sims speculum, and the other position is that in which the patient is placed on the abdomen with the knees hanging over the end of a structure raised up in the centre of an operating table. To use the latter position, Eoss proceeds as follows: The head of the patient should be lower than the buttocks, and therefore different-sized boxes should be used, carefully padded and INJURIES OF THE EXTERNAL GENITAL ORGANS 143 covered with pillows, placed upon the operating table, unless one is fortunate enough to obtain the use of a Bozeman's table. The patient's head is made comfortable, her arms are allowed to hang down on either side, parts under the chest and abdomen are carefully padded, a pillow is inserted under the crests of the ilium where they impinge upon the newly constructed platform, and great care is taken to see that the knees do not touch the table below. If the knees are allowed to press for any considerable time on the table while the patient is under an anaesthetic, sloughs may be produced that will be very tedious to heal. A rubber sheet is placed in such a way that the water that is being used in a constant stream from the " douche can " or " bag " is con- ducted to a foot bath at the end of the table. An assistant then stands on one side of the patient and holds the Sims speculum, or some modi- fication of the same, in position on the posterior vaginal wall. The operator may use the German water speculum for this purpose. It is not easy for the anaesthetist to give the anaesthetic while the patient is in this position unless the pillows are properly arranged. Sims pared the edges of the fistula in such a way as to avoid the mucous membrane of the bladder. He brought together the edges of the fistula with silver wire, without allowing the stitches to pene- trate the mucous membrane. Other operators have not done this, but have cut directly through, paring all tissues evenly, and bringing the edges evenly together with sutures passing through the mucous mem- brane, as well as through the vesico-vaginal tissues. Others use the flap- splitting method in order that they may be able to make use of the larger wound surface thus produced in the healing process. Any of the three methods will answer if certain important details are carried out. The approximation must be exact and thorough; the stitches must be inserted far enough away from the edges to enable them to give the proper amount of support; precautions must be taken to prevent any contamination of the wound by urine, or other septic material, and heal- ing by first intention must, if possible, be procured. Each case must be individually considered. If the rules that are well-known to govern the healing process in this locality are adhered to, success will follow; if these rules are not adhered to, success will not follow the operation, no matter which operator's method is employed. In every case of vesico-vaginal fistula it is advisable to examine for vesical calculus before closing the fistula. It is not wise to operate at too early a period after the formation of the fistula. The tissues must be allowed to contract to their utmost extent and to regain their natural condition after the softening that is produced as a result of pregnancy has disappeared. Unless this is done, they are too friable and too easily torn to stand the strain of stitches. It is not wise to attempt to operate for at least eight weeks after confinement, nor is it wise to do a second operation until at least a month or six weeks have elapsed since the first was performed. A preparatory treatment has been advocated by some for the purpose 144 A TEXT-BOOK OF GYNECOLOGY of loosening cicatricial bands. This may be necessary. Incisions can be made and tissues loosened, and these incisions allowed to nnite before any fresh ones are made. We may thus gain considerable room. Frequent vaginal injections are not necessary in all cases, in order to bring the edges into good condition. Any irritation that is present in the vagina may be relieved by the use of pessaries made of fifteen grains of oxide of zinc to a hundred and twenty grains of cacao butter, introduced into the vagina once or twice a day. It is wise to heal up ulcerations about the buttock. Sims's Operation. — The bowels having been thoroughly evacuated by a cathartic and the rectum having been washed out by an enema immediately before the operation, the patient, having been shaved and sterilized, is placed upon a table on her left side in the Sims position (Fig. 2). The Sims duck-bill speculum is introduced into the vagina and intrusted to an assistant, who is instructed to hold it with consid- erable attention, exerting the force in an upward and forward direction. The fistula will then be brought to view. It should at this point be inspected carefully to determine its natural lines and the consequent direction in which the lips will be approximated. Having determined this point, the margin of the fistula is seized with a volsella or long hemostatic forceps and the continuous strip of cicatricial tissue is cut away from the margin of the fistula along its entire circumference, care being taken to avoid the vesical mucosa. The small amount of blood that oozes from this surface should now be carefully wiped away and the surface inspected. If at any point the surface is not deemed broad enough for the purpose of approximation and union, a little more tissue may be removed. Simon, who was very successful in deal- ing with this accident, included the vesical mucous membrane in the denudation; but Emmet avoided doing so on the ground that it caused unnecessary and often embarrassing hemorrhage. He alludes to a case in the practice of Peaslee in which the patient died from hemorrhage of this character. In some cases in which the vaginal wall was made too thin, it was the practice of Sims, Emmet, Bozeman, and the early operators in this field, to carry the denudation to the vaginal surface; or, if this was impracticable, to split the margins of the flap. It was in this incidental practice that these early operators gave recognition to an important principle of procedure, which many years later was published by Lawson Tait and adopted by his followers. The margins of the fistula having been thus incised, a short, strong, slightly curved needle, loaded with a double loop of silk thread and carrying silver wire, is passed through one lip of the fistula, and brought over and out through the other lip at a directly opposite point. One after another of these sutures is passed at intervals of from an eighth to three sixteenths of an inch apart. When the silver wires are all in situ, the margins are again washed carefully and the sutures, one after another, are closed by simply bringing the opposite ends together and twisting them. Great care should be exercised in this manipulation, as by overdoing it the INJURIES OF THE EXTERNAL GENITAL ORGANS 145 •entire operation may be easily defeated. It is important to cross the wires first and ascertain exactly the point at which they will cross. Each end should be bent by a sharp angle at that point, crossing and twisting thence outward. If they are crossed without any regard to this precaution, the twisting will extend toward the field of operation and toward the distal layer of the wall. In this way a destructive tension will be brought to bear upon the tissues, the wire will cut out before union is completed, and the objects of the operation will be defeated. Silkworm gut may be employed as a suture material, although it is probable that if the technique of Sims is to be followed, it would be better to follow it in its entirety. The operation thus con- cluded, the vagina is again thoroughly irrigated and a little gauze is inserted. The sigmoid catheter with several feet of small drainage tubing attached is inserted into the urethra and the patient is put to bed. Ross's Operation. — The instruments required for the operation are as follows: Sims's speculum, or some modification of | Sims's, such as Simon's, Fritsch's, the self-retaining, or the German water speculum. Retractors or spatulae. Three or four single-toothed, double- bladed tenacula. Douche can and tube. Pressure forceps. Long-handled dissecting forceps. Several other long-handled tissue forceps Small bistouries, or a set of Sims's vesico- vaginal fistula blades. Angular-curved and flat-curved scissors. Small sponges or wipes. Sponge holder. Curved needles, short, but curved almost into an oval instead of into a circle, with cutting sides. Needle holder. Silver wire, best quality. Catgut. Silkworm gut. Wire twister. Blunt hook. Large-sized male sound. In a good light, with the patient in a position on the face and properly placed, the operator standing up to his work, the water specu- lum holding the posterior vaginal wall and allowing water to constantly trickle over the fistulous opening, this operation is rendered an easy one. It may be performed without an anaesthetic and with perfect success. It is the getting at the part that is the most difficult portion of the operation. After the parts have been reached by sight and by touch it is then an easy matter to pass the sutures. Any sponges that may be used must be small. If a current of water is allowed to trickle continuously, it is scarcely necessary to use sponges. When we are ready to pare the wound, a tenaculum should grasp each side of the fistulous opening, taking in all the structures. The tenacu- lum should be one that will lock, so that it can hang in position with- out requiring the attention of a hand. A sound is passed into the blad- der to push out the wall during the paring of the edges of the fistula. Then, either a knife is passed directly through the edges of the wound, in order that a portion may be completely pared off, or a pair of 11 146 A TEXT-BOOK OF GYNECOLOGY sharp-pointed scissors is inserted and is run round the edges as the first step in the flap-splitting process. Some operators cut down on the vaginal side away from the edge of the fistula, as far as halfway through the thickness of the vesico-vaginal septum, and then turn in toward the bladder the two flaps thus removed, so that the bladder con- tains a small portion of vaginal mucous membrane lined with squamous epithelium. The outside raw surface is then drawn together by sutures. Hemorrhage should be checked by means of the hot douche. Any large bleeding points found should be compressed with pressure forceps. This should be done before the edges are brought together, though it. is not wise to lose much time if general oozing continues, as the pres- sure of the sutures will usually stop this. The greatest amount of oozing usually takes place from the congested mucous membrane lining the bladder. The edges must now be carefully adapted with sutures. When the sutures are passed, great care must be taken not to include much, if any, of the mucous membrane of the bladder. A blunt hook is used to make counter pressure during the introduction of the sutures. It is not very frequently needed. The sutures should be passed close enough together to afford ample support. If silver sutures are used, iodoform gauze should be inserted into the vagina, to prevent the suture ends from irritating the posterior vaginal wall. Care must be taken, in removing this gauze, not to use any force that is liable to disturb the stitches, should a portion of it become entangled in the meshes of the wire. With reference to the original operation of Sims, there are several points that are open to criticism, notwithstanding the fact that he and his immediate followers achieved great success in their operations upon this class of cases. The experience of the profession, however, has demonstrated that a modification of the technique will result in greater facility of operation, and in at least equally satisfactory results. Thus the Sims operation requires the presence of an assistant to hold the speculum. When the perineum is retracted and the atmospheric pres- sure is exercised upon the anterior vaginal wall, the fistula drops inward and forward — the farthest possible distance away from the operator. It is necessary for him, therefore, to employ long-shanked instruments to conduct his operation. The method of denudation is one which necessarily sacrifices a greater or lesser amount of tissue from a locality where too much tissue has already been destroyed. In the event of successive operations by this method, the hope of a successful issue is ultimately destroyed by the sacrifice of the septum. Eeed remembers to have seen a case in the Eotunda Hospital, in Dublin, in which the entire base of the bladder had been whittled away in successive efforts to close an originally large fistula. As an example of what some operators recognise as an easier and equally effective technique the following is given: Reed's Operation. — The patient is prepared precisely as indicated in the preceding paragraphs. She is placed on the table on her back,. INJURIES OF THE EXTERNAL GENITAL ORGANS 147 with, her knees drawn well up, and retained in that position. Mechan- ical devices are better, however, as injury to the hip joint has been done by the unguarded action of assistants in exercising too much pressure upon the legs. A Jones's self-retaining speculum is now inserted, by which means the fistula is brought directly into view. The line of closure having been determined, an incision is made outward from either angle, extending through the mucous membrane of the vagina. The margin of the fistula is now split, either by means of the knife or a pair of sharp-pointed scis- sors curved on the flat, and one blade inserted through the incision al- ready made beneath the mucous membrane, and carried around to the in- cision in the opposite an- gle (Fig. 59). The other lip of the fistula is treat- ed in the same way. The mucous membrane of the vagina and of the bladder are by this means sepa- rated into two flaps; those in the bladder can be folded inward and ap- proximated, while those within the vagina can be folded outward and simi- larly approximated. A curved needle mounted on a handle and specially devised for the purpose, is now inserted just be- neath the vaginal mu- cous membrane, made to dip deeply into the cellular layer, and brought out just beneath the vesical mucosa. It is then crossed over and inserted beneath the vesical mucosa; dipped deeply into the cellular layer, and brought out just beneath the vaginal mucosa. It is then threaded with silkworm gut and withdrawn. Other sutures passed in a similar way at intervals of less than a quarter of an inch (Fig. 60) are then drawn together and tied. In this way, the approximation surfaces are increased in area (Fig. 61) while by the old through-and- Fig. 59.—" The margin of the fistula is now split." — Reed. 148 A TEXT-BOOK OF GYNECOLOGY through sutures they are diminished in area (Fig. 62). The sutures are removed on the eighth or tenth Fig. 60. — " Other sutures are passed in a similar way at intervals of less than a quarter of an inch." — Keed (page 147). day. The buried suture may be employed somewhat after the manner introduced by Martin, of Berlin. After the denudation has been made, just as in the operation by means of the interrupted su- ture, formalinized catgut is in- serted so as to include all of the cellular structure between the two mucous layers. A con- tinuous suture is employed for this purpose, involving the cel- lular tissue, but not passing through either mucous layer (Fig. 63), as generally tied, and the superficial intermucous suture is then adjusted. The advantage of this form of clos- ure is that the approximation is very effective and no trouble arises from the removal of sutures. After-treatment. — Some op- erators do not use the semi- prone position and the self- but this treatment is the best retaining catheter after operation; that can be pursued and is adopted by many. If it is intended to place a catheter in the bladder the best form to use is Skene's modi- fication of Bozeman's self - retaining hard- rubber catheter. There is another form of winged soft - rubber catheter that can be used. The urine is then collected in a vessel placed in bed. The catheter should be changed every day, as the salts of the urine are deposited on the perforations, and in this way the instrument is very soon blocked up. The instrument also requires cleansing, but it Fig. 61.—" In this way the approximation surfaces are in- creased in area." — Keed (page 147). INJURIES OF THE EXTERNAL GENITAL ORGANS 149 can be replaced in the bladder a few minutes after its removal. It is better to have two catheters, so that when one is removed for the pur- pose of cleansing, the other can be placed in position. The nnrses must be vigilant, and immediately report any plugging of the catheter to the proper authority. Some prefer to use the catheter for two or three days only, and then to have the urine drawn every three hours. Tsokana, of Athens, Greece, re- ports, in a communication to the editor, that he closes the fistula with interrupted silkworm gut su- tures, tied by a single knot with an extra whirl, and permits his patients to get up and go about shortly after the operation is com- pleted. His results are satisfactory, as he claims that the upright pos- ture favours the natural drainage of the bladder and the retention of the parts in a state of approximation. The after-clangers of the operation are irritation and inflammation of, and hemorrhage into, the bladder. When blood clots collect they Fig. 62. — " By the old through-and-through sutures the approximation surfaces are di- minished in area." — Keed. fflfif**'' r - ^*^^fcfc " ■ 1 O^ ^^i"^ : Bl\'.>il| A . v ----- V ' t V'' "-" ZsL/ JSJafSZ N<^ //^_i WM ' / / /^' mm Fig. A continuous suture is employed for this purpose, involving the cellular tissue, but not passing through either mucous layer.'' — Keed. are troublesome. If the hemorrhage is severe, the fistulous opening must be reopened. This should not be necessary if proper attention to details is given at the time of operation. It is always possible 150 A TEXT-BOOK OF GYNECOLOGY that a hemorrhage may occur, subsequently to operation, in a patient prone to bleed, but all excessive hemorrhage should be checked at the time of operation before the stitches have been finally tied. If secondary hemorrhage occurs from the third to the fifth day, a vaginal tampon may relieve it. The ureter has been caught in a stitch on more than one occasion. If the patient surfers from intense pain in the neighbourhood of the kidney after the performance of this operation, one should suspect that some such unfortunate occurrence has taken place. Symptoms of uremic poisoning may set in as a consequence of this accident. The sutures are usually removed from the seventh to the tenth day. Great care must be taken in removing these sutures. If silver wire is used, the portion of the loop away from the knot should be bent outward, so that the loop then has about the curve of one of the needles used in placing the sutures. Counter pressure should be placed over the parts while the stitches are being withdrawn. Sutures must be counted and must be all removed, because a loop of wire left behind may afterward become the nucleus of a vesical calculus. The catheters placed in the bladder should be kept in situ, except when they are re- moved for cleansing purposes, until the operator feels satisfied that the patient can pass water voluntarily without breaking down the wound. This will depend, to a great extent, upon the appearance of the wound. In some cases, it is possible to let the patient void urine earlier than in others. The smaller the fistulous opening, the earlier the patient may be allowed to void urine; the larger the opening, the longer this act should be delayed. If there is no great amount of vis- ceral irritation, Eoss leaves the self-retaining catheter in situ until after the stitches have been removed, and keeps the patient turned on her face for at least a week after the performance of the operation. When the operation has not been an entire success, a second, a third, or even a fourth must be performed. At each operation a portion of the fistulous opening closes and the fistula becomes smaller. One must not be discouraged. Each operation should bring us nearer the long-looked-for goal. It sometimes happens after these operations that, when the fistulous opening is closed, the patient continues to lose urine involuntarily and does not believe in her recovery. In such cases there has been a loss of tone in the sphincter vesicae muscle, but in others the parts gradually regain their tone. Atresia of the Upper Part of the Urethra is sometimes found in cases in which a vesico-vaginal fistula exists. It will then be necessary to make a new opening, and to keep it open by the use of sounds, unless the operator feels disposed to cut out a portion of the urethra and unite the neck of the bladder to the portion of the urethra below the excision. If atresia exists between a urethral fistula below and a vesico-vaginal fistula above, the readiest way to deal with it is to thoroughly loosen up the tissues and bring the upper edge of the vesical fistula down to the outer edge of the urethral fistula. To unite such a fistula, however, a INJURIES OF THE EXTERNAL GENITAL ORGANS 151 •combination of the transverse and longitudinal operation may be done. A transverse incision may be made by making an artificial vesicovagi- nal fistula just above the neck of the bladder. The upper edge of this can then be stitched to the lower edge of the urethral fistula, and, after healing has taken place, the edges of the original vesico-vaginal fistula can be closed by stitches placed so as to bring the edges together from .side to side, leaving a longitudinal scar. Uretero-vaginal Fistula. — A fistula may readily be formed between the ureter and the uterus, or between the ureter and the vagina. Such fistula? are fortunately rarely met with. They are very difficult to deal with and at times somewhat difficult to discover. These fistula? can be most readily discovered by means of a probe. If the probe passes on farther than the confines of the bladder would indicate, it must be disappearing into the ureter toward the kidney on that side. AVe can make out the pervi- ousness of the lower por- tion of the ureter by in- troducing a probe in the other direction toward the bladder. T rcatment . — Ne- phrectomy may be con- sidered but should only be carried out as a last re- source. If the fistula can be closed by a direct method of operation, this should be carried out. If it can not be closed, we must then contemplate implantation of the ureter in the bladder. To effect closure of the fistula, an incision may be made down over the ureter and a catheter passed into the bladder, and out through an artificial open- ing made in the bladder wall just below the ure- teral fistula. The cathe- ter can then be carried on up into the ureter and the tissues around closed by silver-wire sutures. Another catheter may be placed in the bladder alongside of this one in order that it may be kept empty. The flap-splitting method may be here applied, as in vesico-vaginal fistula operations. (For the operation of implantation of the ureter in the bladder see Uretero-cystostomy.) Fig. 64.— "Recto-vaginal fistula.*"— Mayo Eobsox (p. 152). 152 A TEXT-BOOK OF GYNECOLOGY Recto-vaginal Fistula. — Recto-vaginal fistula is by far the most fre- quent of the fistula between the intestinal and vaginal tracts, and may occur at any part of the posterior vaginal wall (Fig. 64). It is a pecul- iarly distressing ailment, not only because of fasces escaping by the vagina, but from the fact that intestinal gases pass into the vagina and escape with an audible bubbling or hissing noise; and the odour being perceptible to the sufferer, she broods over her condition, secludes her- self from society, and usually passes a miserable existence, which may end in melancholia. Causes. — Cancer, syphilis (see Malignant Neoplasms of the Va- gina; also Syphilis), and injury are the usual causes. Pyosalpinx and other inflammatory diseases of the appendages not infrequently cause fistulas, but these are usually rectal or vaginal, seldom recto- vaginal. Fistula from Traumatism.— -Recto-vaginal fistula may occur from the ulceration induced by the long-continued presence of a pessary, from the presence of some foreign body in the vagina or rectum, or from a stab wound accidental or intentional. In these cases, the fistula usually heals on removal of the cause,, together with careful attention to the wound by mild antisep- tic douches and gauze packing. Sometimes, stretching the sphincter so as to temporarily paralyze it gives rest to the parts and assists the healing process. Injuries occurring in child- birth leading to recto-vaginal fistula are not so infrequent as modern obstetric treatment might lead one to suppose. They not infrequently follow complete rupture of the peri- neum, where the rent has passed well up the recto-vag- inal septum, and where the primary operation has led to healing of the perineum and perhaps of the sphincter, but where there has been a failure in union of the rectal wound. These fistulas may occur at any part on the posterior wall of the rec- tum, from just within the sphincter up to the highest point the finger Fig. 65. — " Lay the whole fistula open by cutting through the tissues intervening between it and the surface."— Mayo Eobson (page 154). INJURIES OF THE EXTERNAL GENITAL ORGANS 153 can reach, and may vary in size from an opening admitting a Xo. 1 catheter to a slit admitting one, two, or three fingers. They may also follow on sloughing caused by pressure from delayed delivery, but from this cause recto-vaginal is much less common than vesico-vaginal fistula. Small fistula? will occasionally heal spontaneously; others require surgical intervention. If the fistula is situated high up in the vaginal canal and fails to close under cleanliness and general attention to the bowels, a plastic operation will be advisable. The bowels should be well cleared by aperients given for three or four days before operation, and during this time the vagina should be douched night and morning with some nonpoisonous anti- septic solution, such as salufer or izal. Mayo Robson's Opera- tion. — With the patient in the lithotrity position, or on the left side, and the perineum drawn back by a retractor, so as to ex- pose the fistula, the edges of the opening are pared by a narrow sharp knife or by means of small curved scissors. The rec- to-vaginal septum is then split by a blunt dissector for a quarter or half an inch round the fistula, so as to make a broad raw surface without material loss of tissue, and so as to be able to bring together the rectal part and the vaginal part by separate sutures. Catgut sutures are first applied to the rectal edge of the fistula by means of a rectangular cleft-palate needle, the sutures taking up the submucous tissue close to, but not including, the mucous membrane, and being placed sufficiently close to occlude the rectal opening. These sutures, being applied from the vaginal surface, are tied, cut off short, and buried by the next row of sutures, which may be of chromicized catgut or of silk or silkworm gut. If catgut is employed, the stitches Fig. 66. — " Sutures are inserted in the margins of the vaginal mucous membrane and in the margins of the rectal mucous membrane." — Mayo Robsox (page 154». 154 A TEXT-BOOK OF GYNECOLOGY may be buried; if silk or silkworm gut is used, the sutures must be tied on the vaginal surface and removed in about ten days. If the vagina is contracted, it may be found easier to repair the rectal edges of the fistula? from the bowel surface, using a Sims speculum through the well-stretched anus. After operation the bowels need not be disturbed for a week, and then an olive-oil injection will, as a rule, answer all requirements. A boric acid or izal vaginal douche should be used night and morn- ing. The employment of a catheter is, as a rule, neither necessary nor advisable. The patient may be allowed to use the sofa at the end of a fortnight. If the fistula is fairly low, say within an inch of the anus, Mayo Eobson finds it best to lay the whole fistula open by cutting through the, tissues (including the perineum or its remains) intervening between it and the surface (Fig. 65). This he does by one sweep of a probe- pointed bistoury or by means of scissors, the va- gina being thus made continuous with the rec- tum by a slit instead of a fistula. The assistants or nurses, standing one on each side, place a hand on the skin over each tuber ischii and retract gently, converting the H- shaped gap into a trans- verse wound, as shown in the illustration; pointed scissors are then employed to open up the recto- vaginal septum so as to convert the narrow edge into a raw surface; slits are then made on each side straight forward for about an inch, as in Tait's operation for peri- neorrhaphy. The angles being drawn forward by catch forceps, chromi- cized catgut sutures are inserted in the margins of the vaginal mucous mem- brane, so as to approximate them and thus form the vaginal floor by closing the V-shaped slit; and in the same way chromicized catgut sutures are inserted in the margins of the rectal mucous membrane, so Fig. 67. — " We now have a large rectangular raw sur- face." — Mayo Eobson (page 155). INJURIES OF THE EXTERNAL GENITAL ORGANS 155 as to form the anterior rectal wall by closing the V-shaped slit in the rectum (Fig. 66); these sutures are cut off short. "We now have a large rectangular raw surface, which can be rapidly closed by four or six silkworm-gut sutures entering on one side at the skin margin, aud emerging on the other at the same spot as in the well-known and extremely valuable perineorrhaphy operation referred to (Fig. 67). Before drawing tight the last series of sutures, the wound is bathed with a l-in-2,000 solution of perchloride of mercury. ~No vessels are ligatured. When the final sutures are tied the parts look perfectly nor- mal and no raw surface can be seen. The bowels are moved daily after the second day by a plain water enema, and the vagina is washed out daily with boric lotion. No catheter is employed if it can be avoided, and, as a rule, its use is not necessary. The parts are dressed with iodoform gauze, over which wool and a T-bandage are applied. The sutures are removed about the tenth day and the patient is allowed to be up about the fourteenth. Mayo Eobson says that he can with the utmost confidence recom- mend the operation as a most satisfactory and expeditious method of treating the class of cases under consideration. CHAPTER XV INJURIES OF THE EXTERNAL GENITAL ORGANS (Continued) Rape— Objective evidences: A. Local conditions; laceration of the hymen, vulva, hemorrhage, evidence of recent injury, venereal infection, laceration of the vagina, etc. , pregnancy ; B. Injuries on other parts; C. Condition of clothing — Schedule for examination— Indecent assault— Prolapse— Injuries to the peri- neum and vagina — Uterus. Rape. — Medico-legal questions in relation to the female generative organs chiefly have reference to — 1. Pregnancy. 2. Parturition. 3. Sterility. 4. Venereal disease. 5. Rape. 6. Indecent assault. 7. Damage claims after injury. 8. Malpractice suits. Rape is defined as the carnal knowledge of a female without or against her consent. In most courts vulvar, not vaginal, penetration has to be proved, a circumstance very disadvantageous to the defence. In cases of rape, the gynecological specialist is rarely the first to examine the victim, who has usually passed through the hands of a police surgeon or the family physician, or both. If a gynecologist is con- sulted at all, it is usually when the case comes into court, or at a time when the characteristic appearances may no longer be present. It would be greatly in the interests of justice to have a regulation enforcing the co-operation of an experienced gynecologist at the very outset in every case. The significance even of the typical lesions is by no means easy to estimate, and the examinations, especially in the case of young chil- dren, often present unusual difficulty. The objective evidences of rape are: (a) Local injuries to the geni- tals; (b) injuries elsewhere, due to a struggle, or possibly to sadism; (c) signs of seminal or blood stains on the clothing, tearing, etc. As the subjective evidence mainly rests on the uncorroborated testimony of the victim, the medical examination should include matters which indirectly corroborate or contradict her statements. There ' is no crime which becomes oftener the subject of groundless charges made 156 INJURIES OF THE EXTERNAL GENITAL ORGANS 157 for purposes of blackmail or revenge. We will consider here those points which call specially for observation from the gynecological point of view. A. Local Conditions. — These are only characteristic in the case of virgins or where unusual force has been exerted. The most important are: (1) Laceration of the hymen, (2) contusions or abrasions of the vulva, (3) hemorrhage, (4) evidence of recent injury, (5) venereal infection (gonorrhoea or syphilis), (6) in rare cases, lacerations of the vagina, perineum, rectum, or bladder may result where there is great disproportion between the male and female organs, (7) pregnancy may also occur. 1. Laceration of the Hymen. — The principal source of error lies in mistaking for lacerations congenital notches or defects. The appear- ance and variety of these are well depicted in photographs in E. V. Hofmann's Hand Atlas of Legal Medicine. The variety of forms which these conditions may assume is remark- able, and the general profession is very little informed about them. The most important form is the fringed or serrated hymen. On the one hand, one of these conditions may give the impression of lacera- tion, and on the other it is often evident that intromission could take place without rupturing it. There is also the danger of con- fusing ulcers with lacerations, or of mistaking old lacerations for recent ones. The examination should be made most carefully with the aid of an assistant and in a good light, the finger being passed round behind the hymen so as to bring it into relief. Whitish scars denote lesions previously existing. Granulating wounds and erosi'ons show that the injuries have existed several days, and prob- ably a week, if they are in process of healing. The recent defloration of the virgin hymen is usually accompanied with a considerable amount of swelling, redness, and pain. Intromission and ejaculation may, how- ever, occur without rupture of the hymen, and, owing to the increased frequency of local gynecological treatment in young unmarried women, the hymen is liable to have been previously interfered with. A typical ruptured hymen is the exception rather than the rule in most cases of rape. Full objective proof is only forthcoming in a small proportion of all cases. The relative proportion of the genital organs in the victim and the accused must be considered in order to give a definite answer in individual cases. During the healing stage there is little that is characteristic in the lesions. 2. Vulva. — The contusions about the vulva should be associated with ecchymosis and persist for a week or ten days. 3. Hemorrhage. — The preservation of blood-stained undergarments, etc., is more important. Their destruction, or washing by the victim's family, may destroy an important proof. 4. If anatomical evidence of recent injury of the genitals is discov- 158 A TEXT-BOOK OP GYNECOLOGY ered, it will usually be accepted as positive proof of penetration. Ab- sence of anatomical evidence does not, however, exclude penetration. 5. Venereal Infection. — The presence of acute gonorrheal discharge in the victim makes it most important to see if that condition exists in the accused. The diagnosis should always be confirmed by bacteriologic methods. It is much less easy to recognise gonococci in the female than in the male secretions, owing to the constant presence of other diplococci. Examinations of stains upon linen, etc., for gonococci rarely give trustworthy results, owing to the numerous sources of possible error. After a first coitus a slight discharge may persist for a few days, and want of cleanliness may in itself cause a discharge. Eepeated visits will be necessary in order to observe the course of the case. Syphilis. — Hard and soft chancres are occasionally met with in connection with rape. The most important point here is a careful in- vestigation of the date of onset as compared with the date of the assault, and the exclusion of lesions elsewhere. Eepeated visits are usually necessary. It must also be shown that the accused was in a condition to communicate the disease. 6. Severe injuries, such as rupture or laceration of the vagina, rectum, bladder, or perineum, are rare, and occasionally they are fatal. They are most liable to occur when a number of men violate the same victim in succession. In the Oriental child-marriage such injuries are fairly frequent. 7. Pregnancy. — The correspondence of conception with the time of the alleged coitus is naturally the chief point to establish. B. Injuries on other parts should be carefully searched for, espe- cially finger prints, scratches and bruises of the abdomen, pubes, and thighs, as well as of the chest, limbs, and face, with or without tearing of the clothing. The absence of these tends to throw doubt upon the allegations of rape, unless there was more than one assailant, or the use of narcotics, intoxicants, or anaesthetics is alleged. The vexed ques- tion of the possibility of rape during natural sleep has little practical bearing upon the ordinary class of cases. Surprise and terror may, of course, lessen the power of resistance. Conditions suggestive of sadism should lead to a very careful examination into the mental state of the accused. C. Condition of the Clothing, etc. — Seminal stains. — Besides ex- amining the clothing for signs of tearing, any stains looking like semen or blood should be carefully preserved and submitted to expert examina- tion. The well-known straight outlined stiffening of the stains is strik- ing. The skin of the abdomen and thigh should be searched for traces of the seminal crust. In the case of seminal stains the Florence reac- tion is invaluable as a prompt preliminary test. A drop of the Florence solution (composed of iodine, 2.5 parts; potassium iodide, 1.5 parts; and water, 30 parts) is brought into contact with moistened filaments from fabrics containing semen observed beneath the microscope. An INJURIES OF THE EXTERNAL GENITAL ORGANS 159 abundant formation of fine brown needle-shaped crystals instantly oc- curs. The sensitiveness is decidedly lessened in the presence of urine, and is greater in cold than warm solutions. If positive results are thus obtained, spermatozoa should be searched for cautiously by moistening the fabric by imbibition, scraping the surface, and dissociating the fibres. The best results are obtained by making a culture film or cover- glass preparation and staining with the eosin and methyl green, which gives a double staining of the head of the spermatozoa. The specimen may then be mounted in balsam and examined under a one-twelfth-inch immersion lens. Unstained specimens examined with the ordinary dry lenses are much less characteristic. Spermatozoa are less numerous in old stains, but age does not impair the Florence reaction. To preserve suspicious stains, cut out the sus- pected portion of the material and place it between flat pieces of card- board during transmission to the laboratory. The fallacies of the Florence reaction as a final test are that lecithin and certain decompo- sition products give similar precipitates, but this in no wise impairs its utility as a preliminary test. Failure to give the reaction does not prove the stain to be nonseminal, but makes it unlikely that positive micro- scopic results will be obtained. The possibility of azoospermia must be borne in mind. Stains from vaginal or nasal mucus or pus can sometimes be recog- nised microscopically by the cellular element. Local lesions produced during rape are, as a rule, trivial, unless gon- orrhoea, soft chancre, or syphilitic infections occur. Occasionally vul- var abscesses or thrombosis have occurred. Among the rare conse- quences, gangrene is mentioned, but the few recorded cases of this seem to have been really noma of the vulva, occurring independently and wrongly attributed to violence. An examination of the assailant should be made as early as possible for signs of scratching or bruises, indicating attempts at defence by the victim, as well as for signs of recent coitus, seminal stains, or blood upon the shirt or drawers. The general state of muscular power should be noted and compared with that of the victim; the hands and nails examined with special thoroughness, if scratches exist upon the victim. An inquiry into the mental condition of the accused as to sanity, responsibility, and unnatural sexual instincts, should be made in every case. The following schedule by Lacassagne will serve as a guide, when in- vestigating a case, to guard against the possible danger of overlook- ing important points. Lacassagne's schedule for medico-legal examination of a case of rape or indecent assault. Name, age, address. Date, day, and hour of visit. Preliminary inquiry; statements about occurrence (let children talk). Examination to be made early; perineal coitus and digital at- tempts kept in mind. Remember frequency of simulation and false accusations. 160 A TEXT-BOOK OF GYNECOLOGY A. Examination of Victim. — C4eneral condition — scrofulous, lym- phatic. Local condition (examine on table or couch in a good light). Condition of thighs and abdomen — scratches, bruises, and nail marks. Labia majora and minora, clitoris for redness, excoriation, ecchymosis, ulcers. Vestibule and vagina (open and close thighs to squeeze out liquids). Hymen — position, form, margin, orifice, folds; defloration by penis, finger, or foreign body (assistant to draw forward labium on one side while expert does the same). Discharge — physical character, amount; microscopic, examine for semen and gonococci. Signs of mas- turbation — elongated lesser labia, large turgescent clitoris, dilated vagina, pigmentation, precocious puberty about vulva, hair, and breasts. Examination of anus and perineum. Suspicious stains on body or clothing, especially chemise or drawers. Place under seal, noting date. Examine by Florence reaction and for spermatozoa; also for evidence of other origin of stain. Absence of spermatozoa not final. B. Examination of Accused. — Physical condition, strength, cuta- neous diseases. Clothing torn. Injuries, showing resistance. Sexual organs — size and appearance. Peculiarities, tattooing, hernia truss. Stains of blood or semen about person or clothing. Urethral discharge (look for semen if seen very promptly). Chronic purulent discharge. Alleged impotence. Mental condition as to sanity or full responsi- bility. Conclusions. — A. (1) Has the person been the victim of rape or sex- ual assault? (2) How has the assault been made? (3) Has there been perineal coitus or intromission of the penis or finger? (4) Is there red- ness, contusion, or laceration of the parts or defloration? (5) Has any •disease been communicated? Is such disease syphilitic? (6) It will be necessary to re-examine in days to note progress of wound. B. (1) Does accused show traces of recent or old venereal disease? (2) Is such disease of same nature as that found on victim? (3) Are there traces of a struggle or of suspicious stains? (4) Is accused sub- ject to bodily infirmity making coitus impossible? (5) Is his mental ■condition normal or otherwise? Indecent Assault. — In a large proportion of cases the victim is usu- ally a little girl under ten years. The attempt is most often made with the finger. As a rule, the signs of a struggle are absent, and on this account the establishment of direct proof is often impossible. The local evidences are usually slight inflammation and reddening with or without laceration of the hymen. A slight discharge often follows. The method of examination is the same as in cases of rape. In such cases care must be taken to exclude local conditions, which frequently cause spontaneous vulvo-vaginitis in children. The pres- ence of the gonococcus is significant, but the possibility of infection from other children or from members of the family must be borne in mind. Evidences of masturbation, such as an elongated or turgescent cli- INJURIES OF THE EXTERNAL GENITAL ORGANS 161 toris with pigmented labia, should be looked for. The pigmentation is usually unilateral. It must be borne in mind that children are naturally mendacious, and may either originate a story of assault themselves, or accept one suggested to them by their parents, or by leading ques- tions put to them by their parents, or by leading questions put to them in the course of the medical examination. Founder's classical advice to medical men charged with the inves- tigation of these cases, that one should close his ears and open his eyes, is to be kept constantly in mind. Another excellent rule is to refuse to give a medical certificate to be used by the friends of the plaintiff as the basis of the case. The civil consequences of injuries to the female genital organs have been but little studied or described. C. Thiem was the first to sys- tematize and collate our knowledge on the subject, and since then a fair number of observations have been recorded. The disabilities resulting from injuries may be classified as follows: Gynecological effects of injury in relation to disability and claims for damage. The effects of accident and injury upon the female genital organs may be classified as follows : 1. Malposition of uterus due to accident. 2. Injury to perineum and vagina. 3. Injury to vulva. 4. Injury to uterus. 5. Injury to uterine appendages. Occasionally the injury may be the sole cause. More often it may act by aggravating existing disease. It is important to remember that the condition must be shown to arise from a single act of traumatism or overexertion, to be considered as the effect of accident. There is no evidence to show that retroversion of the nonpregnant uterus, or that anteversion, or anteflexion, or retroflexion, is ever primarily a result of accident in healthy persons. Any of the above malpositions, if already existing, may be, however, aggravated by falls, or contusions of the pelvic region. Prolapse. — A number of cases are reported by Thiem and others where prolapse has followed accidental straining and heavy lifting. The proof needed to establish this, is sudden and painful onset with swelling, oedema, and tendency to inflammation of the prolapsed parts. This should immediately follow the alleged accident or should produce a certain amount of immediate disability. A thickened or smooth con- dition of the prolapsed portion, with signs of ulcers from attrition, and ease of reposition, should readily enable old cases to be excluded. It may be assumed that prolapse only occurs as a result of accident in per- sons locally predisposed to it. The amount of disability (loss of earning power) in the labouring classes is from ten to twenty-five per cent, according to the success with which reposition by supports can be main- tained. Operation can not be insisted upon if objected to. The 12 162 A TEXT-BOOK OF GYNECOLOGY aggravation of an existing prolapse by accident may also require com- pensation. Injuries to the perineum and vagina occur usually through falls in a straddling position or from impalement; they generally leave no per- manent disability if the immediate effects are recovered from. Lacera- tion of the posterior vaginal wall is the most serious lesion. Indirect laceration from forcible separation of the thighs during falls has been observed. The effects are, of course, most serious when this occurs in pregnant women. In injuries of the vulva and vaginal orifice, hematoma is the com- monest result of injury. It leaves no permanent disability. Tumours of the vulva have not yet been recorded as the result of a single injury. Uterus. — The nonpregnant uterus is only liable to injury in con- nection with some very severe violence, such as fracture of the pelvis; but when enlarged from tumours or pregnancy it becomes exposed to external trauma; interruption of pregnancy, if such exists, is liable to occur, but often does not. Cases of pelvic hematocele from trauma have been reported, but in those cases where metrorrhagia ensues, the existence of pregnancy is extremely probable. The abdominal hemorrhage from ruptured tubal pregnancies is practically never due to trauma. Torsion of the pedicle of ovarian tumours was found by Thornton to be traumatic in 16 per cent of six hundred cases. Laceration and hemorrhage of ovarian tumours from contusions of the abdomen have been observed. Hydrosalpinx and pyosalpinx never arise from trauma. CHAPTEE XVI INFECTIONS OF THE EXTERNAL GENITAL ORGANS Preliminary remarks — Vulvitis and vaginitis — Bacteriology of the external genital organs — Mixed infections — Gonorrhoea — Extirpation of the vulvo-vaginal glands — Tuberculosis; vulva; vagina — Erysipelas — Erysipelas and puerperal infection — Diphtheria — Aphthae — Aerogenous infection — Bilharzia — Chancroid — Hard chancre — Late syphilitic ulcers. Infection of the vulva, the vulvo-vaginal gland, and the vagina, de- pending upon the action of specific micro-organisms, may or may not be limited to — i. e., arrested within — the intrauterine segment of the genital tract. There is a proneness on the part of particularly the more vigorous pathogenic bacteria to progressively invade contiguous mucous areas; it follows, therefore, that infection, once established in the vulva or vagina, is liable to extend upward, involving the endometrium, the mucous lining of the Fallopian tubes, the peritoneum, and the intra- pelvic lymphatics. A proper comprehension of the general subject of infection of the female genitalia involves, therefore, a study of the various pathogenic bacteria (see Sepsis), a consideration of the micro- organisms known to be involved in the infection of these organs, and, finally, a study of the infection, not alone of any one organ, but of the entire genital apparatus. Vulvitis, or inflammation of the vulva, and vaginitis, or inflamma- tion of the vagina, were formerly recognised as clinical entities; at present, however, vulvitis is discussed under the various forms of skin disease of the vulva, or as the result of the action of micro-organisms or of traumatism, while vaginitis can hardly longer be said to exist except as the result of either infection or injury. Inflammations of the external genital organs or of any part of them, except such as occur in the recognised forms of skin disease (see Disease of the Skin of the Female Genitals), will, therefore, be discussed under the heads of In- fections and Injuries. Bacteriology of the External Genital Organs. — The bacteriology of the vulva and vagina in both health and disease has been very carefully investigated by numerous observers. Pioneer work was done by Hauss- man, Kehrer, and Karewski, with primitive methods of investigation which naturally militated against the accuracy of their results. StroganofT, of St. Petersburg, has investigated the bacteriology of the vagina of the newborn child, and finds that it is free from micro-organ- 163 164 A TEXT-BOOK OF GYNECOLOGY isms, which, however, may enter soon after birth. Baths, washings, and especially the application of oleaginous substances, such as are fre- quently used in the early toilet of newborn children, favour the entrance of germs. Winter (CentraTblatt fur Gynakologie, No. 17, 1888) found numerous organisms in the vagina and upon the pudendal structures, in neither of which were there any manifestations of disease. An in- teresting fact was that he found staphylococci, including the Pyogenes albus, aureus, and citreus, together with numerous streptococci, all of which, in morphology, pigmentation, and behaviour in culture media, were identical with similar bacteria found in other loci where they possess pathogenic properties; they differed, however, in the particular that inoculation experiments indicated that they were innocuous. All investigators agree that all pathogenic bacteria lose their virulence the nearer they approach the cervix. This circumstance at once raises the question whether or not the cervical and vaginal secretions have the effect of depriving these bacteria of their virulence. In answer to this question may be cited the observations of Doder- lein, who has found a bacillus which does not grow upon many of the usual media, but may be cultivated on sugar bouillon and sugar agar. It produces an acid, apparently lactic, upon which the usual acidity of the vaginal secretion depends. Lactic acid, which is elaborated by this bacillus in considerable quantity, is presumed to be the agent which either destroys the life or neutralizes the virulence of the pathogenic organisms. In confirmation of this theory large quantities of pus- producing organisms introduced within the vagina disappeared com- pletely within a few days. This acid-forming bacillus, which stands as a sentinel at the introitus and along the vaginal wall, does not itself produce pathologic symptoms, and consequently plays no part in the causation of sepsis. Doderlein is of the opinion that this micro-organ- ism and the products of its vitality are able to resist the invasion of streptococci, which probably never reach the uterus unless either car- ried there mechanically or escorted by the more powerful pus-form- ers. These latter, notably the gonococcus, overpower the bacillus of Doderlein and march practically unopposed to the remotest reaches of the genital tract. The fact that the Bacillus aerogenes capsulatus manifests its activities upon or near the cervix indicates that it is not amenable to the influence of this micro-organism. The importance of bacteriological examination of secretions found upon the vulva and in the vagina can hardly be overestimated. The lesson taught by the investigations of Doderlein and J. Whitridge Williams is conclusive upon this point. The investigations of these gen- tlemen show that the normal vaginal secretion is of very small quantity, of whitish, crumbling material, of the consistence and appearance of curdled milk, containing no mucus, and giving an intensely acid reac- tion 'to litmus, while microscopically it consists entirely of vaginal epithelial cells and a relatively few large bacilli. The pathologic secre- tion, on the other hand, is of a yellowish or greenish-yellow colour, INFECTIONS OF THE EXTERNAL GENITAL ORGANS 165 creamlike in consistence, often containing gas bubbles (dependent upon Bacillus aerogenes capsulatus) and a little mucus, and varies in reac- tion from weakly acid or neutral to alkaline, while microscopically it consists of epithelial cells, numerous pus corpuscles, and all kinds of bacilli. Stroganoff found that micro-organisms seemed to increase in abundance in the vaginal secretion preceding and following menstru- ation. J. Whitridge Williams made a critical study of the secretion in the vaginae of ninety-two pregnant women, upon which he based prac- tical conclusions (Transactions of the American Gynecological Society, 1898) as follows: 1. We agree with Kronig that the vaginal secretion of pregnant women does not contain the usual pyogenic cocci, having found the Staphylococcus epidermidis albus only twice in ninety-two cases, but never the Streptococcus pyogenes or the Staphylococcus aureus or albus. 2. The discrepancy in the results of the various investigators is due to the technique by which the secretion is obtained. 3. As the vagina does not contain pyogenic cocci, auto-infection with them is impossible; and when they are found in the puerperal uterus, they have been introduced from without. 4. The gonococcus is occasionally found in the vaginal secretion, and during the puerperium may extend from the cervix into the uterus and tubes. 5. It is possible, but not yet demonstrated, that in very rare in- stances the vagina may contain bacteria, which may give rise to sapraemia and putrefactive endometritis by auto-infection. 6. Death from puerperal infection is always due to infection from without, and is usually due to neglect of aseptic precautions on the part of the physician and nurse. 7. Puerperal infection is to be avoided by limiting vaginal examina- tions as much as possible and cultivating external palpation. When vaginal examinations are to be made, the external genitalia should be carefully cleansed and disinfected, and the hands rendered as aseptic as if for a laparotomy. Vaginal douches are not necessary, and are prob- ably harmful. Mixed Infections. — A brief consideration of the preceding para- graphs relative to the bacteriology of the external genital organs makes it evident that they are the frequent seats of coincident infections by different micro-organisms. In cases of pelvic suppuration discharging into the genital tract, both staphylococci and streptococci are generally found, together with other pathogenic micro-organisms. In gonorrhoea the diplococcus of Neisser is never the only pyogenic organism pres- ent; and in the destructive stages of tuberculosis the tubercle bacillus is always found in association with other germs. There are cases, how- ever, in which the pathologic changes and clinical phenomena are so distinctly attributable to a particular micro-organism that the infection is given its name rather than that of its congeners. In this category 166 A TEXT-BOOK OF GYNECOLOGY may be mentioned particularly (a) gonorrhoea, (b) tuberculosis, (c) erysipelas, (d) diphtheria, (e) aphthae, and (f) aerogenous infection. Gonorrhoea in women was once thought to be a disease restricted to the vulva, the vagina, and the urethra; but since the days of Tait and Noeggerath it is known that infection of the lower genital canal if left to itself may become a progressive invasion of the mucous tract, causing infection of the endometrium, the Fallopian tubes, the peri- toneum, and the pelvic lymphatics. (See Endometritis and Pyosalpinx.) It should be remembered likewise that the lower segment of the urethra is also, coincidently with the vagina and vulva, a seat of primary infec- tion, and that from this locus it may extend upward, involving the bladder and even the kidneys. (See Cystitis.) The cause of this infec- tion is the gonococcus of Neisser (see Fig. 17). This organism is the morbific agent that is distributed chiefly through the avenue of the " social evil," and restrictive measures have been taken in all enlight- ened communities to diminish its ravages. The prevalence of this micro-organism in the vaginal discharges of prostitutes has been a fre- quent subject of investigation. Laser, of Konigsberg, examined a number of prostitutes with the result that the gonococcus was found in the urethra 111 times in 353 cases; in the vagina 7 times in 180 cases; and in the cervical canal 21 times in 67 cases. These figures indicate that this micro-organism finds a favourable habitat equally in the ure- thra and in the neck of the uterus, and the least favourable abiding place in the vagina — a conclusion which supports the observation of Doderlein relative to the phagocytic action of the acid-forming ba- cillus of the vagina. Out of the 353 patients examined by Laser for gonococci in the urethra, four fifths of the 111 cases that revealed this micro-organism gave no macroscopical evidence of gonorrhoea. In 241 patients in whom no gonococci were discovered, there was more or less inflammation of the mucosa, often with a suspicious discharge. It follows, therefore, that while infection of the genital and urinary tracts may depend upon organisms other than the gonococcus, the latter, in a degenerated form located deep in the mucous folds and follicles, but especially in the crypts of the vulvo-vaginal gland, may be a persistent cause of the disease, even when it can not be detected in the dis- charges. It is evident from these facts that gonorrhoea in women should be classified as acute and chronic. Afanassiew (Gazette de gynecologies No. 167, p. 173) reports the results of bacteriological investigation of the lochia of twenty-four par- turient women. Out of sixty-eight examinations, he obtained cultures in nearly all the cases. The bacteria diminished in the vagina from without inward, and were fewest at the uterine cavity — an observation confirmatory of the conclusions of Doderlein. They were living and culturable, notwithstanding daily washing of the canal with carbolized water of 2-per-cent strength. The gonococcus of Neisser is often demonstrable in secretions from the vagina and vulva. These organisms are frequently found in appar- INFECTIONS OF THE EXTERNAL GENITAL ORGANS 167 ently nonpurulent secretions long after the period of acute infection has passed; their virulence, however, under such circumstances is gen- erally greatly reduced, often to the degree of having lost their patho- genic properties. (See Gonorrhoea in Women.) Freymuth and Pe- truschky (Deutsche medicinische Wochenschrift) have found the diph- theria bacillus in noma of the vulva. The same organism has been dem- onstrated in exfoliative vaginitis not associated with gangrenous ulcera- tion, while Eisner and others have reported puerperal diphtheria in- volving the vagina and endometrium. The Oidium albicans has been demonstrated in aphthous inflammations of the vulva and vagina in both children and adults. The symptoms of acute gonorrhoea in women consist of a burning pain on urination located at first in the meatus urinarius, and next upon the inner and erythematous surfaces of the vulvar folds; and in a copious creamy discharge, bathing the vulva and matting the pudendal hair. On inspection the vulva reveals areas of erythema, which, after a few days, owing to the destruction of the epithelium, may become distinct erosions; the urethra is tender to the touch, swollen, and its mucous membrane is more or less everted at the meatus urinarius. The diagno- sis may be made presumptively upon the foregoing symptoms coupled with the fact of probable exj)osure to infection; but it can be made positively only upon the demonstrated presence in the discharge of the gonococcus of Neisser. The practitioner should be very cautious in giving a final diagnosis of suspected cases of gonorrhoea, on account of the possible social and medico-legal contingencies that may arise. The symptoms of chronic gonorrhoea in women are more obscure. There is generally a history of a preceding acute attack, the exact character of which may not be known to the patient herself, but which can be determined, at least approximately, by Avell-directed interrogatories. Following the supposed cure of the acute attack there has been a per- sistent catarrhal discharge, varying in colour from a whitish to a slightly yellowish tint, and varying in quantity from slight to consider- able. If these conditions exist associated with a present or a past sup- puration of the vulvo-vaginal glands, and if there is a petechial pur- plish red area about the orifice of the vulvo-vaginal ducts, the presump- tion of chronic gonorrhoea is strengthened. If the mischief in the vulvo-vaginal glands has gone to the extent of suppuration, resulting in fistulae or cystic degeneration, the diagnosis may be considered as confirmed. The involvement of the urethra, dark-red spots upon a yel- lowish-white streaked base upon the vulva, and venereal warts, are com- plications of conclusive diagnostic significance. Oskar Bodenstein (Deutsche medicinische Wochenschrift) quotes Sanger to the effect that the local application of a 50-per-cent solution of zinc chloride will cause the granules in the vaginal mucous membrane to spring into relief in chronic gonorrhoea — a convenient diagnostic expedient that is certainly worthy of investigation. The pathology of gonorrhoea in women has been understood but re- 168 A TEXT-BOOK OF GYNECOLOGY cently. Its comprehension involves a study, not so much of the changes that occur in the vulva, vagina, and urethra, as of those occurring in the bladder and kidneys, and in the uterus and its adnexa, to the chapters upon which subjects the reader is referred. The pathology of gonorrheal infection of the vulva and vagina is essentially the pathology of an infective inflammation. The micro-organisms, find- ing a lodgment upon the mucous surfaces of the urethra, in the muco-cutaneous folds of the vulva, or those about the introitus vaginae, readily propagate in the secretions which act as culture media. The direct irritating influence, both of the organisms themselves and of the products of their vitality, results in the establishment of the ordinary phenomena of inflammation — congestion, stasis, exudation, etc. The direct action of these organisms and their products is, to a certain extent, destructive of the epithelium, which, however, would probably withstand the assaults of the invaders if it were not for the circulatory and nutrient changes in progress in the underlying struc- ture. Through these combined influences the protective epithelium is broken down and there is more or less direct invasion of the under- lying cuticular structure; but even here the intrusive cocci are con- fronted by other defenders of the system in the form of leucocytes. Cocci develop rapidly, however, overcome their cellular antagonists, and find their way into the fimbriated intercellular substance and into pre-existing cells of the tissue and in the vessel walls. While these changes are in progress, however, the mucous follicles are invaded, and with the first temporary recession of the local circulatory pressure these follicles are stimulated to extreme activity, manifested in that hyper- secretion which is generally designated as catarrhal. In the presence of a virulent infection these follicles and glands, including even the vulvo- vaginal glands, may suffer the loss of their epithelium and themselves become the avenues for tissue infection. Local abscesses as the result of gonococcus infection but rarely occur, except in the vulvo-vaginal gland, -the efferent duct of which may become occluded, converting the gland into a suppurating retention cyst. Tissue invasions, such as have been described, more frequently result in permitting the passage of the pyogenic organisms — for by this time the infection has generally become more or less mixed — into the lymph channels, whence they are carried to the lymphatic glands, particularly to those in the groin, where, not infrequently, the infection results in abscesses. Coincidently with these changes there occurs more or less systemic intoxication, expressed, it may be, by an initial rigour; this is followed by an elevation of tem- perature, which persists with slight but irregular vacillation until the focus of suppuration has been opened and drained. Treatment. — When gonorrhoea is limited to the vulva, the urethra, and the ostium vaginae, it should be treated by rest, and antiseptic lotions of either boric acid or bichloride of mercury emollient appli- cations. The vagina will seldom be invaded unless the infection is carried upward by mechanical means. This, however, is what unfor- INFECTIONS OF THE EXTERNAL GENITAL ORGANS 169 tunately happens in the majority of cases long before the physician is consulted. The patient of her own accord is prone to use the douche; or, may be before she has become aware of her condition, she has indulged in repeated acts of coition. The physician is, therefore, called upon at the very outset to treat a thoroughly infected vagina. L T nder these circumstances there is no disease with which women are afflicted that calls for more prompt, more vigorous, and more efficient treatment than that of acute gonorrhoea. Its probable extension to the upper reaches of the genital tract, with the inevitable complications thereby engendered, should stand before the practitioner as a spectre warning him to the fullest discharge of his duty. The treatment of acute gonor- rhoea is essentially bactericidal. It should begin with a thorough cleans- ing of the parts; this can be accomplished thoroughly only by first shaving the pudendum; a douche of tepid water, either clear or holding in solution some borax or sodium bicarbonate, should be used to cleanse the vulva and the vagina; after this has been thoroughly done another douche of l-to-2,000 bichloride solution should be employed for a period of from ten to fifteen minutes. This douche should be given, as should the preceding, with the patient lying upon her back, her buttocks drawn to the edge of the bed, in which position the nurse can practise most thorough cleansing of the vagina by repeatedly holding her hand over the vulva, thus forcing the retention of the irrigating fluid in the vagina; the hydrostatic pressure thus exercised will occasion that degree of dis- tention of the vagina which will cause an obliteration of the folds and the exposure of its entire surface to the action of the medicament. Care should also be taken to bring the antiseptic solution in contact with every part of the infected area of the vulva. An older and pos- sibly more efficacious, but certainly more severe, treatment consists in cleansing the parts as above described, and in then introducing a specu- lum, widely distending the mucous membrane of the vagina, which, with the entire vulvar surface, is cauterized with a solution of nitrate of silver, twenty grains to the ounce; this cauterization, to be effective, should be thorough and should include every part of the mucous mem- brane. After the silver nitrate has been applied, a loose pledget of cot- ton, saturated with glycerine, should be carefully inserted, not so as to pack the vagina, but to lie lengthwise in the canal, preventing the ap- proximation of the cauterized surfaces. Other remedies, such as the zinc sulphate, plumbic acetate, tannin, carbolic acid, lysol, and creolin, have been suggested and may be employed; they, however, possess vary- ing germicidal properties, none of them being so valuable as either the mercuric bichloride or the silver nitrate. AVhen the nitrate of silver is used, it should not be reapplied under three or four days. It should be remembered that antiseptic treatment, to be effective, should be con- tinued until the symptoms of infection have subsided. It is not enough to kill an existing generation of bacteria, even though it were possible to do so in a given case, for it should be remembered that many of these micro-organisms propagate by spores, which resist more effectively than 170 A TEXT-BOOK OF GYNECOLOGY do the parent organisms themselves the action of germicidal agents. Doderlein has emphasized the importance of repeated disinfections of the genital tract, for the purpose of securing sterilization, and his teachings should pass into an axiom of practice. The treatment of chronic gonorrhoea in women involves a much more comprehensive regimen. It must be based upon a comprehension of the pathologic changes that have occurred in the case at hand. This may involve the application of surgical expedients to the bladder, the kidneys, the uterus or its adnexa, or to the pelvic lymphatics. So far as the treat- ment of chronic gonorrhoea of the lower genital tract is concerned, it will resolve itself into a persistence in antiseptic measures, or the ex- tirpation of the vulvo-vaginal gland, which is generally found to be the persistent fons et origo of the disease. The antiseptic treatment should consist in the continued practice of irrigation with strong solutions of bichloride of mercury or carbolic acid, always taken in the recumbent posture, the douche bag being elevated from four to five feet above the patient, the nurse practising forced retention of the fluid in the pa- tient's vagina. It should be kept in mind that chronic gonorrhoea of the vagina is a deep-seated process, for the successful treatment of which vaginal distention is a necessity. Forcible tamponade of the vagina, particularly in the lateral fornices and in the upper segment of the canal, should be practised by saturating a long slender cotton tampon with sterilized glycerine. The exosmotic influence of this agent has a tendency to wash the micro-organisms out of their hiding places and to bring them in contact with the stronger sterilizing agents. In these cases it is of special value to distend the vagina to the extreme by means of a multivalvular speculum, and to cauterize the thus tense and distended mucous surface with a strong solution of nitrate of silver, followed with glycerine tamponade. The escharotic influence of the silver salt is not sufficient to produce serious destruction of the mucous membrane, unless frequently applied — i. e., oftener than every three or four days. Extirpation of the vulvo-vaginal glands should be practised when- ever they have become the seat of gonorrhoeal infection, as evidenced by either repeated suppurations or cystic degeneration. This gland is also the occasional seat of malignant disease, the existence of which is an indication for its prompt removal. This is an operation of more magni- tude than the anatomic structures involved would seem to imply. With the patient in the dorsal position, the vulva having been completely sterilized, the labia of the affected side are retracted by the hands of the assistant or nurse, and an incision is made over the gland just at the base of the labium minus. If the gland is distended, dissection should be made with considerable care until the cyst, as the gland may be now designated, is encountered; an effort should be made to carefully enu- cleate this body, which will be found to be held in position by a sort of ligamentous structure, conveying its nerves and nutrient vessels. These are of sufficient magnitude to occasion severe hemorrhage, and INFECTIONS OF THE EXTERNAL GENITAL ORGANS 171 if they are permitted to elude the grasp of the operator, they retract along the vaginal wall to such an extent that they are re-secured with extreme difficulty. Care should be taken, therefore, to get them with- in the grasp of a hemostatic forceps before excising the gland, and to ligate the pedicle before taking off the forceps; the wound should then be closed aseptically and dressed with protective pads. If closed by the buried suture the liability of subsequent infection from external causes is minimized. Tuberculosis of the vulva is a specific inflammatory disease of the external genitalia, caused by the presence of the tubercle bacillus and characterized by both the anatomic lesions and clinical course of lupus. It may exist as a primary disease confined to the vulvar region or a secondary manifestation of tuberculous lesions in the lung, intestine, or internal genital organs. A clear definition of tuberculosis of the vulva is extremely difficult to give in the presence of the confusing classifications of different authors, and must in reality include a very extended description and differentiation of the conditions — ulcus rodens vulva?, elephantiasis, lupus vulva?, Testhiomene, and destructive ulcer. Veit, Schroder, Pozzi, and many others have described ulcus rodens vulva? as a distinct lesion, but they also state that the tubercle bacillus has often been found in such ulcers. It will certainly simplify the subject greatly and bring it more within the limits of this short article to look upon this division as sub judice, and to describe only a tuberculosis of the vulva. Etiology. — Until recent times tuberculosis of the vulva has been considered so rare that it has been given no place, or only passing- mention, in the accepted text-books of gynecology; but the reported cases of Demme, Schenck, Kuttner, Karajan, Paoli, Kelly, Eieck, and others, would indicate that the disease occurs with greater frequency than is generally believed, and that this condition must always enter into the diagnosis of vulvar ulceration. Barbier (Gazette medicate) believes that a woman can be infected by a tuberculous man during coitus. Bacilli have been demonstrated in the semen as well as in the discharge attending tuberculous epididymitis. The uterus may be in- fected by extension from a tuberculous growth on the vulva, without any intermediate trace of infection in the vagina. He even admits the possibility that tuberculous infection may be transmitted by the finger of the attendant, by unclean instruments, or even through the medium of the air. It is manifest, however, that infection transmitted in this way must be taken up through some rent in the continuity of the epi- thelium. The disease occurs alike in children and adults and without refer- ence to the general nutrition. The infection would seem to be by the direct inoculation of a skin abrasion by means of the nails, by infected dust, by tuberculous stools, or by coitus. The case of Schenck occurred in a child who had two tuberculous playmates, and who had no other tuberculous manifestations. Prostitutes are most frequently attacked, 172 A TEXT-BOOK OF GYNECOLOGY a fact that has its explanation in their great liability to direct infection, in continued irritation, and in lack of cleanliness. Masturbation serves as a predisposing cause, and syphilis also by lowering the resistance of the tissues. Koch has considered extirpation of the inguinal glands to be a predisposing cause. Morbid Anatomy. — The starting point of the tuberculous process is usually in the region of the urethral orifice or the clitoris, or in the posterior commissure. The lesion begins as a single or as multiple hard masses, of a dark-red or livid colour, which develop in an indu- rated skin and increase in size very slowly. This mass may exist for a long time as a firm nodule, or in the clitoris as a hypertrophy, or it may soften in the centre and break down to form a small, raised, un- healthy ulcer with ragged edges, which exudes a serous fluid. It is in this stage of ulceration that the patient usually presents herself for treatment. When the lesions are multiple, a number of such discrete ulcers will form on the vulva and gradually run together to form an extensive area of tuberculous granulations involving the entire vesti- bule, clitoris, labia, and lower part of the vagina. The granulations of such an ulcer are un- healthy, friable, do not bleed easily, and show no tendency to caseation. The sur- face is covered by a sero-purulent exu- date. There is a rich vascularization of the part and the tissues around and beneath the ulcer are strongly infiltrated, but not markedly indurated. These ulcers are apt to be serpiginous in character, healing be- hind as the advance is made. A very char- acteristic feature of the disease is a rough, tense, hard elephanti- asic thickening of the labia or clitoris, or both, which causes them to swell to two or three times their normal size. In fact, in the cases of Karajan and De Sinerty the operation was done for elephantiasis of the clitoris, and the tuberculous nature of the disease was revealed only by histological and bacterio- logical examination. A microscopic examination of these ulcers shows the base to be made up of a thin layer of tuberculous granulations and Fig. 68. — " A low power shows the caseous areas (5, c) in the tuberculous tissue and an occasional fistulous tract (a)." — Whitacre (page 173). INFECTIONS OF THE EXTERNAL GENITAL ORGANS 173 Fig. 69.— "A high power picture demonstrates small round cells and giant cells around the irregular caseous areas." — Whitacre. the raised edges of solid tuberculous tis- sue containing more or less typical mili- ary tubercles. A low power (Fig. 68) shows the caseous areas in the tuberculous tis- sue and an occasional fistulous tract. A high power (Fig. 69) demonstrates small round cells and giant cells around the ir- regular caseous areas. Tubercle bacilli may be demonstrated (Fig. 70) among the small round cells in the secretions or in the newly formed tissue. It must be remem- bered, however, that in the serpiginous course of such a tuberculous lesion the older parts of the ulcer may show the entire absence of tuber- cle bacilli, as is shown by the interesting case of Eieck (Fig. 71). The involvement of the urethra is progressive, its inner surface loses its real mucous-mem- brane character, is more or less exposed, and may be con- verted into scar tis- sue. The meatus ap- pears to be torn lat- erally, as Emmet has pictured it for the cervix. The process continues until the urethra is almost en- tirely destroyed and is represented by a funnel-shaped ulcer. The course of the ulcerative process is very slow, however, and the inguinal glands remain free for a remarkably 70. -" Tubercle bacilli may be demonstrated among the small round cells." — Whitacre. 174 A TEXT-BOOK OF GYNECOLOGY long time. Cicatrization is sometimes associated with the ulceration, as an evidence of a tendency to spontaneous healing, and may lead to great deformity. Fistulse often form a marked feature of the disease, and especially in ulcus rodens vulvae. A tendency to a deep penetration of the tissues may be present from the start. They first form underneath the mucous membrane, but very soon penetrate deeply, and may communicate with the rectum high up at the upper end of the perineal triangle. Three or four sinus open- ings on the vulva may coalesce below the surface and open into the rectum as a sin- gle channel. Ulcera- tion in the perineal body may be so ex- tensive as to form a cloaca. Symptoms. — The first symptom of pri- mary tuberculosis of the vulva is often a stinging pain on uri- nation, caused by the urine coming in con- tact with a minute ulcer at the orifice of the urethra. At other times an ulcer giving no symptoms is discovered by the patient, or the nympha of one side, or the clitoris, is found to be increasing in size. A physical examination will reveal the presence of one or more ulcers possessing the above-named characteristics. The course of such an ulcerative process is extremely slow, and may continue for many years as a local phenomenon without affecting the general health of the patient. The dribbling of urine and rectal irritation will, of course, be present in the advanced cases as most distressing symptoms. Death will eventually result from involvement of the internal organs. A secondary tuberculosis of the vulva takes a much more rapid and malignant course; furthermore, the vulvar disease often possesses little significance in comparison with the primary lesion in the lung or other organs. Diagnosis. — The diagnosis of this condition possesses a consider- able degree of importance, first, because of the necessity of radical treatment, and, secondly, because of the difficulty experienced in ar- riving at a correct diagnosis. Askanazy has explained certain of these difficulties by the demonstration that we may meet with tumours not differing in their microscopical anatomy from typical tuberculosis, but Fig. 71. — The case of Kieck : A, C, sinus openings ; B, F, scar- tissue ; D, a small tumour containing typical tubercle tissue ; E, ulcerated surface ; G, urethra ; H, introitus vagina ; J, ele- phantiasic thickening of left nympha. — Whitacre (p. 173). INFECTIONS OF THE EXTERNAL GENITAL ORGANS 175 characterized clinically by an absence of all tendency to caseation, abnormally large size of tumour formation, firm consistence, and, lastly, by a tendency to fibrous metamorphosis which may eventually lead to a complete obliteration of all specific tuberculous attributes. The association of ulceration with elephantiasic thickening of the labia, the slow development, the chronicity of the ulceration, and, most important, the demonstration of tubercle bacilli in the secretions, will serve to distinguish it from carcinoma. Simple elephantiasis is not associated with ulceration. Chancroid will usually be diagnosed by its history and clinical characteristics, by the absence of elephanti- asis, by its multiple character, by its short duration, and by the absence of extensive and deep destruction of tissue. Treatment. — The treatment of tuberculous lesions of the vulva is surgical, and a radical removal of all diseased tissue should be resorted to whenever this is possible. This will often require an extensive plas- tic operation, and it should be remembered that a considerable removal of urethral tissue can be made without impairing the function of the bladder (Kelly, Schroder, Paoli). When this is not possible, thorough curetting with a sharp spoon, followed by cauterization with strong acids, may be tried and repeated as often as the disease recurs. Deep cauterization by the electro-puncture serves as an excellent method of thoroughly removing the diseased tissue and securing good cicatriza- tion. The ulcers unfortunately heal very well oftentimes under such simple applications as iodine or acids, but this cure is not permanent, and the ulcers recur. Under any plan of treatment these cases should be carefully followed up and the slightest recurrence treated as radi- cally as the original focus of infection. Enlarged glands in the groin should be removed at the time of the primary operation or in the in- stance of their later enlargement. Either as an auxiliary to the ordi- nary methods of treating lupus, or as an independent method, Unna ad- vises (MonatsJiefte far praktische Dermatologie) the following lotion: I>. Corrosive sublimate, 1 part; carbolic acid or creosote, 4 parts; alco- hol, 20 parts. The nodules are attacked in series of tens, beginning with those at the edge of the patch. They are first punctured with an aene lance, and a minute shred of absorbent cotton moistened with the lotion is inserted by means of a sharpened stick, the cotton rotated and allowed to remain for ten or fifteen minutes. In a few days the punc- tures and lupus deposits so treated have almost disappeared, and other nodules may be then similarly attacked. This method, Unna believes, has many advantages over the somewhat similar plan of treatment by means of the nitrate-of-silver stick. Tuberculosis of the vagina is usually associated with tuberculosis of the higher portions of the genital tract, but a number of cases have been reported in which no other focus could be discovered in the genital tract, and a single case is reported by Friedlander in which a vaginal ulcer represented the only tuberculous lesion to be found in the entire body. The vagina certainly may be infected from a tuberculosis of 176 A TEXT-BOOK OF GYNECOLOGY the peritoneum or tube without involvement of the intervening organs (Oppenheim), and it was Reynaud who first explained the usual seat of the first vaginal lesion in the posterior fornix, by the observation that it was here that virus-laden secretions from above first came in con- tact with the vagina. The infection may also be introduced from with- out by coitus with men suffering from a tuberculous disease of the sexual organs, by the hands or instruments of the physician or midwife, from the urine, from filthy bed linen or wearing apparel, from the air, from the blood (Davidsohn), and by infection in continuity of tissue from neighbouring organs, as in vesical or rectal fistula?. The infrequency of the disease in both the vagina and vulva, as compared with that of the higher organs, is probably to be explained by the natural resistance of squamous epithelium to bacterial invasion, and it is only after injury, abrasion, or the action of irritating secretions, that the tubercle bacillus can gain entrance to the tissues. The disease occurs with greatest frequency during the period of sexual activity (twenty to forty), yet seven and seventy-nine represent the two extremes of age in the collected cases. Morbid Anatomy. — Two cases in particular are reported where the entire lesion consisted in an eruption of perfectly typical, fresh miliary tubercles over the entire vaginal wall. These tubercles were of millet- seed size, and were made up microscopically of giant, epithelioid, and small round cells, which were supported by a delicate reticulum and showed areas of caseation. Tubercle bacilli were present. Favoured by moisture and warmth, these miliary tubercles soon break down to form minute ulcers, or by their confluence will form larger sharply defined but irregular ulcers. Such ulcers are characterized by perpendicular edges, a depressed grayish or yellowish-gray base, studded by tubercles and covered by caseous material, a size varying with the extent of the confluence, and a decided tendency to the serpiginous type. Such an ulcer is usually surrounded by an area of hyperemia, which is more or less filled with small, yellow, opaque, grainlike miliary tubercles. The usual seat of ulceration, as has already been stated, is in the posterior fornix. When the infection is from without, however, the lower por- tion of the vagina will be first involved. Tuberculous fistula? are found in the later stages of the disease and are formed, as a rule, by an ulcera- tion into the connective tissue, thence into urethra, rectum, bladder, or the skin surface of the perineum. On the other hand, fistula? may be the result of perforating rectal or vesical ulcers, and cases have been reported in which the fistula has its origin in a broken-down tubercu- lous Fallopian tube. These fistula? are peculiar only in the fact that they are lined by the tuberculous membrane. Symptoms. — The symptoms of tuberculous vaginitis are, as a rule, masked by those of the tuberculous disease existing in other parts of the body. A leucorrhcea associated with painful coitus or pain in using the douche tube will usually be the first symptom that brings the patient to the physician for examination, or the symptoms of a vesico-recto- INFECTIONS OF THE EXTERNAL GENITAL ORGANS 177 vaginal or urethrovaginal fistula may be the first that are referred to the vagina. A physical examination will reveal one or many sensitive ulcers possessing the above-named characteristics. The diagnosis of the miliary form from granular vaginitis should not present great difficulties when we remember the frequency of the latter as compared to the condition under discussion, also its usual association with pregnancy and gonorrhoea. Furthermore, the character of the ulceration, and the fact that a tuberculous lesion of the vagina is almost invariably associated with a similar lesion elsewhere in the body, will prevent confusion. A chancre can be easily distin- guished from a tuberculous ulcer by its history and clinical course; the papular or ulcerative syphilides by the history, the total lack of pain, and mainly by their disappearance under antisyphiltic treatment. The reports of many of the recorded cases state that the patient was first subjected to antisyphilitic treatment, leading to the impression that this confusion often arises. Finally, the secretion of every persistent ulceration of the vagina or vulva should be subjected to bacterial ex- amination in smear or culture preparations, or inoculated into the peri- toneal cavity of guinea-pigs. The number of bacilli is often too few for easy demonstration by ordinary staining methods, yet it will cause a tuberculous peritonitis in the guinea-pig in from three to four weeks when present in very small numbers. A microscopic examination of a snipping from the edge of the ulcer may be necessary to distinguish the condition from carcinoma. The treatment of tuberculous vaginitis should be as radical as possible when the lesion can be demonstrated to be a primary one, either in the genital tract or in the body; but it must be remembered that the condi- tion is usually secondary to a much more serious tuberculous involve- ment of the Fallopian tubes, the uterus, the intestine, or the lungs. In these cases palliative measures alone are indicated. When complete excision of the ulcers is possible this should be done, but we must very often limit ourselves to a thorough curetting and cauterizing of the ulcer, and a prompt treatment of every point of recurrence. Palliative measures will consist in local applications to the ulcers, the repair or cleaning of fistulae, the maintenance of an antiseptic condition by the use of astringent and antiseptic douches, the use of general tonics — in fact, the use of those measures which are applicable to tuberculosis in other parts of the body. Erysipelas of the external genital organs, and particularly infection of the genital tract by the Streptococcus erysipelatos {Streptococcus pyogenes), are occurrences of tragic importance. When the infection is strictly local, the streptococcus finding ingress through some abrasion in the epithelium, the resulting phenomena are those of erysipelas in- volving the pudendal structures. The virus, once admitted to the field of propagation, spreads rapidly through the lymph capillaries of the sur- rounding skin. The symptoms that ensue are sudden attack of febrile disturbance ushered in by a rigor; the tongue becomes coated, there is 13 178 A TEXT-BOOK OF GYNECOLOGY a sense of depression over the stomach, and malaise, with possible noc- turnal delirium; swelling of the infected point occurs, associated sooner or later with generally coincident tenderness in the inguinal lym- phatics. The swelling in the vulva progresses rapidly and is associated with pain, throbbing, and a sense of heat and dryness; itching is gener- ally an early and persistent symptom, while diffuse infiltration occasion- ing oedema of the cellular tissue of the vulva rapidly supervenes. Minute vesicles may be discovered, usually arranged in groups, and manifesting themselves in the surface of the skin. The smaller of these vesicles commonly rupture, the resulting discharge of clear or slightly yellowish serum, occasionally tinged with blood, desiccates, and forms crusts. The characteristic feature of this inflammation is to spread rapidly from the point of primary infection. This extension may occur until it involves not only the pudendal structure, lower part of the abdomen, and the inner aspect of the thighs, but it may extend upward into the vagina; it may, indeed, assume the type of " wander- ing " erysipelas, and invade practically the entire surface of the body before it is arrested. The subcutaneous infection may result in the formation of foci of suppuration, manifesting themselves on the surface of the skin in the form of large purulent blebs, or, if more deeply seated, as fluctuating masses. The treatment should be both local and constitu- tional. Of the local remedies, carbolic acid in solution with liquid vase- line painted on the surface with a soft brush has the merit of being both convenient and effective. While the disease is yet limited to the vulva, a 5-per-cent solution may be employed; but when the infection involves a greater area a solution of not more than 1 per cent should be used. Creolin and phenol are really but milder forms of the same treatment. Concentrated solutions of salicylic acid and of sulpho- carbolate of soda, respectively, have been employed subcutaneously around the circumference of the infected area. Comfort is derived from any soft soothing application which will protect the inflamed surface from the air. Silk saturated with carbolized liquid vaseline or with carbolized vegetable oils is a source of comfort, care being taken to maintain, as nearly as possible, an equable temperature in the parts. When suppurations occur they should be freely incised, the cavities being treated antiseptically. Erysipelas as a source of puerperal infection was first recognised by Dr. Oliver Wendell Holmes, his conclusion being based upon the occur- rence of a number of deaths from puerperal fever in the practice of a physician whose finger was known to have been infected while making an autopsy of an erysipelatous subject. The conclusion thus arrived at by the Autocrat of the Breakfast Table has since been confirmed by the clinical experience of the world. The organism of erysipelas, isolated by Fehleisen, was demonstrated by Clivio and Monti in cases of puerperal peritonitis. (See Streptococcus Erysipelatos, ante.) The clinical phenomena produced by this special micro-organism while the infection is limited to the vulva and vagina are not known, for the INFECTIONS OF THE EXTERNAL GENITAL ORGANS 179 reason that, in puerperal cases, the occurrence of this infection is not detected nntil it has invaded the endometrium, at which time it is readily demonstrable in the lochia. As the ensuing essential clinical phenomena are manifested in connection with endometritis, and as the treatment of this infection depends upon the successful treatment of an infectious endometritis, the reader is referred to the chapter on that subject. Diphtheria of the External Genital Organs. — The inner surfaces of the vulva and vagina are sometimes the seat of active diphtheritic infec- tion, which may be either (a) primary or (b) secondary. The latter form, in which the genital manifestation of the disease occurs sec- ondarily to its appearance either in the upper air-passages or other loci, is the more frequent. Leick, of Greifswald, reported a case of primary diphtheria involving the inner aspects of the labia and extending into the vagina, the characteristic exudate yielding the Klebs-Loemer ba- cillus. Eisner has recorded a case of primary infection of the vagina, by the same bacillus, in a puerperal ease. Infection of the vulva by the diphtheria bacillus, whether primary or secondary, in very young subjects may cause noma, or circumscribed gangrene of some part of the vulvar structure. The symptoms of diphtheria of the vulva and vagina consist of an initial chill followed by fever of 105° F. or more, rapid but feeble pulse, prostration — less marked, however, than when the disease attacks the respiratory passages — local tenderness, referable to the vulva or vagina or both, which, upon inspection, reveals the characteristic pearly exu- date. The absolute diagnosis depends upon the demonstration of the Klebs-Loeffler bacillus. The treatment is both constitutional and topical. Constitutional treatment consists in the employment of the antitoxine; the complete disappearance of the membrane has been noticed in sixty hours fol- lowing the use of two thousand units of antitoxine. When the local infection is so virulent as to cause noma or circumscribed gangrene of the external structures, hot antiseptic applications should be made and the sphacelus, as soon as well defined, should be removed, every prin- ciple of antisepsis being observed in the subsequent treatment. Aphthae, or thrush, is a species of infection that frequently involves the vulva and vagina, particularly in nursing women. It depends for its occurrence on the Oidium albicans, a vegetative organism that fre- quently infests the mouths of children. Its appearance in the external genital organs does not differ materially from that in the infant's mouth. Infection occurs in discrete areas elevated with an inflamma- tory base and covered by a milky white exudate. It causes some local pain with but trifling constitutional disturbance. The treatment con- sists in thoroughly cleansing the part with sterilized water, applying, subsequently, a strong mercuric bichloride solution, followed by a tam- pon saturated with boroglyceride. The treatment should be repeated daily for two or three days. 180 A TEXT-BOOK OF GYNECOLOGY Aerogenous Infection of the Genital Organs. — Suppuration attended with gas formation has long been recognised. Rosenbach studied these phlegmons as they occur in different parts of the body and described what he designated as the " emphysema-bacillus," which he isolated on cover-slip preparations. Arloing described a gaseous panophthalmitis of traumatic origin. Levy, in 1891, isolated a short, fine, nonmobile ba- cillus from gas-bearing pus of a pelvic abscess. Other investigations have been made by William Koch, Kitasato, Wicklein, Chiari, and Frankel, the last named of whom isolated, from gas-producing pus, a short, plump, nonmobile bacillus with rounded ends to which he gave the name Bacillus phlegmonis emphysematosus. While to Frankel credit must be given for originality, priority of discovery must be given to Welch and Nuttall (Medical News, September 24, 1892), who isolated the organism which now stands in the literature by the name they gave it — viz., the Bacillus aerogenes capsulatus. Infection of the vagina, manifestly due to a gas former, was first described by Braun (Zeitschrift fur Gesammte der Aerzt im Wien, 1861). The infection manifests itself by the formation of cysts, or, more properly, air vesicles on the surface of the vagina and on the external mucous membrane of the cervix. These vesicles are close set, glistening, and vary in size from a millet to a hemp seed. When punc- tured, as a rule, nothing but air escapes from them; in a few cases, how- ever, the cysts have yielded a slight amount of pale yellow nbnviscid fluid. Of twenty-one cases collected by Herman, seventeen were in pregnant women. Zweifel (Archiv fur Gynakologie) analyzed the gas from these vesicles and found it to be trimethylamine. He made his tests by cleansing the vagina and then filling the speculum with test so- lutions under cover of which the vesicles were punctured. In this way he was able to eliminate ammonia, carbonic acid, coal gas, and hydric sulphide. The smell suggested the latter in small quantities. The odour was peculiarly like that of the plant Chenopodium vulvaria, which is due to trimethylamine. The treatment of this form of infection con- sists in puncturing the vesicles as they appear and washing their cav- ities and the vagina with antiseptic solutions. The vesicles show no disposition to return after being once punctured. Bilharzia of the vagina depends for its existence upon infection of that canal by the Distoma haematobium of Bilharz, an organism be- longing to the genus of distomatous parasites (Cobbold), and is a cylin- drical worm of the order Trematoda. The male is about half an inch long and the female is a little longer and more slender. It abounds in Africa, and when infecting the system it is generally found in the por- tal vessels, and in the veins of the mesentery and of the urinary tract, causing profound constitutional disturbances, hematuria, anaemia, and diarrhoea, being among the more prominent symptoms. This parasite generally affects men who work in water, and, in the majority of cases, produces serious local disturbances in the mucous membrane of the bladder, where it causes single or grouped excrescences, not unlike con- INFECTIONS OF THE EXTERNAL GENITAL ORGANS 181 dylomata, with or without pedicles, and varying both in shape and size. The mucous membrane is thickened and the submucous connective tis- sue is hypertrophied; the capillaries are dilated, in some instances being changed into cavities which contain full-grown specimens of the disto- ma. In the interior of these excrescences numerous ova are found. It is not surprising that an organism which infests the urinary tract of men should find its way into the vagina; and infections of that canal by this parasite are of occasional occurrence. The mucous membrane becomes greatly hypertrophied owing to papillomatous developments, the ex- crescences on the interior of the vagina being numerous and flat-topped, and divided by distinct depressions, while occasionally one of them may become large and pedunculated. The treatment consists in excising the excrescences, cauterizing their base, and treating the wounded surface with bichloride douches. It may be necessary, in removing the larger growths, to incise the mucous membrane so deeply as to render essential the closure of the wound by sutures. Chancroid, or soft chancre, is a local, contagious ulcer, which is not followed by infectious, constitutional symptoms. It occurs as the result of inoculation from another chancroid and is inflammatory in character, with destructive characteristics which never produce syphilitic or other systemic infection. It sometimes, however, causes inflammation of neighbouring lymphatic glands, resulting in their sup- puration — a condition called chancroidal bubo. It sometimes becomes serpiginous, spreading from its original place to the different parts of the pudendum, or even to the abdominal walls; or it may become very destructive, a condition designated phagedenic chancroid. Chan- croid is usually met with in the lowest class of society, where igno- rance and filth are found together. It is essentially a venereal dis- ease, as it is transmitted chiefly, if not exclusively, by the act of sexual intercourse. The secretion of the chancroid, or the pus of the chan- croidal bubo, is the carrier of the contagium. It has been demonstrated that the contagious germs of a soft chancre are contained in the lymphoid bodies or in the pus cells, inasmuch as the inoculation by filtered serum derived from these sources produces only negative results. One of the characteristics of chancroid is its self-inoculability, by which is meant that one surface primarily inoculated will, in turn, inoculate another surface with which it lies in contact. Immunity from such self-inoculation is never acquired. The communication of the infection from one surface to another requires the pre-existence of an abrasion, excoriation, or small fissure, through which the virus finds its entrance into the derma. In some cases the infectious ele- ment finds its way into the ducts of the excretory glands or into the hair follicles, producing round ulcers, called follicular ulcers, which indicate the channels through which the virus entered. Medi- ate contagion is more rare in chancroid than in syphilis. Any article, such as clothing or the seat of a water-closet soiled with purulent secretions from chancroids, it is said, may communicate the conta- 182 A TEXT-BOOK OF GYNECOLOGY gion, but Eavogli has never met a case in which he could verify this theory. Soft chancres may be found in women primarily at the ostium vaginae, on the fourchette, the vestibule, the clitoris, the labia majora, the labia minora, the perineum, the inner surface of the thighs, the two lower quadrants of the abdomen, and around and within the margins of the anus; and they appear, secondarily, by self-infection, upon proximal surfaces, and wherever the infection may be carried to a break in the protecting epithelium. On the labia they are gen- erally associated with follicular abscesses, oedema, and frequently with extensive destruction of tissue. Purulent secretion drying upon the surface occasions an eczematous appearance. The terms exulcerous, follicular, acneform, eczematous, erythematous, serpiginous, and phagedenic, have been applied to chancroids to distinguish obvious physical or clinical characteristics. The prevalence of chancroids varies in different localities, being more common in cities on the seashore than in those inland; and they are more prevalent in the crowded quarters than in the less densely populated districts. Eobert W. Taylor states that the examination of the yuellce publicce revealed the greater prevalence of chancroids among the women of the lowest grades, while there was relatively a greater prevalence of hard chancre among prostitutes who were better conditioned. Eavogli states that relatively few cases of soft chancre occur, annually, in his service at the Cincinnati Hospital, while they are very rare in his private practice. He finds, also, that in private practice they are liable to be of the mixed type. After a few weeks, instead of cicatrizing they become hard and syphilis follows, and for this reason he is cautious in giving an early diagnosis, particularly in the case of young subjects. Eavogli does not accept the theory that chancroids may be the result of pus from any other form of ulcera- tion associated with lack of cleanliness; nor does he believe that chancroid is caused by syphilis; but he concedes the possibility of mixed infection. The course of an ordinary chancroid covers a period of from two to three weeks, the time, however, being influenced by the habits and treatment of the patient. Lack of cleanliness, walking, and alcoholic drinks, prolong the period. Tissue destruction is less extensive and less rapid on the skin than on the mucous membrane. After the chancroid reaches a certain point, there is manifested a spontaneous tendency to repair. The inflammatory halo begins to fade, the oedema disappears, the grayish pseudomembrane at the bottom of the ulcer sloughs off, revealing abundant healthy granulations. The purulent secretion becomes thicker and of good colour. A ring of epithelium forms round the edges of the sore, gradually encroaching upon its centre, until it disappears under a film of newly formed scar tissue. At this point, or, at least, when near recovery, these ulcers may redevelop, manifesting all their original symptoms, the INFECTIONS OF THE EXTERNAL GENITAL ORGANS 1$3 relapse being caused by coitus, alcohol, or uncleanliness. The appar- ently healed ulcers may retain their contagiousness for a long time, and be capable of transmitting a disease. Bacteriology. — Ducrey discovered constant bacterial elements in chancroidal pus. He found in a series of inoculations of chancroid in man, that many microbes, originally in the pus, disappeared from it, but that a peculiar microbe remained constant and abundant so long- as the pus retained its virulence. His observations were supported by those of Unna, Kneftning, and others, all agreeing on the iden- tity of this micro-organism. Ducrey found it in chancroidal pus, and Unna detected it in the infected tissues. It is a rodlike bacillus, from 1.5 to 2 /x in length, and from 0.3 to 1 ft in breadth, with rounded ends. It has a tendency to form chains (strepto-bacillus) and to become agglomerated in masses. In the pus it occurs singly, but in the tissues it is always in chain form. It has been found almost constantly in chancroid: it is stained by carbolic-fuchsin, and by gentian violet, and is decolourized by Gram's method. Although it is a pus bacillus it is characteristic of soft chancre, because it has not been found under other conditions. Pathology. — Chancroidal virus begins its activity as soon as it finds an infection atrium, through which it gains access into the subepi- thelial layer; the ulceration on the surface of the skin appears later, but is more rapid in development on the vaginal mucosa. As a rule the virus manifests its activity by developing within from twenty-four to forty-eight hours a small pustule, surrounded by an intensely red inflam- matory halo. This stage, especially in the mucous membrane, is soon replaced by the characteristic ulceration, round or oval in shape, according to the conformation of the parts; thus, when de- veloped within a fold, it may take on a linear appearance, while on the inner aspects of the labia majora the ulcers may coalesce and be- come irregular. But wherever the chancroid occurs, or Avhatever its shape, the edges are sharply cut as if the disk could be readily punched out. The bottom of a chancroid is uneven, and, in the begin- ning, is covered with a kind of diphtheroid membrane consisting of necrotic tissue. The ulcer exudes abundant, thin, purulent secre- tion, sometimes of a rusty colour; the underlying cellular tissue is sometimes cedematous — particularly when the inflammation is intense, in which case the soft chancre manifests firmer consistence when taken between the fingers, which fact must not mislead the practi- tioner into mistaking the case for one of syphilis. The diagnosis of chancroids may be confusing in the earlier stages. They may then be mistaken for herpes, but the difference will be detectable by a careful examination of the lesions. Vesicles, a nonulcerated surface even when broken, smooth edges, and the coalescence of vesicles, are features of herpes. Sometimes chancroids are mistaken for syphilitic mucous patches; the development, size, in- duration, peculiar colour, elevation of the edges, and symptoms of 184 A TEXT-BOOK OF GYNECOLOGY syphilis, will, however, enable physicians to distinguish between the two conditions. If doubt still remains, recourse may be had to the crucial test of self-inoculation. The prognosis of chancroids is less favourable in women than in men. The conformation of the parts, the difficulty of cleansing them and of retaining dressings, the presence of urine and of the menstrual fluid, are all barriers to a speedy cure. Suppurative adenitis or buboes prolong the treatment. Phagedena, fortunately rare, is generally promptly overcome. In cases occurring in drunkards of lowered vitality, a guarded prognosis should be given. The treatment, to be effective, must be based upon the principle of cleanliness. Eavogli secures this in his hospital service by having the parts washed three times a day with hydrogen peroxide, dusted with iodoform powder, and covered with iodoform gauze. Cure is generally very prompt and free from complications, no buboes having developed in his wards. In rapidly progressive chancroids, cauteri- zation by carbolic acid or nitric acid should be practised. The sur- face should be first rendered insensitive with a 5-per-cent solution of cocaine hydrochloride. Care should be taken to protect the neigh- bouring parts from the action of the caustics. The use of carbolic acid is followed by a little secretion, and is less painful than nitric acid which causes sharp inflammatory reaction. After cauterization the ulcer is treated like any other granulating surface. Iodoform in private practice is objectionable because of its odour. Iodol, europhen, bismuth subiodide, have all been tried and discarded by Eavogli, who still uses aristol but deems it inferior to iodoform. Gaylord has used with success a 10- to 40-per-cent solution of formalin as an escharotic. Strong applications of this kind, however, have been generally aban- doned since the advent of iodoform. A 6- to 8-per-cent solution of sulphate of copper stimulates granulation. If the ulcer is sluggish in healing, it may be curetted. A well-regulated diet, improved hygiene, stimulants and tonics, are indicated in old run-down cases. Opiates are sometimes needed for pain, although hot water containing a little potassium permanganate or mercury bichloride, used in compresses, may be sufficient to allay the pain and to change an unhealthy to a healthy surface. Hard chancres in women are very frequent, their course is irregu- lar, and their diagnosis sometimes difficult. In some cases the chancre is so small and ephemeral that it is often overlooked; in others it is very pronounced, but on account of the associated inflammatory conditions, its exact nature is more or less obscured. In women, the characteristic induration of chancre is less pronounced than in men; occasionally, when located around the fourchette, it produces a hard thick cicatrix which may last for many months. The examination of the genitalia in women is sometimes difficult on account of the conformation of the parts, although in all cases it should be made with thoroughness. Chancres may be single or multiple, only one INFECTIONS OF THE EXTERNAL GENITAL ORGANS 185 being found in the majority of cases. For clinical purposes, chancres in women have been divided into (1) superficial or chancrous erosion; (2) scaling papule; (3) elevated papule, or ulcus elevatum; (4) incrusted chancre; (5) indurated nodules; (6) diffused exulcerated chancre. (1) Superficial, or chancrous erosion is the form most frequently met with in women. It is difficult to recognise in its earliest stages; it is always found on the surface of the mucous membrane, begin- ning as a red spot somewhat deeper in colour than the mucous mem- brane itself. It is liable to pass without notice, so that when first seen by the physician it is already deprived of its epithelium and manifests incipient ulceration. When it is seated on smooth sur- faces like the labia it is easily recognised, but when it is on the fourchette or within the ostium vaginae it is not easily discovered. The chancre is of red colour, round, with a smooth surface, from which oozes a thin serous secretion that assumes the appearance of true pus only in the presence of active inflammation. In these chancres, the induration is only superficial, of that kind which Fornia called chancre parchemine. The diagnosis of this form of chancre is not difficult when due attention is given to the foregoing appearances. The exact character of the trouble is established in the course of a few days when the lymphatic glands of the groin become involved. The course of this kind of chancre is rather short; it undergoes speedy involution, which accounts for the fact that constitutional symptoms of syphilis are manifested in some women in whom we are not able to find the initial sore. In many cases, however, after the disappear- ance of the chancre, there remains on the area that it occupied, a kind of red spot, very persistent, and lasting at times for months. This chancrous erosion, especially when located on the vulvar lips, produces a kind of chronic oedema of the underlying tissues, and sometimes of all the pudendal structures; it lasts frequently after the chancre has completely healed. When the primary ulcer is seated on the fourchette it assumes the typical induration of a hard chancre, pre- senting a raw-beef appearance characteristic of the initial syphilitic lesion. (2) The scaling papule may appear on the skin of the labia majora and of the labia minora as the initial syphilitic lesion. It is a small, dull-reddish papule, slightly elevated. It develops into an elevation of the skin, has a purplish brown colour, sharply defined edges, and in size varies from that of a split pea to that of a quarter of a dollar. It is round or oval according to the shape of the parts where it is located, and is firm, hard, and resistant to the touch. It is usually single, sometimes double, and gradually loses its epithelium, becoming ulcerated and incrusted, when it is called an ecthymatous chancre. (3) The elevated papule, or ulcus elevatum, begins as a chancrous erosion with hyperplastic infiltration, and grows to a considerable size. It is round or oval, deep red in colour, and has a smooth, velvety surface, flat or concave with distinctly elevated edges, and discharges a thin serous fluid. Irritation from walking 186 A TEXT-BOOK OF GYNECOLOGY or from uncleanliness may provoke inflammation, causing a pro- nounced oedema of the labium on which it is seated. Careful pal- pation will reveal a slight induration, parchmentlike in character. This condition is essentially chronic, lasting many weeks, resolving slowly, leaving a deep red spot which is replaced by a scar. (4) Incrusted chancre affects the cutaneous surface of the pudendum, beginning as a chancrous erosion or as an indurated nodule, and speedily developing a kind of film of a light, greenish, creamy tint, or, at other times, of a brownish red necrotic character. (5) The indurated nodule is rather rare in women and is found where the skin and mucous mem- brane join each other. It manifests itself as a sharply circumscribed mass of indurated tissue with a narrow base and sloping edges. (6) The diffiused exulcerated chancre is found in women of the lower class; it begins as a chancrous erosion, grows to an ulcus elevatum, and then spreads over an extensive area. It has an ulcerated and un- even surface, deep red in colour, but only slightly painful, although frequently associated with oedema of the part on which it is developed. The bacterial origin of syphilis, although very probable, has not been demonstrated. The analogy between syphilis and other diseases of known bacterial origin prompts the belief that the various phenomena of the disease depend upon a bacillus, not yet isolated, and its toxines. The pathologic changes occurring in indurated chancre are of an inflammatory character, and are accompanied in any stage of syphilis with a persistent involvement of the blood vessels; an infiltration of small round cells associated with those of larger size, and polyhedral in form, occurs in the meshes of the connective tissue surrounding the blood vessels. There is a constant tendency to the production of new connective tissue, especially in the initial chancre, and again in the later tertiary stage as manifested in the nervous system. The peri- vascular changes and the infiltration of the tissues beyond the chancre are the most important features of the initial sore. The lymph spaces are readily affected with the peculiar infiltration, the virus speedily travelling through this channel to the inguinal glands. The peripheral perivascular lymph spaces are infected by the time the chancre makes its appearance; and the first halt in the march of the virus is shown by the swelling and induration of the inguinal glands. Microscopically, a well-developed chancre reveals a seminecrotic mass of small sphe- roidal cells which constitute the bulk of the ulcer, circumvallated by a zone of oedema and a cellular infiltration of the papillary layer of the derma. This oedema acts as a wall to protect the surrounding healthy tissues from invasion. The virus, having entered the lym- phatics, passes from one gland to another until it reaches the general circulation. This occurrence marks the transition from the secondary, or incubation period, and the disease breaks out in the ordinary form of roseola with all the accompanying symptoms of chlorosis, neuralgia, syphilitic fever, etc. The female genitals, like any other part of the integument, may — INFECTIONS OF THE EXTERNAL GENITAL ORGANS 1ST show ever)' kind of eruption which results from the two morbid pro- cesses of hypersemia and infiltration. The hyperemia is mostly found in the early period of syphilis in the erythematous syphilides; the infiltration is always more advanced in the later stages. In the early eruptions, however, a slight cell infiltration is always present, giving rise to patches and nodules. In this stage of syphilis, Eavogli has repeatedly found a kind of infiltration of the skin of the labia rnajora and labia minora, just at their free edges, showing the epidermis slightly abraded and intermingled with superficial erosions; besides this slight thickening of the skin, the patches show a kind of dirty yellowish colour, and are accompanied with itching. Mucous patches or con- dylomata lata, are quite often found on the external genitals of women, during the first two years of the course of syphilis; this eruption is characteristic of syphilis, and when discovered settles all doubt relative to the diagnosis. Mucous patches, on account of their abundant secre- tion, are the most dangerous eruption for the transmission of syphilis. Ravogli is of the opinion that most cases of syphilis are communicated by mucous patches. They are found on the mucous membranes and on proximal surfaces of the skin which are continually moistened by perspiration. They begin on the skin as flat elevations, circular or dis- coid in form, and of different sizes, showing a depression in the centre with elevated borders; the epidermis in the centre is macerated by the moisture and is transformed into a grayish pellicle. This is soon cast off, leaving a plaque of a raw flesh-coloured appearance. This plaque secretes abundant serum, which .soon becomes altered and causes an offensive smell, and by irritating the skin induces intertrigo. Eavogli has observed a kind of contagiousness in these patches, mani- fested by the development of similar lesions on proximal cutaneous or mucous surfaces. They assume a variety of appearances, accord- ing to location and the local conditions to which they are subjected. On account of the presence of urine, perspiration, etc., they may de- velop superficial ulceration, manifested by an abundance of offensive, purulent secretion. As a result of persistent irritation, the patches may become uneven with a verrucous aspect, caused by hypertrophy of the papilla? of the derma, a hypertrophy which sometimes assumes a vegetating character (condylomata lata). These different appearances of mucous patches have caused authors to classify them as diphtheroid, ulcerative, vegetative, or hypertrophic. They are either round or oval in shape, according to the part upon which they are located; some- times they appear like ulcerated rliagades around the ostium vagina? or between the anal folds. On the mucous membranes, mucous patches have a kind of grayish appearance with marked edges slightly ex- coriated in the centre. The chronological period of mucous patches is the secondary stage from its beginning to its end. Eavogli (Monatshefte fur prahtisclie Dermatologie, 1893) observes that it is not rare to see patches on the tongue and in the mouth of syphilitic patients after four or five years following the primary infection, and 188 A TEXT-BOOK OF GYNECOLOGY in patients who are already manifesting tertiary symptoms. These lesions are sometimes the most stubborn manifestations of syphilis, as they show a tendency to frequent recurrence. When not properly treated, they may become hypertrophic, forming papillomatous masses which may persist for a long time. They usually disappear by a pro- cess of superficial ulceration and without leaving a scar. The anatomo- pathologic lesions of mucous patches consist in hypertrophy of the papillae, and in abundant infiltration of cells throughout the papil- lary layer and the corium. The mucous layer of the epidermis is also affected, showing a proliferation of the cells, and a granular change of their protoplasm that gives to the cells a peculiar appear- ance. In the ulcerated patches this becomes obscure. On account of the dusky appearance of the infiltrated papillae, the mucous layer in many points being absent, and the tips of the papillae mutilated by the ulcerative process, mucous patches when once seen and identified will always be recognised. There can be no doubt that they are an exclusive form of constitutional syphilis. We have already spoken of the acuminated condylomata, which are nonsyphilitic manifestations, and we have pointed out the charac- teristics which distinguish them from the condylomata, or mucous patches. It is possible to make a mistake only in cases of hypertrophic or vegetative mucous patches, but the absence of the pedicles, the characteristic ulceration, the abundant sero-purulent secretion, and the accompanying antisyphilitic symptoms, should be sufficient points of difference to establish the true diagnosis. Treatment. — It is beyond doubt that in order properly to treat mucous patches, a general antisyphilitic treatment must be adminis- tered. The choice of the antisyphilitic remedies is subject to the con- dition of the patient, to the period of syphilis, and so forth: and it would be entirely out of place to enter here into such a difficult and intricate question. The mucous patches require local treatment. Local treatment in a great many cases consists in the observance of the rules of cleanliness. The best treatment, in Eavogli's opinion, for mucous patches, is to wash the surface well with an antisyphilitic solution of mercury bichloride, 1 to 2,000, and, after a while, to dry and powder them with calomel. In some cases the mucous patches are extremely stubborn, with a tendency to ulceration and hypertrophy, and in these cases it is necessary to use caustics. The application of a 4-per-cent solution of acid nitrate of mercury produces a super- ficial cauterization, and we may be sure that after touching the mucous patches two or three times with this solution they will readily heal. Sometimes the mucous patches resist the application of the solution of acid nitrate of mercury, and in these cases it is necessary to resort to stronger caustics; then, nitric acid in full strength is useful for the destruction of these patches. The application of salves or plasters to mucous patches is not to be recommended, because they are found where the skin forms folds and is macerated by the per- INFECTIONS OF THE EXTERNAL GENITAL ORGANS 189 spiraticn; it is better, therefore, to use antiseptic bathing and the application of dry powder, which will prevent the accumulation of the perspiration. Late Syphilitic Ulcers of the Female Genitals. — Syphilitic ulcers of the vulva were studied in 1849 by Huguier, in his article on JEsthio- mene, or Dartre Rongeante de la region vulvo anale, Paris, 1849, and by Matthews Duncan in the Edinburgh Medical Journal, July, 1884. In the venereal ward of the Cincinnati Hospital, Eavogli has had occasion to observe a great many cases of extensive and deep ulcers of the vulva in dissolute women who have been admitted into that institution. He supports the opinion of Hyde in denying that those ulcers of the vulva have anything to do with lupus vulgaris, and thinks that there can be no doubt that the women have been affected with syphilis. He admits that the extreme destruction of the external geni- tals of women which are occasionally observed may be due, not to syphilis alone, but probably to syphilis in connection with tuberculosis; and he remembers one case in his service in which a large and deep ulcer had destroyed part of the labia minora and part of the entrance of the vagina. The woman died, and at the post-mortem the peri- neum was found to be studded with tubercles. Usually, these ulcers are found in weak patients, with a system run down from misery and debauchery. The ulcers are always seated on a strong and thick induration which is confined to one or both labia. This infiltration sometimes extends to the mons veneris, and may also spread downward to the perineal tissues. It is accompanied by a kind of hypertrophy which is felt deeply situated in all the tissues. On these indurated places, ulcers are found which are deep and destructive. One or both labia may be destroyed. Sometimes, when the ulceration affects the perineum, the destruction may extend to the anus producing altera- tion of its function. The edges of these ulcers slope to the bottom, which is red or grayish from necrotic detritus, without a tendency to the formation of healthy granulations. The destruction once begun goes on very rapidly, and it is a difficult task to stop its ravages. Says Eavogli: " In my experience I have found this form of vulvar syphilitic ulcers more frequent in the negro race than in the white race. The date of infection from syphilis was from six to twelve years. No enlarged glands could be found in the groins or in the cervical region, yet, in many of these women, deep scars could be found on the legs, witnesses of progressed gummata, and roughness of the tibia could be found, showing progressed specific periostitis. These ulcers are the result of late syphilis. They are the result of gummatous infil- tration, but there is no doubt that the general condition of these patients has a great deal to do with the virulence of syphilis." The prognosis of these ulcers must be given with great reserve. There are two principal elements for the production of the ulcers: First, advanced malignant syphilis; secondly, weakness of the general system. 190 A TEXT-BOOK OF GYNECOLOGY The treatment consists, first, in improving the general system with good diet, tonics, and better surroundings. Antisyphilitic treatment consists mostly in the administration of potassium or sodium iodide. Mercurials can scarcely be recommended on account of the weak and poor condition of the patients. Beneficial results follow applications of a solution of mercury bichloride, 1 to 2,000, and then covering the ulcerated and infiltrated surface with the emplastrum hydrargyri, which, producing an abundant suppuration, in a short time causes a sloughing out of all the detritus from the bottom of the ulcers. In the same way, the application of the emplastrum hydrargyri helps a great deal toward the absorption of the infiltration and oedema which form the base of these vulvar syphilitic ulcers. The washing with peroxide of hydrogen and the application of powdered iodoform have also given very good results, but only in later stages, when the em- plastrum hydrargyri had already diminished the infiltration. The curette has been used in cases where the surface has been covered with abundant ill-natured granulations. But with this exception, there is but little need for the curetting of such ulcers. The applica- tion of strong caustics, such as nitric acid and the actual cautery, has been tried only in those cases in which the destructive process had taken wide proportions. It is seldom necessary to resort to these means, particularly when good results are realized by the emplastrum hydrargyri. CHAPTER XVII DISEASES OF THE SKIN OF THE FEMALE GENITALS Intertrigo — Erythema — (Edema — Eczema — Folliculitis — Herpes progenitalis — Pru- ritus — Parasitic affections — Atrophy (Kraurosis) — Vulvar adhesions. The skin of the genitals of the woman is subject to all the diseases that are met with in the general integument, and, on account of their anatomical structure and position, some affections are more frequently found here than in other regions. Intertrigo. — This common affection is usually found in fleshy women. It is produced by the apposition of the surfaces of the skin of the thighs with each other and with the external portion of the labia majora, and is a result of friction. Under these circumstances perspira- tion is very abundant, and it macerates the epidermis and causes an inflammation of the skin, which in the beginning is limited to the de- gree of a simple erythema, but, continuing, reaches the degree of a true eczema. Indeed, in the beginning, the surface of the inguino-crural fold and of the labia is red and moist, and the epidermis appears slightly macerated. An itching and burning sensation is associated with the affection. If promptly treated the skin returns to the normal condition in a short time. If the affection is allowed to continue, then, on account of the profuse perspiration and of its chemical changes, associated with impurities and uncleanliness, the epidermis is deeply macerated, the sur- face is excoriated, oozing a serum which starches the linen, and the patient can scarcely move on account of the pain produced by the motion on the inflamed skin. Although the affection is called eczema intertrigo, Eavogii does not consider it a true eczema. Eczema may be the consequence of the intertrigo, just as it may follow any other irrita- tion of the skin. Vulvar intertrigo is caused by gonorrhoea, syphilis, or the accumula- tion of nonspecific but irritating secretions, in the cutaneous folds of the pudenda and groins. The large quantity of sero-purulent secre- tion oozing out of the vagina in cases of gonorrhoea, moistens the skin of the genitals and of the thighs, and by its irritating qualities causes intertriginous eruption. This intertrigo is also found in patients who observe strict cleanliness. In women neglectful of the principles of hygiene the intertrigo assumes a much more aggravated form. In the first case the affection is limited to the front part of the genitals, labia majora, labia minora, and clitoris with its prepuce, as a result of 191 192 A TEXT-BOOK OF GYNECOLOGY the contact of the gonorrhoea! fluid on the skin. In the second case in- tertrigo is spread more on the internal surface of the thighs and of the labia majora in the fossa genito-cruralis, in consequence, not merely of the presence of the purulent secretion, but also of the friction of the two surfaces of the skin, which become macerated by the purulent secretion, perspiration, and other impurities. Intertrigo in these cases is acute, the surface of the affected skin is red and somewhat swollen; the epidermis is macerated, giving it a whitish, soggy appearance; abrasions and small rhagades are formed on the labia majora, in an oblique direc- tion toward the fossa genito-cruralis; the surface is always moist from the discharge of serum, which, together with the gonorrhoeal secretion and the perspiration, produces an offensive smell. A burning sensation accompanies the course of the affection, and motion makes it so painful that the woman can scarcely walk. Another form of intertrigo, more chronic in form but occurring under the same circumstances, was recently described by L. Brocq and Leon Bernard (Annates de dermatologie et de syphiligraphie, 1899, fasc. 1, 3). It is limited to the genito-crural fossa, and when the woman is placed in the position used for the speculum examination, it appears like a triangle with the base at the fossa and the apex downward on the upper lateral side of the thighs. The skin is of an intensely dark-red colour, showing deep furrows in an oblique direction, and between them follicles can be seen. The pigmentation is very deep, due partly to the inflammatory process and partly to the chromatogenous condition of these regions. A kind of small, flat, papillary growth can be seen on the surface like a lichenization, which is due to a proliferation of the connective tissues in the papillae with some hypertrophy of the epider- mic layers. The pathology of this affection is limited to the epidermis and to the superficial layer of the derma. They are the same as are found in any other inflammatory disease of the skin, hyperaemia, overfilling of the blood vessels, which is the cause of the inflammatory redness, and swelling. In consequence, after increased pressure in the blood vessels, some exudation of serum and of the white corpuscles of the blood takes place through the walls of the blood vessels. The small round inflam- matory cells and the white corpuscles of the blood infiltrate the papil- lary layer, and so increase the nutrition of their connective tissues. The epidermic cells are macerated by the presence of the exudation, and the horny lajer is easily detached by the other epidermic layers, and in this wajr excoriations are formed. On the other hand, when the inflam- matory process lasts for a long time the papillae become infiltrated with cells, and their connective-tissue corpuscles may increase in their nutri- tion and proliferate, producing small flat papillary warts as a conse- quence of the irritation. The diagnosis of intertrigo by pathologic alterations from eczema and dermatitis is an impossibility. Eavogli, in reply to the ques- tion whether this affection, being of an inflammatory character, is DISEASES OF THE SKIN OF THE FEMALE GENITALS 193 to be classified as an eczema or a dermatitis, replies: It is a question of degree; it progresses from a pale rose-red colour to a deep reddish-violet colour. From a scarcely perceptible swelling it may attain a thick and pronounced (Edematous condition, and in the same way there can be a thin, serous, scanty discharge, while in other cases an abundant, copious discharge exudes, which wets the linen of the patient. He believes, therefore, that the name intertrigo is well adapted. It gives the idea of the affection as the result of the friction of two cutaneous surfaces, and of the possibility of curing it in a short time by preventing the contact of the cutaneous surface. It is of a rather peculiar nature and has to be referred to dermatitis. Intertrigo is also found in syphilitic women, often accompanying the presence of mucous patches in the secondary stage. The secretion oozing from syphilitic eruptions, which in that re- gion usually are ulcerated, causes the maceration of the epidermis, and intertrigo is the result. In these cases the first thing to do is to treat the mucous patches, and with cleanliness the intertrigo easily disappears. In the same way, for the intertrigo accompanying an acute gonor- rhoea, the first indication is to treat the gonorrhoea and prevent the gon- orrheal fluid from remaining on the skin of the external genitals. Al- though cleanliness may be maintained, and the improvement of the acute gonorrhoea be effected, yet the intertrigo left to itself will not heal, and it requires some attention and some local applications in order to bring about recovery. Treatment. — In intertrigo cleanliness must be observed, so as to re- move all impurities from the irritated surfaces of the skin. After wash- ing and drying, the surface is covered with rice powder or starch pow- der, to which may be added a small quantity of boric or salicylic acid (2 to 100). When the epidermis is excoriated, the surface is sore and there is a great deal of serous secretion. Eavogli finds of great advantage the use of bathing with some astringent solution. The solution of sub- acetate of aluminum and lead, known as Burow's solution, 3 per cent, applied on lint, in order to separate the skin surfaces from each other, is very beneficial. If the patient can remain in bed, with a few appli- cations of this solution the intertrigo will easily disappear; but if the patient must attend to her occupations, then bathing may take place morning and evening, and during the day some salve may be applied, such as Wilson's ointment, or an ointment of — I£ Zinci oxidi, ) __ ,_ Bismuthi subcarbonatis, f Acidi carbolici gtt. x; Vaselini gj. M. Fiat unguentum. This can be rubbed on the surface, and particularly upon the labia majora, which should be kept separated from the thighs by means of soft lint. 14 194 A TEXT-BOOK OF GYNECOLOGY In chronic intertrigo with papillary hypertrophy it is necessary to use more active remedies. Two or three applications of Wilkinson's ointment — 1^ Sulphuris sublimati, ) Picis liquidae, > aa, 3vj; Saponis viridis, ) Terrae albae 3iij; Aclipis suis gj. M. Fiat unguentum. have given good results, for by causing the desquamation of the old epidermis we obtain a new soft epidermis. The application of a re- sorcin salve can also be recommended. IJ Eesorcini 3ss.; Acidi salicylici gr. vj; Vaselini flavi §j. M. Fiat unguentum. When the epidermis has returned to its normal condition and the serous secretion has stopped, the only way to finish the treatment and prevent any relapses is to use scrupulous cleanliness, and after washing, to dust the genitals and genito-crural region with one of the recom- mended dusting powders. Erythema. — The skin of the genitals of the woman is often the seat of erythema, the result of various causes. Obstinate erythema affects the female genitals in consequence of glycosuria, and indeed it is the duty of the physician when he finds cases of erythema localized in the genitals to examine the urine. In these cases the labia minora are red and slightly swollen, the labia majora are red and swollen, the colour is rose-red, of an intense hue, and the epidermis, distended from the scanty exudation of serum, takes on a smooth, silky, and glossy appear- ance. This erythema sometimes spreads to the internal surface of the thighs, but in the usual eases it remains limited to the genitals. Ex- coriations are found on the reddened and swollen surface of the skin, produced by the act of scratching, because this glycosuric erythema is often accompanied by a persistent itching sensation — pruritus vulvae. Pruritius is in these cases very intense, and the patient can not restrain herself from scratching in order to stop this disagreeable itching sensa- tion. This deprives the sufferers of their sleep at night, and the con- stant scratching irritates the skin so much that it produces a persistent oedema or pustules, and superficial ulcerations. The presence of sugar in the urine, moistening the mucous mem- brane and the skin of the genitals, is the cause of the erythema. - It must not be forgotten, however, that the tissues of glycosuric persons offer a good ground for the development of the pus germs, and as a result they are often troubled with persistent furunculosis. DISEASES OF THE SKIN OF THE FEMALE GENITALS 195 Treatment. — Although it is difficult to cure this erythema on ac- count of its persistent cause, yet great benefit can be obtained from general and local treatment. For the first object, it is necessary to sub- ject the patient to the ordinary diet of diabetics, by forbidding all amy- laceous food and thus diminishing the quantity of sugar in the urine. These dietetic rules must be accompanied by the use of some mild purgative mineral waters, like Carlsbad, Apenta, Hunyadi Janos, Blue Lick, Congress, etc., taken regularly every morning in a dose of from half a glass to one glass, according to the tolerance of the patient. For local treatment the most important rule to follow is cleanliness. The external genitalia and the vagina are to be thoroughly washed with green soap and water and then irrigated with a 2-per-cent solution of carbolic acid. The patient is advised to remain in bed and apply com- presses with liniment of oil and limewater, to which may be added from 2 to 4 per cent of ichthyol. When the patient gets up she may make an application of Wilson's salve or the suggested formula of oxide of zinc and subcarbonate of bismuth. Lassar recommends the following formula : ~Ep Acidi phenylici 1 to 2 parts; Hydrargyri sulphidi rubri 1 part; Sulphuris sublimati 25 parts; Vaselini Americani 100 " Olei bergamottee gtt. xxx. M. Fiat unguentum. This mixture, as it contains a great quantity of sulphur, without causing irritation prevents the development of the pus germs which so often occur in the skin of diabetic persons. (Edema of the vulva may depend upon any of the conditions that interfere with the free circulation of the blood in the vulva, only a few of which are here considered. In cases of oedema of the legs as a con- sequence of heart disease or of general anasarca, the skin of the geni- tals of the woman is oedematous, swollen, of a waxy rose-red colour, the labia majora protrude in a round shape, and are sometimes painful on account of the acute distention of the skin. The labia minora and the clitoris are also swollen, presenting the same appearance; the thighs, which are also in an oedematous condition, do not permit the woman to bring the legs close together. There are, however, cases of oedema localized in the genitals of the woman of angioneurotic ori- gin, as described by Quincke, Jamison, and others. This oedema comes in the form of repeated attacks, which are often preceded by general malaise, vomiting, or diarrhoea. (Edema occurs in the form of a local- ized swelling of a whitish waxy rose-colour, with a certain brillianc}^ of the affected skin; it appears in different regions of the body, and the genitals may be included. Eavogli has observed a woman subject to attacks of this affection which could with propriety be called the giant urticaria of Wilson. The swelling in this case was limited to the 196 A TEXT-BOOK OF GYNECOLOGY right labium, assuming the size of a fist, and it was accompanied by some pain and an itching sensation. It lasted for several hours and then gradually disappeared without leaving any trace. It is easy to understand that the swelling was due to an effusion of serum in the meshes of the connective tissues of the derma and of the subcutaneous tissue, and that the acute oedema was the result of an angeioneurotic affection, as the patient had frequently had similar localized oedema on half of her face and on her left shoulder. (Edema of the vulva as a result of passive hyperemia has been ob- served by Eavogli, in the practice of Fackler, in a case of Eaynaud's disease. One of the labia majora was bluish, red, and swollen, with a sloughing patch of superficial gangrene, together with the same as- phyctic symptoms in several toes. (Edema accompanied by stasis sometimes appears in one labium on account of a hard chancre concealed in the internal surface of the labium or in one side of the ostium vaginae. In this case oedema affects only one labium, which is of a bluish-red hue, showing the location of the obstacle to the circulation. It is scarcely necessary to say that as soon as the chancre begins to heal up the oedema dis- appears. Treatment. — In cases of oedema of the genitals accompanying ana- sarca, the treatment has to be directed to relieve the general condition, but the local disturbance must not be neglected. The application, in the form of compresses, of mild astringent solutions, like Burow's solu- tion in a strength of 3 per cent, or Goulard's lotion, has been found very beneficial. In the same way, when stopping the application of the compresses, the use of dusting powder, as starch or rice powder, with the addition of 3 per cent of boric or salicylic acid, is found of great service. The nurse should apply soft linen pieces between the folds of the skin, thus preventing the surfaces from rubbing each other and causing intertrigo, which often complicates oedema of the vulva. Eczema of the Vulva. — Like any other part of the body, the skin of the female genitals is subject to eczema in acute and chronic forms. In speaking of intertrigo it was mentioned that, in consequence of the neglect of care and cleanliness, it may be the starting point of an eczema. In the same way, in cases of pruritus vulvae, the irritation caused on the skin by the continuous rubbing and scratching may be the direct cause of eczema of this region. The propagation of the Staphylococcus pyogenes aTbus on the deeper layers of the skin is to be recognised as the chief causative factor. Acute eczema may affect the vulva, implicating the labia majora and minora, clitoris, and the mucous membrane of the vagina, spreading along the periphery to the upper portion of the thighs. Along with the burning and itching sensation, a diffused redness and swelling affects the parts mentioned, and presently small vesicles appear, which soon break, causing a discharge of serum, which moistens the linen. DISEASES OF THE SKIN OP THE FEMALE GEXITALS 197 Chronic eczema, however, is the form more often met with when localized upon the female genitals. It often occurs in the form of ec- zema rubrum, affecting the labia majora, labia minora, and the mucous membrane of the vagina. The labia majora are red, swollen, and infil- trated, and, in consequence, the rima vulvae is opened by the distention of the labia. On account of the unbearable itching sensation numerous excoriations are produced by the action of scratching and rubbing. In many cases the eczema spreads to the upper portion of the thighs and also to the mons veneris. On account of the spreading of the affec- tion to the vagina, an abundant secretion oozes out of the genitals, which increases the intensity of the affection. In order to be sure that the secretion is not of a venereal origin, Eavogli always makes a micro- scopic examination of it so as to exclude the possibility of the existence of gonorrhoea. Eczema of the vulva may, by continuity, very easily spread to the perineum and to the anus. The parts are red, thick, and excoriated, and serum oozes from the excoriations. Sometimes the excoriations are covered with crusts, but where there are opposing surfaces these become more or less glued. At other times no discharge takes place; the skin is rough, dry, and slightly scaly. It is always accompanied by a violent itching sensation, which causes great misery. This form of eczema may be the result of a local irritation, leucorrhcea and gonor- rhoea being the most effective factors; or it may be the result of the scratching and tearing of the skin incident to intertrigo. It may also be of reflex origin, or it may be referable to the presence of uterine dis- orders. Treatment. — Eavogli has always obtained good results by the appli- cation of ichthyol in different formulae. First, care has to be taken to improve the condition of the vagina by means of irrigations with a solution of biborate of sodium, which the patient will repeat twice a day. Every other day Eavogli inserts into the vagina a tampon satu- rated with a mixture of 25-per-cent ichthyol in vaseline or glyc- erine, which the patient will leave in the vagina for twelve hours. Ex- ternally he directs the patient to apply for a few minutes a solution of carbolic acid, which relieves the itching sensation and sterilizes the affected skin. The formula which he employs is: 1^ Acidi carbolici oj; Glycerini 5ij ; Alcoholis §ij; Aquae rosae giv. M. Fiat linimentum. At first the patient complains of some burning sensation, but she is soon willing to repeat the application for the relief which it affords to the itching. After this application the patient is directed to apply pieces of lint well saturated with the following liniment: 198 A TEXT-BOOK OF GYNECOLOGY ^ Ichthyolis 3ij; Olei amygdalae dulcis, | __ _. a i- /■ aa t)ivi Aquae calcis, ) Glycerini, Aquae ros; M. Fiat linimentum. . aa 51. Aquae rosae, ' The use of salves is to be avoided in this condition, because the abundant secretion, together with the salve, makes rather an irritant mixture. After the repeated applications of the ichthyol liniment in the manner described, the surface of the skin begins to heal up, the itching sensation greatly diminishes, the swelling and the redness nearly sub- side, and at this point there may be applied a salve of oxide of zinc, which will finish the treatment. The formula for this salve is: I£ Zinci oxidi, ) _ r - . Bismuthi subcarbonatis, j Acidi carbolici gtt. x; Vaselini flavi §j. M. Fiat unguentum. When the skin has returned to its normal condition it will retain some redness as the result of the past trouble, for the relief of which Ravogli advises the patient to continue the use of the lotion of carbolic acid twice a day, and, after drying the surface, to dust the skin with an innocent powder, as starch or rice powder, to which some oxide of zinc or subcarbonate of bismuth may be added. Folliculitis. — Either in consequence of an eczema or without a known cause, an inflammatory process may invade the follicles of the hairs which cover the female genitals. The affection is rather rare, as Ravogli has met with this condition in only two cases, where the female genitals presented the exact appearance of sycosis. It is an in- flammatory affection in a subacute or chronic form, affecting the con- nective tissue of the hair follicles and also of the sebaceous glands connected with them. Bacteriological studies have recently explained that, like sycosis of the beard, folliculitis may be of double origin, either the result of the fungus of the ringworm or the result of the development of the pus germs in the follicle of the hair. In both cases which Ravogli had occa- sion to study, the pus cocci were the cause of the disease. In both cases the affection started from a superficial eczema and had developed until the surface gradually became covered with pustules, conical in shape, each one having a hair in the middle. It is easy to understand how the pus germs find their way into the follicles of the hair. The opening from which the hair passes through the epidermis is lined with epidermic cells, forming a kind of funnel around the shaft of the hair. According to Bockhart, the pus germs DISEASES OF THE SKIN OF THE FEMALE GENITALS 199 capable of producing this affection are the Staphylococcus albus, aureus, and citreus, the same that can produce impetigo and furun- culosis. On account of an inflammatory process, especially eczema, the germs find the follicular openings more easy of access than in the nor- mal condition, and insinuate themselves into the follicles, thus causing inflammation of the tissues forming the follicle of the hair, and of the surrounding tissues. It will be seen that this is nothing more than a spreading of the process by continuity, when it is remembered that eczema is only the result of the production and development of the Staphylococcus pyogenes albus in the layers of the epidermis. The hair follicle, inflamed and swollen, is converted into a small abscess, as proved by Wertheim. A transudation of serum and white corpuscles of the blood takes place in the hair follicle, producing a hydropic condition of the membranes covering the root of the hair. The root is softened and swollen by sero-purulent infiltration, and in consequence the hair is easily removed, having no adherence. The papilla is usually spared from destruction, and this is the reason why in all cases of sycosis the hair is easily reproduced. Symptoms. — As in ordinary cases of sycosis, the folliculitis of the female genitals is revealed by the presence of pustules or papulo-pus- tules, each one being perforated by a hair. The pustules are conical in shape and contain a drop of pus at the point surrounding the shaft of the hair. The skin of the labia majora and of the mons veneris, when affected with folliculitis, is usually red and inflamed. This is accompanied by a burning and itching sensation. This affection is often associated with boils in the same region or in the neighbouring parts of the thighs or abdomen, caused by the inoculation with the staphylococci effected by the finger nails in the act of scratching. This affection of the follicles of the hair of the woman's genitals, although chronic and obstinate, is not so difficult to treat as sycosis of the beard. It may be said that without the necessity of removing the hair, either by shaving or by epilation, this disease can easily be treated, yielding readily in a few weeks to the action of remedies. Treatment. — Of course the general system should not be neglected, although the disease is a local one. The condition of resistance of the organism to the development of the pus germs is very important, and when we begin the treatment it is necessary to establish a plan of gen- eral medication. If the patient is in an anaemic condition, prescribe ferruginous and tonic preparations; if she is suffering from a scrofulous condition, the use of cod-liver oil will be of great advantage. In case the woman is inclined to gout, or if she perspires a great deal, we must prescribe anti-gout remedies, such as lithia, salol, salicylates, etc. The local treatment consists in enforcing rules of cleanliness. Ravogli uses with good results an application of compresses well satu- rated in an astringent and antiseptic solution, and frequently repeated; also compresses saturated with a mild solution of bichloride of mer- cury (1 to 1,000) for half an hour twice a day, followed by the applica- 200 A TEXT-BOOK OF GYNECOLOGY tion of a salve, such as Wilson's ointment. In more stubborn cases the following formula can be used with good results: If Acidi carbolici gr. v; Bismuthi subnitratis oss.; Unguenti hydrargyri ammoniati oij ; Unguenti aquae rosse 5iv. M. Fiat unguentum. The application of ichythol is highly recommended. This is used in liniment form applied on lint, or in the form of salve, 10 per cent, in association with zinc ointment and 2 per cent beta-naphthol. Salves containing sulphur, from 4 to 6 per cent, are also found very useful. It can be applied in the form of Lassar's paste : I£ Sulphuris sublimati, ) Zinci oxidi, I aa 5j ; Amyli oryzse, ) Acidi salicylici gr. x; Vaselini §j. M. With this treatment and without any necessity of epilating, as in the case of sycosis of the beard, we can obtain good results in a short time. Herpes Progenitalis. — An eruption of vesicles disposed in groups, in an acute form, is often found on the genitals of women. It corresponds to the herpes preputialis which, with the same frequency, occurs in the male sex. This eruption appears on the internal surface of the labia majora, on the labia minora, on the vestibule and prepuce of the clitoris, at the orifice of the urethra, occasionally on the external sur- face of the labia majora, and at times it spreads to the mons veneris. Eavogli has twice seen groups of vesicles on the cervix uteri, corre- sponding with the observations of Bergh (tlber Herpes Menstrualis, Monatshefte fur Praktisclie Dermatologie, 1890), who has seen similar eruptions, sometimes accompanied by herpes of the vulva. Before the outbreak of the vesicles there are in most cases slight burning and itching sensations. Only rarely is the itching very pro- nounced, and it accompanies the course of the affection. The eruption consists of a single vesicle, or of a group of vesicles closely arranged, or of vesicles scattered on the surface following the ramification of a nerve. It begins as a red patch, which in a few hours shows vesicles. These are usually small, from the size of a pinhead to that of a hempseed, round, transparent, containing clear serum. When affecting the mucous membrane, on account of the succulence and the thinness of the epithelium they soon break, while on the skin they re- main longer. Their contents become turbid and soon form brownish- yellow crusts. DISEASES OF THE SKIN OF THE FEMALE GENITALS 201 When the herpes is seated on the labia minora it may cause oedema of these parts, on account of the tenderness and laxity of their tissues. The vesicles when broken leave a superficial exulceration corresponding to the size of the vesicle. The bottom is of a rose-red colour, some- times covered with yellow detritus, with the edges cleanly cut, but not deep, and never as in chancroid. They are usually arranged in a group, and when broken the remaining exulcerations coalesce into one patch with festooned edges, reminding one of the round pre-existing vesicles. The vesicles are seated on an inflammatory base and heal up usually in a few days; in some cases they are persistent; in rare cases they become ulcerated, and it is difficult to distinguish them from a chancroid. Un- cleanliness and the presence of gonorrhoeal fluid sometimes irritate the resulting exulcerations of the vesicles and make them persistent. Herpes is inclined to relapse at different intervals, but relapses in women are not so frequent as in men. The causes of herpes progenitalis are difficult to determine. Usu- ally this affection is the consequence of an irritation or congestion of the sexual organs. In neurotic women it is found in connection with menstruation, so that nearly every month it is reproduced. In puellce publico? cases of herpes progenitalis are often met with on account of frequent and forced coitus, and also on account of disproportion of the parts. Herpes often appears in cases of gonorrhoeal inflammation of the female genitals, and is often the result of endometritis, salpingitis, and oophoritis. It may be considered as an abortive zoster, proceeding from irritation and the nervous ramifications of the pudenda, and some- times it shows this clearly by the disposition of the eruptive patches. Although herpes progenitalis has been often suspected to be the result of the presence of cocci, yet so far there is nothing positive in this regard. Eohrer (Monatshefte fur Praktische Dermatologie, 1888) found very few diplococci in the serum of the vesicles, and Pfeiffer (ibid., 1887) in a case of menstrual herpes could not find any micro- organisms. The diagnosis of herpes progenitalis is easily made if the vesicles are still present. When, however, the vesicles are broken and an ulceration remains, there may be some difficulty in distinguishing herpes from venereal or syphilitic ulcerations. The superficial character of the lesion, the scanty serous secretion, the peculiar round disposition of the edges, the smoothness of the surface, are characteristics enough to show us that we have to do with a case of herpes. Sometimes, however, a hard chancre in its erosive stage has been mistaken for herpes. (See Syphilis of the Vulva). In women, in whom, especially, the hardness of the lesion is often not clear, we lack one of the most important char- acteristics for diagnosis. The surface of a chancrous erosion is usually deeper in colour, round in shape, with a smooth surface, and is found in places where the herpes does not usually appear, as in the fourchette and in the ostium vaginae. With reference to the possible confusion of herpes with chancroid, 202 A TEXT-BOOK OF GYNECOLOGY it is difficult for it to occur when we keep in mind the appearance of the chancroid lesion, which is the most reliable diagnostic by itself. Indeed, the punched-out, round, irregular, or ragged, often undermined ulcer, which rapidly spreads, accompanied with abundant secretion, and exhibiting an unhealthy, diphtheroid, worm-eaten surface, can not admit of confusion. At any rate, especially in the beginning, when no other diagnostic characteristics are present, in case of doubt it is better to suspend diagnosis, being sure that, on the following day, the doubt will be dispelled. Treatment. — As already stated, the use of douches with warm water, having in solution some borate of sodium or any other mild antiseptic, is advised. The general health of the patient must receive its proper care, and the use of mild saline purgatives is advisable when an- noyed with constipation, alkaline mineral waters when troubled with catarrhal conditions of the digestive organs, iron tonics and recon- structives when symptoms of anaemia and general denutrition are pres- ent. Locally, the application of a wash containing lead and opium is very useful, especially when the herpetic eruption is accompanied with pain and irritation. Touching the ulcerated surface with a solution of nitrate of silver, from 6 to 8 per cent, has given very satisfac- tory results. The surface is then covered with an innocent salve, as Wilson's ointment, or with vaseline containing some carbolic or sali- cylic acid. The application of powders is also used with some benefit. Iodoform is objectionable because of its odour; but aristol and euro- phen are applied with advantage on the exulcerated surface. The pow- ders have the disadvantage that they form crusts with the secretion, which soil the exulcerated surface. Eavogli prefers the use of powders when the surface is healing, at which time the parts may be dusted with oxide of zinc, subnitrate of bismuth, rice powder, or any other substance capable of keeping the surfaces' dry and separated. The application of camphorated alcohol has been used as an abor- tive measure, and in the same way Depas, of Lille, advocates the applica- tion of compresses of absolute alcohol, to which 2 per cent of resorcin and 1 per cent each of menthol and carbolic acid are added. Pruritus Vulvae. — In this affection there is no apparent eruption on the genitals; it is characterized only by an intense itching sensation of the vulva and of the vagina without apparent external causes. In cases of the presence of eczema, of lichen, prurigo, or of insects, the itching is due alike to the alteration of the skin and to the irritation of the insects; but in cases of pruritus vulvae the itching is the only symptom — one so persistent and so intense that it compels the woman to scratch and to rub the genitals, producing excoriations. If this condition lasts some time, then eczema, inflammation, swelling, and oedema of the skin of the genitals are often found, caused by the scratching and tearing of the skin. The continuous itching and the desire to scratch and rub the genitals makes the woman inclined to masturbation or to coitus, rendering her hysterical and nymphomani- DISEASES OF THE SKIN OP THE FEMALE GENITALS 203 acal. The irritation from scratching and the inflammatory process of the external genitals spread to the mucous membrane of the vagina and cause a catarrhal discharge from this organ, which increases the itching sensation. Pruritus vulva? is more often met with at the time of the menopause in women who are of nervous disposition or suffering from the recog- nised neuroses. At other times it is a premonitory symptom of a great many lesions of these organs, as fibroma, and sometimes of carcinoma. The pathology of pruritus vulvse has been carefully studied by J. C. Webster. (Transactions of the Edinburgh Obstetrical Society, 1890-'91.) As regards the naked-eye appearances, there may be more or less hypertrophy, or none at all. As regards the hypertrophy in such cases, it is impossible to say whether it is to be associated with the primary pruritus or to be regarded as resulting from continued rubbing and scratching. It is not a constant factor. There are also many cases of simple hypertrophy without any accompanying itchiness. The micro- scopical changes found in the tissues removed in Webster's cases were of great interest, and were probably the cause of the disease. These changes were of the nature of a slowly progressing fibrosis, affecting chiefly the nerves and nerve endings of the clitoris and labia minora. Many of the nerves, if traced from deeper parts toward their termi- nations, were seen to acquire a dense fibrous character, some appear- ing as well-marked fibrous cords, the nerve fibres being compressed or destroyed. In some cases they could be followed to their special end corpuscles, which also showed the same changes. The changes were most marked in the clitoris. The Pacinian corpuscles did not appear to be affected, save in one instance where there were an abnormal number of cells in the central core. Some globular end bulbs showed an increased number of cells; others appeared as dense fibrous knobs. Some of the genital corpuscles showed the change in a marked degree, the windings of the terminal nerve fibres being often almost obliterated. The changes found in the connective-tissue framework of the clitoris and nymphse were different, being of a subacute inflammatory nature, and evidently more recent in origin than those found in the nervous structures. They were found most marked in the corium under the papillae, and affected especially the prepuce and nymph se, being found in the clitoris only in the glans under the epithelium, and much less marked than in the labia minora. In the corium of the latter were seen many minute vessels with abun- dant exudation of leucocytes into the perivascular lymphatics, while in many parts the subepithelial tissue was a mass of leucocytes and prolif- erating connective-tissue corpuscles. These changes were most marked in the hypertrophic nymphge. They were distinct from the chronic fibrosis affecting the nervous structures, and were, no doubt, due to the long-continued irritation of the scratching. They affected chiefly the superficial parts — viz., the prepuce and nymphae — the nerve fibrosis being most marked in the clitoris, in which there were only a very few 204 A TEXT-BOOK OF GYNECOLOGY acute or subacute changes under the epithelium covering the surface of the glans. The causation of pruritus vulvae has always been shrouded in more or less mystery. While it is true that it is only a symptom, its pres- ence does not imply the existence as a cause of any of the recognised pruriginous diseases of the skin of the vulva. It is true that in these affections itching is a conspicuous and aggravating symptom, but it is one the existence of which is explained by manifest pathologic changes. In pruritus vulvae there are no such obvious changes; or, if there are, they are as liable to be consequences as causes. Bronson considers a general neurotic condition, either congenital or acquired, as a predisposing cause, and recognises a state of impaired conduction in the nerve of tactile sense as another causative factor. Though this usually occurs as a concomitant of hyperesthesia of the skin, it is pos- sible that it may exist independently of the latter, particularly in the atrophic changes of old age, while among the exciting causes he speaks of irritations transmitted from nerve centres, direct or local irritations, from irritants applied to the skin, or from intracutaneous sources, such as the lesions of trophic cutaneous diseases and their products; toxic or noxious materials deposited from the blood; effects of local nutritive disturbance or deranged metabolism in the cutaneous sensory nerves; and, finally, spastic contraction of the arrectores pilorum muscles. While this summarization of the etiology of the disease deals largely with more or less speculative pathology, it is still suggestive of what closer observation may prove to be the real causation of the disease. Ravogli, in common with other observers, recognises diabetes, or rather diabetic urine, as an exciting cause. Feinberg (Centralblatt fur Gynd- kohgie) described two cases of idiopathic pruritus vulvae, occurring during the course of pregnancy, in which the aggravating symptoms subsided after parturition. Treatment consists in cold applications, alcoholic or ethereal, in the form of compresses applied on the genitals. Cold is more apt to relieve the itching than warm applications. In these solutions some carbolic or salicylic acid may be dissolved in the ratio of 2 per cent, and in these cases affords some benefit. Sitz baths with warm water, to which some bran has been added or some sodium bicarbonate, are to be rec- ommended. In the same way the application of vaginal douches with mild solution of borate of sodium, alum, etc., are beneficial; these douches should be followed by the application of tampons dipped in some ointment containing opium; but the application which in Eavog- li's hands has been most frequently successful is a tampon dipped in ichthyol (25 to 50 per cent) and glycerine. In very severe cases resort to suppositories of cacao butter with one fifth of a grain of morphine or cocaine has been recommended. Kholmogoroff reports success from the use of galvanism with the positive electrode, insulated to its distal tip, introduced 4 or 5 centi- metres within the vagina, while the negative, covered with chamois DISEASES OP THE SKIN OF THE FEMALE GENITALS 205 and moistened with a salt solution, was applied over the affected area. It should be remembered in this connection that chamois repeatedly applied to the skin may become infected and itself become the carrier of infection. Heidenhain applies compresses wet with a hot solution of a tablespoonful of tannin in a quart of water, the yagina having been previously douched with an antiseptic solution. This treatment is repeated every night. Mtrate of silver, sulphate of zinc in solution, and thymol in a 10-per-cent ointment, are recommended as valuable remedies. It is probable that for the relief of the purely functional pruritus careful attention to a hygienic regime comprises the best rem- edy. This should consist in frequent local ablution not attended with undue friction, in following a wholesome and laxative diet, and in relieving the generally accompanying constipation. Surgical Treatment. — When, however, pruritus vulvae ceases to be a purely functional disturbance and depends for its continuance upon the development of fibrosis in the terminal nerve filaments, as described by Webster, the change must be looked upon as permanent and topical, and constitutional remedies must be recognised as quite inefficient. Belief under these circumstances can be given the agonized patient only by freely excising the affected area. In determining the extent of this operation it is essential first to ascertain the limits of the pruri- ginous areas. These, when ascertained and delimited, should be freely excised. The operation will generally involve the removal of the clitoris and its prepuce, the labia minora, and frequently the integu- ment from the inner aspect of the labia majora. In the performance of this operation the procedure designated in the chapter on clitoridec- tomy may be followed, the only change consisting in the extension of the area of denudation. Parasitic Affections of the Skin of the Female Genitals. — The skin of this region is sometimes affected with the vegetable parasite Tricho- phyton tonsurans in the form of eczema marginatum. On account of the condition of the skin, which is often macerated by the perspiration, the affection has so peculiar an appearance that for a long time it has been discussed whether it was the result of the same parasite, and for this reason Hebra called it eczema marginatum. At present it is accepted that this affection is nothing else than an ordinary ringworm, modified in its appearance by the locality. The moist condition of the epi- dermis allows the parasite to grow with more vigour, and the increased inflammation gives the different appearance to the affection. It is an affection found, not only on the genitals, but wherever two surfaces of the skin are close to each other. In this way we find eczema mar- ginatum of the axilla, of the breast, and of the cruro-genital fold. It is usually seen when fully developed. It appears as a reddish, moist, pigmented area circumscribed by a red, somewhat raised border, forming a circle or an arc of a circle. The border is formed by small papules or vesicles covered with brownish-yellow crusts. The surface is often excoriated as a consequence of scratching on account of the 206 A TEXT-BOOK OF GYNECOLOGY itching sensation accompanying this affection. The rings do not re- main limited to the genital sphere; sometimes when the disease is left without treatment they grow to reach the anal region, and spread on the pubis. It is rather difficult to demonstrate the presence of the Trichophyton tonsurans in the scales or in the crust, but with some patience and repeated experiments the fungus is found, in appearance like that of the ordinary ringworm. It is easily cured; sulphur is the best remedy. Eavogli directs the patient to wash the parts with green soap, and after washing and dry- ing, the affected skin is covered with a thick layer of Wilkinson's oint- ment, of which we have already given the formula (page 19-1). Bulkley recommends the use of sulphurous acid, applied in the form of com- presses on the surface. Many other remedies are used in trichophyton, such as chrysarobin or beta-naphthol, in the form of salves, which can also be applied with good results. The affection is easily manageable, and after six or eight applica- tions of Wilkinson's ointment, continued until the epidermis exfoliates, we are sure of the success of our treatment. Pediculi Pubis. — A kind of pediculus called Phtheirius inguinalis may be found infesting the hairy parts of the woman's pubic region. Although the hairs of the pubes are the ordinary habitat of this insect, yet it may also find its way to the hair of the axillae, and in the man to the beard. This insect has a peculiar shape, resembling the form of a crab, and for this reason it has been called crab louse, and vulgarly crabs. It hangs to the shaft of the hair, inserting its proboscis into the follicle so as to obtain its nourishment from the sebaceous glands. To the naked eye it looks like a yellowish scale or a little crust. It causes a great deal of itching sensation, but this is seldom so severe as to cause deep excoriation, as in the case of the body louse. It always comes by contagion; sexual intercourse is the most common way of transmission of this insect, but it can be taken also from clothing, bed- ding, and from contact with the seat board of a public water-closet. This insect is very inactive; it hangs fast to the hair and to the skin, so that it is difficult to detach it. With its powerful claws it holds firmly to the hair, so that in attempting to remove it, it slides for some distance before loosening its hold. The eggs of this louse are small and adhere to the hair. A close inspection of the part affected will reveal the presence of the insect and of the nits. Treatment. — The old application of mercurial ointment is still to be recommended; one or two applications are sufficient to destroy the insect and the nits. This application, however, is somewhat dirty and may produce irritation and dermatitis. The ointment of white precipi- tate is also recommended. In his clinic Eavogli finds that coal oil gives good results; two applications are enough to kill the insects and nits. Oleate of mercury has also a good effect. After any one of these DISEASES OF THE SK1X OF THE FEMALE GENITALS 207 applications the patient takes a bath and changes the clothes in order to prevent a new transmission. Atrophy of the External Female Genitals (Kraurosis Vulvae). — Under the name of kraurosis vulvce there has been recently described an atrophy of the vulva. The name was given to the affection by Breisky, using the Greek name Kpavpos, parched, hence withered. The atrophy is strictly limited to the skin and to the subcutaneous tissue, involving the labia majora, the fourchette, and sometimes the perineum. Charles A. L. Eeed (Xew York Medical Journal, September 29, 1894) stated that he had never been able to observe either clinically or micro- scopically the extension of this disease to the mucous membrane of the ostium vaginae, and he believes that this affection is essentially re- stricted to the vulvar integument. For this reason the disease has also been given the more appropriate name of progressive cutaneous atrophy of the vulva. The first description of this disease is due to Eobert F. ^Veir, of Xew York, who in 1ST 5 described this affection as an ichthyosis vulvae. (Ichthyosis of the Tongue and Vulva, New York Medical Journal, March, 1875.) Although he believed that he was describing a case of ichthyosis, yet the symptoms have such an analogy with those of this affection that there is no doubt that he described a case of kraurosis. The knowledge of this disease is reallv due to Breiskv, of Prague (Archiv fur Heilkunde. Prague, 1885). In 1885 he reported twelve cases with a careful study of the symptomatology and of the pathologic alterations. Possibly such cases had come to the attention of the gynecologist before that time, but the condition had not been pointed out as a pathologic entity. Since the publication of Breiskv the sub- ject has been brought to the attention of the Obstetrical and Gyneco- logical Society of Berlin, where, after a full consideration, the disease in question was recognised as a morbid entity. The first changes perceptible to the naked ei/e are small reddish areas around the ostium vaginae; they are not elevated; on the contrary, they are somewhat depressed. They are painful to the touch, and sex- ual intercourse is painful and futile. The vaginal orifice is very nar- row, and there is a diminished elasticity of the tissues. The skin and the mucous membrane have at this point lost a great deal of their pigment and have become thin and translucent, tense and glossy, so as to have lost all the normal folds of the vulva. The ostium vaginae is very narrow. The shrinkage is one of the leading features of this disease, but it is manifested, not over the whole region, but in different areas. From these centres the process gradually extends until the vulva has been entirely involved. The labia minora are fused together with the labia majora, and scarcely a trace of them is to be seen (Fig. 72). In some cases the mons veneris is also found in an atrophic con- dition, associated with complete alopecia. According to the observations of Breisky, in none of his cases had there existed symptoms of inflammation or of exanthematous affection 208 A TEXT-BOOK OF GYNECOLOGY in the external genitals, sensation was present. In some of his patients an unbearable itching Some of the women were pregnant and the itching sensation spontaneously disappeared at tion. In one of the gynecological cases the the j most night; leucor- menor- end of the gesta- woman suffered with an itching sensation, which lasted only a few weeks. In two private cases he found one patient who had been afflict- ed with pruritus for several years, the af- fection bein^ annoying at she also had rhcea and rhagia. In another case the pruritus had been present for nearly three years, with relapses at the time of the menstru- ation lasting from two to three days. Breisky drew his conclusions from the consideration of all his cases as follows: That chronic vaginal catarrh was present in 4 cases; that in 2 cases scars were pres- ent from progressed scrofulous abscesses of the cervical glands; not one had suffered with syphi- lis; 1 was sterile, 2 were multipara 1 , 5 had given birth to one or more children. Not one of the multiparae had had trouble with her delivery, and in no one had there been an inflammatory process of the external genitals. Al- though Breisky was of the opinion that this disease was the result of a chronic eczema, yet he never could find this affection in his cases. In the same way the pruritus seems to be one of the principal causes of this disease, and yet only in 3 of his cases was it present. Indeed, the etiology of this disease is very obscure. It occurs with- out previous existence of other diseases of the skin of the vulva. In t &HTOfo i Fig. 72 (Reed). — " The labia minora are fused together with the labia majora and scarcely a trace of them is to be seen." — Eavogli (page 207). DISEASES OF THE SKIN OF THE FEMALE GENITALS 209 the cases reported by Orthmann no sugar could be found in the urine and there was no history of syphilis. In the cases reported by Reed, in one there was a history of progressed syphilis in early life, but no later manifestations could be found. So that it has been established and confirmed by Lewin (C entralblatt fur Gynakologie, 189i) that the atrophy of the vulva is not of a syphilitic origin. Gonorrhoea and no specific chronic catarrh are considered by some observers as probable etiological factors. This disease is found only in women over forty, which would identify this atrophy with trophic changes induced by advancing age. Olshausen lays a great deal of stress on the extirpation of the uterine appendages as a cause of this atrophy, which relation was found in one of Reed's cases. In one of Jevonsky's cases the affection had started from a cicatrix in a lacerated perineum. From the multi- plicity of the possible causes held to be factors in this disease, it seems that no one must be considered as such, and Reed prefers the theory that the peripheral trophic nerves or their ganglia are to be consid- ered as the origin of this disease. This histologic condition of the skin, as found by H. W. Bettman in Reed's cases, shows, as one of the most important features, a marked hyperemia, which in some places assumes the character of true hemor- rhage. The epi- dermis shows great changes ac- cording to the different places ; in some points it is hardened, thickened, and hypertrophic, in other places thin and atrophic, and in other places has nearly disap- peared (Fig. 73). The corium shows two different con- ditions. One is due to the exuda- tion and infiltra- tion of round in- flammatory cells into the stroma of the corium, and the other is due to the sclerosis and atrophy of the tissues. These are two different condi- tions, one the consequence of the other, and due to the changes of the process. In the first condition the papillae are infiltrated, in the second 15 Fig. 73 (Reed). — " The epidermis shows great changes according to the different places." — Eavogli. 210 A TEXT-BOOK OF GYNECOLOGY they are shrunken and have nearly disappeared. In the same case the different sections show a difference in the pathologic alterations. From the above observations it is plain that the anatomic lesions are of a different character, according to the stage of the disease. In the begin- ning the hyperemia and exudation predominate in the tissues, later the lesions consist of a thickening and shrinking of the tissues in sclerosis. The subjective symptoms of this disease consist at first of painful points and a painful inelasticity, which are impediments to the copula- tive act. In the later period there is a loss of sensation in the entire diseased area. Itching is not a constant symptom, and in most of the cases is absent. In 35 cases referred to by Ohmann-Dumesnil 13 cases were troubled with itching in various degrees. In 5 cases referred to by Orthmann (Z eitschrift fur Geburtshillfe und Gynakologie, Stuttgart, 1890) only 1 patient complained of an itching sensation. In 6 cases re- ferred to by Eeed, 2 only were annoyed in that way, and that only at the beginning of the affection. The diagnosis is often made as vaginismus in the beginning of the affection, but careful inspection will reveal the sensitive areas at the ostium vaginas and the already begun shrinkage of the vulvar integu- ment. When the areas of atrophy have begun it is possible to mistake the disease for ichthyosis, but in this disease there are adherent scales, which are never found in kraurosis. In reference to the prognosis, Tait says that the patient should always be informed that the progress of the disease will extend over years, that it will certainly get well in time, but that treatment from time to time will give relief. It seems that the recovery alluded to is nothing else than the disappearance of the subjective symptoms. We can not promise recovery to the patient affected with this disease under any circumstances. The treatment may be divided into palliative and curative. The first is obtained by remedies to relieve pain. Carbolic acid in the form of a lotion, on account of its anaesthetic quality, affords some temporary relief. Tait recommends the application between the small labia, at bedtime, of a piece of cotton dipped in a solution of neutral acetate of lead in glycerine, as capable of giving relief. A mixture of tannin and salicylic acid in glycerine has been used in the same way with good results. Tait condemns cocaine as useless and irritating. The appli- cation of nitrate of silver in stick to cauterize the degenerated patches, so as to obtain a good cicatricial tissue, diminishes the sufferings, but does not arrest the progress of the disease. Heitzmann tried to scrape off with a sharp curette the hard tissues involved, but the length of time this process takes, and the poor results it gives do not commend it. The general tonic treatment must be strongly enforced so as to improve the general condition of the patient. As a curative treatment Reed mentions an operative process by excision. This he applied in an incipient case of kraurosis, which was limited to a vascular ring around the ostium vaginae. The mucous DISEASES OF THE SKIN OF THE FEMALE GENITALS 211 membrane of this locality was completely excised in the form of an ellipse, and the denuded edges were brought together by means of in- terrupted sutures. The patient had some temporary relief, but seven months after, the disease appeared on the integument. Martin, as re- ported by Orthmann, has begun the method of a complete excision, which must be applied according to the affected parts, removing the tissue thoroughly and approximating the edges. In this way eight cases operated upon by Martin completely recovered. The same operation in the hands of Reed has given very good results (Fig. 74). It is neces- sary not to operate in the be- ginning of the affection, be- cause the process is not yet limited, and it is liable to spread, in spite of the opera- tion. But when the operation is performed at the time that the sclerotic process is lim- ited, then there is no danger of a recurrence of the disease. Vulvar Adhesions. — The vulva externally consists of integument arranged in a series of folds with proximal surfaces. The fold between the labia majora and the labia minora and that be- tween the glans of the cli- toris and its prepuce, are striking examples, while the surfaces of the labia majora lie in approximation, particu- larly in case of pudendal re- dundancy. These proximal surfaces are ordinarily pre- vented from becoming ad- herent through the protective influence of the epithelial layer of the skin. There occur cases, however, of antenatal blending of these structures (see Malformations of the Vulva); others in which adhe- sion occurs speedily after birth; and still others in which, as the result of desquamative or similarly destructive inflammation of the skin, the epithelium becomes destroyed and the now denuded and ap- proximated surfaces unite. Morris (Transactions of the American Asso- ciation of Obstetricians and Gynecologists, 1892) called attention to the frequent adhesion of the prepuce to the glans clitoridis, a condition Fig. 74. — " The same operation in the hands of Reed has given very good results." — Eavogli. 212 A TEXT-BOOK OF GYNECOLOGY which, he insists, exists, to a greater or less extent, in 80 per cent of Aryan American women. He finds it very rare among the negresses; and looks upon its occurrence as a phase of evolutional change. When preputial adhesions are extensive, the glans clitoridis and the impris- oned mucous follicles remain comparatively undeveloped, but attain their normal growth after liberation of the adhesions. When these adhesions are slight they are of practically no clinical importance, but when they embrace a considerable part, or the whole, of the glans cli- toridis, they cause profound disturbances; so much so, that Morris con- siders that preputial adhesions probably form the most common single factor in invalidism in young women. Bacon (^American Gynecological and Obstetrical Journal) summarizes his observations and experience of preputial adhesions in the female, with the statement that they are prone, by the irritation they induce, to cause masturbation and the various neuroses; and that the prevention by them of the development of the glans clitoridis frequently results in eroticism. The damaging influence of these adhesions is experienced relatively more in the child than in the adult, for the reason that in the former the reflex nervous centres are less under the control of inhibitory impulses, and peripheral irritation consequently produces disturbances that would not be ex- perienced in maturer years. The treatment of this condition consists in breaking up the adhesions as soon as they are found, or particularly as soon as they are recognised as causes of mischief. Bacon is of the opin- ion that every female child should be examined, and the clitoris, if found adherent, should be liberated in the earlier weeks of life. The operation for this purpose consists in peeling the prepuce off the glans by means of a grooved director or other blunt instrument, and in keep- ing the area dressed antiseptically until it heals, care being taken fre- quently to separate the proximal surfaces to prevent readhesion. In labial adhesions, particularly when these are of antenatal occurrence, the structures are frequently so intimately fused as to defy separation. In certain of these cases the labia minora will be found implanted upon the surfaces of the labia majora so intimately that upon retracting the latter the former can be detected only in outline. This condition is rarely of any. clinical importance. It may, however, give rise to local disturbance from the accumulation of sebaceous matter secreted by the rudimentary follicles that are incarcerated within the adhesions. When this occurs the accumulation should be liberated by incision, while at the same time an effort should be made to break up the fusion. CHAPTER XVni HYPERTROPHIC AND HYPERPLASTIC DISEASES OF THE PUDENDAL ORGANS Hypertrophy of the clitoris — Condylomata — Elephantiasis — Polypi — Treatment. The hypertrophic and hyperplastic diseases of the pudendal organs are, as a rule, acquired. Congenital hypertrophy of the vulva is com- paratively rare and is confined to single parts of the pudendum. The parts usually found enlarged in congenital hypertrophy are the labia minora and the clitoris. In the case of the former, it is often difficult to decide at the time when the observation is made whether one is deal- ing with a true congenital condition or with one acquired by accidental pathologic processes. Manipulations are employed by certain tribes to bring about a hypertrophy of the labia minora. As is well known, the South African Hottentots, by certain methods practised on their female children, produce that enormous hypertrophy of the labia minora described as the "Hottentot apron." Hypertrophy of the clitoris, while occasionally an acquired condi- tion, is probably the most common form of congenital hypertrophy of the pudendum. A large number of cases of this kind have been de- scribed, one of the most remarkable by Fehling, who reported the case of a girl of twenty-one years with a clitoris five inches long, as thick as a thumb, and with a glans one inch long. Extensive congenital hyper- trophy of the clitoris is frequently combined with atresia of the labia minora, descent of the ovaries, and other anomalies obscuring the true sex of the individual, and bringing about the condition known as female pseado-liermaplirodism. (See Malformations of the Vulva.) This con- dition is simply one in which, owing to anomalous development, the pudenda simulate to a certain degree the male organs of generation. Of the acquired hypertrophies and hyperplasias, there are two im- portant groups of morbid conditions which have to be considered, viz., the condylomata and elephantiasis. Both of these are more prop- erly to be looked upon, not as truly neoplastic formations, but as hyper- trophic and hyperplastic diseases, since they develop upon an inflam- matory basis. Condylomata are usually present as elevated condylomata (C. acu- minata), more rarely as broad condylomata (C. lata). They develop on an inflammatory basis, which may be simple, gonorrhceic, or syphi- litic. Condylomata, are, however, not to be considered as a specific 213 214 A TEXT-BOOK OF GYNECOLOGY process, but as a secondary hypertroplry, developing, as the case may be, on either a specific or a nonspecific soil. In an early stage these hypertrophies form small, pointed elevations, warty in character. They are found on the labia majora and labia minora, the clitoris, the mons veneris, and they spread not infrequently over the skin of the peri- neum, around the anus, and over the inner surfaces of the thighs. They are first found united in smaller groups, with spaces between them free from excrescences. Later on, they often become confluent, forming large masses which hide entirely from view the whole of the pudendum, the latter being then covered by an uneven, irregular, ragged, papillomatous, or cauliflower mass (Fig. 75). In colour they i WTHiPM Fig. 75. — " They become confluent, forming large masses which hide from view the whole of the pudendum." — Herzog. may vary from a grayish-white to a pink or rose-red. The surface may be dry and shiny, or it may be moist. It is usually not ulcerated, unless it has been subjected, in consequence of very improper care, to a good deal of friction or other irritation. One of the notable features of these condylomatous masses is their very rapid growth during the period of gestation. This is evidently due to the increase of the blood supply to the genital organs in pregnancy. Microscopic examination of condylomatous masses shows that they consist mainly of enormous hypertrophies of the papillary layer of the skin. The papilla?, normally short and simple, become elongated and branched like a tree; they divide dichotomously or in a digitate manner. These hypertrophied papilla? consist of connective-tissue fibres and round, oval, or stellate cells, supporting a network of blood vessels. The HYPERTROPHIC AXD HYPERPLASTIC DISEASES 215 finest papillary branches are mainly composed of blood vessels with only scanty connective-tissue fibres and cells as a stroma. The hyper- trophic fibrillar connective tissue frequently shows an extensive round- cell infiltration consisting of polynuclear leucocytes and mononuclear lymphocytes. The epithelial layer covering these complicated hyper- trophic papilla? is thickened. The thickening is noticeable in the Mal- pighian layer, or stratum germinativum, as well as in the older more superficial strata. Condylomatous, cauliflower masses of the vulva, may be confounded with carcinomata of the vulva, which are also apt to form cauliflower excrescences. Besides the clinical features which have to be consid- ered, a careful microscopic examination of a series of sections, made vertically in the direction of the papillary layer, can always clear up the diagnosis. We have in carcinoma as the most prominent histological feature the great proliferation of the epithelia of the skin. These pro- liferating cells form alveolar or tubular nests which are surrounded by connective tissue. In condylomata, on the other hand, we have the great hypertrophy of the connective tissue, and the hypertrophic con- nective-tissue masses are surrounded by layers of epithelial cells. There occur also certain small excrescences on the pudendum, due to frequent masturbatory manipulations, which must not be mistaken for what is to be classified as a true condyloma of the vulva. The excrescences of this type, which may to some extent simulate an early stage of condylomata acuminata, are generally found on the mucous membrane between the margin of the hymen and the labia minora, and -also in the neighbourhood of the external meatus of the urethra. They are easily distinguished from true condylomata by the fact that they are small in size, simple, and not branched. They occur on the mucous surfaces only, and do not spread to the epidermal surfaces of the vulva or neighbouring parts. They are never infectious in nature, and occur most frequently in virgins of a hysterical disposition. Keeping these points in view, one is not likely to mistake these masturbatory excres- cences for true condylomata. The treatment of the venereal warts consists in their removal. This is done either by surgical means or by caustics; the first, however, is always preferable to the second. In case of small warts on the female genitals, they must first be washed with a solution of bichloride (1 to 1,000), or with a solution of carbolic acid (1 to 100). After drying them with cotton they are soaked with a cocaine solution (5 per cent), and then they are scraped off with a sharp curette, removing the small growths completely. On ac- count of the richness in blood vessels of the warts at their points of in- sertion they bleed freely. The bleeding is stopped by the application of a tampon dipped in a saturated solution of perchloride of iron. AVith this process Eavogli has obtained very good results, and he states that very seldom has he seen a recurrence. In case the warts should grow up again, it is better to destroy them at once by touching them with a 216 A TEXT-BOOK OF GYNECOLOGY solution of chloracetic acid, lactic acid, or acid nitrate of mercury. Tay- lor recommends the use of collodion containing bichloride of mercury, 30 grains to the ounce, or salicylic acid, 1 drachm to the ounce. Caustics are used independently of the curetting to obtain the destruction of the venereal warts. A strong solution of chromic acid, from 1 to 4 drachms to the ounce of water, has been applied, but the pain which results is absolutely unbearable, and the cauteriza- tion is not limited, affecting also the healthy skin. J. W. White re- ferred to the case of a woman who died in collapse in twenty-seven hours from the application of this solution on warts affecting the vulva and the anus. (Journal of Cutaneous and Genito-urinary Diseases, 1889.) When the condylomata have attained an extraordinary develop- ment, it is necessary to remove them with the galvano-cautery loop, by which means we can prevent loss of blood. Wlien there are warts round the meatus of the urethra, care must be taken not to cause any laceration or wound, which may be the origin of a scar structuring the meatus. Taylor recommends the application of a powder of equal parts of calomel and salicylic acid, which has often given him very satisfactory results. Caesar Boeck (Monatsliefte fur praktisclie Dermatologie, 1886) rec- ommends the application of a watery solution of resorcin on the con- dylomata, especially when they have a tendency to recurrence. He uses also a powder of resorcin, eight parts, and bismuth subnitrate and boric acid, one part each, to dust the condylomata, claiming prompt and effective results. The following formula, which is applied after the warts have been well bathed with a solution of bichloride, as above described, has been also praised: 3J Acidi salicylici, ) __ x y-^-i -. . . y aa oss. : Cnrysarobmi, j Collodii flexilis §j. M. To be applied twice a day. In Ravogli's clinic he has found formaldehyde very useful, which he applies in a strength of from 8 per cent to 42 per cent, as it comes in commerce. The application of pure formaldehyde is rather painful and requires the previous use of cocaine to diminish the pain. One or two applications have been sufficient to cause the condyloma to become necrotic and slough off. It is necessary to direct attention to the condition of the vagina and of the womb, to be sure that gonorrhoea has entirely ceased. Elephantiasis vulvae may be defined as a pale whitish tumour for- mation, or swelling, arising from the labia majora and labia minora and from the clitoris. It is by no means an easy matter to properly classify elephantiasis vulvae. There is practically nothing known as to the true HYPERTROPHIC AND HYPERPLASTIC DISEASES 217 etiology of this affection, but it appears that most cases of elephanti- asis develop on an inflammatory soil. It is certain that all fully devel- oped and characteristic cases histologically represent an immense hyper- trophy of connective-tissue elements. Hence elephantiasis vulvae is here classified under hypertrophic diseases of the pudendal organs. It must, however, not be forgotten that elephantiasic formations in other parts of the skin have been shown to be true neoplasms, lymphangeiomata — i. e., tumours consisting of newly formed lymph vessels and other lymphatic elements. Elephantiasis vulvse may develop from a single place, or it may be multiple from the start, the single component parts becoming confluent later on in the course of the disease. The connective-tissue prolifera- tion in elephantiasis leads to the largest tumour formations that are found in connection with the pudendal organs. In its incipient stages, elephantiasis can not be distinguished clinically and macroscopically from any simple noninflammatory hypertrophy, but, later on, the enor- mous size of the hypertrophic for- mation distinguishes it clearly from any other known condition. In growing, the tumour gets so heavy and large that it becomes pedunculated in consequence of its own weight, the main mass often reaching down to the knees. While, with us, elephantiasis vulvae is a comparatively rare dis- ease, it is quite frequently met with in some of the Eastern and tropical countries. The different forms of this affection have been variously classified according to certain prominent morphological characters. Tumours showing even surfaces have been called ele- phantiasis fibrosa, while those showing a warty surface have been called papillary elephantiasis (Fig. 76). Another classification makes three subdivisions, as follows: Smooth surfaced tumours cov- ered by skin which is not mate- rially different from the surrounding epidermis — elephantiasis glabra; tumours showing an irregularly nodular surface — elephantiasis tuberosa; and tumours with a surface showing numerous small warts and excres- cences — elephantiasis condylomatosa. The microscopic picture of elephantiasis vulvae varies according to the variety of the tumour and its stage of development. In the smooth Fig. 76.—" Tumours showing a warty surface have been called papillary elephantiasis P — Herzog. 218 A TEXT-BOOK OF GYNECOLOGY and tuberous forms the great mass of the tumour consists of a tissue composed of old fibres quite poor in nuclei. This connective tissue shows a marked cedematous infiltration and is sparingly vascularized. Capillaries and small arteries exhibit a perivascular round-cell infiltra- tion. The papillary body of the derma is poorly developed, the epi- thelial layers are thinned out, sebaceous and sweat glands are present in small numbers only, and even absent over large territories. While in the first two forms described, the papillary body is not hypertrophic, but rather atrophic, the third form, the elephantiasis condylomatosa, is characterized, like the true condylomata, by a well-marked hypertrophy of the papillae of the skin. In all three forms, when well advanced, there is also a great deal of thickening of the subcutaneous connective tissue, in which sometimes evidences of new formation of lymph vessels may be found. Pozzi and other French au- thors describe the his- tory of elephantiasis as presenting a num- ber of stages. The hypertrophied skin, according to their de- scription, first takes on an embryonal type, containing also large lymph spaces like those found in true lymphangeiomata. There occurs then, after an oedema has been established, an extensive lymph stasis and infiltration of the tissues with lymph. In this stage, there are also found in the elephantiasic tissues lymph glands in a state of fibrous de- generation. The last Fig. 77.—" The prepuce, now divided into two flaps, is cut stage is represented away."— Reed (page 220). Dv an enormous thick- ening of the skin, which, according to the French authors, from whom others differ, com- prises all the layers. According to the view now generally adopted, the thickening in most cases is chiefly confined to the subpapillary and sub- cutaneous layers. Superficial ulcerations not infrequently occur when the tumour HYPERTROPHIC AND HYPERPLASTIC DISEASES 219 has attained a larger size, and sometimes the lymph vessels are so greatly enlarged and dilated that they produce a lympliorrhcea from the ulcerating portions. The etiology of elephantiasis is still very obscure. Patients suffer- ing from elephantiasis vulvae not infrequently present the cicatrices of inguinal buboes or scars on the vulva. Frequently a history of syphilis may be obtained, and undoubted syphilitic manifestations may coexist with elephantiasis. The latter, however, can not be eradicated by an antisyphilitic treatment, though one sees occasionally a transitory im- provement after the free exhibition of the iodides. Polypi of the vulva, which authors frequently classify under neo- plasms of the pudendal organs, belong more properly, if one excludes the true fibromata, to the hypertrophic and hyperplastic diseases. These potyps, usually found in the neighbourhood of the external meatus, rep- resent hypertrophies of the mucous membrane of the vestibule. They vary from the size of a pea to that of a hazel- nut. are soft and pinkish in colour, smooth or mulberry- like, sessile or pe- dunculated. Micro- scopically, they show a loose fibrillar con- nective tissue with round - cell infiltra- tion, are covered by squamous epithelial cells, and often con- tain glandular spaces lined with columnar epithelium. They are due to inflammatory irritations, and it has recently been found that they sometimes contain gonococci. The treatment of hypertrophic and hy- perplastic diseases of the pudendal organs is almost surgical, should be the same source of Fig. -" The exposed raw surfaces are closed by a ser of fine catgut sutures."— Reed (page 220). exclusively Polypi treated in manner. Acquired enlargement of the clitoris, when a persistent local or constitutional disturbance, should be treated by extirpation. (See Clitoridectomy.) E. C. Dudley looks 220 A TEXT-BOOK OF GYNECOLOGY upon acquired hypertrophy of the clitoris, and more particularly its prepuce, as being ordinarily the result of masturbation. Those cases in which the clitoris is moderately enlarged and surrounded by an abundance of loose, flabby, redundant preputial skin, he treats by what he calls circumcision. The prepuce is slit up on the dorsum of the cli- toris, as would be done in a similar operation on the male, or as is done in the initial step of clitoridectomy. The prepuce, now divided into two flaps, is cut away by seizing first one flap and then the other with a forceps and cutting it off at its base with the scissors (Fig. 77). The exposed raw surfaces are closed by a series of fine catgut sutures (Fig. 78). CHAPTEK XIX NEOPLASMS OF THE EXTERNAL GENITAL ORGANS (A) Benign neoplasms of the pudendum : Varices, fibromyomata, pure myomata, myxomata, lipomata, enchondromata, neuromata, cysts — Benign neoplasms of the vagina: Cysts, fibromata — Treatment — (B) Malignant neoplasms of the pudendum: Carcinomata, sarcomata, melano-carcinomata — Malignant neo- plasms of the vagina : Sarcomata, carcinomata — Treatment : Excision — Clitori- dectomy — Extirpation of the vagina. Benign Neoplasms The pudendal organs, like other parts of the female genitalia, may become the seat of neoplastic diseases. These neoplasms, from a histo- pathological standpoint, are to be divided into connective-tissue tumours and epithelial new growths. For practical purposes it seems advisable here to separate the nonmalignant from the malignant new growths. Among the former there will be included in this consideration some pathologic conditions which, strictly speaking, do not belong to the tumours at all. Benign Neoplasms of the Pudendum. — It is a matter of doubt whether true henlangeiomata — i. e., tumours developing from and char- acterized by a new formation of blood vessels — have been observed in the pudendal organs. There are to be found, however, in literature very few reports according to which true neoplastic angeiomata have been observed in the vulva. The condition frequently found and described as varicose tumour of the vulva is not a genuine neoplasm, but represents varicosities due either to local or to general disturbances of circulation (Fig. 79). All circulatory disturbances of the lower half of the female body have a tendency to lead to marked manifestations in the vulva, its great sup- ply of blood vessels favouring very much venous stasis and the for- mation of varicosities. Pregnancy is a most fruitful cause of enlarged congested veins in the pudendal organs. We then find the veins of the labia majora greatly congested and dilated, and they rise as promi- nent purple swellings over the level of the surrounding skin. Large tumours of the ovaries, as well as fibromyomata of the uterus, may produce similar swellings. Valvular lesions of the heart, as well as nephritis, cause enormous oedema of the vulva and produce swellings of the labia majora that attain at times great dimensions. Chronic 221 222 A TEXT-BOOK OF GYNECOLOGY inflammatory conditions in the pelvis also lead occasionally to vari- cosities of the pudendum. The greatly dilated and enlarged veins may undergo secondary changes, as phlebitis and fatty or calcareous de- generation, when there may occur, even in the absence of any appre- ciable force or insult, spontaneous hemor- rhage into the tis- sues ; a hematoma vulvas is thus estab- lished. (See Inju- ries of the Vulva.) Among the be- nign true tumours of the vulva the fibromata and fibro- myomata are prob- ably the most com- mon, though they are by no means fre- quently met with. These new growths take their origin from the subcuta- neous connective tis- sue of the labia ma- jora and labia mino- ra, more rarely from the clitoris. They form hard, somewhat nodular, roundish, oval, or elongated masses, covered by normal skin. Histo- logically these tumours consist of newly formed, wavy, fibrous, connect- ive tissue, very poor in nuclei, which is surrounded by a capsule made up of a condensed tissue of the same type. The skin is generally somewhat movable over the capsule and is not much changed in its structure and appearance. The tumour proper frequently contains, besides fibrous connective tissue, nonstriated involuntary muscle fibres or cells, so that the neoplasm assumes the character of a fibromyoma. Pure myomata of the vulva are very rare, though they have been observed occasionally. While the tumours of the fibromyomatous group are, as a rule, firm, hard, and solid, there may occur in them, in con- sequence of lymph stasis, lymphangeiectatic spaces of large extent. In a case of this kind, diagnosis between fibromyoma and elephantiasis may be impossible without the aid of a microscopic examination. The latter, however, will clear up the diagnosis. The fibromata show a Fig. 79. — "The condition frequently found and described as varicose tumours of the vulva." — Herzog (page 221). NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 223 well-circumscribed proliferation and new formation of connective tis- sue, while in elephantiasis the hypertrophic processes of the connective tissue are diffuse and infiltrating, and there are also characteristic changes in the skin, which is practically unchanged in fibroma and fibromyoma. These tumours, as has been shown recently, frequently do not arise from the pudendal organs proper, but from the round ligament, and only later on in their growth and development descend into and en- croach upon the pudendum. Fibrous tumours starting primarily from the fascia of the pelvis may likewise in the course of their development and growth descend into the pudendum and present as tumours of the latter. The fibromata and fibromyomata of the pudendal organs have been observed at all ages from about the age of puberty until long after the climacteric period. They may be single or multiple. Their growth is usually slow, but they may become very large in size, reaching down to the knees, and weighing as much as fifteen pounds and more. When these fibrous tumours attain a large size they have a tendency to become pedunculated. Some fibromata show a pedunculated character from the start, forming small, elongated projections from the integument of the labia majora. They have been described as fibroma molluscum or mol- luscum pendulum of the vulva. The larger fibromata of long standing are apt to become ulcerated on the surface by pressure and lack of proper care and cleanliness. They are also liable to undergo calcareous degeneration. Another sec- ondary change to which they may become subjected, consists in an extensive oedematous infiltration, in consequence of which the fibres composing the neoplasm become pushed apart. Such tumours are not hard, but rather soft; they may even show pseudo-fluctuation, and microscopically their tissue looks very much like a myxoid degenera- tion, though it really only represents an extensive oedematous infiltra- tion. Fibromata so changed have frequently been reported as myxo- mata or myxofibromata. Lipomata of the vulva are rare. They are occasionally found in the mons veneris or in the labia majora and form well-differentiated round- ish tumours. They are very much softer than fibromata, and, like them, are sometimes pedunculated. Like the fibromata, the lipomata of the vulva, have a tendency to increase rapidly in size during pregnancy, to again somewhat decrease after the termination of gestation. A very few cases of congenital lipoma of the labium majus have been reported. Enchondromata and neuromata of the vulva have been described, but since these reports are not based upon a microscopic examination, they can not be accepted as valid evidence of the actual occurrence of such tumours. Cysts of the vulva may here receive some mention, although they are almost without exception not true neoplasms, but mere retention cysts. The cysts found most frequently in the region of the vulva are 224 A TEXT-BOOK OF GYNECOLOGY developed from the glands of Bartholin, either from the gland proper or from its secretory duct. (See Vulvo-vaginal Gland.) Other cysts similar in character to those of the vulvo-vaginal gland take their origin from Gartner's duct, which, as is well known, occa- sionally extends downward into the vulva. There are also sometimes found in the labia majora atheromatous cysts and dermoids. They are lined internally by squamous and some- times by cylindrical epithelium; acinous glandular structures have been described in connection with such cysts. Small, yellowish, translucent cysts, observed not uncommonly on the hymen, are, as their structure and contents show, retention cysts of sebaceous glands. There have also been observed on the hymen small multiple cysts of the character of lymphangeiectatic formations. Aside from the cysts of the vulvo- vaginal glands due to gonorrheal infection, cysts of the pudendal organs, as before described, have no important practical bearing; they are generally discovered only accidentally, not giving rise to any symp- toms. In rare cases larger cysts of this type may give rise to slight in- conveniences in consequence of their size. Benign Neoplasms of the Vagina. — Cysts of the vagina are not so very uncommon. According to the statistics of Neugebauer, they are found in one of every six hundred women presenting themselves for examination. They are usually solitary, and when multiple rarely more than three or four are present, which tend to arrange themselves in rows. Most frequently they are found in the upper part of the vagina, especially growing from the anterior wall, though they may develop in the lateral walls, as well as in the lower part of the vagina. They vary in size from a pea to a hen's egg, though Yeit has reported a case in which the cyst reached the size of a foetal head. In most instances, however, they tend to grow slowly, and rarely reach a large size. Age appears to have no influence in their etiology, as they occur in virgins as well as in women who have borne children. Many the- ories have been advanced in explanation of the origin of these cysts. Huguier and Guerin thought they always grew from ' glands which were present in the walls of the vagina. In later years the tend- ency has been to regard all cysts of the vagina as having their origin in the remains of the Wolffian bodies. While a certain proportion of cysts no doubt originate in this manner, this theory fails to explain the origin of many cysts which develop in locations remote from such embryonal structures and which are very superficial. More recently Preuschen was able to demonstrate the actual existence of ductlike glands in a number of cases examined post-mortem, which were lined with columnar epithelial cells, from which fact he attributed to those cysts occurring in locations other than the anterior or lateral walls of the vagina a glandular origin. It is evident, therefore, that we must admit the glandular theory as explaining the origin of a certain propor- tion of smaller cysts, while most of the larger cysts develop from the NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 225 embryonal remains of the Wolffian bodies. In addition to these theo- ries, the possibility of dislocation of islands of epithelium which become embedded in the subcutaneous tissue, the result of trauma — as, for example, childbirth, or operations on the vagina, which afterward give rise to cysts — must always be borne in mind. Finally, dermoid cysts may develop in the wall of the vagina, usually in the recto-vaginal septum. Cysts of the vagina are rounded tumours, frequently biscuit-shaped, hemispherical, or fusiform, with tense elastic walls encroaching on the lumen of the vagina. Earely they may assume a polypoid shape, having protruded to such an extent as to form a pedicle (Fig. 80). The cyst wall varies much in thick- ness. In case the cyst is large the wall may be very thin and the contained fluid of a clear col- our, giving the cyst a bluish translucent appearance. The cyst con- tents are usually a thin, clear, yellow- ish, transparent fluid, though they may be viscid, tur- bid, and even of a dark - brown colour from the presence of disorganized blood. Microscopic- ally, the cyst con- tents are poor in organized elements, though occasionally there are to be found mucous corpuscles and groups of desquamated epithelial cells, cylindrical and squamous, together with cholesterin crystals and fatty detritus. Should the cyst become infected by pyogenic micro-organisms, suppuration takes place, and the contents will then consist largely of pus. Vaginal cysts are usually simple, though occasionally the remains of septa may still be observed. Earely, multilocular cysts have been described, Poupinel having met with one composed of fifteen small 16 Fig. 80 (Reed).— " They may assume a polypoid shape hav- ing protruded to such an extent as to form a pedicle."— Kothrock. 226 A TEXT-BOOK OF GYNECOLOGY cysts. On microscopic examination the cyst wall is made up largely of fibrillary connective tissue, though in a certain number of cysts, smooth muscle fibres are present, more or less uniformly distributed. Great difference is noted in the epithelial lining of vaginal cysts. Usually it consists of a single layer of columnar epithelial cells, which may be ciliated. Occasionally the epithelial lining is polymorphous, consisting of cuboidal, cylindrical, and squamous cells, or the cylindrical cells may be entirely replaced by the squamous type. Veit attributes this change, especially when the cysts are large, to the pressure of the cyst contents. In a few instances invaginations of the epithelial lining into the cyst wall have been observed, the occurrence of which has been advanced as proof of the glandular origin of such cysts. Fibroids are the rarest of all neoplasms of the vagina. They are usually rounded, very rarely reaching a size larger than an orange, though tumours weighing as much as two pounds have been observed. They are almost invariably solitary and usually sessile, only exception- ally forming a pedicle. Their favourite location is the upper portion of the anterior vaginal wall. The etiology of these tumours is still obscure. They are most frequently met with in middle life, though they have been observed in children. Von Eecklinghausen has advanced the the- ory that these tumours are in reality adenomyomata, which have their origin in the remains of the Wolffian ducts, which view, however, still lacks confirmation. These tumours grow from the fibrous or muscular coat of the vagina, and are usually embedded in a fibrous capsule. Their histologic struc- ture is identical with that of fibroids of the uterus, consisting largely of connective-tissue bundles with a rather sparse intermixture of smooth muscle fibres. Striped muscle fibres are occasionally to be seen, in which case the tumour must be classed as sarcoma,, especially when occurring in children. The mucous membrane covering the tumours is usually in- tact, unless destroyed by pressure, when they will present ulcerated surfaces. Fibroids of the vagina may become cedematous, or gangrenous and sloughing, and may be cast off in this manner. Polypi are simply fibroids which have become pedunculated. They do not differ essen- tially in structure from fibroids. The treatment of benign neoplasms of the external genital organs represents some of the least difficult problems in surgery. Varicose tumours of the vulva, when they exist simply as enlargements of the veins and are not associated with extensive hypertrophy of the con- nective tissue, should be treated by obliteration of the veins. This to be effective must be done thoroughly. When the varices are restricted to the vulva, the larger trunks of the veins are easily detectable and may be tied by subcutaneous ligature. The ligatures should be applied at intervals along the same vessels, and the vessels themselves should be divided between the ligatures. The same principle of treatment may be applied to perivaginal varices, although the technique is rather more difficult. When pudendal varices are associated with extensive hyper- NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 227 trophy, the hypertrophied area may be excised. In many of these cases the varicose condition of the external veins is but an index of the condition of all the veins surrounding the vagina and extending far up into the pelvic structures. The control of such extensive conditions is very difficult, if not impossible. Fibromyomata and cysts of either the vulva or vagina should be treated by extirpation. Malignant Neoplasms Malignant Neoplasms of the Pudendum.— Malignant tumours of the vulva are comparatively rare. If we remember how frequent these neo- plasms are in other parts of the female genital organs this must excite our comment. Schwartz collected 1,177 cases of carcinoma of the uterus and the vulva. Of these, only 30 cases belonged to the latter class; the rest were all carcinomata of the uterus. We are not, however, in a position to account for the comparative rarity of malignant neo- plasms of the pudendal organs. Carcinoma, which we will consider first, is much more frequent than sarcoma. Nothing definite is known as to any predisposing cause, except the advanced age of the patient. Winckel, who has seen 8, and collected from the literature 54, cases, found that 6 cases occurred in women under forty years; 16, between forty and fifty; 20, between fifty and sixty; and 20 cases in women over sixty years. It can not be shown that simple inflammatory processes or gonorrhoea and syphi- lis exert any predisposing influence with reference to the develop- ment of carcinoma of the vulva. The starting points for these tumours are the clitoris, labia majora and labia minora, the perineum, and rarely the glands of Bartholin. In the case of the latter the carci- noma has a glandular, in all other cases a squamous, epithelial-celled type. These tumours are generally characterized by an extensive new formation of tissue, by their inclination to early superficial ulceration, hard diffuse infiltration of the surrounding tissues, and involvement of the neighbouring lymph glands, particularly those in the inguinal re- gion. The glandular involvement, however, in some cases does not seem to supervene early. The carcinomata of the vulva, from certain macroscopic features, may be divided into several groups, which are, however, not distin- guished by fine microscopic differences. One form is characterized by a prominent tumour formation. The affected portion of the vagina presents a roundish tumor, generally of moderate size, usually not larger than a hen's egg or an apple. It is firm and hard in consistence, situated in the upper layers of the integument, and more or less mov- able on the subcutaneous tissues. The surface is formed by an epi- dermis, which has a tendency to form warty prominences and papillary excrescences. If these tumours are seen somewhat later they are not so freely movable and their surface has become ulcerated. A second 228 A TEXT-BOOK OF GYNECOLOGY form takes on from the start the shape of a diffuse infiltration, which does not project materially above the level of the surrounding skin. On palpation of the neoplasm its site is found to be hard, and it is not freely movable, but, on the contrary, is firmly fixed to its surroundings. This variety likewise soon begins to ulcerate; its surface either shows a mass of shallow, uneven granulations, or a ragged tissue covered with a bloody, dirty, purulent exudate. The third form from the beginning has a marked tendency to ulceration, and presents a deep craterlike ulcer with hard, infiltrated, overhanging edges. Microscopically, carcinoma of the vulva presents a typical squamous epithelial-celled cancer. The epithelia of the stratum germinativum proliferate into the underlying connective tissue in the form of pegs or cylindrical masses, and these have a tendency to become branched. The proliferating cells speedily undergo cornification, and one therefore finds in carcinoma of the vulva epithelial pearls or " onion bodies " in great number and very typical in appearance. The younger epithelia, which have not undergone cornification and have preserved a columnar type, together with the somewhat tubular branched character of the cell nests, may, on superficial examination, create the impression of a glandular, tubular carcinoma. This impression is, however, erroneous, for carcinomata of the vulva are true squamous-celled neoplasms, not glandular carcinomata, but " cancroids/' When after removal of the original tumour a recurrence takes place, the latter frequently loses the characteristic structure of a cancroid, and presents a tissue composed of a fibrillar stroma with only small epithelial nests in which epithelial pearls are absent. There are fre- quently found in the neighbourhood of carcinoma of the vulva, near the primary tumour or near recurring metastasis, whitish patches of epidermis, which condition is known as leucoplahia. These spots microscopically show a thickening of the epidermis. They are not characteristic of carcinoma of the vulva, since they are also found in other conditions. Carcinoma of the vulvo-vaginal glands, of which a few cases have been reported, forms a hard tumour situated under the unchanged labium majus. Microscopic examination shows an alveolar carcinoma with remnants of normal glandular tissue of the organ. Carcinoma of the vulva after it is once well established generally spreads quite rapidly and has a tendency to grow around the urethra into the vaginal walls, into the pelvic fascia, and into the perineum. Involvement of the other labium majus from the opposite one originally affected has likewise been several times observed. The prognosis of carcinoma of the vulva appears to be somewhat better than that of cancer of the vagina, but recurrence and final death is the rule even after thorough removal. Goffe has reported a case of primary epithe- lioma of the clitoris followed by speedy lymphatic involvement. A sec- tion taken from a case of Whitacre's shows a typical microscopic picture of epithelioma of the clitoris (Fig. 81). NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 229 Sarcoma of the vulva is very rare. The number of cases of this kind which have been reported is very small. These connective-tissue neo- plasms are, as a rule, very malignant, and there are few well-authen- ticated cases on record of permanent cure after the removal of a sar- Fig. 81. — "A section taken from a case of Whitacre's shows a typical microscopic picture of epithelioma of the clitoris.''— Herzog (page 228). coma of the pudendal organs. The sarcomata of this region usually present themselves as large spherical tumours arising from the labia, the clitoris, or the region of the external meatus of the urethra, or they may first be observed as deeply pigmented warts on the labia. There have been described round- and spindle-celled sarcoma, myxosarcoma, and melanosarcoma. The latter is the form most frequently observed on the vulva. Winckel, among ten thousand female patients, saw only two cases of sarcoma of the vulva. One case was that of a pregnant woman, twenty-five years old, with a tumour the size of a man's head, which was hanging down from the vulva, suspended on a pedicle the size of a child's arm. This tumour had not been very malignant, since it had been present and growing for eight } T ears. Its microscopic ex- amination showed it to be a round-celled sarcoma. AYinckePs second case was a myxosarcoma. Bruhn operated in two cases of fibrosarcoma, and claims that he obtained a permanent cure. "VTernitz reported a case of spindle-celled sarcoma. Eobb has described a nryxosarcoma. Ehren- 230 A TEXT-BOOK OF GYNECOLOGY dorfer has seen a small round-celled sarcoma springing from the anterior part of the meatus urinarius and protruding between the labia. Older reports have been furnished by G. Simon and a few others. There have been reported altogether about a dozen cases of this kind. Somewhat more numerous are the reports of cases of melanosarcoma. It is a well- known fact that the vulva is frequently the seat of pigmented spots and pigmented na?vi. These occasionally become the starting point of mela- notic sarcoma, which is generally of a most malignant type. Other mela- nosarcomata of this region do not begin in superficial pig- ment spots or nam, but in the deeper layers of the mucous membrane. They are first noticeable as a purplish spot, which spreads, be- comes deeper in col- our, and then as- sumes the shape of a simple wart or of a branched papil- lomatous growth. Haeckel reported a melanosarcoma of a deep bluish - black colour springing from the labia mi- nora and the cli- toris. Muller de- scribed a tumour of this kind arising from the clitoris. Most cases reported took their origin from the labia ma- jora. All the mela- nosarcomata of the vulva observed were characterized by a deep pigmentation; they were moderate in size. As a rule, they soon reappeared after removal and speedily led to the formation of multiple metastases. Sometimes general sarcomatosis, cachexia, and death, soon Fig. 82. — " Keed has removed a trilobular melanosarcoma from the meatus urinarius of a young girl." — Herzog (page 231). NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 231 follow operative procedures. Reed, however, has removed a trilobular melanosarcoma from the meatus urinarius of a young girl with complete success (Fig. 82). Histologically, these new growths generally are composed of round cells; occasionally spindle cells are found. The cells contain in their protoplasm a great amount of a brownish granular pigment, which is also found free between the cells composing the tumour (Fig. 83). Melano - carci- nomata of the vulva, likewise very malignant in character, have been described. Dr. Balfour Mar- shall has reported {Glasgow Medical Journal) the case of a widow, aged fifty -seven, in whom the site of the clitoris was occupied by a dark-bluish and bluish-red, slightly lobulated tumour, of the size of a small walnut. The growth was removed and was found to have origi- nated in the clitoris and praeputium clitoridis, being " a melanotic sar- coma with some hemorrhage into its substance/' Dr. Marshall was able to find records of only nineteen cases of sarcoma of the vulva, of which two started in the clitoris. Malignant tumours primarily situated elsewhere in the body not infrequently form metastases in the vulva. Carcinomata and sarcomata of the uterus lead to metastases in the pudendal organs, as also, at times, do malignant neoplasms of the ovaries and of the urinary bladder. Syncytioma malignum of the uterus, which so frequently forms metas- tases in the vagina, is also liable to form metastatic tumour masses in the vulva. Aschoff reports a case of syncytioma where the original tumour has made a metastasis in the left labium ma jus. Malignant Neoplasms of the Vagina. — (a) Sarcoma in Childhood. — Primary sarcoma of the vagina occurs at any period, in infancy as well as in adult life, and, since there is a very great difference in its appear- ance and mode of development in the two ages, allowing a sharp subdivi- sion, it is customary among writers to treat these subdivisions separately. Fig. 83 (Reed). — " A brownish granular pigment, which is found free between the cells composing the tumour." — Hekzog. 232 A TEXT-BOOK OF GYNECOLOGY In children, as in adults, it is a rare disease, and usually manifests itself during the first two or three years of life. Granicher observed a case in a newborn child, which, however, advanced very slowly and did not prove fatal until the seventh year of life. Sarcoma in children commonly appears in the form of polypoid or grapelike protrusions, usually springing from the anterior wall of the vagina. In the beginning, the tumour is rounded or hemispherical with a broad base, but it tends to become polypoid as the disease ad- vances. It is generally of a cherry-red colour, but it may be dark brown if very vascular. Soon the surrounding mucous membrane becomes infiltrated and here and there in the surrounding structure secondary nodules begin to develop. Sarcoma shows a marked tendency to infil- trate the vesico-vaginal septum and invade the bladder, and may, from pressure on the urethra, or infiltration of the neck of the bladder, cause urinary stasis with resulting dilatation of the bladder and nephydro- sis. In advanced cases the tumour is very prone to undergo ulceration or necrosis with resulting infection of the genito-urinary tract, which ultimately reaches the kidneys, terminating in pyelonephritis. Earely, the infection may extend to the uterus, and even to the peritoneal cavity. The recto-vaginal septum may also be involved. Metastasis to distant parts of the body has not been observed, though regional metastasis to the inguinal glands and ovary has been met with. Histologically, the tumour may consist largely of connective tissue, or it may assume the type of myxosarcoma. The sarcomatous ele- ment may consist of round or spindle cells, or both may be present. Occasionally giant cells are observed, and not infrequently striped muscle fibres are to be seen. According to Kolisko, striped muscle fibres are usually present, but other observers have failed to confirm this view. The etiology is unknown. However, since it begins in infant life, Veit (Handbook, p. 355) regards it as probable that in some cases at least it is congenital. Kolisko also regards the presence of striped muscle fibre as evidence of congenital origin. (b) Sarcoma in Adults. — Primary sarcoma of the vagina occur- ring in adults belongs to the rarer tumours. Up to the present time but thirty-one cases have been reported. They have been observed be- tween the ages of fifteen and eighty-two, though the larger proportion has occurred in persons under forty years of age. They most frequently grow from the anterior wall and are rather more frequent in the lower third of the vagina. They appear as more or less circumscribed tumours, which is the most common form, less frequently as a diffuse infiltration of the mucous membrane of the vagina, which tends to ulceration. In the circumscribed form the tumour is usually smooth, rounded or hemispherical in shape, and sometimes is encapsulated. The integrity of the mucous membrane covering the tumour is usually maintained until pressure from its increasing size produces ulceration. NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 233 Metastases to distant parts of the body have been observed, notably to the lungs and skin. Of the etiology of these tumours we know as little as of sarcoma in general. They usually have their origin in the perivaginal connective tissue, or in the submucosa. Occasionally they originate in the blood or lymph vessels, when they are termed endothelioma. Cases of this kind have been reported by Klein, Kalustow, and Waldstein. Histologically, sarcoma of the vagina in the adult may consist of spindle, round, or mixed cells, and occasionally giant cells are present. Sarcoma of the vagina is especially characterized by the tendency to recurrence after removal, and, according to Jung (Monatsschrift fur Geburtshiilfe und Gynakologie, Bd. ix), only three cases are on record which have passed without recurrence a sufficient length of time after removal to be denominated cured. The vagina may be secondarily involved by sarcoma, which pri- marily has its seat in some other region of the body, as, for example, the uterus. Especially is this so in sarcoma of the cervix, where sec- ondary involvement of the vagina is almost the rule. (c) Carcinoma. — Primary carcinoma of the vagina is not common. Gurlt, among 59,600 patients, found 114 cases. Unlike sarcoma, it is a disease of later life, and has not been met with under the age of twenty-five. It appears mostly as an ulcerating excrescence, with sharply circumscribed borders, and is most frequently located on the upper portion of the posterior vaginal wall. The surrounding mucous membrane is usually involved in a catarrhal inflammation, and is fre- quently eroded and bleeds on the slightest touch. Not infrequently a marked thickening of the mucous membrane in the neighbourhood of the carcinomatous involvement appears as a diffuse infiltration, manifested as a thickening of the vaginal walls encroaching upon the lumen of the vagina. At first it may involve only a segment of the vagina, encircling its entire circumference like a band. In these cases ulceration is only observed after a considerable length of time. In the diffuse variety the growth is at first slow, but eventually infiltration of the perivaginal connective tissue takes place and the growth may invade the bladder or rectum, or extend into the parametrium, involv- ing secondarily the iliac and retroperitoneal glands, or, in case the growth is confined to the lower third of the vagina, the inguinal glands may become involved. The etiology is obscure. In a few instances it has been observed to develop at the point of pressure from pessaries, especially where their long-continued use has caused ulceration. These cases have many points in common with carcinoma of the skin, which some- times develops in the border of indolent ulcers. In the present state of our knowledge concerning the etiology of carcinoma, it is difficult to say just what influence the pessary has had as an exciting cause of the carcinoma, and whether the irritation following its use, or the ulceration by producing an atrium of infection, has been chiefly 234 A TEXT-BOOK OF GYNECOLOGY instrumental we do not know. Microscopically, primary carcinoma of the vagina presents the characteristics of carcinoma growing from the skin and consists of squamous epithelial cells. Secondary Carcinoma. — Secondary carcinoma of the vagina is of much more frequent occurrence, and may result from direct exten- sion or metastasis. Most frequently it is secondary to carcinoma of the uterus, especially to involvement of the portio vaginalis. In carcinoma of the hody of the uterus the vagina may he secondarily involved hy implantation metastasis. Carcinoma of the rectum or bladder may secondarily invade the vagina, and occasionally metas- tasis to the vagina has been observed to follow primary carcinoma of the ovary. Secondary carcinoma of the vagina partakes of the nature of the primary growth and is identical in its histologic structure. Treatment of malignant neoplasms of the external organs of gen- eration resolves itself into radical and palliative. The radical treatment consists in the extirpation of the malignant growth whenever it is so situated that its removal can be accomplished with reasonable safety to the life of the patient and with a reasonable prospect of complete- ness. Malignant tumours of the vulvo-vaginal glands, those involving either labium, the vagina, or the clitoris, should be freely excised, care being taken to dissect out all indurated neighbouring lym- phatics. Clitoridectomy, or excision of the clitoris, may be de- manded for the cure of either malignant or tuberculous dis- ease of that body; also for the removal of a malformed or hy- pertrophied clitoris, or for the relief of extreme nervous dis- turbances due to hyperes- thesia of that organ. The technique of the operation is as follows: Divide the tissues around the base of the gland by means of scissors, one blade of which is inserted beneath the integument, at the inner duplication of the preputial fold, and is carried entirely round the organ; the prepuce is then slit toward the pubis (Fig. 84); the clitoris is dissected out, but, before being excised, its base is clamped by a slender-bladed Kocher hemostatic forceps (Fig. 85); after which it is cut away, the vessels being controlled by ligatures. The flaps are approximated by buried Fig. 84. — " The prepuce is then slit toward the pubis." — Reed. NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 235 animal sutures and the margins of the wound are elosed by the inter- eutaneous method. (See Figs. 38, 39.) Extirpation of the vagina is sometimes practised in cases of primary carcinoma or of tuberculosis of that canal. Very satisfactory reports of the operation have been made by Olshausen, Diihrssen, Martin (of Greifswald). and others. In the performance of this oper- ation it may be necessary, as a preliminary step, in cases of narrow or indurated va- gina^ to incise the perineum, or even to carry the incision entirely through the peri- neum, round the anus, and up to the coccyx. As a rule, however, the operation may be done, as Martin directs, by making a preliminary inci- sion round the hymenal ring at the introitus vagina?. Af- ter this has been done, but little difficulty is experienced in enucleating the vagina by means of the finger, separat- ing the entire canal from its underlying connective tissue clear to its juncture with the cervix. If the disease has not gone beneath the mucous membrane, the resulting disturbance of the blood vessels will not be so marked as to occasion serious difficulty in controlling the hemorrhage. If, however, the incision must be made through the perineum, round the rectum, and up to the coccyx, the hemorrhage from the hemorrhoidal plexus may be controlled only with some difficulty. After the vagina has been enucleated in the manner indicated, the remainder of the operation consists in the re- moval of the uterus and adnexa according to the technique described in Vaginal Hysterectomy. The proposition has been made by P. Miiller to extirpate the vagina, leaving the senile uterus in situ; but as even the senile uterus is the source of some secretion which will accumulate above the tract of the vagina, which now becomes occluded, it is essen- tial that even in these cases the uterus should be removed. Partial extirpation of the vagina has been practised by Fritsch and Asch, but the results have not been satisfactory. The method of Martin, as before described, is probably the safer, the operation being concluded by drawing down the peritoneum and stitching it all round at the introitus. After this step has been taken the vulvar orifice closes itself by transverse obliteration. Fig. 85. — "The clitoris is dissected out, but before being excised its base is clamped." — Reed (p. 234). 236 A TEXT-BOOK OF GYNECOLOGY The palliative treatment of malignant neoplasms of the external genital organs consists in making the patient as comfortable as pos- sible during the persistence of the disease, and should be adopted as a line of practice only in cases that are either awaiting operation, or that have ceased to be suited to it in consequence of the extension of the disease. Of the latter class may be mentioned as examples car- cinoma of the vagina invading and penetrating the recto-vaginal sep- tum, thereby causing a recto-vaginal fistula, or other cases, again, in which the disease has perforated the bladder. These are distinctly hopeless conditions, entirely beyond the reach of surgical art, their comfort, or the little that may be secured for them, depending on vari- ous palliative measures. Cleanliness is of the first consideration; douches of lysol or creolin are cleansing, antiseptic, and are better borne than the more irritating solutions of either carbolic acid or the mercuric bichloride. Excoriated surfaces may be dressed with steril- ized white vaseline or other oleaginous product, a little lysol or creolin being incorporated with this agent if desired. Opiates in the form of rectal suppositories, or hypodermic injections of morphine, should be given whenever they are not contraindicated by the idiosyncrasy of the patient. These are cases for euthanasia. CHAPTER XX DISPLACEMENTS OF THE VAGINA The vagina — Varieties of displacements — Cystocele — Rectocele — Urethrocele — Col- porrhaphy, anterior and posterior. The vagina is a canal lined with a mucous membrane partaking largely of the histologic elements of the integument, and is surrounded by some muscular strias that are designated as the sphincter vaginae muscle. The tube thus constituted extends from the vulva to the uterus and is sur- rounded by more or less loose cellular tis- sue. It is slightly curved, being concave anteriorly and convex posteriorly. It is held in position, not alone by its attachment to its surrounding cellu- lar tissue, but more particularly by its at- tachment to the uterus and the pelvic diaphragm, and by the support which it de- rives from the perine- um. This canal is liable, in whole or in part, to displacement. TJpivard displacement may occur, as in the case of a large fibroid tumour, the growth of which carries it above the pelvic brim, caus- ing it to drag the vagina upward. This upward displacement may occur to such a degree as to exercise more or less tension, even upon the lower segment of the canal. Downward displacement, or a prolapse of the vagina or some part of it, is the condition more frequently encoun- 237 Fig. 86. — "Sacculations may occur from the urethra, a con- dition called urethrocele." — Eeed (page 238). 238 A TEXT-BOOK OF GYNECOLOGY tered. The causes of prolapse of the vagina, or of one or the other or both of its walls, may exist either in the pelvic diaphragm or in the pelvic floor. Weakness of the pelvic diaphragm — a condition which depends upon the loss of the retentive power of the pelvic fascia — is generally manifested primarily by descensus uteri. When this condi- tion occurs it is always and necessarily associated with more or less descent of, at least, the upper segment of the vagina. This is gen- erally specially marked in relaxation and descent of the floor of Douglas's pouch. Occasionally this condition of the pelvic diaphragm, with its associated hysteroptosis, is sufficient to cause more or less descent of the anterior vaginal wall. Eelaxation of the pelvic floor or the enlargement of the vaginal orifice by laceration of the perineum may, by removing the support from the superimposed structures, in- duce a similar prolapse of the vaginal wall. When the anterior vagi- nal wall folds inward it forms a sort of pouch from the bladder and is, therefore, designated a cystocele ; when the posterior wall folds into the vagina and forms a pouch from the rec- tum, the condition is designated a rectocele (Figs. 86, 87). Simi- lar sacculations may occur from the ure- thra — a condition called urethrocele (Fig. 86). The pathology of these displacements, particularly of cysto- cele and rectocele, shows them as con- sisting essentially in an atrophy of the perivaginal muscu- laris, with a corre- sponding loss of its retentive power; and in a distention with resulting redundancy of the vaginal mu- cosa. The symptoms of these sacculations are very characteris- tic. In cystocele the patient is conscious of more or less distention of the vaginal orifice when she attempts to urinate; she experiences difficulty in completely emptying the bladder, often being forced to push that viscus upward with the finger before being able to empty it. When Fig. 87. — " There is always more or less residual urine remain- ing in the adventitious pouch." — Reed (page 239). DISPLACEMENTS OF THE VAGINA 239 this sacculation is extreme she may be unable to completely empty the bladder, even though she assists herself by the means indicated; under these circumstances there is always more or less residual urine remaining in the adventitious pouch (Fig. 87) — a condition which sooner or later results in inflammation of the bladder, with the usual pain and tenes- mus. On inspection, a globular mass, which can be readily re- placed by the finger and which increases in size and tension if the patient strains, will be seen present- ing at the vulvar ori- fice. A curved sound, introduced through the urethra into the bladder, can be readily felt on the inside of this pouch, thus ren- dering certain the di- agnosis of cystocele. In rectocele the pa- tient when straining at stool feels as if she were about to defecate through the vagina, and finds it necessary sometimes to replace the protruding mass before she can empty the rectum. If the finger is introduced into the rectum in such a case as this it can be brought for- ward into the pro- truding pouch, which presents at the vulvar orifice as a globular mass, having the colour of the vagina and presenting the half-obliterated rugae upon its sur- face. If the patient strains or coughs the protruding mass increases in both size and tension. The treatment of displacements of the vagina consists primarily in correcting, so far as possible, the causative conditions. When these Fig. 88. — " . . . Transverse denudations, so that the resulting line of approximation may be coincident with the normal folds of the vagina. 1 ' — Keed (page 242). 240 A TEXT-BOOK OF GYNECOLOGY exist in the pelvic diaphragm, as when they depend upon prolapse of the uterus, the remedy is to be found in relieving the vagina of the abnormal pressure. This is generally accomplished by one or other of the recognised operations for the cure of prolapsus uteri. (See Surgical Treatment of Uterine Displacements.) Pessaries are, as a rule, more mischievous than otherwise; although their use may afford the patient a sense of temporary comfort. Those pes- saries, however, which by their con- struction distend the vagina, or impinge forcibly upon any part of its walls, have a tendency to dilate the canal still further and render the original mischief more troublesome. In the place of pessaries it is usually better to employ tamponade with some astrin- gent and antiseptic medicament. In cases of extreme rec- tocele or cystocele, or both, either com- bined or not with complete procidentia uteri, temporary comfort is derived from wearing a firm perineal support. Protruding vaginal surfaces frequently become excoriated, in which case they should be treated by careful cleansing and emollient applica- tions. Such methods of treatment are, however, but tentative, cure depending upon such correction of the un- derlying cause and acquired morbid changes as can be effected only by surgical intervention. If the condition depends upon relaxation or en- RJHQFKINS Pig. 89. — " There are cases, however, in which the anterior sacculation of the recto-vaginal septum exists without ap- parent injury to either layer of the pelvic floor." — Keed (page 242). DISPLACEMENTS OF THE VAGINA 241 largement of the vaginal outlet, the latter resulting from laceration of the perineum or injury to the pelvic floor, the proper remedy is to be found in a restoration of the perineum or pelvic floor, associated, it may be, with a narrowing of the lower segment of the vagina. (See Perineor- rhaphy.) This may need to be associated with the operation for either cysto- cele or rectocele, or both. The operation for cys- tocele consists in narrow- ing the anterior wall of the vagina and, conse- quently, is called anterior colporrhaphy. It is ac- complished, in general terms, by removing a disk of the redundant mucous membrane from the pro- truding vaginal wall, and in approximating the margins of the wound. The disk of membrane thus removed may be el- liptical or circular in form, and may vary in dimensions according to the size of the cystocele. Fritsch removes a circular piece of membrane, from an inch to an inch and a half in diameter, from the most prominent part of the presenting pouch; this denudation is then encircled by a single tobacco-pouch suture which is drawn up and tied, the cystic wall being pushed upward into the bladder as the suture is tightened. The technique is very simple, and in cases of small cystocele the operation is very effective. It is not practicable, however, in very large protrusions, in which there is marked redun- dancy of tissue. In such cases it is better to remove an ellipse of tissue closing the wound by careful linear approximation of its margins. Operators differ as to the direction that should be given to the long axis of this elliptical denudation. They formerly made the long axis of the denudation coincident with the long axis of the vagina; but an increasing number of later operators prefer to make one, or 17 90.- In such cases the vaginal wall should be denuded." — Eeed (page 242). 242 A TEXT-BOOK OF GYNECOLOGY perhaps two, transverse denudations, so that the resulting line of approximation may be coincident with the normal folds of the vagina (Fig. 88). Experience seems to warrant the latter innovation, as there is less tendency to retraction and the results seem to be more permanent. The closure can be effected either by the interrupted, or the buried animal, suture. When the interrupted suture is em- ployed it should be removed on the eighth or ninth day. (See Opera- tive Treatment of Prolapsus Uteri.) The operation for rectocele consists in narrowing the posterior wall of the vagina and, consequently, is called posterior colporrhaphy. It differs from the operation on the anterior wall, chiefly because rectocele as a rule exists as a complication of such conditions as call for the repair of the perineum or the restoration of the pelvic floor. The re- dundancy of tissue is reduced by removing one or more ellipses trans- versely from the vaginal wall and approximating the edges with inter- rupted sutures. (See Perineorrhaphy, Fig. 107). There are cases, how- ever, in which the anterior sacculation of the recto-vaginal septum exists without apparent injury to either layer of the pelvic floor (Fig. 89). In such cases the vaginal wall should be denuded as indicated in Fig. 90, which is drawn from a patient in whom the conditions varied slightly from those in the case just mentioned. The mucous margins are then approximated by interrupted sutures, beginning first with one tri- angle, then with the other, thus forming the expanded arms of a Y. The remaining area is then approximated by passing the interrupted sutures from side to side. CHAPTER XXI THE VTJLVO-VAGINAL GLAND Anatomv — Gonorrhoea! infection — Abscess — Cysts — Carcinoma. The vulvovaginal glands, or glands of Bartholin, are two small rounded or oval bodies from 15 to 20 millimetres in length, varying greatly in size and shape, and situated in the posterior third of the labia majora. one on either side of the lower end of the vagina, immediately below the bulb and in front of and near the upper margin of the perineal septum _____ . _ racemose glands (Fig. 91). They are the acini of which are lined by a single layer of high co- lumnar epithelial cells with basal nuclei. They secrete a muco-serous fluid which is emptied through two slender ducts of about 2 centimetres in length and terminating in small openings in the vestibule about 1.5 centimetre from the posterior median line just out- side the hymen. These ducts are lined by low cuboidal epi- thelial cells and their mouths are plainly visible on close in- spection, being of sufficient size to admit the passage of a fine probe. Functionally, the secretion of these glands serves to moisten the mucous mem- brane of the vestibule, and dur- ing sexual excitation or coitus it is discharged in considerable quantities. These glands become fully developed at the age of puberty, and maintain their full function until the climacteric, when they begin slowly to undergo atrophy and their function gradually ceases. The location of the mouths of these ducts renders them peculiarly liable to infection which may, by extension 243 Fig. 91. — " The vulvovaginal glands . . . are situated in the posterior third of the labia majora." — Rothrock. 244 A TEXT-BOOK OF GYNECOLOGY through the duct, involve the gland and result in a series of inflamma- tory conditions constituting the chief diseases to which it is liable. Inflammation must be regarded as invariably due to bacterial infec- tion, and cases apparently the result of trauma, as for example those following on childbirth, are now generally explained by the pre- existence of pathogenic bacteria in the duct, the trauma having served merely to afford an atrium of infection. While various bacterial flora of the vulva may gain entrance to these ducts, inflammation is almost invariably of gonorrheal origin. The one possible exception to this is the staphylococcus, which, it appears, may produce inflammation either alone or in association with the gonococcus. All other bacteria, therefore, which may at times be present, must be regarded in the light of secondary invaders. Pure gonorrheal inflammation usually remains confined to the ducts, rarely involving the parenchyma of the gland, and then only slightly. Gonorrhoeal Infection of the Ducts. — Infection of the ducts may occur directly, but in the majority of cases it is secondary to infection of other portions of the genital tract. A well-developed case of gonor- rheal inflammation of the vulvo-vaginal gland has been observed four- teen days after exposure to infection (Bumm), but this is exceptional, and frequently weeks or months may elapse before the mouths of the ducts become infected although constantly bathed meanwhile with vulvar or vaginal secretions. In most instances both ducts are in- volved, frequently from the beginning, but almost invariably in cases of long standing. The ducts are usually involved throughout their entire length, though oftentimes the involvement is not uniform throughout, but some portions of the duct are more severely attacked than others. To C. Herbert (Inaugural Dissertation, Leipsic, 1893) we are in- debted for a description of the histological changes which take place in gonorrheal inflammation of the gland and its duct. They consist essentially of desquamation of the epithelial cells, with a small round-celled infiltration of the intercellular substance and subepithelial connective tissue. At first the epithelium lining the duct becomes swollen, and even- tually loosened, by the infiltration of leucocytes, then desquamation begins. In cases of long standing, the desquamated epithelial cells are replaced by cells more cuboidal in character, often approaching the squamous type. The lumen of the duct will be found filled with pus and desquamated epithelial cells in which gonococci may be demon- strated. The gonococci may penetrate to the subepithelial connective tissue but are not found in the infiltration cells themselves. Gonorrheal inflammation of the ducts either begins as a chronic process, or, after a brief and ill-defined acute stage, becomes chronic. It may persist for months, and even years, an ever-fruitful source of infection, and, indeed, together with infection of Skene's glands, THE VULVO-VAGIXAL GLAND 245 may constitute the only points of localization of the infection in women. It usually occurs some time during sexually active life, though. Fischer (Deutsche medicinische TYcclienschrift, 1895) has observed it in children. Symptoms. — In the beginning, gonorrhoea of the ducts gives rise to few or no symptoms, so that the patient may be totally unconscious of its presence. Occasionally, there is a sensation of itching and burn- ing and perhaps some slight sensitiveness on pressure, or the patient may complain of a dull pain increased on walking or sitting. These symptoms when they occur are of short duration, and the patient may be conscious of nothing more than a slight muco-puru- lent discharge. Even this is often so slight as to escape notice. On examination, if the labia are separated so as to bring the mouths of the ducts into view, these appear, in cases of recent infection, in the form of dark-red, glistening, moist, spots resembling small ulcers, this appearance being due to ectropion of the inflamed and swollen mucous membrane lining the duct. If pressure is made along the course of the duct, a thin yellowish pus may be made to exude from its mouth, often in considerable quan- tities, which examination with the microscope shows to consist of pus and desquamated epithelial cells in which gonococci may be demon- strated in large numbers. Occasionally a nodular swelling, or induration, due to an infiltra- tion of the subepithelial connective tissue by small round cells, may be felt along the course of the duct. "When the disease becomes chronic, similar signs may be observed though less pronounced. The secretion now becomes more mucoid in character, and while gonococci may still be demonstrated they are present in diminished numbers. Frequently the only remaining sign of infection is the appear- ance of the mouths of the ducts, which Sanger has compared with flea- bites and has named "macula? gonorrhoea?," since he regards them as an infallible sign of gonorrhoea. Gonorrhoeal inflammation of the ducts may terminate in abscess of the glands or in cyst formation, and these two conditions constitute the chief diseases of the vulvo-vaginal glands, inasmuch as gonorrhoea! disease of the ducts is so devoid of symptoms that the patient is seldom conscious of its existence, and frequently it is only discovered by the examination of a physician. Abscess. — Inflammation of the parenchyma is invariably due to in- fection by pyogenic bacteria, most frequently the Staphylococcus pyo- genes aureus, occasionally the Staphylococcus pyogenes alius, either in association with the gonococcus or alone, and in a few instances the Streptococcus pyogenes has been found present (Dujon). In addition to these, various other bacteria are sometimes present in the pus. fre- quently the Bacterium coli commune; and in one case of relapsing abscess, examined by Eothrock, the Bacillus pyocyaneus was present, 24:6 A TEXT-BOOK OF GYNECOLOGY together with the Staphylococcus pyogenes aureus and other undeter- mined bacilli. The pus has frequently a foul odour similar to that so often met with in abscesses occurring about the anus, and in all probability due to the associated presence of the colon bacillus or putrefactive bacteria. Inflammation of the gland is almost always secondary to inflam- mation of the duct, though Kothrock recalls a case which had been under observation for some time, in which there was no evidence of disease of the ducts, old or recent. In this case the Staphylococcus pyogenes aureus was found in pure culture and no gonococci were demonstrable in the pus. Abscess of the gland may occur at any stage in the progress of disease in the duct, and, according to Bumm, it occurs in about one third of all cases of gonorrhceal infection of the duct. It is frequently met with in prostitutes, in whom gonorrhceal infection is unusually common. In this class of patients the traumatism incident to the abuse of coitus seems to be a fruitful exciting cause. Not infrequently it is met with immediately following menstrua- tion in the absence of any history of traumatism. Abscess usually develops unilaterally and may occur on either side, appearing to have no predilection for one side over the other. In case the disease runs a very acute course, the parenchyma of the gland is quickly destroyed, and the infection may pass through the mem- brana propria into the surrounding cellular tissue, with a resulting phlegmon which terminates in suppuration with the formation of an abscess. Usually, however, the inflammation runs a less acute course and remains confined to the capsule of the gland, which quickly be- comes distended with pus. In such cases the cellular tissue outside the gland becomes cedematous, and this in a large measure accounts for the swelling which is present. Symptoms. — Abscess of the vulvo-vaginal gland as a rule begins abruptly, and manifests itself by swelling of the labia majora accom- panied by the usual signs of acute inflammation — redness, heat, and pain. On examination, there may be felt in the posterior third of the labia majora, and often extending into the vagina, an irregular-shaped swelling the size of a pigeon's egg, and extremely sensitive on pressure. After a few days, during which the symptoms increase in severity, the swelling becomes boggy indicating beginning suppuration, and fluc- tuation may soon be felt. During this time the patient will usually find locomotion difficult on account of the swelling. The pain will have increased in severity, and have become throbbing in character. In severe cases there is usually a slight elevation of temperature reach- ing 101° or 102° F., and the onset of suppuration may be ushered in by a chill. There is usually some swelling of the inguinal glands on the affected side, which always indicates infection by pyogenic bac- teria, as it is never present in pure gonorrhceal infection (Sanger). With the accumulation of pus, a gradual thinning of the skin and sub- THE VULVO-VAGINAL GLAND 247 cutaneous tissue takes place, and the abscess, if not opened, points and ruptures spontaneously. Perforation usually takes place on the inner surface of the labia majora, but the pus may be conducted forward between the layers of the ischiopubic fascia, and point in the fold between the labia majora and labia minora. In some cases, the abscess may be evacuated through the duct by pressure made in that direction; but this is exceptional, as the duct is usually occluded, or at least does not communicate with the main abscess cavity. Earely the pus may burrow, and the abscess may be evacuated through the perineum, or even into the rectum with resulting fistulse. The pus may be yellow, dirty-green, or chocolate- coloured from altered blood. It frequently has a foul odour, and may contain gangrenous shreds. Well-defined abscesses are usually sharply limited by a thick pyo- genic membrane, the inner surface of which may be smooth, or irregu- lar from necrotic shreds, or from trabeculae-like septa which separate the lobes of the gland. Inflammation of the vulvo-vaginal gland almost invariably terminates in suppuration, though occasionally cases are met with in which it is characterized by marked induration with little tendency to the accumulation of pus. In these cases, the induration may remain for a long time, and may serve as a focus of infection for renewed attacks under the stimulus of traumatism. Cysts. — Cysts of the vulvo-vaginal gland are invariably the result of occlusion of the duct, and are therefore retention cysts. The vast majority are secondary to gonorrhceal infection of the duct. According to Sanger, they are an almost certain indication of pre-existing gonorrhoea, while Winter maintains that they may result from occlusion of the duct by traumatism, as, for example, in child- birth. Cysts may be located in the duct or in the gland. Those of the duct are small, superficial, and may remain for a long time without the patient's knowledge, being only discovered accidentally by exami- nation. They are situated in the lower part of the labia majora and at first are fusiform, but later they tend to become spherical. Cysts of the gland proper are larger, and are more deeply situated. From the beginning, they are spherical in shape, and may develop in one lobule, or the entire gland may be converted into a cyst. The wall of the cyst is usually thin and consists of connective tis- sue, and, occasionally, the remains of the epithelial lining of the gland may still be observed. The cyst contents vary in character ranging from a thin clear serous fluid, to a thick, tenacious, or colloidlike, accumulation, vary- ing in colour, sometimes clear or yellow, and, again, brown or chocolate coloured from the presence of altered blood. Microscopically, they may contain blood corpuscles, leucocytes, epithelial cells, cholesterin crystals, and detritus, and frequently the presence of gonococci may be demonstrated. 248 A TEXT-BOOK OF GYNECOLOGY As a rule, the older the cyst, the clearer will be its contents. In case the duct is not altogether occluded, pressure over the cyst may force out some of its contents, and occasionally cysts are met with which empty themselves spontaneously or during coitus, and which refill again after a time. In a few instances, cysts have been described which contained a fatty substance similar to that of sebaceous cysts. It is probable, however, that these were cysts which had their origin in the sebaceous glands of the vulva. Occasionally, cysts are met with which contain gonorrheal pus, the result of occlusion of the duct. Such collections have been termed pseudo-abscesses, as the usual signs of acute inflammation, such as are observed in staphylococcus infection, are wanting, except perhaps slight swelling which is due to oedema. Cysts of the vulvo-vaginal glands may become secondarily infected by pyogenic bacteria, following on which, suppuration ensues and the cyst is transformed into an abscess, with the usual accompanying symptoms. Cysts of the gland proper rarely reach a size as large as a hen's egg; and those especially large ones which have been described, the contents of which were clear and limpid, were probably in reality vagi- nal cysts from the remains of Gartner's ducts. Treatment. — Gonorrhoea of the ducts usually runs a very chronic course if left to itself, and, owing to the difficulty of access of the localized points of infection, often proves most obstinate to treatment. First of all, cleanliness of the external genitals should be secured by antiseptic douches. The duct should be systematically evacuated each day by gentle pressure made along its course from within out- ward, after which an application of an 8-per-cent solution of nitrate of silver should be made by means of cotton wrapped on a slender probe. Good results also follow the use of a 2-per-cent solution of formalin applied in the same manner. When the lumen of the duct is very narrow or obliterated, it is sometimes best to lay it open along its entire length, and this is most conveniently done by a Weber's canaliculus knife such as is employed by oculists for division of stric- ture of the lachrymal duct. When the duct has been laid open it should be washed out with an antiseptic solution, after which, either of the above-mentioned solutions of silver nitrate or formalin may be applied. Pozzi recommends the application of a 2-per-cent solution of chloride of zinc or cauterization by a crayon of nitrate of silver, while others recommend cauterization with pure carbolic acid. Inflammation of the gland is to be treated as is acute inflammation elsewhere, namely by rest in bed and by cold applications until sup- puration, as is the almost invariable rule, occurs, when the abscess should be freely opened, washed out with an antiseptic solution, and packed with iodoform gauze to encourage granulation from the bot- THE VULVO-VAGINAL GLAND 9±9 torn. As a rule the incision should be made over the most superficial point, which, in most cases, is the internal surface of the labium. Kelly prefers, however, to make the incision over the skin surface so as to avoid a painful cicatrix which sometimes follows an incision made over the mucous surface. As a rule, general anaesthesia will not be necessary for the opening of these abscesses, but local anaesthesia by chloride of ethyl, cocaine, or the application of ice, will be quite sufficient. Cysts are best treated by extirpation, after which the opening should be immediately closed by interrupted sutures. In case this is not possible, after thoroughly laying the cyst open, an attempt should be made to obliterate its cavity by cauterization and packing with iodo- form gauze. Examination should, at the same time, be made of the duct, and, if found diseased, it should also receive attention; otherwise it may remain as a source of infection. Carcinoma. — One other disease of the vulvo-vaginal glands deserves mention, and that is carcinoma. While of rare occurrence, the num- ber of cases which have been reported in recent years renders it certain that carcinoma may originate in the epithelium of the gland. Clini- cally, it appears to develop in middle or advanced life, as a rounded tumour of the labium which does not tend to ulcerate. Microscopically, the tumour frequently follows the type of adeno-carcinoma. Cases have been reported by Geist, Martin, Mackenrodt, Wolf, and Kelly. The treatment here, as for malignant disease in other regions of the body, is its early recognition and complete removal. In Martin's case the patient died of recurrence four years after the operation. CHAPTER XXII THE PELVIC FLOOR AND ITS INJURIES The pelvic floor — The "pelvic diaphragm" — Injuries of the pelvic floor — Lacera- tions of the perineum — Restorations of the pelvic floor — Immediate operation — Instruments — Operations for incomplete lacerations, superficial — Emmet's operation, Reed's method of suture; modifications — Operations for complete lacerations; Tait's operation; modifications — Repair of deep injuries of the pelvic floor — Harris's operation. The pelvic floor consists of those structures which by their muscu- lar elements are attached to the lowest plane of the pelvic bones and which occupy the outlet of the pelvis. These structures considered in their entirety include integumentary, aponeurotic, and muscular ele- ments, and are penetrated by three canals, namely, the vagina, the ure- thra, and the rec- tum. The function of the pelvic floor is to serve as a basis of support for the superimposed vis- cera. This power of support is exer- cised by virtue of the aponeurotic, and, particularly, the muscular elements of the floor; and it is to these elements that special atten- tion is invited. The muscles of the pel- vic floor are ar- ranged in two layers, (a) external, and (b) internal. The external layer of muscles embraces the bulbo-cavernosus, the transversus-perinasi, and the sphincter-ani-externus muscle, with fibres from the pubo-coccygeus and the obturator-coccygeus muscles. These muscles meet at a central point of convergence, which may 250 Fig. 92. — " These muscles meet at a central point of conver- gence, which may be designated the nidus perincei. v — Eeed (page 251). THE PELVIC FLOOR AND ITS INJURIES 251 Fig. 93. — " The internal layer, as described by M. L. Harris, is composed of four paired muscles." — Reed. with propriety be designated the nidus perincei (Fig. 92). The perineum proper is a pyramidal structure the base of which lies between the fonrchette and the anus, while its apex blends with the recto-vaginal septum; its essential structures are derived from, and constitute a part of, the external muscular layer of the pelvic floor. The internal muscular layer of the pelvic floor occupies a plane about 1.5 centimetre above the external layer, and, as de- scribed by M. L. Har- ris (Journal of the American Medical As- sociation), is composed of four paired muscles (Fig. 93). Harris says that " it is not always easy in a human subject to draw sharp lines of demarcation between some of these muscles at all points, and some knowledge of comparative anatomy is necessary to a clear un- derstanding of them. Comparative anatomy teaches us that these muscles are the representatives of well-developed, clearly defined mus- cles, which, in the lower animals are concerned in the movements of the caudal appendage, and which, owing to the loss of the caudal appen- dage and the assumption of the erect posture through evolution, have somewhat readjusted their character and attachments, to conform to their new function of closing the pelvic outlet and supporting the pel- vic contents. These four muscles are called the ischio-coccygeus, the ilio-coccygeus, the pubo-coccygeus and the pubo-rectalis. The ischio- coccygeus which arises from the spine of the ischium and is inserted into the lateral border of the lower part of the sacrum and the upper part of the coccyx; and the ilio-coccygeus, which arises from the iliac portion of the obturator fascia and in inserted into the lateral border of the lower part of the coccyx, have comparatively little remaining physio- logical importance or surgical significance." The remaining two muscles, however, are of extreme importance. " The pubo-coccygeus arises from the lower border of the symphysis ossis pubis, from the posterior surface of the os pubis, and from the obturator fascia as far back as the ilio-pectineal eminence. From this somewhat extensive origin the fibres pass meso-dorsad, passing by the urethra, the vagina, and the rectum, lying cephalad of the lower portion of the ilio-coccygeus, and are inserted with those of its fellow 252 A TEXT-BOOK OF GYNECOLOGY from the opposite side by means of a tendinous expansion into the ven- tral surface of the coccyx and the lower part of the sacrum, the more ventral fibres interlacing directly with those of its fellow as a girdle posterior to the rectum. The pubo-rectalis lies beneath, or caudad of, the ventral portion of the pubo-coccygeus, from which it is separated ventrally by an intermuscular fascia. It arises from, the lower portion of the symphysis ossis pubis, or from the beginning of the descending ramus and the cephalic surface of the urogenital fascia. Its fibres usually form a well-defined muscular loop which passes dorsad, encir- cling the rectum at the perineal flexure where it becomes continuous with its fellow. In passing by the rectum, some of its fibres enter the wall of the rectum, gradually become tendinous, and pass caudad as far as the cutaneous surface. A few fibres also pass anterior to the bowel between it and the vagina, some of them eventually becoming con- tinuous with the transversus-perinsei muscle of the opposite side. The pubo-coccygeus and the pubo-rectalis together form what is generally termed the levator-ani muscle, and are the most important muscles of the pelvic floor. They produce the characteristic perineal flexure of the rectum and vagina and form the chief support of the pelvic viscera. They must undergo the greatest elongation during the dilatation of the pelvic outlet for the passage of the child, and, therefore, are most liable to suffer rupture or laceration, as will be shown later. The more ventrally placed fibres pass almost directly ventro-dorsad, while on frontal section the muscular plane slopes from the periphery toward the centre and cephalo-caudad. In the space between the opposite muscles ventrally pass the vagina and urethra, and it is extremely im- portant to clearly understand the relations of these muscles to the lateral wall of the vagina. The normal virgin vagina is not a simple straight tube. In passing from without inward the general direction of the vagina, for a distance of 1.5 to 2 centimetres within the hymen is dorso-cephalad. At this point a distinct change in direction takes place and the vagina passes almost directly dorsad. The point of angu- lation lies opposite, and corresponds, to the perineal flexure of the rectum, and is produced by the pubo-coccygeus and the pubo-rectalis muscles encircling these canals at this point and drawing them for- ward, or in a ventral direction. With the finger introduced into the vagina, one is able easily to recognise the point of angulation, and distinctly to feel the edge of the pubo-rectalis muscle through the lat- eral wall of the vagina, as it passes in its course toward the symphysis. " An incision through the lateral wall of the vagina 1 to 2 centi- metres to the inner side of the hymen or its remains will expose the median edge of this muscle. It may easily be dissected up almost from its origin from the symphysis ossis pubis to the rectum, and in passing by the vagina its fibres do not enter or form an attachment directly to the vaginal wall. The muscle varies from 3 to 6 millimetres in thick- ness and extends in connection with the pubo-coccygeus laterally to the wall of the pelvis, the plane in the transverse direction being oblique THE PELVIC FLOOR AND ITS INJURIES 253 to the wall of the vagina. That portion of the vagina lying internal to the point of angulation or perineal flexure, and which composes by far the major portion of the canal, lies in its ventro-clorsal plane almost parallel with the muscular plane, and rests on it, the rectum alone in- tervening. Contraction of the muscles of this layer tends to increase the perineal flexure of the rectum and vagina by drawing the parts in a ventro-cephalic direction, and the opening through the muscular floor is thereby maintained ventrad of the line of gravity. The weight of the pelvic organs is thus brought to bear on the muscular layer of the pelvic floor; that mass of tissue ordinarily called the perineal body lying be- tween the rectum and the vagina, and extending from the inner muscu- lar floor of the pelvis to the cutaneous surface, has little or nothing to do with sustaining the pelvic organs." (Harris, ibid.) The pubo-coccygeus and the pubo-rectalis muscles, considered joint- ly as the levator-ani muscle, are graphically described by Dickinson {American Journal of Obstetrics) as resembling a horseshoe. Without reference to accurate anatomical details he says that " it is like a sling attached to the pubes in front, its sweep reaching horizontally back- ward to encircle the rectum and vagina like a collar. It sustains the re- lation of an independent encircling constrictor to the rectum and vagina, both of which are drawn by it in the direction of the pubes. It is a voluntary muscle with the capacity of lifting from 10 to 27 pounds. In cases in which it is inordinately developed it may be a serious barrier to the sexual relations while its spasmodic excitation is the frequent cause of dyspareunia and vaginismus." Meyer designated the internal muscular layer of the pelvic floor as the diaphragma pelvis proprium, and there has been a disposition among other writers to speak of this layer as the pelvic diaphragm. But this nomenclature is both erroneous and misleading. The word diaphragm, whether employed in mechanics or biology, conveys the meaning of " a partition or septum which separates one cavity from another." The most extravagant license can not conjure into existence a cavity below the internal muscular layer of the pelvic floor. If the term pelvic dia- phragm is to be employed at all, it should be restricted to that parti- tionlike arrangement of structures at the utero-vaginal junction which divides the recognised cavity of the pelvis from the cavities of the vagina, rectum, and, in part, of the bladder. Injuries of the pelvic floor may embrace any of the recognised varieties of wounds, such as contused, incised, or lacerated. They may be restricted to the skin, or they may involve the external muscular layer (perineum), or only the deeper muscular layer, or, to a greater or less extent, the whole of the structures of the pelvic floor. In this chapter we shall confine attention to those injuries which affect (a) the external muscular layer (perineum), and (b) the internal muscular layer. Lacerations of the Perineum. — Injuries of the external muscular layer are chiefly restricted to the perineum and are ordinarily discussed under the title of lacerations of the perineum. These injuries rarely 254 A TEXT-BOOK OF GYNECOLOGY result from external violence, but the traumatism upon which they depend is generally an incident of parturition. The traumatisms inflicted in this region are generally considered and treated as lacerated wounds. Still, there are instances in which the injury may be classed both as a contusion and a laceration, and upon a proper conception of the true nature of the trauma the treat- ment will, in a great measure depend. Varieties. — The varieties of these lacerations, or tears, must be con- sidered from the standpoint of the direction taken by the tear. This will be governed by the presenting part of the child that comes in con- tact with the least resistant or most inelastic structure, the force of the labour pains, and the anatomic construction at the point of impinge- ment. It must be remembered that the perineal structure, as a whole, is a complex arrangement of muscles, ligaments or tendons, fasciae, and ves- sels and nerves, so interwoven and superimposed as to resist a great amount of force. One of the functions of the perineum being to close the introitus vulvae by the contraction of the sphincter vagina? and levator-ani muscles, it is drawn or held forward by them, pro- ducing an abrupt angle with the lower portion of the birth canal; so that, in the process of descent, the presenting part comes into contact with a de- cided obstruction, and, should it be wanting in elasticity or resiliency, the structure is sure to be injured. A tear occurs at the point of least resistance, whether at this point be situ- ated a muscle, tendon, or fas- cia. This tear will take the direction of the course of the fibres composing the integral part at which the force is spent (Fig. 94); for the rea- son that it does not require so much force to split such a structure as it does to sever it at right angles. Should a tear occur along the course of the central tendon it may be de- nominated a central tear; if along the fibres of the transversus perinaei muscle or the transverse fibres of the triangular ligament, a lateral tear, with the prefix " right " or " left," as the case may be. The central rupture is regarded by most au- Fig. 94. — " This tear will take the direction of the course of the fibres composing the integral part at which the force is spent." — Dorsett. THE PELVIC FLOOR AND ITS INJURIES 255 thors as far the more frequent, but this is not the experience of Dorsett. Out of 1,006 ruptures of the perineum occurring at the St. Louis Female Hospital from July 15, 1887, to March 3, 1892, there were 296 central ruptures, 23? left lateral, 199 right lateral, and 10 ruptures of the third degree, or into the rectum, being more or less central. The remainder were of a superficial nature, or ruptures of the first degree. So great is the tendency for the line of tear to follow the fibres of the different tissues forming the perineum, that there are instances in which the tear, starting at the raphe, runs along the central tendon, here and there breaking a fibre and getting a little farther to one side until the sphincter ani is reached and penetrated; which muscle, on account of its peculiar circular form, may lead the tear around the anus, almost or completely enucleating the lower rectum from the surround- ing structures, or it may pass on backward to the fibres of the coccygeal ligament and split them till it reaches a point at or near the tip of the coccyx. Two cases of enucleation of the lower rectum from these severe tears have been observed by Dorsett. A laceration may start at the fourchette and take a straight back- ward course, following the raphe for a short distance, when, on ac- count of a particularly strong fibre or set of fibres of the triangular liga- ment or transversus perinsei muscle, it may take a different course, pro- ducing a very irregular wound. Lacerations sometimes take a shape not unlike the letter L or an inverted Y or T. When the head is in the first or second obstetrical position and there is not a great disproportion between the child's head and the maternal parts, and when the patient is tractable and can be controlled, the levator-ani muscle, as a rule, escapes injury. When an occiput posterior position is met with, the deeper perineal structures are apt to suffer, whether the delivery is instrumental or not. This is due to the fact that flexion can not take place and the occiput engages the posterior wall of the vagina and ploughs its way through the perineum, tearing the levator-ani and other deep muscles on its way outward. Occasion- ally, these posterior positions may cause what is known as perforating rupture. In other words, the perineum may be perforated by the child's head in such a way that the fourchette and sphincter ani may remain intact. Such injuries are, however, fortunately rare. A most remarkable case of perforating rupture of the perineum is related by Liszt (Monatsschrift fur GelurtsliiUfe unci Gynakologie). The subject was a primipara, aged twenty years, who had a normal pelvis and was in labour thirteen and a half hours. A swelling the size of a goose's egg appeared over the perineum and gradually increased in size until it ruptured two hours later. The child, which presented by the breech, was expelled through the opening, but the head had to be extracted. The fourchette and rectum were uninjured. For the purpose of description, lacerations of the perineum may be described as degrees of injury, according to the extent of solution of continuity. As, for example, a laceration through the skin, mucous, 256 A TEXT-BOOK OF GYNECOLOGY submucous, and subcutaneous cellular tissue, and as far as the muscle but not into it, may be termed a laceration of the first degree; if through the skin, mucous membrane, submucous and subcutaneous cellular tissue, and the muscular structures to, or into, the external sphincter- ani muscle, a laceration of the second degree; if through all the previ- ously mentioned tissues, and also through the anal sphincter into the rectum, a laceration of the third degree. Prophylaxis. — In the conduct of a case of labour it should be a matter of the utmost concern to the obstetrician to guard against a rupture of the perineum, the time for the most watchful attention being at the close of the second stage of labour; for, when the present- ing part is pressing upon the perineum, the tenesmus becomes so great that the inclination to strain, as at stool, becomes almost irresistible. Still, in many instances, if the patient is directed to " breathe out " and to " take short breaths," she may control herself to such a degree that the head may, even in a primiparous woman, slip over the peri- neum without injuring it beyond a slight tear of the fourchette. Yet it must not be forgotten that the maintenance of flexion of the child's head is the desideratum, and it is the duty of the obstetrician, by con- stant manual effort, so to press the occiput downward toward the hollow of the sacrum, that, by the proper amount of moulding of the head, the occiput can come well up under the pubic arch. When this stage is reached, the force now to be exerted is in exactly the opposite direction — that of extension — and is exercised by placing the palm of the right hand, not upon the mother's perineum, as was taught by the older writers, but upon the part of the child's head that shows in the cleft of the vulva, till the parietal eminences are about to escape, when the left hand relieves the right, and the index and middle fingers of the right hand are carried into the rectum and hooked under the supra- orbital arches. Gentle traction is now made with the two fingers of the right hand upward toward the pubic arch, while the left hand holds the head well against the arch. As soon as there is shown to be some progress, the two fingers, already in the rectum, are carried farther upward, and the lower border of the superior maxillary bone (in the child's mouth) is reached, when traction is made upon it, and latterly the child's chin is substituted for the maxilla. During this pro- cess of " shelling out the child's head," very effective assistance can be rendered by the nurse or assistant, by the insinuation of the fingers between the child's occiput and the pubic arch, and by pushing down the upper vaginal commissure which engages the back of the child's neck, like a collar. This rule should be followed whether the forceps is used or not. In the great majority of instances the forceps is only necessary to bring down the head into the vulva and is then taken off; the remainder of the delivery can be accomplished in the manner indi- cated above. In the delivery of all cases, irrespective of presentation or position, traction, manual or instrumental, should be in the direction of the axes of the birth canal for the preservation of the perineum. This THE PELVIC FLOOR AXD ITS INJURIES 257 rule should be strictly adhered to at the outset. Still, with the utmost ■care and good judgment, the perineum will be ruptured in a certain proportion of cases. J. "W. Bullard (Western lledical Review, Xovem- ber 16, 1898), after having consulted Byford, Munde, Martin, Hirst, Baldy, Coe, and Montgomery, as to proportion of lacerations during Urst labours, has found it to be about 30 per cent. Consequences. — The immediate consequences of laceration of the perineum are according to the degree of injury sustained. If the lacera- tion is of the first degree, the consequences are trivial. If of the second or third degree, the normal involution of the vagina and vulva is more or less interfered with, and the danger of sepsis greatly augmented. On account of the resulting torn and lacerated open wound, pathogenic organisms gain ready access. If the laceration extends into the rec- tum through the sphincter-ani muscle, the inability to retain the faeces .and gas will render the patient a miserable sufferer. The remote consequences, when the laceration is of the second or third degree, are many and not confined to the site of injury. For it must be remembered that the perineum is the support upon which rest the internal organs of generation as well as a part of the weight of the bladder; so that an impairment of this structure necessarily disqualifies these organs from performing their functions in a normal manner. TUien the laceration extends to the anal sphincter and is deep enough to involve the levator ani, the transverse muscles, and the transverse fibres of the triangular ligament as well as the different layers of fascia, the anterior wall of the rectum and the posterior wall of the bladder are robbed of their natural support, and a sagging of these organs is the consequence. As soon as the solution of continuity takes place, the divided ends of muscles retract, and, in time, by the pro- cess of healing, will be covered by mucous membrane, which does not give strength but allows a pouching downward of these organs. Strain- ing in the act of defecation or micturition augments the trouble, and, in the case of the bladder, a cystocele — in the case of the rectum, a rec- tocele — is formed. These abnormal pouches grow progressively larger and progressively give more and more trouble. In the case of the blad- der, the loss of its posterior support, viz.. the perineum, together with the tearing away of its natural moorings from their normal attachment around the internal aspect of the pubis by the passage of the child through the birth canal, leaves nothing to hold it up. and a sagging of the viscus is the result. This sagging down prevents the organ from emptying itself completely, and a decomposition of the residual urine soon sets up an often intractable cystitis. A division of the structures composing the greater portion of the perineum, leaving only the sphincter-ani muscle, allows the rectum to pouch forward, thus forming the condition known as rectocele. This tumour is increased in size by the efforts at defecation, for the reason that the anterior wall of the rectum forms almost a right angle to the .anus, and, at each attempt to defecate, this angle is increased, and 18 258 A TEXT-BOOK OP GYNECOLOGY the pouch or sac is consequently likewise increased in size. On account of the inability to evacuate thoroughly the contents of the rectum, a constipation is inaugurated, which tends still further to increase the size of the tumour. Not alone to the bladder and rectum, is the mischief done by a rupture of the perineum. The vagina, uterus, and uterine adnexa, also suffer. The lack of support given the vaginal walls causes them to drag the uterus downward, stretching its suspensory structures — viz., the broad ligaments on either side, the two utero-sacral ligaments pos- teriorly, and the two round ligaments anteriorly. Nature only intended these ligaments to act as " guy ropes," to poise the uterus in the pelvic cavity, and not as supports. The consequence is a giving way of these ligaments, resulting in either descensus or retro-deviations of the uterus and adnexa. The restoration of the pelvic floor is demanded in all cases when the injury is sufficient to cause either destruction or serious deteriora- tion of the functional power of this structure. When injuries are restricted to the external muscular layer (perineum) the impairment of function may consist, either in a mere enlargement of the vaginal out- let, with a consequent tendency to rectocele and cystocele, or, if the laceration has extended through the recto-vaginal septum, dividing the sphincter-ani muscle, the consequent loss of function finds expression in faecal incontinence; the indication, therefore, is for the repair of what are ordinarily designated the perineal structures. If, on the other hand, the injury involves the internal muscular layer of the pelvic floor, the resulting impairment of function eventuates, not only in a tendency to rectocele and cystocele, but in general ptosis of the pel- vic viscera; the manifest indication is, consequently, for a restoration of integrity and tone in the impaired deep muscles of the pelvic floor. When both layers of the pelvic floor are damaged, as is the case in prob- ably the majority of instances, the resulting operation, to be curative, must comprehend a restoration of all the injured parts. It is needless to say that the necessary prelude to correct treatment must consist in careful examination and accurate diagnosis. The immediate operation for external injuries of the pelvic floor, otherwise called lacerations of the perineum — i. e., the operation for restoration of the parts immediately after parturition — is one the expe- diency of which must be determined by the character of the laceration and the condition of the patient. If the laceration is not associated with much contusion, if the line of cleavage is direct and the surface smooth and of easy approximation, and if, moreover, the patient's condition is such as to admit of the operation, sutures may be applied at once and the wound closed. If, however, the laceration is of the eccentric variety, if the tissues are bruised and the proximal surfaces seem to be infiltrated with blood, and particularly if, in the presence of these conditions, the laceration is complete, attempt at imme- diate repair may be set down in the vast majority of cases as a mere THE PELVIC FLOOR AND ITS INJURIES 259 unnecessary and fruitless infliction of pain. The practitioner in justice alike to himself and his patient should, before attempting the imme- diate repair of these injuries, explain that the majority of such opera- tions are failures. Union may be said to occur in less than 50 per cent of even favourable cases. When the practitioner deems the case in Fig. 95. — Hemostatic forceps. — Eobb. Fig. 96.— Scalpel. — EOBB. Fig. 97.— Emmet's left- angled, right-curved scissors. — Eobb. Instruments for Catheter, glass 1 Forceps, hemostatic : Long 2 Intermediate 2 Small (Fig. 95) 2 Long dressing 1 Needles, as for abdominal sections (omitting the largest). Needle-holders 2 Needle, Reed's curved 1 Nozzle, Edebohls's 1 Perineorrhaphy \ Packer, vaginal 1 I Retractor, small 1 Intermediate 1 Scalpels (Fig. 96) 2 Scissors, right-angled. 1 pair. Emmet's left-angled (Fig. 9" Straight-pointed Sound, uterine Tenaculum, straight Tenacula, curved )-• hand a proper one for immediate repair, he should recognise that every step of the operation should be done with the strictest antiseptic precautions. The patient should be put in position on the table and the vagina should be carefully irrigated, preferably with lysol or car- bolic-acid solution; if the mercuric bichloride is used the solution should not be stronger than 1 to 4,000, because a stronger solution coming into 260 A TEXT-BOOK OF GYNECOLOGY contact with the raw surfaces of the wound is liable to cause tissue changes that will interfere with the union. After cleansing the vagina, the upper part of that canal should be carefully packed with sterilized gauze, to prevent the escape of the lochia during the progress of the operation. After having again cleansed the wound, interrupted sutures of sterilized silkworm gut should be inserted, with careful observance of the principles governing their application, as set forth in the paragraph relating to the elective operation of perineorrhaphy. Operations for Incomplete Laceration of the Perineum. — The opera- tion for the repair of superficial lacerations of the perineum is very simple. A V-shaped area is denuded at the site of the former four- chette (Fig. 98), and is closed by interrupted su- tures (Fig. 99), the re- sulting line of approxi- mation representing the letter Y. Emmet's Operation. — The patient, after having been antiseptically pre- pared and anaesthetized, is placed upon her back, her buttocks at the edge of the table, her legs thoroughly flexed and in- trusted to assistants, or preferably, to the me- chanical appliances which constitute a part of the modern operat- ing table (Fig. 100), the clothing worn during operations being omitted from the picture in order to show better the posi- tion of the legs. To hold the legs in a flexed position is both difficult for the assistant and not destitute of danger to the patient, for injuries have happened to the hip joint by injudicious pressure upon the flexed leg. Clover's crutch is not a desirable appliance for the reason that its mechanism is calculated to interfere with respiration and to become an embarrassment to anaesthesia. As soon as the patient is Fig. 98. — " A V-shaped area is denuded at the site of the former fourchette." — Eeed. TT THE PELVIC FLOOR AND ITS INJURIES 261 put in this position and the labia are retracted, the posterior wall of the vagina will appear as a projecting mass within the vagina (recto- cele, Fig. 86). A tenaculum is fixed in the middle and at the apex of this mass, which is now drawn forward and up- ward toward the pubes; as this is done the trac- tion thereby induced will make apparent two folds, one on either side, lead- ing from the point of the tenaculum to each lateral sulcus of the vagina. A tenaculum is then hooked into the caruncle caused by muscular retraction on either side of the vag- inal outlet, and upon the tenacula thus placed lat- eral traction is made by assistants. A gutterlike fold is thus formed, the external end beginning at the caruncle and ex- tending upward into the lateral sulcus where it coalesces with the fold from the central point of traction maintained by the tenaculum drawn up- ward toward the pubes, and another tenaculum is now placed at the site of the fourchette, midway between the two last named. The traction made in this way indicates the area to be denuded, while the approximation of the two lateral tenacula and the final infolding and Fig. 99. — " . . . Closed by interrupted sutures, the re- sulting line of approximation representing the letter Y."— Reed (page 260). the one in the vaginal wall will show approximation of tissue that is to be accomplished by the operation. Again separating these three points, and re-establishing the upward and lateral tension, the operator can see, in clear outline, the area which is to be denuded. The margins of the folds induced by the traction are the indications for the incision, which is carried along the crest of one lateral fold to 262 A TEXT-BOOK OF GYNECOLOGY Fig. 100. — " The patient is placed upon her back, her legs thoroughly flexed." — Reed (page 260). the bottom of the sulcus on the same side, and from the bottom of that sulcus to the central tenaculum, on the posterior vaginal wall; it is then carried from this same central point to the bottom of the sulcus on the opposite site of the vagina, and along the crest of that lateral fold to the vulvar margin; the two ends of this really continuous in- cision are now united by carrying an intermediate incision from one lateral tenaculum directly across to the opposite lateral tenaculum. The territory thus outlined is next de- nuded, after which the me- dian tenaculum on the pos- terior wall of the vagina is drawn down to a level with the lateral carunculse. Su- tures of silver wire are em- ployed and are inserted first into one lateral triangle and next into the other lateral triangle of the wound. They are passed an eighth of an inch back of the margin, and traverse first the mucous membrane and then the underlying muscularis; are crossed over to the other margin of the same triangle and are passed out from below upward, including first the muscularis and then the mucosa. The sutures are inserted about one fourth of an inch apart and, in passing from one side to the other of the respective triangles, they are made to define a V-shaped course, the apex of the letter pointing downward (Fig. 101). This is accomplished by inserting the needle and bringing it downward to the median line of the triangular space, drawing it out, reinserting it at the point of exit, and directing it upward and inward. After the sutures have been placed in first one and then the other lateral triangle, the "crown suture" is inserted (Fig. 101). This suture is recognised by Emmet as the one of principal importance in the entire operation and is inserted *at the point of the caruncular depression on one side, deeply enough to embrace within its sweep the levator-ani muscle. It is brought out on the denuded surfaces, passed over, and is inserted through the cellular tissue underlying the tip of the central mucous tongue. It is then crossed over to the other side, is inserted deeply enough to include within its sweep the levator-ani muscle, and is brought out just back of the caruncular depression of that side. A second suture an eighth of an inch from the foregoing may be similarly inserted if deemed expedient. Interrupted sutures are now passed from one side to the other, between the " crown suture " and the median perineal tenaculum, at intervals of about one fourth of an inch. The sutures are now tied, beginning with those at the apex of THE PELVIC FLOOR AND ITS INJURIES 263 first one and then the other triangle, the resulting approximated wound resembling the letter Y. Care should be taken in tying the sutures; for, if tied too tightly, they may induce necrosis from pressure. It may be taken as a safe rule that a suture is too tight whenever it blanches the tissues that it compresses. The foregoing description is intended to convey a conception of the technique as employed by Emmet, and as yet practised by him and his numerous fol- lowers. Many of the lat- ter, however, while fol- lowing practically every other detail of Emmet's technique, substitute other suture material; McMurtry, for instance, closes the lateral trian- gles with formalinized catgut, using silkworm gut for the " crown su- tures " and for the extra- vaginal sutures. From the fact, however, that formalinized catgut en- dures within the tissue from fourteen to twenty- one days — a longer pe- riod than the interrupted sutures are ever retained — the expediency of in- serting buried " crown sutures " of this material is well worthy of consid- eration. Feed's method of su- turing is as follows: The denudation is made in the same way as in Em- met's operation — but the closure is effected en- tirely by means of the buried formalinized catgut suture. The crown suture is first in- serted. A heavy curved needle armed with strong catgut is passed from left to right through the cellular layer of the mucous tip; it is then inserted a little to the right of the median line and carried deep enough to catch in its sweep the levator ani on the patient's left side. It is brought out beneath the cutaneous surface, and is carried to the opposite side and inserted beneath the cutaneous sur- Fig. 101. — " After the sutures have been placed in first one and then th& other lateral triangles, the crown suture is inserted." — Eeed (page 262). 264 A TEXT-BOOK OF GYNECOLOGY face, being made to embrace in its sweep the levator ani of the patient's right side (Fig. 103), when, being drawn taut, it will show the line& of approximation (Fig. 102). If the laceration is very deep and the separation is very pronounced, another crown suture of the same ma- terial is inserted in the same way; the ends of the crown suture, or of both of them if two are used, are left long and, for the present, untied. The wound is then closed by beginning on the inside near the apex of the left triangle, inserting the suture through the deep connective tissue and the muscularis, and bringing it out through the edge of the mucosa; it is then carried across and in- serted through the edge of the mucosa, through the muscularis, and the deep connective tissue. The suture is now tied and the short distal end alone is cut away. This gives the suture its an- chorage. (See Abdomi- nal Section.) After this, the needle is made to de- fine the same circuit at in- tervals of one quarter of an inch, or less, until the lateral triangle is closed. The needle is then carried through the submucous connective tissue to- the apex of the other triangle, when, without further preliminary fixa- tion, it is made to approximate the margins of the wound as in the pre- ceding triangle (Fig. 103). When both lateral triangles have thus been closed to the crotch of the Y, this suture is fixed by tying it in the deep cellular structures. The crown suture is now tied, the knot being on the inner surface of the approximated tissue. The remaining peri- neal wound is then closed by an intercutaneous suture (see Abdominal Section), forming the stem of the Y. In some cases it is well to fortify the approximation with a supplementary serpentine suture, passed sub- cutaneously (Fig. 109). The advantages of this method of closure are that it insures the best possible approximation of the parts; it gives the Fig. 102. — " Being drawn taut it will show the lines of approximation." — Reed. THE PELVIC FLOOR AND ITS INJURIES 265 patient less pain after operation; it is less liable to infection; and there is no occasion to remove sutures. Various modifications of Emmet's operation have been made, many of them, unfortunately, ignoring its sound philosophic principles; others, however, while observing the principles of Emmet, differ from his operation chiefly in the manner of execution. One of the most valuable of these innovations is the procedure of A. Palmer Dudley, the essential point of which is to take a stitch which will draw up all the posterior mucous mem- brane at the middle of the posterior wall, so that none of it can interpose itself afterward when the parts containing the tendinous centre of the muscular floor of the pel- vis are drawn into ap- position. This elimi- nates the downward-pro- jecting tongue of mucous membrane left by Em- met in his denudation. When a rectocele is present, the denudation is extended upward to the crest of the pre- senting pouch, forming a triangle the apex of which is in the medi- an line of the posterior vaginal wall. The wound is closed by a series of interrupted cat- gut sutures, the ends of which are tied externally. In passing these sutures in cases not complicated with rectocele, the nee- dle is inserted through the cutaneous margin and carried back coinci- dently with the long axis of the denudation for a distance of, perhaps, half an inch; it is then drawn through, reinserted at right angles, and brought out at the mucous margin, the buried portion of the suture making a letter L; the suture, next carried over to the opposite side at Fig. 103. — "The needle is carried through the submu- cous connective tissue to the end of the other trian- gle when ... it is made to approximate the margins of the wound as in the preceding triangle.'" — Reed (page 264). 266 A TEXT-BOOK OF GYNECOLOGY a corresponding point and inserted through the mucous margin at a distance of half an inch, is brought out in the midst of the tissue, and the needle reinserted at the point of exit and brought out through the cutaneous margin, the buried portion of the suture on this side making the letter L precisely as did the same suture on the other side. The second suture is passed in precisely the same way, the horizontal and perpendicular lines being parallel with those of the preceding stitch, from which it is distant about one fourth of an inch. Four or more such sutures are inserted and the ends are tied externally. In cases in which rectocele is present, the sutures are applied beginning at the apex of the upper triangle. The needle is inserted through the mucous membrane, pointing downward and inward toward the median line, at which point it is brought out; reinserted at the point of exit and passed through the tissues upward and outward, it is brought out through the mucous membrane on the opposite side of the triangle at a point directly opposite that of entrance. The buried portion of the suture thus intro- duced is in the shape of a letter V. Other sutures are applied in the same manner, the arms of the V gradu- ally widening until, in the middle of the area of denuded tis- sue, the suture is di- rectly horizontal, while those inserted below this point are parallel with it. The sutures are now tied, beginning with the upper intra vaginal one, the wound when closed making a straight line along the raphe of the peri- neum, the fourchette, and the median line of the posterior vag- inal wall. Lawson Tait adapted the flap- splitting operation to incomplete lacera- tions of the perineum, but with results less satisfactory than those following the Emmet operation, and vastly inferior to those which follow the adoption of the flap-splitting principle in cases of complete Fig. 104.—" The condition that is presented at examination. — Reed (page 267). THE PELVIC FLOOK AND ITS INJURIES 267 laceration. The Emmet operation may be accepted as a safe work- ing method in incomplete tears of the perineum. Operations for Complete Lacerations of the Perineum. — When the laceration of the perineum is complete, involving the separation of the recto-vaginal sep- tum and a division of the sphincter-ani muscle, the resulting condition is much more embarrassing to the patient and much more difficult for the sur- geon. In these cases there is a much more complete retraction of the perineal structures, a much wider gaping of the vaginal orifice, and an incontinence of the faeces. The condition that is pre- sented at examination (Fig. 104) is that of a sep- tum with only a narrow cicatrized margin which, if denuded b}^ the ordi- nary trimming process, would afford but narrow surfaces for approxima- tion. This, indeed, was a cause of failure in the ma- jority of the older opera- tions. To obviate this dif- ficulty and to secure wider margin for approxima- tion, Lawson Tait hit upon the expedient of splitting, rather than trimming, the septum. By this means, turning the rectal side of the flap into the rectum, and the vaginal side of the septum into the vagina, he secured, without the loss of tissue, approximating surfaces varying from half an inch to as much more as might be deemed desirable. Lawson Tait's Operation. — The technique of the flap-splitting operation is as follows: The patient is carefully prepared with due antiseptic precautions and with careful attention to the condi- tion of the bowels. This latter point is of extreme importance and should consume several days in its proper accomplishment. The bowels should be relaxed by repeated doses of salines given in small quantity and at frequent intervals. The Hunyadi or Apenta water or a mild solution of sulphate of magnesium may be given every few hours 105. — " The three incisions form the letter H. Eeed (page 268). 268 A TEXT-BOOK OF GYNECOLOGY until the bowels are relaxed, after which the saline should be kept up at longer intervals for the next couple of days. In the. meantime the diet, while abundant, should be chiefly of the liquid variety. Catharsis should cease at least twenty-four hours before the operation. On the morning of the operation one or two high enemas should be given, washing out, not ~ ' ~ IfJiieiPil only the rectum, but the sigmoid and the colon. No opiates are given to restrain the bowels either be- fore or after the op- eration. The vagina is now thoroughly sterilized and the pa- tient is placed on the operating table. A bistoury or, prefer- ably, a pair of keen- edged scissors curved on the edge or bent at an angle, may be employed to divide the septum. This is done by carrying the incision from one side, to the other, be- tween the vaginal and rectal layers of the septum, to the depth of about half an inch. The inci- sion is next carried out to either side to the outer margin of the distinctly cica- tricial area. Another incision is now made, beginning a little below, and a trifle to the outside of, the um- bilicated point, indicating the location of one end of the retracted sphincter-ani muscle. The incision is carried upward along the outer margin of the cicatricial area to its upper angle. A similar incision is now made on the opposite side. The three incisions unite to form the letter H (Fig. 105). It will now be discovered that by bringing the two upright lines of the H into approximation with the median line there is a restoration of the original contour of the parts. In the act of bringing them together, the vaginal flap and the rectal Fig 106.— "Other operators pass these sutures through the cutaneous margin." — Keed (page 269). THE PELVIC FLOOR AND ITS INJURIES 269 flap of the septum separate, approximating the broad proximal sur- faces. Before the sutures are applied, a little more dissection may- be required to expose the buried end of the retracted sphincter-ani muscle. This precaution is important. Tait was in the habit of closing this operation by passing sutures of silkworm gut by means of the Peaslee needle. Although other operators pass these sutures through the cutaneous margin (Fig. 106), the principle which he always observed in suturing was to apply these interrupted silkworm- gut sutures subcutaneously, the object being to draw forward and into approximation the retracted subcutaneous structures. The needle was inserted into the tissues beneath the jskin, carried under the tissues to the opposite side, and brought out just beneath the cutaneous margin. Several of these sutures were thus passed and then tied. The result was a gaping margin from which protruded the free ends of the silkworm gut. Superficial sutures were next passed be- tween the free ends of the deep tissue su- tures, thus carefully approximating the external margins of the wound. It should have been stated that it was Tait's custom in passing the deep tis- sue sutures, always to make sure that he inserted one of them in such a position as to catch the re- tracted ends of the sphincter-ani mus- cle, which were then brought into appo- sition when the su- tures were tied. The sutures were gener- erally removed on the seventh or eighth day, rarely later than the tenth. Modifications. — The principles of flap-splitting and of sphincter ap- proximation first enunciated by Tait have been very generally adopted by the profession. These were the essential elements of his teaching. Many of his followers have changed the technique of closure by the em- Fig. 107. — " The ends of the sphincter-ani muscle are trans- fixed by a suture of strong catgut." — Reed (page 270). 270 A TEXT-BOOK OF GYNECOLOGY ployment of different suture material and by different methods of apply- ing the sutures themselves. Eeed during the last ten years has adopted the following method of applying the sutures in flap-splitting opera- tions. The rectal flap of the septum is caught at its external corners by a volsella and approxi- mated in the median line, its raw surfaces be- ing brought together. These are now stitched together by means of a continuous catgut su- ture, beginning above and extending down to the anal margin, a step which, for clearness' sake, is designedly omitted from the illus- tration which shows this operation in connection with a completed opera- tion for rectocele. The continuous suture is now fixed. The vaginal flap of the septum is next seized and sutured in a similar way. The previously isolated ends of the sphincter - ani muscle are transfixed by a suture of strong cat- gut (Fig. 107) and are tied in the median line and the suture cut short (Fig. 108). A second suture of this kind may be applied if deemed expedient. A few rows of continuous catgut suture are now passed from side to side, one layer upon another (Fig. 108)y thus carefully approximating in an accurate tissue-to-tissue way the 'previously sepa- rated structures of the perineum. The operation is concluded by means of an ' intercutaneous suture, which may be fortified at the discretion of the operator with a buried serpentine suture of the same material (Fig. 109). There are numerous other operations for the repair of complete laceration of the perineum, that have been devised by able surgeons, adopted by many operators, and have given satisfactory results. Of these the Simon-Hegar operation is one of the most important. It consists in denuding the cicatricial area freely, but, instead of leaving a central tongue of mucous membrane in the denuded area, a similar Fig. 108. — " A few rows of continuous catgut sutures are now passed from side to side." — Keed. THE PELVIC FLOOR AXD ITS INJURIES 271 tongue is removed upward along the dorsum of the vagina. The small triangular area thus made in the vaginal mucous membrane is first ap- proximated by sutures, after which the remaining bat wings are brought together and sutured by their approximated mucous margins. The rectal mucous surfaces are then sutured together by means of interrupted sutures, the free ends of which are left in the rectum. A third row of sutures is finally applied to the cutaneous surface. The operations of Freund, Hildebrand, Heppner, A. Martin, and Le Fort, all contemplate denudation by cutting away the tissue, and closure by the use of interrupted, nonabsorbable, sutures. It is not apparent that any of them are more philosophical in conception, more easily done, or followed by better results, than is the flap-splitting operation of Tait. In conclusion, the practitioner may accept as a safe working method, the operation of Lawson Tait for complete laceration of the perineum, just as he may accept, as already ad- vised, the operation of Emmet for incomplete laceration. The repair of deep in- juries of the pelvic floor has engaged the serious consideration of various operators. One of the principles most emphat- ically enunciated by Em- met was the necessity of reapproximating the separated median fibres of the levator-ani muscle. It would seem, however, that in the case of exten- sive injuries to this mus- cle the technique of the Emmet operation will not reach or control it, and the same may be said of those operations to which are attached the names of Freund and A. Martin. Goldspohn was the first to devise and carry into execution an operation calculated to restore the integrity of the deep muscles of the pelvic floor (Medicine, July, 1897). In connection with this operation he laid it down as an axiom that " direct union of the two lateral halves of the muscle and edges of the pelvic fascia beneath the vagina and Fig. 109. — " The operation is concluded by means of an intercutaneous suture which may be fortified . . . with a buried serpentine suture." — Eeed (page 270). 272 A TEXT-BOOK OF GYNECOLOGY anterior to the rectum, should be the minimum requirement, no matter where the rupture showed itself superficially in the vagina." His opera- tion consists of an adaptation of the advanced views of Schatz and the flap-splitting principle of Tait. It is done by dissecting up the lateral walls of the vagina, exposing the injured muscles, and restoring them, and the associated fascia?, by buried animal sutures. Harris's Operation. — Harris has perfected the technique of this operation which he describes {Journal of the American Medical Association) as fol- lows : " When lacera- tion of the perineum is present the denu- dation of this part is made in the usual manner. If this body be intact, the denudation is omit- ted. An incision is then carried up each lateral wall of the vagina from 3 to 5 centimetres. The edge of the muscle can now usually be felt and an incision parallel therewith is made through the perivaginal connec- tive tissue, exposing the muscle (Fig- 110), which may easily be dissected out with the handle of a scalpel, blunt dissector, or the fin- ger, ventrally as far as the symphysis, and dorsally until it curves round poste- rior to the rectum. Should the muscle retracted that its edge ,can along the line which the Fig. 110.— " The edge of the muscle can now usually be felt and an incision parallel therewith is made." — Reed. ends have been so ruptured and its ends so not be distinctly felt, the incision is made muscle should occupy, and careful dissection is made for separated ends. The ends of the muscle will be found connected by cicatricial tissue. I have yet failed to find the remains of the muscle even when badly torn and the ends widely separated. m THE PELVIC FLOOR AND ITS INJURIES 273 " The muscle may vary considerably in thickness, and, when very thin and ribbonlike, it may be torn by a careless dissection. When multiple small lacerations are present, the muscle will not be entirely separated at any point, but will be lengthened, loose, and relaxed. In width or distance laterally, the muscle may be dissected from 3 to 5 centimetres. When it has been well freed, forceps should be placed on either side of the portion to be resected, so that the ends when cut shall not retract out of reach. The portion resected should correspond to the point of laceration if found, or when no distinct separation is found, to about the centre of the muscle. The extent of the piece resected will depend upon the amount of separation or the degree of lengthening and relaxation. It should be sufficient so that when the ends are drawn together the floor of the pelvis will be restored to its normal position and degree of tension. The ends of the muscle are then sutured together with an interrupted or continuous catgut stitch, which, of course, remains buried. The opposite side is treated in a similar manner when the incision of the lateral walls of the vagina is closed by a catgut suture. This latter suturing should be thoroughly done so that no openings will remain through which fluids or infection may reach the deeper parts. When the perineum has been torn this is closed in the usual way." Hemorrhage in the course of this operation is sometimes free, never excessive and always controllable. It is, however, of extreme importance that all bleeding points be secured before the operation wound is closed, as a hematoma will prevent union by first intention, and, by a favouring infection, may defeat the objects of the operation. The operation in the hands of Harris has proved entirely satisfac- tory. By its means he restores the normal floor of the pelvis in regard to both tone and integrity, carries the vaginal opening ventrad to its normal position, and restores its perineal flexure, while the muscles regain and retain their contractility and resume their elevating and sphincteric action at the vaginal orifice. 19 CHAPTEE XXIII MALFORMATIONS OF THE UTERUS Classification : Embryonic, total, postnatal — Absence — Uterus unicornis — Fcetal r infantile or pubescent — Uterus septus — Uterus bicornis — Uterus duplex — Minor malformations; atresia — Treatment; stomatoplasty. The malformations of the uterus are very numerous and they are among the best known of all the structural anomalies to which the organs of the body are liable. Further, their mode of origin is in most instances fairly well understood, a fact largely explicable by our considerable knowledge of the embryology of the utero-vaginal canal. They have also a marked and practical bearing upon the phenomena of the reproductive life of the woman, gynecological no less than obstet- rical. Classification. — The most recent and most approved classification of the malformations of the uterus is founded directly upon the de- velopment of the organ (F. von Winckel, Eintheilung der Bildungshem- mungen der weiblichen Sexualorgane, 1899). Uterine development may be divided into two periods, an antenatal and a postnatal; the former may again be subdivided into an enibryonic and a foetal period. The embryonic development of the organ takes place, roughly speaking, in the first three months of intrauterine life: it passes through three stages, in the first of which there exist the two Mullerian ducts as solid cords in the neighbourhood of the Wolffian ducts (first month); in the second, the ducts obtain their lumen and unite externally into one utero-vaginal tube (second month); and in the third, the ducts fuse internally into one hollow tube, the utero-vaginal canal, their upper parts, however, remaining distinct as the Fallopian tubes (third and fourth months). The foetal development of the uterus oc- curs during the remaining five or six months of intrauterine life, and chiefly consists in the formation of the fundus of the organ, the transition from the uterus planifundalis into the uterus foras arcuatus, or foetal uterus. Postnatal development takes place in two stages: in the first, corresponding to the first ten years of extra-uterine life, through the greater growth of the body as compared with that of the cervix, the uterus foetalis becomes the uterus infantilis', and in the second, which may be said to extend from the tenth to the sixteenth year, the infantile uterus takes on the characters of 274 MALFORMATIONS OF THE UTERUS 275 the adult but virgin organ. Now, the majority of uterine malforma- tions are simply stages of development normally temporary but which have become permanent, and they may be divided into groups corre- sponding to the developmental stages which have been enumerated. These groups may be put in the form of a table. Embryonic Periods of life. Groups. I. (a) Absence of uterus, complete, together with absence of tubes and vagina (very rare). (b) One-horned uterus, with no trace of the other horn {uterus unicornis sine ullo rudimento cornu alterius). II. (a) Externally double uterus (uterus duplex sine didelphys ; uterus bicornis). (b) Solid or partly excavated uterus (uterus solidus, uterus rudimentarius, uterus par tim excavatus). (c) Combination of («) and (b) (uterus duplex solidus. uterus bicornis rudimentarius). (d) One-horned uterus, with other horn solid or partly exca- vated (uterus unicornis cum rudimento cornu alterius). III. Uterus divided internally more or less completely, without or with external signs of duplicity (uterus septus, subseptus, uterus bicornis septus), f IV. Uterus with flat fundus, with or without complete or par- tial internal duplicity (uterus planifiuidalis septus, subseptus, simplex). V. Uterus with foetal characters (small body, large cervix). Postnatal VI. Uterus with infantile characters (uterus infantilis). Foetal There are some malformations which do not find a place in this scheme of classification. One of them, the trifid uterus or uterus accessorius, is specially difficult of embryonic explanation. To account for it we have to suppose the existence of a double Miillerian duct on one side; possibly it arises in the pre-embryonic or germinal period. Congenital prolapsus uteri also, which may be grouped with the mal- formations, does not represent a stage in the development of the organ so far as is known; since, however, it has always been found associated with spina bifida, it may be really rather a concomitant anomaly of spinal arrested development than an arrest in the evolu- tion of the uterus. As to the cause of these arrests in uterine de- velopment there is still much darkness: inflammatory processes, e. g., foetal peritonitis; defective formation of the abdominal walls, e. g., umbilical hernia: the presence of tumour germs preventing union of the Miillerian ducts, and traction upon these ducts exercised by neigh- bouring structures, have all been adduced as possible teratogenic fac- tors; but they are all insufficient to explain the anomalies which have arisen in the emb^onic period of intrauterine life. It will probably be found that uterine malformations, like malformations and monstrosities of other parts of the body, are due to the action of germs, toxines, and poisons, upon the tissues in the course of evolution (Pathology of the 276 A TEXT-BOOK OF GYNECOLOGY Embryo.) (Scottish Medical and Surgical Journal, v, 481, 1899). It is unnecessary in a work such as this to describe in detail all the varieties and subvarieties of uterine malformation which the pathologist has differentiated; it will be sufficient if the leading types are dealt with in outline. Absence or Rudimentary State of the Uterus. — Complete absence of the uterus, save in sympodial foetuses and the acardiac twin monstros- ity, is of excessive rarity; indeed, it is doubtful whether its occurrence in the adult woman has been established. On the other hand, it is far from uncommon to meet with patients in whom the organ is physiologically absent, or, to put it in other words, in whom there is a rudimentary uterus (solidus, partim excavatus, membranaceus). The tubes and vagina are usually also defective in such cases, but it is common to find a well-formed vulva and even a short vestibular vagina which has been made deeper by attempts at coitus. The symptoms vary with the presence or absence (or at least physiological absence) of the ovaries. There is always necessarily amenorrhcea; but when there are functionating ovaries menstrual molimina are met with, there are occasionally vicarious hemorrhages, and there may be a great deal of pelvic pain. Secondary sexual characters are generally present, but the vulvar hair may be defective. By means of a recto-abdominal bimanual examination (under an anaesthetic if necessary), and with the help of a sound in the bladder, it can usually be made out that the uterus is seriously defective. In the marked cases no thickness of tissue can be felt between the rectum behind and the bladder in front. It is doubtful in these instances whether any treatment of the nature of ferruginous tonics and the like should be adopted, for such will only prove ineffective and disappointing to the patient. When severe monthly suffering exists, the opening of th,e abdomen and the removal of the functionating ovaries must be considered; indeed, it is demanded in many instances, and can be done with not more than the ordinary risks of a coeliotomy. Vineberg {Transactions of the American Gyneco- logical Society, xxiii, 396, 1898) has recently reported a case of this kind in which the removal of the ovaries was followed by the disappear- ance of symptoms; during the laparotomy it was noted that in addition to the ovaries there were two small oval bodies lying at the pelvic brim which were probably rudimentary uterine cornua. Uterus Unicornis. — The absence of rudimentary development of one horn of the uterus produces the unicornate variety; when there is a rudimentary horn it may either be solid or show a cavity, and under the latter circumstances pregnancy or menstrual retention may occur in that cavity. The one-horned uterus has no proper fundus, for it inclines to one side and tapers to a point where it becomes con- tinuous with the Fallopian tube (only one tube is usually present). Concomitant malformations are: small vagina, vagina septa, absence of one kidney and ureter, rudimentary condition of the ovaries. The uterus unicornis is not often diagnosticated during life unless it is dis- *^i MALFORMATIONS OF THE UTERUS 277 covered during a laparotomy. Menstruation is not necessarily affected and pregnancy may occur in the single well-developed horn and pass to a normal termination; but when there is gestation in the rudi- mentary horn, then rupture of the sac commonly happens with results practically undistinguishable from those found after the bursting of a tubal pregnancy. Foetal and Infantile or Pubescent Uterus. — When the uterus in the adult woman instead of taking on its full development retains its foetal or infantile characters, it is common to find along with it a poor mammary and vaginal development with symptoms of defective ovarian formation and sometimes such systemic disorders as chlorosis. There is either amenorrhcea or a scanty flow; sterility is met with; and there may be also dysmenorrhea. The vaginal and bimanual exami- nations, together with the introduction of the sound, should enable a diagnosis to be formulated, and the relation of the size of the body of the organ to that of the cervix will distinguish the foetal from the infantile type. The treatment will be directed toward establishing the growth of the uterus, and this is far from hopeless in the infantile form. Marriage has sometimes a good effect but should not be recommended unless the menstrual function has been established. In the unmarried, reliance must be placed upon the administration of iron, arsenic, and quinine, together with nourishing food and gymnastic exercises; in the married, electrical stimulation of the uterus or simply the periodical passing of the sound may be employed, but the insertion of a stem pessary as recommended by many is not free from risk and is of doubtful efficacy. Uterus Septus. — The least marked form of double uterus is the septate variety in which the only indication of duplicity is found in the division of the interior more or less completely into two cavities {uterus septus, subseptus). Externally the uterus appears to be single but has sometimes a more markedly globular outline than is usual. The two cavities are commonly situated laterally, and there may or may not be indications of duplicity in the cervix. The clinical symp- toms are indefinite: there may be amenorrhcea and dysmenorrhcea : or there may occur the curious twice monthly recurring hemorrhage which may be supposed to be menstruation from the two cavities of a non- synchronous type: and if one of these discharges is small in amount and accompanied by pain we have an explanation of one variety of the midpain or " Miti 'elsch men. " It is possible that a septate uterus may be a cause of habitual abortion, at any rate in one case the division of the uterine septum was followed by a normal pregnancy. During curettage the curette has been known to pass from one cavity of a septate uterus into the other, giving the sensation of perforation of the organ (Blondel. Bulletins et memoires de la Societe obstetricjue et gyne- cologicjue de Paris, p. 53, 1898). The presence of the septum may complicate labour in this form of malformation; it may cause a mal- presentation or a low implantation of the placenta, or to it the pla- 278 A TEXT-BOOK OF GYNECOLOGY eenta may be attached, in which case hemorrhage in the third stage is to be looked for. The diagnosis of this malformation has usually been made accidentally during the extraction of the placenta or in turning. Uterus Bicornis. — In the bicornate uterus the upper part of the body shows distinct duplicity but the lower part and the cervix are single; on internal examination it may be found that the duplicity extends to the cervical canal also. The degree of separation of the two horns varies within wide limits, from a simple notch on the fundus to a wide interval. Further, the horns may be of the same or of different size, and in the interval between them may be seen a band stretching from rectum to bladder (recto-vesical ligament). The ex- ternal genitals are generally normal but the vagina may show different degrees of duplicity (vagina septa, subsepta). One of the horns may be solid or partly imperforate, and in the latter case it may become the seat of a pregnancy or a menstrual blood accumulation (hematometra). The clinical history will be very similar to that met with in the septate variety. As regards menstruation, there may be a simultaneous dis- charge from both cavities each month, or a flow from one cavity one month and from the other the following month, or a discharge from each cavity each month but not at the same time (fortnightly variety). Pregnancy, apparently, not uncommonly happens in the bicornate uterus: during it, hemorrhage may go on from the unoccupied horn or a decidual membrane may form in it; both horns may contain impreg- nated ova, and the age of the gestation may not be the same in each, thus explaining some of the anomalous cases of superfcetation; and, rarely, a twin conception may occur in one horn. Labour may be interfered with in various ways: there may be a malpresentation; there may be delay from the presence of the recto-vesical band; there may be a low implantation of the afterbirth; and, as Halban (Archiv fur Gynakologie, lix, 188, 1899) has lately shown, in cases where the pregnant horn lies obliquely to the empty one the head of the infant may be driven during labour through the septum between the two cavities, and what was a left-sided foetus may be expelled through the right cervical orifice. The diagnosis of the uterus bicornis, like that of the septate organ, is often not made till labour supervenes or till the abdomen is opened for some purpose; but if a double vagina or a double os uteri exists the anomaly may be suspected, and then a careful examination bimanually and with two uterine sounds may suffice to make it plain. Uterus Duplex. — The most complete form of double uterus is the uterus duplex, separatus or didelphys; in it, the Miillerian ducts have failed to unite in that part of them which goes to form the body and cervix of the uterus, and commonly also in the vaginal part, so that there is at the same time a vagina septa. It is much rarer than the uterus bicornis and it is impossible to distinguish the one from the other with certainty during life. In a case reported by Ameiss MALFORMATIONS OF THE UTERUS 279 Fig. 111. -" A bicornate uterus with each horn well developed." — Keed (page 281). (American Journal of Ob- stetrics, xxxiii, 693, 1896) both uteri were some- what retro verted; and in one put on record by Bernhard (Centralblatt -fur Gynakologie,xxi,14:64:, 1897) both were fcetal in development; in Ameiss's case there was pregnancy and in Bernhardt ster- ility. Minor Malformations. — The uterus, in addi- tion to the typical and marked malformations which have been already described, may be the subject of smaller anomalies, such as the want of rounding of the fundus (uterus planifundalis), imperf oration of the cervical canal, or the presence of a diaphragm in it. Congenital pro- lapsus uteri has been re- corded (Ballantyne and Thomson, American Journal of Obstetrics, xxxv, 161, 1897); curi- ously enough in all the reported instances it has been met with in infants suffering from lumbo - sacral spina bi- fida. In one sense pathologic anteflexion and retroflexion of the uterus may be re- garded as malforma- tions; but they are con- sidered elsewhere. Con- genital elongation of the cervix or conical cervix also occurs. Atresia, or complete occlusion of the cervical canal, resulting in reten- tion of the menstrual Ekk 112.-" This secretion . . . often accumulates to a fluid > is sometimes en- degree that results in dilatation of the cervical canal." countered. Among the —Eeed (page 282). minor malformations of 280 A TEXT-BOOK OF GYNECOLOGY the uterus may be mentioned stenosis, by which is meant a narrowing of the calibre of the canal, the constriction being situated as a rule either at the external os or the internal os, or, it may include the entire canal. The treatment of malformations of the uterus must, of course, vary according to the condition. In those cases in which the uterus is absent or extremely rudimentary, but in which there develops a men- strual molimen, the patient may be seriously afflicted with ineffectual efforts at menstruation. Profound neurotic disturbances are liable to ensue. In these cases the only relief lies in extirpation of the rudi- mentary ovaries. In those cases in which the uterus is foetal, infantile, or pubescent, the degree of development encoun- tered will determine the remedial course to be employed. If the uterus is less than an inch and three quarters in longitudinal diameter, any effort to force its development by local means will prob- ably prove unavailing; or, if development is pro- voked, there is but little hope that it can be car- ried beyond that degree which will result only in the most unsatisfactory establishment of the men- strual function. If, however, the uterus is an inch and three quarters or more in depth, intra- uterine faradization may be employed with some prospect of success. Massage of the uterus is like- wise an expedient calculated to promote its growth. But little, however, is to be promised in these cases. Patients or their friends may be assured that in certain instances the uterus has suddenly developed after having remained more or less rudimentary for years. These may be called instances of delayed development. A nor- mal exercise of the menstrual function is never to be promised in these cases, nor is pregnancy to- be held up as either possible or desirable. It is frequently to be noticed that girls with pubescent uteri and corresponding deficiency of the menstrual function show a tendency to obesity. These phenomena can only be accepted as exemplifications of the biologic law of antagonism between growth and genesis. The indication for treatment in these cases is to reduce the flesh and improve the quality of the blood which will generally be found to be deteriorated in some particular. When the flesh is reduced to the normal standard and the normal bal- ance of the nutrient functions is thereby properly established, the uterus sometimes shows a disposition to develop without local treatment. The latter, however, is important and should not be omitted. The bicornate or septate uterus may be capable of exer- cising a menstrual function in either of its compartments. In occa- Fig. 113.— "It is often necessary to remove a segment of tissue from either the an- terior or posterior lip of the cervix." — ■ Eeed (page 283). MALFORMATIONS OF THE UTERUS 281 sional instances one cavity, and still more rarely both, is closed, with resulting hematometra. The condition may be undetected for some time, for the reason that the menstrual discharge may regularly appear from one side of the uterus, while it is retained in the other side. The latter condition, however, sooner or later develops pain which calls for intervention, when the real condition of the uterus is for the first time discovered. The appearance presented in the examination is some- times bewildering in view of the fact that the gradual accumulation of fluid may have forced a comparatively thin and elastic septum down- ward through the exter- nal os, whence it pro- trudes in the form of a cyst. In these cases a mere excision of the wall will result in the collapse of the cystlike accumula- tion. Cullingworth has reported (Transactions of the American Gyneco- logical Society) an inter- esting case which pre- sented all the symptoms of a suppurating cyst outside the uterine cav- ity, with a fistulous com- munication between it and some part of the uterine canal. Explora- tion by abdominal inci- sion revealed a bicornate uterus with each horn well developed, the right being larger, more globular in shape, and situated farther back in the pelvis, than the left. The two horns con- verged toward an isth- mus and were continued in a common cervix. A retroperitoneal mass on the right of the cervix was found to be the origin of the discharge and was removed by vaginal section. It proved to be the expanded right half of the cervix (Fig. 111). Stenosis may be relieved by an operation which Delageniere (Chi- rurgie de Vuterus) appropriately designates as stomatoplasty, which has for its object the permanent dilatation of the cervical orifice. Various expedients have been devised for this purpose. Courty before 1880 and Kuster in 1885 promulgated the idea of discission of the neck Fig. 114. — " Cases where there has been long distention with menstrual fluid." — Reed (page 283). 282 A TEXT-BOOK OF GYNECOLOGY with reference to a permanent enlargement of the external os. Dela- geniere (Chirurgie de V uterus, p. 328) has investigated the literature of the subject, and finds that the examples of Courty and Kiister have been followed by Dudley, Nourse, Beed, and Pozzi; although the object aimed at by these different operators has been somewhat differ- ent. The procedure of Kiister, like that of Dudley, was designed simply to enlarge the otherwise straight uterine canal which terminated in a contracted os; while the operations of Dudley and Eeed were designed more especially to straighten the tortuous canal in cases of ante- flexion. Enlargement of the external os is indicated in all cases of either occlu- sion or narrowing of that orifice. The same may be said of those cases of con- genital atresia that are oc- casionally noted. In both cases the cause may arise from narrowing, either congenital, or due to a cicatricial deposit follow- ing the application of strong caustics or the ex- cessive narrowing of the canal by trachelorrhaphy. One of the first of these sequent conditions is the retention of the normal cervical secretion. This secretion, albumin- ous in character, often accumulates to a degree that results in dilatation of the cervical canal (Fig. 112). In this state the re- tained secretion forms a mucous plug which entirely occludes the lower end of the uterine tract. Such a condition persisting through months or even years results sooner or later in hypertrophy of that organ; not only is the uterus enlarged, but hypertrophic endometritis is developed. Dysmenorrhcea of the obstructive variety is an ordinary result. The endometrial changes may go to the point of fungous degeneration in which case menorrhagia and metrorrhagia are the consequences. In the absence of the fore- going indications, or, for that matter, in cases in which they are pres- Fig. 115. — "There exists a redundant endometrium which may demand subsequent curettement." — Eeed (page 283). M MALFORMATIONS OF THE UTERUS 283 ent, sterility is the condition which brings the patient to the doctor's office. The obstruction to conception which is afforded, mechanically, not only by the narrowed orifice of the uterus, but by the constant plug of mucus within the cervical canal, are the conditions that demand removal. The operation may be performed by different methods. In cases in which the os is of the pin-hole variety, very narrow and with a very considerable amount of retained cervical secretion above it, the cervical margins will be found to be little else than a film of tissue which is easily broken down by a dilator, or may be successfully broken up by means of a stellate incision. This is sometimes all the operation that is necessary; in the majority of cases, however, it will not be found to be sufficient. It is often necessary to remove a segment of tissue from either the anterior or posterior lip of the cervix (Fig. 113) and to bring the mucous membrane out, stitching its margin fast to the denuded margin of the other lip of the incision. If this is done anteriorly and posteriorly, a slight bilateral incision having been previously made, a very slight ectropion is produced. The results of the operation are very generally satisfactory. It should be remembered, however, that in cases where there has been long distention with menstrual fluid (Fig. 114) there exists a redundant endometrium (Fig. 115) which may demand subsequent curettement. Congenital elongation of the cervix or conical cervix may be treated by forcible dilatation; if this is not satisfactory the cervix should be amputated. (See Amputation of Cervix.) CHAPTER XXIV DISPLACEMENTS OF THE UTERUS Normal position of the uterus — Displacements in general : Varieties, causes, pathol- ogy, treatment — Retro-deviations : Symptoms and diagnosis — Treatment : Massage, electrolysis, tamponade, pessaries, surgical — Shortening the round ligaments — Alexander's operation — Mann's operation — Goffe's operation — By- ford's operation — Vaginal fixation: The fundus, the cervix — Pryor's opera- tion — Ventral fixation — direct, indirect — Anterior abdominal cuneo-hysterec- tomy — Ante-deviations : Symptoms, pathology, treatment — Dilatation and curetting — Dudley's operation — Prolapsus: Etiology, pathology, symptoms — Treatment: Conservative, surgical — Emmet's operation (anterior colporrhaphy) — Inversion: Symptoms, prognosis, pathology, treatment. The normal position of the uterus can not be indicated by definite lines or specific limitations. By the nature of its construction and in consequence of its visceral relations, it has a considerable range of mobility. In infantile life its long axis presents but slight deviation from the long axis of the body, while its locus is on a line with the pelvic inlet. In mature life, however, the fundus leans forward to such a degree that the long axis of the uterus lies at right angles with the brim of the pelvis, the change of position amounting to about 45°. There occurs at this time a normal recession of the organ, until its fundus lies a little below a line drawn from the top of the symphysis pubis to the promontory of the sacrum. The distance from this line to the coccyx is about five inches, one half of which distance is occu- pied by the uterus in its long axis. While this definition of the posi- tion of the uterus is as nearly correct as can well be stated in words, the fact should be remembered that this organ vacillates both in actual location and relative position. A loaded rectum or sigmoid may force it forward, while, in the presence of an empty bowel and a distended bladder, the fundus of the uterus is lifted upward and backward. The uterus being swung in the pelvis by attachments upon either side, the focal points of which are situated laterally in the middle segment, it follows that when the fundus is moved in one direction, the cervix must move in the opposite direction. Aside from these movements the uterus has to a certain extent an up-and-down movement, rhyth- mical with the respiratory movements of the abdominothoracic dia- phragm. It is this movement of the uterus, observable in almost any patient upon the examination table, that renders it more appropriate to designate as the pelvic diaphragm the structures in which the uterus 284 DISPLACEMENTS OF THE UTERUS 285 is embedded, rather than to apply that term to the deep muscular layer of the pelvic floor. These movements are normal, and any change of position within this normal range of activity should not be construed as a departure from the healthy standard. The arc of mobility may vary from 45° to 90°, while, with the rectum and bladder empty and with no undue voluntary pressure from above, the uterus will be found to return to a position approximating that already defined. A uterus may be said to be displaced when it ceases to manifest these normal variations of position, and when it persistently remains in a position distinctly at variance with the one which it should occupy under average conditions. A proper comprehension of uterine displacements presupposes an understanding of the anatomic connections and physical forces by which the womb is retained in position in a state of health. It is important, at the outset, to look upon the uterus as a suspended rather than as a supported organ. The suspensory apparatus consists of (a) the peri- toneal duplication called the broad ligaments, (b) the round ligaments, (c) the utero-sacral ligaments, (d) its attachments to the bladder and (e) to the structure comprising the floor of the cul-de-sac of Douglas, while (/) the cellular tissue at either side of the uterus is not to be ignored. The idea that the uterus is supported by a column from be- low was long ago demonstrated as fallacious by Emmet. A moment's reflection upon the intrauterine structures will convince the reader that they are neither constituted nor arranged to furnish support to the uterus; on the contrary, so far as they tend to exercise a modifying influence upon that organ at all it is to draw it farther down in the pelvis, rather than to maintain it at its normal level. It is to be recognised, however, that the vagina, the lower segment of the rectum, and the lower third of the bladder, are kept from exercising undue and overpowering traction upon the uterus and its suspensory apparatus by virtue of the supporting influence of the pelvic floor when in a state of integrity. The varieties of uterine displacement may, in fact, be as numerous as are the variations from its average normal position. For con- venience of study, however, these deviations are classified with refer- ence to the abnormal movement of the fundus anteriorly, posteriorly, or laterally, and with reference to the movement of the entire organ either upward or downward. As a result, we shall have occasion to consider in the order of their frequency and relative importance (a) retro-deviations, (b) ante-deviations, (c) prolapsus, (d) lateral deviations, and (e) inversion. The ante- and the retro-deviations are further divided into versions and flexions. A uterus is said to be in a condition of ver- sion when its longitudinal axis deviates from its normal plane; while flexion of the uterus consists in the bending of the organ upon itself. The causes of uterine displacements are numerous, and are to be considered in their relation to abnormal deviations in general, rather than with reference to the operation of a particular cause in producing 286 A TEXT-BOOK OF GYNECOLOGY a particular displacement. Thus, constipation, by inducing pressure upon the uterus through the direct influence of either a loaded rectum or sigmoid, or by the pressure of the enteroptosis that constipation sometimes causes, forces the uterus downward in the pelvis. Whether the pressure thus exercised exaggerates the pre-existing normal ante- version, or whether it forces the uterus backward into a distinct retro- deviation, depends upon the incidence of co-operative forces. This is illustrated by the downward pressure exercised as above indicated at the same time that the uterus is forced backward by a distended blad- der, a combination of influences calculated to produce retro-deviation; or the same condition may be induced by having the uterus lifted up by means of a distended bladder when the patient receives a sudden fall or jumps from a vehicle, landing upon her heels, thus forcing the fundus suddenly below the promontory and into the excavation of the pelvis. Child-bearing is, perhaps, the most fruitful single cause of uterine displacements. In the parturient act, the uterus is subjected to violent influences which may damage its suspensory apparatus. If the lying-in woman gets up before the womb has had time to shrink, or if she engages in laborious occupation while it is yet heavy, she is very liable to have some form of uterine displacement as a result. In many cases, even after the lapse of considerable time, a remaining sub- involution makes the uterus so heavy that it is thereby forced out of its normal poise. Occupation, particularly those employments ■ that involve the lifting or carrying of heavy burdens, or that necessitate overhead work or much stair-climbing (see General Etiology), tend to force the womb out of position. Malpositions of the uterus are very common among young women employed in shops and factories, where long hours of standing are necessary. Pelvic inflammations, particu- larly cases of metritis of puerperal origin, and of Fallopian tube in- fection, resulting in pelvic exudations and consequent adhesions, are a fruitful source of displacements. The pathology of uterine displacements has been foreshadowed to a certain extent in the etiology. The changes that ensue on the first departure of a permanent character from the normal poise of the uterus are various; thus, in the case of a retro-deviation the fundus drops backward into the cul-de-sac, in a position of either version or flexion. In either of them, in the presence of more or less acute inflammation of the pelvic peritoneum, adhesion is likely to occur. The altered position of the uterus with the consequent interference with the circu- lation, particularly on the venous side, results in a mechanical engorge- ment of the organ. The turgescence results in enlargement, increased weight with more or less oedema, and, in some cases of long standing, hyperplasia. Corresponding hematogenous changes are also mani- fested in the endometrium, which, at the menstrual epoch, is liable to become hemorrhagic, with a constant tendency to more or less metror- rhagia. When the displacement is associated with flexion interesting changes take place at the point at which the organ is bent. On its DISPLACEMENTS OF THE UTERUS 287 under, or concave, surface, there occurs an amount of pressure, varying according to the degree of angulation, upon the bent and approximated surfaces, that sooner or later induces atrophy of the posterior uterine wall at that point. While these changes are occurring on the concave side of the uterus, opposite changes are noticeable on the upper or con- vex side, where the tissues, instead of being subjected to abnormal pres- sure, are in a state of unnatural tension. The anterior, or upper, wall, yielding to this tension, presently manifests appearances of compensa- tory hyperplastic development; the result is a thinned, relatively atten- uated, uterine wall on the one (concave) side, as opposed to the elon- gated and redundant wall on the other (convex) side. These are the cases that are persistent even in the absence of adhesions. In other cases, however, particularly those in which the displacement has fol- lowed upon a puerperal metritis, there seems to have occurred more or less fatty degeneration, with consequent loss of tone of the uterine parenchyma and resulting abnormal flexibility of the uterus, particu- larly at the cervico-corporeal juncture. In these cases the uterus may be found in a state of anteflexion one day, while the next day the surgeon will find the fundus in the cul-de-sac. Coincidently with these changes, others equally marked occur in the uterine ligaments. In many cases associated with intrapelvic infections it may be accepted as true, that the loss of tone due to inflammatory disturbances in the ligaments themselves constitutes the initial change in the development of uterine displacements; but, whether causal or sequent, relaxation with elongation of the ligaments sooner or later occurs. The utero- sacral ligaments, normally taut, become distinctly relaxed, permitting the cervix to go forward, while the round ligaments become stretched and permit the fundus to drop backward; or, the broad ligaments, the seat of an infiltration, cease to exercise control over the poise of the uterus. While these changes, essentially inflammatory in character, permit abnormal mobility of the uterus, it is to be remembered that sooner or later occur, in structures containing considerable connective- tissue elements, those contractions which ensue upon the absorption of inflammatory products. The essentially atrophic changes in this stage of the inflammatory process result in contractions more or less marked in all the involved structures except the round ligaments, and pro- ductive of more or less distortion of the uterus. If it were imaginable that these changes would occur coincidently and equally in all the sus- pensory structures of the uterus, it could be understood that that organ would thereby be drawn back to its normal position and so retained more firmly than before. Unfortunately for such a result, however, the round ligaments do not partake of the contractile changes, while adhesions generally take place by which the fundus becomes anchored in the cul-de-sac, to the wall of the bladder, or to a proximal surface of intestine; or, as too frequently happens, the exudation is so extensive as to involve, not only the uterus and the approximated peritoneal sur- faces, but also the Fallopian tubes and the ovaries, in the general agglu- 288 A TEXT-BOOK OF GYNECOLOGY tination. Under these circumstances, the resulting inflammatory con- traction of any or all of the uterine ligaments can not do otherwise than develop counter traction, causing thereby an intensification of the general intrapelvic distress. Occasionally, the inflammatory process with the resulting adhesion occurs on but one side of the pelvis, or, if it occurs on both sides, one side undergoes resolution while the other side shows the mischievous results of exudation, adhesion and lateral displacement. The pathology of prolapsus of the uterus differs materially from that in which there exists a mere deviation from the normal axis without descent of the organ below its normal plane. It is indeed an open question whether prolapsus of the uterus should be patho- logically classified merely as uterine displacement; for, as a mat- ter of fact, the descent of the uterus in the pelvis is but little more than an incident in a series of broader and more comprehensive morbid changes. It is doubtful whether descensus uteri should be considered otherwise than as a feature of a general intrapelvic hernia. The pa- thology of this condition involves very generally an enteroptosis, a weakening of the suspensory apparatus of the uterus, and a relaxation of the pelvic diaphragm proper, with either a laceration or relaxation of the pelvic floor. The frequent occurrence of descensus uteri in women who have never borne children or who have never sustained sexual relations, indicates that this form of hernia frequently occurs inde- pendently of puerperal conditions. It may be held as true, however, that in the majority of cases, the impairment of all the structures in- volved in this condition is due to the accidents of childbirth. The exer- cise of undue force, involuntary, manipulative, or instrumental, may have done serious damage to the suspensory apparatus; or the undue distention of the cervix, resulting in its laceration or in the laceration of the circumuterine or perimetric fascia, or in damage to the floor of the pelvis (see Injuries of the Floor of the Pelvis), may have laid the foundation for this form of visceral extrusion. Injuries to the floor of the pelvis alone, if permitted to persist, may induce within the pelvis changes that will permit the descent of its contents. This occurs, not from the removal of any fancied support to the uterus, but from the widening of the vaginal outlet permitting the vaginal walls, the rectum, and the bladder, to descend and to exercise undue, and finally overpow- ering, traction upon the uterus and its normal attachments. It thus happens that injuries to the pelvic floor may be the primary and causal condition, while the reverse may be equally true. The Treatment of Uterine Displacements. — The idea that uterine displacements in themselves cause little or no harm is held now by very few gynecologists. The multitude of methods which have been devised for curing these displacements is proof that the vast majority of surgeons see in them something which needs correction. Mann takes it for granted that uterine displacements in themselves have an im- portant pathological bearing; that a woman with a displaced uterus can never be perfectly well, and that the malposition should, there- DISPLACEMENTS OF THE UTERUS 289 fore, be corrected. This may be done in various ways. Unquestion- ably a certain proportion of downward and retro-deviations may be relieved by mechanical devices — pessaries of various kinds. But these, at best, are rarely curative, giving relief only while they are worn. To make a permanent cure, some surgical procedure is necessary, by which the natural supports of the uterus may be returned to their normal condition, or else some new support may be added, whereby the uterus shall be prevented from getting out of place. If there is any exception to what has been said, it is in regard to forward dis- placements. The tendency to their surgical treatment has diminished with time, and now very few operate for anteversion or anteflexion, except by dilatation and curetting. Still, there are cases where some other surgical operations seem to be demanded, and these will be con- sidered. Prolapse has been, and still is, a battle-ground as to the proper method of gaining permanent relief. It is the firm belief of Mann that more good can be done, with less risk, in the surgical treatment of uterine displacements than in any other branch of gynecological surgery. The mortality of these operations in themselves should be nil. Of course accidents may happen and an occasional death occur; but usually they may be considered as being in themselves without danger to life. The dangers, if any, must arise from the serious complications which are often coexistent with the displacement. Retro-deviations of the uterus are of frequent occurrence. The combined observations of Winckel, Lohlein, and Sanger, embracing several thousand patients, show that retro-deviations occur in 1T.74: per cent of all gynecologic patients. These displacements may cause no appreciable symptoms; or, on the other hand, they may create such disturbance that they may properly be classified among the most dis- tressing and persistent maladies with which a woman can be afflicted. They give rise not only to local discomfort but to constitutional ill health; they render a woman unfit for the marital relation and are the cause of sterility; and their prompt detection and effective treatment are among the most imperative duties devolving upon the practitioner. Symptoms and Diagnosis. — When retro-deviation occurs suddenly, as from a fall or a jump, the patient complains of pain low down in the back, sacralgia, and general pelvic discomfort. This discomfort may at times become a sharp lancinating pain. When the displace- ment is of longer standing, the patient complains of pain in the back and in the neighbourhood of the sacrum and the cocc} t x, often radiating down the legs, frequently into the external pudendal organs and often centring in the clitoris. This pain is exaggerated by walking, stair- climbing, or any laborious occupation. Dysuria is generally present, and the patient sooner or later complains of constipation. This latter condition is frequently associated with other disturbances of the diges- tive tract, causing impairment of the general nutrition, loss of flesh, and the general appearances of anaemia. The diagnosis, however, will 20 290 A TEXT-BOOK OF GYNECOLOGY Fig. 116. — "The examination should be made with the patient on her back and her head a little ele- vated." — Eeed. depend upon the physical conditions discovered by local examination. The examination should be made with the patient on her back and her head a little elevated (Fig. 116). Digital examination, particularly in the case of retroversion, will reveal a change in the uterine axis, mani- fested by anterior dis- placement of the cervix. If the ringer is now passed up toward the cul-de-sac, a mass will be felt. This may be due to a loaded sig- moid, a subperitoneal my- oma, an enlarged and dis- placed ovary, or a de- scended and distended Fallopian tube; or it may be the fundus of the uterus. At this point, the diagnosis will be material- ly facilitated by placing the other hand over the abdominal wall, when, if the condition is a retro-deviation, the fundus of the uterus will not be discovered in its normal situation. If the case is one of retro- flexion instead of retroversion, the point of angulation can generally be discovered by the tip of the intravaginal finger. In recent cases of uncomplicated retro-deviation, pelvic engorgement associated with pronounced tenderness may be present, and may temporarily mask the condition of the uterus. Eetro-deviations frequently exist as com- plications of myomata, and of inflammations, enlargements, and dis- placements, of the appendages. The sound was formerly employed as a means of diagnosis in these cases, but so much damage has fol- lowed its use that its employment in this connection has been aban- doned by judicious practitioners. An index finger may be introduced into the rectum whereby some additional information may be obtained. The diagnosis should, however, be made by means of the bimanual examination and without recourse to instrumental or other exploration. The treatment of retro-deviations consists in the application of topical, mechanical, and surgical, measures. The first step in the judicious application of any of these means of cure must consist in determining, with, at least, approximate accuracy, not only the exist- ence of the displacement, but of the various complications with which it may be associated. Thus, in the presence of a metritis, of acute inflammation of the Fallopian tubes, or of recent intense and painful general engorgement of the pelvis, all manipulations having for their object the reduction of the displacement should be interdicted. In the presence of these conditions, the patient should be put in the recumbent posture and should be treated with salines, hot douches, DISPLACEMENTS OF THE UTERUS 291 and glycerine tamponade, until the acute symptoms have subsided. When there are no contraindications reposition of the displaced organ should be undertaken. The patient should be placed in Situs's position (see Gynecological Examinations), or she may be placed in the knee- elbow posture (Fig. 117). With the index finger passed toward the cul-de-sac and pressing against the fundus, that portion of the uterus in the absence of adhesions may be readily thrown forward. The manipulation is sometimes assisted by pressure directed toward the cervix, the hand being placed above the pubes for this purpose. The index finger passed into the rectum will enable the operator to manipu- late the fundus of the uterus with more .force and precision. The various so-called uterine re- positors are to be looked upon as expedients of more than doubtful safety. The old practice of introducing a curved uterine sound and of then turning it round in the uterine cavity thus forc- ing the uterus back into po- sition, has been denounced by intelligent gynecologists and abandoned b}^ consci- entious practitioners. The practical impossibility of introducing a uterine sound without making it the bearer of pathogenic germs, and the extreme probability of establishing an infection atrium by its use, indicate a danger the reality of which has been confirmed by more deaths than have been honestly recorded. Massage has been employed in the treatment of these cases. This consists in a series of intrapelvic manipulations effected by means of bimanual operation, whereby the uterus is subjected to pressure and the contracted ligaments and adhesions undergo tension. (See Mas- sage.) It goes without saying that this method of treatment is contra- indicated in the presence of infectious conditions of the uterine adnexa and of the pelvic lymphatics. The extreme difficulty of detecting these conditions renders massage a dangerous remedy, a fact which is con- firmed by its general abandonment by the profession. Electrolysis, as employed in these cases, consists in the application of strong currents of electricity, for the purpose of causing the absorption of plastic de- posits and of the utero-peritoneal adhesions associated with retro-de- viations. Its method of application implies the repeated introduc- tion of an electrode into the uterus, a fact which, of itself, renders it undesirable as a systematic treatment. Tamponade is an expedient of great value in the treatment of these cases. If the tampon is carefully applied and is of the proper material, it will furnish to the displaced Fig. 117. She may be placed in the knee-elbow posture. ,, — Reed. 292 A TEXT-BOOK OF GYNECOLOGY Fig. 118. — "A tampon which amounts to nothing more or less than a large plug on the vagina." — Reed. uterus an important mechanical support, while, if saturated with glycerine, the exosmotic property of the latter will exercise a valuable influence in effecting the absorption of inflammatory exudates. A tampon, however, which amounts to nothing more or less than a large plug in the vagina (Fig. 118), and which is large enough to distend the vulvar orifice when it is removed and re- quires considerable traction to remove it, is always a source of damage. The repeated downward traction thus exercised upon the vaginal wall has a tendency to drag the uterus downward in the pelvis and thus to aggra- vate the very condition that it is designed to remedy. A tampon properly adjusted should occupy the upper portion of the vagina, should not exercise enough pressure to oc- casion discomfort, and should be so con- structed that its re- moval will not involve traction upon the pel- vic viscera. The well- known chain tampon (Fig. 119) is very good; but a better one consists of a long nar- row roll of either lamb's wool or cotton, with the fibre running lengtlrwise, and with a string attached at one end (Fig. 120). The ends of the string are left about 6 inches long. A strand of silkworm gut used for this purpose is very desirable because of its lack of porosity. The tampon, 10 or 12 inches long, or even longer, is now passed into the vagina through a speculum, care being taken that it does not Fig. 119. — " The well-known chain tampon is very good. — Reed. DISPLACEMENTS OF THE UTERUS 293 extend far enough down in the canal to occasion tenesmus. When such a tampon is removed, but little effort is required, and the patient makes no complaint of the dragging and pulling that is the unpleasant feature in the removal of one that is improperly constructed. (See Nonsurgical Treatment of Sal- pingitis.) Pessaries have long been em- ployed as a means of retaining the replaced uterus in position. In the decades preceding the ad- vent of the present successful surgery of the pelvis, pessaries were very generally employed in the treatment of retro-deviations and cures were reported from their use. So much manifest in- jury, however, came from their employment that it has been very largely abandoned. Of the vari- ous pessaries employed in the treatment of this condition, one devised by Albert Smith for in- travaginal application, and one by Gaillard Thomas for extravaginal support, were probably the most successful. If pessaries are em- ployed the following axioms should be observed: An intra- uterine stem should never be used; no pessary should be ad- justed in the presence of either local or general inflammation within the pelvis ; no pessary should be adjusted to an unre- duced displacement; and no pes- sary should be continued in posi- tion after it begins to cause pain. If these rules are carefully observed it will be discovered that there are but very few pessaries that are adapted to the treatment of these cases. J. Whitridge Williams {Maryland Medical Journal), while contend- ing for the value of pessaries, says that it can not be asserted that they will "cure the trouble in all cases, even when we are able to replace the uterus. Indeed, the contrary must be confessed, if by cure we mean that the pessary will enable the uterus and its supporting structures to reassume their normal tone, and at last remain in place without its assistance. Such a result may be designated as an absolute cure, and Fig. 120. — " A better tampon consists of a long narrow roll of either lamb's wool or cotton, with the tibre running length- wise, and with a string attached at one end." — Eeed (page 292.) 294 A TEXT-BOOK OF GYNECOLOGY only occurs in about 25 per cent of the cases treated. On the other hand, in a much larger proportion of cases, the uterus remains in place and all the symptoms are removed as long as the pessary is employed, but recur as soon as it is removed. These we may designate as relative cures, and they occur in from 40 per cent (Sanger) to 60 per cent (Klotz) of all cases conscientiously treated." The Surgical Treatment of Retro-deviations. — Many methods have been devised for the curing of backward displacements of the uterus. These may be included under three headings: First, Shortening the Round Ligaments; secondly, Ventral Fixation or Suspension; and, thirdly, Vaginal Fixation, as introduced by the German operators. Shortening the Round Ligaments. — The idea of shortening the round ligaments for the cure of backward displacements of the uterus was first suggested, by Alquie, of France, in 1840. This suggestion was not favourably received, and it was not until Alexander, of Liverpool, successfully performed the operation and carefully described the pro- cedure, that the operation was accepted. Adams performed the opera- tion independently a few months later; but it was undoubtedly Alex- ander's monograph, published in 1884, which induced other operators to follow his example, and placed the operation on a firm basis. The idea of shortening the round ligaments internally originated with W. G. Wylie, of New York, who operated first in 1886. Bode, in 1888, did a very similar operation. Ruggi and Frank, also, did analo- gous operations about the same time. The operation has been further modified by Polk, Palmer Dudley, M. Baudouin, Mann, and others. The shortening of the round ligaments through a vaginal incision was first done by Wertheim, and his procedure has been modified and improved upon by Bode and Kiefer, in Berlin, and by Byford, Vine- berg, and Goffe, in this country. The original operation of Alexander has stood the test of time and experience, and, with slight modifications of technique, is done by all who operate from the outside. Within the abdomen, the operation of Mann is accepted by many as the best; and through the vagina, the few who have operated in this country have generally followed either Byford or Goffe. As it is not necessary to describe the various steps in the evolution of these operations, only the three named will be fully described. Alexander's Operation — Indications. — Alexander's operation may be properly performed in any backward or downward displacement in which there are no adhesions. Should adhesions exist, if not too numerous, they may be broken up before the operation, either by the conjoined manipulation, or, better still, by an incision through the posterior wall of the vagina into Douglas's pouch. When adhesions are present, there is usually, also, associated disease of the tubes and ovaries; so that in the majority of the cases of this kind, in Mann's opinion, abdominal section with intra-abdominal shortening of the liga- ments is the better operation. DISPLACEMENTS OF THE UTERUS 295 Where the uterus is greatly enlarged and the utero-sacral ligaments are also relaxed, very little benefit can be expected to follow Alex- ander's operation alone, because, although the fundus may be held for- ward, the cervix will slide down under the symphysis and the uterus will again get into the axis of the vagina, so that, in time, the round ligaments will give way, and the displacement will recur. In these cases it may be necessary for the patient to wear a pessary for some time after Alexander's operation, or the utero-sacral ligaments may be shortened, or Pryor's plan of opening into Douglas's pouch and packing this with iodoform gauze may be followed. (See page 305.) Antiseptic Precautions. — It has been the experience of many opera- tors that suppuration is quite prone to occur in this operation. This can be readily accounted for by the low vitality of the parts involved — adipose tissue and tendon — by the great amount of handling of the tissues, and by the depths of the cutaneous folds affording safe hiding places to the Staphylococcus pyogenes alius and other micro-organisms. Suppuration can generally be prevented by a very rigid asepsis. Un- questionably, the fingers of the surgeon are the great carriers of infec- tion. While experiments show that it is impossible to perfectly steril- ize the fingers, still, the dangers can be reduced to a minimum by care- ful scrubbing with soap and hot water, and subsequent immersion for at least five minutes in a l-to-1,000 sublimate solution, or in the potassium permanganate and oxalic acid solutions. The use of rubber gloves is the most certain way of preventing in- fection from the hands, and they should never be omitted. In a long series of cases done with gloves, not a single suppurative case has been met with. While the gloves at first seem to be a great obstacle, after a little practice their presence is scarcely noticed. The most thorough disinfection of the patient's skin should be employed. After careful shaving, the parts should be covered with a green-soap poultice for some hours, and then thoroughly scrubbed, and a cloth wet in sublimate solution (1 to 1,000) placed over them and left there until the operation begins. Immediately before the opera- tion, an additional scrubbing with alcohol and ether, followed by more sublimate solution, will diminish the chances of suppuration. During the operation all loose pieces of fat, torn muscle, or fascia, should be removed, and all blood vessels carefully tied or twisted, so as to prevent the formation of clots as far as possible. It must not be forgotten that the cut end of the ligament sometimes bleeds and may need a fine ligature. The present technique of the operation shows that no improve- ments of importance have been made in the original plan suggested by Alexander. The patient, being properly prepared, is placed upon the table with the feet toward the light. The uterus must first be carefully replaced and a pessary introduced. In most instances it will be advis- able to precede this by a thorough curettage of the uterus. Should there be a thorough retroflexion, it may sometimes be necessary to 296 A TEXT-BOOK OF GYNECOLOGY introduce a stem pessary, in order to make the uterus rigid and to pre- vent the fundus from turning over round the pessary. Having thoroughly cleansed the skin at the seat of operation and surrounded the parts with antiseptic towels, wet or dry as the opera- tor may choose, either the spine of the pubis or the external abdominal ring is felt for. One or both can usually be readily distinguished. An incision is then made directly over the ring, a short distance above Poupart's ligament and parallel to it. The length of the incision will vary with the amount of adipose tissue present. In many thin persons, the incision may be less than an inch in length; two inches is the maximum length in any case. The fat and superficial fascia should be carefully incised until the tendon of the external oblique muscle is clearly and distinctly visible. This may be recognised by its white and glistening appearance. Between the fibres of this tendon may be seen the covering of the inguinal canal, which is recognised as a somewhat darker line slightly triangular in shape. The finger tip readily recog- nises the external ring. With the scissors the intercolumnar fascia at the external ring is snipped, and immediately a small mass of fat will extrude itself. This may be picked up between the thumb and finger and slowly and carefully raised; or, should the operator prefer, a strabismus hook may be introduced and the tissues within the canal brought forward. These tissues always contain the cord spread out in fan-shape. By raising them carefully, the whitish fibres of the cord may be recognised. It should then be separated from the surrounding connective tissue and also from the nerve. The nerve should not be cut, but carefully laid aside. Then, with the fingers alone, without the use of any instrument, the cord should be slowly and carefully pulled out. In the majority of instances it comes out readily, increasing in size as the lower por- tions are brought up, until a large, white, fibrinous, structure is brought well in view. In some instances the pubic portion of the cord is exceedingly small and requires the most careful handling; but, if great care and delicacy are used, it may be slowly and gradually brought out until the large and well-developed cord is finally secured. If the cord comes with great difficulty, the intercolumnar fascia may be incised and the whole length of the canal laid open, thus exposing the cord at a point where it is usually larger and stronger. Having been once brought out, the cord is allowed to fall back into its place, the pubic end being still connected, and the same procedure is followed upon the opposite side. Most operators prefer to change sides, and to stand upon the side on which they are operating. The length to which the cord should be pulled out varies. In simple retroversions, a moderate amount of shortening is all that is needed. Should the parts be very much relaxed and the uterus en- larged and prolapsed, a greater amount of shortening will be required. No positive rule can be given for this; the judgment of the operator must decide in each case. Both cords being loosened and all hemor- DISPLACEMENTS OF THE UTERUS 297 rhage stopped, the pubic end of one cord is cut close to the pubis, and the cord drawn out and held by an assistant, well up to the abdominal wall. A stitch of catgut is passed through one pillar of the ring, and then through the cord and the opposite pillar. The same stitch is then passed through these tissues in reverse order, the two ends being brought out on the same side. This mattress suture serves to keep the cord in place and effectually to close the canal. The cord is then cut off half an inch beyond the last stitch. Should the inguinal canal be still open to any extent, this should be closed by additional catgut stitches. This procedure having been completed on both sides, the wounds are closed by deep stitches of fine catgut. An antiseptic dressing is applied and held in j^lace by adhesive straps. The bandage devised by Dr. Kelly, and known by his name, has proved very serviceable in still further holding the dressings in place. There are several complications to be taken into account Adhesions in the inguinal canal sometimes effectually prevent the drawing out of the cord. In three cases seen by Mann, the cord was so firmly attached on one side, that it was impossible to draw it out, there having been in each case an inflammatory condition with pus-formation in the neighbourhood of the canal. Upon the opposite side, in each of these cases, the cord was drawn out as usual. It is questionable whether the operation should ever be undertaken under such circum- stances. The shortening of one cord is hardly sufficient to keep the uterus in place, although it may help, and occasionally succeeds per- fectly. We can never predict whether we shall encounter a delicate cord or a strong one, in any given case. In young women who have never borne children, or in whom the uterus is not well developed, the liga- ments are sometimes very small and ill defined. In women who have passed the menopause, and in whom the uterus is atrophied, the atrophic process seems often to include the round ligaments; and in these eases the result of Alexander's operation is not so sure. From these or other causes, the cord is at times so delicate, especially at the pubic end, as to be pulled out with the greatest difficulty. Unless the utmost gentleness is used, it will be broken, and then all clew to its position is lost. By working very slowly and carefully, and opening up the inguinal canal to its full extent, the cord can usually be pulled out, even in the worst cases. Considerable time must be taken, as hurry will surely result in failure. In a few instances the cord will break. If this occurs at the pubic end, and the uterine end of the cord can be kept in view, it may be carefully followed up until it becomes large enough to be firmly seized and so be pulled out. It is impossible to pull upon the cord with a hemostat or any instrument, for, no matter how carefully it is clone, it will crush and cut the cord. The cord must always be pulled with the fingers, and the fingers alone. As the gloved fingers are slippery, it 298 A TEXT-BOOK OF GYNECOLOGY is well, until the cord is entirely loosened, to keep its pubic end attached. In pulling on the cord, it must always be remembered that the force should be applied in the direction of the inguinal canal. If the uterine end of the cord breaks after it has been nearly freed, the difficulties of securing it again are very great. The only chance then will be to follow up the inguinal canal and to open into the abdominal cavity through the internal ring. Goldspohn, of Chicago, recommends that the internal ring should be opened in all cases, and he inspects and operates upon the tubes and ovaries in this way. Mann has performed this operation several times, removing diseased ovaries and tubes before shortening the round ligaments. It does not seem to be generally advisable to adopt this procedure, as the median opera- tion, with the internal shortening of the round ligaments, would seem to be safer and easier. By pulling up the horn of the uterus, the broken end of the round ligament may sometimes be found; but the operation may fail because the cord is broken so close to the uterus that there is not sufficient to sew even to the internal ring. The operator is sometimes embarrassed by anatomical abnormi- ties. In a few instances, the cord has been found not to run through the inguinal canal. Doubt may be thrown upon some of these cases, as only the most careful dissection post-mortem would be sufficient to prove that the cord is not there. Failure to find the cord will be less frequent as the operator becomes more experienced. By keeping the anatomic landmarks carefully in view, and by making sure that the ten- dons of the external oblique muscle, with the external ring, are clearly exposed, and that the incision is made between the pillars of the ring and not to one side, very few failures will be encountered. In about 1 per cent of cases the canal of Nuck will be found to be open from the internal ring to the symphysis. In these cases the round ligament is always found embedded in the walls of the canal and can not be sepa- rated, and the shortening of the ligaments is impossible. The fact that there is a persistent canal of Nuck on one side does not prove that the same condition exists upon the opposite side. Inguinal hernia in the female is comparatively rare, but, when found, often coexists with re- troversion. In these cases, the shortening of the round ligaments and the cure of the hernia can be done together. The round ligament will usually be found upon the hernial sac, and must be carefully searched for before the sac is cut off. The after-treatment is very simple. The patient should be kept in bed for eight or ten days, and the wound left untouched, unless the temperature goes up. At the end of that time the dressings may be removed; when the wound should be found perfectly healed. Upon the tenth day, the patient may be allowed to sit up, and may leave her room as soon after as her strength will permit. The pessary which was introduced at the time of the operation should be worn for two or three months; and, if there is much relaxation of the utero-sacral ligaments, it may be necessary to keep it in for a longer period. DISPLACEMENTS OF THE UTERUS 299 Intra-abdominal Shortening of the Round Ligaments — Mann's Operation. — The operation here to be described is a modification of the procedure first suggested by Wylie (Fig. 121). It has been de- scribed by Mann in the American Gynecological Transactions for 1897. It was first done in June, 1893. The special indications for this operation are a backward displace- ment and such complications with other diseased conditions as to make the opening of the abdomen advisable. It can be done, therefore, Fig. 121.—" The procedure first described by Wylie. 1 '— Mann. where it is necessary to open the abdomen for reparative work on dis- eased tubes and ovaries, for the breaking-up of adhesions, the removal of one tube and ovary, or the removal of ovarian cyst or pedunculated fibroid. It may also be done when Alexander's operation has been tried and has failed, or is contraindicated for any reason. In any abdominal section for pelvic disease, if the uterus is displaced backward, this or some operation having a similar purpose should be done. Where both tubes and ovaries are removed, or when pregnancy can not possibly occur, some might prefer ventral fixation. This operation does not com- pete with Alexander's operation, as it fulfils entirely different indications. The abdomen being opened, the technique of the operation is as follows: Adhesions are broken up, and any other necessary operative procedure completed. The patient is then placed in the Trendelen- burg position, and the abdominal retractors put in place. A large, flat sponge is spread over the intestines, and the uterus is seized by a small volsella forceps and pulled up to the abdominal wound. The round ligament on one side is made tense by pulling the uterus to the opposite side, and is then seized by two hemostatic forceps, the points of seizure dividing the ligament as nearly as possible into three equal portions. Next, a needle, threaded with silk, is passed through the angle in the round ligament made by pulling upon the hemostat. This passes, therefore, twice through the ligament at points quite near to each other. It is then passed through the wall of the uterus at the point where the round ligament is inserted into the anterior uterine wall. It is well that a considerable quantity of uterine tissue be included in this suture. The usual method of passing the sutures through the anterior wall of the uterus is wrong (Fig. 122). 300 A TEXT-BOOK OF GYNECOLOGY The hemostat being removed, the loop of the ligament is tied to the uterus. A second stitch is passed through the ligament just as it leaves the abdominal wall, and then through the second angle in the round ligament at the site of the other forceps. This ligature is tied Fig. 122. — " The usual method of passing the suture through the anterior wall of the uterus is wrong." — Mann (page 299). and cut as before. In this way the ligament is doubled on itself, and three thicknesses of round ligament are stretched between the sides of the pelvis and the wall of the uterus. The same thing being done upon the opposite side, the wound is closed in the usual manner. Reed has adopted Mann's operation as the one of choice in practically all retro-deviations of the uterus. He em- ploys a forceps, having four flat approxi- mating prongs, the whole being an inch or more wide, with which to seize the round ligament in its middle (Fig. 123). A half turn of the forceps makes the de- sired fold in the round ligament (Fig. 124). The folds of the ligament are now fixed at the uterine and parietal ends as already described, interrupted sutures being employed; the middle zone is next fixed by a continuous suture passed be- tween the prongs of the forceps. The result is a triplicate ligament of desirable shortness and great strength (Fig. 125). The character of the suture material with which the round ligaments are sewed up is of some importance. Silk- worm gut is satisfactory, and has been used in many cases without harm; and, should an abscess occur and the removal of the suture be found neces- sary, it can be more easily found than a suture of any other material, as the sharp cut ends can be appreciated by the sense of touch. Catgut, which is readily absorbed, may produce adhesions, but the adhesions are Fig. 123.—" A forceps with four flat approximating prongs, the whole being an inch or more wide." — Reed. DISPLACEMENTS OF THE UTERUS 301 not always permanent, and some cases of failure, or, rather, of recur- rence, have been reported. In one case operated on by Mann, in which catgut was used, in the year subsequent to the original operation all traces of the doubling of the ligaments had disap- fig pearecl. For this reason an unabsorbable ligature seems preferable. The results as shown by a number of cases which have been reported by different operators have been satisfactory. When pregnancy has oc- curred after this opera- tion, the labour has been entirely normal in each instance. As the uterus is held in its normal posi- tion, and as the round ligaments can stretch and grow as well as they could were they not stitched to- gether, there is no reason why pregnancy and la- bour should be interfered with in any way by this operation. The after-treatment is that which is usual for cases of abdominal sec- tion. For those who prefer the vaginal route, the op- erations of Goffe or Byford for shortening 1 of the round ligaments through the vagina are practical and give good results, though they are confessedly more difficult of performance than where the round liga- ments are shortened through an abdominal incision. For those who are skilled in vaginal work, this operation may be indicated whenever the uterus is displaced, whether there are adhesions and tubal and ovarian disease or not. Unless the adhesions are very dense and the disease of the adnexa extensive, they can all be treated through the vagina, thus widening materially the indications for this operation over that of Alexander, and bringing it in direct competition with the abdominal operation. Gaffe's Operatian. — Goffe, after placing the patient in the dorsal position, with the thighs well flexed, seizes the cervix through a specn- Fig. l-2-i. — •• desired folc \. half turn of the forceps now makes the in the round ligament." — Reed (page 300). 302 A TEXT-BOOK OF GYNECOLOGY lum, and pulls it strongly away from the pubis. An incision is then made halfway round the uterus, through the vaginal wall. Another incision at right angles to this, in the median line, converts the opening into a T-shaped incision. Through this, the bladder is carefully sepa- rated from the vaginal wall by the finger, and the peritoneum opened. The fundus of the uterus is next pulled down until the round ligaments are brought into view. They are then doubled upon themselves in two places, much as in Mann's opera- tion. It is impossible, however, to get the out- side stitch as near the pelvic wall as is done when the abdomen is opened. Otherwise, the operation is practically the same. With the uterus pulled down through the vaginal wound, the tubes and ovaries can be inspected and operated on, if de- sired, and adhesions broken. After the liga- ments have been short- ened, the vaginal wound is closed with catgut su- tures and a small open- ing for drainage left, if thought desirable, though usually this is unnecessary. The vagina is then dusted with iodo- form, and the patient placed in bed. Byford's operation differs from the procedure of Goffe in that he draws down the fundus of the bladder and stitches the fundus of the uterus to the post-pubic peritoneum, which is drawn down after the bladder but recedes upward when released, and draws the fundus with it. The fundus is thus sutured to the peritoneum over the blad- der, much in the same way as in abdominal hysteropexy. For the suture of the bladder to the fundus, he uses formalinized catgut, placing two stitches about an inch apart. He draws down the round ligaments and uterine horns into the vagina, suturing the for- Fig. 125. — " The result is a triplicate ligament of desir- able shortness and great strength." — Eeed (page 300). DISPLACEMENTS OF THE UTERUS 303 mer as taut as possible to the uterus just above the uterine insertion. As he finishes the suturing of the ligament, he throws the same catgut thread around the neck of the loop thus formed, and ties it securely. This last step he considers an important detail. He pays no attention to the remainder of the loop, which forms adhesions to the bladder and uterus just below the sutures. After all intraperitoneal oozing has ceased, he closes the peritoneum with fine catgut and the vaginal wound in the ordinary way. Byford asserts that the simple shortening of the round ligament is not sufficient, because, if it depends simply on adhesions, these ad- hesions will stretch and give way, and allow a recurrence of the dis- placement. This objection does not hold if a nonabsorbable ligature is used in the shortening of the ligaments. Byford reports a number of cases with generally satisfactory results. The principal complication which is likely to give trouble is narrow- ness of the vagina. This is particularly the case in virgins and in women past the change of life, in whom atrophy has occurred. The narrow vagina makes the operation very much more difficult, and may be a positive contraindication unless the operator is an adept. Exten- sive disease of the tubes or ovaries may also contraindicate this .method of operating, and may even, where it has been begun, necessitate its abandonment, and the opening of the abdomen instead. This method has the great advantages of rapid recovery, absence of an unsightly scar, and freedom from danger of ventral hernia. As compared with the abdominal operation, it is more difficult of perform- ance, requires a large experience in vaginal work, and occasionally it is even necessary to open the abdomen to complete it — this, however, only in the presence of formidable complications. As compared with Alexander's operation, it is much more difficult and more dangerous. In simple cases the vaginal operation should always give way by prefer- ence to the Alexander. Vaginal Fixation. — Fnder this heading Mann includes all those operations which have for their purpose the fixation of the uterus through the vagina. Either the body or the neck of the uterus can be fixed directly; or it can be fixed indirectly by acting upon the vaginal walls. Fixation of the fundus originated with Eabenau (1886); but at pres- ent there are a number of methods of performing it in use, and no one fixed method seems to be generally adopted. The operation employed ly Mutter is as follows: After curetting in the usual way, the uterus is pushed into a position of anteflexion by means of Orthmann's instru- ment, and drawn strongly downward. (See Macnaughton Jones, Diseases of Women.) The anterior vaginal wall is then cut from the point of insertion into the cervix almost to the meatus urethral If a cystocele is present, an oval of mucous membrane upon the anterior vaginal wall is removed. The bladder is then separated from the vagina, the former being drawn up and held by a retractor. Great care 304 A TEXT-BOOK OF GYNECOLOGY must be taken to have the bladder thoroughly separated, in order to avoid injury by suture or pressure by the uterus. The fundus is then reached, and half a dozen strong catgut sutures are next passed trans- versely in the anterior uterine wall, beginning at the wound above. The points of entrance and exit of the stitches are 2 centimetres apart. Then these stitches are carried through the edges of the wound, 1 centi- metre from the margins. The sutures are not tied yet, but the vaginal wound is closed; after which Orthmann's instrument is removed and the sutures tied in the order of insertion. The uterus, being in a posi- tion of anteversion, is held there by a firm tamponade of the vagina with iodoform gauze. In Mackenrodtfs operation, after separation of the bladder from the uterus and the opening of the abdominal cavity, the anterior flap of the peritoneum is stitched to the front of the uterus, and then to the posterior surface of the bladder, thus closing the vesico-uterine pouch. A. Martin does an intraperitoneal vaginal -fixation after colporrhaphy in a somewhat similar way. In this coun- try, Vineberg has practised an operation which involves both the short- ening of the round ligaments and the anterior fixation of the uterus. All of these operations of anterior fixation have the very great dis- advantage that they interfere more or less with pregnancy; and in the earlier cases, where the fundus was fixed to the vagina, very serious results followed. These earlier methods have been almost entirely given up, and seem to have very little place in gynecological practice. Besides the methods described, there are a variety of others, each operator seeming to have a plan of his own. It is not thought advisable to multiply descriptions of slight modifications of technique. Fixation of the cervix has been attempted, the object being to fasten it back in the hollow of the sacrum. It can be readily understood that, if the cervix is held upward and backward in the sacrum, the fundus will be thrown forward. This may be clone either by shortening the utero-sacral ligaments, or by causing adhesions between the posterior surface of the cervix and the rectum — in other words, by obliterating Douglas's cul-de-sac. The operation for shortening the utero-sacral ligaments has not been successful, no technique having been developed which could make the operation available. Mann made attempts to do this a number of years ago, putting the patient in the Trendelenburg position. In this way each utero-sacral ligament was folded upon itself and sewed with catgut. In some cases it may be done with com- parative ease, but in the majority of cases it is a very difficult matter, and the results have not been altogether satisfactory. Freund has proposed to shorten these ligaments by sewing them to the posterior wall of Douglas's pouch. Probably the best operation is that sug- gested by W. E. Pryor. His plan is as follows: Pryor's operation is done by preparing the patient locally and gen- erally as for a capital operation. After the uterus is curetted, the cul- de-sac is opened, the patient being in the dorsal position. If no pus is found, the operation is then continued. The tubes and ovaries DISPLACEMENTS OF THE UTERUS 305 are treated as circumstances may require. After this, the pelvis is wiped dry and a gauze pad inserted. The patient is placed in the Trendelenburg position and the gauze pad removed. After the uterus has been packed with iodoform gauze, a piece of the gauze suffi- ciently vide to fill the vaginal opening, and about an inch and a half long, is inserted just within the edges of the vaginal wound. Over this enough strips are placed to fill the incision in the vagina. The uterus is then put in place, the gauze plug being carefully retained in position. Holding the uterus in place by the tampons pushing against the cervix, pieces of gauze are inserted to the sides of the cervix and in front of it, until the vagina is filled to the margin of the levator-ani muscle. The operator now takes a stout roll of gauze, as thick as his thumb, and about two inches long. This Pryor calls the gauze pessary. One end of this is introduced in front of one side of the cervix, just behind the levator-ani fibres, and the other end is pushed into a similar posi- tion on the other side. This plug lies transversely across the vagina and in front of the cervix. It will prevent the descent of the cervix, even in the face of the most severe vomiting. The uterine packing should be so arranged that it can be removed without disturbing the anchoring plug. (Fig. 36, p. 120, Pelvic Inflammations, Pryor.) A self-retaining catheter is introduced and is left in for two days. The after-treatment is important. In from seven to ten days, the patient is placed in Sims's position and all the dressings are removed and replaced exactly as they were at first. The operation will fail unless the supporting plug is properly inserted. Dressings are con- tinued as long as there is any raw surface in the vaginal vault. The supporting tampon is used for six weeks. The cervix must be kept pressing high and backward until the cul-de-sac opening closes and the posterior cervical scar is healed. Among the advantages claimed for this operation are that it leaves the corpus uteri perfectly in place, pregnancy is uninterrupted, and labour normal. The laceration and diseases of the cervix and peri- neum, according to Pryor, are to be corrected by subsequent operations, and not done at the time of the cul-de-sac operation. This is certainly a disadvantage as compared with Alexander's operation, which may very properly be joined with the various plastic operations on the vagina, cervix, and perineum. This operation may be clone in any case of retroversion, and is espe- cially indicated when the utero-sacral ligaments are relaxed, particu- larly in cases of retroversion with prolapse. It may be combined with Alexander's operation in cases of great relaxation. When the back- ward position is accompanied by occluded tubes, by hydrosalpinx, or by cystic ovaries, Pryor thinks this is the preferable operation; but when pus is present in either tube or ovary, he thinks laparotomy preferable. Ventral Fixation. — Under this head it is proposed to consider all the operations by which the uterus is fastened, either directly or indi- rectly to the abdominal wall. According to Delageniere, this opera- 21 306 A TEXT-BOOK OF GYNECOLOGY tion was first done in 1869, by Koeberle, who, after removing an ovary, fastened the pedicle into the abdominal wound. Lawson Tait first fixed the body of the uterus to the abdominal wall by passing a ligature through the fundus and through the edges of the wound. These two operations represent the direct and indirect methods which have been developed by later operators. Direct fixation of the fundus to the abdominal wall may be accom- plished in two ways — either by passing ligatures so as to simply ap- proximate the peritoneal surfaces; or the fundus may be sewed to other structures of the abdominal walls. In the first method the suture is passed first through the fascia, subperitoneal fat and peritoneum, and then through the posterior wall of the uterus a little below the fundus. It then passes through the opposite edge of the wound, com- ing out above the fascia. A similar stitch is passed a quarter of an inch nearer the umbilicus and a little lower upon the uterine wall. These stitches, when tied, approximate the posterior surface of the fundus to the abdomen; adhesions then form, and in time the perito- neum pulls down, forming what has been described as a " suspensory ligament." The second method is employed in cases of great enlargement of the uterus, and particularly in cases of prolapse, in which the adhesions formed by the first method are not sufficient to permanently support the uterus. Under these circumstances, it is well to attach the uterus more firmly. It may then be drawn out of the abdominal wound and the peritoneum sewed with a running suture entirely around the fun- dus, going farther down upon the posterior wall than upon the ante- rior. In this way half an inch of the fundus is brought above the peritoneum. It is then sewed firmly with buried catgut stitches to the fascia and the edges of the recti muscles. In this way very firm adhesions are formed and the most obstinate case of prolapse may be relieved. Kelly inserts the sutures through the peritoneum and fascia in such fashion that, when tied, the knots are within the peritoneal cavity (Fig. 126). In Mann's experience this method is satisfactory, but should never be performed in cases where pregnancy may possibly occur. It is especially indicated in women past the menopause, in whom very great relaxation of the vagina and perineum exists. The needle which should be used in this operation should have no cutting edge. The needles known as Emmet's vesico- vaginal-fistula needles are particularly appropriate, having large eyes and a round body with a slight curve. If such needles are used no hemorrhage will occur from the puncture of the uterine tissue. If the uterus is brought up against the line of the abdominal incision, sufficient adhe- sions will take place. If, however, it is brought up against a portion of peritoneum which has not been cut, then either the uterus or the peritoneal surface against which it is brought should be scarified. The early operators used silk, but to-day nearly all writers recommend the use of catgut. The chromatized or formalinized catgut is prefer- DISPLACEMENTS OF THE UTERUS 307 able, as it lasts longer and creates more irritation, and stronger adhesions are consequently formed. By bringing the posterior surface of the uterus in contact with the abdominal wall, intra-abdominal pressure is brought to bear upon the posterior surface in such a way that there is no tendency to a recurrence of the malposition. The indications for this operation, by either method, would seem to be limited to those cases in which pregnancy is impossible, and where Fig. 126 (Eedrawn from Kelly). — " Kelly inserts the sutures through the peritoneum and fascia in such fashion that when tied the knots are within the peritoneal cavity." — Mann (page 306). the abdomen is opened for some other purpose; also to cases of very severe prolapse with great relaxation, as already mentioned. "Where there is a possibility of pregnancy the operation should not be done, as a large number of cases have been reported where pregnancy and labour have been materially interfered with by the binding clown of the fundus uteri. Indirect Ventral Fixation. — Dr. A. H. Ferguson (Journal of the American Medical Association, November 18, 1899) describes a method 308 A TEXT-BOOK OF GYNECOLOGY of transplanting the round ligaments and attaching them to the abdomi- nal wall. After the usual preliminary antiseptic precautions, he opens the skin of the abdomen in the median line, the incision being three inches in length and beginning an inch and a half above the sym- physis. The linea alba and the anterior sheath of the recti muscles are exposed, and an incision is made on either side through the anterior sheath of the rectus. The rectus muscle is retracted outward, and an incision is made di- rectly behind it into the peritoneal cavity through the transversalis fascia and the perito- neum. Next, the round liga- ment and the portion of the broad ligament are seized by forceps one inch from the origin of the former at the inter- nal ring. These struc- tures are then tied, ex- ternally to the forceps, and divided (Fig. 127). The distal end of the round ligament is dropped into the peri- toneal cavity, and the proximal end is also pulled well out of the wound into it. The round ligament and its accompanying portion of the broad ligament are next sewed with catgut to the margins of the wound in the trans- versalis fascia and peritoneum (Fig. 128). The fibres of the rectus muscle are then replaced, and the opening in the anterior sheath closed with continuous catgut suture, which grasps the end of the round ligament. A similar operation is carried out upon the other side of the median line, and the incision closed. Dr. Ferguson claims in this way to get a firm support for the uterus, which is not adherent to the abdominal wall, but is suspended free in the pelvis and capable of motion. He reports twenty-two cases operated Fig. 127. — " Next [in Fergusson's operation], the round ligament and the portion of the broad ligament, are seized by forceps, one inch from the origin of the former . . . tied . . . and divided." — Mann. DISPLACEMENTS OF THE UTERUS 309 on in two and a half years, with ideal results. One of the patients be- came pregnant, and the pregnancy went on to normal termination. The indications for this operation are the same as for intra-abdomi- nal shortening of the round ligaments, for which it may be substituted. In comparing these various operations for the treatment of posterior displacements, it will be seen that each has its special indications, and no operator should become so attached to one method as to employ this to the neglect of the others. Alexander's operation unquestion- ably fulfils the indications in a large majority of simple cases. Where adhesions have occurred, if they are slight, they may be broken up through a vaginal inci- sion, and Alexander's operation done after- ward. In view of the excel- lent results obtained by Alexander's operation, the opening of the abdo- men for ventral fixation alone is scarcely war- ranted in simple cases. Where the abdomen is opened, and the tubes and ovaries left in such a condition that pregnancy may occur, then the in- tra-abdominal shortening of the round ligaments would seem to offer bet- ter chances of perma- nent cure without inter- ference with gestation. If serious disease of the tubes and ovaries ex- ists, then either the ab- domen must be opened or the vaginal operation done, as the operator may elect. For an operator with small experience, the abdominal operation unquestionably offers the fewer obstacles. For those skilled in vaginal work, the vaginal operation causes the woman the least trouble and annoyance from the operation. Where the abdo- men is opened for other cause, and pregnancy is rendered impossible, either by disease, age, or the operation, then ventral fixation would seem Fig. 128. — " The round ligament and its accompanying- portion of the broad ligament are next sewed with catgut to the margins of the wound in the transver- salis fascia and peritoneum." — Mann. 310 A TEXT-BOOK OF GYNECOLOGY to be the simplest and easiest of performance, and to give promise of equally good results. Vaginal fixation has found little favour in this country, and, in view of the great difficulties encountered where preg- nancy has followed, should never be done in women liable to become pregnant. The tendency in this country, even among those who have been its advocates, seems to be to substitute some other form of opera- tion for it. Anterior Abdominal Cuneohysterectomy for Retroflexion of the Uterus. — In 1895 Eeed applied Thiriar's operation of cuneohysterectomy to the anterior wall of the uterus for the relief of retroflexion. Jonnesco made a similar adaptation of the operation in 1897. The technique does not differ in any essential particular from that described in the treatment of anterior displacements of the uterus, except that the site of operation is the anterior instead of the posterior wall. Eeed has done the operation but a very few times because the indications in retro-deviations generally are more effectively met by the operations upon the uterine ligaments, as described under another heading. The operation of anterior cuneohysterectomy is indicated only in those cases of retroflexion presenting marked hypertrophy with induration of the convex wall. When this condition exists, the removal of an ellip- tical segment is necessary to restore the organ to its normal axis. Jonnesco and Reed perform this operation in connection with shortening of the round ligaments. Ante-deviations. — The facts that the uterus occupies normally a position of anteversion and that there are no definite lines by which its normal position may be prescribed and limited, make it relatively diffi- cult to determine when an anterior displacement exists in a pathological degree. This is particularly true of anteversion; while the detection of a point of flexure in the axis of the uterus on its anterior surface is conclusive evidence of the existence of an anteflexion. The symptoms of forward displacements are pain in the sacral region with more or less vesical irritation and tenesmus; dysmenorrhea and sterility are usually present. The diagnosis is generally made without difficulty by bimanual examination. The fundus is felt to occupy a position anterior to its normal plane, the cervix generally pointing backward. If, with the patient lying upon her back, the finger is passed behind the cervix and the latter is drawn forward to- ward the pubis, the fundus will naturally be drawn upward and back- ward; and if, when the force is removed from the cervix, the uterus returns to the state of extreme anteversion, it may be known, not only that forward displacement exists to a pathological degree, but also that the anterior wall of the uterus is attached to the fundus of the bladder. The existence of a point of flexure on the anterior wall about the cervico-corporeal junction will establish the difference between anteversion and anteflexion. It should be remembered that a small subperitoneal fibroid on the anterior wall may feel like anteflexion — and the difference may not be detected without the use of the sound or an DISPLACEMENTS OF THE UTERUS 311 abdominal section. The sound ought to be employed only under circumstances of exceptional importance. The pathology of ante-deviations, like that of other forms of dis- placement, is not confined to the uterus itself, but embraces a con- sideration of important changes in its suspensory apparatus. In the organ itself, however, in anteversion there frequently exists a condition of hyperplasia, and, occasionally, of neoplastic growth that makes the organ top-heavy, as it were, and acts as a potent cause in producing and maintaining a displacement. In other cases of anteversion paren- chymatous changes are sequent rather than causal. "When this devia- tion exists to such a degree as to interfere mechanically with the circu- lation — particularly on the venous side — more or less passive conges- tion of the organ results. This is expressed, not only in the gross enlargement of the uterus, but in the thickening and excessive epithe- lial growth of the endometrium. In anteflexion important structural changes are added to those already enumerated. If the angle of flexure is acute, atrophy of the uterine wall occurs at the point of angulation on the concave side, while hypertrophy is likely to occur on the con- vex side (Fig. 131). (See Pathology of Retro-deviations.) Contrac- tion of the utero-sacral ligaments, whether as a cause or as a conse- quence, generally exists in connection with forward displacements. It is probably a causative factor in many cases and one to be taken in account in the treatment. When the uterus is displaced forward in an extreme degree, the fundus of the uterus riding upon the fundus of the bladder, adhesion of the proximal peritoneal surfaces is liable to occur, particularly in the presence of infectious inflammatory condi- tions within the pelvis. When this complication exists, there is always more or less inflammatory mischief in the wall of the bladder. Ex- treme ante-deviations imply more or less constant tension on the broad ligaments, which, sooner or later yielding to this influence, become relaxed and cease to exercise their function of holding the uterus in its natural poise. The treatment of forward displacements of the uterus, aside from surgical measures, has been unsatisfactory. Pessaries, while occasion- ally affording temporary relief, have more frequently caused discomfort and damage. Graily Hewitt's cradle pessary at one time had a con- siderable vogue, but it, like its congeners, is now generally abandoned. The judicious use of tampons has been attended with comfort and fol- lowed by substantial improvement. When acute pain exists with for- ward displacements the patient should go to bed, take a laxative, and be given frequently repeated hot douches, with occasional glycerine tampons. A case that can be controlled by a pessary can, in all proba- bility, be relieved with equal efficiency and greater comfort by the measures just enumerated. When, however, in spite of careful atten- tion to the details given, forward displacements exist to such a de- gree as to interfere with health, recourse should be had to surgical treatment. 312 A TEXT-BOOK OF GYNECOLOGY Forward displacements of the pregnant uterus occur either by re- laxation of the abdominal wall or by a ventral hernia. Sometimes the entire gravid uterus occupies a large hernial sac (Fig. 129). A sup- port should be furnished to the protruding mass until delivery lessens its volume and renders it reducible. The case after this period is to be recognised and treated as one of ventral hernia. The surgical treatment of forward displacements has as yet embraced no operation for anteversion of the uterus. Where that condition is due to retrac- tion and shortening of the utero-sacral ligaments pulling the cervix upward and backward, and thus throwing the fundus too far forward, it has been proposed to cut through the posterior vaginal wall and resect the ligaments, thus allowing the cervix to come forward and as- sume a more normal posi- tion. This operation is rarely necessary. It has also been pro- posed to do Alexander's operation in these cases, and to raise the fundus by the round ligaments. As the round liga- ments were never made for this purpose, it is not likely that the opera- tion would be permanently successful. At any rate, these operations have never achieved a position in gynecological surgery, and are rarely even mentioned in literature. A history of the operations which have been devised for the cure of pathologic anteflexion would form a very interesting chapter. From the operations of Simpson, Sims, and Peaslee, down to the present time, very many operations have been devised, all having for their object the straightening of the uterine canal. The earlier operations of Sims were not successful, owing, however, largely to the conditions in which they were done — the want of a proper aseptic technique. The later opera- tions which have been done have been much more successful and satis- factory. The majority of operators, however, are content with the operation of forcible dilatation, usually conjoined with curetting. Dilatation and Curetting. — This was suggested by Dr. John Ball, of Brooklyn, in 1877 (New York Medical Journal, vol. xviii, p. 363). Fig. 129. — "Sometimes the entire gravid uterus occu- pies a large hernial sac." — Reed. DISPLACEMENTS OF THE UTERUS 313 Ellinger did a similar operation, and Goodell modified Ellinger's dilator and followed Ball's method, and was the first to popularize it in this country. Hanks also operated about the same time, using graduated dilators instead of the expanding dilators of the other operators. That dilatation is better than cutting is now generally admitted, and the large number of good results which have followed it has made this one of the most beneficent operations in gynecological surgery. That it cures the flexion is not asserted by its most ardent supporters; but that the flexion is benefited and the symptoms relieved, is, in the major- ity of cases, generally admitted. This operation is indicated in any uncomplicated case of anteflexion where the flexion seems to be productive of symptoms. There is usu- ally present an endometritis, and this has more to do with the symp- toms than the flexion, and is, in turn, largely the result of the flexion. The operation has in view, not so much the cure of the flexion, as the relief of the complication — that is, the endometritis. Technique. — The patient being anaesthetized and placed upon the table, with the hips overhanging the edge and the thighs held in place by suitable legholders or assistants, the vagina is thoroughly scoured with gauze and green soap. The advisability of this procedure has been doubted by some, as it is a well-known fact that the normal vagina is aseptic. While this is generally admitted, it is not true in morbid conditions; and, as we can hardly make a complete bacteriological in- vestigation in every case, it is better to be upon the safe side and thoroughly to wash out and disinfect the vagina. After the scrubbing with the green soap, the vagina should be washed with a solution of bichloride (1 to 3,000). An Edebohls's or Jones's speculum is then introduced, and the cervix seized with the traction forceps and pulled down toward the vulva. After the direction of the cervical canal has been carefully made out by the uterine sound, a small uterine dilator (Hanks's or Palmer's) is introduced, and sufficient dilatation effected to admit the introduction of the Ellinger-Goodell dilator. "With this the cervix may be forced open, at least up to the inch and a quar- ter mark upon the index. A few minutes should be allowed for this, as the uterus is sometimes very friable, and too rapid dilatation may tear the tissues. "When the dilatation is complete, the uterus should be washed out with the bichloride solution, and then thoroughly curetted with the Sims sharp steel curette. After this, it is again washed, and packed with iodoform gauze. Some operators, instead of packing with gauze, prefer to introduce a large stem pessary, half an inch in diameter, and then to pack the upper part of the vagina around the stem with iodoform gauze. If the cavity of the uterus has been packed with gauze, the gauze may be removed on the fourth day, or sooner if it causes too much pain. If the glass stem has been introduced, upon the fifth day the stem should be withdrawn, the interior of the uterus carefully washed out with peroxide of hydrogen, and mopped out with a 5-per-cent 314 A TEXT-BOOK OF GYNECOLOGY solution of ichthyol and glycerine. The stem should then be reintro- duced, and a tampon of cotton or iodoform gauze put in, to keep it in place. This procedure should be carried out daily until all the tender- ness upon the interior of the uterus has disappeared. The patient should be kept in bed for four days, though she may be allowed to sit upon the commode for the purpose of emptying the bladder and bowels. After this, she may be up and dressed, and gradu- ally resume her ordinary mode of life. In this way a very large proportion of cases will be relieved, not always of the anteflexion, but of the symptoms to which the anteflexion has given rise. Dudley's Operation. — Dr. E. C. Dudley, of Chicago {Diseases of Women, 1898), recommends an operation for anteflexion which has for its object, not only the curing of the endometritis, but also the com- plete correction of the deformity. Mann has had some experience with this operation, and has been entirely satisfied with the results,, although his cases have not been numerous enough to enable him to speak with a great deal of positiveness. Dudley, however, recom- mends the operation, and it certainly accomplishes what he claims for it — namely, the complete rectification of the displacement. Technique. — The operation is done as follows: The patient is placed in Sims's position, and the speculum is introduced under ether. The uterus is then dilated and curetted in the usual manner. The cervix is divided with scissors, backward in the median line, past the utero- vaginal attachment, nearly to the utero-peritoneal fold, in the pouch of Douglas (Fig. 381, Dudley). " The cut surfaces thus incised are then held widely apart by means of two tenacula in the hands of an assistant; the incision is somewhat deepened by means of a scalpel, especially in the uterine wall next to the cervical canal, and a small angle is cut out on either side, as shown by the dotted lines in Fig. 382. The cut surface on each side is now folded on itself by a single silkworm gut suture, as shown in Fig. 382. This suture is tied and fortified by interrupted sutures on either side. The lines of union thus made are shown in Fig. 383. " These sutures are not introduced in such a manner as to stitch the intracervical to the vaginal margin of the wound, but the cut surface is folded upon itself in a direction at right angles to this. On either side, that point at the margin of the os externum where the back- ward incision commenced is stitched to the very angle of the incision, so that each cut surface is folded upon itself, not from within outward, but from before backward. Thereby the os externum is carried di- rectly back to the angle of the incision. The cervix now points back- ward in its normal direction toward the hollow of the sacrum, instead of forward toward the vaginal outlet (see Fig. 383). " In some cases of extreme anteflexion, there is a disproportionately long anterior lip. This elongation is shown by the dotted line in Fig. 377. It is the result of a relatively greater pressure on the DISPLACEMENTS OF THE UTERUS 315 posterior lip by the posterior vaginal wall; this lip should be caught with the tenaculum and partially removed by the scissors. The incised surface is then closed upon itself with sutures as shown in Fig. 384. The dotted line in Fig. 377 shows in section the line of incision through the protruding lip; the incision should extend to, but not into, the os externum. This part of the operation is not required unless the anterior lip decidedly protrudes, and is therefore usually omitted. The removal of a portion of the lip in a suitable case is not only not a mutilation, but it even contributes to the straightening of the uterus. " Conjoined examination upon completion of the operation in each of the author's cases has invariably shown the uterus either to have been straightened or the anteflexion to have been reduced to a degree quite within physiological limits. The results have been substantially the same whether the point of flexure was at the os internum or be- low it. " The two posterior lines of sutures have the effect of transplanting the os externum to the very angle of the posterior incision. The an- terior sutures, if used, have the effect of carrying the cervix back by a distance equal to one half the length of the anterior cut surface, which is doubled upon itself. By these means a permanent change, quite equal to overcoming the flexure, is effected in the direction of the cervix. As the result of the anterior portion of the operation, the uterus in a suitable case is lifted also in a higher plane in the pelvis, where it ceases to be a mechanical irritant to the bladder. This por- tion of the operation may therefore be indicated for descent when complicated with anteflexion." (Dudley, Diseases of Women, p. 581, etc.) This operation is not a substitute for dilatation and curetting, but rather supplementary thereto. An operation called cuneoliysterectomij has been devised for the cure of anteflexion. It is done by abdominal section and consists in removing a cuneiform piece of tissue from the convex side of the uterus at the point of angle. Its object is to straighten the anteflexed uterus by reducing to normal dimensions its elongated posterior wall. When done on the posterior wall it is called posterior cuneohysterec- tomy, and vice versa. The procedure was devised and practised by Thiriar in 1892. Eeed did it for the first time in 1894. The details of the operation, as he has modified and now practises it, are as fol- lows: The patient is prepared with the usual aseptic and other pre- cautions for abdominal section. An incision about 12 centimetres in length is made in the median line and is carried as low as practicable with safety to the bladder. The patient is now placed in the Trende- lenburg position. All adhesions between the uterus and bladder or between the uterus and other organs are carefully broken up, and rents in the serosa that may be induced thereby are carefully stitched. The uterus is then brought toward the incision by gentle but firm 316 A TEXT-BOOK OF GYNECOLOGY ■L •'"■ % T HUMS Fig. 130. — ". . . an ellipse of tissue about one centimetre wide, and having a length corresponding to the breadth of the organ, is removed from the convex side at the site of flexure.' 1 — Keed. traction and an ellipse of tissue about 1 centimetre wide, and hav- ing a length corresponding to the breath of the organ, is removed from the convex side of the site of flexure (Fig. 130). Care must be taken not to carry this dissection into the cavity of the uterus (Fig. 131), or to wound either the circular artery or the anastomosing branches of the uter- ine arteries. Should the latter accident occur, its result is best counteracted by ligatures en masse passed deeply into the uterine tissue at either end of the yet gaping ellipse. Retraction of the vessels generally prevents their isolation and closure by direct ligature which, when practicable, is al- ways the preferable meth- od. After all hemorrhage, except mere capillary ooz- ing, is controlled, the margins of the ellipse should be carefully ap- proximated and closed by an interrupted suture, or a continuous animal su- ture fortified with two or three interrupted ones of the same material. The uterus is then dropped back, and, after pausing a moment to make sure of complete hemostasis, the abdomen is closed with- out drainage. A further modification of this op- eration, and one which Reed has practised with satisfaction, consists in stitching a reef of the posterior folds of the broad ligament to either Fig. 131. — "Care must be taken not to carry this dis- section into the cavity of the uterus." — Keed. DISPLACEMENTS OF THE UTERUS 317 side of the posterior surface of the uterus (Fig. 132). The utero- sacral ligaments, if found contracted, are nicked and stretched. He has been able by these combined methods to relieve the most dis- tressing and persistent symptoms, vesical, uterine, ovarian, and neuro- tic, due to otherwise intractable anteflex- ion of the womb. Prolapsus Uteri. — Prolapsus is that anomaly of position of the uterus in which the organ has shifted from its normal site, has descended or fall- en to a lower level, and projects partly or completely outside of the vulva (Fig. 133). According to the degree of the descent we distinguish between partial or total prolapse. There is only a difference in degree between these varieties, their entire etiology Fig. 132. — " A further modification . . . consists in stitch- ing a reef of the posterior folds of the broad ligament to either side of the posterior surface of the uterus." — Reed. HS^ «3HfiPS&S 133. — "Prolapsus is that anomaly of position in which the uterus projects partly or completely outside the vulva."— Herzog. being the same, and they do not call for a separate consideration. Par- tial prolapse is frequently spoken of as descensus uteri; the term pro- lapsus is then reserved for the total prolapse. 318 A TEXT-BOOK OF GYNECOLOGY Prolapsus uteri is almost invariably an acquired condition, though there have been reported by Ballantyne and Thomson, Heil, Krause, and Kemy and Quisling, a few cases of congenital prolapse. These cases were always found in connection with other congenital anoma- lies. A condition simulating partial prolapse, which, however, anatom- ically, as well as from an etiological point of view, is entirely different from the morbid condition under discussion, is that of primary hyper- trophy of the portio vaginalis uteri. This anomaly is always congeni- tal, and it may and does secondarily lead to a true prolapse. There exists still a good deal of controversy as to the etiology and mechanism of prolapsus. A view formerly held almost universally, and still adhered to by some, is that the primary factor in the produc- tion of a prolapse of the uterus is the prolapse of the vagina. The latter again is traced back to a subinvolution during the puerpefium. This opinion is contested by Kustner, who has studied the subject extensively and who very clearly and forcibly elaborates his observa- tions and views in a most excellent treatise (Veit's Handbuch der GyndJcologie, Wiesbaden, 1897, vol. i, p. 168). This author holds that it is impossible that a uterus normal in position can be forced out of the pelvis into the vagina. As long as the uterus is in its normal antero-versio-nexio position abdominal pressure acts upon its posterior wall and presses the body upon the bladder. The portio vaginalis under increased abdominal pressure has a tendency to rise, if anything. When, however, the uterus is in a retroverted- retroflexed position its vaginal portion becomes dislocated in the direction of the symphysis pubis and moves at the same time nearer the pelvic outlet. The uterus and its cervix now lie so that their axis has the same direction with, or forms the continuation of, the axis of the vagina. Increased intra-abdominal pressure can now easily force down the uterus into the vagina, this being made still easier since in retro-versio-flexio the vaginal portion of the cervix is nearer the pelvic outlet than under normal conditions. It is quite common that a history of retro-versio-flexio can be obtained in cases of prolapsus. The reason this condition is most frequently found among women in the lower walks of life is easily explained. Women of the better classes, as a rule, when retro-versio-flexio leads to any symptoms, seek medical aid and receive the proper attention. Women who have to work hard for a living often find no time to consult the physician, and, even if they do, they can not submit to the proper treatment and regimen to correct the retro-versio-flexio. If this goes on uncorrected and the woman suffering from it is performing hard physical work, the constant exertions, and the persistent abdom- inal strain in consequence thereof, will, in a large percentage of cases, force down the uterus and produce descensus and prolapsus. There are also some cases, however, in which the causation of the affection may be different. If, after childbirth, the vulva remains gaping for too long a time, there may occur a prolapse of the anterior vaginal DISPLACEMENTS OF THE UTERUS 319 wall, even if the uterus is not in retro-versio-flexio, and this may be followed by prolapse induced by the persistent traction upon the uterus and its ligaments. Prolapse may be preceded and caused by extensive untreated perineal lacerations, the mechanism of causation being the same as just indicated. Another set of conditions which may bring about prolapse is senile changes of the genitalia, accom- panied by atrophy of muscular, and disappearance of adipose, tissue. A factor which may greatly hasten the establishment of an extensive prolapse, if the other conditions are favourable, is great increase in the intra-abdominal pressure in consequence of large pelvic tumours or ascitic accumulations. In prolapse of the uterus there is, of course, present a prolapse of the vagina. The upper part of the latter is either invaginated into the lower part, or the whole of the vagina lies inverted in front of the vulva. Total prolapsus uteri, however, does not always mean total prolapse of the vagina, and vice versa. Combined with the uterine prolapse, there is present a displacement of the bladder (cystocele), and of the urethra. Eectocele may be present but is usu- ally absent. The pathologic changes are various. That such a malposition, such a complete change of conditions as is found in prolapsus uteri, is accompanied by grave and profound anatomical lesions, is self-evident, though of course some of the pathologic changes precede instead of follow descensus. Very marked are the changes of the lining of the inverted vagina. The epithelia become dry and horny. In some places the epithelial covering is thickened, while in others, particularly in the neighbourhood of the external os of the cervix, it becomes thinned out and is entirely lost, so that ulcerations appear in this neighborhood. These changes are due to the fact that the inverted vagina is no longer moistened by the cervical secretion but is exposed to the air and subjected to other insults. The ulcerations frequently show sharp margins, or they present clefts caused by traction upon the changed tissues. There is generally noticeable a hypertrophy of the prolapsed parts. It is most marked at the portio vaginalis uteri, but is also well seen in the supravaginal portion. The cervix as a whole is often greatly elongated and thickened in its anteroposterior and lateral diameters (Fig. 134). The uterine body is likewise en- larged, though proportionately to a lesser degree. In women advanced in years, the enlargement of the corpus may be very insignificant or even absent. The enlargement of the uterus is, however, not so much due to a true hypertrophy as to an extensive oedema caused by circulatory disturbances. That this is indeed the case, is proved by the observation that after reposition of the organ, its size is often ma- terially decreased in a very short time. The mucous membrane of the uterus in prolapse is thick and succulent, and there occurs not infre- quentty an endometritis glandularis hypertrophica. The higher de- grees of prolapse being usually combined with prolapse of the bladder, this organ likewise shows morbid changes, such as catarrhal inflam- 320 A TEXT-BOOK OF GYNECOLOGY mation of the vesical mucous membrane, or inflammation of the muscu- lar coat which may even lead to destructive processes. The vesical inflammation may spread by continuity to the ureters and the pelves of the kidneys. Kustner in a case of prolapsus uteri saw a profound purulent pyelitis which ran a fatal course. Inflamma- tory changes of the internal sexual or- gans, the tubes and ovaries, and the pelvic peritoneum, are quite frequent in prolapse. Kustner, in a series of eighty cases of laparoto- mies, ventrofixa- tions, and plastic operations on the vagina for prolapse, carefully examined the internal sexual organs and found that in almost one half of them chron- ic inflammatory pro- cesses could be ob- served in the ova- ries, the pelvic peritoneum, and the fimbriated extremi- ties of the Fallopian tubes. The patho- logic conditions found were oophori- tis corticalis, hy- drops folliculorum ovarii, perimetritis, perisalpingitis with or without closure of the abdominal end of the tube, and hydrops of the tubes. The same author frequently noticed a mild degree of serous infiltration of the pel- vic peritoneum. In some of his fatal cases of prolapse he saw, in conse- quence of profound septic infection due to streptococci, abscess forma- tion in the subperitoneal connective tissue, particularly in the con- nective tissue between the bladder and uterus. Also purulent infil- tration of the muscular coat of the uterus, abscess of the ovary and Fig. 134 (Martin). — " The cervix as a whole is often greatly elongated and thickened in its antero-posterior and lateral diameters." — Herzog (page 319). - DISPLACEMENTS OF THE UTERUS 321 encapsulated or general purulent peritonitis. (See Pathology of Uter- ine Displacements.) The symptoms of prolapsus uteri may be so mild in the earlier stages as easily to escape attention, or, if detected, they are liable to be interpreted as indicating a less important condition than a displace- ment of the uterus. Pain in the loins, sacralgia, increased by walking, prolonged standing or overhead work, and, particularly by straining at defecation, is the first to attract attention. This pain increases as the condition advances until the patient becomes conscious of what she construes to be a foreign body in the vagina. Pressure by the descending organ is liable to cause vesical and rectal tenesmus. In a still further stage of development the cervix presents at the ostium vaginae, or the entire uterus may protrude externally and occupy a position between the thighs. The diagnosis in the earlier stages is not always easily made. Patients are generally examined in either the recumbent or the semiprone (Sims's) position — in either of which, but particularly in the latter, a uterus in the earlier stages of descent has a tendency to gravitate into its normal situation. It occasionally hap- pens that the first suggestion of an existing prolapse is derived from the fact that a well-adjusted tampon is being unaccountably extruded from the vagina. This fact will prompt an examination of the patient in the standing posture — provided that this has not already been done, as a part of the earlier examination of the case. The uterus will be found to have descended from its normal plane and to occupy a posi- tion of relative retroversion. It may be found in any degree of de- scent. Complete procidentia may be mistaken by the patient herself for cystocele and hydrocele, but this point is easily cleared up by care- ful examination. A uterine polypus, or even one of vaginal origin, may simulate complete procidentia uteri. The diagnosis is cleared up under these circumstances by careful digital examination, with par- ticular reference to detecting the location and condition of the cervix. Bimanual exploration, by determining the location of the fundus and the size of the uterus, will clear up any remaining doubts. Inversion has been mistaken for prolapsus of the uterus, but the history of the case, the existence of the hemorrhage, the character of the mucosa, and the existence or nonexistence of the fundus in its normal relations as determined by bimanual examination, will lead to an accurate con- clusion. Treatment. — Conservative, or, more properly speaking, the nonsurgi- cal treatment of these cases, resolves itself into medicinal, hygienic, and mechanical. The medicinal treatment consists, for the most part, in the administration of laxatives to overcome the constipation, which, in many cases, is a potent factor in the causation of the trouble. For this purpose saline waters, such as the Hunyadi Janos or the Apenta, should be given persistently in comparatively small doses after, but not be- fore, meals. If given before meals, they will cause catharsis, enerva- tion of the bowels, and consequent aggravation of the constipation; 22 322 A TEXT-BOOK OF GYNECOLOGY but if given after meals they will mingle with the food, and, after a. couple of days, induce normal dejections not followed by serious conse- quences. Hygienic measures consist in attention to all the secretory functions, and especially avoidance of errors in diet. Massage of the uterus has been recommended, and as a remedy for relieving passive engorgement or chronic hyperplasia it is of value, and should be employed for the relief of prolapse, especially in its incipiency, when- ever dependent upon these conditions. It should not, however, be employed in the presence of acute inflammation of either the uterus or its appendages. Under the head of mechanical treatment tamponade must be given first place. This should be practised as elsewhere de- scribed in this volume. If tampons saturated with some astringent agent are carefully adjusted they will give excellent mechanical sup- port and afford the relaxed ligaments an opportunity to regain their strength. Pessaries are employed for the same purpose and a certain percentage of cures is realized from their employment, which, how- ever, is not destitute of danger. The pessary with an intrauterine stem should never be employed; cup-pessaries are for the most part mis- chievous in their results, and, to avoid their damaging influence, must be frequently removed. The martingale ring of hard rubber may keep the uterus within the pelvis, but it does so by distending the vagina laterally and by resting upon the pelvic floor. The inflated soft-rubber pessary has an even better power of retention, but it is, at best, a dirty and stinking thing, and should be used only when other means of treatment are not available. This instrument is very popular with practitioners because of the facility with which it is placed and the effectiveness with which it keeps the womb from dropping out of the vulvar orifice. The fact, however, is generally lost sight of, that this pessary never cures prolapsus in the sense of restoring the uterus to its normal position and keeping it there, and but few practitioners take into account the other fact, namely, that by a continuous pressure upon the pelvic floor and by persistent lateral distention of the vagina, this instrument has a tendency really to aggravate pre-existing troubles, notwithstanding the fact that it affords temporary relief. The soft-rubber pessary favours germ propagation and is, therefore, a constant menace to the health. The best device among pessaries is Thomas's retroversion pessary already alluded to. If carefully ad- justed, it affords comfort in these cases and its use is sometimes fol- lowed by cure. The surgical treatment of downward displacements of the uterus has for its object the return of the organ to its natural position and its retention there by the restoration, so far as possible, of its normal anatomic connections. Any treatment, to be effective, must be carried out in full recognition of the fact, that prolapse of the uterus commonly occurs as the result of either serious lacerations of the pelvic floor and the perineum, or as the result of atrophy and relaxation of all the uterine supports. The final result is the same in each case. In a DISPLACEMENTS OF THE UTERUS 323 limited number of cases, the injuries below are not so much the cause of the prolapse as the great relaxation of the uterine ligaments, particu- larly the utero-sacral. No prolapse can take place without relaxation of these ligaments. The first step in a prolapse is always a retroversion; so that relaxa- tion of the round ligaments is a universal accompaniment of this con- dition. If, with the relaxation of the round ligaments, there is also relaxation of the utero-sacral ligaments, then the uterus, following the axis of the pelvis, slowly and gradually makes its way downward under the influence of intra-abdominal pressure, until it finally appears at the vulvar orifice, and may eventually be forced outside the patient's body. These being the causes of prolapse, all operative procedures must have for their object the restoration of the normal supports of the body. If these can not be restored, then some new support must be sought. With the object of relieving the downward traction on the uterus, operations may be performed on both the anterior and pos- terior vaginal walls. Unquestionably, the best operations for this purpose are those devised by Sims and Emmet. Emmet's Operation upon the Anterior Vaginal Wall (Anterior Col- porrhaphy). — " I first ante vert the uterus with my finger, as the patient lies on the back. The neck of the uterus is then kept crowded up into the posterior cul-de-sac by a sponge probang in the hands of an assistant, while the patient is being placed on the left side for the intro- duction of the speculum. I then endeavour to find two points, one about half an inch from the cervix on each side, and a little behind the line of its anterior lip, which can be drawn together in front of the uterus by means of a tenaculum in each hand. When two such points can be thus brought together without undue tension, forming trian- gular-shaped folds, the surfaces are to be freshened. One of the te- nacula must be securely hooked in the tissues, to indicate the point. Then, one hand being disengaged, a surface half an inch square about the point of the other tenaculum is to be denuded with a pair of scissors. Next a similar surface is to be freshened around the point of the first tenaculum, and a strip afterward removed from the vaginal surface, in front of the uterus, about an inch long by half an inch wide." (Emmet's Gynecology, third edition.) A ligature of catgut is then passed beneath each of these freshened surfaces, which, when tied, brings them all together in front of the cervix, with the effect of forming a fold at this point. There are also, upon the anterior vaginal wall, tAvo folds in the shape of an ellipse, extending from the surfaces secured in front of the uterus, nearly to the vaginal outlet. These folds are now to be denuded, turned in, and secured with a continuous catgut suture. The stitches should be placed about a quarter of an inch apart, and should include a liberal amount of tissues. The patient should be confined in a re- cumbent position for two or three weeks after the operation, until the parts are firmly united. 324: A TEXT-BOOK OF GYNECOLOGY Following this operation, or at the same sitting if thought advisable, the perineum should be firmly closed by Emmet's method. (See Chap- ter on Rupture of the Perineum.) The cervix uteri, if lacerated or diseased, should be closed by the operation of trachelorrhaphy, or amputated, as the case may be. It is Mann's belief that these operations alone will not generally cure permanently a bad case of prolapse. As the uterus is always retroverted in this condition, if it is left turned back it will remain in the axis of the vagina, and, acting as a wedge, will gradually force its way down and out, and the old conditions will be reproduced. To ob- viate this condition, it will be necessary to restore the round ligaments and the utero-sacral ligaments. In this way the cervix can be kept up in the hollow of the sacrum and the fundus turned forward. If this is done, the uterus will be at nearly right angles to the vagina, and the danger of a return of the prolapse will be done away with. After the operations upon the vaginal outlet the patient may wear a pessary, which takes the place of the utero-sacral ligaments, and this in itself may be enough. If not, then Alexander's operation may be done and the fundus kept forward by the tightened round ligaments. All idea of curing a prolapse by doing Alexander's operation must be laid aside, as the round ligaments alone are not strong enough to sus- pend the uterus, but, in a very short time, will give way and allow a relapse. In very bad cases where the uterus is greatly enlarged, and in old women, in whom very great atrophy of the parts has taken place, all these procedures are apt to fail, and we must then resort to ventral fixation, as already suggested. The removal of the uterus for the cure of prolapse, in the opinion of Mann and other representative gynecologists, is wrong. It is not, in his view, the weight of the uterus merely which brings it down, but the relaxation of the supporting structures. After the uterus is re- moved, the vaginal walls will come down as badly as ever, and Mann has seen one case at least in which hysterectomy failed to cure, the previously existing rectocele and cystocele recurring and becoming worse, until a complete hernia of the vagina existed. The cure of this condition is exceedingly difficult, and is harder than before removal of the uterus, as the possibility of ventral fixation is done away with. Inversion of the Uterus. — Inversion of the uterus means a turning inside out of that organ, and consists of the invagination of the fundus into or through the cavity of the womb. This form of displacement is not frequent; Braun and Spaeth report that not a case of complete inversion of the uterus has occurred in 250,000 births in their clinics; while it has been observed but once in 191,000 deliveries in the Eo- tunda Lying-in-Hospital of Dublin. The causes of inversion of the uterus are generally, but not always, connected with parturition. At this time, when the uterus is enlarged and its walls are softened by the ordinary evolutional changes of preg- nancy, but two additional conditions are required to render inversion Tl DISPLACEMENTS OF THE UTERUS 325 probable, viz.: relaxation of the uterine wall and downward traction upon the fundus. This traction may be exercised by drawing upon the cord in a case of fundal implantation of the placenta; or, given a case of adherent fundal placenta, the involuntary efforts of the uterus to expel the afterbirth, may cause the latter to drag the fundus down- ward into the cavity, or, for that matter, through the open cervix into the vagina. A large pedunculated polypus attached to the fundus of the uterus and finally expelled by that organ may, by persistent trac- tion, induce inversion in the nonpregnant uterus. A case of this kind came under the observation of Eeed. Small sessile fibroids have been found in the wall of the inverted uterus and have been construed as causes of the condition. The mechanism of inversion in these cases has been explained by Treub, who states (British Gynecological Journal) that in them there " is no regular contraction of the uterine wall and that there can not be. The base of a sessile tumour can not contract, because of the implantation of the tumour, which diminishes or alto- gether abolishes the contractility of that part of the wall, and it can not be that only the contractility of that base is diminished; the sur- rounding parts must necessarily be feebler within a greater or smaller circumference. If from the outset the tumour was intramural, the smaller degree of resistance of that part of the uterine wall, coupled with intra-abdominal pressure, may occasionally bring about a slight beginning of inversion. And when this is the case, the conditions are essentially the same for sessile and intramural tumours, and for the partial inversion described by Rokitansky. A circle of uterine tissue is abruptly curved in the place where Rokitansky found the external indentation. I need hardly say that in that incurved circle the uterine muscle must be absolutely paralyzed. And this paralysis again will not be confined to a linear circle, but gradually diminishing will extend over a greater or smaller surface. The contractions of the normal part of the uterine wall will try to expel the part of the wall that acts as a foreign body. These expulsive efforts may slightly increase the inver- sion as far as the paralysis surrounding the circle of inversion permits, thus displacing the circle itself; and paralyzing another part of the uterine wall. Necessarily the extension of the partial paralysis proceeds farther in the uterine wall, too, and by the repeated action of this mus- cular play the inversion may gradually become complete as regards the body of the uterus. As soon as the body is inverted, there is no longer any excitement for uterine contractions, and the inversion of the cervix generally does not take place. And it is the intra-abdominal pressure again that may invert the cervix too." Inversion of the uterus may be complete or incomplete; in the for- mer case the organ is turned completely inside out, the inverted fundus and body of the uterus lying within the vagina (Fig. 135), or protruding from the vulvar orifice. The condition may also be described as recent or old, acute or chronic, the one type being represented by the recent inversion of the organ with its attendant alarming symptoms; the 326 A TEXT-BOOK OF GYNECOLOGY other, when the condition either complete or incomplete has occurred, involution of the uterus having taken place after the occurrence of the displacement, which remains in a chronic and more or less perma- nent form. The symptoms of inversion of the uterus following parturition con- sist, first, in profuse hemorrhage ensuing upon the delivery of the placenta; or, when the fundus is drawn down by the still adhering placenta the latter may be peeled off by external action, and violent hemorrhage ensue. Physical ex- amination should be made at once by the bimanual method. The intra - vaginal finger will detect a globular mass, pre- senting either just without or just with- in the thoroughly re- laxed cervix; while the hand upon the abdominal wall will readily detect the disappearance of the fundus from its nor- mal site with the development of a dis- tinct ring at the point of its disap- pearance. In an in- teresting case reported by Cordier wherein an inversion had fol- lowed an operation for the removal of a polypus, the symptoms during the next few months were those of frequent yet slight discharge of blood-stained fluid from the vagina; there were no menstrual pains, nor was there a histoiy of extrusive contractions of the uterus. Digital examination revealed in the vagina a pyriform mass about 3 inches in length by 2.5 in breadth, of a soft and velvety nature, and not painful to the touch. The finger could be carried all round the mass, which disappeared through the os by a constricted neck, and could be swept around the neck of the mass for nearly an inch within the cervical canal. The speculum revealed the openings of the Fallo- pian tubes, on the presenting aspect of the mass. A probe could be easily introduced into the uterine ends of the tubes under vision while the speculum was in position. Such appearances as the foregoing, coupled with the disappearance of the fundus from its normal situa- Fig. 135. — " Inversion of the uterus may be complete . . . the . . . fundus and body . . . lying within the vagina." — Keed (page 325). DISPLACEMENTS OF THE UTERUS 327 tion, as determined by bimanual exploration, comprise the essential diagnostic criteria in these cases. If the abdominal wall is thick, and the condition of the uterus, particularly in nonparturient or in chronic cases, can not be outlined by the bimanual manipulation, the index finger of one hand should be introduced into the rectum while a sound is passed into the bladder; if the sound and the finger meet above the presenting tumour the evidence is conclusive that inversion exists. The prognosis of inversion of the uterus is never favourable, although A. F. Jones, of Omaha, reports a case of spontaneous reduc- tion of an inverted uterus three years after the occurrence of the acci- dent. Crosse studied the histories of nearly 400 cases, with the result that he ascertained the mortality from this condition to be nearly 35 per cent, death occurring either very soon after the accident or within a month. Of 109 fatal cases, the fatal termination in 72 ensued within a few hours, and in the majority within half an hour. Eight died in from one to seven days and six in from one to four weeks. After the first month the danger is slight, but it begins again with the resumption of menstruation, which has a tendency to become hemorrhagic. Orampton's table {American Journal of Obstetrics, October, 1885) re- veals the fact that of 120 recent cases, 87 recovered, 32 died, 1 remained unrelieved. Twelve of the cases, however, were moribund when first visited. In the fatal cases, reposition was usually effected readily enough, but too late to save life. Of 104 chronic inversions, 91 recov- ered, 7 died, and 6 remained unrelieved. The average mortality as shown by Crampton's table is about 20 per cent. Pregnancy may occur, followed by normal delivery, in cases in which the uterus has been inverted and has either reduced itself spontaneously or has been reduced by operation. The pathology of this condition is by no means distinct. When the accident occurs in the puerperal state the probably one essential factor in its causation is uterine inertia, which is a functional rather than an organic condition. After the occurrence of puerperal inver- sion, the womb, if left in position, seems to undergo the ordinary course of involution. Aside from the malposition there seems to be no special pathologic state induced. Treub, of Amsterdam, made a careful microscopic examination of a uterus which he removed for nonparturient inversion, and found the muscular structure normal with absolutely no appearance of atrophy. There existed, however, a very ©edematous hypertrophy of the exposed mucous membrane. The treatment of inversion of the uterus differs materially in acute and in chronic cases. In acute cases — i. e., those of recent occurrence — the first indications are to secure hemostasis and to effect reduction. The hand should be immediately inserted into the vagina and upward pressure should be exercised by the fingers directly against the centre of the protruding mass, while counter pressure should be exercised from above by a hand placed against what may now be designated as the 328 A TEXT-BOOK OF GYNECOLOGY cervical ring. It is better to conduct the intravaginal manipulations under a current of water heated to 110° F., or, preferably, water and vinegar, half and half, brought to the same temperature. Vinegar is an excellent hemostatic with distinct antiseptic properties. If the fountain syringe or other reservoir is hung very high, the hydrostatic pressure thereby secured becomes an additional force available in the work of reduction. If these measures do not at once control the hemorrhage, and if its continuance for any length of time is a menace to the patient's life, an elastic band should be placed around the neck of the protruding mass and should be left in situ for several hours. It should not be adjusted so tightly as to induce strangulation, nor should it be left on so long as to produce destruction of the tissue. When it is unwound the hemorrhage will generally be found to have ceased, in which case manipulations looking to the reduction of the organ should be resumed. Mechanical repositors, consisting of a staff with a bulbous extremity, may be made from wood or other ma- terial and used with persistent pressure. Lawson Tait utilized con- stant elastic pressure, which he applied to a repositor by means of an elastic perineal belt fastened before and behind to an abdominal girdle. There are some dangers attached to this method of treatment. If the intrauterine extremity of the repositor is not very blunt, or else bulb- ous or cup-shaped, an apparently slight elastic pressure may be suffi- cient to force it through the soft uterine tissues. Then, too, if the repositor with a large bulb, or a cuplike intrauterine end, succeeds in accomplishing its purpose, the instrument itself may become incar- cerated by contraction of the cervix. While this complication is by no means insurmountable, it has proved embarrassing. If the extem- porized repositor is made of wood or other porous material, it may speedily become septic and a consequent source of extreme danger. To avoid this accident, it should, if conveniently possible, be given two or three coats of shellac before being used. The treatment of chronic inversion of the uterus has been a source of great perplexity since the days of Hippocrates. This master genius de- scribed with great fidelity the condition of inversion, which he treated by placing the woman on her back, upon a couch, elevating her feet, extending her legs, and applying compresses and sponges against the tumour, holding them in place by means of a perineal bandage. This was kept up for seven days. If it failed, the woman's womb was anointed, she was fastened by her heels to a ladder with her head hang- ing down, and was violent^ shaken with the object of thus reducing the displaced organ. Strange as it ma}^ seem, Castex, as late as 1859 (Gazette liebdomadaire de medecine et de cliirurgie), reported the success- ful adoption of this Hippocratic practice by a Moorish midwife at Tangier. The condition and its treatment through the succeeding centuries commanded the attention of Ehazas, Avicenna, Aretaeus, and Themison, among the ancients. Various modern methods have been devised to effect the reduction DISPLACEMENTS OP THE UTERUS 329 of chronic inversion of the uterus. White, of Buffalo, as long ago as 1858, published a plan of reduction by continued pressure, which he applied by adjusting the soft rubber cup-shaped end of a repositor against the presenting fundus of the uterus; to the other end of this repositor a spring capable of maintaining ten pounds pressure was adjusted, and so arranged as to lie against the breast of the operator. Pressure was thus exerted, while counter-pressure was made by the hands against the cervical ring, the pressure being exercised through the abdominal wall. This method was modified by Tyler Smith, Ave- ling, Wing, Robert Barnes, Lawson Tait, and others, but with no essential deviation in principle. Carl Braun, in 1851, introduced a method of reduction by vaginal tamponade by means of a caoutchouc bag which he called a colpeuryn- ter. When this bag is properly adjusted to the uterus, the latter is pressed upward in such a way as to place the vaginal attachments upon the stretch, causing them to draw open the cervical cavity by lateral tension, thus acting not only as a dilator but as a repositor. The same principle is applied to-day by many practitioners. Neugebauer utilizes an intravaginal elastic bag which is gradually distended with water from a high plane. The hydrostatic pressure thus induced is found to be effective, a case in which the inversion had existed for two years having been thus reduced in nineteen days. The patient suffered no pain and learned to fill and empty the bag herself when it was necessary to relieve the pressure upon the urethra. When conservative means at reduction fail, recourse must be had to surgical intervention. T. Gaillard Thomas advised an operation of forcible dilatation of the inverted uterine canal. This was practised by first making an abdominal section, stretching the uterine tissues by means of a strong uterine dilator, and then reducing the uterus by conjoined manipulation. The mortality following this operation was large and it has been practically abandoned. The principle involved in Gaillard Thomas's operation, viz., the forcible dilatation of the inverted uterine canal, has been so modified as to avoid the necessity of the preliminary abdominal section. This modification consists in drawing down the uterus carefully enveloped about its neck with some sterilized gauze. An incision is then made through either the anterior or the posterior uterine wall, and through this incision a dilator is introduced. When the dilatation has been carried to a sufficient de- gree, as determined by the introduction of the finger through the operation wound and through the now dilated cervical canal, the incision is sewn up with sterilized catgut and the fundus is forced back into position. Kehrer (Centralblatt fur Gynakologie) draws the in- verted uterus down to the entrance of the vagina and makes an incision on its anterior surface through the whole length of the cervix from the os externum to a little beyond the middle of the corpus, and ex- tending directly through into the peritoneal cavity. The wound is then stitched from the fundus to the os internum, after which the 330 A TEXT-BOOK OF GYNECOLOGY inversion is reduced, when, finally, the lower part of the wound is sewn up as far as the os externum. Hirst operates by dividing the posterior cervical wall as far up as may be necessary to gain space through which to effect the reduc- tion, which he has been able to do without making the extensive inci- sion of Kehrer. After the uterus has been restored by Hirst's method, the only remaining step consists in applying a few interrupted sutures to the incised posterior lip. This operation impresses one as being at once simple and effective. Vaginal hysterectomy as a remedy for chronic and irreducible inversion of the uterus is not a modern conception. Themison sug- gested it b. c. 50, but it was not adopted in practice until Soranus, of Ephesus, amputated an inverted uterus about the end of the second century of our era. The suggestion has been recognised as one of practicability from that day until the present. In its adoption the general principles of technique should be observed that are outlined in the chapter on vaginal hysterectomy. In view of the fact that the inverted uterus, when once restored, is capable of exercising the functions of reproduction, vaginal hyster- ectomy should not be performed in child-bearing women. CHAPTER XXV INJURIES OF, AND FOREIGN BODIES IN, THE UTERUS Injuries: (a) parturient: rupture, laceration of the cervix — Trachelorrhaphy (Em- met) — Amputation of the cervix — (b) nonparturient : wounds from external causes — Foreign bodies. Injuries of the uterus divide themselves naturally into (a) par- turient, and (b) nonparturient. Rupture of the uterus is an accident of parturition. It may be complete or incomplete. In the latter, the injury is restricted to the muscularis while the peritoneum remains intact. This was regarded by Lusk as more likely to occur in lateral tears at the site of the folds of the broad ligament — though, owing to the relatively loose attach- ment of the peritoneum at the lower segment, incomplete ruptures are not necessarily confined to those points. In the complete form the tear extends through the muscularis and the peritoneum, making, usually, a communicating wound with the abdominal cavity, although lacerations have occurred in that zone of the uterus which lies in normal attachment to the bladder. The causes of rupture of the uterus may be summarized by saying that they may consist of any condition that interferes with the descent of the child, that favours the ascent of the body and fundus, or dimin- ishes the normal powers of resistance of the uterine walls. A mon- strosity, a hydrocephalic head, neglected shoulder presentation, are examples of causes that may exist in the foetus. Fibroid tumours, dis- tortion of the pelvis, and malignant disease of the cervix, are among the maternal causes. Some writers have placed emphasis upon fatty degeneration of the uterine parenchyma as a demonstrated cause of this condition. The mechanism by which uterine ruptures are caused was first satisfactorily explained by Bandl. He explained that in normal labour the contractions of the uterus resulted in a thickening of the fundus and body, while the lower segment was stretched and thinned by the downward pressure exercised by the presenting part of the foetus. This process was strictly physiologic, so long as no obstacle existed to interfere with the descent of the child. The natural result of this dilatation was the practical conversion of the uterus and vagina into a continuous canal. When labour was advanced, the lower circum- ference of the body of the uterus was ordinarily distinguished from 331 332 A TEXT-BOOK OF GYNECOLOGY the stretched lower segment by the ridge induced by the contractions, and now known as the ring of Bandl. This ring was ordinarily found in the neighbourhood of the pelvic brim, but its development was proportionate to the difficulty of the labour. In the presence of some obstruction to the normal descent of the child, the retentive force exercised by the suspensory ligaments of the uterus resulted in the upward retraction of the fundus and body of that organ. This up- ward migration of the superior zone of the uterus resulted in a cor- responding upward migration of the contraction ring, or the ring of Bandl. The ascent of this ring deprived the lower segment of the uterus of those accessions to its volume and resistant force, which, under normal circumstances, would be derived from the natural dilata- tion of the ring of Bandl. As a consequence, the lower, or cervical, structures became stretched and thin, often to a degree that they could no longer maintain their integrity against the expulsive and divulsive force from within. In this way, according to Bandl's explanation, the majority of all ruptures of the uterus begin in the lower segment, a philosophic conclusion which is amply confirmed by clinical observa- tion. The view has been urged that, while ruptures of the uterus, for the reasons already given, generally begin in the lower segment and extend upward, their further extension toward the fundus is arrested by the action of the now migrated ring of Bandl, which, in certain cases, may be felt through the abdominal walls above the pubis, or, even as high as the umbilicus. Many of the ruptures reported, indi- cate that a tear probably started in the lower segment of the uterus, and extending upward part way to the fundus, had been deflected to one side or the other. This was manifested in two cases by Eeed. (New York Medical Journal, November 9, 1889.) The symptoms of rupture of the uterus, when partial, may consist of only an evanescent and not severe shock, a temporary interruption of the pains, and a persistence of hemorrhage after delivery. When the rupture is complete, however, the phenomena induced by the accident are striking and unmistakable. There is profound shock; the uterine contractions and pain cease instantly; the presenting part of the child recedes; the fundus of the uterus tilts to one side, or entirely disappears in the presence of a new, strange, and indefinite tumefaction within the abdomen; a bloody discharge makes its appear- ance; and frequently there is prolapse of the funis. A careful exam- ination at this time will indicate, not only a recession of the presenting part of the child, but an apparent atony of the cervical structures. If the child has escaped into the abdominal cavity, the hand is intro- duced without difficulty into the uterus, and may, in certain cases, be carried through the rent in the uterus into the peritoneal cavity. The diagnosis, according to Ludwig, is not always easy, even when the fore- going symptoms are taken into account. He has found the best diag- nostic sign to be, (a) in lateral rupture, the interruption of the natural contour of the uterine quadrant, when either a projection or a nodule "TT INJURIES AND FOREIGN BODIES OF THE UTERUS 333 is formed; (b) suddenly acquired abnormal mobility of the uterus; and (c), a sign upon which he places great emphasis, viz., emphysematous crackling at the seat of rupture. If the head presents and can be pushed back, the bimanual examination under deep narcosis makes the diagnosis certain. The treatment of rupture of the uterus is to be directed to the saving of the life of both the mother and child, when possible. If the child is yet within the uterine cavity, the vertex presenting, forceps should be applied without delay; if breech or shoulder is presenting and the child is known to be alive, version may be practised. If the child is still within the uterine cavity but is known to be dead, it may be delivered by craniotomy, morcellement , or by any other means that will most speedily empty the uterine cavity. After delivery the uterine cavity should be carefully explored, and, if the rupture is found to communicate with the peritoneal cavity, an abdominal section should be done at once. If rupture has been complete and has been followed by the escape of the child into the peritoneal cavity, the child should be delivered by abdominal section. The same course is to be followed when the child has been delivered per vias naturales, and the placenta has escaped into the abdominal cavity — indeed it may be adopted as a safe rule that the abdominal cavity should be opened whenever rupture of the uterus can be demonstrated to be complete, no matter what may or may not have passed through the rent. This conclusion is based upon the fact that although neither the child nor the placenta may have escaped into the abdominal cavity, complete rupture could not occur without the escape into the peritoneal cavity of either blood, amniotic fluid, or other products of gestation, liable to be either the bearers or the sources of infection. The abdomen should in such cases be opened and thoroughly washed out with normal salt solution. If hemorrhage is in progress, it should be controlled either by the application of forceps to the broad ligaments, far enough down to control, not only the ovarian, but the uterine arteries; or by an elastic ligature temporarily applied below the site of rupture. The treatment of the uterus at this point is one of extreme importance. The rent may be closed, which is best done by paring the edges, and approximating and closing them by the seroserous suture, adopted by Czerny and Lembert, in Cesarean section (see Cesarean Section); or the uterus may be removed, converting the procedure essentially into a Porro operation. Unless there is extensive destruction of the tissues of the uterus, with obvious infection, its removal is not justifiable. Women who have sustained rupture of the uterus and who have been successfully operated upon by closure of the tear, have subsequently borne children. Deutsch (Centralhlatt filr Gynlikologie, November 14, 1889) reported a case of symmetrically contracted pelvis in which rupture of the uterus had been treated by abdominal section four years previously. The patient went to term, when examination revealed the uterus adherent to the abdominal wall, causing a marked projection 334 A TEXT-BOOK OF GYNECOLOGY of the abdomen. The foetus being found to be living, the patient was narcotized, the os was dilated, and a living child was delivered by po- dalic version. If carcinoma or fibroids are either the underlying cause or the associated condition of a rupture of the uterus, no hesitancy about its ablation need be entertained. The operation should be done as soon after the condition is detected as necessary preparations can be made. The possibility of hemorrhage and the still greater pos- sibility of infection make it imperative that intervention should be practised as speedily as possible. Patients may, however, live for a considerable time after the occurrence of this accident, even without treatment. Thus St. Braunwas, of Cracow, reports a case in which he had extracted the foetus by abdominal section six weeks after it had escaped through a rupture of the uterus into the peritoneal cavity. The foetus was bathed in pus, which filled the cavity of the abdomen. The patient, of course, died from chronic sepsis. In cases in which abdominal section is practised, the operation proper should be both preceded and followed by free administration of normal salt solution, either by intravenous injection or by hypodermoclysis. Lacerations of the cervix occur chiefly as accidents of childbirth — although latterly they are encountered in occasional instances as re- sults of forcible dilatation of the cervix. (See Dilatation of the Cer- vix.) When this operation is performed with too much rapidity and by one of the powerful instruments now in use, the divulsion may result, not merely in the separation of submucous fibres, but even in a complete severance of continuity of the cervical tissue. It may be said that laceration of the cervix, when occurring as the result of for- cible dilatation or of parturition, is always caused by divulsion carried to a point beyond the resistant power of the cervical structures. Lac- erations of the cervix may be either superficial or deep, extending as far up as the cervico-corporeal junction, and are, in reality, but examples of rupture of the uterus, the damage occurring in the lower segment of that organ and involving the cervical margin. More than one rup- ture of this kind may occur at once, occasioning what is spoken of as multiple or stellate laceration of the cervix. When lacerations occur chiefly within the cervical canal, but do not extend entirely through to the lateral vaginal surfaces of the cervix, they may result in a permanent enlargement of that canal. The attention of the profes- sion was first called to the pathologic character of these injuries by Emmet, who devised the operation for their repair. (See Trache- lorrhaphy.) The pathology of lacerations of the cervix relates chiefly to ante- cedent and subsequent changes. The antecedent changes consist of those modifications of the cervical structure — e. g., fatty degeneration and oedema — occurring during the course of pregnancy, which result in a loss of the normal elasticity of the tissues. The subsequent changes relate to those interferences with involution, and those modifi- cations of local nutrition, which are caused by the tear, and the con- INJURIES AND FOREIGN BODIES OF THE UTERUS 335 sequent interference with the circulation. After the receipt of the injury, laceration of the cervix rarely if ever heals spontaneously. Eepair occurs by process of cicatrization; the tissue thus formed subse- quently contracts; and the underlying cervical structures are distorted. When the laceration is bilateral the resulting contraction of the cica- tricial tissue causes a retraction outward of the cervical lips, with con- sequent eversion of the mucous membrane. The mucous membrane itself, exposed on the everted surfaces of the cervix, presently under- goes glandular hypertrophy, giving to the unpractised eye the appear- ance of ulceration, and abounding in granulations. There is no doubt that many of the so-called " ulcerations of the womb," treated in the years gone by with repeated applications of lunar caustic, were, in reality, but eversions of the endocervix in a state of glandular hyper- troph} r . The enlarged follicles of the cervical mucosa manifest an augmentation of function corresponding with their abnormal develop- ment; and, as a consequence, the cervix is always covered in such cases with a clear viscid mucus, sometimes tinged with blood. Changes in the parenchyma of the cervix are equally marked and may present two extremes, namely, atrophy or hyperplasia. When the laceration is comparatively superficial, the resulting inflammation goes through all the consecutive stages from preliminary engorgement to final atrophy; but when the laceration is deep and the consequent cervical eversion is pronounced, there is so much mechanical interference with the circulation, particularly upon the venous side, that passive engorgement ensues, resulting finally in an actual increase of the tissue elements. This state of hypertrophy is sometimes associated with oedematous in- filtration; but, as a rule, there occurs an organization of the adventi- tious tissue elements with consequent enlargement and induration of the cervix. These changes may be more pronounced in some parts of the cervix than in others, the difference being determined by the location, depth, and consequent influence, of the laceration. The body and fundus of the uterus, being largely supplied with blood by the ovarian artery, and being drained by the ovarian veins, are not subject to the influences arising in the injury of the cervix. It is noticeable, however, notwithstanding the fact that the upper zones of the uterus possess a practically independent circulation, that they undergo the post-parturient involutional changes tardily in the presence of deep injuries of the cervix. Glandular hypertrophies are, consequently, not uncommon in these cases in the corporeal endometrium. (See Endometritis.) The inflammations producing this increase in tissue, both glandular and parenchymatous, are manifestly dependent in a large degree upon mechanical disturbances of the pelvic circulation; but, from the facts that lacerations of the cervix never heal without at least superficial bacterial invasion, and that infection once established at the seat of laceration readily extends upward, these inflammations must be recognised as infectious quite as much as traumatic. Symptoms of laceration of the cervix at the time of its occurrence 336 A TEXT-BOOK OF GYNECOLOGY may be absolutely nil. The absence of all symptoms indicating lacera- tion of the cervix accounts for the fact that the majority of these acci- dents are never discovered until long after their occurrence, when the patient presents herself for treatment for vague and indefinite pelvic symptoms. In occasional instances, however, the laceration is so deep, extending up to and involving the circular artery, that hemorrhage results. This symptom is often overlooked for a time under the im- pression that the flow of blood is nothing more or less than that which occurs in normal cases following delivery. When, however, this hemor- rhage persists for a considerable time, imparting an arterial tinge to the otherwise dull-coloured lochia, it becomes the occasion for a local examination. Digital exploration at this time, particularly if done by an inexperienced operator, is liable to be negative, if not misleading, in its results. The cervix during the first few days following delivery is enlarged, dilated, cedematous, and flabby; its normal contour can not be detected, while superficial abrasions, or even deep lacerations, can not be distinguished by the touch. Under these circumstances the patient should be placed in the Sims position, the perineum should be retracted, and the cervix should be drawn down and carefully inspected, when the bleeding point, if within the area of a laceration, can be detected and controlled. In the later stages of a laceration — i. e., sev- eral weeks or months after delivery — there is vastly less difficulty in detecting the actual conditions. The patient may or may not com- plain of pain. Cicatricial deposits, particularly in the angle of lacera- tion, and especially in cases of long standing, may impinge upon ter- minal nerve filaments and occasion severe distress, and that not only in the uterus, for through its intimate nerve connections with both the sympathetic and cerebro-spinal systems, this relatively slight local injury may cause a widespread perturbation of nerve function. It would seem in certain cases, as if the cervix under these circumstances were a sort of central telegraphic office, with radiating lines over which morbific impulses are telegraphed to the remotest parts of the system. Erratic behaviour of the apparatus of accommodation, eccentric dis- turbances of hearing, evanescent or persistent turgescences of the turbi- nates, congestions of the Schneiderian membrane, asthmatic disturb- ances, localized variations of cutaneous sensibility, and that congeries of nerve perturbations designated as hysteria, have been known to fol- low in the wake of this accident and to have been cured by repair of the cervix. These so-called reflex symptoms, however, never occur with that degree of constancy necessary for them to be accepted as indications of an existing laceration of the cervix. It may be said in short that there are no symptoms of a subjective character that are pathognomonic of this condition. Local examination alone detects the condition, which has existed, possibly, for years, without being suspected, either by the patient or her medical adviser. Introduction of the finger into the vagina will reveal the cervix with an irregular contour; it may be multilobular, each lobule being divided by a distinct ; ^ INJURIES AND FOREIGN BODIES OF THE UTERUS 337 fissure (stellate laceration), or it may be divided into an anterior and a posterior lip (bilateral laceration), or it may be fissured upon only one side (single laceration). If examined by the speculum, these appear- ances may be much modified; as, for instance, if a bivalve speculum is employed, its dilatation will result in stretching farther apart the antero-posterior lip of the cervix in a bilateral laceration; indeed, in cases of long standing in which the eversion has become pro- nounced, the retracted lips may have been drawn up to the utero- vaginal junction, and, when distended by means of a bivalve speculum, the marginal contour of the cervix may entirely disappear. The pic- ture presented in the speculum will be that of a double, elliptical, area of apparent erosion. This will be nothing more or less, in practically every case, than the hypertrophic endocervium. If, now, this patient is placed in the Sims posture, the perineum retracted, and the retractor intrusted to an assistant, the examiner may, by means of a volsella placed in the apex of each lip, draw the severed portions of the cervix into approximation. He will thus be enabled to determine the depth and other exact characters of the laceration. The complications of laceration of the cervix are worthy of con- sideration. They naturally coexist with atrophies, hypertrophies, or hyperplasias of both the parenchyma and endometrium. As already indicated when considering the pathology of this lesion, bacterial in- fection of the laceration takes place at the time of its occurrence; pro- gressive invasion, either of the contiguous mucous surfaces or of the opened lymph spaces, ensues; the result being either infection and enlargement of the pelvic lymphatic glands, with possible resulting suppuration, or infection with purulent accumulation in the Fallopian tubes, involving the ovaries in the general pathologic processes. These complications are frequently encountered and are directly traceable to the original injury for their causation. It not infrequently happens that laceration is not detected until an examination is demanded for symptoms of carcinoma. This disease, indeed, exists as a frequent complication of laceration, the carcinomatous process in many in- stances having its origin in the cicatricial covering of a cervical tear. Fibroids and other neoplasms may coexist with laceration of the cervix. The treatment of laceration of the cervix consists essentially in restoring that structure, so far as possible, to its normal state. The steps by which this may be accomplished must vary according to the pathologic conditions present in the case; thus, if the case is one simply of laceration without marked tissue changes, the treatment will consist in revivifying the margins of the wound and approximating them by sutures; if, however, there is extensive hypertrophy, it may be necessary to remove, at least, a part of the enlarged segment of the uterus. At the same time, associated pathologic states in the endometrium must be appropriately treated. 23 338 A TEXT-BOOK OF GYNECOLOGY Instruments for Trachelorrhaphy Catheter, glass Curette, dull Sharp (Siras's modified) Martin's Recamier's Dilators, different sizes Hegar's, three sizes. Forceps, hemostatic, two of each size, Long dressing Rat-tooth dressing. Bullet Needles, assorted sizes , Needle holders 2". Nozzles, glass or Edebohls's hard rubber 1 Retractor, small 1 Intermediate 2 Scalpels 2 Scissors, straight 1 Shot compressor and shot. Sound, uterine 1 Speculum, Sims's small 1 Simon's, with handles and four blades 1 Tenaculum, straight 1 Tenacula, curved 2. Trachelorrhaphy, or the operation for repair of the lacerated cervix,, is conveniently done as follows : The patient is placed in the dorsal position, her buttocks at the edge of the operating table, her knees well drawn up,, her flexed legs being intrusted either to an assistant or to the efficient mechanical attachments of the modern operating table. A Jones's perineal retractor with a short blade is now inserted and the pos- terior lip of the cervix is seized with a self-locking volsella and is drawn down. Newman has devised an excellent reverse- acting, self -locking volsella (Fig. 136) which on being inserted into the cervical canal and expanded, becomes fixed in the uterine tissues. The instrument is an ex- ceedingly convenient one, as its shaft lies along the mucous track of the cervical canal and becomes a convenient guide, both in denuding the surfaces and in pass- ing the sutures. The downward traction on the uterus must be judiciously regu- lated, force beyond a few pounds never being exercised. Whenever distinct and sudden resistance is experienced in effect- ing the temporary prolapse of the uterus, it is to be construed as an evidence of adhesions, and is a danger signal admon- ishing the operator against more forcible traction. When the uterus is thus drawn down, the endometrium, if the seat of glandular hypertrophy, should be vigor- Fig. 136.— "Newman has devised & n V" ^ -,n -i j an excellent reverse-acting, self- OUsly Curetted, the muCUS, blood, and locking volsella."— Eeed. debris, being carefully washed away with a, INJURIES AND FOREIGN BODIES OF THE UTERUS 339 Fig. 137.—" A very good knife ... is that devised by- Newman." — Eeed. jet of bichloride water, after which the surface is dried and painted with pure carbolic acid. The next step consists in denuding the sur- faces to be approximated. Their respective areas should be defi- nitely determined in advance by making a preliminary approximation. The denudation may be accomplished either by a knife or by scissors, prefer- ably the former. A very good knife for the purpose is that devised by New- man (Fig. 137) and its sharp point is so arranged that it can be easily passed through the cervical tissue in the upper angle of the laceration. It is a good rule to begin the denudation by first outlining with the edge of a bistoury the tissues to be removed. These may then be cut away, leaving two equal, denuded, approximating surfaces. Great care should be taken to remove the deposit of cicatricial tissue from the upper angle of the laceration. In the case of a bilateral laceration, all the surfaces to be approximated must be denuded before the work of sutur- ing is begun. The sutures may be in- serted by means of a short, heavy, de- tached needle, which is employed by means of a needle holder; or, they may be inserted by means of an obliquely curved needle such as that used by Eeed (Fig. 138). The sutures themselves should be of nonabsorbable material. Emmet does this operation with a silver wire, and annealed iron wire is employed by some operators. As a rule, however, the silkworm gut is the material of preference. Which- ever material is employed, careful antiseptic precau- tions should be taken. Catgut has been used with suc- cess since the process of preparing it with formalin and boiling it has been perfected; it generally lasts fourteen days, which is long enough, while the facility with which the external and unabsorbed remnants are removed is a point in its favour. The suture should be passed beneath and on a level with each surface to be approximated, as illustrated (Fig. 139). Two, three, or even four, sutures may be required upon either side, the number being governed by the depth of the laceration. After all of them have been passed the volsella may be removed, the remaining traction on the uterus being exercised by means of the ends Fig. 138. An obliquely curved needle used by Eeed." — Eeed. 340 A TEXT-BOOK OF GYNECOLOGY of the sutures on one side being gathered together in a forceps. The surface of the wound should be irrigated and removed by means of sterilized water. If there is no pulsating hemorrhage, no further atten- tion need be given to hemostasis which will be effected by the approxi- mation of the surfaces and the pressure of the sutures. The sutures are tied, beginning upon one side at the upper angle, care being taken that, as they are tightened, the underlying margins of the tissues are brought into accurate coaptation. Care should be taken to avoid tying the sutures too tightly, as tissue ne- crosis may thereby be in- duced and the success of the operation be com- promised in consequence. After being twisted, if silver wire is used, or tied, if other material is employed, the distal ends should be cut off about an inch from the knot, and so arranged as to avoid causing mechanical irri- tation of the parts. The sutures, if of nonabsorb- able material, should be left in situ for about ten days, antiseptic vaginal irrigation being practised twice daily during the entire time. To remove the sutures, the patient should be placed in the Sims position and each suture seized with long-fixation forceps and subjected to gentle traction. The loop of the suture will thereby be drawn up so that the point of a scissors blade may be easily in- sinuated beneath it. It is important that the stitches should be re- moved under inspection, for, if the effort is made to remove them by the sense of touch alone, there is a likelihood of cutting both ends of the loop near the knot, leaving the loop itself buried in the tissues. It is true that this is not a matter of any serious moment, but it may occasion annoying local infection; and the escape of a loop of suture material at some subsequent time is always construed by the patient as a more or less serious reflection upon the surgeon. Amputation of the cervix, in whole or in part, is demanded for hypertrophic and hyperplastic conditions that are sometimes associated Fig. 139. — " The suture should be passed beneath and on a level with each surface to be approximated." — Eeed (page 339). INJURIES AND FOREIGN BODIES OF THE UTERUS 341 with and result from lacerations. Emmet (Transactions of the American Gynecological Society, 1897) believes that these conditions should be subjected to preliminary local treatment, consisting of douches, elimi- native tamponade, alterative topical applications, or even local deple- tion by puncture. Treatment of this kind may, in some cases, so far reduce hypertrophy that amputation or excision is unnecessary. "When, however, the desired reduction in the volume and consistence of the tissues is not realized by such conservative treatment, Emmet's opera- tion of amputation may be adopted. He first draws the uterus down by gentle and steady traction to the vaginal outlet, always taking care to avoid a jerking movement which would be liable to rupture some blood vessel, especially if there has been a pre-existing intrapelvic in- flammation. The cervix is steadily held by an assistant just within the vaginal outlet, for at this point the arteries will be placed suffi- ciently on the stretch to lessen their calibre, and thus to render the operation to a great extent bloodless. Care is taken to accurately deter- mine the line of vaginal junction, since the bladder will be entered in front and the peritoneal cavity behind, if an attempt is made to remove what seems to be the cervix over which a mass of thickened vaginal tis- sue has been crowded. In those cases in which atrophy takes place as already described in this chapter, the field of operation can not be a large one at the beginning. An incision is now made round the cervix near the vaginal juncture; the subsequent dissection should be made by cutting always toward the centre as a precaution against entering the bladder and the peritoneal cavity, and with the object of removing a cone-shaped piece of tissue. As the operation advances, the excava- tion must continually be drawn up to the vaginal level so that the operator may have the parts under observation and the bleeding under control. As each blood vessel is divided, the neighbouring tissues should immediately be seized by an assistant and held as a fresh point for traction, when the vessels will promptly retract and cease to bleed. The cervix is to be removed segment by segment until underlying healthy tissue is reached. The most efficient instrument for this purpose is the pointed scissors which Emmet devised nearly thirty years ago for clearing out the angles in the operation for laceration of the cervix. After having removed the tissues in the manner just de- scribed, nonabsorbable sutures are inserted; Emmet employs the silver wire. The sutures are inserted antero-posteriorly. Those to either side of the cervical canal are inserted (Fig. 1-10) through the posterior lip. into the excavation, into the tissues at the fundus of the excava- tion, out again, and then through the anterior lip of the wound. The sutures that are passed coincidently with the cervical canal are intro- duced through the posterior lip of the wound, out again, in again through the posterior lip of the cervical canal, and out through the cervical canal. Another suture is passed similarly to the last, through the lip formed by the anterior wall of the cervical canal, out again and through the anterior lip of the cervix. As many antero-posterior 342 A TEXT-BOOK OF GYNECOLOGY sutures are passed transversely to the cervical canal as may be required. " If," says Emmet, " we follow the course of either of these sutures it will be apparent that when the front suture, for instance, is twisted, the free vaginal surface must be drawn over the stump, and as the edge of the uterine canal is a fixed point, the former will be secured at that point, and a similar effect will be produced posterior to the cervical canal when the posterior suture has been twisted in the same manner. The result of thus securing these sutures will be that the edge of the divided mucous membrane on the vaginal surface, front and back, will be rolled over in contact with the edges of the uterine canal, and when primary union has taken place the natural calibre of the passage must be preserved. But before securing these, or any of the sutures, as many as may be deemed necessary should be first introduced on each side of the cervi- cal canal. Here the loose vaginal edge is first caught up, and then the needle is made to include a sufficient portion of the uterine stump on a line with and lateral to the uterine canal, and in turn it should take up the vaginal tissue behind. The only difficulty is in catching up enough of the uterine tissue in the centre of the stump to hold it firmly in contact with the flaps after the sutures have been secured. But this difficulty can be overcome by using a properly-shaped needle with the pointed end slightly bent on itself. The passage of the needle is greatly facilitated by snipping with pointed scissors a sulcus in the tissues at a sufficient depth in front of the advancing needle, and from the bottom of this cut its point should be brought out to pass over to secure the vaginal edge. " After all the silver sutures have been twisted it will be made evident, by the introduction of a uterine sound for half an inch, that the canal has been left fully open, and it will be seen at the same time Fig. 140. — " Those to either side of the cervical canal are inserted through the posterior lip, into the exca- vation, into the tissues at the fundus of the excava- tion, out again, and then through the anterior lip of the wound." — Eeed (page 341). INJURIES AND FOREIGN BODIES OF THE UTERUS 343 that the vaginal tissues have been drawn over the stump and firmly secured to its surface. " At the completion of the operation it is necessary that the uterus should be carefully replaced with the finger to its natural position, and it must be done without displacing the ends of the sutures, which have been carefully bent down on to the vaginal surface. As soon as the uterus is replaced in its normal position the lateral traction then exerted in the vagina will keep the vaginal covering in close relation with the stump. " Xo surgical operation with which I am familiar yields a more uniform and satisfactory result than this one, when performed under the following conditions: The proper use of silver sutures, keeping the patient in bed for three weeks after the operation including the menstrual period when possible, and not removing the sutures before the nineteenth or twentieth day, when the parts will have become nrmly united and the uterus greatly reduced in size." Vesicouterine Fistulae. — These fistula? are of two kinds. In one form the cervix is partially destroyed, and in the other form the fistu- lous opening occurs into the cervical canal and is so concealed that the •cervix must be split during any operation for its obliteration. These fistula? can only take place in the cervix. It is important that a diagnosis should be made in these cases dis- tinguishing between a vesico-uterine fistula and a uretero-uterine fistula. In each case the urine is discharged from the os uteri. Sometimes a probe can be passed through the fistulous opening from the bladder into the cervical canal or vice versa. Clear fluids injected into the bladder will come out of the os uteri. If continued pressure is kept up in the cervical canal no acute nephydrosis will occur if the fistula is vesico-uterine and not uretero-uterine. The electric cysto- scope should be of great assistance. With it one should be able to make out any perforation of the bladder wall, and thus to distinguish between vesical and ureteral fistula?. (See Examination of the Bladder.) Prognosis. — These fistula? oftentimes heal very kindly owing to the fact that the thick wall of the uterus, during the process of heal- ing, is likely to close the opening. Treatment. — The treatment is the same as that for vesico-vaginal fistula, namely, closure by suture. Each of these cases must be judged upon its own merits and the operator must think out for himself his •exact method of procedure. If the main principles, previously stated, are adhered to, he will, in all probability, meet with success. If the fistula is situated close to the cervix the anterior lip may be made use of to close the opening. If a great deal of the anterior lip has been destroyed it will then be necessary to use the posterior lip, and if this is done the menstrual fluid will be discharged into the bladder and out through the urethra. It is unfortunate to have this happen and if possible it should be avoided. 344 A TEXT-BOOK OF GYNECOLOGY Fig. 141. — " The bladder, thus separated, should be drawn down with a forceps or volsella." — Keed. Reed's Operation for Vesico-uterine Fistula. — The condition is best controlled by a free incision, dividing the uterus from the blad- der, just as is practised in the preliminary step of vaginal hysterec- tomy. The bladder, thus separated, should be drawn down with a forceps, or volsella (Fig. 141); the fistula will then be brought into clear view and can be closed by a double line of continuous catgut sutures. If the fistula opens di- rectly into the ute- rus (Fig. 142), the latter should be curetted and packed and a single suture should be placed across the orifice of the fistula as it presents at the denuded anterior uterine surface. If the fistula traverses the uterus longi- tudinally and opens at the cervical margin (Fig. 143), a curved director should be inserted and the uterine tissues split up to the point of en- trance of the fistula. If the tract has become cicatricial it should be carefully dissected out, and the place that it for- merly occupied should be closed by repeated inter- rupted sutures. In split- ting up the uterine tis- sues, the circular artery is more than likely to be divided. The hemor- rhage may be somewhat difficult to control. This, however, is best done by passing a deep suture en masse to either side of the incision, so situated as to embrace the severed ends of the artery within its grasp. Both the bladder and the uterus having been thus repaired, the parts should be brought into apposition and closed by interrupted sutures. The vagina should be packed with antiseptic gauze and the Fig. 142. — " The fistula opens directly into the uterus. — Reed. INJURIES AND FOREIGN BODIES OF THE UTERUS 345 i^///M*;'d//> usual precautions observed during convalescence. The most notable of these precautions is the introduction and retention of a sigmoid cathe- ter during several days after the operation. The evacuation of the bladder, either by catheter or spontaneously, at intervals of not more than three hours during the succeeding week should be rigorously practised. Wounds of the uterus from external causes are of occasional oc- currence. The injudicious use of the uterine sound sometimes re- sults in perforation of the walls of that organ. Cases of this kind have been recorded by Law- son Tait and others. If the instrument is aseptic the accident is rarely followed hy serious con- sequences; if, however, infection ensues, death may follow. The intro- duction into the uterus of catheters, sounds, and bougies for the purpose of inducing criminal abortion, generally re- sults in more or less in- jury to the endometri- um, if not to the deeper structures of the wound. Injuries of this kind, when inflicted by unclean instruments, result in those deaths from constitutional sepsis which occur so frequently in the annals of crime. There is probably nothing more dangerous to a woman than an effort, particularly on her own part, to induce abortion h\ intrauterine instru- mentation. In many cases of perforation of the uterine wall by the sound, at the hands of experienced operators, the diseased condition of the uterus itself is responsible for the accident. The walls of the uterus are very nonresistant in all inflammatory conditions, but par- ticularly so in the presence of puerperal infection. In ordinary cases of subinvolution, the uterine tissue is very friable. TThen the walls of the uterus are soft and eodematous as the result of a flexion at an acute angle, the muscularis is easily penetrated; and the same is true when the organ is the seat of malignant disease, such, for example, as sarcoma, syncytionia malignum, and adenoma malignum. Under these circumstances the uterus is sometimes perforated by means of a curette, many of these instruments being so constructed that they offer no safe- guard against the accident. Gau, of Cincinnati, has devised an ex- cellent curette with a safety point and edge calculated to prevent acci- dents of this character (Fig. 144). The diagnosis of uterine perforation is not difficult. Perforation may be suspected whenever the sound or Fig. 143. — " The fistula traverses the uterus longitudi- nally and opens at the cervical margin." — Reed (page 344). 346 A TEXT-BOOK OF GYNECOLOGY curette penetrates farther than the previously ascertained limits of the uterus. The treatment consists in quietude and vigilance. In a septic case it may be prudent to await the development of menacing symptoms, which, as soon as they occur, should prompt the surgeon to extirpate the uterus. Intrauterine injections are to be carefully avoided, even when administered by means of a recurrent syringe, for the reason that any force, however slight, may be sufficient to carry infectious material from the uterus into the peritoneal cavity. In some cases the injury inflicted, particularly by the curette, may cause an opening which may result in the protrusion either of omentum or of a loop of intestine. In the presence of this complication the protruding struc- ture should be replaced and the uterine cavity packed pending the completion of preparations for hysterectomy, which should be done as promptly as possible. In cases in which injury has occurred to the intestines, as rarely happens from either the sound or the curette, an abdominal section should be done at once. Gunshot wounds of the uterus, particu- larly when pregnant, are recorded. Ben- brook {Medical Times) relates an interest- ing case of this sort, in which a 44-calibre pistol ball passed in just below the crest of the ilium going downward and back- ward, and a second one entered the ab- dominal cavity from a point between the eighth and ninth ribs. Three days later, the woman was taken with hemorrhage from the uterus associated with labour pains, and resulting in the expulsion of a quantity of blood clot together with a bul- let, which had passed into the cavity of the uterus through the fundus. Another case by Eobinson {Lancet) revealed the fact that a ball had en- tered the abdomen a little to the right and below the umbilicus; an hour later labour set in, resulting in the instrumental delivery of a dead child near full term, with a gunshot wound in its right shoulder. The ball was found in the debris. The mother made an uninterrupted recovery. Metert records {Medical Review) an interesting case of a self-inflicted gunshot wound in the abdomen of a pregnant woman, the ball passing through the uterus and the arm of the child, an abdominal section being followed by the recovery of the mother. Gunshot wounds gen- erally occur either at the fundus or the anterior wall of the uterus. Their infliction is followed by pronounced shock and collapse, pain in the abdominal region, at first located at the site of injury, but presently becoming diffuse, while symptoms of peritonitis of the dif- fuse form shortly manifest themselves. In the course of a few hours pains with rhythmic contractions of the uterus occur, whether in the Fig. 144. — " Gau has devised an excellent curette with a safety point and edge." — Reed. INJURIES AND FOREIGN BODIES OF THE UTERUS 347 impregnated or the nonimpregnated uterus. In either instance the organ is more or less distended; in the first by the products of con- ception, and in the latter by clots. The gravid uterus in many cases throws oil: its contents, a fact which does not in the least diminish the necessity for prompt intervention. As to treatment, it may be laid down as a rule that every case of perforating wound of the abdomen of a pregnant woman would be subjected to an exploratory abdominal section without reference to symptoms. The probability of perforation of the uterus and of the consequent escape of amniotic fluid and blood into the peritoneal cavity, makes it imperative that intervention should be both prompt and thorough. The fact, also, that in these cases the womb and its contents act as a sort of shield to the intestines, saving them from injury, increases the prospects of the mother and forms an additional reason for speedy intervention. The character and extent of the operation must be determined by the conditions revealed by the exploratory incision. If there has been extensive destruction of uterine tissue, offering no reasonable prospect of recov- ery, with the uterus in situ, hysterectomy should be done. This rule applies whether the uterus has been emptied or not. All debris should be washed from the abdominal cavity by copious irrigation with normal salt solution, and intravenous injection or hypodermoclysis should be practised in the presence of the generally pronounced shock, or when- ever there has been a free loss of blood. If the gravid uterus has thrown off its contents, the necessity for abdominal section is all the more imperative, for the very contractions of the uterus which result in the expulsion of the embryo, result also in the extrusion of the liquid contents of the uterus into the peritoneal cavity. Cattle-horn wounds of the uterus are of occasional occurrence in the cattle-raising districts of the world. A number of these cases have been reported describing accidents with revolting details but attended with a singularly slight mortality. These injuries considered as ab- dominal wounds may or may not involve the uterus; the latter class need not be considered in this connection. Of the former it may be said that they divide themselves naturally into those wounds which involve the uterine wall alone, and those which involve both the uterus and the child. The prospect of the child living under these circum- stances depends, naturally enough, upon the stage of pregnancy and the degree of injury sustained by the child. Occasionally the rent in the uterine wall is so great that the foetus and secundines escape into the abdominal cavity; and, even under these circumstances, a viable child has been known to survive. Harris (American Journal of Obstetrics, 1887) collected the histories of nine cases of this char- acter, with a mortality of four women and four children. In an injury of this character the diagnosis declares itself. Whether a hysterectomy should be done in these cases, or whether the wound in the uterus should be treated just as in an elective Cesarean section, must be determined at the time by the conditions presented. As a rule the uterus contracts 348 A TEXT-BOOK OF GYNECOLOGY vigorously after the receipt of the injury and particularly after being emptied. In certain of the recorded cases occurring before the modern surgical epoch, closure of the uterine wound was effected by suture, and even in cases of recovery the treatment was destitute of those features which we should to-day designate as antiseptic. In some of the recorded cases subsequent pregnancies with successful deliveries have occurred. These facts should prompt the operator to be cautious before sacrificing a womb by ablation, even though it may be the seat of extensive injury. In those cases in which exploratory incision reveals the fact that the perforating wound of the uterus is small, delivery may be effected by the Cesarean section. (See Csesarean Section.) In such cases it is important that the gunshot wound be carefully closed on the peri- toneal surface of the uterus. Foreign bodies in the uterus are occasionally encountered in prac- tice. They may consist of pledgets of cotton or of gauze left by acci- dent in the uterine cavity in the course of treatment, the broken end of a uterine electrode, or the stem of an intrauterine pessary. Schauta (Ceniralblatt fur Gynakologie) reported a case in which a hard-rubber pessary, 2.5 inches in long diameter, inserted into the vagina, had escaped into the uterine cavity from which it was delivered with ex- treme difficulty by morcellement. Neugebauer, in his collected series of 297 cases of pessaries neglected and incarcerated in the vagina or escaped into adjacent parts, notes six in which a vaginal pessary slipped into the uterus. Bodies usually found in the uterine cavity are hairpins or broken-off ends of instruments employed for the most part by patients themselves in an effort to produce abortion. Fig. 145. — " W. E. Ashton reports an interesting case in which ... a false passage was made from the internal os through the anterior uterine wall." — Reed. W. E. Ashton reports (Medical Bulletin) an interesting case (Fig. 145) in which, as the result of an attempt to forcibly insert a tupelo tent, a false passage was made from the internal os through the an- terior uterine wall to a point above the utero-vesical fold where the tip of the tent protruded into the peritoneal cavity. Laminaria and INJURIES AND FOREIGN BODIES OF THE UTERUS 349 other tents introduced into the cervical canal have escaped into the uterine cavity proper. Mittermaier reports a case in which a loosely tied silk ligature had become the nucleus of an infection and of a foreign body following an operation for fibroid, and another case in which the glass catheter used for irrigating the uterine cavity had broken in situ, the fragments having become so thoroughly embedded that all attempts to remove them had proved futile. The diagnosis of some of these cases in the absence of a definite history can be made only by forcible dilatation of the cervix, and either instrumental or digital exploration of the uterine cavity. The treatment consists in dilating the cervix and, if possible, removing the foreign body. This is sometimes a matter of extreme difficulty. Thus Schauta, in his efforts to remove the long incarcerated pessary from the uterine cavity, perforated the latter repeatedly with a Pacquelin cautery for the pur- pose of getting some means of grasping the ovoid body. The removal of smaller foreign bodies can generally be effected by means of the curette, the Emmet curette forceps, or the Lawson Tait colpocystotomy forceps. In some cases, however, this will prove unavailing; thus, Mit- termaier found it impossible by such means to remove the fragments of broken glass from the cavity of the uterus, to accomplish which he had to divide the uterus from the bladder, draw the fundus down into the vagina, and make an incision into the uterine cavity. Having removed the glass, he stitched up the incision, and returned the womb to its nor- mal position. It is important to bear in mind in cases in which such an operation is necessary that the operation should be made anteriorly, rather than posteriorly, to the cervix. When a foreign body results in injury and consequent infection, hysterectomy may be done, as Ashton did successfully in the case to which reference has just been made. CHAPTEE XXYI INFECTIONS OF THE UTERUS The uterus — The endometrium — The myometrium — Bacteria of the uterus — Infec- tions : (a) Mixed, (b) specific — Endometritis and metritis — Pathology — Causes — Symptoms — Diagnosis — Treatment : (a) Topical, Reed's method ; (6) curettage. The uterus being a frequent seat of infections, a proper compre- hension of them mnst presuppose a knowledge of (a) the endometrium,. (b) the myometrium, (c) the bacteria of the uterus, and (d) the recog- nised infections in their clinical, pathological, and therapeutical aspects. The endometrium consists of a stroma of fibro-connective and mus- cular tissues in which are embedded glands covered by a single layer of columnar ciliated epithelium. It contains lymphatics and nerves, and the mucous glands are large and numerous. The endometrium is not supplied with separate blood vessels, but receives its nutrition from the superficial capillaries of the uterus. The ciliated columnar epithe- lium lines the entire uterus, also the uterine glands, and is continued through the Fallopian tubes. As the endometrium approaches the external os it loses its cilia and becomes blended with the pavement epithelium upon the vaginal portion of the cervix. The glands are tubular and narrow, dip down to the muscularis, and constitute a large portion of the volume of the endometrium. These glands are active and maintain a free secretion upon the surface of the membrane, with a plug of thick mucus in the cervical canal. Lymph spaces and vessels are abundant throughout the uterus, lying in the interglandular spaces around the bundles of muscular fibres and in the serosa, and con- verging into large channels which pass outward in the broad ligaments. The cervical endometrium has a peculiar arbor vitse arrangement, is more dense than the corporeal, and is attached to the muscularis by looser tissue; it does not participate in menstruation. The normal secretion of the endometrium is alkaline in reaction; the corporeal mucus is clear and watery, the cervical, viscid. One important func- tion of the cervix is to close as by a sphincter the uterine cavity; the great function of the corporeal endometrium is to form the decidua and nourish the embryo. A knowledge of this function of the cervix should of itself forbid the much-abused operation of forcible cervical dilatation in virgins. The gland crypts of the cervix readily become a culture bed for germs, which may long remain therein in an attenu- 350 INFECTIONS OF THE UTERUS 351 ated form, and under favourable conditions develop new cultures and activity. The endometrium, says MeMurtry, is one of the most variable tis- sues of the body. It is subject to alterations that are physiologic, so that it is most difficult to establish a normal appearance that is typical. This fact often leads to a mistaken diagnosis of endometritis. The endometrium is suffused with blood during menstruation, under- goes marked disintegration at that time, and is afterward regenerated. During adolescence there is an increase in glandular tissue; during pregnancy this is even more marked, and atrophy supervenes after the menopause. The blood supply of the uterus is altered by physio- logic and pathologic conditions extraneous to that organ, such as nerv- ous states and wasting disease. These observations are of the utmost importance in the practical diagnosis and treatment of uterine dis- eases, and will convince the painstaking observer that the common diagnosis of endometritis, followed by aggressive instrumentation and chemical antisepsis, is a grave error both in diagnosis and treatment. The secretion of the uterine cavity is alkaline; that of the vagina acid. Under normal conditions, the acid secretion of the vagina is a protection from pathogenic organisms and the endometrium is always sterile. Pathogenic cocci and other germs which might enter from adjacent cutaneous surfaces perish in the acid vaginal secretions, which are unsuited for their growth. The reaction of the vagina, however, may be altered by the presence of inflammatory products, so that in- fection may occur through this route. The epithelium on the crests of the endometrial folds is usually described as having cilia, which Wyder insists have a motion from the os internum toward the fundus. Hofmeier (Centralblatt fur Gynakologie) criticises this view. Not only were his own studies conducted upon fresh uteri removed from mammals, in which the conditions ought to be the same as in the human female, but he also examined organs removed at the operating table and at once immersed in warm saline solution. In several of these latter he demonstrated conclusively, by removing strips of endometrium and placing them under the microscope, that minute particles of charcoal were invariably carried by the ciliary movement from the fundus toward the os internum. This observation of Hofmeier's seems at least to be in harmony with an intelligent design of Nature by which obstacles are interposed to the easy invasion of the upper reaches of the genital tract. The endometrium, responsive to the increased nutrition which comes from the premenstrual afflux of the blood to the pelvis, under- goes a sort of periodical hypertrophy, preceding each onset of the monthly flow. (See Normal Menstruation.) The exuberant epithe- lium undergoes a sort of desquamation. Yon Kohlden (Centralblatt fiir Gynakologie), who has studied the endometrium during and after menstruation, states that immediately after menstruation large gaps are seen in the superficial layer of the epithelium, and that during men- 352 A TEXT-BOOK OF GYNECOLOGY stmation the entire epithelial layer is cast off, and that there is infiltra- tion and hemorrhage into the mucosa. This infiltration may extend through two thirds of the thickness of the latter. The blood clots which are fonnd within the uterus contain desquamated epithelium and glands. No true solution of continuity of the endometrium can be established. Von Kohlden has never been able to find the giant cells described by Leopold, or evidence of dilatation and tortuosity of the glands. The reproduction of epithelium begins de novo within the glands, not from islands of cells which were not cast off ; there is also a new formation of blood vessels. Lohlein (Ibid.) prefers this expression to either " membranous dysmenorrhoea " or " exfoliative endome- tritis/ 7 since dysmenorrhoea is a prominent symptom in only one half of the cases, and most observations show that there is no real inflamma- tory trouble. He believes that the membrane bears more of a resem- blance to a product of conception than to that of inflammation. The myometrium, or the muscularis of the uterus, consists of bands of decussating fibres arranged in different directions and in more or less definite concentric layers. Within the meshes of this fibrillation are to be found numerous nutrient vessels, branches of the uterine and ovarian arteries, with their accompanying veins. There are also freely interspersed within the muscularis numerous lymphatic vessels, which in the nongravid uterus are minute and generally closed, but which during pregnancy and immediately after parturition are greatly en- larged, their orifices communicating directly with the placental site. There are also numerous nerve filaments, derived, for the most part, from the sacral sympathetics. The Bacteria of the Uterus. — From just within the os externum upward, says Professor Sinclair, the female genital tract in health is free from bacteria. Confusion has arisen from methods of obtaining material for micro- scopic examination and cultivation experiments. Many observers have not succeeded in getting rid of the drop of mucus at the external os which should be considered as vaginal, and so have obtained results vitiated by the presence of vaginal bacteria in the material examined. Another trifling question which has received too much attention is the limit of the vagina in case of laceration of the cervix. The dis- cussion is mere logomachy. The part of the cervical canal which, by reason of laceration, is exposed to the vagina, must count as vagina from the point of view of bacteriological research. The part is well worthy of examination and comparison with the vagina and cervix proper, because of the change in the reaction of the secretion, which is alkaline within the lacerated portion; the difference in anatomic structure of the part which is cervical, and the inability of its lacerated muscle to completely contract, thus leaves the fissure in a state of stagnation. The external os uteri, then, thus defined, is the boundary line be- tween the vagina which in health swarms with all sorts of bacteria, and INFECTIONS OF THE UTERUS 353 the canal of the cervix and body of the uterus which in health is abso- lutely free from germs. Upon this point at least there is almost abso- lute unanimity among the bacteriologists. Winter, who differed so egregiously from the majority with regard to vaginal bacteria, found, on examination of the healthy uterus with apparently healthy secretion, no bacteria in the cervix. When the cervical secretion was purulent he found bacteria in the cervical canal. The material on which he worked consisted of uteri obtained by ex- tirpation. He reached the following conclusions: (1) The healthy uterine cavity contains no micro-organisms; (2) the vicinity of the os internum in half the cases contains no bacteria; (3) the cervical secretion of every healthy woman contains numerous bacteria, and in pregnancy the bacteria, especially the bacilli, increase to a large extent. These statements coincide with those of many other German bacteriolo- gists, including Lomer and Bumm. Goenner, who made numerous observations, found bacteria in the cervix of pregnant women, but he failed to cultivate any. From this experience he draws conclusions against the theory of self-infection. Solowieff examined women suffering from gonorrhoea or from tuberculous disease. He found micro-organisms in the cervix in 39 out of 45 women examined. In 7 cases he found streptococci and staphylococci. He concluded that bacteria are frequently found in chronic endometritis. Acute puerperal endometritis depends upon the presence of pyogenic bacteria. He reached the conclusion that the possibility of self-infection from the genital canal must be ad- mitted. Brandt (Zur Bacteriologie der Cavitas Corporis Uteri bei den Endo- metritiden) found, in 22 out of 25 cases, bacteria in the cavity of the uterus, and in 31 per cent of cases of endometritis, he found patho- genic organisms. Similar results of examinations have been published by many others. Menge published the results of some work in 1893. He always found the cervical canal free from germs except in cases of gonorrhoea. In these the gonococcus was always found in the cervical canal, and in many cases he obtained the bacterium in pure cultivation. In preg- nant women infected with gonorrhoea he always found the gonococcus and made pure cultivations from it. The secretion of the cervical canal was always alkaline. Stroganoff made observations on women during menstruation. After complete cleansing of the os externum he always found the canal free from bacteria. In elderly women, Stroganoff found the cervical canal free from bacteria in 50 per cent. When the uterus was prolapsed, bacteria were always found in small quantities in the cervical canal. In pregnant women under ordinary conditions he always found the canal free from bacteria. Stroganoff therefore concluded: (1) in normal circumstances the cervix contains no bacteria; (2) the normal cervical secretion possesses a bactericidal quality; (3) in the genital 24 354 A TEXT-BOOK OF GYNECOLOGY canal the os externum forms the dividing line between the germ-con- taining and the germ-free portions. Bnmm maintained in 1895, that in chronic endometritis of the body and cervix, in hyperplastic conditions resulting from inflamma- tion, as well as in the catarrhal form, no micro-organisms can as a rule be demonstrated to exist. The continuance of the disease of the mucosa does not depend upon the presence of micro-organisms. In a small number of cases there may be found in the secretion, but not in the tissues, of the diseased mucosa, a small number of bacteria includ- ing pyogenic cocci. These must usually be considered accidental ac- companiments of the endometritis. Wertheim says that gonorrhceal infection of the uterus always causes a purulent catarrhal endometritis, which, when it runs a chronic course, leads to hyperplastic-hypertrophic changes in the glands. The inflammation also extends frequently to the myometrium, and it is less marked in the cervix than in the cavum uteri. In about half the cases, the gonococcus was demonstrated in the secretion, and pure cultivations were obtained. No other bacteria were ever found when the gonococcus was present. Wertheim concludes that the external os presents no barrier whatever to invasion by the gono- coccus. Gottschalk and Immerwahr examined 60 cases and found bacteria, including Staphylococcus pyogenes, in the uterine canal in 65 per cent. They concluded that there was a secondary invasion of the endometrium by the staphylococcus in connection with a gonorrhceal infection which had run its course or become chronic. Menge made his investigations on 50 pregnant women. Of these, 34 appeared to be without any disease whatever; in 16 there was something suspicious about the discharge. He found the gonococcus in 4 cases. In only 3 others were cultivations obtained, and these were white saprophytic masses which softened gelatine very slowly. He attributes their presence to filth from the vagina. Microscopic examination did not reveal the presence of cocci. Bacteria were seen with the microscope, but could not be cultivated. No bacteria which we know, that is to say, which can be cultivated by methods usually employed for aerobic and anaerobic germs in acid or alkaline media, or suitable for the gonococcus, could be discovered. The conclusion which Menge reaches is, consequently, that with the exception of the gonococcus no bacteria are found as a rule in the cervix of pregnant women. The material which Menge employed for his further work con- sisted of the extirpated uterus in 50 cases suited for operation. He was thus able to eliminate the errors arising from the necessity of obtaining secretion through the os uteri. The diseased conditions which called for operation had, however, led in many cases to the in- vasion of the cervix by bacteria which had only a modified interest for the gynecologist. INFECTIONS OF THE UTERUS 355 In 20 cases Menge found nothing to suggest pathologic changes in the endometrium. In 30 cases there existed some turbid slimy discharge or other changes suggestive of gonorrhoeal infection. Of the 20 normal cases the cultivation material remained abso- lutely sterile in 16. In the remaining 4 cases only colonies of saprophytes were discovered. Vaginal bacteria were also found by other methods of cultivation, including an anaerobic streptococcus. In a large proportion of the suspicious cases the gonococcus was found. All the rest were considered to be vaginal bacteria. It was found in the course of examination of another series of uteri extirpated for various reasons, that the tubercle bacillus existed in the canal of the body and cervix when tuberculous disease affected the uterus or tubes. "When necrotic tissue was present, as in cancer of the vaginal portion of the uterus, innumerable saprophytic bacteria were found to flourish. Among the causes of the immunity from bacterial invasion of the cervical canal Professor Sinclair suggests: 1. The difference in the reaction of the secretion, which keeps away from the cervix the facultative aerobes and pathogenic organisms which sometimes gain a footing in the vagina. 2. The sudden change in the calibre of the canal. 3. Increase of the muscular power of the walls of the canal. 4. The downward stream of the secretion, which may add another mechanical influence. 5. Some germicidal quality in the secretion — that is, in the leuco- cytes and in the fluid. 6. The presence of the gonococcus when it has obtained access to the cervix. In reference to this last point there can be no doubt that the os externum and all the influences at work in the cervix present no obstacle to the advance of the gonococcus, and there is reason to believe that the presence of the gonococcus has some deterrent influence on the development of other bacteria. From what has now been said about the cervical canal, and a fortiori about the canal of the uterus as a whole, certain practical conclusions may be indicated without unpardonable irrelevancy. It must be obvi- ous that the cervical canal of the pregnant or parturient woman does not require disinfecting, and that any proceedings with that object are, to say the least, unnecessary. When the cervical canal is found to be the source of gonorrhoeal dis- charge in the woman in labour, disinfection is not possible. From the bacteriological standpoint, attempts to disinfect the cervix before or during labour are inadvisable. In women suffering from fibromyoma of the uterus, it used to be the custom during operation to dissect out or destroy by cautery the mucosa of the cervix, for fear of the stump in the intraperitoneal 356 ' A TEXT-BOOK OF GYNECOLOGY operation becoming infected. The fear of infection at this point was also used as an argument in favour of pan-hysterectomy. It is obvi- ous from the teaching of bacteriology that all these operative details are unnecessary, and the argument as to pan-hysterectomy is all on the other side. Some interesting reflections arise in connection with this subject, in relation to the vicissitudes in the history of lamina ria tents. In Sinclair's opinion, tents are still the unrivalled means of dilating the nonpregnant uterus. The tents can be disinfected, the bouchon muqueux can be removed from the os externum, and then the canal is germ-free. Whence arise the exceptional cases of acute bacterial infection following the use of tents? Probably from some occult arrested condition of the gonococcus or from the life energies of bac- teria not yet discovered. We are now in a position to appreciate the dictum: The asepsis of the healthy genital canal in a pregnant woman begins at the introitus vagina, and the germ-free portion begins at the os externum. In the non- pregnant woman the cervical canal is also germ-free. It is hardly necessary to consider the cavity of the uterus as a dis- tinct part of the genital tract — a conclusion in which Professor Sin- clair is in accord with other advanced investigators. The result of such consideration is to emphasize the fact of immunity from organ- isms. All the work of bacteriologists who have obtained material by the curette or spoon, as applied to the cavity, may be set aside as vitiated by the mixing of material from the vagina. The most trust- worthy results have been obtained by examination of the uterus im- mediately after extirpation. Wertheim, whose work was pursued chiefly with the object of investigating the pathology of the sexual organs resulting from gonorrhceal infection, concluded that the cavity of the uterus contained either the gonococcus or no bacteria of any kind. Menge worked on the vast material of 118 uteri obtained by ex- tirpation, and the uterine canal in every case was immediately ex- amined for bacteria both by microscopic examination and by cul- tivation experiment. He devoted a good deal of time and trouble to the investigation of pyometra, which is almost always a result of bacterial invasion from malignant disease of the cervix, a work of supererogation as far as our subject is concerned. He might as well have given us the results of researches on the bacteria which infest the cancerous area itself and produce the foul smell of the discharge and other phenomena. On the ground of bacteriological researches Menge concluded that, neither in the secretion, nor in the tissues of the mucosa of the normal cavity of the body of the uterus, did bacteria exist which could be culti- vated in our usual media; and that, neither in the secretion, nor in the tissues of the mucosa of such uteri as showed in the corporeal mucosa the usual anatomic changes marking the individual forms of chronic endometritis with small-cell infiltration, did bacteria exist which could INFECTIONS OF THE UTERUS 357 be cultivated according to any of our known methods. An exception must always be made as to the gonococcus and the tubercle bacillus. With regard to the tubercle bacillus it is a curious fact, to which Professor Sinclair calls attention, that though tuberculous disease exists either primarily or, more frequently, secondarily, in the cavity of the body, it seldom extends downward beyond the os internum, while in most cases of malignant disease of the cervix, the process comparatively seldom extends upward beyond the os internum. Individual cases of chronic endometritis stand probably in some causal relationship with the bacterial producers of puerperal infection and intoxication. The chronic endometritis of the nonpregnant woman is, however, not perpetuated by these micro-organisms. The cavity of the body of the uterus can be invaded by bacteria, or can for a considerable time harbour bacteria when it is injured, and bacteria are conveyed to it by direct inoculation, or when the defensive power of the cervix is inhibited by dilatation and the unfold- ing of its ruga?, either by new growths or by products of conception. Infections of the uterus may be appropriately classified as (a) mixed, and (b) specific. The mixed infections are those in which patho- genic bacteria of various classes are carried into the uterus and estab- lish inflammatory changes in the endometrium, or possibly subse- quently in the myometrium, or even in the perimetric structures. As will be seen when the pathology of these infections is considered, they are but rarely limited, at least in their sequent changes, to the lining membrane of the uterus; but through the utricular glands or the open lymph spaces the infection extends into the underlying muscular struc- ture; or, in the absence of absolute invasion by morbific micro-organ- isms, the secondary inflammatory phenomena, in view of the non- existence of a submucous connective tissue within the uterus, are manifested directly in the myometrium. Specific infections probably never exist as such if the term is construed to mean an infection due exclusively to a particular micro-organism; there are, however, cases in which a special bacterial organism — e. g., the Streptococcus pyogenes, the gonococcus, the Bacillus tuberculosis — exercise a predominating influence in producing pathologic changes, some of which are charac- teristic of the respective specific infection. It is probably not a demon- strable fact that any well-developed infection, however closely it may approximate the specific standard, ever exists except as a mixed infec- tion; yet, as in the cases of puerperal fever, gonorrhoea, tuberculosis, and especially in parasitic invasions — e. g., the echinococcus — the organism which exercises the controlling influence is so distinct, its characteris- tics are so well understood, its clinical manifestations are so definite, that the condition should be discussed as one of specific infection. Endometritis not depending upon specific micro-organisms for its causation, is the first and most frequent manifestation of ordinary mixed infections of the uterus. This term, etymologically, means an inflammation of the lining membrane of the uterus. There is serious 358 A TEXT-BOOK OF GYNECOLOGY question whether this condition ever exists as a distinct clinical and pathologic entity — although Welch has stated that he has seen cases of genuine inflammation which can be called nothing but endometritis (American Obstetrical and Gynecological Journal). The connection between the endometrium and the myometrium being intimate, there being no intervening cellular structure and a common circulatory and lymphatic arrangement, it follows that inflammatory processes origi- nating in the endometrium are exceedingly prone to penetrate the muscularis. In those cases in which the inflammatory process is limited to the endometrium, such limitation probably exists simply in con- sequence of either the relatively slight virulence of the infectious elements, or the relatively short duration of the disease, or, a third possibility, because resolution has taken place in the deeper struc- tures. As a matter of fact, inflammatory exudations are generally observed in at least the superficial striae of the muscularis in practically all demonstrated cases of endometritis; and it is also true that in many cases of infections which must of necessity commence in the endometrium, the most essential pathologic changes are manifested in the parenchyma. It is to be concluded, therefore, that, patholog- ically speaking, infection of the endometrium implies an inflammatory disturbance, not alone of the mucosa, but also of the muscularis, and should, therefore, be designated as metritis. Backer denies that inflammation of the uterine mucous membrane exists as a separate condition. He believes it to be always associated with inflammation of the body of the uterus, and classifies it accord- ing to the French plan among the metritides. He divides metritis into the following groups: I. Uncomplicated infectious form: (a) catarrhal metritis; (b) gonor- rheal metritis. II. Complicated forms: (a) metritis post abortium; (b) metritis ex- foliativa; (c) metritis atrophicans. The diagnosis between the forms of Group II is easy, but the catarrhal is hard to distinguish from the gonorrhceal metritis. The pres- ence of gonococci is pathognomonic; in their absence the clinical his- tory must furnish the decisive details. The ordinary " catarrhal " metritis, such as results from excessive venery, onanism, and displace- ments of the uterus, is not an inflammation but simply a hyperemia which disappears when the cause is removed. The position assumed by Backer is that entertained by Pozzi and numerous other modern writers and pathologists; and it is the view upon which the discussion of infection will be based in this work. The terms endometritis and metritis will both be employed; the former, in particular, because it designates inflammation of the lining mem- brane of the uterus, to whatever extent the myometrium also may be involved. It is convenient for the purpose of designating inflammatory processes of the uterus since the most important phenomena of them are manifested upon its internal surface. INFECTIONS OF THE UTERUS 359 The ground upon which endometritis should be considered as a mixed infection is firmly established. Brandt found pathogenic organisms in 31 per cent of his cases of endometritis. Other ob- servers have found them in larger proportions of cases. The fact that Brandt's cases embraced both acute and chronic endometritis favours the doctrine of a bacterial causation in a much larger per- centage of the acute cases than was demonstrable; for, as is well known, bacteria within the uterus are relatively self-limiting, while the pathologic changes which they induce may continue. It follows from this, that in many cases of so-called chronic endometritis in which no bacteria can be demonstrated, the organisms have disap- peared by process of self-limitation. The pathologic changes that are induced by an acute mixed infec- tion are simply those characteristic of an acute inflammation in the mucous membrane. There is an immediate turgescence of the sub- Fig. 146. — " The stage of inflammatory exudation is speedily reached.'* — Eeed. epithelial capillaries, with a consequent overstimulation of glandular activity. The influence of the micro-organisms or of their toxines is such as to destroy, in some cases, the superficial epithelium in the more exposed area, while the germs themselves penetrate deeply into the mucous folds and the utricular follicles. The stage of inflamma- tory exudation is speedily reached (Fig. 146), and differs from the same 360 A TEXT-BOOK OF GYNECOLOGY stage of inflammation in other tissues in the fact that there is no underlying submucous connective tissue to become the receptacle of the transuded liquor sanguinis and the migrated cellular elements of hematogenous origin. The exudation on the other hand takes place, at least, to an important degree, directly among the fibrillge of the myometrium. In exceptional cases, however, the exudation takes place more distinctly between the mucous membrane and the mus- cularis, with the result that the former is sometimes separated, in part at least, from the latter. It is this condition that occasions severe dysmenorrhea. Winter asserts that it is the origin, of some cases of dysmenorrhcea of the membranous variety. The sero-albuminous de- posit gives to stained sections an appearance more transparent than is observed in the normal mucous membrane. The changes incident to resolution now manifest themselves in the disappearance of the liquid elements of the exudate, and in the migration of the leucocytes toward the surface or into the minute lymphatics, until presently both the cel- lular and the noncellular elements of the exudation have disappeared. In many cases, however, in consequence of the peculiar structure of the endometrium, there exist within the deep follicles bacterial elements, which, modified in their virulence, perpetuate in a lesser degree the original inflammatory changes. The persistence of this irritation is sufficient, not only to prevent the resorption of the exuded elements, but to effect their continued deposition and organization. The result is a distinct hyperplasia, characterized by an increased thickness of the mucous membrane. A section of the mucosa reveals that it is of increased depth, while its cellular elements are not only relatively but absolutely increased in number. The leucocytes are found in some cases in large interstitial deposits, while the blood vessels them- selves show but slight thickening of their walls. As a result of these interstitial deposits increased pressure is exercised upon the glands which now seem smaller and relatively fewer in number. In this stage, bacterial elements have generally disappeared from the secretion, the withdrawal of their influence resulting in the more or less speedy super- vention of the next stage of the process; this is characterized by an absorption, to a certain degree, of the remaining free elements of exudation, but without any material diminution in the number or size of the hyperplastic products. These, on the contrary, con- tinue to exercise pressure upon the already compressed glands which now undergo atrophy; or, as may happen, an efferent duct may be- come occluded and the underlying follicle thus become converted into a retention cyst. Some of the glands, instead of being at right angles to the mucous surface, as under normal conditions, become oblique, and the stroma is characterized by increased density, and, on section, shows cells that have become elongated and arranged in bun- dles and fasciculi. The changes that are now presented are very much like those observable in the senile uterus. In these cases there is generally diffuse sclerosis of the muscularis. INFECTIONS OF THE UTERUS 361 The most ordinary, and more or less persistent, change following an acute infection of the uterus is that of glandular hypertrophic endo- metritis. In this form the cellular changes are restricted chiefly to the epithelium, the cells of which undergo, not only hypertrophic, but hyperplastic changes. The result is essentially one of increased glandular development, with corresponding increase of functional capa- city. The glands seem to be increased in size and number and to be studded more closely together than in normal conditions. The exuberance of epithelial cell growth results in an apparent thickening of the endometrium, which now appears to be arranged in slight folds, on the apices of which, more distinctly than elsewhere, the cell de- velopment seems to be luxuriant. On section, the mucous glands, instead of being straight tubules projecting downward into the stroma, are found to be tortuous, or, in other cases to show simple devia- tion in axis. On cross section their calibres are found to be widened, their lumen being largely occupied by the exuberant cell growth. In this class of cases the lumen of the mucous gland often becomes so distended with newly formed epithelial elements that the latter project from the ostium and appear upon the surface with a sort of granu- lation. In the more distinctly hyperplastic varieties, there seems to be not only an increase in the number of the tissue elements, but a multiplication of the glands themselves. These glands increase in size and number, and sometimes show a marked increase in the interglandu- lar stroma. The exuberant cell growth in these cases results in a thickening of the mucous membrane, the surface of which presents a fungous appearance. It is for this reason that the condition is some- times called fungous endometritis. As the epithelial cells develop from the matrix there is demonstrable a certain proliferation of the sanguiferous capillaries to give them support. The cell growth is, however, so active that it gets beyond the influence of the nutrient supply and undergoes fatty degeneration. When this occurs, the ter- minal filaments of the newly proliferated vessels are exposed, and hemorrhage results. It is sometimes important to distinguish areas of glandular hyper- trophy occurring upon a limited area of everted cervical membrane, from syphilitic infection. In the first place the primary syphilitic sore of the portio vaginalis is rare, and when it occurs it is manifested by a distinct erosion, ulcerative, with sharply defined borders. It is in nearly every case associated with induration of (1) the intra- pelvic lymphatics, and later (2) those in the inguinal regions. Chan- croids are liable to be overlooked, as they are generally painless and, aside from an offensive discharge, produce no symptoms. The causes of endometritis may be summarized in the general word infection. There are, however, numerous conditions which seem to contribute to this infection. As has been shown by Sinclair, the uterine cavity from the os externum to the fundus is normally free from bacteria. When infection occurs above the external os it must be as 362 A TEXT-BOOK OF GYNECOLOGY the result of the carriage thither of the infectious element. The use of instruments to produce abortion, and the employment of the uterine sound for more legitimate purposes, may be held responsible for a large number of cases. The use of an unclean speculum is a reasonable explanation of the infection of the upper portion of the vagina, whence the infection may extend by progressive invasion of the mucous sur- faces to the endometrium. Pessaries, for the most part unclean and stinking things, are to be looked upon with more than suspicion. The use of an unclean syringe nozzle is dangerous. There are certain phys- ical conditions of the uterus that are undoubtedly predisposing causes of infection. Laceration of the cervix, by exposing a portion of the endocervium to the infectious elements that abound in the vagina, may pave the way for a more general involvement. Schultze has called attention to the influence of a chronic dilatation of the cervix in favour- ing the introduction of morbific agencies into the uterine cavity. Pro- lapsus of the uterus, when complete, is generally associated with more or less infection of the endometrium. Uterine displacements in gen- eral may be looked upon as contributory influences in producing the pathologic states which are found in patients with associated demon- strable infection. Neoplasms of the uterus, particularly when they have become the seat of retrogressive changes, are a source of infection. Abel and Lan- don, after making numerous careful microscopic studies, arrived at the conclusion that in cases of cancer of the cervix the corporeal endo- metrium undergoes marked changes — especially of an inflammatory character. Acute infectious diseases have been looked upon as causes of endo- metritis. Massin of St. Petersburg (Archiv fur GynaJcologie) made an effort to settle this question by conducting a series of experiments upon eighteen cases. Of these, twelve were cases of relapsing fever, two of pneumonia, two of enteric fever, one of dysentery, and one case of acute general peritonitis of unknown causation. The uterus, with the adnexa, was removed at the autopsy and placed in Miiller's fluid, and allowed to remain therein from a month to six weeks. Sections were made from different portions of the uterine walls, including the os internum and cervix. They were first kept in alcohol (70 per cent), then placed in absolute alcohol for one week, and then in photoxylin solution. The sections were stained with borocarmine, picrocarmine, eosin, and methylene blue. From an examination of these specimens the follow- ing conclusions were arrived at: " The mucosa is affected in all of these acute infectious diseases, as are the glands, the vessels, and the uterine muscular fibres. Firstly, they are all markedly injected. The injec- tion may be marked in one portion of the mucous membrane, or, as was usually the case, may affect the entire mucous membrane. The in- creased size of the vessels was especially noted in the small veins and capillaries. The arteries were empty, and in only a few cases did they contain formed blood elements. In many cases the dilatation was so INFECTIONS OF THE UTERUS 363 great as to cause a rupture of the vessels, and consequently hemorrhages into the mucous membrane and between the muscular layers. These ecchymoses occurred in cases irrespective of the age of the patients. The most marked cases of dilatation and rupture were those in which the disease had been continuous, as in the cases of pneumonia and enteric fever, whereas in the cases of relapsing fever hemorrhages were only found in half of the cases. Next, in reference to the glands. The epithelium lining these was always swollen and cloudy, having rounded edges; the cells were coloured with difficulty. The epithelial cells secreted more mucus than normally. In some cases the glands were markedly enlarged. In many cases the epithelium was detached from the glandular tissue and lay in irregular masses in the glandular cavi- ties. The membrana propria of the glands and the surrounding layer of spindle-shaped cells were well marked in nearly all of the cases. We frequently observed new-formed granular elements, which were arranged around the glands in the form of a belt. The muscular layer of the uterus did not seem to be much affected by the disease. As stated above, the vessels in the muscular layer were injected. The changes which we observed represent a parenchymatous and interstitial inflammation of the mucous membrane and an interstitial inflammation of the muscular layer. Furthermore, in all of the cases a condition was observed which can be termed a hemorrhagic endometritis. We naturally conclude, after having made these experiments, that the endometritis undergoes three processes: 1. Increased amount of blood to the uterus, venous stasis, and inflammation of the vessels; 2. Granu- lar inflammation; 3. Diffuse spreading of this inflammation. In our experiments we were unable to ascertain whether micro-organisms were present or not. We must, therefore, consider acute infectious diseases as important factors in the causation of uterine diseases, so that when we consider the etiology of acute and chronic endometritis we must always think of the possibility of the affection being the result of an acute infectious disease." The symptoms of endometritis vary somewhat according to the pathologic changes upon which they depend. In the simple infec- tions of the endometrium involving only the superficial epithelium and the mucous follicles, there occurs a discharge ordinarily designated as uterine leucorrhcea. This discharge is generally clear and viscid and is occasionally stained with blood. It is sometimes of a distinctly muco-purulent character. Schultze, recognising the fact that purulent elements may be so slight in the uterine discharge as to escape detec- tion, advises the use of a glycerine tampon for diagnostic purposes. The tampon should be removed by the surgeon, who should carefully inspect it and thereby ascertain with accuracy the presence or absence of puru- lent elements. In cases of long standing, frequent hemorrhages, oc- curring either in connection with menstruation or during the inter- menstrual period, are to be construed as evidences of fungous degen- eration of the endometrium. There may or may not be dysmenorrhcea, 364 A TEXT-BOOK OF GYNECOLOGY and the uterus may or may not be enlarged. The cervix in the major- ity of cases is, however, the seat of more or less engorgement or infiltra- tion, or may even be cedematous. In some cases the uterus may be painful, a condition which Sneguireff of Moscow designates as endome- tritis dolorosa. Sensibility of this character is generally more marked at the fundus. The diagnosis depends not only upon the symptomatology, but especially upon the demonstration by microscopic and bacteriological examination of bacterial elements in the uterine secretion. If the endometrium is everted at the cervix and presents a granular appear- ance the case is one of glandular hypertrophy. If hemorrhages are present there exists a strong suspicion of endometritis fungosa. It should be remembered, however, that hemorrhage is a conspicious symptom of various malignant processes, not only of the cervix but of the corpus uteri. (See Symptoms of Malignant Neoplasms of the Uterus). In view of these facts and under these circumstances it is imperative that the uterine cavity be explored. The cervix should be dilated. This is done preferably by some of the mechanical dilators, such as Palmer's convenient device; or, as preferred by Sinclair, a carefully sterilized laminaria tent may be then employed. The chief objection to the latter is the time and discomfort involved in its use. Dilatation should be carried to a degree that will admit of the easy introduction of a curette or of a curette forceps. Either one or the other of these instruments should then be inserted and by gentle scraping some of the intrauterine tissue should be removed. This should be carefully preserved and examined microscopically. Gessner (Zeitschrift fur GeburtsMilfe u. Gynakologie) in a careful discussion of the technique of exploratory curettage states that anaesthesia is useful although not indispensable. The dilatation is to be carried to a degree that will admit of the introduction not only of the curette, but subse- quently of an irrigation catheter. A sharp curette is to be employed and the whole interior of the uterus must be carefully scraped and every fragment so removed must be examined under the microscope. Unless this precaution is taken, evidences of malignancy which may be derived from a very limited area may escape detection. Sanger recommends that the uterine canal be dilated by means of laminaria tents until not only a curette, but also the finger, can be introduced into the uterine cavity. He states that in those affections of the corpus in which malig- nancy is always to be suspected, the use of the curette is superior to simple palpation, but palpation with curettage and microscopic exam- inations of any debris that may be removed will give more information than the two latter only. While Sanger insists upon this technique in cases of abortion and of myomata of the corpus uteri, he recognises in digitation a valuable diagnostic expedient in certain enlargements of the uterus associated with involvement of the endometrium. Gessner, in speaking of the diagnostic value of exploratory curettage, states that in the Frauenklinik of the University of Berlin, a diagnosis of INFECTIONS OF THE UTERUS 365 malignant disease of the corpus uteri had been made and the organ had been extirpated in fifty-eight cases during a few years. In eleven, carcinoma could be distinctly felt through the dilated cervix; in three others in which the finger could reach the new growth the disease was found to be sarcoma. In forty-one cases, however, the diagnosis was made, not by digitation, but by exploratory curettage. He looks upon the latter as the more valuable expedient. When the scrapings are examined the diagnosis will be established by their resemblance to the histopathologic appearances already described. The treatment of endometritis must depend somewhat upon the particular pathologic condition that may be presented at the time. In the simple catarrhal forms, in which the most annoying symptom is a persistent leucorrhcea, reliance is often placed upon topical remedies. As has been shown in the discussion of the pathology of this condition, there exist such organic changes that any results that may follow the use of local medication must be at best slow and uncertain. It may be stated as a rule that intrauterine medication for catarrhal conditions is unsatisfactory. There are patients, however, who prefer to be treated locally for a long time rather than to submit for a few days to anything suggestive of surgical intervention. In these cases treatment should consist in the use of bactericidal agents. These should be so applied that the entire mucous surface should be subjected to their influence; for, if a portion of the mucous surface remains untreated, and consequently infected, it becomes the focus for the reinfection of the entire structure. Another principle of equal importance is, that an intrauterine application of a bactericidal character should be repeated or maintained for several days, so that, not only the bacteria themselves, but their spores also will be destroyed. There is probably nothing in the whole range of gynecological therapeutics that is so futile, not to say farcical, as the repeated applications to the cervical membrane of various medicaments of undetermined antiseptic value, and many of them of unknown ingredients. As a rule these applica- tions are made to a canal bathed with tenacious mucus, which of itself constitutes an efficient protective for the underlying micro-organisms. Topical treatment, to be effective, must be brought into direct contact with the micro-organisms. These, as already described, are hidden away within the epithelial folds or deep down in the mucous follicles. The tissues themselves, both epithelial and subepithelial, are more or less hypertrophied; an agent, therefore, which will be effective must modify this histologic state. Most practitioners have, therefore, aban- doned the use of nonescharotic agents. Those that are employed, however, are not viciously destructive of the tissues like nitric acid or sulphuric acid, or pure formalin. Feed's method of treating these cases is as follows: The cervical canal is dilated, if necessary, to a very slight degree by means of a Nott or other small dilator. The posterior lip of the cervix is seized with a volsella or the serrated cervix forceps of Dumont-Lelois and held by slight downward traction. The uterine 366 A TEXT-BOOK OF GYNECOLOGY cavity is then packed with a very slender ribbon of dry sterilized gauze; this is immediately withdrawn, bringing with it all the mucus from the endometrial surface. If a first packing is not satisfactory for this purpose, a second may be utilized. After the mucous surfaces have thus been carefully cleansed, the uterine cavity is again packed with a slender ribbon of gauze saturated with 98-per-cent carbolic acid. This is left in situ. In applying the carbolic acid it is important to avoid bringing it in contact with the integument of the mucous mem- brane of the vagina; but if this accident should happen, the place should be immediately touched with pure alcohol, which will neutralize the carbolic acid. A tampon of glycerine or of boroglyceride is applied and the patient is permitted to go home, returning in forty-eight hours for a repetition of the treatment. Three or four applications of this kind, made at lengthening intervals during ten days, are generally sufficient to cure an ordinary case of catarrhal endometritis. The treatment, contrary to usual theoretic preconceptions, is not particu- larly painful and never requires an anaesthetic. The destruction of epithelium from these repeated applications is not sufficient to inter- fere with its speedy reproduction. Cases have been reported in which cures have been effected by the introduction into the uterine cavity of a piece of lunar caustic, which was permitted to dissolve in situ. The uterine cavity has been packed with boric acid and with iodoform, both of which have some bactericidal properties. Canquoin has re- ported successes from the intrauterine application of a paste the essential ingredient of which is the chloride of zinc. It is prepared in the form of a pencil and is introduced into the uterus; Pichevin, Emmet, Schroder, Martin, Munde, Jacobs, and others, have reported adversely on its use, and it seems to have been discontinued. As an escharotic agent, the chloride of zinc is vastly more destructive than even the silver nitrate, the use of which has been very generally abandoned. Sneguireff recommended the action of steam upon the inner surface of the uterus as a means of arresting intrauterine hemorrhage, and it has been quite extensively employed, especially in Russia. Its applica- tion requires a steam generator with a safety valve and with a central opening for the insertion of a thermometer, the generator being con- nected by rubber tubing with a metal catheter of necessary length for intrauterine application. The temperature should be kept between 100° and 110° C. (212° F. to 230° F.). A Fritsch uterine irrigator may be used for the application of the steam. The patient is placed in the lithotomy position, and a short cylindrical speculum of some noncon- ducting material, such as celluloid or hard rubber, or preferably wood, is inserted. A catheter is then inserted and the steam is turned on. The instrument should be encircled with gauze, or provided with a nonconducting handle, to avoid burning the hands of the operator. The patient should remain in bed for a few days. There is generally considerable reaction with pronounced perimetric irritation. It has INFECTIONS OF THE UTERUS 367 been recommended by Pincus for senile endometritis with profuse hemorrhage or leucorrheea; where irregular hemorrhages are associ- ated with subinvolution of the uterus; for diffuse myomata; for hyperplastic or catarrhal endometritis; and for gonorrhceal and strep- tococcous infections of the uterus. It must not be used in the presence of diseased adnexa or in cases of stricture of the cervical canal, while it is not advised in polypoid myomata. This method is spoken of as vaporization, but it is really a cauterization with extensive destruction of tissue. It is possible that the principle may survive, although the present technique seems to be defective. The use of superheated steam destroys tissue to a depth that is dangerous. Baruch reports a case of atrophy of the uterus with occlusion of the cervical canal and apparently of the whole uterine cavity, following vaporization in a woman only twenty-seven years old. This condition amounting to the practical destruction of the uterus was induced by a single intrauterine application of steam for the purpose of checking puerperal hemorrhage, an object which was speedily accomplished. Von Guerard (Central- Matt fur Gynal'ologie) reports the case of a woman who had persistent hemorrhages following delivery, with evidences of subinvolution of the uterus and fungous degeneration of the endometrium. Atmocau- sis, as this method of vaporization is called, was employed. There was a cessation of the menses following the operation, but at the menstrual periods unendurable pains were felt, becoming intensified as time went on. The uterine cavity was so obliterated by the steam jet that the sound entered it for about 2 centimetres only. Von Guerard was forced to relieve the patient by a total hysterectomy, from which she recovered. In commenting upon the case, he insists that atmocausis was absolutely contraindicated before the menopause. Schick, of Prague (C entraMatt fiir Gynakologie), recognising the valuable prop- erty of heat for antiseptic and hemostatic purposes and as an escharotic agent, has endeavoured to secure its desired effect by the use, not of superheated steam, but of boiling water. He kept up the irrigation for half a minute, only the vagina and vulva being protected by con- stant irrigation of ice-cold water. Of the four cases in which he tried it three were successful. While this treatment may be of great value, its employment is certainly associated with great danger, and it is mentioned in this connection only with the hope that the valuable principle which it embodies may find safe exemplification in more re- fined methods. It may be stated, as a rule to which there are no exceptions, that in all cases of infection of the uterus in which the condition has assumed the chronic form with associated histologic changes, the topical application of any medicament, escharotic or otherwise, is less satisfactory than curettage followed by appropriate antiseptic treat- ment. 368 A TEXT-BOOK OF GYNECOLOGY Curettage of the Uterui Instruments for Dilatation of the Catheters, glass (Fig. 147) 1 Catheter, irrigating two-way, small. . . 1 Curette, sharp (Sims's modified) 1 Martin's blunt, double 1 Martin's sharp (Fig. 148) 1 Dilators, Palmer's medium. Hegar's, 4 sizes (Fig. 149). Goodell-Ellinger. Forceps, Bozeman's long dressing (Fig. 150) 1 Rat-tooth 1 Cervix and Curetting of the Uterus Forceps, bullet 2 Serrated cervix forceps of Dumont- Leloir (Fig. 151) 1 Nozzle, Edebohls's Packer, vaginal 1 1 Sound, uterine 1 Speculum, Jones's (Fig. 152) 1 Sims's small 1 Simon's, with handles and four blades (Fig. 153) 1 Tenacula (Fig. 154). • In those varieties of intrauterine infection resulting in the develop- ment of fungous granulations with associated hemorrhage, intra- uterine medication of whatever sort is futile. The only available remedy consists in the removal of the adventitious tissue. Patients who are the victims of hemorrhage, and are consequently greatly reduced in strength, are generally less persistent in urging objection to the slight surgical pro- cedure of curettage. This, with associated antiseptic meas- ures, is distinctly the most valuable means of treating infec- tions either acute or chronic, either mixed or specific, of the endometrium; while if not followed by antiseptic measures it is a worthless and dangerous expedient. The uterine curette, according to Pozzi, was invented by Kecamier, after which it fell into discredit. J. Marion Sims did much to re-establish the instru- ment in favour, while Thomas Roux and the elder Martin have been instrumental in defining its uses and limitations. The curettes, as now found, vary in size and form; some of them are dull wire loops, bent at various angles; others are spoon-shaped, \some with dull and some with sharp edges; some are steel loops with sharp edges, while others, like that recently invented by Gau (Fig. 144), are pro- ^ IG - U8 - vided with a safety end, and yet can be used as either a sharp or a dull instrument. All of them are found illustrated in the instrument makers' cata- logues. The object of the curette is to remove ad- ventitious tissue from the uterine cavity or cervix. The method of its employment does not differ from that already described in connection with exploratory curettage as a means of diagnosis in endometritis (ante). As a matter of fact, curettage, whether undertaken for diagnos- tic or other purposes, should always be conducted with the same ante- cedent and sequent precautions. The same rigorous antisepsis should precede the operation, the interior of the uterus should be treated in Fig. 147 catheter. — Kobb. Martin'i sharp curette. — Kobb. INFECTIONS OP THE UTERUS 369 precisely the same way, and the operation itself should be just as ex- tensive when undertaken for diagnostic as for other purposes. It may be accepted as an axiom of practice that the existence of any condi- tion demanding the use of a curette can be determined by macro- scopic appearances; while the more refined diagnosis may be based upon subsequent examination of the scrapings. The first contraindication of curettage is nonexperience in uterine surgery on the part of the operator. There is probably no manipula- Fig. 149. — Hegar's dilator. — Kobb. tion in surgery for the proper practice of which more dexterity, more deftness, or more of that judgment which depends on the tactus eru- ditus, is demanded than curettage. Among other contraindications, summarized by Currier (International Journal of Surgery), are igno- rance on the part of the operator of the exact limits and outline of the uterine cavity; the presence of the menstrual flow; extreme dis- placements of the uterus; and acute infectious diseases of the uterine appendages. Polk (New Yor~k Journal of Gynecology and Obstetrics) takes the ground that curettage is an eligible operation in cases of chronic metritis associated with salpingitis, asserting that, when prop- Fig. 150. — Bozeman's long dressing forceps. — Kobb. erly done, it affords much-needed depletion to the uterus and is not followed by peritonitis or acute salpingitis; and in support of his statement presents a tabulated list of forty cases giving the maximum diurnal temperature for eleven days following the operation. It is certainly a gratifying exhibit showing but trifling and evanescent reaction, and that only in a few cases. But gratifying as these facts are, they can not be accepted as demonstrating the safety of curettage in the presence of inflammatory conditions, whether acute or chronic, in which pus, although in undetectable quantities, is liable to exist 25 370 A TEXT-BOOK OF GYNECOLOGY in the uterine appendages. The necessary traction and vigorous manipulation essential to a thorough curettage is liable to produce cleavages in adhesions and consequently to liberate previously con- fined pus. Objection has been urged against the use of the sharp curette upon the ground that it destroys the epithelium which is replaced by cica- tricial tissue. This objection is not tenable unless the operation amounts to a practical endometrectomy involving the complete re- moval of the basis membrane of the endometri- um. As has been shown by Von Kohlden and others, there occurs physiologically in con- nection with the menstruation a periodical loss of epithelium. This physiologic function may be carried to the patho- logical degree involving the shedding of the en- tire membrane. (See Membranous Dysmenor- rhea). When this oc- curs, however, the membrane is again speedily reproduced. Bossi has studied the repro- duction of the mucous mem- brane of the uterus, following its apparent complete destruc- tion by Canquoin's paste of the chloride of zinc. From his ob- servations and a more or less thorough investigation of the question, he has arrived at the following conclusions (Nou- velles arcliivzs d'obstetrique et de gynecologie, December, 1891): 1. The mucous membrane of the uterine body in the bitch, abraded by free cuts of the bis- toury extending through its whole thickness, is reproduced in its integrity, that is to say, with a formation of true glands. 2. Re- production takes place slowly, and sometimes, by reason of conditions not well determined, is subject to considerable retardation. 3. The covering epithelium, which primarily extends over the wounded sur- face, derives its small glands from the borders of the cut. 4. The newly formed glandules derive from the proliferation of cells a new covering epithelium when it has acquired the cylindrical form. As a final word on curettage in the treatment of endometritis, let Fig. 151. — Serrated cervix for ceps of Dumont-Leloir. Fig. 152. Jones's speculum. INFECTIONS OF THE UTERUS 371 it be said that the mere scraping away of inflammatory products is curative to that extent and to that extent alone; that if the treat- ment; stops at that point it will be worthless; that curettage is not necessary in the many cases, even to remove these inflammatory prod- ucts; that its value consists in removing those tissue elements which serve as hiding places for the morbific micro-organisms; and, finally, that the essential element of the treatment consists in the thorough