Class JRJ>_LC I. Copyright N" COPVRIOIIT DEPOSIT. I PRACTICAL GYNECOLOGY MONTGOMERY Practical Gynecology A COMPREHENSIVE TEXT- BOOK FOR STUDENTS AND PHYSICIANS BY E. E. MONTGOMERY, M.D., LL.D. PROFESSOR OF GYNECOLOGY, JEFFERSON MEDICAL COLLEGE ; GYNECOLOGIST TO THE JEFFERSON MEDICAL COLLEGE AND ST. JOSEPH'S HOSPITALS ; CONSULTING GYNECOLOGIST TO THE PHILADELPHIA LY'ING-IN CHARITY- AND THE KENSINGTON HOSPITAL FOR WOMEN XTbtrb IReviset) lEMtton WITH FIVE HUNDRED AND SEVENTY-FOUR ILLUSTRATIONS, THE GREATER NUMBER OF WHICH HAVE BEEN DRAWN AND ENGRAVED SPECIALLY FOR THIS WORK, FOR THE MOST PART FROM ORIGINAL SOURCES PHILADELPHIA P. BLAKISTON'S SON & CO. I0I2 WALNUT STREET 1907 -^^ \0 LIBRARY of congress] Two Cooles Received APh 23 \901 ^ «opyiriKht Entry , CUSS 5S A XXc, No. COPY B. Copyright, 1907, by P. Btakiston's Son & Co. WM. F. FELL, cor EUECT ROT YPE RS, P PHll-ADEUPHIA, TO Dr. m. lb. Marker, A\Y CONSCIENTIOUS INSTRUCTOR AS QUIZ = MASTER AND HOSPITAL CHIEF, AND MY GENEROUS FRIEND, THIS BOOK IS RESPECTFULLY DEDICATED. PREFACE TO THE THIRD EDITION. This book has been carefully revised for the third edition, and some seventy pages of new material have been added. Micro- scopic diagnosis, gynecic bacteriology, and the pathology of carcinoma uteri have been rewritten. The subjects of Etiology and Blood Examination have been added. Of the new illustrations Nos. 42, 295, 471, 472, 473, 474, 480, 481, 482, 484, 486, 488, 492, 511, 512, 519, 520, 532, S33^ and 556 were prepared by Miss S. L. Clark, and Xos. 78, 79, 415, 416, and 417 by Miss E. A. Cantner. I desire to express my indebtedness to Dr. P. B. Bland for having written the blood examination and microscopic diagnosis, and for valuable suggestions in the pathology of cancer; and to Miss E. A. Cantner for preparation of the index. Philadelphia, March 2j, iQOj. PREFACE TO THE SECOND EDITION. In presenting a second edition of this work, I desire to express my sincere gratification over the generous and flattering recep- tion the first edition has obtained from the medical press and the profession. ]^Iany changes have been made in the arrangement of the different divisions which experience has led me to believe will prove of benefit to the student. ^Malformations are confined to congenital conditions, while the lesions of parturition are treated under the designation of Traumatisms. Disorders of the Fallopian tube and the ovary are more specifically treated in Inflammation. The specific treatment of the various de- viations is discussed in close relation with each subject. The division comprising genital tumors has been extensively changed in the consideration of myomata and malignant growths. It has been my purpose in the entire revision to increase the usefulness of the work to the student by treating, in closer detail, the later operative procedures, and in order to accomplish this the greater part of the work has been rewritten, which has added some seventy pages. The illustrations have been increased in number and many of them redrawn. Xew illustrations made from material secured from my own practice have been largely substituted for the microscopic drawings of the former edition. I here take occasion to express my thanks to Mr. H.J. Shan- non for the care and painstaking skill with which he has cor- rected many of the old drawings and constructed several new ones, notably those illustrating the Doyen operation for uterine myomata; to ]\Iiss S. L. Clark for drawings of microscopic sec- tions from which the following illustrations were prepared, figures 48 and 49 a and b, 126, 130, 132, 133, 296, 299, 300, 302, 306, 307, 5io» 513* 53I' 534, 535, 549; to Miss Karin M. Hall for drawings for figures 301, 310, 311; to Professor W. M. L. Coplin, M.D., X PREFACE TO THE SECOND EDITION. for his kind supervision of the preparation of the microscopic drawings and for many valuable suggestions; to Drs. J. M. Fisher, John C. DaCosta, Wilmer Krusen, and C. P. Noble for the loan of specimens from which illustrations were prepared. I am indebted to Dr. P. Brooke Bland for the preparation of the slides from which the microscopic illustrations were made, for correction of the manuscript, and for assistance with the index ; to Miss E. A. Cantner for the rearrangement and preparation of the index and table of contents. The publishers deserve m}^ un- stinted praise for their generous expenditure for redrawing the old and in the preparation of new illustrations, and for their purpose to present the work in an attractive form. It is my sincere hope that this edition shall render the phy- sician more efficient in lessening the ills of women and adding comfort and pleasure to their lives. Philadelphia, September 15, 1903. PREFACE TO FIRST EDITION I will offer no apology for presenting an additional text -book upon gynecology. This work has been under consideration for the last fifteen years, and much of it has been several times rewritten. An effort has been made to make it a comprehensive work upon the subject, giving the experience and methods of the most careful men, while my own experience has been utilized to indicate that which I have found most useful and worthy of acceptance. Each general subject is considered with reference to its influ- ence upon the entire genital tract, and the work is divided into sections rather than chapters. This course, although a departure from the ordinary text-book arrangement, is that which expe- rience has demonstrated to be most effective in impressing the subject upon the student, and would seem to me preferable to him who uses the book to refresh his knowledge upon any par- ticular subject. The illustrations are arranged solely with the purpose of rendering clear the text and to promote the work of diagnosis and treatment. For their excellence and character I am greatly indebted to the generosity of the publishers and to the skill and patience of their artists, Messrs. Shannon and Von du Lancken. To the kindly oversight of Dr. Robert L. Dickinson is due much of the exactness of the drawings. Acknowledgment is due Miss Eleanor A. Cantner for her ability in the preparation of preliminary sketches and of the index. Should it be the means of lightening the work of the student, of making more clear the pathway of the busy practitioner, and, most of all, of benefiting suffering women through improved methods of diagnosis and treatment, I shall feel well repaid for the many days and nights of labor which it has cost The Author. Philadelphia, August, igoo. TABLE OF CONTENTS. INTRODUCTION. SECTION. PA(;E. 1 . Definition and Antiquity, i 2. Theories, i 3. Foundation, i 4. Purpose, I ETIOLOGY. 5. Importance of Etiology, 2 6. Classification, 2 7. (A) Hereditary and Congenital Causes, 3 8. (B) Hygienic Causes, 5 9. (C) Sexual Causes, 7 10. (D) Traumatic Causes, 8 11. (E) Infective Causes, 10 12. (F) Causes Incident to Age, 11 13. Difficulties in Study, 12 14. Observation, 12 15. Exercise of Judgment, 13 16. Value of Notes, 13 1 7 . History, 13 DIAGNOSIS. 18. Subjective Symptoms 14 19. Causes of Error, 14 20. Method of Procedure, 14 2 1 . General Symptoms , 15 22. Visceral Neuralgias, 15 23. Neuralgia 15 24. Motor and Sensory Paralysis, 15 25. Disorders of Nutrition, 16 26. Chlorosis 16 27. Anemia, 16 28. Local Symptoms, 16 29. Rectal Reflexes 17 30. Vesical Reflexes 18 3 1 . Genital Symptoms, 18 3 2 . Hemorrhage, 18 33. Pain, 19 34. Seats of Pain 19 3 5 . The Iliac Pain, 19 36. Lumbar Pain, 20 37. Hypogastric Pain, 20 38. The Accessory Seats of Pain 20 39. The Anal or Perineal Pain, 20 40. Vaginal Pain, 20 41. Pelvic Pain, 20 42. Leukorrhea 20 43. The Secretion from the Fallopian Tubes and Cavity of the Uterus, . . 20 44. The Secretion of the Vagina and Vulva, .' 20 xiii XIV TABLE OF CONTENTS. SECTION. PAGE 45 Catarrhal Discharge, 21 Origin of Discharge, 21 Discharge Simulating Abscess, 21 Other Sources for Purulent Discharges, 21 Cervical Discharge, 22 Vaginal Discharge, 22 Effect of Age upon the Discharge, 22 Physical Signs, 22 Senses Employed, 22 Examination, 23 Pelvic Examination, 23 Abdominal Examination, 23 Preliminaries, 23 Positions, 23 The Dorsal Position, 23 The Lateral Position, ' 24 The Semiprone or Sims' Position, 24 The Genupectoral Position, 25 The Trendelenburg Position, 26 The Erect Position, 27 PELVIC EXAMINATION. 65 . Inspection, 27 66. Simple Touch, 27 67 . Preparation, 27 68. Procedure, 27 69. Bimanual Procedure, 30 70. Difficulties, , 30 7 1 . Virgins, 30 72. Rectal Touch, 31 73. Simon's Method, S3 74. Vaginal Section, ;^s 75. Precautions, 34 76. Instrumental Examination, 34 7 7 . Probes, ._ 35 78. Piccautions .■ . . 37 79. Speculum 37 80. The Tubular Speculum, 37 8 1 . Valvular Speculum 38 82. The Univalve or Duck-bill Speculum, 41 83. Uterine Fixation and D( wnward Traction, 43 84. Dilatation of the Uterus 43 85. Dilatation by Tents, 44 86. Divulsion, 45 87. Gradual Dilatation 46 88. Incision of the Cervix, 46 89. Complete Bilateral Incision of the Cervix, 47 90. Dilatation by Gauze Packing, 48 91. Microscopic Examination, 48 92. Collection of Tissue, 49 93. Test Excision, 49 94. Test Curetment 5° 95. Disposition of Tissue, 52 96. Examination, 52 97. Preservation of Gross Specimens and Slides, 5^ 98. Failure, 60 99. Bacteriology of the Genital Tract, 60 100. Parasites of the Genital Tract 61 10 1. Natural Agents of Immunity, 62 102. Loss of Protection, 62 103. Parasites, 63 TABLE OF CONTENTS. XV Staphylococcus, 63 Streptococcus, 64 The Gonococcus, 65 Bacillus Coli Communis, 68 Bacillus Tuberculosis, 68 Syphilis and Chancroid 70 Bacillus Typhosus 71 Smegma Bacillus. 72 Bacillus Pyocyaneus 72 Bacillus Aerogenes Capsulatus, 72 Diphtheria Bacillus 72 Pneumococcus 73 Diplococcus of Siegelman, 73 ANIMAL PARASITES. 117. Pediculosis Pubis or Inguinalis, 73 1 18. Acarus Scabiei ■. 73 I ig. Oxyuris Vermicularis, 73 1 20. Ascaris Lumbricoides, 74 121. Tenia Echinococcus 74 122. Collection of Fluids and Secretions 75 123. Blood Changes, 76 124. Examination of the Blood, 76 125. The Specimen 76 126. Method of Collection 77 127. Microscopic Examination of Fresh Specimen, 77 128. Fixation for Staining 78 129. Staining, 78 130. Counting the Corpuscles, 8a 131. Estimation of Hemoglobin, 81 132. Composition of the Blood, 82 133. Erythrocytes 8^ 134. Color Index, 83 135. Relation of Hemoglobin to Surgery, 84 136. Normal Number of Red Cells, 84 137. Increase in the Number of Erythrocytes, 85 138. Pathologic Alteration of the Erythrocytes 85 139. Platelets 85 140. Hemoconia, 85 141. Leukocytes 86 142. Leukocytosis, 87 143. Leukocytosis of Digestion 87 144. Leukocytosis of Pregnancy and Parturition, 87 145. Thermal and Mechanical Agencies, 87 146. Terminal Leukocytosis 87 147. Pathologic Leukocytoses, 88 148. Post-hemorrhagic Leukocytosis, 88 149. Leukocytosis (Phagocytosis) 88 150. Inflammatory Leukocytosis, 88 151. Malignant Leukocytosis, 89 152. Toxic Leukocvtosis 80 153. Experimental Leukocytosis, 89 154. Bacteremia 9a 155. Bacteria Found in Blood 90 156. Blood Culture, go 157. Blood Coagulation, 91 158. Exploration of the Urethra, Bladder, and Ureters, 91 ABDOMINAL EXAMINATION. 159. Preliminaries, 96 160. Inspection, 97 XVI TABLE OF CONTENTS. SECTION. PAGE, i6i. Palpation, 98 162. Difficulties, 99 163. Percussion, 99 164. Auscultation, 99 165. Exploratory Puncture, 100 166. Tapping, or Paracentesis Abdominis, 100 167. Aspiration, i o i 168. Exploratory Incision, 102 THERAPEUTICS. 169. Classification 102 170. Extension, 102 171. Infection, 102 172. Terms, 102 173. Sterilization Methods, 103 174. Sterilization of Instruments, . . .' 104 175. Sponges, _ 105 176. Ligature and Suture Material, 106 177. Dressings, 108 178. Operator and Assistants, 108 179. Precautions 109 180. Room and Environment, no 181. Examination and Preparation of Patient, no 182. Special Preparation, in 183. Irrigating Tubes, 112 184. Gauze, 113 185. Antisepsis of the Cervix and Uterine Cavity, 113 186. The Use of Tents, n4 187. Abdominal Section, 114 188. Indications for Anesthesia, 115 189. Agents Employed, 115 190. Administration, 117 191. Local Anesthesia, 118 192. Preliminary Details of Operation, 119 193. Arrangement, 120 194. Positions of Operator and Assistants, 120 195. Clothing of Patient, 120 196. Incision, 121 197. Adhesions, 124 198. Toilet of the Peritoneum, 125 199. Drainage, 125 200. Objections to Drainage, 126 201. Gauze Drain, 128 202. Where Placed, 128 203. Postural Drainage, 128 204. Closure of the Wound, 129 205. Dressing, 131 206. Postoperative Treatment 131 207. Comfort of Patient, 132 208. Vomiting, 133 209. Tympanites, 134 210. Shock, 135 211. Anodynes 135 212. Internal Hemorrhage, 135 213. Peritonitis, 135 214. Wound Infection, 136 215. Parotiditis, 137 216. Ileus 137 217. Phlebitis, 138 218. Precautions in the Use of the Hypodermic Syringe, 138 219. Catheterization, 139 TABLE OF CONTENTS. XVll SECTION. PAGE. 2 20. Removal of Sutures, 139 221. Getting Up,. . ._ , 140 222. Plastic Operations 140 MEDICAL TREATMENT. 223. General Treatment, 140 224. Specific Remedies, 141 225. Rest and Exercise, 142 LOCAL THERAPEUTICS. 226. Baths 143 227. Douche. 143 228. External Applications, 144 229. Counterirritants, 144 230. Bloodletting, 144 231. Local Applications, 145 232. Various Agents, 145 233. Astringents, ' 146 234. Caustics 146 235. Tampons, 146 236. Massage 147 237. Pelvic Massage, 147 ELECTRICITY. 238. Forms, 149 239. Franklinism, 149 240. Galvanism, 149 241. Apparatus for Application, 150 242. Method of Procedure, 151 243. Indications, 152 244. Contraindications, 152 245. Faradic 152 246. Sinusoidal, 153 247. Rontgenic 154 248. Finsen Light, 155 249. Electrocautery and Light, 155 EMBRYOLOGY AND ANATOMY OF THE GENITO-URINARY ORGANS OF THE WOMAN. 250. Development of the Genito-urinary Organs, 156 251. Division of the Genitalia, 159 252. The External Genital Organs, 159 253. The Mons Veneris, 159 254. The Labia Majora, 159 255. The Labia Minora, '. 160 256. The Clitoris 161 257. The Vestibule, 162 258. The Hymen, 164 259. The Fourchet, 165 260. The Muscles of the Perineum, 165 261. The Perineal Fascia, 168 262. Pelvic Diaphragm, 170 263. Perforations 171 264. Internal Genitalia, 172 265. The Vagina, 172 266. The Uterus 178 267. The Fallopian Tubes 184 268. Ovaries 186 269. The Parovarium, 191 XVm TABLE OF CONTENTS. SECTION. PAGE. 270. Urinary Organs and Rectum, 191 271. The Urethra, 191 272. The Bladder, 192 273. The Ureters, 194 274. The Rectum, 194 275. Pelvic Peritoneum, 197 276. Pelvic Connective Tissue, 200 277. The Vascular Supply, 201 278. The Lymphatic System, 208 279. Consideration of the Pelvic Organs and Structure Studied as a Whole, 211 PHYSIOLOGY. 280. Functions, 212 281. Puberty, 212 282. Nubility, 213 283. Menstruation and Ovulation 213 284. Menopause, 221 285. Copulation, 223 286. Fecundation, 223 MALFORMATIONS. 287. Classification; Definition, 223 288. Bifidities, 224 289. The Degrees of Division, 224 290. Double Uterus, 225 291. Unequal Development of the Two Sides, ' 226 292. Absent Uterus, 228 293. A Rudimentary Uterus, 228 294. Fetal and Infantile Uteri, 229 295. Congenital Prolapsus Uteri, 230 296. Accessory or Trifid Uteri, 230 297. Absent or Rudimentary Tubes, . 230 298. Accessory Tubal Ostia, 231 299. Anomalies in Length, 231 300. Absent or Rudimentary Ovaries, 231 301. Supernumerary Ovaries 231 302. Accessory or Constricted Ovaries, 231 303. Displacements, 231 304. Defects of Round or Broad Ligaments, 231 305. Complete Absence or Rudimentary Development of the Vagina, 232 306. Unilateral Vagina, 235 307. Double Vagina, 235 308. Atresia of the Genital Canal, 237 309. Lateral Atresia, . . . : 240 310. Absence of the Vulva, 241 311. Infantile Vulva, 241 312. Defects in Nymphae 241 313. Defects of the Clitoris, 241 314. Defects of the Hymen, 242 315. Hermaphroditism, 243 316. Gynandria, 244 317. Androgyna, 245 318. Atresia of the Urethra and Vagina, 246 319. Hypospadias,. 246 320. Epispadias, 246 321. Duplication of the Bladder, 248 322. Open Urachus, 249 323. Irregular Exit of Ureter, 249 324. Abnormal Communications, 249 TABLE OF CONTENTS. XIX TRAUMATISMS. SECTION. PAGE. 325. Injuries of the Genital Organs, 250 326. External Violence, 250 327. Coition, 251 328. Parturition, 252 329. Injuries of the Body of the Uterus, 253 330. Injuries of the Cervix Uteri 254 331. Symptoms of Laceration of the Cervix, 255 332. Diagnosis 255 333- Treatment, 257 334. Complications, 257 335. Trachelorrhaphy, 259 336. Amputation of the Cervix, 261 337. After-treatment, 263 338. Lacerations of the Vagina, 263 339. Fistulae, 264 340. Etiology 264 341. Symptoms, .' 265 342. Diagnosis, 265 343. Prognosis 267 344. Treatment, 267 345. Cauterization, 268 346. Preliminary Treatment, 268 347. Visicovaginal Fistula, 268 348. Flap-splitting or Flap-sliding, 270 349. Flap Formation, 275 350. After-treatment, 277 351. Closure of the Vagina; Colpocleisis; Episiostenosis, .• • • ■ 278 352. Urethrovaginal Fistula, 279 353. Vesico-uterine Fistula, 280 354. Hysterostenosis or Hysterocleisis, 281 355. Vesico-uterovaginal (Cervical) Fistula, 282 356. Ureterovaginal-ureterocervical Fistulae, 283 357. Accidents of the Operation and Results, 287 358. Rectovaginal Fistula 289 359. An Anovulvar Fistula, 290 360. Preliminary and After-treatment, 290 361. Enterovaginal Fistulse, 291 362. Cervico-vaginal Fistula 291 363. Lacerations of the Pelvic Floor, 291 364. Causes, 292 365. Degree or Extent, 293 366. The Results 294 367. Treatment 295 368. By Primary Operation 296 369. The Advantages of the Primary Procedure, 297 370. Contraindications, 298 371. The Intermediate Operation, 298 372. Secondary Operation, 299 373. After-treatment 323 374. Choice of Operation, 325 INFLAMMATIONS. 375. The Recognition of the Development of the Genital Tract, 326 376. Micro-organisms as a Cause 327 377. Natural Protection against Infection, 327 378. How Immunit}" is Lost 327 379. Inflammation and Its Varieties 327 380. The Causes of Inflammation 328 381. Characteristics of Inflammation, 329 XX TABLE OF CONTENTS. SECTION. PAGE. 382. Classification of Inflammation, -^^o 383. Vulvitis and Its Varieties, 331 384. Causes, 331 385. Vulvitis, Simple or Catarrhal, 332 386. Follicular Vulvitis, 332 387. Venereal Vulvitis, 332 388. Eruptive Diseases of the Vulva, 334 389. Phlegmonous Vulvitis, 335 390. Diphtheric Vulvitis, ^^^ 391. Diagnosis of Inflammatory Disease of the Vulva, 335 392. Treatment, 336 393. Edema and Gangrene, 338 394. Bartholinitis, , 339 395. Pruritus Vulvae, 341 396. Kraurosis Vulv£e, ' 343 397. Vaginismus, 345 398. Vulvo- vaginitis, 347 399. Vaginitis, Elytritis, or Colpitis, ; 348 400. Varieties, 350 401. Pathology, 350 402. Etiology, 351 403. Symptoms, '. 351 404. Diagnosis, 352 405. Prognosis, 353 406. Treatment, 353 407. Urethritis, 354 408. Hyperemia, 354 409. Acute Catarrhal Urethritis, 355 410. Chronic Catarrhal Urethritis, 356 411. Follicular Inflammation, 356 412. Ulceration, 357 413. Vesico-urethral Fissure, 357 414. Diagnosis of Urethral Inflammations, 358 415. Treatment of Urethral Inflammations, 359 416. Cystitis, 361 417. Symptoms of Acute Cystitis, 362 418. Symptoms of Chronic Cystitis, 363 419. Cystitis of Gonorrheal Origin, 363 420. Tubercular Cystitis, 363 421. Diagnosis of Cystitis, 363 422. The Prognosis of Cystitis, 367 423. Treatment, 368 424. Ureteritis, 372 425. Acute Ureteritis 372 426. Chronic Ureteritis, 373 INFLAMMATION OF THE CERVIX AND BODY OF THE UTERUS. 427. Classification 374 428. Endocervicitis, Chronic Cervical Catarrh, 375 429. Causes, 379 430. Symptoms 379 431. Physical Signs 380 432. Diagnosis 380 433- Prognosis, 381 434. Treatment, 381 435. Acute Metritis and Endometritis, 384 436. Pathologic Alterations 385 437. Varieties and Their Source, 385 438. Symptoms, 386 439. Diagnosis, 387 TABLE OF CONTENTS. XXI SECTION. PAGE. 440. Prognosis, 389 441. Treatment, 389 442. Chronic Endometritis, 394 443. Symptoms, 396 444. Diagnosis, 397 445. Treatment, 398 446. Chronic Metritis, 400 447. Etiology, 402 448. Symptoms, 403 449. Physical Signs and Diagnosis, 404 450. Course and Prognosis, 405 451. Treatment, 405 452. Inflammation of the Fallopian Tube, 411 453. Symptoms, 418 454. Diagnosis, 419 455. Prognosis 420 456. Inflammation of the Ovary, 421 457. Symptoms, ; 424 458. Diagnosis, 425 459. Treatment of Inflammation of the Appendages, 425 460. Pelvic Inflammation, . . , 430 461. Varieties, '. 430 462. Pelvic Cellulitis, Parametritis, or Periuterine Phlegmon, 430 463. Etiology, 432 464. Symptoms 433 465. Physical Signs, 433 466. Diagnosis 436 467. Prognosis 438 468. Treatment, 438 469. Pelvic Peritonitis, Perimetritis, Perisalpingitis, or Perioophoritis, .... 440 470. Etiology 440 471. Pathologic Anatomy, 444 472. Symptoms, 446 473. Diagnosis, 447 474. Prognosis 448 475. Treatment, 449 DISPLACEMENTS OF THE PELVIC ORGANS. 476. Changed Relations of Structures of Vulva, 466 477. Physiologic Movements of the Uterus and the Forces by which it is Sustained, 467 478. Pathologic Changes and What Constitute Them, 469 479. Classification of Displacements, 471 480. Ascent, 472 481. Diagnosis, 473 482. Descent, or Prolapsus, 473 483. Etiology 475 484. Symptoms 477 485. Diagnosis, 481 486. Prognosis 485 487. Treatment, 488 488. Urethrocele .• 499 489. Dislocation of the Uterus, 500 490. Diagnosis 500 491. Torsion, 501 492. Anteversion 501 493. Etiology 502 494. Symptoms 502 495. Diagnosis 502 496. Treatment, 502 497. Retroversion, '. 504 XXll TABLE OF CONTENTS. SECTION. PAGE. 498. Etiology, 504 499. Symptoms, 505 500. Diagnosis, 506 501. Lateral Version, 506 502. Anteflexion, 506 503. Etiology, 508 504. Symptoms, 508 505. Diagnosis, 509 506. Treatment, 509 507. Retroflexion, 514 508. Etiology, 516 509. Symptoms, 516 510. Diagnosis, 518 511. Treatment of Retroversion and Retroflexion, 520 512. Lateral Flexion, 546 513. Complications Associated with Displacements, . 546 514. Prognosis of Displacements, 547 515. General Treatment, 5-47 516. Summar}^ 548 517. Inversion of the Uterus, 550 518. Etiology, 553 519. Symptoms, 554 520. Diagnosis 555 521. Treatment, 557 522. Displacements of the Appendages, 564 523. Symptoms, 565 524. Diagnosis, 565 525. Treatment, 566 GENITO-URINARY HEMORRHAGE. 526. Hemorrhage a Symptom, 566 527. Site and Varieties, 566 528. Hematuria and Its Causes, 567 529. Symptoms and Diagnosis, 567 530. Treatment,. 568 531. Genital Hemorrhage or Bleeding, 569 532. Diagnosis, 570 533. Treatment, 572 534. Vulvar Hematoma or Hematocele, 573 535. Vaginal Hematoma or Thrombus, 573 536. Diagnosis, 575 537. Treatment, 575 538. Periuterine Hemorrhage, 576 539. Causes, 576 540. Symptoms, 577 541. Extraperitoneal Hematocele, 578 542. Symptoms, 578 543. Diagnosis, 579 544. Prognosis, 580 545. Treatment, 580 EXTRA-UTERINE PREGNANCY. 546. Definition, 582 547. Causes, 582 548. Varieties, 584 549. Course and Progress, 585 550. Symptoms, 596 551. Diagnosis 599 552. Difi^erential Diagnosis, 604 553. Prognosis 608 554. Treatment, 609 TABLE OF CONTENTS. XXUl GENITAL TUMORS. SECTION. PAGE. 555. Definition 621 556. Classification, • 621 VULVA, VAGINA, AND BLADDER. 557. Characteristics of Benign Neoplasms, 622 558. Unclassified, 623 559. Hernias, 623 560. Hydrocele, 624 561. Erectile or Vascular Tnmors, 625 562. Urethral Caruncle, 626 563. Varicose Veins, 628 564. Edema, 628 565. Elephantiasis 628 566. Tiimors of the Vulva, . 629 567. Serous Cysts, 629 568. Sebaceous Cysts, 629 569. Blood Cysts, 629 570. Neuroma of the Vulva, 630 571. Simple Vegetations, 630 572. Fibroma and Myxoma, 633 573. Lipoma, 633 574. Enchondroma, 633 575. Malignant Disease of the Vulva, 633 VAGINA. 576. Cysts of the Vagina, 637 577. Fibroid Tumors and Polypi, , 638 578. Papillomata, 639 579. Malignant Neoplasms, 639 BLADDER. 580. Tumors of the Bladder, 642 581. Mucous Polypi, 642 582. Myoma, 643 583. Carcinoma, 649 UTERUS. 584. Fibromyomatous Tumors, 650 585. Pathologic Anatomy, 652 586. Microscopic Appearance, 652 587. Varieties, 653 588. Submucous Fibroids, 654 589. Interstitial, Mural, or Centric Fibroid Growths, 657 590. Subperitoneal GroT^-ths, 660 591. Fibromyoma of the Cervix, 662 592. Etiology, 664 593. Symptoms 667 594. Diagnosis of M3^omata, 671 595. Difterential Diagnosis of Myomata, 674 596. Alterations and Degenerations, 681 597. Mixed Growths: Enchondroma, Sarcoma, Osteoma, and Carcinoma, . 686 598. Complications, 687 599. (a) The Influence of the Myoma upon Conception, 690 600. (b) The Influence of Pregnancy upon the Myoma, 691 601. (c) The Influence of the Myoma upon Pregnancy, 692 602. (d) Influence upon Labor, 693 603. Course and Prognosis, 693 604. Treatment 696 605. (a) Medical Treatment, 697 XXIV TABLE OF CONTENTS. SECTION. PAGE. 606. (b) Electric, 700 607. (c) Surgical, 704 Vaginal Procedures: 608. (i) Dilatation and Curetment of the Uterus, 705 609. (2) Incision of the Cervix, 708 610. (3) Incision of the Capsule, ' 708 611. (4) Removal of the Growth, 709 612. (5) Ligation of the Vessels, 715 613. (6) Hysterectomy, 716 Abdominal Route: 614. (7) Castration, 718 615. (8) Ligation of the Vessels, 719 616. (9) Myomectomy .' 720 617. (10) Enucleation, 720 618. (11) Partial Hysterectomy, or Supravaginal Amputation of the Uterus, 723 619. (12) Panhysterectomy, 729 620. Summary, 734 621. Accidents during Operation, 737 622. Causes of Death Following Hysterectomy, 740 623. Puerperal Tumors; Physometra, 741 624. Hydrometra, 742 625. Hematometra, 742 626. Pyometra, 742 627. Hydatid Cysts of the Uterus, 742 628. Mucous Polypi of the Uterus, 742 629. Malignant Tumors, 743 630. Classification, 744 631. Anatomic Classification of Carcinoma, 744 632. Development of Squamous-cell Carcinoma, 746 633. Histology of Squamous-cell Carcinoma , 748 634. Adenocarcinoma of the Cervix, 749 635. Histology of Adenocarcinoma, 751 636. Adenocarcinoma of the Body, 752 637. Histology of Adenocarcinoma of the Body of the Uterus, 754 638. Dissemination of Carcinoma, 756 639. Clinical Forms, 762 640. Etiology, 764 641. Symptoms, 767 642. Physical Signs, 772 643. Complications, 773 644. Diagnosis, 775 645. Duration of Cancer, 781 646. Prognosis, 782 647. Treatment, 783 648. (A) Operable. — Partial Vaginal Operations, 784 649. Total Extirpation of the Uterus, 786 650. Vaginal Hysterectomy, 790 651. Accidents of Vaginal Total Extirpation, 797 652. Abdominal Hysterectomy, 799 653. Comparative Advantages of the Two Proceedings, 805 654. The Sacral Method, 806 655. The Perineal Method, 813 656. The Mortality of Abdominal and Vaginal Operations, 814 657. Duration of Recovery, 814 658. Recurrence, 815 659. (B) Inoperable, 818 660. Pregnancy Complicating Carcinoma 829 661. Summary, 830 662. Chorio-epithelioma Malignum, 832 TABLE OF CONTENTS. XXV 663. Endothelioma Uteri, 835 664. Sarcoma Uteri, 836 665. Varieties, 836 666. Pathology, 836 667. Etiology, 841 668. Symptoms, 842 669. Duration, 845 670. Diagnosis, 846 671. Recurrence, 849 672. Treatment, 850 673. Treatment Following Operations for MaUgnant Disease, 850 FALLOPIAN TUBES. 674. Tumors (Benign), 852 675. Fibroma or Myoma, 852 676. Fibrocyst, 853 677. Enchondromata, 853 678. Dermoid of the Tube, 853 679. Cysts of Small Size, 853 680. Polypus, 854 681. Papillomata, 854 682. Malignant Tumors, 855 683. Sarcoma, 855 684. Chorio-epithelioma Malignum, 856 BROAD LIGAMENTS. 685. Cysts of the Broad Ligament, 856 686. Echinococcus Cysts, 857 687. Parovarian Varicocele; Phleboliths, 858 688. Lipomata, 858 689. Fibroma, 858 690. Malignant Growths, 858 OVARIAN TUMORS. 691. Characteristics, 859 692. Classification, 859 693. Small Residual Cysts, 861 694. Simple or Follicular Cysts; Hydrops Folliculorum, 862 695. Cysts of the Corpus Luteum, 863 696. Tubo-ovarian Cysts, 863 697. Glandular Proliferating Cysts, 864 698. Pedicle, 865 699. Structure, 868 700. Papillary Proliferous Cysts, 872 701. Dermoid Cysts 873 702. Parovarian Cysts, 875 703. Solid Ovarian Tumors, 876 704. Fibromyoma, 876 705. Sarcoma of the Ovary, 877 706. Carcinoma of the Ovary, 877 707. Endothelioma of the Ovary, 878 708. Etiology, 878 709. Natural Progress, 879 710. Symptoms, 880 711. Complications, 880 712. Degenerative Changes in the Cyst-walls, 887 713. Diagnosis, 888 714. Exploratory Puncture, 901 715. Exploratory Incision, 902 716. Treatment 902 717. Ovariotomy, 903 XXVI TABLE OF CONTENTS. SECTION. PAGE. 718. Indications, 903 71Q. Contraindications, 904 720. General Considerations, 905 721. Operation, 906 722. Incomplete Operation, 916 723. Rupture of the Cyst 917 724. Hemorrhage, 918 725. Visceral Injuries, 918 726. Prognosis, 920 727. Intestinal Complications, 921 728. Causes of Death 922 List of Authors Quoted •. . ; 923 Index, 929 I Ik LIST OF ILLUSTRATIONS FIG. . PAGE. 1. Chadwick Table, 23 2. Dorsal Position, 24 3. Sims' Position. Proper Method of Holding the Speculum, 25 4. Genupectoral Position. Organs Shown in Outline, 25 5. Trendelenburg Position, 26 6. Proper Position of Fingers for Examination, 28 7. Half Section of the Pelvis with Patient Erect, Showing Normal Posi- tion of Uterus (Deaver), 29 8. Bimanual Examination, 31 9. Recto-abdominal Palpation, 32 10. Recto-vagino-abdominal Palpation. Index Finger of One Hand in the Rectum, Thumb in the Vagina, and the Fingers of the Other Hand over the Abdomen, 33 11. Rectovesical Palpation. Sound in Bladder, 34 1 2 . Simpson's Sound, 35 13. Sims' Probe, 35 14. Whalebone Probe, 35 15. Spring Probe Covered with Rubber, 35 16. Introduction of the Sound, 36 1 7- Ferguson's Speculum, 37 18. Milk-glass Specula, 38 19. Nott's Speculum, 38 20. Higbee's Specula (three sizes), 39 21. Talley's Speculum, , 39 22. Goodell's Speculum, 39 23. Sims' Speculum, 40 24. Proper Method of Holding Sims' Speculum. The Cervix Brought into View with the Tenaculum, 40 25. Sims' Depressor, 41 26. Goodell's Tenaculum, 41 27. Self-retaining Sims' Speculum, 41 28. Simon's Retractors, 42 29. Edebohls' Speculum, 42 30. Edebohls' Speculum in Position 42 31. Double Tenaculum Forceps, 43 32. Traction upon Uterus with Double Tenaculum during Digital Exam- ination by the Rectum, 43 2,s- Hollow Laminaria Tent, 44 34. Uterine Forceps — Dressing, 44 35. Dilated Tent Showing Constriction from Internal Os (Thomas), 45 36. EUinger's Dilator, 45 37. Goodell's Modification of Ellinger's Dilator, 45 38. Pratt's Dilators, 46 39. The Method of Dilatation with the Graduated Bougies, 47 40. Kuchenmeister's Scissors, 47 41. Douche Curet, 49 42. Tissue removed by Test Curetment, 51 43. Cabinet with Trays and Card Index for the Preservation of Slides 59 44. Coplin's Method of Indexing and Preserving Slides 60 45. Same as Fig. 44 Folded with Slide Enclosed, 60 46. Staphylococcus Pyogenes Aureus (CopUn), 64 xxvii XXVni LIST OF ILLUSTRATIONS. FIG. PAGE. 47. Streptococcus Pyogenes (Coplin), 64 48. Secretion from Gonorrheal Vaginitis, Showing Gonococci, 65 49. Secretion of Simple Vaginitis Showing Various Forms, 66 50. Bacillus Coli Communis (Coplin), 68 51. Bacillus Tuberculosis (Coplin), 68 52. Needle for Puncturing Finger, 77 53. Hematocytometer, 81 54. Dare's Hemoglobinometer, 82 55. Tallqvist Hemoglobin Scale, 82 56. Needle for Securing Blood, 91 57. Skene's Urethroscope, 94 58. Cystoscopes, 94 59. Kelly's Specula (Urethra), 95 60. Mouse-tooth Forceps for Cotton Pledgets, 95 61. Kelly's Evacuator, 95 62. 63. Ureteral Catheters. Metal and Soft, 95 64. Harris' Double Catheter for Obtaining Urine from Kidneys Separately, 96 65. Abdomen Prepared for Examination, 97 66. Nest of Trocars, 100 67. Aspirator, 10 1 68. Arnold Steam Sterilizer, 103 69. Steam-pressure Sterilizer, 104 70. Sterilizer for Boiling Instruments, 104 71. Gauze Pads, 105 72. Irrigating Glass Tube. Open End, 112 73. White's Oxygen Apparatus, which can be Utilized for Anesthesia by Placing Anesthetic in the Bottle, 116 74. Northrup's Apparatus for Administering a Mixture of Chloroform and Oxygen, 116 75. Arrangement of Tables and Assistants in Operating Room, 121 76. Abdominal Wall Incised; Peritoneum Picked up by Dissecting For- ceps, 122 77. Peritoneum Incised, 122 78. Crescent Incision Exposing Aponeurosis, 123 79. Aponeurosis Excised, Showing Pyramidalis Muscles, 123 80. Scalpels, 124 81. Pressure Forceps, 124 82. Dissecting Forceps — Long Bladed, 125 83. Glass Drainage-tubes, 126 84. Uterine Syringe for Cleaning Drainage-tube, 126 85. Tube Forceps for Cotton Pledgets, 126 86. Gauze Wick in Drain, 127 87. Mikulicz Drain, 127 88. Gauze Drain Covered w4th Rubber Tissue, 128 . 89. Curved and Straight Needles, 129 90. Needle Forceps, 129 91. I. Peritoneum Nearly Closed with Continuous Catgut. 2. Silkworm- gut Sutures through All Structures above Peritoneum. 3. Aponeurosis being United with Continuous Suture of Catgut, .... 130 92. Silkworm-gut Sutures Tied, 130 93. Butt Uterine Scarifier, 144 94. Aluminium Uterine Applicator, 145 95. Long Glass Pipet, 145 96. Insufflator — Straight Stem, 146 97. Tampon, 146 98. Position of the Fingers in Pelvic Massage, 148 99. Portable Galvanic Battery with Galvanom.eter, 150 100. Intra-uterine Electrode w4th Movable Insulating Cover, 151 10 1. Vaginal Electrodes of Different Sizes, 151 102. Faradic Battery, 153 103. Bipolar Uterine Electrode, 154 104. Vaginal Electrode — Bipolar, 154 LIST OF ILLUSTRATIONS. XXIX FIG. PAGE. 105. Human Embryo at end of Thirty-five Days {Coste), 157 106. Coalescence of Miiller's Duct, 158 107. 108, 109. Progress of Development of the Genitalia, 158 no. Virgin Vulva: Labia not Separated (Deaver), 160 111. Virgin Vulva: Labia Separated, Showing the Hymen Unruptured (Deaver), 161 112. Hymen Crescens, 162 113. Hymen Annularis, 162 114. Hymen Serratus, 163 115. Hymen Infundibularis, 163 116. Hymen Biseptus, 164 117. Hymen Cribriformis, 164 118. Laceration of the Hymen, 165 119. Muscles of the Female Perineum (Deaver), 166 120. The Under Surface of the Levator Ani Muscle (Deaver), 171 121. The Upper Surface of the Levator Ani Muscle (Deaver), 172 122. A Mesial Section: the Body Erect (Deaver), 173 123. A Mesial Section: the Body Recumbent, 174 124. Arteries and Nerves of the Female Perineum (Savage), 175 125. Anterior Wall of Vagina Showing Columnae Rugarum (Byford, after Savage), 176 126. Horizontal Section of the Vagina and Urethra of an Infant, 177 127. Median Section of Uterus from Side to Side through the Fallopian Tubes. Mode of Junction of Vagina and Uterus (Savage) 179 128. Virgin Uterus. Median Section (Byford, after Sappey), 181 129. Mucous Membrane of Uterine Body Showing Follicles (Alann), 181 130. Section of Normal Endometrium, 182 131. Virgin Os and Cervix (Sappey), 183 132. Section of Fallopian Tube through the Isthmus, 185 133. Section of Tube through the Ampulla near the Isthmus, 186 134. Section of Ovary, Showing Graafian Follicles (Wyder), 188 135. Large Corpus Luteum in Association with an Ovarian Dermoid. Re- moved from an Unmarried Woman who had Never Been Pregnant (Sutton), 190 136. Vesicovaginal Septum and Base of Female Bladder. Anatomic Re- lations of Ureters at Their Entrance into the Bladder. Contents of Alar Ligament (Savage), 193 137. Superior View of the Pelvic Cavity (Deaver), 196 138. Curved Dotted Line Shows Covering of the Anterior Uterine Wall by Peritoneum (Winter), 198 139. Posterior Surface of Uterus Showing Extent of Peritoneum; also Fal- lopian Tubes, Ovaries, and Ovarian Ligaments (Winter) 198 140. Vertical Transverse Section of the Pelvis, Showing Peritoneal Pouches (Liischka), 199 141. Distribution of the Uterine and Ovarian Vessels, 202 142. Arteries of the Female Pelvic Organs (Savage), 203 143. Distribution of the Pudic Artery to the Structures of the Perineum (Deaver), 204 144. Relation of the Urethral and Vaginal Venous Plexuses to the Veins of the Clitoris and Bulb; The Right Side of the Pelvis Re- moved by a Section in Front, through the Pubic Body, About an Inch from the Symphysis, and, Behind, through Sacro-iliac Joint (Savage), 205 145. Veins and Erectile Venous Plexuses of the Female Pelvis (Savage), . . 206 146. Erectile Organs and Veins of the Female Perineum (Savage), 207 147. The Lumbo-iliac Lymphatics and Glands. Lymphatics of the Gravid Uterus and Appendages (Savage) 208 148. Nerves of the Unimpregnated Uterus with the Nerves of the Clitoris (Savage), ' 210 149. Changes of Uterine Mucous Membrane during Menstruation (Wyder), 216 150. Degrees of Division of the Genital Tract, 224 151. Uterus Bicornis (Auvard), 224 XXX LIST OF ILLUSTRATIONS. FIG. PAGE. 152. Uterus Bicornis Unicollis (Am. Sys. Gyn.) , 225 153. Uterus Bifidus (Auvard), 226 154. Uterus Didelphys (Am. Sys. Gyn.), 226 155. Uterus Unicornis (Auvard), 227 156. Atresia of Rudimentary Horn with an Accumulation of Menstrual Blood (Auvard), 227 157. Uterus Bipartitus or Duplex (Byford), 228 158. Uterus Biseptus (Courty), 229 159. Absent Vagina, 232 160. Line of Incision for Formation of Flaps, i, 2. Flaps from Labia Minora which are Split and Used to Line the Vagina, 233 161. Flaps Outlined in Fig. 160 Sutured in Place, and Denuded Surfaces which have Furnished Flaps to Line Posterior Wall, 234 162. Sims' Glass Dilator, 235 163. Double Vagina (Photograph taken from patient of Dr. J. M. Fisher),. . 236 164. Imperforate Hymen, 237 165. Hematocolpos, 238 166. Hematometra, 239 167. Hematocolpometra, 240 168. Enlarged Clitoris, 242 169. Apparent Hermaphroditism — (American Journal of Obstetrics), 244 170. External Genital Organs of Madame Le Fort (Auvard), 244 171. Outline of Internal Organs of Madame Le Fort (Auvard), 245 172. Androgyna (Pozzi), 246 173. Imperforate Anus. Communication between Rectum and Vagina, . . 247 174. Congenital Defect of Vagina. Communication with the Rectum 247 175. Congenital Absence of the Urethra. Communication of Bladder with the Vagina, 248 176. Communication of Rectum and Bladder with the Vagina, 248 177. Suprapubic Opening of Vagina and Urethra, 249 178. Knives for Denudation, 252 179. Curved Scissors,. 252 180. Retractor, 252 181. Blunt Hook, 253 182. Needle-holder 253 183. Needles, 253 184. Needle with Loop for Suture, 253 185. Slight Fissure of Cervix, 255 186. Extensive Laceration of Cervix (Munde), 255 187. Bilateral Laceration of Cervix (Munde), 256 188. Slight Stellate Laceration of Cervix (Munde), 256 189. Extensive Stellate Laceration of Cervix (Munde), 256 190. Laceration of Cervix with Hypertrophy and Eversion of Cervical Mucous Membrane (Munde), 256 191. Blunt and Sharp Curets, 258 192. Edges of Laceration Turned by Tenaculum Hooked into Each Lip,. . 259 193. Denudation of Lacerated Cervix, 260 194. Surfaces Denuded Ready for Union, 260 195. Sutures Introduced, 260 196. Sutures Tied, 260 197. Double Flap Amputation of the Cervix (Auvard), 261 198. Sutures Introduced (Auvard) 261 199. Wound Closed, 261 200. Schroder's Single Flap Operation, 262 201. Schroder's Operation Completed, 263 202. Scheme Showing Various Fistulas, 265 203. Large Vesicovaginal Fistula with Prolapse of the Anterior Vesical Wall through the Opening, 266 204. Denudation of the Edges of the Fistula, 267 205. Sutures Introduced, 268 206. Wound Closed, 269 207. Method of Suturing to Decrease the Tension upon the Sutures, 270 LIST OF ILLUSTRATIONS. XXXI FIG. PAGE. 208. Showing Continuation of Suturing to Close Fistula with Incisions to Decrease Tension with Suture Introduced on Left Side to Close the Secondary Opening 271 209. Wound Closed, 271 210. Fistula Preparatory to Splitting into Vesical and Vaginal Flaps, 272 211. Demonstration of Flap-splitting, 272 212. Suture Introduced into Vesical Flap, 273 213. Suture Tied in Vesical Flap Introduced in Vagina, 273 214. Wound Closed, .' 273 215. Sutures Introduced to Close Vesical Surface, as Suggested by Wal- cher, 274 216. Flap-formation as Suggested by Ferguson, 275 217. Flap Turned in and Vesical Opening Closed, 276 218. Introduction of Vaginal Sutures, 277 219. Section Showing Projection upon Vesical Surface, 278 220. Self -retaining Catheter, 278 221. Vesico-uterine Fistula, 278 222. Colpocleisis, 279 223. Closure of Fistula after Its Exposure by Incision through Anterior Vaginal Fornix, 280 224. Fistula Closed into Vagina. Uterine Opening Remains, Which Will Close of Itself 281 225. Section Showing Suture for Hysterocleisis, 281 226. Closure of Fistula within Cervical Canal after Splitting Cervix, 282 227. Hysterocleisis, 283 228. Anterior Lip of Cervix Utilized to Close the Fistula, 284 229. Vesico-uterovaginal Fistula in which the Posterior Lip of the Uterus is Utilized to Close the Opening, ■ 284 230. Vesical Wall Loosened and Sutured. Vaginal Wall Sutured in Oppo- site Direction, 285 231. Operation for Ureterovaginal Fistula, 286 232. Vaginal Implantation of the Ureter into the Bladder, 287 233. Abdominal Transplantation of Ureter for Ureterovaginal Fistula,. ... 288 234. Ureteral Anastomosis, 289 235. Sagittal Incision for Rectovaginal Fistula, 290 236. Lauenstein Suture in Rectovaginal Fistula through Rectal Wall,. .... 290 237. Rectal Wall Closed by Transverse Line of Sutures; Vaginal by Ver- tical Line of Sutures, 291 238. Rectovaginal Fistula Closed in Operation of Perineorrhaphy, 292 239. Rupture of Perineum into Rectovaginal Septum, 293 240. Cystocele, 294 241. Rectocele, 295 242. Right and Left Curved Scissors, 296 243. Incomplete Rupture of the Perineum, 297 244. Simon-Hegar Method of Denudation, 297 245. Sutures Introduced to Close the Wound, 298 246. Garrigues' Modification of the Hegar Operation, 299 247. Upper Part of the Wound Closed; Last Sutures Introduced, 300 248. Wound Completely Closed, 300 249. Lauenstein Suture, 301 250. Rectum and Vagina Closed with Lauenstein Suture, 301 251. Hildebrandt's Method of Suturing, 302 252. Hildebrandt Suture Closed, 303 253. Heppner's Figure-of-8 Suture, 304 254. Martin Suture to Close the Rectal Opening, 305 255. Martin Suture Continued, 305 256. Denudation for Freund's Operation, 306 257. Sutures Inserted in Rectal Wall and Lateral Vaginal Angles, 307 258. Vaginal Angles and Rectal Wall Closed. Suture in Place for Peri- neum, 307 259. Denudation Completely Closed, 307 260. Emmet's Operation, Surface Denuded and Lateral Sutures in Place, 308 XXXll LIST OF ILLUSTRATIONS. FIG. PAGE. 261. Emmet's Operation. Lateral Angles Closed and Perineal Suture Introduced, 309 262. Emmet's Operation Completed, 310 263. Emmet's Operation for Complete Laceration, 310 264. Suture to Unite the Ends of the Sphincter, 310 265. Outerbridge's Suture, 311 266. Cleveland's Suture, 312 267. Dudley's Operation with Interrupted Sutures, 312 268. Dudley's Operation Completed, 313 269. Denudation for Martin's Operation, 313 270. Vaginal Surfaces United; Perineal Sutures in Place, 314 271. Bischoff's Operation, 314 272. Splitting Vaginal Wall Preparatory to Suture (Andrews), 315 273. Introduction of Suture in Retracted Flap (Andrews), 316 274. Suture Tied; the remaining Surface to be Closed by Transverse Su- tures (Andrews), 317 275. Incision for Tait's Operation for Incomplete Laceration, 318 276. Line of Incision for Tait's Operation for Complete Laceration, 319 277. Appearance of Surface after Formation of Flaps, 319 278. Outline of Flap to be Turned down to Form Raw Surface for Union. Flap thus Formed to Protect from Fecal Infection (Ristine), 320 279. Flap Turned down. Sphincter Closed and Sutures Introduced (Ris- tine) , 321 280. Outline for Simpson's Operation, 322 281. Sutures Introduced in Simpson's Operation, 323 282. Denudation for Fritsch's Operation, 324 283. Catgut Sutures for Union of the Rectal Wall, 325 284. Incision for Duke's Operation, 325 285. Incision Separated in Vertical Direction, 326 286. Incision United by Transverse Sutures, 326 287. Follicular Vulvitis (Thomas and Munde), ;^;^;^ 288. Cyst of Bartholin's Gland (Auvard), 339 289. Kraurosis Vulvse, 344 290. Urethra Laid Open with Probes, Distending Skene's Glands, Poste- rior Wall Divided (Byford, after Skene) , 357 291. Reflux Catheter, . 361 292. Double-current Catheter, 371 293. Simple Papillary Erosion of the Cervix, 376 294. Simple Papillary Erosion with Enlarged Follicles, 376 295. Extensive Cystic Disease of the Cervix, 377 296. Chronic Endocervicitis, 378 297. Lines of Incision for Contracted or Pinhole Os (Thomas and Munde), 382 298. Union of Vaginal and Cervical Mucous Membranes, 382 299. Interstitial Endometritis, 393 300. Hypertrophic Glandular Endometritis, Showing Increase in Size and Numbers of Glands, 394 301. Hypertrophic Glandular Endometritis, Vertical Section through the Mucous Membrane, 395 302. Polypoid Masses Associated with Chronic Endometritis, 396 303. Membranous Dysmenorrhea, 397 304. Uterus Dilated with Graduated Bougies, 409 305. Uterine Cavity Packed with Gauze after Dilatation, 410 306. Acute Salpingitis, 412 307. Chronic Salpingitis Showing Agglutination of Folds, 413 308. Extensive Pus Collections with General Adhesions, 413 309. Pyosalpinx, 4^4 310. Section from Wall of Pus Tube 415 311. Single Fold from Wall of Pus Tube Enlarged 415 312. Distended Pus Tubes Removed from Young Girl, 416 313. Convoluted Fallopian Tube from Perisalpingitis, 417 314. Incomplete Inflammatory Closure of the Fallopian Tube. Portions of Fimbriae Unretracted, 417 LIST OF ILLUSTRATIONS. XXXlll FIG. PAGE. 315. Double Tubo-ovarian Collection, 418 316. Hydrosalpinx, 419 317. Double Pyosalpinx Showing Adhesions to the Rectum, to the Uterus, and on the Right to the Appendix, 420 318. Peri-oophoritis. Tube and Ovary Encysted, 423 319. Resection of Tube, 428 320. Operation of Resection of Tube Completed, 428 321. Exudation in Broad Ligament from Pelvic Cellulitis, 434 322. Exudation of Cellulitis over Rectum, 435 323. Induration from Peritonitis, 449 324. Induration from Pelvic Cellulitis, 450 325. Intestines Held Back by Gauze. Patient in Trendelenburg Posture,. 454 326. Three-pronged Vulsellum, 456 327. Vaginal Incision for Pus Collection in the Broad Ligament, 457 328. Incision through Vagina with Thermocautery in Vaginal Excision of the Uterus, 458 329. Clamp Forceps for Securing the Broad Ligament, 459 330. Deschamps Needle Ligature Carrier, 459 331. Drawing down the Fundus {Landau), 460 332. Application of the Clamp Forceps to the Lower Portion of the Broad Ligament {Landau), 461 7,7,7,. Ligation of the Broad Ligament in Vaginal Hysterectomy, 462 334. Upper Portion of the Broad Ligament Secured by Clamp Forceps {Landau) , 463 335. The Introduction of Gauze after the Rem.oval of the Uterus, 464 336. Closure of the Vaginal Wound by Sutures, 465 337. Landau's Method of Delivering the Uterus after Its Complete Median Section, 466 338. Uterus Displaced by Distended Bladder, 467 339. Uterus Displaced by Impacted Rectum, 468 340. Scheme of Dislocated Uteri {Dudley) 469 341. Uterus pushed up by Tumor in Douglas' Pouch, 470 342. Uterovaginal Prolapse, 471 343. Vagino-uterine Prolapsus, 472 344. Vagino-uterine Prolapsus with Hypertrophic Elongation of the Cervix {Auvard), 473 345. Uterus Detached Showing Hypertrophic Elongation of the Cervix {Auvard), 474 346. Vulvar Appearance of Vagino-uterine Prolapsus, 475 347. Pseudoprolapsus. Cervix within the Vagina, 476 348. Pseudoprolapsus. Cervix Protruding from the Vulva, 477 349. Anterior and Posterior Colpocele, 478 350. Cystocele, 47p 351. Prolapsus with Both Rectocele and Cystocele, 480 352. Irreducible Prolapsus. The Tumor Contained Uterus and a Large Pyosalpinx. Ulceration of the Cervix 481 353. Prolapsus without Protrusion of the Vaginal Walls, 482 354. Determination of the Position of the Uterus by Bimanual Palpation, 483 355. Recognition of the Uterus with Thumb and Fingers of One Hand, . . . 484 356. Diagnosis of Position of the Uterine Body by Rectal Touch, 485 357. Hypertrophic Elongation of the Cervix. Anterior Vagina Everted, while Posterior Retains Its Normal Position {Auvard), 486 358. Enterocele through the Posterior Vaginal Fornix, 487 359. Vagino-uterine Prolapse Complicated by Proliferating Epithelioma,. . 488 360. Ring Pessary, 490 361. Disc Pessary, 490 362. Smith-Hodge Pessary, 490 363. Munde Pessary, 490 364. Hoffman Soft-rubber Pessary, 491 365. Zwank Pessary, 491 366. Gehrung Pessary, . 491 367. Hewitt Cradle Pessary, 491 XXXIV LIST OF ILLUSTRATIONS. PAGE. 368. Anterior Colporrhaphy. Anterior Vaginal Wall Removed , 493 369. Wound Closed, 494 370. Stolz's Purse-string Suture (Pozzi), 495 371. First Stage of Dudley's Bilateral Denudation of the Vaginal Walls for Prolapsus (Dudley), 497 372. Dudley's Operation Showing Denudation upon One Side of the Vagina (Dudley), 498 373. Urethrocele, 499 374. Anteversion of the Uterus, 501 375. Sims' Operation for Anteversion (Auvard) 503 376. Abdominal Belt, 504 377. Retroversion, 505 378. Slight Degree of Anteflexion, 507 379. Acute Anteflexion, 507 380. Thomas Anteflexion Pessary, ' 510 381. Stem Pessary, 510 382. Section Showing Thinning of Cervical Walls at the Angle of Flexion, 511 383. Anteflexion Associated with Contraction of Uterosacral Ligaments,. . 511 384. Dudley's Operation for Anteflexion, by Incising and Suturing the Posterior Lip (Dudley) , 513 385. Completion of Dudley's Operation, by Transverse Denudation and Suturing of the Anterior Lip, 514 386. Nourse's Operation by Splitting the Cervix and Resuturing the In- cisions, 515 387. Operation Completed, 515 388. Retroflexion of Slight Degree, 516 389. Retroflexion of Extreme Degree, 517 390. Retroflexion Following Version, 517 391. Retroflexion Produced by Fibroma of Anterior Uterine Wall, 518 392. Retroflexion the Sequel of Inflammatory Adhesions (Thomas and Munde), 518 393. Retroflexion Simulated by Posterior Uterine Myoma, 519 394. Retroflexion Simulated by Small Ovarian Cyst in Posterior Culdesac, 519 395. Anteflexion and Retroflexion Simulated by Pelvic Exudation, 520 396. The Retroverted Uterus Replaced; Patient in Dorsal Position, 521 397. Schultze's Method of Replacing an Adherent Retroverted Uterus,... . 522 398. Second Step in Replacing Uterus by Schultze's Operation, 523 399. Schultze Pessary, 525 400. Proper Position of the Pessary, 525 401. Faulty Position of the Pessary, 526 402. Schultze's Sledge Pessary, 527 403. Alexander Operation: Round Ligament Exposed (Edebohls), 528 404. Round Ligament Being Drawn out (Edebohls), 529 405. Round Ligament Sutured (Edebohls), 530 406. Continuous Catgut Suture Uniting Internal Oblique Muscle to Pou- part's Ligament (Edebhols), 531 407. Return Layer of Suture Bringing External Oblique Muscle in Apposi- tion (Edebohls), 532 408. Wylie's Operation for Shortening the Round Ligaments within the Abdomen (Am. Sys. Gyn.), 533 409. Mann's Operation for Intra-abdominal Shortening of Round Ligaments (Am.. Sys. Gyn.), 534 410. Dudley's Operation of Desmopycnosis (Am. J. Obs.), 535 411. Dudley's Operation Completed (Am. J. Obs.), 535 412. Gilliam-Ferguson Operation. Round Ligament Seized through Stab Wound, 536 413. Round Ligament Drawn through the Abdominal Wall, 537 414. Section Showing Position of the Uterus with Completion of the Operation 537 415. First Step in my Modification of the Gilliam Operation for securing Round Ligament Support, 538 LIST OF ILLUSTRATIONS. XXXV FIG. PAGE. 416. Second Step, Showing Ligament Fixed with Hemostat while Tempo- rary Ligature is Carried Beneath Anterior Leaflet of Broad Liga- ment with a Deschamps Needle, 539 417. Operation Completed. Differs from Gilliam-Ferguson in having no In- ternal Sutures, 540 418. Sutures Introduced for Ventro-suspension, 541 419. Partial Inversion of the Uterus, Showing Three Degrees {Auvard),. . . 551 420. Intravaginal Inversion; Three Degrees (Auvard), 551 421. Extravaginal Inversion; Three Degrees (Auvard), 552 422. Nonpuerperal Inversion. Fibroid Tumor Attached to the Fundus Uteri, •. 552 423. Palpation of an Inversion of the First Degree (Auvard), 553 424. Palpation of an Inversion of the Second Degree (Auvard), 554 425. Appearance of Inversion of the Third Degree, 555 426. o. Inversion of the Uterus, b. Fibroid Polypus, c. Fibroid Poly- pus, with Stenosis of the Cervical Canal, 556 427. a. Submucous Fibroma, b. Partial Inversion, c. Partial Division of the Uterus, 557 428. Prolapsus Uteri without Inversion, 558 429. Inversion of the Uterus, Extravaginal, 558 430. Central Taxis (Auvard), 559 431. Lateral Taxis (Auvard), 560 432. Peripheral Taxis (Attvard), 561 433. The Use of the Air Pessary to Reduce an Inversion (A^ivard), 561 434. Reduction of Inversion with White's Apparatus (Thomas) 562 435. Intraperitoneal Dilatation of the Uterus (Thomas), 563 436. Incision of the Posterior Uterine Wall PreHminary to Reduction of an Inversion, 564 437. Prolapsus of Ovary and Tube behind Uterus, 565 438. Intraperitoneal Hemorrhage (Auvard), 577 439. Extraperitoneal Hematoma (Courty) 578 440. Tubal Pregnancy (Sutton), 584 441. Tubo-ovarian Pregnancy, 585 442. Tubo-uterine or Interstitial Pregnancy, 585 443. Tubal iVbortion, 586 444. Complete Rupture of a Tubal Sac, 592 445. Incomplete Rupture of Gestation Sac, 592 446. Ectopic Gestation Sac Ruptured Showing Fetus, 601 447. Large Ectopic Gestation Sac, 605 448. Anterior Labial or Inguinal Hernia, 624 449. Posterior Labial Hernia, 625 450. Urethral Caruncle, 626 451. Prolapsus Urethrse, 627 452. Varicose Veins of the Vulva (Dr. W. Krusen), 628 453. Vulvar Vegetations, 631 454. Elephantiasis of the Vulva, 632 455. Fibroid of Labium, 633 456. Cancer of the Vulva, 634 457. Appearance of the Vulva after an Operation for Cancer of the Vulva, 635 458. Cysts of the Vagina, 638 459. Myoma of the Anterior Vaginal W^all (Dr. J. C. Da Costa), 639 460. Primary Cancer of the Vagina, 640 461. Microscopic Section; Myoma Uteri (Coplin), 653 462. Liomyoma of the Uterus (Coplin) 654 463. Submucous Myoma (Polypoid), 655 464. Sessile Submucous Myoma, 656 465. Submucous Myoma Occupying Uterine Cavity, 656 466. Submucous Myoma Extruded into the Vagina, 657 467. Voluminous Myomata Occupying Anterior and Posterior Walls (Auvard), 658 468. Circumscribed Interstitial Myomata (Auvard), . 659 469. Local Interstitial Myomata (Auvard), 659 XXXVl LIST OF ILLUSTRATIONS. FIG. PAGE. 470. Uterus Opened, Showing Multiple Interstitial Myomata, 660 471. Sectioned Surface of Uterus Showing Several Fibroid Tumors, 661 472. Serous Surface of Same Specimen, 661 473. Uterus Incised Containing Interstitial Fibro-myomata, 662 474. Uterus Incised Showing General Circumscribed Fibro-myomata, 663 475. Subserous Myomata, 664 476. Pedunculated Myoma of the Cervix, 665 477. Sessile Myoma of the Cervix, 666 478. Bicornate Uterus. Both Cornua Containing Myomata, 670 479. Intraligamentary Myoma, 673 480. Large Desmoid Tumor of Abdominal Wall Weighing Upon Removal 19J Pounds, 677 481. Histologic Section of Desmoid Tumor, 678 482. Myoma Uteri with Large Intraligamentary Fibromata, 681 483. Fibrocystic Tumor of the Uterus (Auvard), 683 484. Submucous Fibromyoma Undergoing Cystic Change, 684 485. Myoma of the Body and Cancer of the Cervix, 685 486. Uterus Incised Displaying Numerous Fibro-myomatous Growths and Incipient Cancer of the Cervix, 686 487. Myoma Uteri Complicated by Pyosalpinx, 688 488. Uterus Containing Several Fibroid Tumors Complicated by a Large Tubo-ovarian Cyst, 688 489. A Myoma Which, from the Associated Ascites, Had Been Mistaken for Pregnancy, 689 490. Tumor Shown after Removal, 690 491. Myoma Complicated by Pregnancy, 691 492. Uterus Containing Large Fibroid Tumor and Three Months' Fetus, . . 692 493. Incision of Cervix to Expose Intra-uterine Myoma, 706 494. Cervix and Capsule Incised, the Latter Pushed Back, 707 495. Removal of Myoma by Torsion of Its Pedicle, 709 496. Incision of Pedicle of Myoma, 710 497. Enucleation of Tumor through the Vagina, 711 498. Interstitial Tumor Exposed by Vertical Incision of the Anterior Lip,. 712 499. Myoma of Anterior Wall Exposed by Transverse and Vertical Incision, 713 500. Myoma of Posterior Wall Exposed by Retro-uterine Incision, 714 501. Removal of Myoma by Morcellement, 715 502. Abdominal Myomectomy (Dudley), 721 503. Abdominal Enulceation of Myomata and Method of Closing the Uterine Wound (Dudley), 721 504. Supravaginal Removal of Myomatous Uterus (Kelly), 725 505. Cervix Cut Across Preliminary to the Complete Ligation of One Ligament (Kelly, modified) , 726 506. Stump Covered with Peritoneum, 727 507. Panhysterectomy. Doyen's Method, 731 508. Cervix Separated from the Vagina, and Being Pulled away from the Bladder and Ureters, 732 509. Mucous Polypi, 743 510. Squamous-cell Carcinoma of the Cervix, 746 511. Squamous-cell Epithelioma of the Uterus, 754 512. Adenocarcinoma of the Cervical Canal, 755 513. Adenocarcinoma of Body of the Uterus, 756 514. Cauliflower Growth Involving the Vaginal Part (Winter), 757 515. Cancerous Ulceration of Intracervical Canal (Ativard), 758 516. Cervical Wall Infiltrated while the Vaginal Portion is Largely De- stroyed (Veit), 759 517. Circumscribed Cancer of Body of Uterus (Ativard), 760 518. Diffuse Cancer of Uterine Body, 761 519. Adenocarcinoma of Uterine Body, 761 520. Incipient Adenocarcinoma of Uterine Mucous Membrane, 762 521. Entire Cavity Covered with Nodular Growths 762 522. Communication between Bladder, Vagina, and Rectum (Auvard),. ... 763 523. Cervical Canal Destroyed by Progress of Disease, 764 LIST OF ILLUSTRATIONS. XXXVll FIG. PAGE. 524. Uterus Removed from an Unmarried Woman Twenty-two Years of Age, 771 525. Formation of Flap to Cover Diseased Surface Preliminary to Opera- tion, 789 526. Ligation of the Anterior Trunk of the Internal Iliac, 803 527. Skin Incision for Sacral Resection, 807 528. Sacrum Resected; Rectum Exposed, 808 529. Rectum Pushed Aside; Uterus Exposed, 809 530. Patient from Whom Uterus, Ovaries, Posterior Wall of Vagina, Perineum, and Five Inches of the Rectum Have Been Removed, 812 531. Chorio-epithelioma of the Uterus, 832 532. Chorio-epitheHoma Malignum {Noble and Tracy), 833 533. Histologic Section of Chorio-epithelioma, 833 534. Endothelioma of the Uterus, 835 535. Sarcoma of the Body of the Uterus, 837 536. Fibroma Undergoing Sarcomatous Change {Auvard), 847 537. Papilloma of the Fallopian Tube {Doleris), 854 538. Broad Ligament Cyst {Sutton), 856 539. Broad Ligament Cyst, with Torsion of Its Pedicle, 857 540. Large Ovarian Tumor, 860 541. Small Residual Cysts {Dudley), 861 542. Cyst of the Corpus Luteum, 862 543. Tubo-ovarian Cysts, 863 544. Large Ovarian Cyst. Patient Upright, 864 545. Ovarian Cyst. Patient Recumbent, 865 546. Pedicle of an Ovarian Cyst {Doran), 865 547. Intraligamentary Ovarian Cyst, 866 548. Cyst Embedded in the Pelvis, 867 549. Adenocystoma of Ovary, Showing Papillary Formation, 868 550. Areolar Ovarian Cyst, 869 551. Unilocular Ovarian Cyst {Winter), 870 552. Multilocular Cyst {Doran), 871 553. Small Papillary Ovarian Cyst, 872 554. Papillary Tufts upon Inner Wall of Cyst {Doran), 872 555. Surfaces of Ovaries Infected with Papillary Vegetations {Doran), .... 873 556. Papillary Ovarian Cyst, 874 557. Dermoid Ovarian Cyst, 875 558. Fibromyoma of Ovary {Veit), 876 559. Sarcoma of the Ovary {Veit), 876 560. Torsion of the Pedicle, 882 561. Dermoid Which Had Lost Its Original Relations and Was Nourished by Adhesions from the Omentum, 884 562. An Ovarian Cyst beneath a Pregnant Uterus, 886 563. Desmoid Tumor of Abdominal Wall, 889 564. Relative Zones of Dullness and Resonance in Ascites, 891 565. Relative Zones of Dullness and Resonance in Ovarian Cyst, 892 566. Hegar's Method of Determining Relation of Tumor to the Uterus (Winter), 894 567. Cyst Forceps, 906 568. Wall Incised; Cyst Exposed, 907 569. Cyst Punctured and Being Withdrawn, 908 570. Withdrawal of Sac, Showing Adhesions, 909 571. Ligatures Introduced through Broad Pedicle, 910 572. Interlacing of Sutures to Prevent Splitting of Pedicle, 910 573. Sutures Interlaced and Tied, 912 574. Splitting of Pedicle when Sutures are Tied without Interlacing, 915 A Text-book of Gynecology. INTRODUCTION. 1. Definition and Antiquity. — Gynecology comprises the study of the diseases peculiar to women. The description of the sotuid and various forms of specula, specimens of which have been found in the ruins of Pompeii and Herculaneum, and directions given in manuscripts for the treatment of special conditions, make it evident that the ancients possessed some knowledge of the disorders of the female genital tract, but it can not be disputed that the greatest progress in the development of the science occurred during the last half of the nineteenth century. 2. Theories. — The study of the progress of the science is not without interest and profit, and in its development we wit- ness the pendulum swing from one extreme to another. The origin of disease is based upon local inflammation by one; by another it is ascribed to constitutional conditions of which the local condition is only an expression. The cervix has been considered the offending portion of the tract, and its inflammation the cause of every trouble. The ovaries have been accused of dominating the other organs, and producing in them secondary or reflex phenomena. Displacements of the uterus, particularly the flexions, have been, and still are, asserted to be the main source of the disorders of the pelvis. The tubes have been indicated as the instigators of the function of menstruation, and consequently to pathologic lesions of these organs are at- tributed the majority of abnormal conditions of the genital tract. 3. Foundation. — An analysis of the different theories discloses that the truth is contained, not in one but in a proper com- bination of all. The influence of one organ upon another due to the arrangement of vascular and nerve supply is signiflcant, and a proper appreciation of the subject is reached only after- a very careful study and analysis of all the phenomena presented. 4. Purpose. — It should not, upon the one hand, be considered the true province of the student of gynecology to ascertain that a patient has a uterus which should be subjected to the routine use 1 1 Z GYNECOLOGY. of Speculum, sound, and applicator; nor, upon the other, that the recognition of the existence of ovaries and tubes justifies the con- clusion that every symptom of distress or discomfort from which the patient complains must indicate in them a pathologic lesion which will of necessity justify their sacrifice. The gynecologist should be one who will be assiduous in the study of the history of disease; ready to discern its cause; careful in eliciting the subjective symptoms, and proficient in determining physical signs, who will exercise correct judgment in comparing and analyzing the knowledge thus secured, and has such in- tegrity that the patient may feel assured she will not be treated for diseased conditions which are not present. He must be so conservative that he will sacrifice no organ whose physiologic integrity is capable of being restored ; so bold and courageous that his patient shall not forfeit her opportunity for life or restored health through his failure to assume the respon- sibility of any operative procedure necessary to secure the object. ETIOLOGY. 5. Importance of Etiology. — A knowledge of the causes which result in the production of disorders of the genital tract are essential to the ready recognition of their character and to the employment of proper measures for the relief of the suffer- ing victim. The study of the forces which combine for the production of genital disorders are especially complex, for they comprise not only the actions of the diseased, but also of those with whom she is associated and those who have been her pro- genitors. Here, truly, we see the sins of the parent visited upon the children not only to the third, but to many generations. 6. Classification. — The causes of disease are difficult to clas- sify, and are sometimes divided into two great classes, the pre- disposing and exciting. When considering some particular class of disease, as, for instance, inflammation, such classification can readily be arranged, but when we come to consider all the disorders to which the genital organs are subject, it becomes more difficult to assert what are predisposing and what are ex- citing. In one individual the diseased state can be directly traced to abnormalities in development; in another to defects in her manner of life; a third may have had disease brought to her through her sexual life, and a fourth sufter from injuries incident to reproduction. The following seems sufficiently comprehensive : (a) Hereditary and congenital. (b) Hygienic. ETIOLOGY. 6 (c) Sexual. (d) Traumatic. (e) Infective. (/) Causes incident to age. 7. (a) Hereditary and Congenital Causes. — It seems impos- sible, yet is demonstrated day by day that the atoms supplied by the male and female which unite to set up processes of con- struction for a new life contain within their minute compass the impetus which is to lead to the development of traits and char- acteristics similar to those possessed by their progenitors. These traits and characteristics involve not only shade, form, and color, but mental and moral attributes. Imperfections and unfortunate traits which are common to the parents are intensified in the offspring. A knoAvledge of such transmission is employed by the stock raiser to improve his herds. Only such males are employed as will improve and correct the rec- ognized defects of his herd. While it is impossible to introduce in the relation of the sexes of the human race the precision of the stock breeder, it cannot be denied that the production of healthy offspring is too rarely the motive for such union. Family, position, and wealth are more frequently considered essential than are good health and good morals upon the part of the elected husband. The worn out roue, the debauched or decrepit son of wealth are preferred to the virile young man who has his fortune to make. A feeble or sexually exhausted male united to a cold, dispassionate woman with no, or but little, inclination to maternity must result in the production of offspring with still lower sexual virility. Sterility, defective sexual and phy- sical development, and lessened powers of resistance are likely to characterize the offspring of such a union. Intemperance in eating and drinking, overwork, exhaustion from indulgence in the exigencies of fashionable life, and a tendency to marked fat production in one or both parents, lessens virility and vitality in the children. Intensification of pre-existing traits, the oc- currence of vicious tendencies, lessened resistance to certain constitutional diseases as tuberculosis, the gouty diathesis, and malignant degenerations may be transmitted from parent to child and are known as hereditary causes of disease. Not infre- quently from careful hygiene, improved environment, and other favorable conditions such tendencies may not make their ap- pearance in one or more generations and apparently become intensified in one less favorably situated. The most marked influence upon the sexual life of the individual will be rec- ognized in the study of the development of the ovum. During ,its progress of development the ovum is subjected to vari- ous disorders which may lead to arrest or deranged formation 4 GYNECOLOGY. of the structures of the genital tract, dependent, of course, upon the period or stage of development in which this may take place. Should the change occur before the separation of the Miillerian ducts and the genital bodies from the Wolffian, there may be an absence of the structure upon the side affected, so that kidney, ovary, tube, and one horn of the uterus are want- ing. In the later stages of development one or both Miillerian ducts may be affected, resulting in absent, rudimentary or defective uteri. The ducts may fail to coalesce or form ap- parently well developed uteri and vagina, with a septum between ; or the coalescence may be partial. Failure to coalesce causes the development of separate and generally rudimentary uteri and vagina. Partial coalescence may involve only the vaginal portion of the tubes, with the two horns of the uterus com- pletely separated, making a double uterus, or it may be a bi- comate uterus joined together with a common neck; or the division may be in the fundus of the uterus only. In the devel- opment of the tubes, the inflammatory process which results in the arrest of development may affect one tube only, while the other goes on to full development. The rudimentary duct may encircle to some degree the well developed organ. Such a condition may result in the development of a uterus which is unequal to the proper performance of its functions and en- danger the life of the woman in a subsequent gestation, or the horn may be so well developed as to carry on its functions with- out the abnormality being suspected until some operative pro- cedure discloses, the actual condition. The rudimentary horn may in some cases be associated with an atresia of the corre- sponding vagina. Such a condition would not attract attention until subsequent to puberty, when fluid unable to escape would accumulate in the defective tube, forming a more or less defi- nite tumor. Such a tumor may be situated to one side of the vagina, but more frequently pointing somewhat anterior to the well formed canal. In a patient coming under my observation the woman had given birth to two children and was at that time a victim of a large interstitial fibroid growth in the uterus. Examination revealed a pouch to the anterior and right of the vagina, the character of which was not recognized until during the operation, when it was found that it was the blind pouch of a rudimentary uterus. The septa dividing the vagina pro- duced no appreciable influence and are unlikely to be discovered until after the marriage of the individual. The septum pro- duces so small a tube as to lead to discomfort and pain during the marital relations and to obstruction during parturition. The amount of obstruction, of course, in the latter will depend upon the thickness and firmness of the septum. Generally it ETIOLOGY. . O is torn through the greater part of its extent during parturi- tion. Occasionally, subsequent to parturition, a bridle or remnant of this septum will be found connecting the anterior and posterior wall of the vagina, the remaining portion of it having either been torn through or sloughed away as a result of parturition. The defective development may involve the lower part of the genital tube, affecting the vagina and vulva. Thus, there may be an absence of the urethra, a condition of hypospadias, in which the urethra opens into the vagina. The portion of the vagina may have undergone atresia or the vulvar orifice of the vagina may be closed by an imperforate hymen. These conditions are not likely to produce symptoms until the woman has reached and passed the period of puberty, when the occurrence of the menstrual moHmina without the pres- ence of a discharge indicates something abnormal. If the con- dition is not recognized a tumor will ultimately develop as a result of the retention of the menstrual discharge. The de- formities may affect the labia majora, the labia minora, the former being thin, a slight amotmt of fatty tissue, or the inguinal canal may remain open, permitting the secretion from the peritoneal cavity to descend into the sac, forming a hydrocele, or the intestine pushed down, causing hernia. The labia minora may be elongated or may be almost absent. The clitoris may be defective in its development or be so large and hypertro- phied as to lead to doubt as to the sex. This malformation may affect the genital organs of either sex, giving rise to uncertainty as to the sex of the individual under consideration, when it is known as hermaphroditism. True hermaphroditism, the presence of both organs in the same individual, probably does not exist. Pseudohermaphroditism, or a condition in which the organs of one resemble the other sex, are quite frequent. IMalforma- tions of this character, Avhich have occurred during the progress of the development of the ovum, are known as congenital con- ditions in contradistinction to those Ave have been considering as hereditary. 8. (b) Hygienic Causes. — Woman is hke a flower. To reach the highest development she must generously absorb the rays of the sun and drink deeply of pure air. Unfortunately, the tendencies of civilization have been to deprive her of these essentials at the period of life when she is in most need as she enters into womanhood. Her male companions, with whom until this time she has enjoyed almost equal freedom, are still permitted to enjoy the freedom of Nature, while she is con- demned to interest herself with indoor pursuits. No longer allowed to romp and play she is doomed to practice being a lady. Stiffly and often tightly dressed, she is compelled to 6 GYNECOLOGY. assume the attitude and thoughts of a mature woman, and what exercise she secures is taken so sedately as to be unworthy of that designation. At the period of hfe when the development of her sexual functions are making the greatest draft upon her nervous system, she is confined closely to her books and music, securing the accomplishments and embellishments which are to be her capital. At an early age she is introduced to society, and if fortunately (?) situated her life becomes a continuous whirl of parties and entertainments entailing late hours, irregu- lar meals, undue exposure, excitement, and a continual appeal to the emotions. Her social position demands that the natural contour of the body be distorted by tight dresses, which dis- place the viscera from their normal relations, increasing intra- abdominal pressure, and driving the pelvic organs to a lower level. The circulation in these organs is necessarily influenced by the interference with the venous return, thus causing stasis. The compression of the lower part of the chest interferes with the expansion of the lungs, with the action of the stomach, heart, and liver, so that the processes of nutrition are affected, and the individual suffers from anemia, neurasthenia, defective action of the digestive tract, and disturbances of the functions of the genital organs. The faults enumerated are still further enhanced by enveloping the central portion of the body with skirts supported from the waist, while the extremities are clad in network hose and thin shoes or slippers, and the neck, chest, and arms bare. She ordinarily will go fairly clad and make the above changes in the coldest weather; occupying crowded rooms, subject to drafts, and this regardless of the menstrual periods. Should it be surprising that serious pelvic disorders are frequent? That pelvic disease is the rule rather than the exception? The usual life of the young woman precludes regu- larity in the performance of her functions. The evacuation of her bowels and bladder are neglected. Retention of the con- tents of these viscera produce repeated displacements of the uterus which finally become permanent ; the failure to evacu- ate the bowels causes a toxemia which profoundly influences nutrition and produces toxic symptoms, in which the pelvic organs have a considerable part. Want of general cleanliness necessarily has a marked influ- ence upon the health and nutrition of the individual. The skin takes a very active part in the processes of elimination and must be kept in good condition by proper and systematic bathing to do effective work. Neglect of local cleanliness re- sults in the decomposition of the accumulating secretions from the vaginal tract, and the sweat and sebaceous glands of the vulva, which are to some degree soiled with urine. Such an ETIOLOGY. / accumulation forms an excellent culture fluid for micro-organisms and diseases of the vulva and vagina are thus produced. The retention of the smegma beneath the prepuce of the clitoris leads to irritation and adhesions between it and the glans, to irritation of the bladder, frequent micturition, wetting of the bed, to nervous disorders, sometimes convulsions, and frequently to masturbation. 9. (c) Sexual Causes. — With the development of puberty the sexual instinct dominates the female organism. Her view- point of life changes. However exalted her ambition to attain eminence in some unusual line the impetus to maternity cannot be extinguished. Less passionate, less lustful than man, she yet clings with greater constancy and devotion to the companion of her choice. Her more limited- sphere of action in life; her more delicately organized nervous system, renders her especially susceptible to the influence of the emotions. While the sexual desire or eroticism varies in individuals, the majority of women yield to the sexual relation through a desire to please the man rather than from any sexual inclination, from a desire to gratify rather than to be gratified. Many women experience no sense of pleasure during or as a result of the sexual act, and regard it as only a means to an end, viz., the retention of the affections of her companion and the production of offspring. Some women experience so much physical discomfort during the act and such a degree of nervous irritation following it as to cause them to regard the approach of the male with absolute disgust and re- pugnance. The life of a woman of the latter class with an erotic man — a man who is so selfish as to care only for his own gratification — ^becomes a "hell on earth." She considers herself a sexual slave, bound to a man whose only regard for her is as an instrument to minister to his passion. Whatever regard she formerly entertained for him soon becomes dissipated. Constant dwelling upon her sense of wTong and fretting against the bonds which envelop her, leads not only to the production of local disorder but to melancholia, hysteria, neurasthenia, and even mental derangement. Stimulation of eroticism by bad literature, by intimate association with the opposite sex, or by onanism, are prolific in the development of local disease. Long engagements, unless occasioned by separation, are prejudicial in that the frequent hyperemia produced by repeatedly awakened and unsatisfied longings causes chronic oophoritis. Equally disastrous is the union of a young erotic woman with an old and especially impotent man. The most potent factor to-day in the production of pelvic disease is consequent upon efforts to avoid maternity. Nature 8 GYNECOLOGY. has her revenge upon those who would violate her laws. When the natural result of the marital relation is avoided by withdrawal of the penis before the act is completed both parties to the act are injured. The incomplete discharge causes the man an irritation which produces a sensation of discomfort and unrest that leads to more frequent coition and consequent nervous exhaustion, or neurasthenia for both participants. The con- tinuous engorgement without the salutary influence of the com- pleted orgasm and the failure of impregnation produces a con- tinued hyperemia which renders the soil favorable for the de- velopment of the various pelvic inflammations. The deliberate indulgence of the sexual appetite with the premeditated inten- tion of avoiding its legitimate result, begets a lowered moral attitude toward the sexual relation. The w^oman who con- tinually avoids the possibility and responsibility of maternity becomes little more than her husband's mistress, indeed, it may often be questioned whether she is regarded so highly. If her sexual appetite be strong and she resents the apparent neglect of her husband, it does not become a long step for her to become the mistress of another. A woman so lost to the purpose of the marital relation will not hesitate to employ, or have employed, agents for the arrest of pregnancy when it occurs in spite of the precautions observed. Abortions or repeated abortions necessarily induce disorders of the pelvic or- gans. Nature makes her provision for the evacuation of the uterine contents when the fruit has matured and earlier separa- tion finds it unprepared to easily resume normal relations. Involution is less rapid and prone to be incomplete. Subin- volution, descent, displacements, chronic endometritis and metritis, periuterine inflammation, and tubal and ovarian disease are consequences of such interference. The genital organs may become so crippled as to render subsequent conception impossi- ble, or so irritated as to render the uterus unable to supply the necessary nutrition to mature the implanted ovum and abortion becomes the habit. 10. (d) Traumatic Causes. — The injuries to which the genital tract are subject may be accidental, the result of violent efforts at intercourse, consequent to parturition, or the result of opera- tive procedures. The accidental injuries are comparatively infrequent, and, while capable of producing cicatricial changes, are generally insignificant in their ultimate effects. Coition has produced laceration of the perineum, tearing off of a rigid and resisting hymen, tearing of the vagina, and the formation of rectovaginal fistula. The act of coition is most likely to produce severe injury in the very young or in the elderly virgin. The greater majority of injuries occur from lesions of parturi- tion. These may involve the body of the uterus, the cervix, ETIOLOGY. y the vagina, perineum, or pelvic floor, and the adjacent viscera. The lesion may be in the nature of a tear with healthy tissue which if kept free from infection soon heals, leaving only a more or less well marked cicatricial band, or as a result of long con- tinued pressure or bruising, is followed by extensive sloughing and loss of tissue, which, if recovery occurs, must be attended by deformity. Lesions of the genital canal are favored by malformations of the bony and soft part of the pelvis; small and contracted genital canal, undersize or malposition of the fetus, rigid and unyielding muscular structure, an inordinate amount of fat in the maternal tissues. Enfeebled muscular action and ineffective labor pains by which the tissues are sub- jected to long continued pressure between the bones of the fetal head and those of the pelvis, and the rash and unskilful employment of manual and instrumental manipulation. The prompt and skilful resort to assistance has greatly lessened the frequency of seyere lesions. It is true lacerations of the cervix and pelvic floor may be relatively more frequent under early interference, but such lesions are easily repaired and pro- duce far less serious consequences than the extensive destruc- tion of tissue resulting from protracted labor Any lesion of the pelvic floor becomes an avenue for the entrance of infection. Extensive lacerations of the cervix and pelvic floor interfere with the process of involution so that the organs are much longer in reaching the normal, which may be prevented by various sequels. In laceration of the cervix, in addition to subinvolution, the cervical lips are frequently separated, the posterior may undergo involution while the an- terior becomes hypertrophied. Increased secretion occurs from the cervical glands or superficial inflammation may lead to stenosis of the gland ducts and distention of the Nabothian glands until the entire cervix has undergone cystic degeneration. In some cases the torn surfaces may become cicatrized, fllling up the angles of the tear with wedges of cicatricial tissue, in which the nerve tendrils are imprisoned and pinched, produc- ing various reflex phenomena. Occasionally the pressure of the cervix against the posterior wall of the vagina will lead to turning of the lips, the posterior upward and the anterior down- ward, in which position they are held by indurated tissue within the injured surfaces. The resulting endocervicitis, thickened mucosa, and distended glands produce ectropion of the mucosa, which increases the separation of the lips. That this condition is an incentive to the occurrence of carcinoma of the cervix is made evident by the fact that this is most frequently found in the cervix and in the cervices of women w^ho have given birth to one or more children. Lacera- 10 GYNECOLOGY. tion of the pelvic floor in slight degree lessens the support of the viscera and retards involution, and the combination of de- creased support and increased weight of the superimposed viscera promotes descent, displacement, and chronic inflamma- tion. Laceration through the sphincter leaves the intra-ab- dominal pressure unantagonized and renders the patient unable to control the contents of the lower bowel. The enforced de- privation of society by this condition not infrequently results in melancholia and mental disturbance. Fistulous openings between the genital canal and the adjacent viscera produce con- stant soiling of her person with urine or feces, irritating the skin of the vulva and of the thighs, and make her a source of distress to herself and her friends. The discussion of the traumatic causes of pelvic disorder is incomplete if some consideration is not given to those which result from operative procedure. They are mostly the result of want of skill, improper technique, inexperience, and faulty judgment. No man should undertake pelvic surgery who has not had large opportunity for observation in diagnosis, and a careful training in surgical technique. Every surgeon is sad- dened by seeing patients who had not been seriously ill prior to a cureting, with conditions demanding sacrificial operations, women bemoaning the loss of ovaries, who from the history evi- dently did not require such a sacrifice. Patients with fistulae, hernia, adhesions, intestinal constrictions, living lives of misery and discomfort, who could have been readily restored to health had their operators been better trained. II. (e) Infective Causes.— Inflammatory diseases of the pelvis are with extremely rare exceptions the result of the pres- ence of micro-organisms. Those which are the most frequent in their baleful influence are the gonococcus, the staphylococcus, pyogenes aureus, the streptococcus, the bacillus coli communis, and the bacillus tuberculosis. The retention of portions . of tissue which are exposed to the atmospheric air through the introduction of the saprophites cause putrefaction and through the absorption of the resulting toxins develop high tempera- ture. The condition is denominated sapremia as contradis- tinguished from the multiplication of septic germs which pro- duces septicemia. The gonococcus is without question the most prolific source of infection and invades the vulvo- vaginal glands, the vagina, cervix, body of the uterus, the tubes, the ovaries, and the pelvic peritoneum. Its occurrence in a severe degree makes uncer- tain its subsequent cure. Certainly no case is cured in the sense of restoration to normal relations, nor can we be certain that the subsequent symptoms will be in the form of sequelae, for ETIOLOGY. - 11 numerous cases occur demonstrating recurrence of the disease without opportunity for fresh infection. Such attacks burst forth, following sexual excess, intemperance in eating or drink- ing or after exposure. Experiences of this character have been manifested when previous examinations of its secretions have demonstrated that the gonococcus was absent. Recent re- searches have seemed to demonstrate that the gonococci lapse into forms indistinguishable from pus cells or leukocytes and return to their characteristic form when galvanized into activity by some irritation. Such an explanation accounts for the re- infection in the previous A'ictim and its transmission by him to others. The gonococcus renders the soil by it infected more favorable for the reception and nutrition of other micro-organisms. The simultaneous action of some other organism w4th the gono- coccus is known as a mixed infection. The retention of decom- posing products and the occurrence of sapremia is also favorable for the development of the graver forms resulting in sepsis. Infection from the staphylococcus, or streptococcus, is always grave. Its progress depends upon the virulence of the infec- tion and the vital resistance of the patient. It may become promptly localized or rapidly infect the blood and ultimately result in death. The bacillus coli communis is most likely to expend its baneful influence upon the peritoneum of the ad- jacent structures. The tubercle bacillus may affect any portion of the genito -urinary tract. Next to the lungs it probably most frequently invades the peritoneum. 12. (f) Causes Incident to Age. — The most superficial obser- vation reveals that the age of the woman renders her more sus- ceptible to certain forms of disease. Some disorders are prone to occur at certain ages. The period prior to the manifestation of puberty is especially free from disorder. This is a period of quiescence. Even dur- ing this period we find the individual suifering from gonorrheal infection, producing vulvo-vaginitis, a condition requiring prompt treatment to prevent its extension to the uterus and, indeed, to the appendages, causing irrecoverable alterations. Ovarian growths occasionally manifest themselves during this period. A¥ith the advent of puberty the disorders multiply. Malformations render their existence recognizable in retention of menstruation, from atresia, vagina or uterus, or imper- forate hymen. A poorly developed uterus may be unable to readily perform its functions, so the patient suffers from dysmen- orrhea and sterility. During the years of active menstrual life, the chaste unmarried woman sufters from endom.etritis, oophoritis, the occurrence of mvomata, and chronic inflamma- 12 GYNECOLOGY. tion of the ovary. Ovarian tumor and occasionally carcinoma may be manifested. The latter in the virgin is most likely to affect the body. The married woman, while possibly slightly less susceptible to myomata, suffers from infection, producing endometritis, metritis, salpingitis, oophoritis, and periuterine inflammation, either perimetritis or parametritis, or the two combined. She is more prone to cervical carcinoma from the injuries the cervix receives during parturition. Infections are much more prone to be found in such patients from their greater exposure in the contingencies incident to the sexual relations, the possible inter- ruption in the course of pregnancy, and the increased exposure at the period of parturition. Carcinoma, while possible at any period, is more prone to manifest itself at or near the menopause, ovarian cystomata are more frequent during this period, but may occasionally develop before or after the period of menstrual life. Subse- quent to the menopause carcinomata, prolapsus, and senile en- dometritis are the affections most frequently seen. 13. Difficulties in Study. — The discussion of etiology has demonstrated the difficulties in the study of gynecology, but will be found no less marked where the student essays a correct diagnosis. Probably no department of medicine interposes greater barriers to its accomplishment. In the study of the dis- eases of women much must depend upon proficiency of touch, which is acquired only b}^ extensive practice. The delicacy and proficiency of this sense varies so greatly in different indi- viduals that it is difficult to convey an adequate idea of the relative hardness or softness of the structures under observa- tion. The ovaries and tubes in which important lesions occur are in many patients quite inaccessible to the ordinary methods of examination. Pathologic lesions must often, then, be the sub- ject of inference or speculation, rather than capable of absolute demonstration. To render the study of symptoms more difficult, the suggestion that she must subject herself to examination is repugnant to the modesty of every woman, and the disease ex- ists in organs so sensitive that manipulation can not be repeated by a number of persons in succession. The patients who are willing to be brought before a class of students and subjected to such examination are exceedingly few, consequently many practitioners must enter upon their vocation with but little or no practical knowledge of the subject. 14. Observation. — The cultivation of habits of close observa- tion is of the utmost importance. The observing physician will generally be able to determine with considerable accuracy the cir- ETIOLOGY. . 13 cumstances, condition, and diseased state of the patient from her conduct, manner, and general appearance. Thus, a woman with an abdominal enlargement who enters a physician's office with a face presenting the rosy hue of health, and appears well nourished, would naturally be suspected of suffering from a physiologic rather than a diseased condition, and would be pronounced pregnant; while such an enlargement associated with a pale countenance, an emaciated face, thin cheeks, and sunken eyes would be re- garded as indicating an ovarian growth. This special association of the features is known as fades ovariana, and is of value in forming the diagnosis. The conduct and deportment of the patient will frequently announce whether she is married or single ; her manner of walking or sitting, the existence of a pelvic inflammation. 15. Exercise of Judgment. — Errors in diagnosis are most fre- quently the result of hasty conclusions founded upon insufficient investigation. The recognition of the existence of some lesion is at once accepted as an explanation for all the distressing symptoms. The accurate diagnostician will not come to a con- clusion until a careful and thorough examination of every organ capable of producing such symptoms has been made. 16. Value of Notes. — The young physician should accustom himself to taking notes of his office cases ; he thus forms the habit of more careful and systematic investigation of every patient, accumulates data from which he is enabled to formulate more definitely judicious plans of treatment, and, probably most im- portant of all, has the means of refreshing his mind from time to time as to the condition of any particular patient. 17. History. — The notes should record the name, residence, age, condition of patient, married or single, family history, per- sonal history (as previous sickness, duration of present illness, supposed cause, progress, and symptoms). Menses: first appearance, regularity, duration, what changes have since occurred; present habit, date of last menstruation. Pain, whether it precedes, accompanies, or follows the periods, its character, severity, and where experienced. Leiikorrhea: amount of discharge, duration, continuance, color, consistence, and effect upon the parts with which it comes in contact. Number of children or miscarriages:' character of labor and convalescence and the influence upon subsequent health. Coition: painful, sensation, frequency, methods employed to avoid conception. Interrogation of other organs: regularity of alvine dejections, frequency of micturition, digestion; pain in head, in lumbar region, in groins, doAvn the limbs, etc. 14 GYNECOLOGY. The inquiry need not, possibly should not, in all cases pursue the order here laid down. In some instances it will be better to permit the patient to tell her own story ; in others it will be neces- sary to guide her course by an occasional judicious question, or to assume the position of questioner, and patiently endeavor to secure a complete history. While the appearance and the char- acter of the symptoms may indicate a certain interpretation, the physician should reserve his judgment as to the condition until the testimony of subjective and objective symptoms has been completely secured, and then arrive at the diagnosis after their careful analysis. DIAGNOSIS. i8. Subjective Symptoms. — The subjective symptoms are those which are elicited from the patient or her attendants. As already asserted, the difficulty experienced in determining the physical signs frequently make these symptoms of great value. Every such symptom, however, must be carefully weighed, as both patient and attendants are prone to exaggerate the charac- ter and severity of symptoms or may err in observation and in interpretation. 19. Causes of Error. — Lisfranc* writes: "By their almost latent state, their great variety of symptoms (often very transi- tory), their sympathetic effects on all parts of the economy, and their immense influence on the nervous system, uterine diseases are peculiarly apt to lead medical practitioners into errors of diagnosis." The reason for these errors is the difficulty in understanding their cause. The uterine symptoms are not always the most prominent, are slowly developed, and do not always attract the attention of the patient. Not infrequently is the physician con- sulted for disorder of the stomach, of the heart, or of the liver; for vomiting, nausea, want of appetite, or diarrhea; for neuralgia or hysteria ; for a train of evils having their origin in poverty of the blood, as chlorosis, anemia, emaciation, and exhaustion — all of which may be symptomatic manifestations of an obscure uterine malady. 20. Method of Procedure. — The examiner should proceed from general to local symptoms so systematically as to bring the patient to the conviction upon the completion of the exami- nation that the only logical outcome is a physical investigation of her pelvic organs. *" Cliliique Chirurgicale de la Pitie," vol. 11, p. 182, Paris, 1842. DIAGNOSIS. 15 21. General Symptoms. — In many women the general or constitutional symptoms are so predominant, as to wholly ob- scure the diagnosis and cause both patient and physician to believe that organs other than those of the pelvis are directly at fault. The symptoms of which complaint will be most fre- quently made are gastric, such as gastralgia, nausea, vomiting, perverted appetite, anorexia, and regurgitation associated with a clean tongue. Nausea and obstinate vomiting are likely to be associated with ovarian disease. Intestinal indigestion, indicated by gaseous distention, the formation and absorption of toxins, produces disturbed sleep, unpleasant dreams, perver- ted nutrition, and neurasthenia. Nervous anesthesia affects portions of the lower extremities, as over the front of the thighs. It is especially prone to extend to and involve the clitoris, geni- tals, and vagina, when all sexual desire and pleasurable sensa- tion during coition become lost. This condition is particu- larly associated with retrouterine inflammation complicating retrodisplacement . 22. Visceral Neuralgias. — The bladder and rectum are not alone the seat of pain, but remote organs are also affected, such as the liver, stomach, intestinal canal, and heart. Patients not infrequently suffer from symptoms which cause them to believe themselves the victims of a serious disorder of the heart, which entirely disappear upon proper treatment directed to a pelvic lesion. 23. Neuralgia in the lumbar and dorsal regions, — intercostal neuralgia of the left side, — leading the patient to fear the exist- ence of organic heart disease, is common. The trifacial nerve may be involved, producing the sensation of a nail being driven into the head. Sympathetic pains are frequently noticed in the heart, with a sensation of swelling, especially marked during menstruation. I have often observed intense pain in the breast associated with a chronic inflammation of the correspond- ing ovary. The pain is usually ameliorated or absent during menstruation, but aggravated during the menstrual intervals. 24. Motor and sensory paralysis is not an infrequent con- comitant of uterine disorder. It is sometimes difficult to rec- ognize its cause. Occasionally it is unquestionably due to hysteria, but numerous cases can be cited where the replacement of a retroverted uterus has resulted in the rapid restoration to health of patients who were apparently suffering from complete paraplegia. I have seen a patient in whom the incoordination of motion was so marked as to lead to the diagnosis of advanced locomotor ataxia recover without a vestige of the disorder subsequent to an amputation of a hypertrophied and inflamed cervix and the repair of a relaxed pelvic floor. 16 GYNECOLOGY. 25. Disorders of Nutrition. — Every physician is familiar with the profound influence upon the processes of nutrition fre- quently engendered by the occurrence of pregnancy. It does not seem unreasonable to anticipate that the substitution of a pathologic lesion for a physiologic condition will exert equal if not greater disturbance of these processes and an impoverished condition of health necessarily results. The conditions which will most frequently occur are chlorosis, anemia, and general debility. 26. Chlorosis is found in poorly nourished girls, who suffer from it at puberty, or in women during pregnancy, and is often a result rather than the cause of the pelvic disorder. 27. Anemia may occur at any age. In the earlier periods of life it may be both a consequent and a cause of pelvic disease. It is especially associated with chronic inflammation of the uterus and appendages. It is marked in uterine myomata of the inter- stitial and submucous varieties, in the various forms of malig- nant disease, and in chronic inflammation of the urinary tract. Repeated and prolonged hemorrhages, continuous leukorrhea, loss of rest from pain, or from frequent micturition are contrib- uting causes. The condition is indicated by loss of color in the skin, transparency of the tissues, local edema, frequent weak pulse, and general debility. These disturbances of nutri- tion are accompanied not only by general debility, but also by progressive emaciation, until the disorder producing them has been corrected. Under the influence of the diseased con- dition the patient becomes prematurely aged. The head is stooped, the limbs are bent, the features are drawn, and she presents a look of suffering; the flesh is soft and flabby; the countenance is expressionless, the complexion pale and faded, especially when leukorrhea has been long continued and profuse. The paleness is different from that of ordinary anemia ; it causes the characteristic appearance that has been recognized under the name of fades uterina (Courty). Emaciation may not always be present; on the contrary, the patient may sometimes be corpu- lent, particularly when amenorrhea, rather than leukorrhea or hemorrhage, occurs. The obesity is sometimes so great as to lead the patient to believe herself pregnant, and not infrequently, while suffering severely, she is congratulated by her acquaint- ances upon her excellent appearance. 28. Local Symptoms.— Disturbances of function and dis- agreeable sensations which are directly traceable to the genital organs and the structures in immediate association with them are designated as local symptoms. These symptoms comprise: discomfort in sitting, a sensa- tion of weight and pressure in standing or walking, heat and DIAGNOSIS. 17 burning in the vagina, pain upon movement, tenderness to pressure over the abdomen, frequent and painful micturition, more or less profuse discharge, absent, too frequent, irregular, and painful menstruation, pain during the act of coition or even upon touching the vulva, and a sensation of distress and aching following the sexual relation. Reflex phengmena from the rectum or bladder, or, on the other hand, sympathetic irri- tation of the uterus, when either of the former organs is the seat of disease, are very common, and the frequency of their occurrence can be appreciated when aa'c remember that the nerve supply to the uterus, rectum, and vagina is derived from the cervico-uterine ganglia of the hypogastric plexus. 29. Rectal Reflexes. — It is not unusual to find that during menstruation women suft'er from diarrhea, proctitis, and rectal tenesmus. The pelvic vascular system is so general that en- gorgement or inflammation of the uterus Avill not fail to produce congestion in the other pelvic organs; and in any marked in- flammation of the organ, associated with displacement, and par- ticularly in retrodisplacements, the hemorrhoidal vessels will be found to be distended; thus, hemorrhoids in the female very frequently result from the presence of retrodisplacements of the uterus, and these should never be subjected to operative treatment until the displacement has been corrected. In anteversion the cervix Avill frequentty be found to project against the anterior wall of the rectum, and can be readily distinguished through this viscus. When the cervix is inflamed, the im- pingement of hard fecal matter against the organ not infrequently causes severe pain. In some cases this pain is experienced only during menstruation. The most frequent functional dis- order of the rectum is constipation; partly from neglect, and partly from want of nerve irritation, the bowel becomes fllled with fecal matter, the watery portions are absorbed, and hard, dense, scybalous masses form, which are evacuated with difliculty, and possibly only after repeated enemata. The muscular coat of the bowel becomes distended, loses its tone, and results in a form of paralysis ; fecal matter undergoes decomposition, is partly re- absorbed, and causes the condition which Barnes has denominated as copremia, in which the skin is of a sallow, dirty hue, presenting ill-smelling secretions; the patient suft'ers from dyspepsia, flatu- lence, and pyrosis — a condition akin to that known as uremia. The violent efforts at evacuation of the bowels lead not only to the formation of hemorrhoids, fissure, sometimes fistula, but they may, through the increased intra-abdominal pressure, cause dis- placement of the uterus and the vagina. When fissures exist, the pain during defecation is so great that the patient is likely to per- 18 GYNECOLOGY. mit the bowels to go unevacuated rather than endure the result- ant pain. 30. Vesical Reflexes. — The relation of the bladder to the uterus is more intimate than that of the rectum, and consequently this organ is much more likely to be affected in inflammatory conditions of the uterus. Retention of the urine may be pro- duced by pregnancy or by pelvic growths, such as fibroid tumors or tumors of the ovaries. Sometimes also, as a result of irritation of the orifice of the vagina, a condition known as vaginismus occurs. The pain may be so great as to produce a spasmodic contraction of the sphincter of the bladder. The most usual functional derangement of the bladder, however, is frequent micturition. It may occur as the result of reflex irritation from the pelvic organs, or in consequence of pressure from the uterus, produced by the presence of a tumor or by a pregnant uterus or a displaced organ in which either the fundus rests forward upon the bladder or is turned backward, causing the cervix to press against the latter. Either of these conditions may lead to functional derangement of the bladder, so marked as to cause the patient to suspect the existence of disease of that organ, or, as she will more probably say, disease of the kidneys. 31. Genital Symptoms. — The symptoms attributable to the genital organs are derangements in the performance of their functions. The particular symptoms are disturbances of men- struation, such as a decreased, an increased, or an irregular menstrual flow, the existence of sterility, the presence of pain and excessive discharge ; consequently, in determining the history of the patient, if she is married, we endeavor to elicit information regarding previous pregnancies and the character of the labors. Sterility in a woman who has been married for a number of years is an indication of some abnormal condition. It may be due to a malformation, to functional disturbances, to actual disease, or to efforts to avoid the responsibility of maternity. It should be remembered, however, that there are cases of relative sterility. The most unvarying function of the uterus is that of menstruation, consequently some disturbance in the performance of this func- tion is one of the first indications of the existence of uterine dis- order. Amenorrhea is a term employed to designate absent or greatly decreased menstrual flow; menorrhagia the flow, which though regular, is increased, and the menstrual period lengthened ; metrorrhagia a flow that does not correspond with the regular periods; while dysmenorrhea indicates the existence of pain occurring at the beginning of, during, or immediately following the menses. These conditions will be considered more fully later. 32. Hemorrhage is by no means a constant symptom of DIAGNOSIS. - 19 Uterine disease. Its significance varies according to the amount of blood lost and the time of life at which it occurs. During the earlier periods of menstrual life it is not uncomxmon for the menses to be very profuse, as a result of defective development of the ovaries or ovarian hyperemia. AVhen hemorrhage occurs in women who have borne children, it may be produced by inflam- mation of the mucous membrane of the uterus — hence a hemor- rhagic endometritis. Hemorrhage is a usual symptom of fibroid groAvths of the submucous variety. Uterine polypi, whether due to a fibroid growth or to vascular growths upon the endometrium, are a very prolific cause near the climacteric. The occurrence of hemorrhage subsequent to the menopause should always cause the ph^^sician to suspect the possibility of malignant disease in either the mucous membrane of the cervix or the body of the uterus. When hemorrhage occurs during or following pregnancy, it is probably due either to a threatened abortion or to retention of portions of the fetal envelopes. It should not be forgotten, however, that hemorrhage may occur from cystic disease of the ovaries, and in some cases in which the pelvic organs present no lesion, as from valvular disease of the heart, Bright's disease, and obstruction of the portal circulation of the liver. The occurrence of hemorrhage should always be re- garded as an important danger signal, and should be considered as demanding careful investigation to elicit its cause. 33. Pain is a very frequent symptom, and may be associated with the menstrual function, when it is known as dysmenorrhea, or may be independent of it. When it occurs during coition, it is called dysparennia (Barnes). It may be dependent upon, first, vaginismus; second, chronic nervous irritability due to in- complete or awkwardly performed first coitus; third, infiam- mation; fourth, tumors; and fifth, malformations. 34. Seats of Pain. — Courty describes six seats of pain, three of which are principal and three accessory. The principal seats are, first, the iliac regions; second, the loins; and, third, the hypogastrium. 35. The iliac pain is the most frequent ; it is felt in the region of the iliac fossa, and extends from it to the hypogastric and lumbar regions, particularly toward the pelvic brim and cavity. This pain is most often felt upon the left side. It is probably due to tension of the broad ligament, and occurs upon the left side more frequently on account of the arrangement of the circulation through the veins. The left ovarian vein enters the left renal at a right angle, and passes behind the sigmoid flexure of the colon to reach it. The frequent impaction of this portion of the gut with feces would account for the obstructed circulation. Courty ascribes pain in this region, hoAvever, to the inclination 20 GYNECOLOGY. of the uterus to the right ; hence any increase in size of the organ causes a gradual dragging upon the left broad ligament. 36. Lumbar pain, generally spoken of as backache, is felt in the lower part of the lumbar region, sometimes extending to the region of the kidneys, and, in others, and more frequently, down over the sacrum. In some cases the abdomen is encircled as with a belt of pain. This pain is usually ascribed to traction upon the uterosacral ligaments. It is doubtless not infre- quently due to retention of secretion w^ithin the cavity of the uterus, by which that organ is obliged to go into labor in order to secure its expulsion. Its presence indicates disease of the cervix ; when it is particularly marked in the sacrum, it is the probable result of retrodisplacement of the uterus. 37. Hypogastric pain is experienced above the pubes, and, more than any other, seems to have its origin in the uterus. It is elicited artificially, rather than occurring spontaneously. Patients w^ho do not experience it ordinarily, complain as soon as pressure is made over the lower portion of the abdomen. This pain is greatly aggravated in walking, so that the patient not in- frequently experiences the necessity of support over the hypogas- trium by means of a belt or by placing the hands in front, partly for support and partly for protection against injury. 38. The accessory seats of pain Courty ascribes first to the anus or perineum; second, to the vagina or cervix; and, third, to the cavity of the pelvis. 39. The anal or perineal pain is usually produced by a retro- uterine tumor or retroflexed uterus. Patients with hypertrophy of the cervix not infrequently suffer pain in the anus or perineum while walking or riding, and often when sitting. 40. Vaginal pain is not so frequent. It is felt in women who have inflamed uteri, particularly during an orgasm. 41. Pelvic pain results usually from inflammation about the uterus or from inflammation of the tubes, fixation of the ovaries, or when organs have become cystic or the seat of pus collections. 42. Leukorrhea. — Leukorrhea, or whites, is a term given to discharges other than sanguineous that occur from the genital tract. To appreciate the significance of a discharge as an indica- tion of disease, we must recognize the character of the normal or physiologic secretion. 43. The secretion from the Fallopian tubes and cavity of the uterus is a thin, whitish alkaline fluid; that from the cervical glands is also alkaline, but is very viscid, tenacious, and trans- parent like white of egg. 44. The secretion of the vagina and vulva is whitish, made up of a serous fluid intermixed with scaly epithelium. The DIAGNOSIS. 21 vulvar discharge also contains oil-globules from the sebaceous glands. The secretion of both vagina and vulva is acid. The superfluous discharge from the cervix is coagulated by that of the vagina, forming a smeary material at the upper part of the vagina, and will be found to coat over the surface of a pessary. When the cervical fluid is in excess, it may pass from the vagina unchanged and perfectly transparent. Another discharge or secretion is that which takes place from the vulvovaginal glands during coition or under excitement. This is a clear, viscid discharge. In very erotic women this dis- charge is ejected upon the approach of a person of the opposite sex, and nocturnal discharges occur during erotic dreams. It is sometimes difficult to determine whether a discharge is the result of over -stimulation of a physiologic secretion, or is pro- duced by a pathologic condition. 45. Catarrhal Discharge. — A profuse discharge is not an infrequent result of exposure to cold. An increased secretion from the uterine glands occurs instead of the ordinary nasal flow. A hypersecretion which results from the hyperemia of the preg- nant uterus may be considered physiologic. In some undeveloped and strumous young women a leukor- rhea occurs as a substitute for the menses. In many individuals a slight leukorrhea, preceding or following the menses, has no abnormal significance. 46. Origin of Discharge. — The source of origin of an abnormal discharge can be determined to some degree by its appearance and character. When from the cavity of the uterus, it will be a thin, watery fluid, loaded with ciliated columnar epithelium, and containing also pus and blood-corpuscles, according to the extent of the disease. 47. Discharge Simulating Abscess. — The discharge may be a continuous flow, but more frequently it is intermittent, due to defective drainage from swelling of the mucous membrane of the outlet, which leads to dilatation of the cavity and not in- frequently of the orifices of the tubes. The uterus then empties itself only by occasionally going into labor to evacuate its con- tents. Such a fluid, loaded with pus and blood-corpuscles, coming away in gushes, leads the patient to believe that an abscess has formed and been evacuated. Patients will not infrequently inform you that they have abscesses form and discharge at short intervals. The conditions described, however, may not be the only explanation. An accumulation in a tube, the uterine end of which is still patulous, may occasionally drain through the uterus. Such a condition has been denominated hydrops tuhce profiuens. 48. Other sources for purulent discharges are found in the 22 GYNECOLOGY. rupture and escape into the vagina of the contents of a tubal or peritoneal abscess, of a suppurating ovarian tumor, of an extra -uterine pregnancy sac, or of an abscess about the vermi- form appendix. 49. Cervical Discharge. — The discharge from the cervix is usually very viscid and tenacious ; it may be clear and transparent, or clouded by desquamated epithelium and filled with pus-cells, when it is yellowish or greenish-yehow in color, or it may be a dirty brown from admixture Avith blood-corpuscles. The cervix will usually be dilated and patulous, its membrane thickened, abraded, and covered with papillae. 50. Vaginal Discharge. — A thin, serous discharge flows from the vagina in simple inflammation; in more severe attacks it is loaded with epithelium, and the vagina is red and inflamed and has apparently shed its entire epithelial coat. When due to gonorrhea, the discharge is profuse, purulent, ichorous, irritating to the external parts, and attended with a burning sensation during micturition. 51. Effect of Age upon the Discharge. — The significance of the discharge is also dependent upon the age and physical condition of the patient. Prior to puberty it is usually due to irritation of the vulva, and is thin and serous, resembling that from eczema. After puberty, in the unmarried, it is generally vaginal. In the more mature and in married women it is usually uterine. As the individual approaches puberty the vulvar discharge becomes more oleaginous from the secretion of the sebaceous follicles. Not infrequently, in uncleanly persons, the secretion from these glands is so abundant that it decomposes and sets up an inflammation similar to the blennorrhea of the male. Prior to or following the climacteric a thin, watery flow, of a sweetish, sickening, or decayed-flesh-like odor, should be considered a strong premonition of cancer of the uterus. 52. Physical Signs. — The careful study and analysis of the subjective phenomena may afford an approximate idea of the disorder present, but the diagnosis should not be attempted until the objective symptoms, or physical signs, have been in- vestigated. 53. Senses Employed. — In the study of the physical signs all the senses except that of taste are employed : The sight is used in inspection of the abdomen and external genitalia and in examining the internal organs by the use of the speculum. The touch is practised in abdominal palpation and percussion, in simple vaginal or rectal touch, in conjoined manipulation, and in the use of sound or catheter. The hearing is employed in percussion and auscultation. The smell is exercised in the examination of discharges. DIAGNOSIS. 23 54. Examination. — The investigation of the physical signs is called an examination and may be made through the vagina, rectum or' urethra, or a combination of one or more of these with pressure over the abdomen. 55. Pelvic examination comprises inspection, touch, and in- strumental investigation. 56. Abdominal examination may be classified under inspec- tion, palpation, percussion, auscultation, and exploratory punc- ture or incision. 57. Preliminaries. — The verbal examination should have been so conducted that upon its completion the patient will be im- pressed w^ith the fact that a physical examination is the only logical conclusion. The examination may be made upon a sofa or a common bed, as would be the custom when made at the home of the patient ; but in office practice it will be found more convenient to have provided a suitable table or chair. The choice of table will depend upon the custom and conve- nience of the operator. One made by Codman & Shurtleff , of Boston, known as the Chad wick table, is very satis- factory. (Fig. I.) In the first examination for the con- sideration of obscure condi- tions the clothing should be loosened and corsets removed, so that the abdominal walls can be completely relaxed. The bladder and rectum should be empty. The latter suggestions are very important in order to permit_ the normal relations of the uterus and its adnexa to be determined. Fecal accumulations have been mistaken for ovarian and tubal en- largements or inflammatory exudates. A distended bladder has been confounded with an ovarian tumor. The patient should be so placed for examination that the pelvis will be exposed to a good light. 58. Positions. — The patient may be placed in one of six positions for examination: viz., (i) dorsal; (2) lateral; (3) semi- prone (Sims); (4) genupectoral ; (5) Trendelenburg; (6) erect. Of the positions named, the dorsal and Trendelenburg are the most important. 59. The Dorsal Position. — The patient lies upon her back, with the hmbs flexed and feet placed upon supports. The feet may be on a level with the buttocks or placed on supports a Fig. I. — Chadwick Table. 24 GYNECOLOGY. foot higher. The latter affords greater relaxation to the ab- dominal muscles. The clothing is lifted over the knees. The lower part of the body has been previously covered with a sheet, which is folded about the widely separated limbs, and permits the inspection of the vulva. (Fig. 2.) This position permits the ready practice of the bimanual examination, and is the most favorable for vaginal and abdominal palpation and for the use of the valvular and Edebohls' specula. For operative procedure the dorsal position may be favorably modi- fied by strongly flexing the legs upon the body, in which posture they may be retained by assistants, or the employment of a suitable leg holder. 60. The Lateral Position. — The patient lies upon the left side, with the limbs at a right angle to the body. This position was formerly much used by English gy- necologists, and was pre- ferred because it permitted examination to be made without danger of touching the tender structures at the anterior part of the vulva. This position was thought less vulgar, and it allowed the finger to follow more readily the curve of the sacrum and to reach with greater ease the highly situated cervix. Its chief advantage, however, is in permitting more minute in- vestigation of the lateral fornices of the vagina. In abdominal palpation it affords increased opportunity to recog- nize changes of position of tumors and displacements of the viscera, particularly of the kidney. 61. The Semiprone or Sims* Position (Fig. 3). — The patient is placed upon the left side and chest, with the left arm behind her, the left leg partly extended , the right being flexed at a right angle to the body. The intra-abdominal pressure is neutralized. The mobiHty of the uterus is readily determined, replacement more easily accomplished, and some anteflexions recognized as the organ falls forward that are not apparent in any other posi- tion. The chief value of the position is in the use of the Sims' speculum. Fig. 2. — Dorsal Position. DIAGNOSIS. 25 62. The genupectoral position (Fig. 4), also called the knee- chest position, is one in which the patient rests upon the chest and knees. The left side of her face rests upon her left hand. The Fig. 3. — Sims' Position. Proper Method of Holding the Specukim. thighs are at right angles to the surface of the table. The chief value of this position is in replacing a retrodisplaced uterus or Fig. 4. — Genupectoral Position. Organs Shown in Outline. prolapsed ovary, or for elevating from the pelvis a more or less impacted tumor. 26 GYNECOLOGY. 63. The Trendelenburg Position. — The patient lies upon her back and on a plane inclined at an angle of 45 to 60 degrees, with the feet and legs ovei: a flap of the table. (Fig. 5.) Heavy patients should have additional support by the application of shoulder pieces. Pryor modified the position by supporting the patient from the shoulders and flexed the legs upon the body for the pur- Fig. 5. — Trendelenburg Position. pose of examination of the pelvic viscera free from the intestines, which gravitate upward when free to do so. This posture is of especial value in cystoscopic investigation of the bladder. The greatest value of the Trendelenburg posture is in the free- dom of view afforded in abdominal section, permitting the operator to employ the sight as well as touch in the manipulation. PELVIC EXAMINATION. 27 64. The erect position is of limited application. The patient stands with feet separated, with one hand resting upon the shoulder of the physician, while he sits or kneels before her and introduces the index-finger into the vagina. The chief value of this position is in determining the amount of downward displace- ment of the pelvic contents and in securing ballottement in the early stages of pregnancy. PELVIC EXAMINATION. 65. Inspection. — The patient is placed in the dorsal position. (Section 52.) In the first examination of every patient a visual examination should always precede the practice of touch. By carefully arranging the clothing this can be done without shock- ing the sensibility of the most modest. It affords information as to the cleanliness of the patient ; the presence of pediculi ; venereal warts or sores ; malformations ; traumatisms ; eruptions upon the vulva; tumors of the labia majora; elongation and thickening ot the labia minora; hypertrophy of the clitoris; elongated or ad- herent prepuce ; lacerations of the perineum ; presence of hemor- rhoids, ulcerations, or fissures; urethral caruncle; anomalies of the hymen; cystocele; rectocele; prolapse of the uterus; and the quantity and character of vaginal discharge. Inspection may be a simple preliminary to the touch. 66. Simple Touch. — The pelvic floor presents three apertures or perforations: the urethra, the vagina, and the anus — through either one or all of which an exploration may be made. The vagina is the route usually chosen as affording the best oppor- tunity for securing the most extended information. 67. Preparation. — The hands should be carefully cleansed. Independent of any possible danger of conveying infection, the educated woman will be doubtful of the physician who proceeds to her examination with unclean hands and nails. The latter should be cut close. Either hand may be used in examination. In some cases it may be desirable to use first one and then the other. When the vagina is sufficiently roomy, two fingers should be introduced. This affords additional length and surface for touch. The fingers should be lubricated with soap or some un- guent, such as carbolized alboline. The soap is preferable, for in washing it is removed with the secretions ; but in some patients, however, it aggravates any existing irritation. 68. Procedure. — The physician with one hand separates the vulva in order to avoid carrying up the hair, and holds the labia separate as he proceeds to make the digital investigation. Press- ing back the perineum, the finger or fingers more easily enter, 28 GYNECOLOGY. and without impinging against the anterior delicate structures. The perineum may be depressed with the index finger while the middle finger is inserted above it, thus permitting the employ- ment of two fingers with but little discomfort. The unemployed fingers of the hand can be carried back, either extended or closed, but the latter shortens the distance accessible to touch. (Fig. 6.) The touch affords information as to the presence of cysts in the labia ; the size of the vagina ; relaxation of its walls ; condi- tion of its mucous membrane; amount of secretion; the con- tents and tenderness of the rectum; inflammation and projec- tion of the urethra; tenderness, prolapse, and distention of the bladder; and relation of the uterus to the vaccinal axis. In Fig. 6. — Proper Position of Fingers for Examination. its normal position the cervix looks backward, the axis of the uterus being nearly at right angles to that of the vagina. The situation, size, and density of the cervix are recognized. It may be normal, lacerated on one or both sides, or. present a number of fissures — a stellate laceration. Its lips may be soft and velvety, from enlarged papillse; nodular, from enlarged or cystic Nabothian glands; widely everted and dense, from chronic inflammation following laceration; enlarged and indu- rated, from chronic inflammation or malignant infiltration ; en- larged, friable, or excavated in epithelioma. The os will be a slightly transverse depressed dimple when normal, or when PELVIC EXAMINATION. 29 abnormal, will be fissured laterally, bilaterally, through the anterior or posterior lip, or in a number of directions. It may be firmly closed or may stand open to such a degree as to ad- mit the finger. The spaces about the vaginal projection of Fig. 7. — Half Section of the Pelvis with Patient Erect, Showing Normal Position of the Uterus. — (Deaver.) the uterus are known as the fornices. The posterior fornix is the deeper; the anterior is slight. The resistance and density recognized indicate the existence or absence of inflammation. 30 GYNECOLOGY. A mass in the posterior fornix, if continuous with the cervix, the axis of which is paraUel to that of the vagina, is a retro- version of the uterus. If there is an angle between it and the cervix, the condition may be a retroflexion of the uterus, a tumor of the posterior uterine wall, an enlarged ovary or tube, or an inflammatory exudate. Digital examination also affords an idea of the mobility of the uterus, but the investigation is con- fined to the lower segment. 69. Bimanual procedure, also called the conjoined manipu- lation, or vagino-abdominal touch, affords definite informa- tion. In every examination the introduction of one or two fingers into the vagina should be associated with the application of the fingers of the other hand upon the abdomen. The external hand may be placed about midway between the symphysis and umbilicus, pressing downward upon the anterior abdominal wall. It may be moved from one side to the other, in order to examine the contents of the pelvis. This procedure enables us to outline the size, shape, density, and situation of the uterus, and to deter- mine the presence of growths in its walls and its relation to other pelvic growths or to inflammatory deposits. The normal tube is rarely palpable. When it is readily perceived, it has been the seat of an inflammatory condition. The ovaries are more easily recognized. To arrive at a definite conclusion in an obscure case, it is better to introduce into the vagina one or two fingers of the hand corresponding to the ovary to be palpated, as the extreme rotation necessary to bring the sensitive surface of the finger in contact with a small mass diminishes the sense of perception. (Fig. 8.) 70. Difficulties. — The bimanual examination is rendered diffi- cult by a large deposit of fat in the abdominal wall and by rigidity of the abdominal muscles. The latter is sometimes so marked that the patient can not relax the muscles, and the deter- mination of the pelvic condition is unsatisfactory. When this is due to nervousness, much can be accomplished by allaying the patient's fears and securing her cooperation. Have her breathe with the mouth open, fill her lungs, and then expel the air, while the hand over the abdomen depresses the wall during expiration, and thus secures an outline of the pelvic organs. The procedure may sometimes be rendered less difficult by diverting the patient's attention through inquiries regarding other symptoms. When the resistance can not be overcome, or the sensitiveness arises from an inflammatory condition, or the abdominal walls are very fleshy, an anesthetic may be necessary. 71. Virgins. — It is often a serious question to determine when an examination should be made upon a young unmarried woman. It should be the rule to avoid such an examination, unless the PELVIC EXAMINATION. 31 symptoms are of such a character as to indicate the existence of conditions which endanger her health. The regular occurrence of menstrual molimina, without the appearance of bloody dis- charge, after the age when puberty should be expected, must be considered an indication for a physical investigation. In many patients requiring a digital examination the procedure can be accomplished through the rectum. Where a vaginal examina- tion by the finger seems indispensable, the discomfort can be ^^PK»„ Fig:. 8. — Bimanual Examination. lessened by carefully lubricating the examining finger and directing the patient to bear down as it is being introduced 72. Rectal Touch. — (The rectal touch, recto-abdominal [Fig. 9], rectovagino-abdominal, or rectovesical touch.) The routine practice of digital examination by the rectum in the first in- vestigation of a patient is to be commended. The finger should be carefully washed after removal from the vagina and before its introduction into the rectum, and vice versa. Neglect of this 32 GYNECOLOGY. precaution may lead to a severe proctitis from the introduction of infectious material. The anointed finger, first directed for- ward, and after its entrance carried baclrv^^ard, is gently rotated. It enables us to recognize the condition of the rectum ; the pres- ence of fissures; hemorrhoids, ulcerations; contractions of the sphincter; sensitiveness of the coccyx; encroachment upon the bowel by the uterus ; the condition of the posterior surface of that organ; the presence of inflammatory exudate in the pelvis; malignant infiltration of the broad ligaments or peritoneum; 9. — Recto-abdominal Palpation. and the position of the uterus, when we desire to avoid a vaginal examination of the virgin. The rectal procedure promotes the replacement of the displaced organ. The correction of malposi- tions is facilitated by the introduction of the middle finger into the rectum and of the index-finger or thumb into the vagina. (Fig. 10.) The conjoined. rectal manipulation is known as the recto-abdominal, the rectovaginal, the recto vagino-abdominal, or the rectovesical, according to the position of the fingers of the two hands. The absence or presence of the uterus in congenital PELVIC EXAMINATION 33 atresia vaginalis may be determined by rectovesical touch; that is, the introduction of the finger into the rectum and of a sound (Fig. ii), bougie, catheter, or finger of the other hand through the urethra. It is rarely that it will be necessary to explore the bladder with the finger. 73. Simon's method consists in the introduction of the whole hand into the bowel, and is capable of affording additional in- ^- Fig. 10.— Rectovagino-abdominal Palpation. Index-finger of one hand in the rectum, thumb in the vagina, and the fingers of the other hand over the abdomen. formation as to the condition of the pelvic organs. Such serious injuries have resulted from its practice, however, that it is now considered an unjustifiable procedure, unless the surgeon has an exceedingly small hand. 74. Vaginal Section. — Ferguson advocates exploration of the abdominal viscera by an incision through the posterior 3 34 GYNECOLOGY. vaginal fornix as preferable to the exploratory abdominal in- cision. It is true that such an investigation can frequently be made; that it avoids the prolonged convalescence from an external incision, but its practice will frequently result in a weakened pelvic floor which will subsequently prove an in- effective barrier to vaginal hernia. 75. Precautions. — It would be unwise to dismiss the subject of bimanual examination without a word of caution. The pro- cedure should always be exercised with care not to do injury. Anxiety to arrive at a correct diagnosis may lead to rupture of a tubal collection or an ectopic gestation sac, and to the necessity for prompt operation to save life. I have seen two patients, and have been informed of others, in whom examination has been followed by rupture of ectopic gestation sacs, with death from internal hemorrhage. '^& Fig. II. — Rectovesical Palpation. Sound in Bladder. 76. Instrumental Examination. — The order generally rec- ommended for the employment of instruments has been: First, the use of the sound and then of the speculum. The difficulty, however, in rendering the vagina sterile has justly led to the reverse procedure. The sound is a long, flexible instrument, twenty-five centimeters in length, two or three millimeters in diameter, terminating in a bulbous end, and generally has a slight elevation about six centimeters from its end, which in- dicates the normal length of the uterine cavity. For conveni- ence in measurement its posterior surface is marked by a scale in inches or centimeters. The instrument should be perfectly smooth, having no notches or indentations which may serve PELVIC EXAMINATION. 35 to retain infection. It is made of silver, or copper (silver or nickel plated), and should be sufficiently flexible to admit of its being readily bent. The handle should be roughened upon one side so that the concavitv of the instrument can ahvavs ^_^^.:-^|_^^^=_^^^_ Fig. 12. — Simpson's Sound. be determined. Such an instrument is known as Simpson's sound. Sims advocated the use of a finer and more flexible instrument, known as the probe. 77. Probes are made of metal, hard rubber, and whalebone. Fig. 13. — Sims' Probe. The metal probe may be made of twisted steel and covered with a rubber sheath, rendering it more flexible. (Fig^ 15.) The uses of the sound or probe are to ascertain the patency of the cervical canal, the depth of the uterus, its width or capacity, Fig. 14. — Whalebone Probe. the thickness of its walls, the presence of intra-uterine tumors, the condition of the mucous membrane, the direction -of the uterine canal, and the mobilitv of the uterus. In treatment it has been used to replace the displaced uterus. The experi- s^ Fig. 15. — Spring Probe Covered with Rubber. enced ph^^sician will be able to obtain much of this knowledge fully as effectually by the bimanual examination, and in the majority of cases the disadvantages of the instrument greatly 36 GYNECOLOGY. outweigh the value of the information obtained by its use. It affords knowledge as to the patency of the canal which can not otherwise be determined; in all other instances the omis- sion of its use is preferable to its employment. It is true it is capable of affording information as to the direction of the uterus Avhen the situation of that organ is rendered doubtful by the presence of inflammatory exudate, but in such cases its use is contraindicated. Our inability to secure an aseptic vagina should lead to the introduction of the instrument through Fig. 1 6. — Introduction of the Sound. the Speculum, and then only after the vault of the vagina has been carefully mopped with absorbent cotton wet with a 2 per cent, solution of formalin. It is almost impossible to introduce the instrument without injuring the mucous membrane of the uterine cavity, an injury which will afford a favorable culture- field for the development of germs which are found in the vagina, or, exceptionally, even in the cervical canal. Such injuries explain the inflammatory irritation following the use of the sound and still further demonstrate the wisdom of dis- PELVIC EXAMINATION 37 continuing its employment for replacement of the uterus. When it seems desirable to use the sound without the speculum, the vagina should be previously scrubbed and two fingers introduced to the cervix, by which the sound is guided into the OS. (Fig. i6.) No force should be employed and the in- strument should have such a curve as will permit it to pass readily in the direction which a bimanual examination has dem- onstrated should be that of the uterine cavity. 78. Precautions. — The date of the last menstruation must be known, and the use of the instrument should be avoided when there is the slightest suspicion of pregnancy. It should not be employed in the presence of acute inflammation or when inflam- matory exudate or old infiltrations can be determined. Its em- ployment in a case of malignant disease may lead to dangerous hemorrhage. In the uterus softened and rendered friable by inflammation the sound may penetrate its wall and enter the abdominal cavity. This accident produces no inconvenience unless the instrument carries infection. The sound may also pass into a Fallopian tube. This is m*ore likely to occur in a bicornate uterus. The instrument should be scru- pulously clean , indeed, should be sterilized by boiling, or when this is inconvenient be removed Fig- 17.— Ferguson's Speculum. from a 5 per cent, solution of carbolic acid prior to its use. After its use the instrument should be sterilized by heat. 79. Speculum. — A patient placed in the dorsal position, with the limbs separated, reveals the mons veneris, with the larger labia. The latter are separated by a cleft or slit — the rima pudendum. Frequently the labia minora are elongated, and they, with the clitoris, are prominent. The posterior commissure may have been injured, and, instead of a slit, we will have a triangular opening, through the posterior part of which projects the vaginal wall. In lacerations of the pelvic floor its posterior segment may be drawn back, permitting one or two inches of the vagina to be inspected. By hooking back the vagina with two fingers the cervix can frequently be seen. The necessity for satisfactory inspection of the uterus led to the invention of the speculum. A great variety of instruments for this pur- pose have been devised, but all may be classed in two divisions: the tubular and the valvular. 80. The tubular speculum, known as the Ferguson speculum, may be made of glass, wood, rubber, celluloid, or metal. The 38 GYNECOLOGY. Fig. 1 8. — Milk-glass Specula. instrument is cylindric, the external end with a flange, the inter- nal beveled, and having one long side. (Fig. 17.) Glass instru- ments may be made of milk-glass (Fig. 18), as the German speculum, or such covered with quicksilver, and over this a coating of pitch or rubber. Such specula can not be sterilized by heat ; glass is brittle, easily broken, and is subsequently use- less. They are very ser- viceable in making appli- cations to the cervix, but only the wooden instru- ments are utilizable for the use of the actual cautery. The application of medica- ments to the uterine canal, or the use through it of the sound, are to be con- demned. The tubular speculum is not self -retain- able. Its range of appli- cation is so limited that it is now infrequently used. To introduce this instru- ment the physician separates the labia with the left hand and holds the speculum with the right thumb and middle finger on either side and the index-finger upon its upper surface. The longer side is placed against the posterior commissure of the vulva, which is depressed, and the speculum is pushed upward and backward, at the same time rotating the instrument so that its shorter side does not impinge against the tender anterior structures. The situation of the cer- vix has been pre- viously located by the touch. If the cervix is not brought at once into the field of the speculum, it can usually be ex- posed by rotating the instrument. When this procedure fails, it may be drawn into the field by a tenaculum. If the cervix is large, only a part of it can be exposed at one time, and consequently a dis- torted idea of the condition is frequently obtained. 81. Valvular Speculum. — The valvular speculum may have Nott's Speculum. PELVIC EXAMINATION. 39 one or more valves, and is called univalve, bivalve, tri valve, and quadri valve, according to the number of its blades. These Fig, 2 1. — T alley's Speculum, Fig. 20. — Higbee's Specula (three sizes). specula afford a much better exposure and are self-retaining therefore, they have largely supplanted the tubular in- strument. The quadri valve instrument is now rarely used, as it affords but slight additional advantage over the bivalve, and besides it is difficult to keep clean. The Nott (Fig. 19) and Nelson specula have three blades and afford an oppor- tunity to inspect the an- terior vaginal wall. The bivalve speculum is the most satis- factory for general use. Of the great variety of specula, Hig- bee's (three sizes) (Fig. 20), Talley's (Fig. 21), and Goodell's (Fig. 22) are probably the most satisfactory. The blade should be from 7.5 to II centimeters in length. When the vaginal portion of the cervix is short, the Higbee speculum, which has a long posterior blade, will not ex- pose the OS. In such cases the Goodell or Talley specula, with Fig. 22. — Goodell's Speculum. 40 GYNECOLOGY. blades of equal length, are better. The speculum is introduced by separating the vulva with the fingers of the left hand, while the instrument, held in the right, is intro- duced with its trans- verse diameter parallel to the long diameter of the vulva. As the widest diameter of the vagina is at right an- gles to that of the vulva, the instrument is rotated and car- ried upward, directing the blades behind the cervix, the position of which has been previously determined by a digital examination. As the blades are separated the cervix is Fig. 23. — Sims' Speculum. ^ Fig. 24. — Proper Method of Holding Sims' Speculum. The cervix brought into view with the tenaculum. generally exposed. In marked anteversion it may be necessary to use a tenaculum to bring the cervix into view. The speculum PELVIC EXAMINATION. 41 is a therapeutic instrument, although it confirms the diagnosis which has been made by digital examination. 82. The univalve or duck-bill speculum (Fig. 23), introduced by Sims, is used with the patient in the semiprone position. The instrument has two blades at either end of a handle, which are about 10 centimeters long, the smaller blade being 1.5 centime- Fig. 25. — Sims' Depressor. Fig. 26. — Goodell's Tenaculum. ters and the large blade 4 centimeters in width. To introduce this instrument the physician raises the buttock, passes the blade with its width parallel to the vulva, and after its entrance rotates it with the handle directed backward. The assistant then holds the other blade with the right hand, using the in- strument as a retractor. (Fig. 24.) His elbow is held against his hip, while the left arm rests upon the patient, the hand elevating the buttock. Care must be exercised to follow the curve of the sacrum or the instrument will slip out. As the perineum is drawn back the vagina is ballooned by the atmos- pheric pressure and the cervix and upper vagina are exposed. When the vagina is large, with re- laxed walls, the cervix may be obscured from view. The depressor (Fig. 25) to push back the anterior wall or a tenaculum (Fig. 26) hooked into the cervix will overcome the difficulty. The univalve speculum affords a better exposure of the cervix and upper portion of the vagina than any other form of instrument. Its particular disadvantage is that it is not self-retaining, and in office practice requires Fig. 27. — Self-retaining Sims Speculum. 42 GYNECOLOGY. the assistance of a nurse. Various devices (Fig. 27) have been instituted to render it self-retaining, but they require con- siderable time for their use. In operating with the patient in the semiprone position, the irrigating fluid and blood run forward, between the patient's limbs, and hence render it Fis:. 28. — Simon's Retractors. difficult to keep her person and clothing clean. The Sims speculum can be used with the patient in the lithotomy- position, but it is uncomfortable to hold. The Simon posterior and side retractors serve a similar purpose. (Fig. 28.) The perineal retractor known as the Edebohls speculum (Fig. 29) is Fig. 29 — Edebohls' Speculum. Fig 30. — Edebohls' Speculum m Position. the most satisfactory. With the patient upon her back, and the limbs acutely flexed, the perineum is retracted and held back by a weight attached to the instrument. (Fig. 30.) The cervix and the upper and anterior vagina are thus exposed to manipu- lation. PELVIC EXAMINATION. 43 83. Uterine Fixation and Downward Traction. — Reference has already been made to the use of the tenaculum to bring the cervix into the field of the speculum. The same instrument, or, better, a double tenaculum known as bullet-forceps (Fig. 31), guided to the cervix by the finger, may be used to fix the organ, or in some cases to exert traction (Fig. 32) upon it during digital _jO Fig. 31. — Double Tenaculum Forceps. examination. Such a procedure enables us to examine through the rectum the whole posterior surface of the uterus and even to pass the finger over its fundus. It is utilized in replacing the retroverted and retroflexed organ and in differential diagnosis of abdominal and pelvic growths. 84. Dilatation of the Uterus. — It is frequently necessary to Fig. 32. — Traction vipon Uterus with Double Tenaculum durin« ination by the Rectum. Digital Exam- explore the cavity of the uterus, either to complete the diagnosis of a condition rendered probable by other procedures or as a preliminary to an operation. The method of operation may be divided into two classes: (i) Bloodless — tents, divulsion, and gradual dilatation; (2) by incision of the external os and bilateral incision of the cervix. Before the practice of any of these pro- 44 GYNECOLOGY. cedures the presence of inflammation in the organ or vestiges of inflammatory exudate about it should be excluded. The existence of such conditions presents an element of serious danger. 85. Dilatation by Tents. — The use of tents was formerly very popular and a general method of dilatation. The materials used for this purpose were sponge, laminaria, tupelo, slippery elm, decalcified ivory, and gentian root. The sponge has the greatest dilating power, but is the most difficult to render aseptic and to maintain in that condition. The frequent unfortunate sequelae that followed their use have larg^elv led to their discontinuance. Fig. 33- — Hollow Laminaria Tent. The laminaria (Fig. ;^t,) and tupelo tents are the most used. The former may be introduced in nests. Their dilating power is enhanced by having them hollow. A number of small ones to fill up the canal is to be preferred to one large tent. They may be rendered aseptic by subjection to a dry heat of 250° F. The tent should be placed in an envelope before its introduction into the sterilizer, and the envelope should be broken only when it is to be used. The tents may also be rendered safe by immersion prior to their use in a saturated solution of iodoform in ether. Pozzi advocates their immersion in equal parts of carbolic acid and alcohol. They may be placed in 95 per cent, carbolic acid Fig. 34. — Uterine Forceps — Dressing. for a few minutes and afterwards washed in alcohol before in sertion. I prefer immersing the laminaria tent in tincture of iodin for a few minutes before its employment. The vagina and cervix should be carefully cleansed with an antiseptic solution ; the cervix is seized through the speculum with bullet forceps, while the tents are held in (Fig. 34) dressing forceps, and introduced, one after another, until the canal is filled. Care must be exercised to mold the tents to the curve of the canal, and no force should be employed in their introduction. The tents should project from the external os, and should be PELVIC EXAMINATION. 45 held in place by a tampon of iodoform gauze. They should be removed at the end of ten or twelve hours. They are removed by pulling upon a string fastened to the end of the tent. Re- moval is sometimes rendered difficult by irregular dilatation; the internal os, being more resistant, causes an hour-glass- I^ig- 35- — Dilated Tent Showing Constriction from Internal Os. shaped distention. (Fig. 35.) The tent is removed by plac- ing the finger against the cervix during traction. The irreg- ular dilatation is less likely to occur with a tupelo tent, though its dilating power is not so great. Pain during the dilatation can be relieved by the use of from two to five grains of acetanilid Ellinger's Dilator. or from J to ^ of a grain of codein. The removal of the tent should be followed by careful antiseptic irrigation, after which another tent or series of tents may be introduced. The use of the tent affords an opportunity to make a digital exploration of the uterine cavity, and is of advantage in small submucous Fig- 3 7- — Goodell's Modification of Ellinger's Dilator. fibroids, in suspected epithelioma, and in retained products after abortion. 86. Divulsion consists in the rapid dilatation of the uterine canal by the various dilating instruments. The preferable in- struments are the parallel bar dilators, such as the Ellinger 46 GYNECOLOGY. (Fig. 36), with the Baer and Goodeli modifications (Fig. 37); the latter, with its roughened blades, is a powerful instrument. The vagina and cervical canal are carefully cleansed, and through the speculum the cervix is seized with a double tena- culum and stretched with small dilators, and subsequently with the large instrument to the extent of tw^o or three centimeters, if desired. The principal objection to the procedure is that the pressure is confined to the lateral surfaces of the cervix and, therefore, may lead to laceration. 87. Gradual dilatation is accomplished by the use of graduated bougies, made of steel or hard rubber. The former are prefer- able, as they can be sterilized by heat. The Pratt series of bougies, which have two bougies to each handle, making eighteen in the set, the maximum being No. 43, will be useful. (Fig. 38.) Each bougie is two millimeters larger than the preceding. After thorough cleansing of the vagina and cervix the Edebohls specu- lum is introduced, the cervix is seized with vulsellum or double tenaculum, and the bougies are used one after an- other, up to the largest size. (Fig. 39.) Care should be exercised not to puncture the uterine wall. This accident is more likely to oc- cur in acute flexions ; the point of the in- strument makes so much pressure upon the thin convex wall near the flexion that it finally ruptures. Rupture or perfora- tion of the uterine wall is not of infrequent occurrence, and when done by the bougie is of but little significance. The tear by the parallel bar dilators is much more serious, as the wall of the uterus is torn, just as wide as the dilators have sepa- rated. Through such an opening, omentum or a knuckle of intes- tine may be drawn into the uterine cavity. It is sometimes ad- vised to precede this method by the use of a tent, but it does not seem necessary. The dilatation can be accomplished by the bou- gies in shorter time than by divulsion. 88. Incision of the Cervix. — The external os, when very rigid, or when the cervical canal is partly dilated by an extruding fibroid, may be incised. This procedure may be resorted to for abortion in the absence of proper dilating instruments. An Fig. 38. — Pratt's Dilators. PELVIC EXAMINATION. 47 incision from i centimeter to 1.5 centimeters should be made with scissors upon either side. As the ordinary scissors shp off, the Kuchenmeister scissors (Fig. 40) are more effective. The procedure is most readily accomplished by grasping each lip with Fig. 39. — The Method of Dilatation \Yith the Graduated Bougies. a double tenaculum and incising on either side with a knife. The operation completed, the incised cervix should be closed with sutures. 89. Complete bilateral incision of the cervix is rarely indicated, Fig. 40. — Kuchenmeister's Scissors. as other measures of less severity can be utilized. The operation may be supplemented, if necessary, by ligation of the uterine arteries. The vessels may be secured by drawing the cervix to one side and passing a ligature with a strongly curved needle. 48 GYNECOLOGY. Care should be exercised to keep close to the uterus and not to carry the ligature forward of a line tangent to the anterior cir- cumference of the cervix, in order to avoid ligation of the ureter. A second ligature is passed upon the opposite side, when the cervix can be incised with a knife to the vaginal fornix on either side without danger of hemorrhage. Although generally advised that ligation should precede incision, it is unnecessary. Hemor- rhage does not always occur, and when it does, the bleeding vessels can be seized with forceps and then ligated. If the finger can not be passed through the internal os, the canal can be still further enlarged with a probe-pointed bistoury. After ex- ploration or operative procedure the cervix should be carefully sutured. The lateral ligatures should be removed in two or three hours, or in a shorter time if there is any reason to fear that the ureter has been ligated. The prolonged retention of the ligatures would result in sloughing of the vagina. 90. Dilatation by Gauze Packing. — VulHet has devised a pro- cedure for prolonged dilatation, which he denominates a ''method of dilatation by progressive plugging." It consists in repeated plugging of the cervical canal w4th medicated gauze. Strips of gauze, after the uterus has been carefully cleansed, are packed into the cervical canal until it is completely filled. These are permitted to remain for forty-eight hours, when they are re- moved, and if the uterus is not then dilated sufficiently to admit the finger, the cavity is again cleansed and packed. Pieces of compressed sponge have been used for a similar purpose, and, from their increase in size under moisture, are probably more effective. The only source of anxiety is the uncertainty as to their being absolutely sterile. This plan of procedure may be carried over a series of days or weeks, without inflammatory re- action. It is, however, not effective in cases of rigid cervix, and the same purposes may be accomplished by a more rapid dilatation. 91. Microscopic Examination. — It is evident from the pre- ceding that careful investigation of tissue changes is often neces- sary to confirm, and add to, the data secured by inspection and touch. The microscope here proves an important diagnostic factor. It throws light upon obscure conditions, and affords opportunity for the recognition of the incipient stages of lesions so insidious and grave, that were the investigator deprived of the information it affords the accurate diagnosis would frequently come too late for radical treatment. Through the microscope the knowledge of the histologic structure of the genital organs has been secured, and it is apparent that it w^ould prove equally val- uable in betraying pathologic alterations in the course and prog- ress of disease. Consequently, it not only proves a valuable aid PELVIC EXAMINATION. 49 in methods of diagnosis, but also upon the result of its findings definite ideas concerning the prognosis are based, and suitable methods of treatment instituted. 92. Collection of Tissue. — Tissue collected for microscopic examination is procured by test curetment and test excision. Occasionally sufficient tissue can be expressed from the genital tract or escape in discharges, from which reasonably satisfactory microscopical examinations can be made. Generally, however, only small particles of tissue escape and these usually indicate the existence of marked degenerative changes, and, therefore, the tissue must necessarily be so altered by necrobiotic processes as to render positive microscopic diagnoses uncertain and difficult. Test excision is employed in cases of suspected disease in the loAver part of the genital tract and cervix. The test curetment is performed in cases of suspected disease in the interior of the cor- pus uteri. In certain conditions these two methods of collecting tissue may with distinct advantage be combined. 93. Test Excision. — The method of collecting tissue from either the vagina or the cervix by test excision must be regarded Fig. 41. — Douche Curet. as a surgical operation and, therefore, the patient should be as carefully prepared as in preparation for a plastic operation. The bowel and bladder empty, the patient should be placed in the dorsal position upon the table, the parts thoroughly cleansed, and the cervix exposed by introducing Edebohls' speculum or suitable retractors into the vagina ; the cervix grasped with double tenac- ula, one upon each side or upon the anterior and posterior lip; gentle traction is made to fi^ the cervix nearer the vaginal orifice. With sharp scissors or scalpel a triangular or V-shaped piece of the cervix is so excised as to secure both healthy and diseased structure and a portion of the mucous membrane lining the cervi- cal canal. The wound left from the excision should be closed with one or two sutures of catgut. Closure of the wound is followed by irrigation of the parts with warm sterile salt solution, the vagi- nal canal is lightly packed with iodoform gauze, and a sterile peri- neal occlusion dressing applied. It is better, in the majority of cases, to employ general anesthesia for test excision, although it can be done bv anesthetizing the surface with a four per cent, solu- 4 50 GYNECOLOGY. tion of cocain applied on a cotton tampon. Infiltration anesthe- sia would permit of painless excision, but it destroys the cell structure and would,, consequently, be misleading. Each step of the procedure for test excision should be executed with the utmost delicacy. This can not be too strongly emphasized in order to avoid disturbing the architectural construction of the tissue and, therefore, alteration in the living histological cell picture. Un- fortunately, many surgeons collect tissue for investigation by the microscopist in so careless a manner that by the time the tissue reaches the pathologist's hands its structure is so changed as to render intelligent study almost impossible. The excised tissue should be washed in running water and care- fully inspected with the naked eye, and also with a magnifying glass ; by which its color, consistence, and general structure can be recognized and noted. During this examination the question can be determined as to what course shall be pursued in fixing and preparing it for a more complete examination. As the tissue will undergo marked change in this process of fixing, it is wise that a drawing should be made and the direction in which the future sec- tions are to be cut determined. Abel advises that excised por- tions be divided so that one part can be examined while fresh, and the other be prepared for finer sections. 94. Test Curetment. — In employing the curet to secure mate- rial for examination the same precautions concerning antisepsis and thorough preparation must be observed as in doing test exci- sion. The operation is performed as follows : the patient under general anesthesia, in the dorsal position, the vulva and vaginal canal are thoroughly sterilized. The cervix is exposed by an Edebohls' speculum or suitable retractors, the anterior cervical lip fixed with double tenacula, the cervical and uterine canals are deli- cately and carefully dilated. The utmost caution should be prac- ticed in every step of the procedure and undue force must posi- tively be avoided in order to prevent injury of the tissue cells and distortion of the histology of the collected tissue, which would render microscopic examination unsatisfactory. Dilatation is best accomplished by Pratt's graduated dilators. By their use rapid and uniform dilatation is secured, with but little congestion or traumatism to the endometrium. Laminaria tents also serve excellent purpose for dilatation. Dilatation with tents should be done with all surgical cleanliness. One or two are introduced and allowed to remain for a period of twelve hours ; when, if sufficient dilatation is not secured, a nest, comprising three or four tents, is introduced and allowed to remain twelve hours more. Dilatation by tents has the great advantage that it permits digital explora- tion of the uterine cavity. This exploration, however, should follow the curetment, for the previous introduction of the finger PELVIC EXAMINATION. 51 would, to a certain degree, disarrange and render unsatisfactory the endometrium for microscopical examination. Tent dilatation has the disadvantage of requiring twelve to twenty-four hours for its performance, but this additional time is often compensated by the information afforded the exploring finger, because digital exam- ination of the uterine interior may disclose lesions which the curet has failed to reveal. In the employment of either of the methods described a high degree of dilatation should be secured. The uterus is cureted with a long, sharp douche curet having an acute angle. Fig. 42. — Tissue Removed bv Test Curetment. It is well to start the curetment at a fixed point, either the poste- rior or lateral wall, and with long successive sweeps, proceed from the fundus to the cervical opening, removing the membrane to the muscle structure. As the tissue escapes from the uterus it should be collected by an assistant in a sieve made of paraffin paper, (Fig. 42.) The collection of cureted tissue on sterile gauze is to be con- demned, as the tissue adheres to this material, and in its removal the individual elements are torn and distorted. The tissue thus collected is examined microscopically and any peculiarities re- corded, after which it should be immediately transferred to a fix- ing solution unless frozen sections are preferred. 52 GYNECOLOGY. 95. Disposition of Tissue. — The injuries resulting from undue and careless handling of tissue after test excision or curetment has been previously mentioned and can not be too strongly empha- sized. Surgeons often fail to realize the value of avoiding careless manipulation of the specimens and frequently unwittingly destroy the living cell construction by prolonged exposure of the specimen to the air and to injudicious handling. The advantages of imme- diately fixing the tissue after removal are many. The wrapping of any specimen or specimens in gauze, as already mentioned, is to be positively condemned. Tissue so treated soon dries, the gauze becomes firmly adherent to it, and in its removal tears and disar- ranges the surface cells. In case the fixative agent is not at hand, cureted or excised tissue can, without harm or injury, be tempo- rarily placed in paraffin paper, although it is decidedly advan- tageous to have fixative agents prepared and ready for the recep- tion of the material prior to its removal. By such means the individual cell elements are permanently fixed as they occur in life, and the microscopist is thus enabled to satisfactorily study the cell chemistry and general cell construction of the specimens. After the specimens are placed in fixative agents the vehicle con- taining them should be numbered and properly labeled. The label should contain the name of the patient, her age, the date of operation, the character of the operation, the part from which the tissue is obtained, together with a brief history. 96. Examination.— The specimens may be examined as teased specimens, or be cut with the freezing microtome. The latter course is preferable, as it interferes less with the relations of the structures, and, consequenth^ permits a more correct judgment as to the condition. By teasing, the elements are separated from each other when it is impossible to decide whether the surface epithelium sends processes into the tissues or whether a simple hyperplastic or destructive process exists — points of the greatest importance in arriving at a correct diagnosis. The fresh specimen should be cut with the freezing microtome, but the sections should not be too thin, as they are likely to tear in subsequent manipulation. , Each section is removed from the knife with a camel' s-hair brush and placed in distilled water. To prevent the sections from being torn in transmission to the slide, it is better that the latter be pushed under the section as it swims in the fluid and be gently held with a glass rod. The section, having been carefully spread upon the slide, is then covered with a fine cover-glass. The latter is grasped at one edge with forceps, the other side brought at an acute angle upon the fluid covering the surface of the slide and gently released, re- PELVIC EXAMINATION. 53 moving the superfluous fluid with blotting-paper. The section can now be studied with high or low power, but when unstained is best placed upon a dark under layer. Specimens so studied have the advantage that we see the cells as they were during life, and the character of the normal tissue or any degenerative process can thus be recognized. The specimen may be subjected to various microchemical reactions which will afford valuable information. The section may be rendered more transparent by a drop of a 2 or 3 per cent, solution of acetic acid placed under the edge of the cover-glass. A piece of blotting-paper held at the other side causes it to penetrate the section quickly. Fatty tissues may be removed by the similar use of alcohol, chloroform, or ether. Elastic fibers are rendered prominent by caustic soda in a I to 3 per cent, solution. A marked swelling of the contractile elements of the smooth and striated muscles and of the nuclei occurs, and the horn}^ substance becomes transparent. A ;^^ per cent, solution of caustic potash is especially valuable as a preservative. Red blood-cells preserve their form well in such a solution. Infarctions or plethora of blood-vessels are in no way so well observed as in fresh specimens. They may be permanently pre- served by replacing the salt solution with glycerin, or preferably with a 55 per cent, solution of potassium acetate. Pick's method presents the best procedure for preserving frozen specimens, and consists in the use of alum-carmin combined with formalin. The alum-carmin of Grenach (4 to 5 per cent, of carmin) is added to Schering's formalin 10 to 100, which should be kept in a dark-colored bottle. Pick's process is as follows: 1. Preparation of the frozen section with Jung's microtome. 2. Transference of the section into a 4 per cent, formalin solution for one-fourth minute. 3. Formalin-alum-carmin, two to three minutes. 4. Washing in water, one-half minute. 5. Eighty per cent, alcohol, one-half minute. 6. Absolute alcohol, ten seconds. 7. Carbol-xylol, one-half minute. 8. Canada balsam. Coplin says that his experience convinces him of the necessity for thoroughly fixing all tissues before attempting to section them, otherwise the results are always open to criticism, because the distortion incident to congelation masses; maceration; and the difficulty of removing the infiltrates produce conditions which would mislead the most experienced observer. He advises the following fluids : 54 GYNECOLOGY. 1. Flemming's solution, which consists of a i per cent, aqueous solution of chromic acid, 25 volumes; i per cent, aqueous solution of osmic acid, 10 volumes; i per cent, aqueous solution of acetic acid, 10 volumes; water, 55 volumes. All water in stock solutions and final mixtures must be dis- tilled. Small pieces (five-tenths — i cm. cube) will undergo sufficient fixation in from one-half to two hours. After this process is complete they should be w^ashed in running water for six hours. 2. Hermann's solution: i per cent, aqueous solution of platinic chlorid, 15 volumes; 2 per cent, aqueous solution of osmic acid, 2 volumes; glacial acetic acid, i volume. 3. He regards corrosive sublimate solution as the most useful fixing agent for general use, although for pure cell study the first two solutions are probably better. It consists of 125 gm. of corrosive sublimate dissolved in a liter of 0.5 per cent, solution of sodium chlorid in water. Small pieces fix in this solution in from one-half to two hours. The used solution is filtered back into the stock solution, while the hardened tissue is washed in water, or preferably in 70 per cent, alcohol. This solution is of advantage because of its cheapness, keeping qualities, and simplicity of technique. In the process of fixing with any of the plans, the quantity of fluid should several times exceed the volume of tissue to be fixed. It is important for purposes of diagnosis that the tissues should not only be properly fixed, but that sections should be made with as little disturbance of cell relation as possible. At- tention must also be given as to the direction in which sections shall be made through the tissues. Sections parallel with the surface of a mucous membrane are of but little value, as they cut across glands and afford no indication of the true character of epithelium. The most serviceable are the vertical or slightly oblique. Embedding. — A small piece of tissue may be prepared for section-cutting by being embedded in either gelatin, celloidin, or paraffin. Glycerin-gelatin. — Ten grams of the finest gelatin are placed in a clean vessel and covered with water. After four to six hours the water is poured off, and the mass liquefied by a mod- erate heat. While stirring with a glass rod, ten grams of glycerin and five drops of carbolic acid are added, and the mixture left in a wide-mouthed bottle. To embed a specimen, a piece of this mass is taken and liquefied by heat. A thin layer is poured upon the surface of a cork, the specimen placed upon it, and then covered with a mantle of gelatin which soon becomes hard. PELVIC EXAMINATION. 55 After being immersed in absolute alcohol for twenty-four hours good sections can be made. Celloidin. — The specimen is placed for twenty-four hours in absolute alcohol, and the same length of time in sulphuric ether. It then remains twenty-four hours in a tight bottle containing thin celloidin. At the end of this period it is placed in a thick solution, a small opening being left so that the alcohol and ether evaporate very slowly. In a few hours a semi-solid mass has formed, a block of which containing the specimen is cut out, fastened with thick celloidin upon cork or wood, after which it remains for twelve hours in a 70 to 80 per cent, solution of alcohol, when it has the proper consistence for section-cutting. Paraffin. — Abel prefers to stain the specimen preparatory to embedding in paraffin. The specimen, hardened in alcohol, is placed in the staining solution. This may be Bohmer's hem- atoxylin, eosin, or safranin. It should remain in a well-filtered solution two to eight days, according to its thickness. It is removed from the staining solution to 70 per cent, alcohol for twenty-four hours, then is dehydrated in absolute alcohol. It is placed in xylol for twelve hours to prepare it for saturation with paraffin. The specimen is placed in a mixture of equal parts of xylol and parafhn, in which it remains for twenty-four hours, subjected to a continuous temperature of 37° C. in a paraffin oven, after which it is kept in paraffin at a temperature of 48° to 50° C. The latter is then permitted to solidify at the room- temperature, when a paraffin block of suitable size containing the specimen is cut out and fastened to a cork or a piece of w^ood with paraffin, after which it is ready for cutting. The sections thus secured are thinner than those secured by any other method. Section-cutting. — Sections are preferably cut with a microtome and should be of equal thickness. A thickness of fifteen to twenty microns will be satisfactory. The sections are conveyed with a camel's-hair brush to a basin containing dilute or absolute alcohol; the celloidin sections to a 70 per cent, solution of alcohol, the gelatin sections to absolute alcohol. The sections are very much shriveled by the alcohol and should be placed in water for several minutes before being transferred to the staining fluid. The paraffin sections can not be transferred from one vessel to another; it is better to treat them on the slide. Abel applies one drop of a solution of collodion in alcohol upon a slide, and upon this the section, pressing it down with filter-paper. The paraffin is dissolved out with xylol, and covered with equal parts of xylol and Canada balsam, and over this the cover-glass is carefully placed. 56 GYNECOLOGY. Staining. — We will consider only those methods which are most effective in rendering prominent the histologic structures we are desirous of utilizing in the diagnosis. Picrolithiocarmin and hematoxylin are both very satisfactory. The picrolithiocarmin, introduced by Orth, is prepared by uniting one part of lithiocarmin (a cold saturated solution of lithium carbonate in which carmin powder has been dissolved in the proportion of 2.5 grams of the latter to 100 grams of the for- mer solution) with two parts of a saturated solution of picric acid. This stain is best suitable for specimens which have been hardened with alcohol. The section is placed in the staining solution by a spatula and remains five to ten minutes, from which it is conveyed for one to two minutes to a solution of alcohol (70 per cent.) one hundred parts, hydrochloric acid one part, then washed in dilute alcohol and dehydrated in absolute alcohol. The specimen is made clearer by oil of cloves, oil of bergamot, or xylol. It is conveyed to the shde and spread out free of folds. It is then mounted in Canada balsam. Horny cells, fibrin, hyaline substances, and red blood-corpuscles take on a yellow color. The nuclei of the epithelium become a pale pink, fibrillar tissue remains undyed, affording a clear picture of the specimen stained. Hematoxylin stain is prepared by Coplin after Delafield as follows: Dissolve 4 gm. of hematoxylin crystals in 25 c.c. of strong alcohol; add this solution to 400 c.c. of a cold, filtered, sat- urated aqueous solution of ammonia alum; expose to light and air for several days. Filter and add glycerin 100 c.c. and methyl alcohol 100 c.c. This preparation is allowed to stand in the light, with the bottle loosely corked ; this mixture turns dark purple or almost black. i\fter assuming this color it should be filtered and placed in tightly stoppered bottles. Before being used it should be largely diluted, and if properly prepared this stain will last for years. The great objection to Delafield 's mixture is that it re- quires time for ripening and therefore can not be used immediately after being made. Harris has overcome this objection by prepar- ing the mixture as follows: Dissolve i gm. of hematoxylin in 10 c.c. of alcohol and add the resulting solution to 200 c.c. of dis- tilled water in which 20 gm. of ammonia or potassium alum have previously been dissolved. This fluid is heated in a flask to boil- ing, at Avhich time i gm. of mercuric acid is added. The solution darkens (ripens) at once and is now ready for use, but should always be diluted. From this stock solution an acid hematoxylin may be prepared by adding 4 c.c. of glacial acetic acid and 30 c.c. of glycerin to 70 c.c. to the primary solution. This acid prepara- tion has the great advantage of rendering overstaining almost impossible. Hematoxylin Staining. — To use the hematoxylin stain of Dela- PELVIC EXAMINATION. 57 field or Harris the sections cemented to the slides are covered with the diluted stain from five to fifteen minutes. They are then washed in water, dehydrated in alcohol, cleared with creasote, and mounted in Canada balsam. Coplin states that a better result is obtained by placing enough distilled water in a staining dish to immerse the slide on end, to this sufficient hematoxylin is added to tinge the water rather deeply. The sections adherent to the slides are permitted to remain in this solution twelve to twenty- four hours. They are then cleansed in water and treated as di- rected previously. Hematoxylin stains the nucleus purple and gives a faint tint to the protoplasm shapes. Definition of the pro- toplasm can be secured by following the hematoxylin staining by placing the slides and section in an 0.5 alcoholic solution of eosin for one or two minutes. The excess of water is removed and sec- tion washed in alcohol, cleared in creasote, and mounted in balsam. This method stains the nuclei purple and the surrounding proto- plasm pinkish, besides, the eosin stains the erythroc^^tes pres- ent. One of the very best contrast stains is that suggested by Van Geison, which is composed of the following : Acid fuchsin (i per cent, aqueous solution), 15 c.c. Picric acid (saturated solution), 50 c.c. Water, 50 c.c. In using this stain the sections are first stained with hematoxy- lin, washed in water, followed by applying the Van Geison stain for four or five minutes, dehydrated in alcohol, cleared in xylol, and mounted in xylol balsam. By this method the connective tissue appears red or pinkish red, the cell protoplasm yellow, the nuclei dark brownish or reddish purple. Hematoxylin stain is prepared by dissolving i gram of hematoxylin in 30 grams of absolute alcohol. To a solution of powdered alum (0.5 to i gram in distilled water 30 cm.) the above preparation is added drop by drop and shaken until the fluid takes a deep violet color. Celloidin-embedded sections remain longer (ten to twenty minutes, according to size and thickness) in the solution than sections prepared by other methods, and are placed in alcohol con- taining hydrochloric acid until they begin to assume a red tint, from which the}^ are removed to 70 per cent, alcohol. They are placed in absolute alcohol until the mantle of celloidin begins to curl. Care must be exercised that all the celloidin is not dissolved or the finer sections would fall to pieces. The section is made transparent in oil of bergamot or in xylol. Should the celloidin mantle at this stage become cloudy or milky, the section should be placed in absolute alcohol until it clears. With a spatula the section is placed upon a shde and mounted in xylol-Canada balsam after removing the oil with filter-paper. This method 58 GYNECOLOGY. gives ^Splendid staining of the nuclei, the protoplasm is slightly stained, the celloidin not at all. The diagnosis of malignant conditions is greatly enhanced by staining the elastic fibers. For this purpose Taenzer's orcein stain is employed. The sections are taken from water and kept' in this solution from six to twelve hours or longer (Griibler's orcein 0.5, alcohol 40.0, aq. dest. 20.0, hydrochloric acid gtt. xx) , then placed for a few seconds in hydrochloric acid alcohol (hydrochloric acid o.i, 95 per cent, alcohol 20.0, aq. dest. 5.0), where they become differentiated and are washed in water. After five to ten minutes' dehydration in absolute alcohol, they are cleared in oil and mounted in Canada balsam. The elastic fibers appear as an intense red upon a pale pink background. Weif^ert's fuchsin-resorcin stain is made by taking 200 c.c. of the following mixture: Resorcin 2.0, fuchsin i.o, distilled water 1 00.0, and bringing it to a boil in a porcelain vessel, when 25 c.c. ferri liq. sesquichlor. (German Pharmacopeia) are added, the whole boiled while stirring for two to five minutes longer. The muddy mass thus formed is permitted to cool and then filtered. The portion which runs through the filter is thrown away, and the deposit left upon the filter until it ceases to drip. The filter with its contents is removed from the funnel, placed in a bowl, and boiled under constant stirring with 200 c.c. of 94 per cent, alcohol. While boiling the filter-paper is removed and the solution is permitted to cool, after which it is filtered and the filtrate brought to 200 c.c. by the addition of alcohol. After adding 4 c.c. of hydrochloric acid the solution is ready for use. The sections are placed in this solution for twenty minutes to one hour, washed in alcohol, and cleared in xylol. The elastic fibers are stained dark blue, almost black, on a quite light background. The nuclei may be stained with a carmin preparation. 97. Preservation of Gross Specimens and Slides. — In order to keep a complete case record it should be the rule to preserve the gross specimens and slides containing sections therefrom. Many agents have been recommended for the preservation of gross specimens. Alcohol is perhaps the reagent most commonly em- ployed, but by its use the density of the specimens is altered, the color entirely lost, and general outline indifferently retained. For- malin has recently gained considerable prominence as a valuable preservative. A ten per cent, solution of the commercial prepara- tion is usually employed. Specimens prepared by this method can be used with a higher degree of satisfaction for histologic study than those prepared with alcohol. Specimens when not too large can also be preserved in formalin vapor by placing them PELVIC EXAMINATION. 59 in an air tight jar containing a bed of cotton which has been pre- viously moistened with pure formaHn. The specimen should be placed upon the cotton and covered with filter-paper moistened with the reagent. For the retention of the color of gross speci- mens no method possesses such advantages as those afforded by the use of Kaiserling's solution. Two solutions are necessary and are composed of the following : Solution A. Formalin 250 c.c. Nitrate of potassium, 10 gm. Acetate of potassium 30 gm. Water, i liter. SOLUTIOX B. Acetate of potassium 200 gm. Glycerin, 400 c.c. Water , 2000 c.c. Formalin, to point of saturation. The specimen prior to being placed in the preservative is lightly washed with running water to remove adhering blood and is then placed, according to size, from one to twenty-four hours in Solution A, at the end of which period it is changed to a fresh Solution A, in which it is allowed to remain from two to thirty-six hours. It is then w^ashed in running water from fifteen min- utes to one hour and placed in eighty per cent, alcohol in order to cause a reappearance of the color. Unless the color shows signs of returning the specimen is transferred to ninety-five per cent, alcohol, in which it is allowed to remain until the color is fully restored. After the color is thus restored the specimen is placed in Solution B and at the end of twenty-four to forty- eight hours it should be placed in a fresh portion of Solution B. In preserA^ation of slides the best results are obtained by using a card index system. Special histologic or slide cases are made containing trays for the slides and also a card index as shown in Fig. 43. By using this method the slide is labelled and numbered and the number corresponds to the number on the index card which contains the name of the" patient, her age, date of occupa- tion, name of organ from which tissue was removed, and patho- Fig. 43. — Cabinet with Trays and Card Index for the Preservation of Slides. 60 GYNECOLOGY. logic diagnosis. An ingenious slide card index has been devised by Coplin. (Figs. 44 and 45.) The slides are properly labeled and numbered and then placed in the card and secured by sealing the free end of the card paper. The index card is marked in the same manner as that de- scribed above. The cards containing the slide are preserved in dust proof drawers. This method offers the advantage that the slide can not be separated from the name of the patient, and from its ingeni- ous arrangement can be submitted to microscopic exami- nation without re- moval from the card . 98. Failure. — Examination may fail to reveal the true character or presence of disease, because the section was made through the adjoin- ing healthy tissue. The examination may also prove un- satisfactory and worthless as a result of mutilation and distortion of the specimen incident to undue manipulation and carelessness in collection and from improper technique in preparation for study. 99. Bacteriology of the Genital Tract.^ — The importance of careful bacteriologic examinations of the secretions of the geni- Fic 44- -Coplin's Method of Indexing and Preserv- ing Slides. m. 473, MRS. 3. R. VATH. JULY 10^i90e. • TISSUE FBOM UTERINE BODY. DIAG. HYPERTROPHIC GLAHOUIAR ENDOMETRITIS. Fig. 45. — Same as Fig. 44. Folded with Slide En- closed. PELVIC EXAMINATION. 61 tal tract can not be overestimated. Careful bacteriologic an- alyses of the genital secretions not only increases the clinical in- terest of a case, or special cases, but stimulates scientific re- search, and, therefore, renders the case records complete and more worthy of preservation. Furthermore, scientific bac- teriologic examinations of the secretions of the genital tract will enable us to diagnose definitely the provocative factor in conditions which might otherwise remain obscure. We are also enabled to determine the specificity, sterility or viru- lence of infiammatory accumulations and thus become better qualified to advise and institute proper methods of treatment and interpret, to a certain degree, the probable outcome of a given case. 100. Parasites of the Genital Tract. — Parasites, both of animal and vegetable origin, as in all other cavities of the body, are found in the genital tract. Of course, here, as elsewhere in the body, bacteria or vegetable parasites preponderate and are the most provocative of harm. In health, micro-organisms inhabiting the genital canal are limited to the structures of the vulva and the vaginal canal. Furthermore, even in this part of the geni- talia, they are found in minimum numbers and attenuated in virulence. The special organism cultivated and described by Doderlein is found more or less constant in the vaginal canal and has been termed the acid vaginal bacillus of Doderlein. It is said to generate lactic acid and is a rod-shaped bacillus of the anaerobic type whose discoverer believes it to be a protective force against the invasion and action of pathogenic germs. He further believes that even if pathogenic bacteria gain entrance to the vagina their virulence is attenuated by the presence of this germ. This micro-organism flourishes in the normal acid secretion of the vagina, and if the acidity of the vaginal secretion is destroyed it disappears and other bacteria enter. It has been demonstrated by Stroganoff that micro- organisms are more numerous in the vagina preceding and following menstruation. It has been discovered that the in- fectious properties of bacteria are diminished as they ascend the vaginal canal and approach the cervix. In the newborn the vaginal canal is entirely bacteria free, but soon after birth their presence can be demonstrated. In the normal individual, according to Kronig, ]\Ienge, and Whitridge Williams, it is not possible for bacteria to exist long in the healthy vaginal secre- tion. Kronig demonstrated the germicidal action of vaginal secretion by introducing various organisms into the vagina of a normal individual. At the end of two days the vagina be- came entirely bacteria free. Streptococci were the first to suc- cumb, staphylococci and pyocyanei living twice as long. Dur- 62 GYNECOLOGY. ing pregnancy it is asserted that the acidity of the vaginal secre- tion is increased and that bacteria are not present. WilHams, in ninety-two pregnant women, found the skin staphylococcus twice, never the streptococcus. Kronig, in forty-eight pregnant women, did not find any. From extensive observations it is asserted, therefore, that pyogenic bacteria, when found in the puerperal genital tract, have been introduced from without. From a bacteriologic standpoint the healthy genital canal can be separated into three portions: the inferior portion, com- prising the vulva and vagina to the cervix, containing bacteria; the middle comprises the cervical canal between the external and internal os and, as a rule, is free from bacteria. The remain- ing portion is formed by the uterus, tubes, and ovaries and is entirely free from germs. Alenge, in his investigations of uteri removed in Zweifel's clinic, was not able to cultivate germs on any ordinary culture media. The external os can then be said to be the boundary line between that part of the genital tract containing micro-organisms (vulva and vagina) and the part bacteria free (uterus, tubes, and ovaries). The vulva and the vaginal canal always contain bacteria, and Edgar found in twenty-eight pregnant w^omen and two parturient women pyo- genic bacteria present in forty per cent. loi. Natural Agents of Immunity. — It has been demonstrated that parasites of many varieties, both animal and vegetable, are found more or less constantly in the lower portion of the genital canal in the normal healthy woman. They are present, however, only in small numbers and with attenuated speci- ficity. This is because Nature provides natural agents for protection or securing immunity. .The protective powers of the normal genital canal are found, i, the acid secretion of the vagina which is decidedly inimical to pathogenic bacteria; 2, the dense arrangement and phagocytic action of the wall of stratified epithelium lining the vagina is also hostile to invading micro-organisms; 3, the plug of coagulated secretion commonly found in the os externum, while not truly germicidal, does act as a barrier against the entrance of germs into the uterine cavity and structures above. The restraining and destructive influ- ence exerted by the bacillus of Doderlein against invading pathogenic bacteria has been mentioned. It may, therefore, be asserted that so long as the vaginal epithelium remains healthy and intact, the natural secretions normally generated and the vaginal bacilli present, pathogenic bacteria may be found, but their excessive production is in- hibited and their destructive influence allayed. 102. Loss of Protection. — Certain conditions alter the normal acid secretion of the vagina, rid the canal of its protective micro- PELVIC EXAMINATION. . 63 organisms, and change the epithelial wall and permit thereby the proliferation of infectious micro-organisms and the generation of their poisons. Traumatisms produced by manipulation, indelicate examinations, raw surfaces left by operation, and in- juries resulting from labor afford gateways for the introduction of infectious germs into the absorbing tissue tracts. The natural bacterial secretion of the vagina is rendered neutral or alkaline or wholly destroyed by increase of discharges from above, such as takes place during menstruation, during parturition, and in alterations of general health. Repeated examinations and per- sistent douching also destroy the antiseptic properties of the vaginal canal. 103. Parasites. — I have already indicated that parasites of all varieties, both animal and vegetable, are found in the genital tract. I stated that the vegetable were, of course, the most frequent and most powerful for harm. The following table shows the varieties of parasites most frequently found : Vegetable (Bacteria). Staphylococcus pyogenes aureus Smegma bacillus. Staphylococcus pyogenes albus Streptococcus pyogenes. Bacillus typhosus. Staphylococcus pyogenes. Bacillus pyocyaneus. Gonococcus. Bacillus aerogenes capsulatus. Bacillus coli communis. Bacillus diphtheria. Bacillus tuberculosis. Pneumococcus. Organism of syphihs. Diplococcus of Siegelman. Organism of chancroid. Animal. Pediculosis pubis. Ascaris lumbricoides. Ascaris scabiei. Taenia echinococcus. Oxyuris vermicularis. 104. Staphylococcus. — The staphylococcus pyogenes aureus is perhaps the micro-organism most commonly found in localized suppurative processes, and, according to Coplin, Curry found it present in fifty-two of one hundred and fifteen abscesses. The staphylococcus pyogenes albus was present in twenty-nine. (Fig. 46.) The tendency of the staphylococcus is to cause local sup- purative lesions, although it may produce general pyemic infec- tion and fatal septicemia. I recall one case of fatal staphylococ- cemia in which pure cultures of staphylococci were found in the blood following a plastic operation on the perineum and cervix. This germ is found singly, in pairs, in fours, and in short chains, but generally in irregular clusters or grape-like bunches. It grows in all ordinary culture media at a temperature between 20° C. and 40° C. It rapidly liquefies gelatin and in the process of growth the colonies fall to the bottom of the medium, assuming a bright orange yellow color, hence its name. The culture colonies are at 64 GYNECOLOGY. first small and of a white hue, but by the third day they assume the characteristic golden yelloAv or orange color. The staphylo- coccus stains by all the common anilin dyes, but does not respond to Gram's method. The staphylococcus and its kin are perhaps the most frequent cause of local inflammation and suppuration of the uterus and its appendages and of the pelvic peritoneum. A special feature of this germ is its strong attractive chemotactic influence upon leukocytes, particularly the polynuclear cell. In two thousand and ninety-eight cases of purulent salpingitis three hundred and seventy-four were found to be due to puerperal sep- tic infection, mostly of staphylococcic origin. 105. Streptococcus. — The streptococcus pyogenes generally occurs in chains. It is the most virulent of all the pyogenic cocci and measures one-half to one micron in diameter. (Fig. 47.) It grows well at a temperature of from 30° C. to 40° C, but does not Fig. 46. — Staphylococcus Pyogenes Aureus. From Pure Culture in Bouillon. (Zeiss, 2 mm., Oc. c.) 47. — Streptococcus Pyogenes. From Culture in Bouillon. (Zeiss, 2 mm. Obj., Oc. c.) grow readily below 20° C. and is killed in ten minutes at 5 2° C. It groAvs on all common culture media, appearing as small elevated circular colonies of a grayish-white color. It does not liquefy gel- atin. The streptococcus stains with the common anilin dyes and is positive to Gram's method. This germ is found in spreatl- ing inflammatory processes, with or without suppuration, in serious phlegmonous and erysipelatous conditions and suppura- tions, in serious membranes and joints. Streptococci are also found in malignant endocarditis and suppurative periostitis. They are found in inflammatory disease of the mucous membrane, particularly the mucous membrane of the throat, where they cause a pseudo-diphtheritic inflammation. In puerperal perito- nitis they are found in a condition of purity, and this organism is undoubtedly the most frequent cause of puerperal septicemia. The streptococcus is less local in its action and far more virulent PELVIC EXAMINATION. 65 than the staphylococcus. In septic peritonitis and puerperal septicemia the organism is easily conveyed to the vaginal canal or uterus from without, and it is transported from the vagina or the uterus to the pelvic peritoneum through the lymph channels, blood-vessels, and by penetration of the uterine wall. The late Dr. Pryor asserted that the passage of this germ through the uterine wall should be counted by hours and not days. Sections of puerperal septic uteri demonstrate that Dr. Pryor was not in- correct in this assertion, for in nearly all cases the organism can be recognized microscopically throughout the tissues of the uterus. Doderlein, in his investigations of the vaginal secretions of nearly two hundred women, found only one-half normal. The remainder were bacteriologically abnormal. In ten per cent, of the normal Fig. 48. — Secretion from Gonorrheal Vaginitis, Showing the Gonococci Both Within and Without the Pus-cells. a, Pus-cell Containing Gonococci; b, Pus-cell Undergoing Dissolution; c, EpitheHal Cell. Large cases the streptococcus pyogenes was present, and inoculations with the secretions from fifty per cent, of these revealed that they were pathogenic for animals. Secondary abscesses in the lymphatic glands are more frequently caused by streptococci than by staphylococci. The virulence of the streptococci varies. 106. Gonococcus. — The gonococcus was first described by Neisser in 1879, and later cultivated in solidified serum by Bumm and others. It has been definitely determined to be the specific cause of gonorrhea. The gonococcus under the microscope re- sembles in appearance two coffee-beans placed side by side, with an unstained oval interval. Sternberg applied the term * ' biscmt- shaped" coccus. (Fig. 48.) Irregular and degenerative forms of the germ are, however, seen. This germ is sometimes difficult to 5 66 GYNECOLOGY. cultivate on artificial culture media. (Fig. 48.) It grows slowly on human blood serum or acid urine agar and blood-smeared agar or on Wertheim's media, appearing, at the end of twenty-four or forty-eight hours after inoculation, as small, irregular, rounded colonies of a grayish-yellow color. The margins of the colonies are undulated and sometimes show small projections. Colonies vary in size and tend to remain separate. They reach their maxi- mum size on the fourth or fifth day, and, according to Muir and jRitchie, on the ninth day or earlier die. The germ stains readily with the basic anilin dyes, but does not stain by Gram's method. The gonococcus is found in large numbers in pus of acute gonor- rhea, both in the male and female. It, for the most part, is con- tained within the leukocytes. In the earlier stages it is also found Fig. 49. — Secretion of Simple Vaginitis, Showing Various Forms of Organisms Found and Preponderance of Epithelial Cells. a, Bacilli; b, Streptococci; c, Staphylococci; d, Pus-cell. outside the pus-cells, but when the discharge is wholly purulent the greater portion are found within the pus-cells. Gonococci are also found in purulent secretion of gonorrheal ophthalmia and throughout the genital tract when these organs are the seat of Neisserian infection. The tendency of the organism is usually to remain and cause local genital lesions. It is not alone responsible for disseminated genital infections, but is also responsible for generalized or systemic lesions, and has been found in pure culture in the blood. Gonococcemia usually results from infec- tions of the genito-urinary organs, but cases have been recorded where blood infection has occurred from gonorrheal ophthalmia. Cases of endocarditis, endarteritis, suppurative arthritis, and gen- eral pyemia have resulted from the absorption of the organism. The gonococcus is, unfortunately, found present to an alarming PELVIC EXAMIXATIOX. 67 degree, and in the female is undoubtedly the most destructive of all the pyogenic cocci, and when once implanted on the mucosa of the female genital tract, is rarely, if ever, eradicated. Sanger, in a series of nineteen hundred and thirty cases, reports two hundred and thirty suffering from gonorrheal infection. A committee ap- pointed by the American ]\Iedical Association found that in pelvic disorders of women requiring surgical interference forty per cent, were of the specific diplococcus origin. In the gynecological wards of Jefferson ]\Iedical College Hospital one in five or twenty per cent, of operations are performed for lesions resulting from the action of the gonococcus. Andrews, discussing the etiology of salpingitis from a series of statistics collected from twenty-eight sources, shows that in six hundred and eighty-two suppurative tubes the gonococcus was found present one hundred and fifty- five times in three hundred and eight cases in which micro-organ- isms were demonstrated. In three hundred and seventy-four the pus was sterile, and he believed that many of these were primarily of gonorrheal origin. Kleinhaus, in two hundred and eighteen pus tubes, found the gonococcus present seventy-four times. The large number of sterile tubes found was explained by the fact that the gonococcus disappears early from pus, and it is, moreover, extremely difficult to demonstrate the micro-organism in the tubal wall. The gonococcus, however, does not always disappear from the contents of the pus tubes early, because cases have been re- ported of old-standing pus tubes being operated upon, followed by suppurative peritonitis in which pure cultures of gonococci were obtained. The gonococcus, while violent and destructive in action, is perhaps the most prolific cause of chronically invalided women and also the causative factor in destroying the structure of the uterine mucous membrane, rendering it unfit for lodgment, maintenance, and successful maturation of a fertilized ovum. It is also productive of great harm in the appendages of the uterus — the tubes and ovaries — working such changes in these organs as to demand their total sacrifice or cause such structural alterations as to prevent the proper performance of their especial functions. Despite the virulent influence which the gonococcus exerts upon the generative organs of women, it, however, rarely causes death. It is frequently responsible for violent attacks of peritonitis with alarming symptoms, but the inflammatory changes usually re- main localized and do not spread as infections of this membrane do when caused by the staphylococcus, or more particularly, the streptococcus. This is due to the fact that gonococci find a natural habitat and favorable nutrition in the cells and fluids of the mucous membrane lining the genital tract, particularly the cer\'ix and Fallopian tubes, whereas the endothelial cells of the peritoneum and the peritoneal fluid are, to a certain degree, hostile 68 GYNECOLOGY. and phagocytic to the gonococci, thus destroying many and driv- ing others into a localized field of battle. 107. Bacillus Coli Communis. — This organism is found present normally in the intestinal canal. It is very similar, morphologically, to the typhoid bacillus. The colon bacillus is usually found in mixed infections, though pure infections by this organism do occur. Andrews, in his bacteriologic statistic study of pus tubes, found that the colon bacillus was present in 2.5 per cent. (Fig. 50.) This germ is frequently respon- sible for inflammatory disorders of the intestinal canal and sup- purative processes in the peritoneal cavity. It is often found in inflammation of the urinary passage, such as cystitis, pyelitis, and pyelonephrosis. Colon suppuration of the organs in the pelvis does occur, and Reed says that it is responsible for a cer- 50. — Bacillus Coli Communis. From. Pure Culture in Bouillon. (Zeiss, 2 mm. Obj., Oc. c.) Fig. 51. — Bacillus Tuberculosis. (Zeiss, 2 mm., Oc. c.) tain percentage of cases of ovarian abscess. He claims that the diseased organ as it becomes adherent to the bowel affords an opportunity by the contiguous surface for the introduction of the germ. Roberts states that suppuration of ovarian cysts, especially after twisting of the pedicle and the resulting adhesions to the bowel, has a similar explanation, and many suppurative infections of the abdominal incision can be traced to this germ. 108. Bacillus tuberculosis, discovered by Koch in 1882, is a rod-shaped bacillus, one and one-half to three and one-half microns long, one -fourth to one-half micron thick. It grows readily upon solidified blood sertim and glycerin agar. It develops slowly — does not appear for two or three weeks after inoculation. (Fig. 51.) The colonies are of a creamish color and somewhat granu- lar. This becomes more marked as the growth ages, and, accord- ing to Coplin, the surface of the colony takes on a bread-crumb PELVIC EXAMINATION. 69 appearance. The bacillus stains with most of the basic anilin dyes and by Gram's method. It takes the stain slowly but securely, and is with difficulty decolorized. It resists strongly the decolorizing action of mineral acids in common with certain other organisms belonging to the acid-fast bacteria. Primary tuberculosis of any part of the genital tract is rare, though tuber- culous lesions may occur in any portion. The Fallopian tubes are the organs most frequently infected, and next in order of frequency are the uterine body, ovaries, vagina, cervix, and vulva. Tuberculous infection of the vulva and vagina is rare, and is usually secondary to infection from the uterus. Tubercu- losis of the vagina is frequently associated with or is secondary to tuberculous inflammation in other portions of the genito-urinary tract, as the bladder, bowel, peritoneum, or distant organs, as the lung or joints. Primary vaginal tuberculosis, however, has been reported by Friedlander. It has been demonstrated that the freedom of the vulva and vagina from tuberculosis is due to the resistance of the squamous epithelium to bacterial invasion. Tuberculosis of the vulva and vagina (lupus), while extremely rare, is a very destructive disease. In one case under my observation in the terminal stages the entire vulva was totally destroyed, establishing fistulous communication between the vagina and rectum and vagina and bladder. I have fre- quently seen rectovaginal fistulas as a result of tuberculous disease of the rectum. Tuberculous infection of the uterus also is rarely a primary disease : it is generally associated with or is secondary to tuberculous lesions in the tubes, peritoneum, or some other structure of the body. Tuberculosis of the uterus and the organs above occurs with greater frequency than is clinically observed, as careful postmortem examinations of individuals dying from pulmonary tuberculosis has proved, yet Martin, in sixteen hundred examinations of the uterine mucous membrane, found only twenty-four instances of tuber- culous lesions in the uterus. According to Spaeth, tuberculous infection of the cervix constitutes about five per cent, of the cases of genital tuberculosis in women. The Fallopian tubes are the most frequent seat of genital tuberculosis. In a total of one hundred cases of pyosalpinx collected by Andrews ten per cent, were tuberculous. The infection is usually secondary to tuberculous foci elsewhere in the body. In primary tuber- cular salpingitis the bacilli are introduced from without, and attack the tube by ascending the genital canal. Secondary infection of the tubes usually results from tuberculous peritonitis, but it may also result from metastatic deposition through the blood- or lymph- vessels. Infection may be conveyed by contigu- ity of structure from a tuberculous ulcerating intestine to an 70 GYNECOLOGY. adherent tube. Meyer reports fifty-seven cases of primary tuberculous tubal disease out of sixty-seven cases of genital tuberculosis. Orthmann states that primary tubal tubercu- losis occurs in eighteen per cent, of all cases of genital tuber- culous infection in women. Rosthorn, in eighteen hundred and fourteen cases of inflammatory disease of the tubes, found tuberculous infection to be the exciting cause in twent^^-nine. Tuberculous infection, particularly of the tubes, occurs in young children and in virgins. All cases of tuberculous peritonitis, however, are not necessarily associated with tuberculous inflam- mation of the tubes or uterus. I have operated on several cases of tuberculous peritonitis in young women, and in most of these careful observation failed to reveal any marked tuberculous process in these organs, yet some of the cases were of long dura- tion. It is stated by certain investigators that pre-existing gonorrheal infection of the tube predisposes to tuberculous disease. Infection of the ovaries by the tubercle bacillus is exceedingly rare, one or two cases of primary ovarian tuber- culosis having been recorded, but in the vast majority of cases it is secondary to tuberculous infection of the Fallopian tubes, peritoneum, and intestines. In forty-eight cases of ovarian tuberculosis Orthmann traced the infection to the tubes in twenty-six and the peritoneum in twenty-two. Infection of the peritoneum by the tubercle bacillus occurs in men, women, and children. The disease may occur in the acute miliary, the caseating, or a chronic fibroid form. The disease is most fre- quent in women, and the relative frequency given by different obsen^ers is from fifty to ninety-eight per cent. It usually occurs in young women between twenty and thirty years of age, though the infection occurs at all ages. Tuberculous peri- tonitis was found two hundred and eighty-four times in thirteen thousand four hundred and twenty-two autopsies studied by Grawitz and Brum, and the Mayos, in five thousand six hundred and eighty-seven operations, found it present eighty-nine times. Osier found that in abdominal operations for tuberculosis lapar- otomy was performed twice as often in females as in males. An interesting feature of tuberculous infection of the peritoneum is the unusual occurrence of extensive lesions in other portions of the body. 109. Syphilis and Chancroid. — The organisms of chancroid and chancre have not been definitely demonstrated, though a characteristic bacillus was discovered and described first in chancroid by Ducrey in 1889. Unna, in 1892, described the appearance of this bacillus in prepared histologic sections of the soft sores. It appears as small oval rods measuring one to two microns in length and half a micron in thickness. It is PELVIC EXAMINATION. 71 usually present with other organisms in the purulent discharge from the surface of the specific sore. It stains readily with basic anilin dyes, but decolorizes rapidly. It has not been successfully cultivated outside of the body. Regarding the specific organism of syphilis, much definite knowledge can not be given. Lustgarten, in 1884, described an organism which he discovered m a primary sore and in the lesions of internal organs. It resembles somewhat the tubercle bacillus, occurring in slender rods from three to four microns in length. It stains with the basic anilin dyes and -is easily decolorized by mineral acids. Lustgarten 's bacillus has not been cultivated outside of the body. Many other micro-organisms have been described as present in syphilitic lesions, but the causative relation of bacteria in the production of this disease has not been fully determined. no. Bacillus Typhosus. — The typhoid bacillus may be found in any part of the genital tract during typhoid infection, and for months, or even years, after subsidence of fever. It is found in acute infectious inflammations of the endometrium, and Pfan- nenstiel reported three cases of post -typhoid ovarian abscess. Several other cases have been reported. The typhoid bacillus has been found in suppurating ovarian cysts several months after the primary typhoid infection. It is probable that the bacilli reach the ovarian structure by passing through the in- testinal wall. Typhoid infection of the vulva and vagina also occurs, and, according to Keen, the lesions usually occur as dis- tinct vulvar gangrene and gangrenous ulcerations in the vagina. He collected eight cases, seven of which were in young persons from seventeen to twent^^-seven years of age, and one of thirty- four years. In six of the cases there was gangrene of the labia, extending sometimes to the perineum and thigh. Fistulous communications between vagina and bowel were established. The gangrenous ulcers were commonly located on the posterior vaginal wall. Ulceration of the anterior vaginal wall is also reported, with the formation of vesicovaginal fistula. In some of the cases great distortion of the vagina developed from cicatri- zation, and in one case complete occlusion, resulting in retention of menstrual fluid which required operation for its liberation. Keen reported a patient under his observation with both recto- vaginal and vesicovaginal fistula. Typhoid infection of the uterus during pregnancy frequently occurs and generally results in the expulsion of the fetus. Typhoid bacilli have been found in the placenta, and Keen studied a case reported by Freund and Levy in Avhich spontaneous abortion occurred at the fifth month. The patient Avas in the declining stages of typhoid in- fection. Bacilli were found in the blood of the placenta, in the 72 GYNECOLOGY. Spleen, and in the heart of the fetus. Other similar cases have been reported. 111. Smegma Bacillus. — This micro-organism normally in- habits the secretions of the external genitals, and may be found in the urine associated with particles of detached smegma. The germ is not pathogenic. Morphologically it resembles somewhat the tubercle bacillus, but is shorter and differs tinc- torially in that it is not an acid-fast bacillus, and, therefore, is readily decolorized by the mineral acids. 112. Bacillus pyocyaneus, a short, rod-shaped, motile organism which measures one to one and one-half microns in length by one- half micron in width, grows readily in nearly all culture media at a temperature of 20° C. to 37° C, liquefying gelatin, and in the process of growth the colonies assume a greenish hue. It is found in green pus and in the discharge of the intestinal dis- orders of infancy. It has been found in suppurative peritonitis, otitis media, endocarditis, and other affections. 113. Bacillus aerogenes capsulatus is a gas-producing bacillus, measuring three to six microns in length and one to one and one-half in thickness. It is truly anaerobic, grows in all culture media in chains of three and four, and generates gas and acid in the process of development. It has a distinct capsule. The germ has been found in emphysematous gangrene, in cases of emphysematous vaginitis, and in the uterus in puerperal septic infection. The distention of the puerperal uterus with gas, which sometimes occurs (physometra) , is, no doubt, due to the presence of this micro-organism. 114. Diphtheria Bacillus. — Infection of the genital canal with Klebs-Loeffler bacillus while rare, occasionally occurs, and cases of diphtheritic infection of the vulva, vagina, and uterus are reported. Infection generally occurs during the puerperium and is implanted on injured tissues. The infectious process presents the same pathologic anatomy as noted when occurring in the throat, and responds likewise to the administration of antitoxin. The poison, when implanted upon abraded structures rapidly generates the characteristic false membrane, which hastily spreads over the entire vagina and even into the uterus and tubes. Diphtheroid infection frequently results from the presence of the streptococcus and other pathogenic bacteria, particularly the former, following labor, but the membrane formed by the streptococcus develops in patches and is confined to abraded surfaces (Edgar) ; therefore, if the entire genital tract is covered by the pseudo-membrane, true diphtheria is suggested. Infec- tion of the genital tract by the bacillus of diphtheria is usually conveyed by the attending physician, and it follows, therefore, that no case of labor should be attended by men who are at PELVIC EXAMINATION. 73 the same time caring for patients suffering with diphtheritic infection. 115. Pneumococcus. — The diplococcus of Frankel has been found in suppurative conditions of the female genital tract, particularly of the Fallopian tube. Andrews, in his cases col- lected from literature, found the pneumococcus present fourteen times, thirteen times in pure culture and once mixed with other germs. Pneumococcic infection of the genital canal, however, does not bear any definite relation to pneumonia. The infec- tion usually has been introduced from without into the lower genital canal. The pneumococcus has been found in suppura- tive processes of the ovary; it has been reported to have been collected in pure culture from an ovarian abscess. 116. Diplococcus of Siegelman. — This organism occurs in pairs and somewhat resembles the gonococcus. It is smaller and is further differentiated from the gonococcus in that it accepts Gram's stain. The germ was discovered by Siegelman in several cases of pruritus vulvas in which there was no other demonstrable cause. Siegelman attributes, therefore, the so- called cases of idiopathic pruritus vulvae to the action of this coccus. ANIMAL PARASITES. 117. Pediculosis Pubis or Inguinalis. — The ordinary crab louse is generally found in the hair of the pubic region, sometimes in the axilla, and occasionally in the eyebrows. Careful ex- amination will reveal the parasite near the roots of the hairs, with its head downward and buried in the follicle. The spores will be found deposited on the hair shafts. In the pubic region this parasite is responsible for intense pruritus, resulting in hyperemia and excoriation from scratching. 118. Acarus scabiei, the itch-mite, while found on the tender skin areas of the body, is frequently present in the skin of the lower abdomen and vulva, inducing intense itching with ex- coriation and abrasions of the skin from constant scratching. 119. Oxyuris Vermicularis. — The ordinary seat or pin worm inhabits the colon and rectum. From these regions it wanders to the vulva and vagina and may wend its way into the interior of the uterus. Fallopian tube, and ovaries. Mano, quoted by An- drews, reports a case of a large cyst of the ovary and two small cysts of the tube in which were found the eggs of this parasite. Mano believes that the parasite reached the tube and ovary by traveling from the rectum, the vagina, and uterus. The pin worm is found at all ages, but commonly in children. The parasite causes intense pruritus, which is always worse at night, 74 GYNECOLOGY. due to its nocturnal migration. From the itching and scratch- ing, excoriations and inflammation of the vulva result, and even perirectal abscesses may form. 120. Ascaris lumbricoides, the ordinary round worm of the intestinal canal, is the most common animal parasite found in human individuals. It usually occurs in children and occupies generally the upper portion of the small bowel. From this region they migrate through the various channels connected with the alimentary canal, and even penetrate the intestinal wall. Cases are recorded where they have completely occluded the biliary passages, and traveled through the Eustachian tube and projected from the external ear. They have been found in the vagina, uterus, tubes, and free in the pelvic cavity. J. H. Koch found the ascaris in an abscess in the pouch of Douglas. The portal of entry was through a fistulous communication from the rectum. Bizzozero found the ascaris in the right Fallopian tube ; the parasite had entered the tube by traveling through a perforation in the rectal wall. 121. Taenia Echinococcus, or Dog Tapeworm. — This para- site inhabits the intestinal canal of the dog and wolf. The adult worm is composed of five segments. The first segment is slender and continuous with the head ; the second is the shortest ; and the posterior segment, the longest, is frequently more than half the length of the parasite. The adult worm is not found in the human individual. The larvae of the parasite are taken into the alimentary canal of the individual, or in the female they may enter also by way of the vagina. When conveyed by the alimentary canal the embryos are hatched and these wander into the tissues of various organs, forming a cyst, the hydatid cyst. In Iceland, where human beings and dogs live together in closely confined quarters, echinococcus disease is. endemic. The liver is the organ most frequently affected, being involved in fifty per cent, of the cases. Echinococcus cysts may develop in any part of the body. The disease is more frequent in women than in men, and Finsen found that in two hundred and forty-five cases seventy per cent, occurred in women. In the pelvis the disease is usually situated in the cellular tissue of the posterior pelvis and also in cellular tissue anterior to the uterine body. Cases have been reported where the cysts have developed in the uterine body proper. Hydatid disease develops in the Fallopian tube, and Doleris collected eighty cases of hydatid disease of the tube from the literature, one of which, his own, was possibly primary in the tube. Primary echinococcus infection of the ovary is rare, though a few cases have been reported. The diagnosis of this condition is made positive by finding the booklets or scolices. A cystic tumor con- PELVIC EXAMINATION. 75 taining fluid of comparatively low specific gravity (1005-1012) and non-albuminous, or containing only a small trace of albumin, and neutral in reaction should be suggestive of echinococcus dis- ease. 122. Collection of Fluids and Secretions. — To make a positive diagnosis of certain infectious conditions and to determine the character of the specific infectious agent present, it is neces- sary to collect specimens of the secretions or fluids and submit them to careful bacteriologic analyses. Microscopic and bac- teriologic examinations, however, of secretions and fluids from the genital tract should not be the only bases considered in making a diagnosis, but should be regarded as an additional resource for establishing the diagnosis. Bacteriologic examina- tions of the secretions can be made with carefully prepared cover-glass spreads from the vulva, vagina, and cervical canal, and the orifices of the various communicating glands, such as Bartholin's and Skene's. Spreads should also be prepared from secretions expressed from the urethra. The preparation of the spreads should not be left to the nurse, but should be made by the physician himself. Cover-glass specimens are pre- pared from the vulva by transferring the secretion from the parts with an applicator provided with a small swab of sterile cotton or the ordinary platinum needle, the end of the needle proper being rolled together in order to afford a larger collecting surface. This is applied to the part containing the secretion and then transferred to the cover-glass. Specimens may be secured from the vagina and cer\dx in a similar manner, though material from the cervix should be obtained after exposing the cervix with a speculum, when the secretion can be collected as it escapes directly from the cervical canal. It is important in preparing cover-glass spreads to collect secretion from the parts most com- monly the seat of infection, such as the orifice of the urethra, orifice of Skene's and Bartholin's glands, and from the cervical canal. In long-standing infections of the cervix the germs are found to inhabit the glands ; so to demonstrate their presence, therefore, the glands should be punctured and the contents collected on a cover-glass as they emerge at the site of puncture. In infecting culture media inoculations should be made with the suspected secretion from the different parts of the tract, not one part alone, and several cultures should be prepared. It is important in collecting discharges for bacteriologic exami- nation that the patient should not receive any antiseptic douche for at least a period of twenty-four hours before the collection is made. This procedure destroys the microscopic value of secretions and, therefore, renders examination practically worth- less. Cover-glass spreads can also be employed in private prac- 76 GYNECOLOGY. tice — both in office work and in outside practice. The secretions and fluids can also be collected in especially prepared glass pi- pets, the material being drawn into the pipets with a syringe, after which the ends of the tubes are hermetically sealed. With the secretion contained the pipets should be enveloped in cotton or other protecting material and conveyed to the patholo- gist for examination. It is also always important in preparing cover-glass spreads, cultures, or secretion tubes to letter or number each in order to designate the organ from which the collections were made. Fluids from cysts are sometimes col- lected and examined microscopically to ascertain their true character, but only in hydatid disease can we deflnitely assert the true nature of the lesion by finding the booklets of the para- site. Secretions of the genital tract are, as a rule, only collected and examined to determine the presence and virility of bacteria present, although sometimes particles of benign or malignant neoplasms may be discharged, which are collected and studied intelligently, but usually only very small pieces of tissue are thus obtained, and from these positive microscopic diagnoses can not be made. Moreover, sections of material escaping in secretions are generally so altered by necrobiotic processes that the recognition of their true character is necessarily rendered extremely difficult. 123. Blood Changes. — The importance of careful scientific blood analyses in the diagnosis of various gynecologic affections, particularly those of an inflammatory character, is now so generally recognized, as evidenced in the recent medical litera- ture, that the insertion of an article on this department of medi- cine seems necessary. The systematic and careful examination of the blood in certain gynecologic affections will reveal definite clinical facts that can not be positively elucidated by any other means. Gynecologic diagnoses, however, must be made by utilizing all clinical methods of examination, and too much value should not be placed on any one method. 124. Examination of the Blood. — The blood is examined microscopically to ascertain the number and character of the corpuscles and their relative proportion, to estimate the amount of hemoglobin, and to determine the presence or absence of para- sites. The examination further involves: (a) The estimation of the specific gravity. (b) The estimation of the alkalinity. (c) The determination of the rapidity of coagulation. (d) Spectroscopic examination. (e) Bacteriologic examination. (/) The determination of the serum reaction. 125. The Specimen. — The blood for examination is usually PELVIC EXAMINATION. 77 obtained from the finger-tip or the lobe of the ear, the finger-tip being preferred in most instances because of its special con- venience. In patients nervous and easily disturbed the lobe of the ear should be employed, because it is not so sensitive as the tip of the finger. The region selected, however, should always be freely cleansed and kept separate from any area of infection or other pathologic condition. 126. Method of Collection. — The part selected to furnish the specimen should be thoroughly cleansed, first with sterile water and then with alcohol. During the cleansing the parts should be rubbed briskly with a towel to dry the part, and at the same time cause a free determination of the blood to the parts selected. A puncture is made with a specially prepared needle (Fig. 52) or, what is undoubtedly of better service, a pen with one nib broken off. The part to be punctured is supported by the thumb and index-finger of the left hand, and slight pressure is made upon it. The patient, if nervous, is directed to refrain from observing the operation, and then with a quick, firm prick the skin is punctured. Dr. Coplin objects to the continuous employment of one instru- ment for puncturing or pricking the skin, and recommends the use of a pen such as I have described and which is used in my Fig. 52.— Needle for Puncturing Finger. service. A three- cornered needle or an ordinary surgical or sewing needle may be employed in an emergency. All the instruments used in the examination of the specimen should have been previously ar- ranged. Several cover-glasses and slides should be included, and these should be carefully cleansed and dried. After the first few drops of blood have been wiped away the summit of the next drop as it oozes from the puncture is touched lightly with a cover-glass which is placed blood side downward upon the sur- face of a clean glass slide or upon another cover-glass and drawn apart. The first method is employed if the specimen is to be examined in the fresh state, and the second if the speci- men is to be fixed and stained. The study of the fresh specimen can be prolonged by excluding air from the film. This is done by sealing the margin of the cover-glass with a thin layer of cedar oil or vaselin. After the cover-glass is placed upon the slide pressure must be avoided in order to prevent distortion of the cells. 127. Microscopic Examination of a Fresh Specimen. — The fresh specimen thus prepared is examined with both low and high power lenses. The one-twelfth oil immersion, hoAvever, is the 78 GYNECOLOGY. lens usually employed. The changes to be looked for in the erythrocytes, according to DaCosta, are any decrease in the number of these cells or an abnormal increase of them, corpuscular richness in hemoglobin, recognized when the cells appear as pale, washed-out bodies (abnormal viscosity, their tendency to- ward rouleau formation, presence of deformities, and the occur- rence of structural degenerative changes, and the presence or absence of parasites). The first change in the leukocytes to be noted is whether their number is greater than normal, but too much stress should not be placed upon an apparent increase, as it may be due to a reduction in the number of erythrocytes, and, therefore, the impression would be deceptive. To- one familiar with the appearance of the various forms of leukocytes in a fresh specimen a differential count is possible. Degenerative changes, ameboid movement, and pigmentation of these cells may be observed in examining a fresh specimen. The parasites found in fresh blood are those of the Plas- modium of malarial fever, the spirillum of Obermier, and the em- bryo of the filaria sanguinis hominis. Foreign bodies, such as fat droplets, extracellular bodies, and, rarely, Charcot's bodies, may also be observed. 128. Fixation for Staining. — Cover-glass films are fixed usually by heat, placing the glasses in a hot-air oven at a temperature of 125° to 140° C. for twenty to thirty minutes. Special small ovens are constructed on the principle of hot-air sterilizers foi' the fiixation of films. The films can also be fixed by placing them upon a copper plate supported over a flame and protected from air, and also by making three or four circular turns with the films through a flame from a Bunsen burner, as in fixing bacteria. Placing the cover-glass films in equal parts of alcohol and ether for half an hour secures excellent fixation. 129. Staining. — After the films are properly fixed they are grasped in cover-glass forceps and the stain is then applied with a dropper. By using Kalteyer's cover-glass forceps the film may be immersed in a dish containing the stain. Slides containing fixed blood should be placed in jars containing the stain as in staining tissue on slides. In staining fixed specimens and blood for microscopic investigation it is better, when possible, to com- pound preparations which will stain the largest number of ele- ments in the prepared blood film. This method is spoken of as panoptic staining. The stain most frequently used and perhaps endowed with special properties is the Ehrlich triacid stain. This stain should be made from concentrated aqueous solutions of the dyes. The stain is composed as follows: I. Saturated aqueous solution of orange G: PELVIC EXAMINATION. Orange G, 6 gm. Distilled water, i oo c.c. 2. Saturated aqueous solution of acid fuchsin: Acid fuchsin (fuchsin S), 9 gm. Distilled water, too c.c. 3 . Saturated aqueous solution of methyl green : Methyl green (00 crystal), 6 gm. Distilled water, 1 00 c.c. These solutions keep fairly well, but the mixed stain pre- pared from them is not a lasting one and, after a period of two or three weeks, usually does not act well, but even then an experienced investigator will recognize the deficient dye, and can add the required stain. Films stained by Ehrlich's method will show the stroma of the red cells an orange hue ; the nuclei of the white cells greenish-blue ; the neutrophile granules violet or lavender, and the eosinophile granules copperish red. Nucleated red cells of normal size, according to DaCosta, stain deep purple or black; those of normal size (normoblasts) and those of large size (megaloblasts) pale or greenish-blue. The basophile gran- ules do not take the stain and appear as a dull Avhite coarseness in the cell protoplasm^. The methylene-blue eosin stain, introduced by Wright, is one of the most satisfactory now in use, and the one introduced by Jenner is also of value. Preparations having qualities similar to the Wright and Jenner stains have been advo- cated by other men. The chief advantages claimed for these agents are that no special fixation of films is required and that blood plates and basophilic granules and the malarial parasites are all well stained by these preparations. The Wright stain is employed as follows: (i) Cover thin, air-dried films with stain for one minute. (2) Add to the stain water, drop by drop, until an iridescent scum forms on the surface ; for seven-eighths inch square cover-glass films four to eight drops of water usually suf- fice. Allow the diluted stain to act for two or three minutes. (3) Wash with water until the film becomes pink or yellow in color. (4) Blot with filter-paper, dry in air, and mount in balsam. Under the microscope the erythrocytes will appear orange or pink ; nuclei of leukocytes and erythroblasts a dark blue to lilac ; cytoplasm of lymphocyte robin's-egg blue; hyaline cell, pale to dark blue; neutrophile granules, reddish lilac; eosinophile gran- ules, pink ; basophile granules, blue to royal purple ; blood plates, pale blue with dark lilac or blue granules. After washing off Ehrlich's stain, Dr. Hewes recommends that a saturated aqueous solution of meth^dene-blue should be used as a stain for several minutes. Cabot savs that anv one who has used this Ehrlich 80 GYNECOLOGY. methylene-blue stain will never employ any other for clinical purposes. The blue count erstain also brings out clearly the out- lines of the parasite against the yellow of the corpuscle. Many other methods of staining blood specimens have been rec- ommended, but the stains thus enumerated will serve practically every clinical purpose. lodopkilia. — The behavior of leukocytes to iodin, originally described by Ehrlich and Gabritschowsky, is a decided progressive step in the clinical examination of the blood. This reaction of the leukocytes to iodin is called iodophilia, while the cells taking the iodin are spoken of as iodophiles. The reagent employed to obtain the iodin reaction is a syrupy mixture, composed of the following elements: Iodin, I Potassium iodid, 3 Aqua dest., 100 Gum arabic sufficient to make syrupy mixture. This syrupy solution is placed upon an air-dried film of blood for two or three minutes. The excess is then drawn off and the cover-glass placed blood side downward on the slide. Under the microscope the red cells, leukocytes, and blood plasma of a normal specimen are found to stain a uniform pale yellow. In a positive iodin reaction the leukocytes stain brown, either diffusely or in a granular or network distribution. As a rule, variable sized granules, ranging in color from brownish yellow to a deep brown, are found, which, in location, are intracellular or extracellular. These brownish, granular bodies are found within the polynuclear leukocytes. The presence of iodophilia may be generally con- sidered indicative of a septic or suppurative process. It is not, however, a positive sign of the presence of pus. DaCosta says that a reaction is positive in all purulent collections, and that the reaction persists as long as the suppurative focus exists. It is present in puerperal sepsis and other forms of septicemia. It is not found in pure tuberculous formations, and, therefore, the presence of iodophilia in all other forms of abscess may be the deciding factor in the differential diagnosis of pus accumula- tions. This peculiar reaction of the leukocytes to iodin is also a valuable diagnostic agent in other diseased conditions which are of more interest to the general practitioner than the gyne- cologist. 130. Counting the Corpuscles. — The instruments employed for counting the corpuscles are called hemocytometers. An instru- ment devised by Thoma is the one in most common use, and is regarded as the standard for blood counting. It consists of two graduated pipets for diluting and mixing blood, and a counting chamber in which a measured volume of diluted blood is placed PELVIC EXAMINATION. 81 for the purpose of counting the corpuscles under the microscope. (Fig. 53.) One of the pipets is intended for counting the er3rthrocytes or red cells, and, therefore, is spoken of as the red pipet or erythrocytometer. The other pipet, used for count- ing the leukocytes or white cells, is called the leukocytometer. The pipets are graduated in order to secure accuracy in dilution. The blood is drawn into the tubes to an indicated point, and then the diluting solution. The tube is thoroughly agitated in order to mix the blood completely with the diluent. For ordinary counting a one-half of one per cent, or a one per cent, solution of sodium chlorid is used as a diluting agent for the erythrocytes, and a one per cent, or a one-half of one per cent, aqueous solu- tion of acetic acid is used as the diluting agent for the leukocytes. This acid solution is used in order to dissolve out the erythrocytes titiYt'iVtfTl Fig. 53. — Hematocytometer. and at the same time render clear the leukocytes. Diluting fluids are also used to secure different shading of the corpuscles dur- ing the process of counting. The most satisfactory for this pur- pose is Toisson's solution, composed as follows : Methyl-violet, 0.025 &i^- Sodium chlorid, i.o " Sodium sulphate, 8.0 " Glycerin, 30.0 c.c. Distilled water, 160.0 " Or the following solution of Sherrington may be employed : Ehrlich's purified methylene -blue, o.i gm. Sodium chlorid 1.2 " Neutral potassium oxalate, 1.2 " Distilled water, 300.0 " 131. The Estimation of Hemoglobin. — The estimation of the percentage of hemoglobin is determined by the hemoglobinometer. Several instruments have been devised for this purpose, but the 6 82 GYNECOLOGY. hemoglobinometer originated by Dr. Dare is one of the best. (Fig. 54.) It is of simple construction, easy of manipulation, and answers every purpose well. The instrument of von Fleischl is also extensively used, but it is more complicated and requires more time in manipulation than the Dare instrument. The Tall- qvist hemoglobin scale is simple and good for use in emergency. It is composed of a book (Fig. 55), 1 ' sPH Fig. 54. — Dare's Hemoglobinometer. R. Milled wheel acting by a friction bearing on the rim of the color disc. S. Case inclosing color disc, and pro- vided with a stage to which the blood chamber is fitted. T. Movable wing which is swung outward during the observation, to serve as a screen for the observer's eyes, and which acts as a cover to inclose the color disc when the instrument is not in use. U. Telescoping camera tube, . in position for examination. V. Aperture admitting light for illu- mination of the color disc. X. Capil- lary blood chamber adjusted to stage of instrument, the slip of opaque glass, W, being nearest to the source of light. Y. Detachable candle- holder. Z. Rectangular slot through which the hemoglobin scale indi- cated on the rim of the color disc is read. Fi< 55-- -Tallqvist's Hemoglobin Scale. a color scale forming the first leaf, and the remaining leaves being composed of absorbent paper. This apparatus, how- ever, is only approximately accurate. 132. Composition of Blood. — The normal circula- ting blood is composed of two portions. The first, the liquid portion, known as the liquor sanguinis or blood plasma, and a solid portion, which is composed of corpuscles or blood-cells. The plasma is a straw-colored fluid with a specific gravity ranging from 1026 to 1030. It is alkaline in reaction and contains approximately ten per cent, of solid matter, of which three-fourths are proteids and the remainder fibrinogen, serum-albumin, and serum-globulin. PELVIC EXAMINATION. 83 The corpuscles are of two varieties: i, Erythrocytes, or red cells; 2, leukocytes, or white cells. Besides these, two other elements are found: namely, the blood plaques or platelets, and the hemoconia, or "Miiller's dirt." The salts of the blood consist of sodium chlorid, potassium chlorid, sodium carbonate, sodium phosphate, magnesium phosphate, and calcium phosphate. Of these, the sodium chlorid is the most abundant and forms from sixty to ninety per cent, of the total amount of mineral matter. 133. Erythrocytes. — The erythrocytes or red corpuscles in man are thin, non-nucleated, biconcave discs. From seventy to eighty per cent, of the red cells have an average diameter of 7.5 microns. Of the remaining twenty per cent, about one -half are slightly larger and the remaining slightly smaller. Unduly small red corpuscles are called microcytes, and when these are abundant in the circulating blood, the condition is spoken of as microcytosis. Unduly large red cells are known as macrocytes ; regular shaped erythrocytes, as found in certain diseases, are called poikilocytes, and where this is marked, the condition is denominated poikilocytosis. The term " blast " is applied to red cells containing nuclei. The normal red cells containing nuclei are called normoblasts, small cells containing nuclei microblasts, and the extremely large cells containing nuclei macroblasts. Poikilocytes containing nuclei are called poikiloblasts. The hemoglobin or coloring-matter of the blood is a highly complex albuminoid substance contained within the stroma of the red blood-cells. It forms about nine -tenths of the total bulk of the erythrocytes, and its special function is to convey and dis- tribute oxygen to the tissues in its passage through the capillary circulation. The normal percentage of hemoglobin is fixed at one hundred, but in estimating this element in individuals apparently normal, one hundred per cent, is rarely obtained. One hundred per cent., however, is considered normal, and this means that every one hundred gm. of blood contains approxi- mately fourteen gm. of hemoglobin. A reduction in the per- centage of hemoglobin is called oligochromemia. This condition characterizes, as a rule, all the primary and secondary anemias. It is usually associated Avith a diminution in the number of red cells. Pronounced reduction in the hemoglobin is present in chlorosis, pernicious anemia, leukemia, and in the secondary anemias — those resulting from hemorrhage, acute and chronic infections, malignant disease, and general systemic exhausting diseases. A slight reduction (ten to fifteen per cent.) usually occurs a few days prior to menstruation. 134. Color Index. — The normal color index or valeur globu- laire of the blood is the amount of hemoglobin in the individual red cell. 84 GYNECOLOGY. 135. Relation of Hemoglobin to Surgery. — Many investigators have asserted that it is dangerous to administer an anesthetic or operate upon patients when the hemoglobin is below thirty per cent., while others claim that forty per cent, should be fixed as the minimum safety. In my experience the standard thus fixed is too high, and I believe that with a hemoglobin percentage of twenty per cent, anesthesia can be induced and operations per- formed with wisdom and safety. I have operated upon several patients successfully with a hemoglobin percentage ranging be- tween tAventy and thirty per cent. In one patient, indeed, the percentage was but nineteen. This patient was suffering with extensive malignant disease of the uterus. I performed a com- plete hysterectomy and the patient made an uninterrupted re- covery. I would not, however, insist that it is wise to operate in all cases where the hemoglobin percentage is inordinately low. I believe it better, when the condition of the patient will permit, to wait and employ means to increase the hemoglobin richness of the blood, but where this can not be done, particularly in cases of progressive exhaustive disease, I believe operation indicated despite the presence of a low hemoglobin percentage. One of the principal objections, however, to operation on patients with profoimd oligochromemia is the failure of the wound to unite readily. In one patient upon whom I operated for uterine carci- noma and who had only twenty per cent, of hemoglobin, the tissues failed to unite, and with the removal of the sutures the abdominal incision separated, exposing the intestine. Low hemoglobin per- centage also predisposes patients to shock, infection, and in all, convalescence is prolonged and disturbed. The normal nucleated red cell is regarded as an immature form of the erythrocyte, and is found normally in the bone-mar- row, and only in the peripheral blood when special demands are made upon the blood-making organs for cellular elements, as in certain pathologic states, particularly the anemias of both the primary and secondary varieties. 136. Normal Number of Red Cells. — At ordinary sea level and in the adult normal individual the average number of red cells to the cubic millimeter of blood is five million in man and four mil- lion five hundred thousand in woman. In the robust, healthy person this number may be increased to five million five hundred thousand, six million, or more. Altitude above the sea level raises the count. Concentration of blood from various causes will also increase the number of erythrocytes. The influence of menstrua- tion, childbirth, lactation, and digestion is to cause a temporary decrease in their number. Prolongation of exercise reduces the number. In the newborn the red cell count is high (seven to eight millions). PELVIC EXAMINATION. 85 137. Increase in the Number of Erythrocytes. — An increase in the number of erythrocytes above what is fixed as the normal standard is called polycythemia. A decrease in the number is known as oligocythemia. 138. Pathologic Alterations of the Erythrocytes. — Ameboid movements are said to have been observed in the red cells in cer- tain pathologic states of the blood. Disassociation of the hemo- globin from the stroma is also observed in certain diseased states. In most inflammatory conditions and in the profound anemias a hyperviscosity of these elements is observed. De- formity of shape and size of the red corpuscle is noted in all the severe anemias. The terms applied to the alteration in size and shape were mentioned in discussing the physiology of these cells. Polychromatophilia or abnormal staining reaction occurs in several forms of anemia, and is particularly noted in pernicious anemia and myelogenous leukemia. Nucleation of red cells is noted in various pathologic conditions, and the various forms of nucleated red cells (erythroblasts) have been mentioned. Gran- ular changes of the protoplasm in the red cells occurs in certain pathologic states, but is most constant in chronic plumbism. This granular change is present also in pernicious anemia, leu- kemia, carcinoma, malaria, septicemia, and chronic suppuration. The granules in the erythrocyte are basophilic, and they may be distributed throughout the cell or aggregated in small masses. The size of the granules varies. The presence of basophilic granulating erythrocytes is spoken of as basophilia. 139. Platelets. — The blood platelets or blood plaques are small spherical bodies, somewhat smaller than the erythrocyte. They are of a pale yellowish tint and measure one to four microns in diameter. They are non-nucleated bodies and react to both basic and acid stains. Their normal number to the cubic milli- meter of blood is fixed at from one hundred and eighty to four hundred thousand, and by some men their number is fixed at ■eight hundred and sixty thousand. They are non-nucleated and do not contain hemoglobin. Many observers claim that they have their origin in extruded particles of the erythrocytes, while others believe they originate from the nuclei of leukocytes. They are the chief constituents of white thrombi. These bodies are increased in most of the anemias. They are present in pneu- monia, tuberculosis, and other conditions. They are diminished in purpura, hemophilia, and in acute infections. 140. Hemoconia. — In normal and pathologic blood, elements have been described by Miiller to w^hich he applies the term ' * hemoconia' ' or * ' blood dust . ' ' This material is present as small, round, colorless granules which measure from one-fourth to one micron in diameter. These bodies are refractile and have the ob GYNECOLOGY. power of molecular action, but no true ameboid movement. Their presence in the blood is not of special diagnostic or prog- nostic value, though by some men they are believed to bear some relation to the process of immunity. Their true origin is not known. Some claim that they are products of the erythrocyte, while others present evidence to show that they are granular bodies derived from neutrophile and eosinophile leukocytes. Hemoconia is also found in pus and in hydrocele fluid. 141. Leukocytes. — The leukocytes or white blood-cells are pale, nucleated bodies, the greater portion being larger in size than the red cells, but, unlike the red cells, they are found in several varieties. The proportion of leukocytes to erythrocytes varies, but it ranges approximately between one of the red cells to five or six hundred of the white cells. The size of the normal leukocytes varies from seven to twelve microns. The general outline while at rest is an irregular ellipse. The total number of leukocytes in a cubic millimeter of normal blood is given at from four to ten thousand. The mean normal average has been set at seventy-five hundred per cubic millimeter. The number of leukocytes present in the blood varies to a considerable degree under physiologic conditions. Several varieties of white cells are found in stained specimens of fresh blood. The different varieties and the percentage present and the number per cubic millimeter in the normal blood are given in the following table : Variety. Percentage. Cubic Millimeter. Polynuclear neutrophiles, 60 to 75 3000 to 7500 Small lymphocytes, 20 to 30 1000 to 3000 Large lymphocytes and transitional forms, 4 to 8 200 to Soo Eosinophiles, 0.5 to 5 25 to 500 Basophile rarely exceeds 0.5 25 As stated before, these percentages vary greatly under both physiologic and pathologic conditions. Decrease in the number of leukocytes is called leukopenia, or hypoleukocytosis. Leukopenia occurs in certain of the in- fectious diseases, such as typhoid fever, measles, influenza, malarial fever, and also in uncomplicated tuberculosis. It is also present in certain of the primary anemias and in some secondary anemias. In conditions characterized by an increase in the number of leukocytes a reduction is sometimes noted. This is due to the overwhelming influence of the toxin and is said to be of graA^e significance. It signifies the patient's in- ability to combat the infectious process. Leukolysis, or the de- struction of leukocytes, most marked in the polynuclear cell, occurs in suppurative processes. Pus-cells are polynuclear cells altered by the action of bacterial poisons. PELVIC EXAMINATION. 87 142. Leukocytosis.— This theory teaches that the circulating; blood contains certain bodies (chemotactic) of a chemical nature which have an attractive and repellent influence upon the phago- cytes. Chemotaxis is both positive and negative — positive when the cells are attracted by chemotactic bodies and negative chemotaxis when the cells are repelled by these substances. Leukocytosis may be defined as an increase in the number of the- Avhite cells over the normal number in the peripheral circulating blood. The increase may be absolute and relative in the poly- nuclear cell with a relative decrease of the other forms, or the increase may be general in all varieties alike, but the increase never involves a diminution of the polynuclear forms ; therefore leukocytosis is of two kinds : ( i ) That in which the relative pro- portion of the different varieties to each other is unchanged; (2) that in which the increase is made up solely or largely by a gairt in the polynuclear leukocytes. Leukocytosis may be temporary or permanent. The latter is spoken of as chronic leukocytosis. Leukocytosis is divided into — (i) physiologic leukocytosis; (2) pathologic leukocytosis. Physiologic leukocytosis is classified under the following heads: leukocytosis of the newborn; leu- kocytosis of digestion; leukocytosis of pregnancy and parturi- tion ; leukocytosis due to thermal and mechanical agencies ; and leukocytosis of the moribimd state. Physiologic leukocytoses are generally of short duration and are characterized by only a moderate increase in the leuk:ocytes. The causes of physiologic leukocytosis are said to be an tmequal distribution of the cells in favor of the peripheral vessels and upon the temporary con- centration of the blood. 143. Leukocytosis of Digestion. — Leukocytosis of digestion rarely reaches a high count, but after a meal rich in proteids the count may rise to thirty-three per cent. Ten thousand cells maybe considered the average, according to Cabot, three or four hours after a rich meal. 144. Leukocytosis of Pregnancy and Parturition. — Leuko- cytosis occurring in pregnancy is most marked in primiparce. Thirteen thousand is considered an average count, and is quite constant. In multiparse it occurs in only about fifty per cent, of the cases. Leukocytosis of the parturient state may endure for several weeks and is important for the reason that it may be mistaken for a pathologic leukocytosis. 145. Thermal and Mechanical Agencies. — Thermal and me- chanical leukocytosis results from blood concentration, and this is due to vasomotor contraction with increased arterial tension. 146. Terminal leukocytosis, or leukocytosis of the moribund state, occurs in many cases. It is not present if death is sudden or rapid. It seems to be analogous to the preagonal rise_of 88 GYNECOLOGY. temperature. The increase in ordinary cases occurs in the polynuclear cell. 147. Pathologic Leukocytoses. — Pathologic leukocytoses are classified as posthemorrhagic, inflammatory, malignant, toxic, and experimental. The exact cause of pathologic leukocytoses has not been determined, but the general belief at the present time is that the increase is due to chemotactic influence. 148. Posthemorrhagic Leukocytosis. — Leukocytosis results from loss of blood, is rapid in its development, and of short dura- tion. The count may reach sixteen to eighteen thousand. The increase, as a rule, is in the polynuclear cell. 149. Leukocytosis (Phagocytosis). — The function of leuko- cytosis is to protect the individual against infectious micro- organisms and their toxins. It is one of nature's methods of antagonizing and rendering inert micro-organisms and their poisons. Cells having this power are called phagocytes, and they exert their force in two ways: (i) By mechanically destroy- ing the infectious generators of bodies (bacteria); and (2) by the generation of chemical products (alexins) which are an- tagonistic to the bacterial poison and destructive to bacteria also. 150. Inflammatory Leukocytosis. — This variety of patho- logic leukocytosis, as its name implies, is associated with suppura- tive, septic, or inflammatory processes. It should not be, ac- cording to Cabot, described as infectious leukocytosis, for the reason that in many of the infectious diseases the leukocytes are not increased. Furthermore, in certain infectious diseases there is an actual diminution (leukopenia) in the number of white cells. The extent or degree of leukocytosis depends: (i) Upon the reaction of the patient; and (2) upon the virulence of the invading micro-organisms. Therefore, a high leukocy- tosis usually indicates good reaction and strong resistance upon the part of the patient and is considered a favorable prognostic sign. Persistent hypoleukocytosis in the presence of infection, however, indicates lessened tissue reaction and virulent infec- tion. The leukocytic count in inflammatory conditions varies greatly. It is not unusual to find a leukocytosis of forty-five thousand, forty-eight thousand, or fifty thousand, and even greater. The individual cell most prominent in inflammatory leukocytosis is the polynuclear leukocyte, and this type forms from ninety to ninety-five per cent. In other cases the in- crease is found in the lymphocyte. Leukocytosis in inflamma- tory diseases of the female genital tract is quite constant and of value as a diagnostic aid in pelvic conditions. A leukocytosis ranging from twelve thousand to eighteen thousand as a rule indicates suppurative disease in the adnexa, if other causes can PELVIC EXAMINATION. 89 be excluded. Pankau believes that a leukocyte count of ten thousand indicates suppuration in the appendages. DaCosta found in thirty -four cases of pelvic abscess, ovarian abscess, and pyosalpinx, an average leukocyte count of fifteen thousand five hundred and forty-eight per cubic millimeter. Of course, the increase in the number of leukocytes will depend upon the degree and limitation of the suppurative process. If an abundance of the toxic material is absorbed from the pelvic lesion and the resistance of the patient is good, the increase will be marked, while if the lesion is enveloped by a non-absorbing inflammatory wall, the count will be low. 151. Malignant Leukocytosis. — According to Julliard, in malignant disorders leukocytosis is not present early, but is associated with ulceration, necrosis, and absorption of specific toxic matter. When generalization of malignant neoplasms occurs, the leukocyte count rises, providing the patient still re- tains powers of reaction. The effect of malignant disease on the leukoc3rtes will depend upon:, (i) The position of the tumor; (2) its size ; (3) rapidity of growi:h ; (4) the occurrence of metastases ; (5) the resisting power of the individual; and (6) the degree of necrotic change. In cancer of the uterus the leukocytes are, as a rule, slightly increased. In seven cases reported by Cabot a leukocytosis was observed in five which ranged from sixteen thousand eight hundred to thirty-four thousand. In the two remaining cases no decided alteration was noted in the number and appearance of the leukocytes. It may be said, however, that malignant leukocytosis is generally moderate, and, accord- ing to DaCosta, counts of less than twenty thousand are the general rule. Malignant leukocytosis is generally most pro- nounced in sarcoma. 152. Toxic Leukocytosis. — Increase in the leukocytes due to uric-acid diathesis, quinin poisoning, illuminating gas poison- ing, intestinal intoxication, nephritis, chloroform narcosis, and the ingestion of certain chemicals is spoken of as toxic leuko- cytosis. 153. Experimental Leukocytosis. — This is an increase in the number of leukocytes due to the administration of certain drugs. Artificially induced leukocytosis or leukotaxis has been resorted to in order to increase the local and general resistance of individuals against infection. Petit endeavored to increase infection resistance of the peritoneum by the injection of heated horse serum, and for the same purpose Mikulicz employed on patients preparatory to operation injections of nucleinic acid hypodermically. I have used the latter for this purpose, but am unable from my experience to assert any beneficial infiuence. The increase produced by artificially induced leukocytosis occurs 90 GYNECOLOGY. in the polynuclear cells, which is asserted to be from nine to four hundred and twenty-five per cent. 154. Bacteremia. — Bacteremia is defined as the presence of micro-organisms in the circulating blood. Normally the blood is regarded as bacteria-free, yet recent investigations show that even under normal conditions bacteria exist in the blood. The condition has been denominated "latent microbism." This mild bacteremia is wholly consistent with health, because the bacteria present are small in number and not virulent, and, therefore, can not do harm unless the individual is weakened in resistance and the bacteria become virulent. 155. Bacteria found in Blood. — A large number of bacteria have been isolated from the circulating blood. Among the most important are: I. The pyogenic bacteria. (a) Staphylococcus pyogenes. (b) Streptococcus pyogenes. (c) Gonococcus. (d) Pneumococcus. (e) Diplococcus intracellularis meningitidis. Other bacteria found in the blood are : Bacillus anthracis. Bacillus coli communis. Bacillus influenzae. Bacillus leprae. Bacillus mallei. Bacillus pestis. Bacillus tetani. Bacillus tuberculosis. Bacillus typhosus. Besides these vegetable parasites, certain animal parasites are found in the blood, the most important of which are the ma- larial Plasmodia, the embryo of the filaria, and spirilla of Ober- meyer. 156. Blood Culture. — The blood secured for bacteriologic examination should be aspirated by puncturing a superficial vein which has been exposed by an incision, and not by punc- turing the vein through the skin. Examination of prepared cover- glass films is unsatisfactory. In obtaining the blood the veins in front of the elbow- joint (median basilic or median cephalic) may be selected. The tissues of the part should be thoroughly sterilized in order to rid them of the common dermal bacteria. According to DaCosta, fluid culture media are pref- erable to the solid. One-half cubic centimeter of blood should be drawn for each culture, and about one hundred parts of media to each part of blood should be used. A special needle can be PELVIC EXAMINATION. 91 secured for withdrawing the blood (Fig. 56), but in an emer- gency a sterile antitoxin or hypodermic syringe may be em- ployed. 157. Blood Coagulation. — The coagulation of the blood under normal conditions is stated to occur, as a rule, in about five minutes, but, according to the personal observations of Coplin, a considerably longer time is required. Several methods are recommended to determine time of coagulation, but none are entirely satisfactory. A convenient method is that utilized by Milieu, which consists in placing a large drop of blood on a thoroughly clean slide, which after a few minutes is tilted toward a vertical plane to determine whether the shape of the drop is changed thereby. The hemogilometer of Biffi or the coagu- lometer of Wright may also be used to determine the time of coagulation. A proper knowledge of the coagulability of the blood is important to the surgeon in certain conditions requiring surgical intervention, and this will govern him in adopting and carrying out the proper course. The coagulability of the blood is decreased in cases of ob- struction of the biliary pas- sages, as in cholelithiasis with or without icterus, in acute exanthemata, in pur- pura, hemophilia, and other forms of blood dyscrasia. I • Fig. 56. recall two deaths resulting from uncontrollable oozing after operations upon patients suffering from jaundice produced by cholelithiasis. Therefore, before operating upon patients suffering from lesions associated with decreased coagulability of the blood, proper treatment should first be instituted to restore the blood to as near a normal condition as possible, and thus increase the safety of operative interference. 158. Exploration of the Urethra, Bladder, and Ureters. — The bladder can be explored by the introduction of the finger through the urethra, but the dilatation required is so great that, notwith- standing every precaution which can be exercised, the procedure must necessarily often be followed by loss of sphincter control. A careful urethral and vesical examination may be made de- sirable by frequent and painful micturition, by admixture with the urine of blood, pus, desquamated epithelium, fragments of tissue, and the presence of bacteria. Limitation of the inflam- mation to the urethra is indicated by a pain and burning during |iN -Special Needle for Securing Blood. 92 GYNECOLOGY. the act of urination, followed by comparative comfort (unless complicated by cystitis) unaccompanied by frequency of micturi- tion. Inspection will reveal the orifice of the inflamed urethra as red, pouting, and angry. Frequently by pressure along the course of the canal from above downward a drop or two of dirty or purulent fluid will be expressed. When the inflammation involves the w^all of the urethra, it can readily be distinguished upon palpation of the anterior vaginal wall as a distinct cord- like projection. Skene's urethral endoscope is of value in de- termining the condition of the urethral mucous membrane. (Fig. 57.) It discloses points of inflammatory redness, desquamated epithelium, thickened membrane, and fissures of the internal urethral orifice. The instrument should not be unduly large, as the distention of the urethra obscures pathologic alterations. Irritation and inflammation of the bladder is indicated by fre- quent and painful micturition and violent tenesmus unrelieved by urination. The attacks may recur and appear to be induced by exposure to colds, as drafts, changes of temperature, damp- ness, indiscretions in diet and drinking, and by excessive venery, or the discomfort may be more or less continuous. The distress- ing symptoms may have arisen from infection which has reached the bladder from the urethra, the kidney through the vesical walls, or from the presence of foreign bodies, as calculi, fragments of catheter, or extraneous bodies which have been inserted into the urethra in the process of onanism. The existence of the various neoplasms may be manifested by similar symptoms. Inflam- mation of one or both ureters is prone to be associated with pain, which may be referred to the bladder. Incontinence of urine association with a forcible dejection of the fluid in small quantities is especially characteristic of inflammation of the ureter. Ex- amination of the urine is of particular value in the determination of the lesions of the various portions of the urinary tract. In urethritis and functional irritation of the bladder, the urine will be clear and free from deposits. In cystitis, ureteritis, and pyel- itis the urine may be loaded with sediment, which under the microscope will be found to consist of blood and pus corpuscles, renal and vesical epithelium, portions of tissue, crystals of the various salts, and in some cases casts of the uriniferous tubules. The determination of the portion affected by the character of the desquamated epithelium is impracticable. The examination of the urine secured after careful irrigation of the bladder, or, better still, after the catheterization of the ureters, not only differentiates renal from vesical conditions, but affords informa- tion as to the state of the individual kidney. If after irrigation of the bladder the urine secured is clear and comparatively free from sediment, it is a fair inference that the disorder is confined PELVIC EXAMINATION. 93 to the bladder; and, on the contrary, the continuation of pus, blood, and desquamated epithelium in the urine is an intimation that the upper urinary structures are the seat of disease or are actively involved by it. Inflammation of the bladder causes the secretion of a large quantity of mucus, and the urine contains but little albumin, while in inflammation of the pelvis of the kidney the proportion of albumin is comparatively large. Pyel- itis is distinguished from nephritis by the absence of tubular casts. Bloody or high colored urine is not uncommon in acute inflammation of the kidney or bladder. Hemorrhage from the urinary tract may occur from a variety of causes and from any portion of the tract. From the urethra it may occur indepen- dently of urination as a few drops or clots in the first discharge of urine, or after the completion of micturition. Vesical hemor- rhage may cause the urine to be bright red or appear as almost pure blood, according to the severity of the hemorrhage. When very profuse, the bladder may become filled with clot, so that the patient is unable to void urine, and the presence of the clot interferes with catheterization. Free bleeding from the kid- ney may be seen with the cystoscope (see Fig. 58), and makes its exit from one of the ureters as pure blood or distinct casts of the ureter may be found in the urine, and the patient gives a history of having had severe pain over the kidney and along the ureter corresponding to the side from which the hemorrhage has occurred. Pain is a characteristic symptom. It is felt above the symphysis in cystitis, along the affected ureter in ureteritis, or over the affected kidney in pyelitis, or where the kidney con- tains a calculus. The hypogastric region is tender to pressure, in cystitis the tenderness being more noticeable upon sudden withdrawal of the hand after deep pressure when tubercular cystitis exists. The bladder may be palpated by one or two fin- gers in the vagina and the hand over the abdomen. The inflamed bladder will be thickened, contracted, and very tender. Calculi and neoplasms may thus be recognized. The inflamed and thickened ureter is easily recognized upon one side or upon both sides when bilateral. The shortened ureters stand out as firm, dense cords. Not infrequently in such cases the pressure along the ureter may cause a sudden discharge of urine, which may reach the person of the investigator. The inflamed kidney is readily palpated when the patient assumes the dorsal position with the limbs flexed. The physician stands upon the affected side, places one hand upon the back beneath the ribs, and pushes gently forward, while at the same time the patient is asked to take a long breath and allow it to be expelled quickly. Pressing the thumb of the hand beneath the ribs in front during expiration the enlarged kidney may be felt to have slipped upward, or, where 94 GYNECOLOGY. it is quite movable, may be held below the fingers. In thin patients the kidney may thus be easily distinguished. Care must be exercised, however, that a prolapsed or malformed liver is not mistaken for the kidney. During the first week in July, 1906, I saw a woman who, I was convinced after an examination under an anesthetic, had a very movable kidney, but examina- tion through an abdominal in- cision, which was made for short- ening the round ligaments, re- vealed the fact that the supposed movable kidney was a tongue - like projection from the anterior margin of the liver which, through the abdominal wall, greatly re- sembled in size and shape the kidney. Pawlik and Kelly de- vised specula through which the bladder could be inspected and medications applied to the most affected portion. The orifices of the ureters could be inspected and the ureteral catheter em- ployed. They require the urethra to be dilated, sometimes close to or beyond the limit of safety, in order to afford opportunity to inspect and properly treat the affected structures. Of late Fig. 57. — Skene's Urethroscope. A\\ B C ,,C:^ D Fig. 58. — Cystoscopes. years the procedure of Nitze, in which the illuminating lamp is introduced within the bladder, and to add to its effectiveness the image is magnified, renders the investigation more satisfactory. The bladder is distended with water or air, preferably the former, when the entire cavity can be carefully inspected. The elec- tric illumination can be obtained through a transmitter from PELVIC EXAMINATION. 95 the street current or the dry cell battery may be employed. An instrument not larger than a No. 30 bougie, French scale, is sufficient for every purpose in the inspection of the bladder and ■catheterization of the ureter. Such an instrument may be em- ployed without an anesthetic ; the bladder may be irrigated and Fig. 59. — Kelly's Specula (Urethra), Fig. 60. — Mouse-tooth Forceps for Cotton Pledgets. Fig. 61, — Kelly's Evacuator. Figs. 62 and 62,. — Ureteral Catheters — Metal and Soft. filled through the tube, after which its escape is perfected by the introduction of a magnifying lens. The cystoscopic inspec- tion is of value, as it discloses the condition of the vesical mucous membrane, permits the differentiation of desquamation and catarrh from gonorrheal and tubercular cystitis, and has demon- 96 GYNECOLOGY. strated the dependence of obstinate cystitis upon torpid ulcera- tion of the vesical mucous membrane. It permits the inspection of the inflamed, pouting orifices of the ureters and allows the determination of the affected kidney by the observation of blood or pus coming from the orifices of the corresponding ureter. It has permitted the recognition and dislodgment of calculi situ- ated in the lower end of the ureter. The condition of the ureter and kidney is also determined by passing through the posterior slit of the cystoscope a long, soft, ureteral catheter. Fig. 64. — Harris' Double Catheter for Obtaining Urine from Kidneys Separately. This procedure permits the exploration of the ureter and the accumulation of the urine for examination, affording an oppor- tunity to determine whether one or both kidneys are involved. By a wax-tipped bougie, as suggested by Kelly, the presence of a calculus can be recognized in the ureter or in the pelvis of the kidney. The segregator, as devised by Harris, of Chicago, will permit the accumulation of the urine from the kidneys in separate receptacles, but it is inferior to the use of the ureteral catheter through the cystoscope. ABDOMINAL EXAMINATION. 159. Preliminaries. — An examination from the diaphragm to the pelvis should be made of every woman who presents symptoms which indicate that she is suffering from pelvic disease. Such an investigation will reveal ptoses of the abdominal viscera, tumors, hernia, disease of the gall-bladder or appendix, and other conditions which otherwise would be overlooked. The ABDOMINAL EXAMINATION. 97 patient must have her clothing so adjusted that the entire sur- face of the abdomen can be exposed. She should lie in the dorsal position, upon an examining chair, bed, or table, with her limbs slightly flexed. A sheet is thrown over her lower extremities and drawn over the symphysis, when the clothing is raised and her abdomen exposed. 1 60. Inspection. — An investigation of the external surface of the abdomen is of great value. The linea nigra, linea striata, and increase of pigment about the umbilicus and lower abdomen are signs indicative of a previous or present pregnancy. These dis- Fig. 65, — Abdomen Prepared for Examination. colorations having once occurred are never effaced, and are conse- quently of significance only during a first pregnancy. The linea striata are red or purple, when recent ; white and glistening, when old. They are caused by overstretching of the skin, hence may result from any abdominal enlargement. Discolorations from blisters and counterirritants or scars from leech bites and wet-cups are indications of previous inflammation. The superficial abdom- inal veins are enlarged by any pressure upon the deeper vessels, and the enlargement occurs in pregnancy, in fibroid, ovarian, and other large tumors. The subcutaneous tissues become edema- tous in general dropsy and from acute abdominal inflammation. 7 98 GYNECOLOGY. The abdominal enlargement is symmetric, irregular, or nodu- lar ; the abdomen is flattened and broadened in ascites, narrowed and projecting in pregnancy, myomata, and ovarian cysts. The tumor is spheric, most prominent above to the right in pregnancy, rises abruptly, attaining the greatest prominence near the um- bilicus in ovarian cystomata, and is less likely to be symmetric in myomata. The surface of the skin is smooth and glistening from internal enlargement, and hangs in folds over the symphysis in obesity. A very dependent mass may be due to the protrusion of a large tumor between the separated recti muscles, or to a des- moid tumor of the abdominal walls. A large projection from the median line may be caused by a ventral hernia. Frequently the movements and outlines of the intestinal coils may be recognized. Fetal movements, contraction of muscles, and peristaltic action of the intestines can often be seen. Enlargements in the upper abdomen are due to growths in the liver, distention of the gall- bladder, enlargement of the kidney, or malignant disease of the ascending or transverse colon. In the median line the liver, stomach, pancreas, or transverse colon may be the seat of origin. Above, upon the left side, it may be the spleen, the left lobe of the liver, the cardiac end of the stomach, or the left kidney; and below, the descending colon. Ptosis of the stomach and liver can frequently be recognized. In the lower abdomen the genital organs are the seat of the majority of abnormal growths. A tu- mor in the right inguinal region should always awaken a suspicion of appendiceal inflammation or malignant disease of the colon. i6i. Palpation. — Palpation may be practised during the exer- cise of the preceding step. It consists in placing the hands, pre- viously warmed, upon the bare abdomen, and gently moving them from side to side, now close together, or again bringing the entire abdomen between their grasp. The tips of the fingers or the entire hand may be applied. Palpation enables us to recog- nize the presence of an abnormal growth: its situation, mobility, density, and relation to the abdominal viscera. Its dimensions, smoothness or irregularity, are recognized by carefully outlining the tumor. The relations and mobility of the growth are deter- mined by changing the position of the patient. The patient generally should be placed upon her back, with the limbs flexed and the head and shoulders slightly elevated. The confidence and cooperation of the patient must be obtained in order to secure relaxation of the muscles. It is necessary to proceed with the utmost consideration and gentleness, as rough, hasty, and inconsiderate palpation causes muscular rigidity and defeats the object. Pelvic abnormalities may require vaginal touch in conjunction with palpation, which has already been discussed under the bimanual examination. (Section 69.) ABDOMINAL EXAMINATION. 99 162. Difficulties. — Information may be difficult to secure by palpation because of a large deposit of fat in the abdominal walls or rigidity of the muscles from fear or actual tenderness. The patient can in general be so reassured as to permit the in- vestigation to be satisfactorily accomplished. In inflammatory collections it is often necessary to exercise care in the procedure to avoid rupture of the mass and the escape of its contents into the peritoneal cavity. 163. Percussion, though described separately, may be prac- tised in conjunction with the two preceding steps. It consists in eliciting resonance or dulness by mediate or immediate percus- sion. Fluctuation is recognized by placing a hand upon one side and striking upon the abdomen, more or less remotely, with the finger-tips of the other. A long wave indicates that the fluid is free or contained in a large sac. A short or indistinct w^ave is produced by fluid contained in a sac with numerous partitions or septa. The chief value of percussion is in determining solid or fluid tumors from distentions of the abdomen by gas or ascites. The ability to elicit resonance and dulness is utilized in the diagnosis between free fluid within the abdomen and that con- tained within a cyst. In the former a zone of resonance is elicited over the summit of the distention, while the remainder of the surface will be dull. The zone of resonance changes with the position of the patient, while in a cyst there is dulness over its surface and resonance above, and generally upon one side. In the latter the relative outline of the zones of resonance and dulness do not vary with change of position. The solid or cystic tumor, as it increases in size, pushes the viscera upward and to the opposite side; hence the situation of the zone of resonance. Resonance at the summit of the swelling in ascites is due to gas in the intestines, floating them to the surface. Should the mesentery be too short, from inflammation or great abdominal distention, to reach the surface, percussion gives dulness; while deeper pressure displaces the intervening layer of fluid, and again affords resonance. In localized peritoneal accumulations percus- sion aids only in defining their boundaries, and presents the sen- sation of fluctuation. 164. Auscultation is practised directly by placing the ear over the abdomen, Avith a towel or sheet intervening; and, indirectly, through the medium of a stethoscope. The former enables the physician rapidly to find the sound, the latter to study it minutely. Auscultation is of limited application. It enables us to hear the fetal heart-sounds, the bruit produced by the rush of blood through the uterine sinuses, and various sounds induced by gas and liquids in the intestines. The fetal heart-sounds are characteristic of pregnancy ; the bruit is heard in pregnancy and tofa 100 GYNECOLOGY. fibroid tumors alike. Efforts have been made to diagnose the seat of intestinal obstruction by the gurgling noise in the intes- tines, but our knowledge of the normal sounds is not sufficiently definite to enable us to make it of much value. 165. Exploratory Puncture. — Exploratory operations for the purpose of diagnosis may be one of two classes: puncture and incision. Puncture is divided into two procedures : tapping and aspiration. The former is applicable to the diagnosis and treat- ment of ascites ; the latter, where it is desirable to lessen the size or to determine the contents of a cyst. 166. Tapping, or paracentesis abdominis, was at one time the only method of treating abdominal collections of fluid, whether free or confined within a cyst. The instruments used should consist of a trocar and cannula, about J of an inch in diameter, to which a rubber tube may be attached. If Wells' blunt cannula is used, a bistoury must be employed to make the incision. The patient is placed upon her side near the edge of the bed ; a point is selected in the median line, about midway between umbilicus and symphysis, which percussion has demonstrated to be free from intestine ; and the surface is frozen by the application of ice iiMiMMiis^^^atii Fig. 66. — Nest of Trocars. and salt or a spray of ethyl chlorid. An incision is made through the skin, and the trocar is plunged, by a quick, rotating thrust, into the peritoneal cavity. The finger is held upon the instru- ment to govern the distance it is to be introduced. The trocar is withdrawn and a rubber tube is applied to the cannula to convey the fluid into a receptacle. The complete evacuation of the fluid is secured by pressing upon the abdomen toward the cannula. Arrest of the flow by the intestines floating against the end of the cannula can be obviated by changing its position. As the contents are evacuated the entrance of air into the abdomen may be prevented by keeping the end of the rubber tube submerged. The cannula is withdrawn and a piece of aseptic gauze is placed over the opening and held by a small strip of plaster. The withdrawal of a large quantity of liquid is frequently followed by symptoms of syncope. The patient should be kept in the horizontal position, and, if necessary, given whisky or brandy (fSj), spt. ammon. aromat. foj, well diluted, per oram, strychnin sulphate (gr. -^-^ to 3-^), atropin sulphate (gr. yio-), hypodermically, hypodermic injections of an aseptic ergot, or inhalations of a few drops of amyl nitrite. ABDOMINAL EXAMINATION. 101 167. Aspiration should be the procedure chosen when it is desired to evacuate the contents of a cyst. The use of the trocar favors the entrance of air and of pathogenic germs, and its open- ing permits the escape of the cyst-contents into the peritoneal cavity, which not infrequently promotes the development of peri- tonitis. The contents of a cyst should consequently be entirely removed if the wall has been perforated. The use of the hy- podermic syringe for the withdrawal of a small quantity of fluid for examination is reprehensible. The patient encounters a greater risk from the escape of a portion of the contents of a tense cyst through even a small opening than can be compen- sated by any advantage derived from an examination of the fluid. For aspiration two instruments may be used, one of which will hold a few ounces, in which the needle is connected with the reservoir; the other, used in large accumulations, consists of a large air-pump connected by tubing with a needle, a quart bottle intervening. (Fig. 67.) Rapid suc- tion exhausts the air in the bottle and causes the fluid to run until the cyst is emptied or the bottle filled. Strong suction w^hen the cyst is nearly empty draws its sides into the needle and stops the flow. The with- - drawal of the contents of the cyst is an advisable procedure when the pressure of the tumor is so great as to obstruct the circulation and lead to dyspnea, decreased renal secretion, and more or less anasarca. The operation in such cases, by facilitat- ing restoration of secretion, promotes a favorable result in subse- quent removal of the cyst. The procedure may be necessary, also, to prolong the life of the patient until a skilled operator can be secured. Broad-ligament cysts are occasionally cured by aspiration. It affords an opportunity to clear up the diagnosis in otherwise obscure cases. Two conditions particularly can be determined by microscopic examination of the fluids. Hydatid disease is recognized by finding even a single booklet. Malignant disease is determined by finding the presence of blood-corpuscles or particles of malignant tissue. The blood is mixed with the fluid. To examine it, the fluid should be drawn into a clean vessel, covered, and permitted to stand for twelve hours, when the blood-corpuscles will be found at the bottom or adherent to the sides of the vessel. Tapping and aspiration should always be done through the abdominal walls, never through the vagina or ^ ^ & \ fi \ It 2 ^ '"" '■' a 1 ^ 1 1 I 1, - 1 \J ^ &ji pr Fig. 67. — Aspirator. 102 GYNECOLOGY. rectum, on account of the more difficult antisepsis and consequent greater danger of infection. 1 68. Exploratory incision in cases of difficult or doubtful diagnosis is a most effective method for making known the con- dition, but should be very infrequently practised. The more carefully the sense of touch is cultivated, the less frequently will an incision be required. The position of a patient who has nerved herself to undergo an abdominal operation, only to ascer- tain that her trial and suffering have been without avail, is most distressing, and is not calculated to lead the surgeon frequently to repeat it in cases of extremely doubtful character. THERAPEUTICS. 169. Classification. — Gynecologic therapeutics may be divided into general and local, medical and surgical, and the time will not be misemployed if we consider the subject from the stand- point of preventive and curative. 170. Extension. — A cursory consideration renders it evident that the capable gynecologist must be versed in general medicine, and must be able to distinguish affections of the genital organs from disturbances of other organs and to recognize the indica- tions and contraindications for special methods of procedure. 171. Infection. — We need but to review the consideration of micro-organisms presented under diagnosis to appreciate the im- portance of combating infection in its various manifestations. Not infrequently deaths following operations are attributed ta heart failure, shock, pyelonephrosis, and pneumonia, when they are without question due to infection. Infection is more likely to reach a wound from unclean hands or instruments than through the atmosphere. 172. Terms. — The study of such conditions has originated the terms sepsis, antisepsis, and asepsis. Sepsis, of course, in- dicates the existence or sequela of infection; antisepsis, the use of agents which are either destructive to bacteria or hinder their baneful influence. Asepsis comprises the exercise of such means as shall exclude from the field of operation all pathogenic germs and their products. The latter is the ideal procedure, but when we have to deal with agents so intangible that it requires a micro- scope to discover their presence, and when it is absolutely im- possible to preserve aseptic or sterile ever^^hing that may come in contact with the affected tissues, a combination of the two methods seems the wiser plan of procedure. Sterilization means the entire destruction or removal of germs. Complete sterilization of everything is an ideal asepsis. THERAPEUTICS. 103 173. Sterilization Methods. — The most effective agent for sterilization is the flame, but this can rarely be used because of its destructive influence upon the temper of instruments. It is employed to destroy worthless and dangerous objects, such as soiled dressings. Heat may be employed in the dry and moist forms. The vegetative bacteria are destroyed by comparatively low tem- peratures, from 106° F. to 150° F. The spore-bearing bacilli require a higher temperature and stronger chemical solutions. Sterilization by dry heat is infrequently employed, for the reason that a temperature of 284° F. for three hours is required to insure the destruction of the spore-producing micro- organisms (Robb). It is rendered unavailable, not only by the time required, but it is injurious to in- struments and destruc- tive to ligatures and dress- ings. An effective and easy method of sterilization is by the use of steam, which requires an apparatus from which the air can be ex- pelled and the temperature maintained evenly at 212° F. A convenient and cheap apparatus for this purpose is an Arnold copper steril- izer. (Fig. 68). The most effective sterilization is accomplished in a steril- izer which employs super- heated steam under pressure. Steam at a temperature of 220° to 230° F. at a pressure of 15° insures the sterilization of large packages, but to prevent reinfection the sterilized packages should be thoroughly dry before removal from the sterilizer. The sterilizing apparatus is usually so constructed that steam can be turned out of the central chamber into the surrounding jacket and thus insure the drying of the contents of the chamber. Ligatures and sutures may also be sterilized in the same way, but much more effectively by boiling. Silk will not stand long or repeated boiling without becoming friable. The towels, sheets, and operating gowns should be subjected to what is called the fractional method. This consists in placing the -Arnold Steam Sterilizer, 104 GYNECOLOGY. Fig. 69. — Steam-pres- sure Sterilizer. material in the sterilizer for one hour the first, and one-half hour each succeeding, day for two days. They should be care- fully protected until used._ When dry and properly protected, they will remain aseptic for an indefinite time. 174. Sterilization of Instruments. — The instruments for ex- amination and operation should be capable of being thoroughly cleaned, and after every operation should be cleansed in hot water and boiled before the next operation. They should be placed in trays dry, or upon a sterile table. It was formerly the custom to place instruments in a five per cent, solu- tion of carbolic acid. If the instruments are properly cleansed, the use of this agent is unnecessary, and in many operative pro- cedures, particularly those upon the peri- toneal cavity, it is objectionable, in that it causes irritation of the delicate structure of the peritoneum. The instruments should be sterilized before beginning an operation. Davidson says five minutes' boiling in water destroys all germs, but if the instruments have been used in pus or about gangrenous cases it is important that we should exercise still further precau- tions to render them absolutely sterile. They may be boiled for half an hour in a five per cent, solution of carbolic acid. The water should be boihng before the instruments are placed within it or they will rust. Rust- ing can be prevented by using a one per cent, solu- tion of carbonate of soda. This method of procedure affords a ready means of sterilizing an instrument which has been dropped during an operation. It has the advantage that any vessel can be used. The in- strument trays — preferably of glass or porcelain, as be- ing most readily disinfected — should be sterilized by heat, or, after careful washing with soap and hot water, should be filled to the brim with i : 500 solution of bichlorid. Trays should be emptied and washed out with plain sterilized water before the instruments are placed in them. Fi?. 70.- -Sterilizer for Boiling- Instruments. THERAPEUTICS. 105 175. Sponges. — sponges require more care and attention than any other part of the operation. I formerly used gauze pads made by taking a yard of gauze and folding it six or eight times, so that it made a pad from six to eight inches square. All selvage edges were turned in and whipped over by continuous suture. These pads were boiled for half an hour, dried, and kept in sterile vessels ready for use. They were again boiled im- mediately before the operation. They were inexpensive, and, therefore, could be thrown away after each operation. The majority of operators now use dry gauze for sponges: pieces of gauze a yard in length are so folded that the raw edges are not ■exposed. They are done up in packages or placed in a metal receptacle so arranged that steam will pass through them, and are subjected to sterilization by the fractional method. They should be kept protected from dampness or any possible source of infection until used. The person who dispenses them at the operation should only handle them with a sterilized metal in- strument. The greatest care must be exercised to make certain that pp^pii^ipii^^^^i all pieces of gauze are accounted f^^'^^''^'^^^^^^^''''^"^'^^'^^'^- for before closing the abdominal ■!__ IIm cavity. It is advisable to assign to" I ip^ two persons to the sponges. One Mh. A|P: gives them out, and as she does so ^1 '^^'fi counts them. The second person ^^fc:.:, :^i:-t 14^=;==^^ accumulates and counts the sponges ^^^^SUmm^^^^^^^^^^^^^^^ ^^^^ after removal from the wound. Fig. 71.— Gauze Pads. The tally of sponges issued and re- ceived should agree before the wound is closed or the operator should satisfy himself by very careful examination that none are retained. An aseptic sponge may be retained without delaying the healing of the wound and become encysted, but later may form an abscess and open externally into the vagina, bladder, or rectum. Occasionally a large vessel may be eroded and a fatal internal hemorrhage occur. When the operator is to depend upon uncertain assistants, it is better to return to smaller pieces of gauze, which can be washed and used over and over during the operation. When the operator prefers sponges, a good, fine, tough Turkish sponge should be chosen, using a definite number each of round and flat sponges. They should be care- fully cleansed by being placed in a towel or bag and pounded with a cane until as much as possible of the dust and sand is removed. Then they are placed in water acidulated with muriatic acid sufficient to give a strong acid taste, in which they remain for twelve hours. This dissolves out the sand and earth. The sponges are then washed in green soap through 106 GYNECOLOGY. a number of waters until they become perfectly clean, after which they are placed in a five per cent, solution of carbolic acid. A good plan of procedure in cleansing sponges is to place them in a solution of hyposulphite of soda — a pound of the salt to a gallon of water for each dozen sponges. Add to this an ounce of muriatic acid or half a pound of oxalic acid. The addition of the acid to the soda results in a double decomposition, in which sulphurous acid and sulphur are set free. The acid burns out the organic material in the sponge and at the same time bleaches it. Sponges should not be permitted to remain in this solution longer than from five to ten minutes. They are then washed in water until there is no longer any whitening of the water with the sulphur. They may then be placed in a five per cent, solu- tion of carbolic acid. When the sponges have been used, they may be washed and used again, unless they have been soiled by contact with some special poison or infectious material, when they should be thrown away. In recleansing the sponges they should first be washed in cold water to remove the blood, then soaked in a solution of washing soda, half a pound to the gallon, and afterward in a solution of hyposulphite of soda and oxalic acid. The solution in w^hich the sponges are kept should be changed every two or three weeks. The marine sponge is now rarely used because of the difficulty in maintaining it in an aseptic condition. The dry sterile gauze is almost as effective for drying a bleeding surface. It can be kept sterile and is much cheaper, so there is no temptation to reemploy it. 176. Ligature and Suture Material. — Methods for Its Prep- aration and Preservation. — The material used by the majority of operators is silk. Pozzi recommends that it shall be boiled with carbolic acid, 50 : 1000, wound upon glass reels, and kept in this solution, which should be changed every week. Not too large a quantity should be prepared at a time, as the nearer to the opera- tion, the less irritating it is. Hegar uses iodoform silk, which is immersed twenty-four hours in iodoform 20 grams, ether 200 grams. This is dried, wound upon bobbins, and kept in glass boxes. Silk may also be boiled in a sublimate solution (i : 1000). Nilson recommends that suture material for superficial stitches should be boiled in wax and carbolic acid, as it is thus less likely to become infected. Apropos of this method, I used a suture of this kind in closing the lacerated perineum of a patient immedi- ately following labor. Sutures were removed a week later. Tw^o years subsequently, during examination of this patient, I noticed a dark speck or groove upon the perineum, and on closer in- spection found it to be a ligature that had not been removed. It was raised up, cut, and withdrawn, when it was found that it occupied a groove, which was completely cicatrized and ap- THERAPEUTICS. 107 parent ly was not irritated. The possibility of infection of silk when used upon the stump of a suppurating tube, or in a pelvic cavity when suppuration is present, and the long-continued sinus that results until the ligature itself has discharged, have led me to prefer some material for ligation that is more certain to be absorbed and will not remain in the tissues so long. I have had occasion to open a sinus and remove a large ligature from a patient upon whom the operation had been done four years be- fore, and the abscess did not form for three and one-half years. Consequently, for some time I have used nothing but catgut for ligatures and internal sutures. This material, when carefully prepared, is perfectly safe, and we have no reason to feel that the patient will experience inconvenience after convalescence occurs. Patients in whom no suppuration has occurred, nor sinus resulted, have subsequently suffered from pressure upon the nerve-fibers by an encysted ligature, requiring reoperation a year or more later for removal of the ligature in order to secure relief. Catgut for ligature is prepared as follows: No. oo, No. o, and No. 2 cat- gut, as obtained from the shops in long pieces, is placed in ether or benzin for a number of days, or even weeks, to extract the fat. It is removed from this and tightly wrapped upon wooden blocks or glass tumblers, and placed for thirty hours in a solution of dichromate of potash : R . Potassii dichromat., 1.5 Acid, carbolic, Glycerin, / ' ^^ ^°-° Aqua 480.0 The dichromate is dissolved in the water, and the carbolic acid and glycerin are added. The previous fixing of the gut before its immersion in the solution is very important, as it otherwise becomes hopelessly twisted and entangled. After removal from the solution the strands should be wTapped upon previously prepared boards about a meter long, and while so wrapped they should be care- fully dried. From these boards it is cut in meter lengths, and the pieces are tightly wrapped upon glass drainage-tubes. Each tube contains two pieces of gut. These tubes are placed in a 1 : 1000 solution of sublimate in water for eight hours. This solution is poured off and replaced by a i : 500 solution of sub- limate in alcohol (90 per cent.), in which the catgut remains for twenty-four hours. From this solution the tubes are lifted by sterile forceps into absolute alcohol, to each half pint of which one dram of sterile glycerin has been added. The tubes are removed from this solution for use. Any unused catgut after an operation is not replaced. The No. 2 gut is employed for ligatures, the No. 00 and No. o 108 GYNECOLOGY. for sutures. Gut so prepared is, in my experience, unirritating, and a satisfactory materiai for ligatures and sutures. When it is not desired to harden the catgut or there is no need for its remaining in the tissues for such a length of time, the solution of dichromate of potash may be omitted. Boeckman suggests the following method of rendering the catgut safe for use. The gut, after being cleansed in ether, hardened if desired, and thoroughly dried, is cut into desirable lengths, wrapped in waxed paper, sealed in small envelopes, and subjected to a tem- perature of a little above 284° F. for four hours. Pus-forming germs are destroyed at lower temperatures, but spore -bearing germs, as anthrax, so common in the intestine of the sheep, are killed only at the higher temperature. The envelopes remain unbroken until the catgut is desired for use. A number of manufacturers now put up catgut in alcohol or chloroform, sealed in glass tubes, in which it is kept free from contamination until desired for use. It is thus prepared plain or chromicized. By some it is marked 10-, 20-, and 40-day catgut, but experience has taught me not to place reliance upon such promises. In the acid secretion of the vagina none of it is likely to last more than ten days or two weeks. Silkworm-gut forms an excellent suture, is clean, not readily infected, and is easily taken care of. It may be boiled for ten minutes prior to the operation. 177. Dressings. — Gauze medicated with various germicidal or inhibitory agents has been advocated, but it does not present any advantages over the sterilized gauze. The latter is non- irritating, and serves every purpose. It should be sterilized by subjecting it to steam, the fractional method, of course, being employed. It should be sterilized one hour the first day, the second day half an hour, and the third day the same length of time, then dried in a hot oven and placed in a closed vessel, and kept carefully wrapped until it is used. 178. Operator and Assistants. — Personal cleanliness should be a matter of conscience. A person with nasal catarrh or bad breath from decayed teeth or foul stomach is disqualified to be either an operator or assistant. This is particularly true in peritoneal operations. Even the slightest examination should not be undertaken unless the hands and nails are carefully cleansed, in order to insure against the introduction of infectious material, and in every operative procedure the hands and arms should be scrubbed with soap and hot water, giving thorough attention to the condition of the nails. The longer the hands are scrubbed with soap and water, the less active are the germs that inhabit the surface beneath the finger-nails. After thorough washing with soap and hot water, the nails should be scraped and the washing again repeated. The fingers, and especially about THERAPEUTICS. 109 the nails, should be scrubbed with a piece of sterile gauze wet with a 1 : 500 solution of bichlorid in 70 per cent, of alcohol, and subsequently washed in sterile water. Probably still better is a solution suggested by Charles Harrington, of Boston, which con- sists of commercial alcohol (94 per cent.), 640 c.c. ; hydrochloric acid, 60 c.c; water, 300 c.c; corrosive sublimate, 0.8 gram, in which the hands and arms should be bathed for thirty seconds to a minute after having previously thoroughly washed them with sterile soap and hot water. I have used this solution for the last year and a half with very gratifying results. Nurses and assistants who are to take part in the operation and handle sponges or dressings should be required to exercise rigidly the same precautions, and should be taught the importance of care- fully avoiding contact with any nondisinfected article; and if they should accidentally touch a door, basin, clothing, the face, or any nonsterile object, they should again scrupulously cleanse their hands before coming in contact with dressings or instru- ments. Kelly advocates, subsequent to scrubbing the hands in soap and hot water, that they should be placed in a solution of permanganate of potash (4: 1000), and this stain removed by washing in a concentrated solution of oxalic acid, then in lime- water, and finally in sterile water. Furbringer suggested that the hands and arms should first be washed with soap and hot water, then with bichlorid, preferably the acid solution, subse- quently with alcohol at 90 per cent. An effective method of cleansing the hands is to wash them with equal parts of sodium carbonate and calcium chlorid to which water is gradually added. The chlorin set free is the effective agent. There are but few persons, however, whose hands will endure the employment of this method of cleansing several times daily. Before examining a case of cancer w^here there is considerable decomposing material, it is well to anoint the fingers with turpentine, and then with vaselin, as in this way the disagreeable odor is more readily re- moved from the fingers. It Avould be better for the operator to wear rubber gloves or draw a condom over two fingers before examining cases of cancer or other infectious cases. The im- possibility of rendering the hands absolutely sterile, the varying susceptibility of different individuals to the influence of infectious germs, makes the habitual wearing of rubber gloves a prudent policy. Certainly, surgeons engaged in general surgical practice would do wisely to wear rubber gloves when operating within the peritoneal cavity. GloA^es should always be worn when the operator has recently examined or operated upon patients who were suffering from some infectious disease. 179. Precautions. — During the progress of an operation the operator should have, conveniently situated, two vessels, one 110 GYNECOLOGY. containing a solution of i : looo acid sublimate, and the second sterile water, into which he can occasionally dip his hands. In operations within the abdomen it is better that the bichlorid should be removed by sterile water. He should wxar clean linen and should have his clothing entirely covered by a sterilized apron. When there is much fluid, as in plastic operations on the vagina, in which continued irrigation is practised, the clothing should be covered with some waterproof material beneath the apron. Where conditions will permit, it is better that the surgeon should make a complete change of attire, both in the interests of his own health and for the safety of his patient. 1 80. Room and Environment. — The room and surroundings of the patient should receive careful consideration. The room should be well lighted and ventilated and thoroughly cleaned; be free from matting, hangings, and everything that is likely to retain dust; in fact, no more furniture should remain in the room than is absolutely necessary. The operating room should be one whose walls can be thoroughly washed and carefully cleansed; its furniture should be made of metal and glass. When the opera- tion is to be performed in a dwelling, the room should be carefully scrubbed with a carbolic-acid solution (50: 1000) two days in advance. In a private house where the rooms are old or their condition at all suspicious, they should be disinfected with a formaldehyd apparatus. It was formerly the practice to operate under the carbolic acid spray, but it was found to have a pre- judicial influence upon the peritoneum. Until quite recently some operators still kept a spray in the room for the moisture and to secure the beneficial influence of the carbolic acid, but the drug is so disagreeable and injurious to many patients that the practice has been discontinued. Sterilized water should be at hand in carefully covered vessels, and when antiseptic solu- tions are used, they should be designated so that no mistake can be made. 181. Examination and Preparation of Patient. — An examina- tion should be made of the urine, as to its specific gravity, quantity of urea, presence or absence of albumin or sugar, approximate quantity of solids, and where the conditions in- dicate it, the -microscope should be employed. A fair estimate of the amount of solids may be obtained by Haine's modification of Haeser's method, viz. : ' ' Multiply the last two figures of the specific gravity by the number of ounces of urine passed in twenty-four hours, and this product by one and one-tenth." This estimate includes urea and all other solids. The quantity will depend upon the avoirdupois of the patient. Etheridge has prepared the following table: THERAPEUTICS. Weight. Urinary Solids. Weight. Urinary Solids. 90 pounds TOO " no " 120 " 130 " 789 grains 854 " 916 974 " 1028 " 140 poun 160 170 180 ds 1078 grains 1150 1198 1237 " 1260 " 111 The performance of the respective functions of the heart and lungs should be investigated. Frequently an examination of the blood will be of service. While a low percentage of hemo- globin does not preclude operation (as I have performed a hysterectomy upon a patient with recovery in whom the hemo- globin was only 20 per cent.), it has, however, an important in- fluence upon the healing of wounds and the convalescence of the patient. A careful blood examination is valuable, therefore, in the prognosis of operative conditions associated with anemia. The bowels should be thoroughly evacuated; this is particularly important when a plastic operation is to be performed upon the rectovaginal septum. The diet should be regulated according to the proposed operation. In peritoneal and intestinal opera- tions milk and other foods containing much waste should be excluded. A thorough evacuation of the bowels should be secured by the administration of half an ounce of Rochelle or Epsom salts, or two drams compound licorice powder, or half a bottle of magnesium citrate two nights previous to and the morning preceding the day set for the operation. A large rectal enema of soapsuds should be given the preceding night. The patient should be kept in bed for twenty-four hours prior to a serious operation. She should be given a general bath twice daily for two days, with special attention to washing the external genitals, the anus, and the depression of the umbilicus. Vaginal ir- rigation with 1 : 2000 sublimate solution should accompany each bath. The abdomen and genitalia should be shaved the evening before the operation and the abdomen should be washed with tincture of green soap and hot water, the flesh-brush being diligently applied. If the patient is uncleanly or the skin is oily, the surface should be washed with ether, then with soap and water, and finally with a (i : 1000) sublimate solution. This washing should be repeated on the morning of the operation, and the abdomen should then be covered with a pad saturated with sublimate solution, which should be retained by a bandage, to be removed when upon the operating table. In all cases it is desirable that the field of operation should be again thoroughly scrubbed after the administration of an anesthetic, with soap and hot water, the superfluous soap being removed with alcohol. 182. Special Preparation. — Vaginal Operation. — The first step should consist in a careful cleansing of the vagina. For this 112 GYNECOLOGY. purpose a combination of creolin with green soap is very effectual, using creolin, one or two drams, green soap, one or two ounces, to the quart of hot water. The vaginal canal should be thoroughly scrubbed with this solution, introducing two fingers wrapped with gauze. This procedure will remove all debris which may have lodged in the crypts and folds of the vagina. The solution should be removed by washing with sterilized water and then with alcohol. Creolin is not so effective an agent in sterilizing the vagina as the acid sublimate solution, but it has the advantage that it leaves the vagina soft and flexible, which is an important consideration in obstetrics as well as in all operative procedures upon the vagina. The bichlorid and carbolic-acid solutions, on the other hand, have a const ringing eft'ect upon the vagina, which renders it less elastic. 183. Irrigating Tubes. — All the cannulas used for the purpose of cleansing the vagina should be made of glass (Fig. 72), as they are more readily cleansed, are less likely to contain infectious material, and are sufficiently cheap to permit them to be thrown away when used in suspicious cases. If injections are used by Fig. 72. — Irrigating Glass Tube. Open End. the patient, there should be no central opening of the nozle, for the reason that it may be introduced directly into a patulous cervical canal, and fluid thrown with force into the cavity results in severe uterine colic. Indeed, fluids have been thrown into the uterus and forced by uterine contraction through the tubes, which caused serious, if not fatal, pelvic inflammation. There is no special advantage in having a curved cannula or tube for irrigation. The nozle used by the physician in an operation should have but a single orifice, and that should be a central one. After irrigation has been practised, pressure should be made upon the fourchet, to insure the entire escape of fluid. It is sometimes advised that the irrigation should follow the ex- amination or operation, but we can not too strongly impress upon the student the fact that the genital canal sometimes con- tains dangerous germs, and that antisepsis must precede as well as follow an operation. In cancer or sloughing fibroids we may, in addition to the ordinary disinfection, require the use of de- odorizing agents. For this purpose a three to five per cent, solution of thymol or two or three tablespoonfuls of Labarraque's solution to the quart of water may be used. THERAPEUTICS. 113 184. Gauze. — iVfter the uterus and vagina are carefully cleansed, the canal can be packed, if preferred, with iodoform or other antiseptic gauze which will remain sweet for a number of days. Iodoform is preferable to the simple sterilized gauze. To prepare it, ten layers of plain gauze are sterilized by boiling, pref- erably in a solution of carbonate of potash, washed, then soaked in a solution consisting of iodoform 50, glycerin 100, and ether 700 parts, after which the gauze is passed through a wringer and dried in a darkened, isolated room at a temperature of 85° F. When dry, it is placed in tin boxes. This gauze should always be sterilized before its use. This can best be accomplished by heating it to the temperature of 250° F., by which both germs and their spores are destroyed. It should be remembered that iodoform is not a germicide. Its value is in its reductive in- fluence upon the ptomains and leukomains, by which their deleterious effects are arrested. Iodoform is poisonous to some patients. Sometimes it produces high temperature, irritation of the skin, and a smoky, darkened urine, and in others, extreme disturbance of the digestive tract. In such idiosyncrasies one of the other forms of antiseptic gauze should be preferred. These comprise borated, salicylated, carbolized, formalized, and acetan- ilid gauze. Sublimated gauze can be made by first boiling it in a solution of carbonate of potash (20: 1000), then an hour in a (i : 1000) sublimate solution, when it is dried in a sterilizing oven and preserved in closed glass jars. Salol and iodol are infe- rior in their action to iodoform. Carbolic acid is unreliable. Aristol, an agent that is made by the combination of thymol and iodin, is probably preferable to iodoform. It has the ad- vantage of the absence of disagreeable odor. The powder is very dry, not rapidly soluble, and coats over and protects the surface. 185. Antisepsis of the cervix and uterine cavity is secured by intra-uterine injections of sublimate solution, carbolic acid, dioxid of hydrogen, or, preferably, formalin (1:1000). Of the solutions of mercury, the acid sublimate is preferable, for the reason that it does not form an albuminate of mercury by com- bination with the serum of the blood, and is less hkely to be absorbed and to produce a toxic effect. This agent is not so dangerous as in obstetrics, unless there has been a large denuded surface. In such cases its use should be followed by an injection of sterilized water. I prefer a hot i to 2 per cent, solution of sodium chlorid or a 2 per cent, solution of the sodium bicar- bonate for irrigation of the uterine cavity during or following a curetment. It is fully as efiicient as the stronger germicidal agents, and if a perforation should occur, or fluid pass through the tubes, this fluid will prove innocuous in the peritoneal cavity. 8 114 GYNECOLOGY. In intra-uterine injections a double catheter should be employed, in order that the return flow may not be obstructed. It may be made of hard rubber, glass, celluloid, or metal; the last- named are more likely to be acted upon by the mercury salts. If the uterine cavity is well dilated, the double tube will be unnecessary. ^Vfter the cavity is carefully cleansed it may be packed with an iodoform gauze tampon, or a pencil of iodo- form may be introduced. Von Hacker recommends the follow- ing: Iodoform, 5 drams; gum acacia, glycerin, starch, each, 30 grains ; mix, make pencils, introduce into the cavity of the uterus. When these pencils give rise to uterine coHc, it may be pref- erable to dust the cavity with iodoform through an insufflator, or, still better, the use of aristol by the same means. In sloughing fibroids or intra-uterine cancer the cavity should be irrigated with an acid sublimate solution (i : 2000), followed either by sterilized water or a solution of chlorid of sodium (6: 1000). In operations upon the vagina or cervix continuous irrigation may be practised, using for this purpose a solution of carbolic acid (5 : 1000), sublimate (i : 2000), formalin (i : 1000), or, better, chlorid of sodium (6 : 1000). The irrigation washes away the blood, renders unnecessary the use of sponges, and the surfaces are constantly kept bathed with the antiseptic fluid. It is the preferable procedure in all operations upon the vulva, vagina, and cervix. 186. The Use of Tents.— In dilating the uterus the sponge, tupelo, or laminaria tents, although carefully disinfected, are not without danger. Pozzi recommends the latter tent, but he first immerses it in a saturated solution of carbolic acid and rectified spirits, or in a solution of iodoform and ether with a tenth part alcohol. In my judgment the best method of rendering the tent safe is to immerse a laminaria or series of such tents in the official tincture of iodin for a few minutes prior to its introduc- tion into the uterine cavity. The objection to the use of tents is the difficulty in previously sterilizing the uterine canal. Unless it is thoroughly done, as you would in the performance of any operation, the patient is in danger of subsequent inflammatory attacks. For this reason, in the majority of dilatations, I prefer to use the bougies and accomplish rapid dilatation in preference to the slower procedure with the tent. 187. Abdominal Section. — The peritoneum is a membrane exceedingly susceptible to the influence of all chemic agents, and its delicate structure would be injured or destroyed by any agent of sufficient strength to have a germicidal influence ; consequently, our aim should be rather to procure asepsis than antisepsis. Assistants must be personally clean. They should have taken a thorough bath on the morning of the operation and should have THERAPEUTICS. 115 seen no case of contagious disease prior to its performance. They should remove their coats and vests, bare their arms to above the elbows, thorough^ scrub their hands and arms with soap and hot water, and wash in disinfectant solutions. Their clothing should be covered with clean sterile linen. They should subsequently avoid shaking hands or touching any objects not disinfected. The greatest safety against infection will be secured by the opera- tor and his assistants wearing rubber gloves. 1 88. Indications for Anesthesia. — The use of some anesthetic is necessary in the performance of many operations, and is of great advantage in all. In the virgin, in nervous patients, or those in whom the abdominal and pelvic organs are very tender from the presence of inflammation, the administration of an anesthetic renders an examination much more satisfactory to the physician and less distressing to the patient. 189. Agents Employed. — In an examination it is undesir- able that the patient should be long under the influence of an anesthetic or should have a large quantity administered. Ether and chloroform are objectionable, first, because of the length of time required to secure insensibility and recover consciousness; second, the subsequent nausea and vomiting, which frequently last for hours. Nitrous oxid gas is an agent w^hich produces prompt unconsciousness, and from which the patient as promptly recovers, but it requires a special, quite expensive, and rather unwieldy apparatus. Bromid of ethyl is almost as rapid in its effects as the nitrous oxid, requires but a small quantity, the patient regains con- sciousness almost immediately after the inhalation is discon- tinued, and its use is much less frequently followed by nausea and vomiting. It can be administered in one's office, and the patient, shortly after return to her home, feeling but little the worse for her experience. This agent is very satisfactory for short operations, such as opening abscesses or dilatation of the urethra or anus. In very nervous patients it may precede the administration of ether or chloroform, whereby the stage of excitement and struggling is avoided. With the assistance of Dr. P. B. Bland, during 1902-03, I made some experiments with the chlorid of ethyl and found it to act very satisfactorily in pro- ducing quick anesthesia. I employed the drug for anesthesia in a number of serious operations. In one patient I did a hysterectomy under its use, the time occupied for anesthesia being fifty minutes, without any unpleasant symptoms. With a suitable inhaler it can be effectually employed with the ad- ministration of a very small amount of the agent. It has not seemed to produce any uncomfortable sensations following the operation, although the anesthesia is not as profound and 116 GYNECOLOGY. durable as that induced by other anesthetics.* For prolonged operations ether and chloroform are to be preferred. Eiher is generally recognized as the safer drug. In the very young or the aged it is less satisfactory than chloroform, and probably not so safe. Chloroform should be preferred in the pres- ence of renal disturb- ance and when the pa- tient is suffering from emphysema or chronic bronchitis. Some of the French surgeons advocate the adminis- tration of -J- of a gr. of sulphate of morphin and ylo- of a gr. of sulphate of atropin hypodermically about twenty minutes prior to the administration of chloroform, and they claim: (i) that it increases the safety by Fig. 73. — White's Oxygen Apparatus, which can be UtiHzed for Anesthesia by Placing Anes- thetic in the Bottle. Fig. 74. — Northrup's Apparatus for Administering a Mixture of Chloroform and Oxygen. diminishing the danger of syncope; (2) that the patient is much * Since writing the above I have had a death from ethyl chlorid and would advise the greatest caution in its employment. THERAPEUTICS. 117 less likely to suffer from nausea and vomiting; (3) that the patient, having taken a smaller amount of the vapor, recovers consciousness more quickly. Scopolamin-morphin narcosis.- — A combination of these drugs was advocated by Schneiderlin in 1900 as a means of rendering patients sufficient^ insensible to pain to permit of the per- formance of the various surgical procedures. Recently they have been extensively^ employed. Korff, who administered the combination in tAvo hundred cases, advised scopolamin hydro- bromate -^ milligram, Avith morphin sulphate 25 milligrams, divided into three doses, to be given hypodermically, three hours, one and a half hours, and half an hour before the operation. The first dose renders the patient drowsy, the sec- ond puts her to sleep, and the final one renders her insensible to pain. Scopolamin-morphin narcosis has been advocated as lessen- ing the danger of anesthesia. The employment of a combination of drugs, though capable of rendering the patient unconscious for hours, cannot be considered as free from danger, and the results seem to shoAv that the procedure should be avoided in persons AA'ith Aveak A'essels and enfeebled heart action. It has been claimed that the preliminary administration of y^ grain of the scopolamin hydrobromate AA^th -g- of a grain of morphin Avould enable the administrator to giA^e much less of the ordinary an- esthetic, and in the majority of cases the patient will be free from the postoperative nausea and vomiting. The experience of nearly one hundred cases at the Jefferson Hospital clinic has demonstrated that a greater number of patients haA'ing this pre- liminary injection will suffer from nausea and A'omiting than AA^hen ether is given alone. The onty adA^antage which I Avould concede it is that where the patient is nerA'ous and fearful of the operation, she is so doped before she comes to the operating room that she is oblivious to CA'crything and takes the anesthetic AA^th but little difficulty. The administration of a mixture of chloro- form and oxygen, obtained by passing oxygen through a bottle of chloroform to the inhaler, decreases the danger of this agent and accomplishes anesthesia with the minimum quantity of the drug, AAithout discomfort, AAdth lessened nausea, and AA^th slight subsequent distress. (Figs. 73 and 74.) The patient does not haA^e the blanched appearance of the face, and rapidly recoA^ers when its administration is suspended. I do not feel it neces- sary to describe the administration of the anesthetic further than to caution that false teeth and foreign bodies should be remoA^ed from the mouth. 190. Administration. — The patient should be directed to breathe deeply. She should be reassured by the physician, both in speech and manner. Talking upon the part of the 118 GYNECOLOGY. administrator or attendants should be avoided. The pulse, respiration, and condition of the pupil should be continually observed. Dilatation of pupils, blanching of the face, arrested or stertorous breathing, and sudden feebleness of the pulse should indicate the temporary withdrawal of the vapor. Con- tinued syncope, particularly in chloroform narcosis, requires resort to artificial respiration, and often suspension of the pa- tient with head downward. The administrator of the anes- thetic should be provided with a hypodermic syringe, solutions of strychnin and atropin, and some nitrite of amyl. The latter agent is of advantage because of its rapid action as a primary heart stimulant, and its influence in dilating the arterioles by its action upon the vasomotor system. When chloroform is largely given, a bellows and mask, by which the lungs can be inflated with air, will not infrequently be effective in saving life. In suspended respiration forcible pulling upon the tongue acts as a respiratory stimulant. The inhalation of vinegar following anesthesia appears to lessen the tendency to nausea. 191. Local Anesthesia. — General anesthesia is attended with danger in renal disease, in marked pulmonary changes, in fatty degeneration of the heart, and in atheroma of the large vessels. In such cases, and when general anesthesia is objectionable, local anesthesia may be employed. Freezing by ice and salt, by ether, or by ethyl chlorid spray may be utilized, but its application is limited. Continuous irrigation with carbolic acid has a benumbing effect upon the mucous surfaces, by which pain is obtunded. Cocain. — The most effective agent for local anesthesia is one of the cocain salts. In operations about the genitals or anus it is preferably given hypodermically, and for this pur- pose the phenate of cocain is the most satisfactory. It is slower in being absorbed, and is less likely to be a source of infection from the presence of micro-organisms. Some have advocated eucain in preference to cocain, as it is less volatile and hence more readily sterilized. It is also less likely to cause depression. Stovain, a synthetic preparation, is claimed to be free from the depressing and toxic effects incident to cocain. The injections should be made with a one or two per cent, solution, using as much as from one to three grains of the drug. The injection pro- duces anesthesia for the distance of half an inch from the point of the needle; consequently a number of injections may be re- quired. This method of anesthesia has been effective in am- putation of the cervix, trachelorrhaphy, and operations upon hemorrhoids and fistula in ano. The drug sometimes has an alarmingly depressing effect. This symptom, it is said, may be avoided by combining nitroglycerin in the injection. When THERAPEUTICS. 119 symptoms of depression occur, resort should be had to strychnin, atropin, alcohohc preparations, and nitroglycerin. Schleich, of Germany, after considerable experimentation, has suggested three solutions for infiltration anesthesia. The basis of all is a solution of two parts sodium chlorid, one-fourth part morphin hydrochlorate, in water one thousand parts, to which, for what is called the stronger solution, two parts cocain hydrochlorate are added — one part for the medium and one-tenth part for the weaker solution. The water and salt are sterilized by heat. A larger syringe than usual is used. The site for operation is carefully cleansed ; then, after numbing the surface with an ethyl chlorid spray, a puncture is made and fluid injected until a wheal the size of a dime is raised; the needle is introduced in its margin, and so continued until the entire length of the proposed wound is completed. The first puncture is the only painful one. The insensibility of the skin lasts for from fifteen to twenty minutes. Spinal anesthesia is secured by the injection of one to two grams of a sterilized (2 per cent.) solution of cocain into the spinal cavity. The injection is made between the lumbar vertebrae, and on a line level with the crests of the ilia. A long needle is introduced, the entrance of which into the spinal canal is indicated by the escape of spinal fluid. This form of anesthesia has been largely practised by Tuffler, of Paris, who has observed no untoward symptoms and has found it very satisfactory in all operations below the diaphragm. In a patient who had had one kidney removed and the remaining one so diseased as to render the employment of a general anes- thetic unwise, under this method I opened up a sinus which extended down to the vertebrae and into the pelvis without pain to the patient, and without the depression and horrible nausea which had been associated with her previous operations. A second patient, a young girl, had a large necrotic ovarian cyst, a portion of one lung consolidated, and a mitral murmur with beginning cardiac insufficiency — factors which made her condition very unfavorable for ether or chloroform narcosis; spinal anesthesia was employed, and I was able to remove the tumor without pain, and the patient had an uninterrupted recovery. 192. Preliminary Details of Operation. — The presence of the patient, anesthetized, in the operating room presupposes the thorough preparation detailed in the previous paragraphs. A sufficient number of well-drilled assistants should have their duties assigned, so that the operation may proceed without confusion or delay. Instruments, ligatures, dressings, sterilized water, and sponges have been prepared. In abdominal opera- 120 GYNECOLOGY. tions the number of sponges or pieces of gauze should be known, so that they may be accounted for before the wound is closed. It is also important to have a definite number of instruments, as both sponges and instruments, especially hemostatic forceps, have been left in the abdominal cavity. Every step of the opera- tion, to the minutest detail, should be conscientiously watched, for, as the chain is only as strong as its weakest link, so an otherwise perfect aseptic procedure may fail through a single flaw. I have seen the most careful preparations for an opera- tion, and the operator place his silk sutures upon a syringe box ; an assistant stroke his mustache, a nurse use her handkerchief, or stroke her hair, each instance being a break which imperils the result. 193. Arrangement. — The instruments should be placed at the right of the operator, so that he can reach them as needed. The sponges should be in the care of a nurse upon the opposite side. The sponges or gauze pads should be removed from the receptacle and passed to the operator or his assistant by the nurse with a pair of forceps. After being used they should be placed in a basin. The nurse dispensing the sponges should keep an accurate account of the number given out, with which those returned should correspond. The wound should not be closed until it is certain all sponges have been removed. It is well to have one large, broad piece of gauze for walling off the intestines, or several smaller pieces may be employed and the end of each secured with a pair of forceps. A basin of sterilized hot water should be alongside the instruments for the hands of the operator, and his principal assistant should have another. 194. Positions of Operator and Assistants. — In an abdom- inal section I prefer to stand on the patient's left, with my assistant opposite; the second assistant gives the anesthetic; a third looks after the instruments, ligatures, and sutures. One nurse attends to the sponges, a second changes the water in the basins, especially in those for the hands of the operator and assistant, prepares sterilized water or salt solution for irrigation, and counts the pads which have been used and re- turned, which count should tally with the one made by the nurse dispensing them. A third may be ready for emergency and have the dressings ready upon the completion of the operation. 195. Clothing of Patient. — The patient will be better to have all clothing removed, in order to prevent it becoming soiled during the operation. Separate and clean blankets should be wrapped about the upper part of the body and the lower ex- tremities. These should be covered with sterilized towels, and over all a sterilized sheet, in the center of which an opening has been prepared for exposure of the field of operation. THERAPEUTICS. 121 196. Incision. — The linea alba is chosen for the site of in- cision in the majority of cases of abdominal section. A cut, varying in length from two to twelve inches, according to the condition for which the operation is done, is made with a sharp NURSE lATITH SPONGES Operating fwoM FROM ^BOVE^ NURSE AT /NSTRUMENT TABLE Fig. 75. — Arrangement of Tables and Assistants in Operating Room. knife. When the abdomen is moderately distended with a growth, the first sweep of the knife should reach the fascia over the peritoneum. The operator and his assistant with 122 GYNECOLOGY. long dissecting forceps pick tip the peritoneum and cut it be- tween them, thus avoiding injury to the cyst, or, when the abdomen is undistended, a knuckle of intestine. As soon as the peritoneum is opened, the atmospheric pres- sure carries the intestine out of the way, when the incision may be completed with a knife or with probe-pointed scissors, in- troducing two fingers as a guard. Should considerable bleeding occur after the first sweep of the knife, it can usually be con- Fig. 76. — Abdominal Wall Incised ; Peritoneum Picked up by Dis- secting Forceps. trolled by pressure with a gauze pad. AA^hen this is insufficient, the bleeding vessels should be seized Avith hemostatic forceps. The length of the incision has been a prolific source of dis- cussion. It has but little influence upon the result. It should be sufficiently long to permit the object of the operation to be accomplished with ease and as little irritation as possible. A long incision, if properly united, will be as firm as a short one. A combined transverse, or better, crescent-shaped and vertical incision, was reported at the International Congress on Obstetrics and Gynecology, held in Geneva in August, 1896, also described THERAPEUTICS. 123 in a paper by Kiistner in an article in September of the same year, and has been largely practised by Stimson and Cumston in this country. It consists of a crescent-shaped incision just above the Fig. 78. — Crescent Incision Exposing Aponeurosis. Fig. 79. — Aponeurosis Excised, Showing Pyramidalis Muscles. symphysis, and, where possible, confined to the hair surface. It extends through the skin, superficial fascia, and aponeurosis. These tissues are drawn up, separating the aponeurosis from its 124 GYNECOLOGY. attachment to the pyramidalis muscles. The rectus muscles are separated in the median line, and the peritoneum incised verti- cally. This incision permits free access to the pelvic viscera, and is satisfactory unless a large growth is present, which will require a longer incision. The advantages of the procedure are that the subsequent growth of the hair hides the incision ; the probability of hernia is lessened, as the suture closing the peritoneum and muscle wall is at right angles to that of the aponeurosis. The disadvantages are: the increased bleeding from cutting across Fig. 80. — Scalpels. vessels^and the inability ahvays to avoid the occurrence of hema- toma either below or above the aponeurosis. Where there is much disposition toward oozing, it is better to insert one or two small drains for the first two days. 197. Adhesions. — In inflammation complicating a cyst it may be difficult to determine when we are through the perito- neum. In case of doubt it is better to continue the incision until the cyst is opened, when the line of union can be more readily determined. It is well to remember that at the um- bilicus the peri- toneum is closely united to the over- lying tissue, and this fact may be utilized in cases of uncer- tainty. As far as possible, separation of adhesions should take place under the eye, by drawing them down to the incision. Vascular adhesions and every bleeding vessel should be secured with forceps or should be ligated. With' the application of forceps the number of necessary ligations will be reduced, as the pressure will often prevent subsequent bleeding. The wound should not be closed if any large bleeding points are present. In short, firm intestinal adhe- sions the greatest safety is assured by keeping close to the cyst. In some cases it may be necessary to cut into the cyst, leaving a portion attached to the intestine, always taking the precaution. Fig. 81. — Pressure Forceps. THERAPEUTICS. 125 however, to remove its inner, secreting surface. Frequently the worst adhesions the operator wih meet are associated with infec- tive processes in the tubes, ovaries, or in relation to myomatous growths of the uterus. In both of these conditions the adhesions may be so firm as to require the use of the scissors for their separa- tion. All bleeding vessels should be secured and where possible the raw surfaces sutured. 198. Toilet of the Peritoneum. — In the removal of large cysts care should be exercised that their contents do not escape into the abdomen. If the contents are uncontaminated, con- sisting of thin serous fluid, it should be removed by sponging only. It is difficult for me as an operator to get over early impressions. My education leads me to resort to abdominal irrigation, preferably with normal salt solution, whenever infection is possible, but experience has demonstrated that patients do equally well when pus is sponged out with dry gauze pads as when irrigated. It is a serious question whether the measures we often institute in the name of toilet of the perito- neum are not more prejudicial than helpful. When irrigation is Fig. 82. — Dissecting Forceps — Long Bladed. done, it is most effectively accomplished by pouring the belly full of normal salt solution, churning it about, pressing it out, and removing the remainder with sponges. All bleeding points must be secured. If there is oozing from the surface, sponges wrung out of hot water should be packed firmly upon it until the operation is completed, when they can be removed. If bleeding still continues, the surfaces should be sponged with a hot solution (10 per cent.) of ferripyrin, sprayed Avith a 4 per cent, solution of antipyrin, or infiltrated with a solution of one part (i : 1000) adrenalin chlorid to three parts sterile water. Should hemor- rhage be persistent, a gauze pack affords an efficient means of control. 199. Drainage. — The question of drainage was formerly a momentous one. Keith's rule that it should be used only when there was something to drain was a good one, but with improved methods of technic we can depend more and more upon the natural absorptive power of the peritoneum. The employ- ment of the glass drainage-tube, which was formerly a matter of routine, is now more honored in the breach than in the ob- servance. When a glass drainage-tube is employed, it should 126 GYNECOLOGY. be from six to eight inches long, with a number of small perfora- tions at the lower extremity. These openings should be small, otherwise portions of intestine or omentum slip into them and become strangulated or render the removal of the tube pain- fully difficult. The openings should be smooth, and should be beveled at the expense of the outer surface. The lower end of the tube should be open; the external end should be pro- vided with a flange, over which /^— ^-3--;^- ^™^- "^^ ^^^^^^^^'^^/pl ^ piece of rubber dam may ^^^^B^^^^^^^^^^sll J be placed to prevent soiling of the dressings. The caliber of the tube should not exceed one- third of an inch. The use of the drainage-tube required most exacting care upon the part of the nurse and the physician. Every precaution had to be exercised to prevent it becoming a gateway for the entrance of infection. It needed to be cleaned every half hour or oftener Fig. 83. — Glass Drainage-tubes. Fig. 84. — Uterine Syringe for Cleansing Drainage-tube. SO long as there was any discharge. This was accomplished by the use of a suction tube which reached to the bottom of the tube, or, better, by tube forceps and pledgets of sterilized absorbent cotton. By either method micro-organisms in large number, in spite of every precaution, found ready entrance. The Fig. 85. — Tube Forceps for Cotton Pledgets. frequent cleansing of the tube was ai^oided by passing a strip of sterile gauze to its bottom, which acted as a wick. 200. Objections to Drainage. — The glass drain was objec- tionable because: (i) It obliged the patient to remain upon her back; (2) unless carefully placed it caused sufficient pres- sure upon the rectum to produce ulceration and even a fecal THERAPEUTICS. 127 fistula; (3) it increased the difficulty in maintaining the wound aseptic, and afforded ingress to pathogenic germs, either through its cavity or along its sides; (4) it rendered the abdomen weak and increased the danger of ventral hernia; (5) it endangered ,the formation of a sinus which was long f^f~x in closing. The fre- quency with which drainage was thought to be required, it was found, could be les- sened by the introduc- tion of large quantities of normal salt solution, by which the infectious material was diluted and rendered more readily con- trolled by the peritoneum. Later experience has demonstrated that such cases do equally well by careful walHng-off of pus col- FiCT. 86. — Gauze Wick in Drain. I r- M Fig. 87. — Mikulicz Drain. lections with gauze before they rupture and then thoroughly removing the pus and blood with dry gauze. The peritoneum, if given an opportunity, will take care of infection; the means 128 GYNECOLOGY. which have been employed for the removal of infection have crippled the antagonistic processes of the peritoneum. 201. Gauze Drain. — Drainage has been accomplished by a twist of gauze, or, where there was much oozing, by gauze pressure. The ■Mikulicz drain consisted of a piece of gauze with a string tied to its center, placed in the bottom of the pelvis, within which strips of gauze were packed. These strips were ordinarily marked, to designate the order in which they were introduced. The pain in removing was greatly decreased by covering it with rubber tissue except at its extremity. Drain- age, whether by tube or gauze, is of but short duration, and its influence is confined to a limited area. Lymph exudate soon walls it off as a foreign body from the general cavity. The gauze is very efficacious as a tampon. Its pressure arrests hemorrhage and promotes the formation of exudation, which closes oozing vessels and bars the avenues for the entrance of infection. 202. Where Placed. — The drain, whether glass tube or gauze, was generally placed in the lower angle of the wound, i;*;«sS,-Ss::-j!'-s~- T^^ '^ ^-^^_ -S-i P> Fig. 88. — Gauze Drain Covered with Rubber Tissue. though it could be placed between sutures at whatever part of the wound was most favorable. 203. Postural Drainage. — The uninjured peritoneum is a very active absorbing surface, and Clark utilized the knowl- edge of this fact to avoid the introduction of a drain by ele- vating the foot of the bed eighteen inches for from twenty- four to thirty-six hours, by w^hich the fluid gravitated away from the injured surfaces. The danger of infection was lessened by active irrigation with a large quantity of normal salt solution before the wound was closed. The activity of any pathogenic material remaining within the abdomen was diminished by dilution, through the retention of a considerable quantity of the solution when the wound was closed. This position also decreases the pain following an operation by the lessened quantity of blood sent into the vessels of the elevated pelvis. The pendulum has now swung backward, and we elevate the upper part of the body and favor the accumula- tion of fluid in the pelvis, from which it is removed by gauze wicks through the abdominal wound, or, better still, by an open- THERAPEUTICS. 129 ing into the vagina. The latter channel of egress should be emplo^^ed whenever possible, because it favors by posture the evacuation of the most dependent portion of the tract and the danger of sinus or hernia is lessened. 204. Closure of the Wound. — Before the sutures are intro- duced, the omentum is generally drawn over the intestines. Formerly, when extensive adhesions or purulent discharges were present, the belly was left filled with a sterile normal salt solution. While we now urge the dry gauze sponge, it is yet difficult not to re- sort to the flushing with normal salt water when abscess cavities are rup- tured. The wound can be closed by through-and- through interrupted sutures or with buried sutures in separate layers. The interrupted sutures of silk, silkworm-gut, and silver wire or chromic catgut are intro- duced through the entire thickness of the abdominal wall, about three-fourths to one inch apart, including one-eighth of an inch of the peritoneal and one-fourth of the skin surface on each side. Each suture is secured with a pair of hemostats, and after all are introduced, the gauze pad placed over the intestines is removed, the cavity is inspected, and the sutures are tied. Care must be exercised that a knuckle of intestine Fij -Curved and Straight Needles. Fig. 90. — Needle Forceps. or a piece of omentum is not caught by the sutures. The most important consideration for the future of the patient is the union of the aponeurosis, for upon its accurate union depends the subsequent strength of the abdominal wall. While the single suture for all the structures will frequently afford a good wall, it too frequently results in a weakened ven- trum which gives way with increasing corpulency and becomes the site of hernia. After many trials with different methods of suturing I have accepted the following routine as affording 9 130 GYNECOLOGY uniformly the best results. Begin external to the aponeurosis at the upper angle of the wound, carry a No. i chromic cat- gut suture through all the tissues below the aponeurosis at the right side of the wound, secure the end of the suture by hemostat, and ask the assistant to maintain at least three inches of it ex- ternally. With tissue forceps pick up and pass the suture through the peritoneum only upon the left side. The subse- Fig. 91. — I. Peritoneum Nearly Closed with Continuous Cat- gut. 2. Silkworm-gut Sutures through all Structures above Peritoneum. 3. Aponeurosis Being United with Continuous Suture of Catgut. Fig. 92. -Silkworm-gut Sutures Tied. quent turns of the suture are confined to the peritoneal margins 'of the wound until the lower angle is reached, when the suture is brought through the aponeurosis at the left side of the incision. (Fig. 91.) With the Reverdin needle silkworm-gut sutures are now passed about one-half to three-fourths of an inch apart through all the structures above the peritoneum, and the ends THERAPEUTICS 131 secured with pressure forceps. After drying the surface, begin at the lower angle of the wound with the remaining portion of the catgut suture, which closes the peritoneum and returns, closing the aponeurosis only until the upper angle is reached, when tie to the end at the right side of the wound. This method insures the accurate apposition of the aponeurosis and the res- toration of the rectus to its normal sheath. The silkworm-gut sutures are now tied with moderate pressure, insuring the obliter- ation of dead spaces, and places the muscle surface of the wound in a splint until the union can be secured. The ends of the silk- worm-gut sutures should be left long. (Fig. 92.) Left long, they promote drainage from the wound and facilitate their removal. The combined crescentic and vertical incision is closed by a con- tinuous suture for the vertical incision, which includes the peri- toneum and edges of the recti muscles. This suture of chromic catgut is only drawn sufficiently tight to hold the surfaces in apposition. A second continuous suture brings in apposition the edges of the aponeurosis, and a third will hold in contact the skin edges. This suture may be subcuticular, but a continuous suture through the skin edges, unless drawn tight, is equally effi- cient and more quickly introduced. The skin edges accurately apposed and the incision confined to the hair surface the scar is completely obscured in a few months. Great care must be exercised to control all bleeding vessels and, where there is a disposition to oozing, drainage should be installed to prevent the formation of a hematoma and its subsequent infection. 205. Dressing. — After the wound is closed it is washed with alcohol and a sterile towel is pressed upon it, while the remaining surface of the abdomen is being cleansed and dried. The wotind surface should be dressed with several layers of plain sterile gauze. When the sutures are left long, the first pieces of gauze should surround them and the remaining portions be placed over the ends. The gauze should be covered with a pad of gauze and cotton or wood wool. The dressings are held in place with tapes attached to pieces of plaster, three on each side, and, finally, a sterilized bandage. The use of the tapes affords a ready access to the wound without annoyance to the patient. 206. Postoperative Treatment. — The struggle for Hfe is too often, both by the laity and physicians, regarded as won when the operation has been completed, but in many cases this period but indicates the beginning of a grave battle. It is true that much may be done to lessen the trials of the after-period by care- ful study and preparation of the patient for operation, by the greatest expedition in the operation consistent with the most 132 GYNECOLOGY. conscientious discharge of every detail of the procedure, the Hmitation of the amount of the anesthetic, and the early and care- ful regulation of the circulation. After the operation has been begun or half completed is no time for the surgeon to stop and hold a consultation as to what shall be the next step. He must have prepared himself by study, meditation, and experience for every possible complication and be ready to meet it when it arises. Postoperative or after-treatment comprises the con- sideration and exercise of those details which promote comfort, advance the convalescence, and enhance the restoration of the individual to normal health. Much of this work he must dele- gate to her attendants, but by his watchfulness and advice they must be governed. He should not himself, or allow^ others to, fall into the habit of following a routine treatment, but it should be directed to meet the necessities of the individual case. Under the old method of treatment where many cases had a glass drainage-tube inserted, it was necessary that the patient should be restrained to the dorsal position. Unless the patient is exceed- ingly nervous, very restless, apparently suffering intense pain, it is better to give no anodyne. When she is nerv^ous or com- plaining, an enema of tincture of valerian f5ij, with tinctura opii deodorati gtt. 20 to f o j, may be given. 207. Comfort of Patient. — The patient is transferred from the operating to the private room, where she is placed in bed, covered warmly, protected from draft, and kept quiet ; the room should be darkened. If the operation has been protracted or the patient is depressed, hot-water bottles should be placed about her to maintain the body heat. These bottles should be tightly corked and a blanket should be placed between them and the skin. The patient, unable to understand or to make known her discomfort, may be badly burned if such precautions are not exercised. It should be recognized that the patient profoundly shocked has a lowered resistance, which will cause her to burn at a lower temperature than would occur in health. As she recovers, it becomes very irksome to remain in one position. An attentiv^e nurse can greatly add to her comfort by passing her hands under the patient so that the cool air reaches the heated back, by changing her from one side of the bed to the other, and by keeping the clothing under her smooth and dry. Unless there is some special contraindication, as the presence of a drainage- tube, she may be turned upon her side. Indeed, the early and frequent turning of the patient will prove beneficial. It pro- motes peristalsis, favors the early passage of flatus, and lessens the danger of unfortunate intestinal adhesions. The nurse should support the patient's back and limbs with pillows. One of the earliest symptoms of which the patient complains is intolerable THERAPEUTICS. 133 thirst. It is better to limit the quantity of liquid for the first few hours to small quantities of hot water — a half ounce every hour, given with a horn spoon, as the china cup would burn the lips. Ice should not be given ; it increases the thirst and the patient will not be content without a piece constantly in her mouth. Both mouth and stomach soon become irritated. When the patient does well, she can have a cup of tea or coffee on the morning following the operation, small quantities of ice-water or soda-water, equal parts of effervescent vichy and orange- juice, a teaspoonful of beef -juice every three hours; and on the second day light food, and by the end of the week a generous diet. 208. Vomiting should be an indication to discontinue every- thing by the mouth. Enemas of warm water, six to eight ounces, may be given to assuage thirst, and when the patient is in need of nourishment, nutrient enemas may be given every three or four hours. Nausea and vomiting occur very fre- quently after an operation and may continue several days. The ejected material may be the fluid which has been ingested, or bile, mucus, or the contents of the small intestine. The application of a mustard-plaster and an enema of 30 grains of chloral and i dram of potassium bromid in 2 ounces of warm water will often be sufficient to quiet the irritability. If the patient is constantly retching, it is better to give a large draft of water with i dram of bicarbonate of soda, a cup of weak tea, or some soda-water. Professor Hare has suggested 2 grains of acetanilid and ^ of a grain of caffein citrate, to be repeated in two hours. I have found this formula of advantage in vomiting following etherization. Other remedies of more or less value are : cocain (4 per cent, solution), 3 drops every hour; tincture of mix vomica, 2 drops every hour; 2 drops of compound tincture of iodin and |- of a grain of carbolic acid every hour; or i drop of Fowler's solution every half -hour. The earlier the bowels can be evacuated, the sooner will the offensive material be removed; hence the most effective treatment will be the administration of a saline, or, when it cannot be retained, the use of calomel alone or in combination with bicarbonate of soda (gr. j-ij of the latter to from -^-J gr. of the former) every fif- teen minutes until gr. j-iss of calomel are taken, when magnesium sulphate one dram in syrup of ginger and cinnamon water is given every hour until the bowels are moved. In frequent vomiting a seidlitz powder is very efficient, for if vomited, it generally empties the stomach, and when retained, starts the current through the canal. The powder should not be given in the usual manner, but the sodium carbonate portion should be 134 GYNECOLOGY. dissolved in water fSiij, tartaric acid dropped upon this dry and given immediately. The patient should be encouraged to retain this as long as possible. If vomited, the stomach is well cleansed and generally a portion of the drug passes the pylorus to exercise a good influence upon the intestine. A second pow- der may be given in the same manner a half -hour later if the first is ejected. If the intestine is distended and has not yielded to enemas or to the purgatives suggested, and the patient is constantly vomit- ing small quantities of dark fluid, nothing will give quicker or more lasting relief than irrigation of the stomach through a stomach-tube. When it is evident that the vomiting is an indi- cation of peritonitis, it is wiser to discontinue purgatives and be content with lavage. No food, not even water, should be given by the mouth, and peristalsis should be arrested by small doses of morphin hypodermically. Rectal feeding may be re- quired because of irritable stomach and the enfeebled condition of the patient, and especially in conjunction with the treatment suggested for peritonitis. Peptonized milk or broth may be given every three or four hours. When the patient is much depressed, a normal salt solu- tion and whisky or bovinin in combination may be given. When rectal feeding is practised, the bowel should be irrigated once or twice daily. 209. Tympanites may be the result of a passive collection of gas in the intestines, or may indicate the development of peri- tonitis. The early passage of flatus is always an encouraging symptom. The sensation of distention may be promptly met by the use of an enema of — Magnesium sulph.,^ Glycerin, V aa 5 j. Water, J If relief is not secured, an enema of two tablespoonfuls of turpentine beaten up with the yolks of two eggs and strained into a quart of soapsuds should be administered. Keith recom- mends an enema consisting of six grains of quinin dissolved in four drams of whisky and two ounces of warm water, to be given every two hours until three doses have been administered. This prescription stimulates the nerve-centers and favors peris- talsis. The most effective agent to influence increased peristalsis is an enema consisting of an ounce of powdered alum dissolved in a quart of hot water. If peristaltic action is marked, but reversed, lavage should be employed, a hypodermic injection of morphin given, and followed, after a rest of three or four hours, by a repetition of the quinin. THERAPEUTICS. 135 210. Shock. — Severe shock should be combated by the use of artificial heat, enemas of coffee and stimulants, suppositories of ice, elevation of the foot of the bed, bandaging the limbs, and the injection of normal salt solution into the buttocks, beneath the scapula, or directly into a vein. A hypodermic injection of strychnin (gr. 3-V— t) should be given according to the urgency of the condition, and followed by some aseptic preparation of ergot. Ergone in 20-minim doses is valuable, or it may alternate with (i : 1000) solution adrenalin chlorid, 20 minims every two hours. Atropin sulphate (gr. y^) twice daily will be serviceable in controlling the vessels. Where the loss of blood has been great, the renal secretion arrested, or shock profound, the intravenous injection of two to three pints of a one per cent, salt solution is the most effective agent Avhich can be employed. 211. Anodynes. — The patient should be encouraged to bear the pain without an anodyne. When the pain is very severe, it may be allayed by the rectal use of chloral, 30 grains in two ounces of warm water. When the patient is very much distressed, it may become a choice between morphin and restlessness ; and a hypodermic in- jection of from ^ to J of a grain should be given. Morphin decreases peristalsis and favors tympanites, and consequently should, if possible, be avoided. Whenever it is evident that peritonitis has developed, that purgatives are ejected as fast as given, morphin with lavage should be considered our sheet anchor and be given for effect, giving an initial dose of gr. ^-J-, and fol- lowing with iV "to i every three hours. 212. Internal hemorrhage, if the technic is perfect, should not occur. Its existence will be indicated by paleness of lips, feeble or absent pulse, sighing respiration, and clammy perspira- tion. The use of strychnin or the injection of salt solution favors the increase of hemorrhage. The only proper treatment is the prompt reopening of the wound, and the ligation of the bleeding vessel. 213. Peritonitis. — Peritonitis is dependent upon infection and will occur early or late according to its virulence. The aim of the operator is, of course, to avoid the possibility of its occurrence, but the patient may in many instances have been infected prior to the performance of the operation, and all the skill of the opera- tor could not have removed the sources for further development. It is likely to occur in acute gonorrheal and septic infection of the tubes and pelvic structures, in large accumulations of blood, either prior to or subsequent to the operation, which have been infected from their juxtaposition to the intestines, soiling of the peritoneal cavity by the contents of dermoid, glandular, and papillary ovarian cysts. Peritonitis is characterized by in- 136 GYNECOLOGY. creasing tenderness of the abdomen, decreased peristalsis, tym- panites, fre(^uent vomiting, especially when occurring on the second and third days; rapid, feeble, thready pulse, more or less elevation of temperature. The vomited material may be considerable, quantities of dark-greenish, bitter, and oftentimes foul-smelling fluid — apparently a much larger quantity vomited than the patient has taken. The tongue is dry, the patient com- plains of intense thirst, is constantly crying for water and ice. The administration of purgatives in these cases is generally in- effective, for the reason that the patient vomits or regurgitates everything as soon as taken. Enemas are of little value, as they only empty the lower bowel. The proper plan of treatment is to wash out the stomach with stomach-tube, give the patient a hypodermic injection of morphin, gr. -| or J, repeating this in doses of gr. yV to } every two or three hours, keeping the patient under its influence. As all efforts at increasing the per- istalsis are ineffective, we aim to place the intestines in a splint, remove the offensive material from the stomach and upper part of the intestine by lavage. Under this course we will frequently see patients that seem to be almost moribund become quiet, comfortable, resting easily; after two or three days there will be a profuse evacuation of the bow^els and the patient go on to recovery. The strength of the patient during this period should be maintained by hypodermic injections of ergone, strychnin, hypodermoclysis of normal salt solution in the breasts and the buttocks, and rectal feeding. If there is reason to suppose that an accumulation of fluid within the abdominal cavity has oc- curred, a vaginal incision should be made for its evacuation or the abdominal wound reopened and drained by gauze wicks. Having begun this treatment for peritonitis, the attendant should not be in too great haste to secure the evacuation of the bowels, as oftentimes the flame may be relighted by the too early ad- ministration of a purgative. 214. Wound Infection. — It is the aim of the operator to se- cure healing of the wound by first intention, and every safeguard is thrown about the operative prpcedure in order to secure this object. Occasionally, however, in spite of all precautions the wound becomes infected from the material that is taken out of the abdominal cavity, or in closing the wound a vessel is punc- tured and hemorrhage of considerable quantity takes place into the tissues directly over the peritoneum. If the depth of the wound does not contain pathogenic germs, such an accumulation is likely to become infected from its close proximity to the intestine, and three to six or even ten days after the operation the patient may develop a temperature, complain of more or less tender- ness over the abdomen; the parts will be 'swollen. Where the THERAPEUTICS. 137 abdominal walls are thick it will be difficult to recognize and determine the existence of any accumulation. It is better in these cases, however, where careful examination discloses the absence of any trouble within the pelvis or other portion of the body to account for the elevation of temperature, to make an exploratory puncture through the structures sufficiently deep that it may reach the space between the muscle wall and peri- toneum. If the operator fears to penetrate the peritoneum after making the incision through the aponeurosis, he can enlarge the opening by introducing a grooved director. The early evacua- tion of such an accumulation will prevent the suppuration and burrowing of the pus and will promote more rapid convales- cence. The infection in some cases may have been carried into the depths of the Avound in the removal of the sutures. 215. Parotiditis.— Inflammation of the parotid gland is a complication of rather infrequent occurrence. It formerly, how- ever, occurred so frequently that it was considered that there was some intimate relation between this gland and the pelvic structures that caused metastasis of inflammation to it. It is now recognized, however, that its inflammation and infection are due only to the fact that this gland is more susceptible to the influence of some forms of bacteria than other structures of the body. Then, too, it is recognized that in the majority of in- stances the infection reaches the gland through the mouth and is due to local rather than general conditions. Where the patient is suffering from peritonitis or septic conditions, with dry tongue, decreased amount of saliva, the patient should be carefully watched and the mouth kept clean to prevent the entrance of infection to this gland. Where the gland shows signs of develop- ing inflammation, the most eft'ective treatment is to apply at once an ice-bag over the infected gland, keeping it constantly applied, thus limiting the amount of the inflammatory process, and where suppuration has occurred, the prompt evacuation of the pus by an incision. 216. Ileus. — Ileus is an obstruction of the intestine that may take place one or two weeks after an operation is performed. It develops by nausea, vomiting, which goes on to the ejections of stercoraceous material, intense pain, profound depression, shock, rapid pulse, haggard, anxious expression, and, if unrelieved, is likely to terminate in the collapse and death of the patient. It is due to paralysis of a portion of the intestine from infection, from adhesions constricting and making difficult the passage of contents of the intestine through the tract, and twisting of the ^ut, forming what is known as a a^oIvuIus or intussusception. If the patient is not relieved by lavage and hypodermic injection ■of morphin, the wound should be reopened and the condition 138 GYNECOLOGY. overcome. In the majority of cases the mere opening the abdo- men, freeing the adhesions, reestabhshing the caliber of the gut, wih be sufficient to accomphsh reHef . This procedure, how- ever, should be done early, as otherwise the patient will be so exhausted that it will be ineffective. 217. Phlebitis. — Phlebitis generally affects the saphenous vein, sometimes extending into and involving the femoral and iliac. This infection may occur at a later date in a patient who otherwise has exhibited every indication of a normal convales- cence. A week or even two weeks after the operation has been performed the patient complains of intense pain in the calf of one leg, most frequently the left. The pain extends up along the course of the vein and most frequently is associated with tender- ness over the saphenous and the iliac veins. The patient should be kept perfectly quiet, the limbs should be raised, bandaged, first smearing over the course of the vein some ichthyol and bella- donna ointment, taking ichthyol and extract of belladonna aa 3j, lanolin §j, wrapping well the limb with cotton, and apply- ing a bandage, making moderate pressure its entire length. The limb should then be elevated and kept more or less immobile by placing a sand-bag on either side of it. An ice-bag should be applied over the saphenous and iliac veins. Even after the acute symptoms have subsided the patient should be kept in the re- cumbent position and the limb perfectly quiet, as it is impossible to say in any individual case what may be the termination. A clot in the vein may become organized, obliterating the vein. It may break down, indicating suppuration and the formation of a localized abscess. Fragments of the clot may disintegrate, be carried into the circulation, and form emboli, blocking up the circulation to important viscera and giving rise to a fatal termi- nation. The nutrition of the patient should be maintained to the utmost degree. 218. Precautions in the Use of the Hypodermic Syringe. — In the use of the hypodermic syringe there are four sources of infection: (i) The hands of the operator; (2) the instrument; (3) the fluids to be injected; and (4) the skin of the patient. The syringe is difficult to keep aseptic. The metal instrument may be boiled in a soda solution. If you have a glass instru- ment, the piston should be withdrawn and it and the barrel should be placed in a five per cent, solution of carbolic acid; the needles, if platinum, may be passed through an alcohol flame, but ordinary needles would be destroyed, and, therefore, they should be boiled. Solutions of atropin, morphin, cocain, strychnin, and ergotin favor the development of bacteria, and when kept for some time, will be found swarming with micro- organisms. Cocain may be kept in a (i : 10,000) bichlorid THERAPEUTICS. 139 solution; the others named may be preserved by the addition of a few drops of carboHc acid to the ounce of solution. Prob- ably the safest method is to make up the solution of morphin, atropin, or strychnin from tablets, which can be dissolved by boiling without affecting the action of the drug. 219. Catheterization. — No procedure, fraught with so much discomfort to the patient when carelessly employed, is so fre- quently performed with so little consideration as is the use of the catheter. We have to regard not only the distressing symptoms produced by infection of the urethra and bladder, but also the serious results of extension of the disease to the ureters and pelves of the kidneys. Fortunately, the female urethra is short, and permits the use of a glass catheter, which can be kept clean. The instrument should be scalded before and after being used, and should be kept in a five per cent, solution of carbolic acid during the intervals. It should be free from cutting edges. The labia should be separated to expose the urethral orifice, when the vestibule should be sponged with a solution of boric acid or sterile water. The catheter should be gently introduced, being held between the thumb and middle finger of one hand, while the index-finger is placed over its opening to prevent the premature discharge of urine. The instrument is carried up- ward and backward as the patient lies upon her back, and when it enters the bladder, as is evident by the absence of resistance and the appearance of urine in the instrument, its external end should be brought over the receptacle between the limbs of the patient. Should the quantity of urine be larger than the reser- voir will hold, the finger placed over the end of the catheter will permit it to be emptied and replaced. The bladder can be com- pletely emptied by making pressure over the lower abdomen with the unoccupied hand. With the discharge of the last urine the finger should be again placed over the end of the cathe- ter to prevent the urine flowing over the vulva or soiling the bed. When pressure has been made over the abdomen, the finger should be so placed before the removal of the pressure as to prevent the aspiration of air into the bladder. Should the urethra be- come painful or irritation of the bladder occur from frequent use of the catheter, the bladder should be irrigated with a hot boric-acid solution. After an abdominal operation the catheter need not be used for twelve hours unless the patient experiences much distress. 220. Removal of Sutures. — The sutures in an ordinary case should be removed about the seventh to the tenth day. If the patient has had a complicated convalescence, the union will not be so firm, and it would be better not to remove them 140 GYNECOLOGY. until the end of two weeks. If the sutures are pulling and causing pain, a part of them may be removed. The same care regarding cleanliness and avoidance of sources of infection should be practised as in the operation. Leaving the sutures long (see Fig. 92) will facilitate their removal and dispense with the neces- sity for forceps to lift up the knot. All the sutures should be cut before any are withdrawn, then the long ends may be gath- ered up and, bracing the wound with the fingers of the other hand, they may all be withdrawn at once, thus giving the minimum of discomfort. The wound should be dressed as in the begin- ning. 221. Getting Up.— In uncomplicated cases the patient may be allowed to sit up at the end of two weeks. In complicated operations or in disturbed convalescence the patient should be kept recumbent for three weeks or more. When the patient sits up it should be for but fifteen or twenty minutes, and preferably in a chair, as the strain is less than if she is supported by a bed- rest. The time should be increased daily. 222. Plastic Operations. — In plastic operations the same precautions as to cleanliness must be observed. Sponging can be replaced by the use of continuous irrigation. The parts may be dusted with acetanilid or iodoform and boric acid. The parts should be dressed with sterilized gauze held in place by a bandage. Vaginal irrigation should not 'be practised during the first forty-eight hours subsequent to an operation, for it interferes with the sealing of the wound by plasma. The patient should be confined to bed at least two weeks, and in perineal operations three weeks are preferable. In combined uterine, vaginal, and perineal operations the internal sutures, if nonabsorbable, should remain for three or four weeks. I prefer chromic catgut for all plastic work, for the reason that the patient is spared the dis- comfort of the removal of sutures, and the newly united tissues are not subjected to the strain. MEDICAL TREATMENT. 223. General Treatment. — In every case of genital disease it is very important that the various organs of the body should be care- fully investigated as to the proper performance of their functions. It is a hopeless task to attempt to treat the disease of one organ of the body as if it were not an integral part of the whole, and capable of producing reflex effects upon organs near or remote, or of being itself the seat of reflex conditions. Engorgement of the hepatic system and the consequent hemorrhoidal congestion must be corrected. This is effected by purgatives, laxatives, and MEDICAL TREATMENT. 141 alteratives. The patient should have calomel (gr. yV) ^^ podo- phyllin (gr. -2^) at night, followed the next morning by a Seid- litz powder, Rochelle or Epsom salts, phosphate of soda (5ij), or a wineglass of Hunyadi Janos or Friedrichshall water. If the liver is particularly sluggish, frequent applications of hot water over the hepatic region should be made. Ammonium chlorid or potassium iodid internally may be of service. Efficient action of the kidneys should be secured by the use of diuretics, or want of action should be compensated by increased action of the boAvels and skin. As anemia 'is a frequent accompaniment, the administration of the reconstructives, such as quinin, strychnin, arsenic, mercury, the bitters, and, in proper subjects, when the system has been prepared, the use of iron. Because of the profound effect this class of diseases exert upon the nervous system, the antispasmodics have found favor. In many cases the valerianate of zinc, asafetida, and the bromid salts will prove very grateful. In very nervous and anemic patients the cold pack, followed by massage, will be exceedingly beneficial. The state of the stomach, the heart's action, and the character of the respiration should always receive consideration. 224. Specific Remedies. — The remedies w^hich may be con- sidered as specifically uterine in their action are ergot, hama- melis, hydrastis canadensis, and viburnum prunifolium. Ergot is generally given in hemorrhage. It acts in two ways ;■ (i) By stimulating the nonstriated muscle-fiber of the blood- vessels, increasing the rapidity of the circulation; (2) its direct action upon the uterine muscle, by which compression is made upon the vessels and a mass within the uterus is gradually extruded. A satisfactory prescription is — R. Ext. ergot f ^j Ext hamamelis.l aa f5ss M Tr. cinnamomi, / ^^ ^ 5 ss. m. SiG. — f 3j every two or three hours. This combination is generally more effective than the ergot used alone. If the contractions are painful, one or two drop's of the fiuidextract of cannabis indica will be of benefit. Hamamelis and hydrastis undoubtedly owe their action to the large amount of tannic acid they contain. Hydrastin or hydrastinin, in doses of from J to ^ of a grain, is more effectual in controlling hemorrhage than the fluidextracts. Viburnum prunifolium has been greatly vaunted as a remedy for the relief of dysmenorrhea or the arrest of threatened abor- tion, but I have never been able to obtain any perceptible value from its use. The extract of thyroid gland seems to exercise a specific 142 GYNECOLOGY. influence upon the uterine mucous surface. In women who are very obese and have associated with the condition amenorrhea, or very scanty flow and steriHty, the administration of the thyroid extract, in addition to the reduction of flesh, increases the flow, and frequently appears to overcome the steriHty. The late Dr. E. H. Coover, of Harrisburg, found thyroid extract very effective in allaying the pain of advanced carcinoma of the uterus. He also thought that it had an influence in delaying the progress of the disease. This opinion seems in harmony with the observations of Beatson and others in carcinoma of the mammary gland. Thyroid extract is frequently of value in producing an im- provement in the conditions which occasion uterine hemorrhage, whether these be from interstitial endometritis, submucous fibroma, or carcinoma. Marked changes in the nutrition and the reduction in the size of myomata have been claimed for the use of this drug, but experience does not seem to justify them. Adrenalin, or extract of the suprarenal gland, through its action upon the involuntary muscular fiber, exerts a decided influence upon the uterine circulation. It is consequently a valuable addition to our armamentarium for the control of hemorrhage. Apiol and the manganese salts cause a hyperemia of the uterine mucous membrane, as indicated by increased normal menstrual flow and its return in amenorrhea. 225. Rest and Exercise. — It is very difficult to flx definite rules to guide a patient as to the amount of either rest or exer- cise she should take. What one person may regard as a pastime, another will consider violent exercise. Women with inflam- matory or engorged uteri are beneflted by certain hours of rest each day. The recumbent position permits the blood-vessels to secure relief. Not infrequently relief is enhanced by ele- vating the foot of the bed or by resting the pelvis upon a firm pillow. In predisposition to hemorrhage from fibroid growths, the patient should be kept in bed for a few days prior to and during the menstrual period. Rest is obligatory in all acute inflammatory troubles. Some patients will, however, have to be stimulated to take exercise; they are disposed to go to bed on the slightest provocation, and remain so long that their muscles become flabby and the vessels grow feeble; the patient becomes bedridden, and every effort of exertion is at- tended with real or imaginary pain. Such patients may require resort to massage and electricity to enable them to resume their ordinary duties. Judicious use of the bicycle or encouragement to play golf LOCAL THERAPEUTICS. 143 will be found most valuable auxiliaries in nervous patients who are dominated by imaginary aches and pains. The in- creased oxygenation and elimination without doubt free the patient from the cause of her distress. LOCAL THERAPEUTICS. 226. Baths. — The sitz-bath of hot water in inflammatory and congestive conditions is capable of giving great comfort. This should be followed by rest, and it would be contraindicated where there was a tendency to hemorrhage or in a possible preg- nancy. In neurotic patients, a systematic course of hydro- therapy will frequently prove restorative when all other means have proved futile. 227. Douche. — The value of the hot douche was made known by Emmet. It should be given with a gravity syringe while the patient is in a recumbent position; the more pro- longed, the larger the quantity, and the higher the temperature (115° to 120° F.), the more enduring will be the effect. The ordinary fountain syringe, a large vessel with a tube leading from its lower end, or an ordinary pitcher with a rubber tube carried to and held at its bottom by a weight, may be used. Instead of the ordinary rubber, wooden, or metal nozle, a glass end-piece is preferable, as it can be more readily cleansed. When preferred, the water may be medicated with astringents, such as alum, sulphate of zinc, acetate of lead, hydrastis, or hamamelis; or with antiseptics, as boric acid, carbolic acid (two to five per cent.), or permanganate of potash (one to two per cent.). The difficulty of saving the clothing from staining renders the use of the latter agent less frequent. Creolin (one to four per cent.) and acid sublimate (i : 5000 to i : 2000) are valuable. The antiseptic injections are of especial value in vaginal discharge, more particularly when of a specific character. The advent of menstruation is considered as contraindicating irrigation, but it may be resumed before it ceases, particularly when the odor is offensive or the parts are irritated, using plain water at a temperature of 100° F. If the vaginal discharge is particularly offensive, as in malignant disease, a douche of thymol solution, one or two per cent., is a most excellent deodorizer. Astringent douches are used in excessive vaginal secretion, but should not be used when the patient is wearing a pessary, as the salts are deposited upon the instrument, roughen its surface, and thus increase the irritation. Rectal douches may be employed to cleanse the bowel 144 GYNECOLOGY. and for the relief of inflammation of the rectal mucous membrane or for their effect upon the neighboring pelvic organs. The close proximity to the uterus and broad ligaments, and the ability to retain the fluid longer in contact, make the use of the rectal enemas of hot water of especial value. Medicated enemas are used to unload fecal accumulations for the relief of tympanites, and to medicate local inflammations. Vesical douches are used for the relief of inflammatory dis- ease of the bladder and urethra. 228. External Applications. — In acute inflammatory con- ditions the popular plan of treatment is to employ hot applica- tions, but we have in the ice-bag a far more efficient means of allaying pain and of limiting the area of inflammation. Its persistent application will in many cases secure resolution in what would otherwise prove a serious disorder. The ice-bag over the sacrum affords prompt relief of dysmenorrhea of the congestive form. 229. Counterirritants are productive of benefit in the more chronic forms of disease. Painting the skin over the lower mr—- — H I I » Fig' 93' — Butt Uterine Scarifier. abdomen with tincture of iodin is more frequently resorted to. It may be repeated and continued so long as the skin will bear it. The irritation is increased by the addition of croton oil. R. 01. tiglii, f.^j Tr. iodi, f 3 ij ^theris, f 3 V. M. SiG. — Apply with brush externally. It produces a crop of pustules, w^hich should be allowed to dry before the application is repeated. The most effective procedure is the application of a blister over the seat of pain or to the inflammatory exudate two or three times a month, but this should not be practised when the patients are much depressed or very anemic. 230. Bloodletting. — The general abstraction of blood is now rarely practised. Doubtless there are many cases in which a good bleeding would cut short a severe iUness or abort an inflammatory attack. The local abstraction of blood by the use of a scarifier or by puncturing the cervix will often prove effective in relieving the pain of engorgement and in promoting absorption and resolution of inflammatory conditions. LOCAL THERAPEUTICS. 145 231. Local Applications. — A few years ago the routine treatment was the introduction of soHd silver nitrate into the uterine cavity, the use of fuming nitric acid, and other power- ful caustics. Such treatment cured by destroying the glan- dular tissue of the part. Milder measures are now practised. It should be an accepted rule that no intra-uterine medication should be practised unless the uterine canal is freely open to permit of thorough drainage. Applications to the uterine cavity are made by wrapping a probe or applicator with absorbent cotton, which, after being Fig. 94. — Aluminiuin Uterine Applicator. saturated with the medicinal agent, is carried into the canal. A few drops of the medicinal agent may be introduced by the long pipet. In the use of either procedure it is desirable that the cervix shall be freely opened and the uterus in good posi- tion. If not, the medication will produce uterine contractions which will result in violent colic. Such attacks not infrequently are followed by severe inflammation of the adnexa and even of the peritoneum. To render intra-uterine treatment of value, the plug of thick mucus which generally fills up the diseased Fig. 95. — Long Glass Pipet. cervix must first be removed, in order to permit the contact of the medicinal agent with the aft'ected surfaces. 232. Various Agents. — The agents generally applied locally may be classified as antiseptic, astringent, and caustic. The antiseptic applications are the combination of carbolic acid, creasote, iodin, and iodoform. Useful preparations are: K . Acid, carbolic. , ^ ss Tr. iodi, f gj. M. H . Creasoti, "] Glycerin., v . . . . ^ aa f 5 ss. Alcohol., ) M. R . Iodin (crystals), q.s. ad sat. Acid, carbolic. (95 per cent.), foj. M. E . 40 per cent, solution argvrol. 10 146 GYNECOLOGY. An astringent effect can be secured by a combination of tannin, as: R . Acid, tannic, .^ j Tr. iodi, . . \ 7^^ fXi t\t Glycerin., | ^^^^^ ^^• The most frequent applications are the tincture of iodin and Churchill's tincture. Iodoform may be used in the form of crayons, as an oint- ment, or as a powder, with the insufflator. The various as- ■^^;;; Fig. 96. — Insufflator — Straight Stem. tringents may be applied in powder alone or in combination with boric acid, iodoform, or acetanilid. 233. Astringents. — The most available astringents are alum, borax, sulphate of copper and sulphate of zinc, the tincture of the chlorid of iron, fiuidextract of hydrastis, and fluid- extract of hamamelis. The solid substances are best used in mild solution. Some of these agents when used without dilution are strongly caustic. 234. Caustics. — Crayons of sulphate of zinc (fifty per cent.) are very effective for caustic pur- poses, and are used in aggravated forms of endometritis. Still more effective is the chlorid of zinc in crayons (thirty-three per cent.). Liquid caustics are nitric acid, acid nitrate of mercury, sulphuric acid, hydrochloric acid, chromic acid, solution of zinc chlorid, solu- tion of silver nitrate, tincture of iron chlorid, carbolic acid, and crea- sote. In my judgment the more active caustics are rarely re- quired, and very frequently their employment is followed by cicatricial changes more grave than the original condition. 235. Tampons made of absorbent cotton, lamb's wool, or gauze afford an efficient method of treating the cervix. The best tampon is composed of a combination of gauze and cotton or lamb's wool. It should have a thread attached, by which it can be withdrawn. The tampon may consist of simple sterilized Fig. 97. — Tampon. LOCAL THERAPEUTICS. 147 material, or may be medicated with antiseptics, astringents, styptics, anodynes, or alteratives. The principal purpose of the tampon is to sustain the uterus at a higher level, which relieves the patient from the dragging pains due to want of support of a heavy organ, and the change of position improves the circu- lation; the addition of an antiseptic permits it to be retained for a longer period without becoming foul. Sublimate, from its tendency to irritate the vagina and vulva, can not be satis- factorily used. Carbolic acid, boric acid, and iodoform are most satisfactory. The addition of glycerin is of value. By its affinity for the watery portions of the blood it produces a profuse dis- charge, which depletes the vessels and favors the absorption of exudates. Boroglycerid, glycerite of tannin, and a ten to twenty per cent, solution of ichthyol are popular applications upon the tampon, but the patient should be cautioned, in the use of the two latter, to wear a napkin in order to prevent hei clothing from becoming stained. Besides supporting the uterus, the tampon may be used to control hemorrhage or discharge; to complete the diagnosis, through the discharge which it induces; to assist in maintain- ing the uterus in a normal position; and to prepare the way for the use of a pessary. 236. Massage. — General massage affords an effective means of promoting nutrition and of improving the condition of pa- tients suffering from chronic pelvic troubles. It increases the number and the activity of the red blood-corpuscles, carries oxygen to the remote tissues and organs, facilitates oxgenation and combustion, and favors absorption, but, best of all, it im- proves the nerve tonus. Many patients are incapacitated by illness, by aggravated pains, or by disinclination to take exer- cise. Judiciously regulated massage accomplishes the con- stitutional changes ordinarily effected by exercise, free from its possible deleterious influences. Slowly the individual is rehabilitated, and as she gradually and insensibly resumes her self-control, she is emancipated from, the preexisting un- fortunate nerve phenomena. 237. Pelvic Massage. — The beneficial results of massage in local inflammations of joints and superficial portions of the body justified the hope that it might be practised with advantage in the conditions of acute and chronic exudations within the pelvis. It has been systematized into a recognized procedure, known as pelvic massage, largely through the study and experiments of Thure-Brandt, a Swedish masseur. It is practised by having the patient lie upon her back upon a couch or table, with her buttocks close to its edge; the limbs are flexed upon the body. One or two fingers of the left hand 148 GYNECOLOGY. are introduced into the vagina, with which the uterus is gently pushed forward against the anterior abdominal wall. The fingers of the right hand are placed upon the abdomen, and are moved in a circulatory or rotatory manner over the sur- face, or, rather, moving the surface with them in this manner. (Fig. 98.) The greatest gentleness must be exercised in the beginning, increasing the pressure as the patient becomes Position of the Fino:ers in Pelvic Massag^e. reassured or as the pain is lessened. As we progress, the fin- gers may be made to dip down, to push off and separate ad- herent organs, and to follow lines of cleavage indicating in- flammatory adhesions. The seances vary in length from five to fifteen minutes, the shorter time being preferable in the earlier applications, and they should be repeated from three times weekly to once daily. The exercise of this procedure ELECTRICITY. 149 will be found to produce a rapid alteration in inflammatory accumulations, setting free the uterus and its adjacent organs. The -procedure will be indicated in all subacute and chronic inflammations of the pelvic organs unassociated with pus-for- mation; in displacements, when fixed by inflammatory adhesions; in subinvolution and hypertrophy of the uterus from chronic interstitial inflammation; and in relaxation of the pelvic floor induced by increased weight of the pelvic organs. It is contraindicated in the presence of pus-formation, whether contained in the tubes or within the pelvic tissues. Massage is rendered difficult by thick abdominal walls, and in nervous, hysteric women. In the latter, however, much may be done by gentle procedure until the patient's confidence and cooperation are secured. ELECTRICITY. 238. Forms. — The immense influence exerted by the use of electricity in the development of the arts and sciences nat- urally has led to its study and utilization in the treatment of disease. The various electric currents were early employed in an empiric way in gynecology. It remained for Apostoli, however, to formulate plans for their more accurate dosage and systematic use. The principal forms in which the electric current is generated and applied are Franklinic, galvanic, faradic, sinusoidal, and Ront genie. 239. Franklinism. — Franklinism, or the static current, is the employment of electricity generated by friction. It is not generally used, but is an excellent nerve stimulant and counterirritant, from the use of which great benefit has been claimed in cases of hysteria and neurasthenia. It has afforded the greatest service to patients in whom the local pelvic lesions are slight or difficult to recognize while the element of pain is a marked factor. It has been employed with advantage in amenorrhea, dysmenorrhea, ovarian, lumbar, or lumboabdom- inal neuralgia, vaginismus, hyperesthesia, and various neu- rasthenic conditions. The seances may be continued from six to thirty minutes. The number of applications is indefinite. 240. Galvanism. — The galvanic current has an extensive field for its application in the treatment of diseases of the pelvic organs. As a therapeutic agent its effects are recognized as polar, interpolar, and general (Martin). The polar effects are acid and alkaline at the respective poles. In very strong cur- rents the action becomes caustic. The positive pole is a power- ful sedative to the sensory nerves, and acts as a vasoconstrictor 150 GYNECOLOGY. of the blood-vessels in its vicinity. As a result of the accumu- lation of certain salts from the metal electrode employed, it proves destructive to germs. The negative pole with current of proper density causes liquefaction of the tissues, and if the current is very strong, it exerts an alkaline caustic action. It is a powerful irritant to the sensory nerves of the parts, and also acts as a vigorous vasodilator of the blood-vessels. Inter- polar action consists of electrolysis and cataphoresis, or transfers- Fig. 99. — Portable Galvanic Battery with Galvanometer. all fluids in bulk from the positive to the negative pole. Gal- vanism in its general effect, when forced through a portion of the body, acts as a tonic to the entire system. The beneficial influence of the agent in gynecology is most effectively dis- played in the treatment of chronic endometritis, pelvic inflam- matory exudates, and in some varieties of fibroid tumors. 241. Apparatus for Application. — The investigations of Apostoli demonstrated that the application of high powers. ELECTRICITY. 151 of electricity resulted in the destruction of tissue in which acid materials were found about the positive pole, while alkalies collected at the negative. The former caused a dry, brownish eschar; the latter, a soft, watery, elastic slough, which did not contract. The resistance of the skin required for the use of high powers a large, inactive electrode externally. Apostoli devised and employed a moist clay pad. Other operators have used a bladder or other animal membrane filled with a salt solution, or a large metal disc covered with wet cotton or a towxl for the external electrode. The internal electrode ^^^^^.m^ Fig. loo. — Intra-uterine Electrode with Movable Insulating Cover. may be vaginal or intra-uterine. The former may consist of a knob or a nest of knobs, from which a suitable one can be selected and attached to a gutta-percha-covered metal rod. The intra-uterine electrode may consist of a platinum wire or a steel rod insulated to within one or two inches of its end. The insulating sheath of gutta-percha or celluloid may be mov- able and thus permit a variable surface to be subjected to the application. A battery, either portable or stabile, will be required, cap- able of generating a current of from 200 to 400 milliamperes, and so arranged that the strength of the current can be gradually Fig-. 10 1. — Vaginal Electrodes of Different Sizes. increased. It should be provided with a galvanometer or a milliamperemeter to measure the current; a rheostat, by which the strength of the current can be governed; a commutator, to permit a change of poles without removal of the electrodes (as a reversal of the poles can not be made without shock, the precaution should be exercised greatly to reduce the in- tensity of the current before such a change is made). 242. Method of Procedure. — Apostoli's employment of the electric current requires a careful examination and an accurate diagnosis. If a growth, careful measurement from various fixed points should be made in order to be able to determine 152 GYNECOLOGY. the results of treatment. The hands, genitaHa, and electrodes must be thoroughly cleansed or disinfected. Before the external electrode is applied the skin should be carefully examined and all broken places covered with collodion or plaster; otherwise the electrode will be unendurable. The internal electrode should be introduced without the speculum. The patient should be apprised that there will be a slight burning, and that there may be a bloody discharge subsequently. Her clothing should be loosened, her corsets removed, and the bladder and lower bowel emptied. The application should not follow a full meal. While the electrodes are being introduced, the current should be closed, and gradually opened subsequently. The first ap- plication should be carefully made for the purpose of determin- ing the patient's sensibility. The pole used for the active or intra-uterine electrode must depend somewhat upon the existing conditions. The positive pole, possessing the most electrolytic action, and being an effective hemostat, should be employed for hemorrhage. The negative pole acts like an alkali, is the most painful, and is used to decrease the size of a growth or to enlarge a stenosed canal. The duration of the applications may vary from three to ten minutes. The num- ber of applications for an individual case is difficult to fix — generally from twenty to thirty. Their frequency is dependent upon the condition, varying from every eighth day to two or three times weekly. 243. Indications. — The employment of galvanism is advocated in amenorrhea, dysmenorrhea, and menorrhagia; in chronic inflammation dissociated with suppuration; for the arrest of hemorrhage, relief of pain, and decrease of size in myomatous growths of the uterus, particularly in the submucous and inter- stitial varieties; and for chronic ovarian inflammation. This agent seems particularly valuable in women suffering from bleeding fibroids near the menopause,, in whom the conditions render a radical operation unjustifiable. 244. Contraindications. — ^According to Apostoli, the galvanic current is contraindicated in the following conditions: (i) Hysteria; (2) intestinal catarrh; (3) pregnancy; (4) malignant degeneration of a tumor; (5) fibrocystic tumors; (6) suppurative inflammation of the adnexa. To these, Schaefler would add any acute or subacute inflammation of the pelvic viscera, a very hard or fully matured tumor, an excessively large growth, a submucous growth which is pedunculated, enfeebled heart action, and acute nephritis. 245. Faradic. — The current of induction has a primary and a secondary current. One pole may be applied in the ELECTRICITY 153 vagina or the uterus; the other, over the abdomen. ApostoH advised a bipolar electrode in which the negative and positive poles were placed in the same electrode, with a band of non- conducting material between them. In this way the current of electricity was limited to a greater extent to the tissues de- sired to be affected. This method of procedure was less painful. The primary current is one of quantit}^; the secondary one of tension. The latter is dependent upon the length and fineness of the wire. The current of tension is effective in subduing pain, such as ovaralgia, abdominal pain in hysteric women, vaginismus, and pain from pelvic inflammation. It proves Fig. I02. — Faradic Battery. to be an emmenagog. It may be applied three times weekly, or even daily, each sitting lasting from ten to thirty minutes. The electrode is first introduced; the current is then opened slowly, and gradually closed before the electrode is removed. This is necessary in order to prevent severe pain. 246. Sinusoidal. — Apostoli employed a current introduced by d'Arsonval, known as the sinusoidal. The patient is placed upon an insulated couch beneath which is a large coil of wire through which a current of 450 milliamperes is passed. The patient is enveloped in an electric atmosphere in which the effects will depend upon the number of alternations in a second, the degree of electromotive force, and the quantity of current. 154 GYNECOLOGY. It acts more particularly upon the muscular structures with- out inducing pain or disagreeable sensation. Its employ- ment modifies nutrition by an increased absorption of oxygen and the greater ehmination of carbonic acid. The current exerts ^ a marked analgesic effect, which frequently induces the disappearance of painful symptoms. It is consequently of benefit in dysmenorrhea, but has displayed its beneficial effects to the greatest extent in the treatment of peri-uterine inflammations and pelvic exudates, in the resorption of which it is one of the most effective means at our disposal. Fig. 103. — Bipolar Uterine Electrode. + . Positive pole. — . Negative pole. 247. Rontgenic. — This term is applied to peculiar rays of light which are engendered by light under electric excitement, being transmitted through tubes of very high vacuum. The discoverer of this phenomenon. Professor Rontgen, of Wurz- burg, designated these rays as the :r-rays. The influence of the discovery of a procedure capable of transillumination of the structures of the body can hardly be estimated. The x-TSiys have proved both diagnostic and therapeutic aids. They can be generated through the employment of the static machine. Fig. 104. — Vaginal Electrode — Bipolar. the induction coil, batteries, and the electric-lighting main. The essential portions of the apparatus are the vacuum tube and fluorescent screen. The latter consists of a lightly con- structed tight box, somewhat similar in shape to the stereo- scope. The small end has an aperture which is made to fit tightly over the eyes and bridge of the nose. The inner sur- face of the broad end is covered with a uniform layer of fine crystals of a fluorescent material, generally barium platino- cyanid or calcium tungstate. Not only is the operator able to inspect the internal structures of the body, but he is also ELECTRICITY. 155 able to record what he sees upon a sensitive photographic plate for the benefit of others. The employment of the procedure has afforded information of value in the diagnosis of obscure cases, notably in pregnancy and ectopic gestation. The beneficial infiuence of the rays in the treatment of superficial malignant and tubercular con- ditions suggests the hope that it may be equally eftective in arresting the ravages of these disorders when they involve the deeper structures. The rays are found to exert a more destructive action upon the less resisting malignant cells than upon the healthy tissues. If subsequent investigation shall demonstrate the correctness of this view^ which now seems probable, the operator who does not follow his radical opera- tion with the employment of the Rontgen rays to destroy in- fectious germ-cells w^hich have possibly lodged in the neighbor- ing lymphatic spaces and vessels will fail of doing full justice to the interests of his patient. In carcinoma of the cervix the depth from the surface of the tissues involved renders the application more difiicult, and requires special care to pro- tect the superficial structures from burns which would delay and arrest the necessary treatment. In deep-seated cancer my observation and the careful anal- ysis of that of others lead me to believe that not sufficient benefit is derived from the employment of the :^-rays to com- pensate for the discomfort of the applications and the occasional dermatitis arising from their employment. In superficial cancer, tuberculosis, obstinate eczema, acne, and pruritus the :r-rays have proved of advantage, but in malignant " disease of the deeper structures their employment should not precede surgical measures in operable cases. 248. Finsen Light. — The Finsen light consists of the ultra- violet rays, which are invisible to our vision and are capable of refraction and concentration. They exist largely in sun- light, but may be artificially produced from the arc light. Glass is a non-conductor to these rays, therefore it is necessary to construct a plate or disc of quartz, or, still better, of trans- parent rock-salt. The Finsen light differs from the Rontgen rays in being very destructive to bacterial life, while the latter, if it has any effect, rather facilitates bacterial growth. The application of the Finsen light must, under present conditions, have a limited application in gynecology, because it causes an anemia of the tissues upon which it is purposed to exert its influence. 249. Electrocautery and Light. — The employment of elec- tricity as a means for the production of heat for cautery pur- poses has won a well-recognized place through the work of 156 GYNECOLOGY. Byrne with the galvanocautery, and later its ingenious applica- tion by Skene and Downes to electrothermic hemostasis. The power can be secured by batteries of large size, by storage cells, or, better, from the street main through a trans- former. Dr. Dow^nes has modified and improved the instru- ments devised by Skene. He applies a special form of angio- tribe to the broad ligaments, which, when raised to a dull red heat, divides and cooks the tissues, thus rendering ligatures unnecessary. The great advantage of this procedure is in hysterectomy for cancer of the uterus, as it enables the removal of a large amount of possibly infected tissue. The malignant cells which have been carried into the parametrium are supposedly less resistant to the effects of heat than healthy tissue. There- fore it seems reasonable to infer that some of these are de- stroyed by the electrothermic measures which w^ould other- wise survive to cause relapse if other methods of operating had been employed. The same class of batteries enumerated for cautery pur- poses may also be employed for electric lights. The electric light is especially useful in inspecting the urethra, bladder, ureters, and rectum. The electric light in a cystoscope can be introduced through the urethra and the entire cavity of the bladder exposed, the orifices of the ureters recognized, and any changes in the structure of the bladder are readily observed. The instrument may be employed to irrigate the bladder by closing its end; the bladder can be distended w4th air or gas, thus determining the capacity of the organ. Loss of structure, thickening, growths, and other changes in its walls are also perceived. It can also be employed for local medication and for catheterization of the ureters. The electric light can be employed to illuminate the rectum through long or short proc- toscopes, the vagina by an attachment to a speculum, and even to look into the uterus, but as the latter canal has to be previously dilated, the instances are rare when its illumination will be of practical service. EMBRYOLOGY AND ANATOMY OF THE GENITO -URINARY ORGANS OF THE WOMAN. 250. Development of the Genito - urinary Organs. — Some knowledge of the origin and processes of development of the organs is necessary to a proper understanding of the condi- tions in which they have failed to attain the normal. The embryonic period may be divided into five periods or stages. EMBRYOLOGY. 157 rk • • The first period extends to the eighth week. Up to the fifth week from fecundation there is developed no sexual indication. The primordial kid- ney, the Wolffian body, the duct of Miil- ler, and the Wolffian duct, from which the genital organs are to be developed, are found one upon each side of the median line. A cloaca is situated at the site of the future vulva, into which the urachus and intestine open. From the ex- ternal surface of each Wolffian body a struc- ture known as the genital gland develops, which subsequently becomes either the tes- ticle or ovary. Simul- taneously, the cloaca is divided by a projec- tion — the genital emi- nence or tubercle — - which is marked by the genital furrow or groove. Their appear- i8 19 18 Fig. 105. — Human Embryo at End of Thirty-five Days.— (Co5/^.) I. Tongue. 2. Aortic Bulb. 3. First permanent aortic arch. 4. Second aortic arch. 5. Third aortic arch, or ductus BotalH. 6. The two filaments to the right and left of this figure are the pulmonary arteries. 7. The trunk of the superior vena cava and the right azygos vein. 8. The common venous sinus of the heart. 9. Left auricle of the heart. 10. Right ventricle. 11. Left ventricle. 12. Lungs. 13. Stomach. 14. Left omphalo- mesenteric vein. 15. Wolffian body. 16. Right omphalomesenteric vein. 17. Intes- tine. 18, 18. Umbihcal arteries. 19. Um- bilical vein. tween the tube and the uterus. The cloaca, by the development of the perineum, is divided into two portions — the urogenital sinus and the anus. ance at the eighth week affords no clue as to the probable sex. The Second Period (Eighth to the Twelfth Week).— The Afiiller- ian ducts coalesce, and the septum disappears in their lower two- thirds, while the in- sertion of the round ligament indicates the point of division be- 158 GYNECOLOGY. The third period (twelfth to twentieth w^eek) witnesses the fusion of the uterine horns ; the appearance of the arbor vit« in the cavity of the uterus; the formation of the cervix; enlarge- Fisr. io6. — Coalescence of Miiller's Duct. ment of the perineum; and development of the vagina, which opens into the urogenital sinus and forms the vestibule of the vagina, in which the hymen appears. The genital tubercle, which Progress of Development of the Genitalia. Fig. 107. — All. Allantois. Fig. 108. — CI. Cloaca. Fig. 109. — Su. Urogenital R. Rectum. M. Miil- B. Bladder. R. sinus. R. Rectum, ler's duct. X. In- Rectum. V. Va- separated from the dentation of the skin gina. — {Schroder.) former by the peri- which forms the neum. B. Bladder, anus. — {Schroder.) V. Vagina, u. Ure- thra. — {Schroder.) has been large, is reduced to the proportions of the clitoris, and the edges of the genital fissure become the nymphse. The fourth period extends from the twentieth week to the ANATOMY. 159 end of fetal life. During this period the fundus of the uterus increases in size ; folds form in the vagina, as well as in the cervix, and the labia majora become fuller and more rounded. The fifth period comprises the time from birth until puberty. The uterus increases in size and thickness; the uterine mucous membrane, which up to the sixth year is folded like that of the cervix, becomes smooth. The vagina is elongated, and the vulva is larger and more rounded. 251. Division of the Genitalia. — The special generative organs of the woman are situated in the pelvis in close associa- tion with the bladder and urethra, the rectum, and the anus. The female genitalia are divided into two classes: the external and internal organs, the former of which, with the vagina, form the organs of copulation, and the latter the reproductive organs proper. 252. The external genital organs are, enumerated from before backward, the mons veneris, the labia majora, the labia minora, the clitoris, the vestibule, perforated by the meatus urethras externus, the orifice of the vagina, surrounded in the virgin by the hymen, the fourchet, the fossa navicularis, and the perineum, situated between the vulva and the anus. The external genitalia are also called the vulva, pudendum, or cunnus; the cleft between the labia majora is known as the rima pudendum. 253. The mons veneris is a cushion of fat situated over the pubes, covered with thick skin which is abundantly sup- plied with hair. The hair protects the vulva from the per- spiration of the body. When the nude woman is erect, the mons veneris is the only portion of the genitalia visible. 254. The labia majora are skin folds which unite in front of the mons veneris. Posteriorly they thin off and terminate about one and one-half inches in front of the anus. Externally they are covered with short, crisp hair, which is continuous with that of the mons veneris. They are profusely supplied with sebaceous and sudoriferous glands. Their internal sur- faces lie in contact and present a smooth, moist surface which resembles mucous membrane. The apposition of the labia majora, slightly separated by the labia minora and clitoris, forms the cleft of the vulva, the rima pudendum. Each labium contains a sac-like structure called the dartoid. This is anal- ogous to a similar structure in the male scrotum. The round ligament, and in the fetus an open canal, called the canal of Nuck, terminates in this dartoid sac. Occasionally the latter remains open in the woman and permits the formation of a hydrocele. In fat subjects these folds contain a large quantity of adipose cellular tissue. 160 GYNECOLOGY. 255. The labia minora are situated between the labia ma- jora, slightly projecting beyond their level, and are much more prominent anteriorly. Upon wide separation they are seen to be continuous with the fourchet, and form the posterior com- missure. Anteriorly they bifurcate and form two folds, an anterior, which passes in front of the clitoris and forms its prepuce or hood; the second passes behind the glans clitoris f Fie. no. -Virgin Vulva; Labia not Separated. — {From Deaver.) and forms the frenulum. The labia minora, also called the nymphse, have a smoother, but slightly roughened surface, with free convex, sometimes notched, borders. Frequently small openings or perforations will be seen. The size of the nymphse varies greatly according to the age and race. They project considerably beyond the vulva in the young child, but, owing^ ANATOMY. 161 to the increase in size of the labia majora as puberty approaches, they are rendered less apparent. In the Bush women the labia minora frequently become so long that they reach to the knees, and are then spoken of as the Hottentot apron. The skin is covered with a stratified pavement epithelium, similar to that of the true epidermis. They are plentifully supplied with sebaceous glands, especially at the base of the folds, where they form a crowded layer upon the inner surface. In the brunette the pigment deposit is frequently so great as Fig. III. — Virgin Vulva; Labia Separated, Showing the Hymen Unruptured. — (Frojn Deaver.) to make them noticeably dark. The skin folds contain a small amount of connective tissue. During the act of coition the labia minora draw the glans clitoris against the male organ. 256.^ The clitoris, as in the male, is an erectile organ, having its origin from the posterior surface of the ischiopubic rami, arising on either side as a crus clitoridis or corpus cavernosum. These unite to form one body in front of the symphysis. The organ is secured to the symphysis by the action of the sus- pensory ligament, and its circulation is influenced by the ischio- cavernosus muscle, in which respect, therefore, it resembles 11 162 GYNECOLOGY the penis. The corpora cavernosa are enveloped by a fibrous investment and separated by a median septum of cavernous tissue composed of fine trabeculae, in which the muscular ele- ments predominate. The free extremity of the clitoris is situated at the anterior part of the vulva, about one-half inch behind the anterior extremities of the labia majora. The organ is surmounted by a median tubercle known as the glans clitoridis. The glans is more or less covered by the prepuce, which is formed by the anterior folds of the labia minora or nymphag. The glans is imperforate and is generally but slightly developed. Fi^. 112.— Hvmen Crescens. Fig. 113. — Hymen Annularis. When it appears enlarged, the other parts of the vulva will generally be found small and ill developed. 257. The vestibule is, by some anatomists, described as the entire space between the labia minora, which, prior to the rupture of the hymen, includes its external surface; but as this portion largely disappears after successful coition, and completely after parturition, it seems better to confine this term to the portion ordinarily called by that name, which is^ the space bounded on each side by the labia minora, and posteriorly by the anterior border of the vagina. This triangular space has the glans clitoridis at its apex. At its center, near the posterior border, is a rounded, pouting orifice — the meatus ANATOMY. 163 lorethrffi externus. The openings of the ducts of two clusters of large mucous follicles are also found in this situation. One of these groups lies immediately behind the clitoris, and when the ducts become occluded, a cyst is formed. The other group is near the sides of the meatus. Mucus is secreted very freely by these follicles under any persistent local irritation. In the virgin a grooved ridge is found which, according to Pozzi, represents the corpus spongiosum of the male and is known as the vestibular band. The orifice of the meatus urethras is situated behind the clitoris in the posterior part of the vesti- bule, and about one inch in front of the fourchet. It ordi- /I im »^- % s -^r^' %' '^-^■ Fig. 114. — Hvmen Serratus. Fig. iir — Hymen Infundibularis. narily presents a longitudinal or starred slit, the borders of which are shghtly notched and projecting. Occasionally its mucous- membrane bulges, forming a ring-like margin. Within the elevated margins of the meatus and slightly posterior to its center is found a minute opening, on each side, which usually is not easily detected in healthy subjects ; but following gonorrhea or leukorrhea they may be readily recognized. These openings are the orifices of Skene's ducts, w^hich are parallel to the ure- thra and about two centimeters in length. Thev should be recognized, as they are sometimes so large that a catheter may enter one of the canals instead of the orifice of the urethra. 164 GYNECOLOGY. 258. The hymen is a thin membrane acting as a sort of diaphragm between the internal genital parts, on the one side, and the external parts and orifice of the urethra, on the other, which is revealed by separation of the labia minora. (Fig. iii.) Its external surface resembles the structure of the latter, while the internal presents not infrequently the rugae of the vagina. When the labia are not forcibly separated, the hymen appears as a vertical slit with its lateral edges in contact. With the labia held apart, however, the opening is usually crescent ic with its concave margin anterior. (Fig. 112.) Sometimes it is annular with a central opening. (Fig. 113.) The h3^men may -*^ > I Fig. 116. — Hymen Biseptus. Fig. 117. — Hymen Cribriformis. present a variety of forms and openings, such as the labial form, in which the lateral folds may be mistaken for the labia minora; the linguiformis, which presents a tongue-shaped projection posteriorly, and the falciform, which has a some- what long and wide orifice. The free edge of the hymen may be smooth, denticulated, or serrated. (Fig. 114.) Its structure may be thick and fleshy, and present irregular folds resembling fimbriae. The infundibular form (Fig. 115) presents a funnel- shaped appearance with the margins looking downward and backward. There may be two openings, the septus or biseptus ANATOMY, 165 (Fig. ii6), or a number of openings, as the cribriform (Fig. 117). The membrane is usually thin and easily torn, but occasionally it is so firm that it withstands the most strenuous efforts at coition, and, therefore, will require incision before the sexual act can be accomplished. The hymen usually ruptures during the first coition, and occasionally its tear is followed by pro- fuse and often dangerous bleeding. (Fig. 118.) The greater portion of the hymen is destroyed during the process of par- turition, the remainder shrinking together to form small masses at the vaginal outlet. These masses are known as the carun- culae myrtiformes. The number, form, and situation of these caruncles vary extremely. Generally there are three. One is situated at the posterior part, the others at the sides of the entrance to the vagina. Both surfaces of the hymen are cov- ered with pavement epithelium. The hymen guards the entrance to the vagina. 259. The fourchet is a continua- tion backward of the labia minora in the form of a thin fold, and is rend- ered prominent by the separation of the vulva. Between this fold and the hymen is a boat-shaped depres- sion called the fossa navicularis. Between the fourchet and the anal opening is an intervening space cov- ered with integument, some four cen- timeters in length, which is called the perineum. 260. The muscles of the perineum are exposed by the removal of the skin, the superficial fascia, and a layer of the deep fascia. The mus- cles thus mapped out are : The erec- tor clitoridis; the bulbocavernosus and the transversus perinei, paired muscles; and the sphincter ani and levator ani, which are single. The erector clitoridis arises from the anterior margin of the rami of the pubes and ischium and is inserted by tw^o ten- dinous expansions, one above the junction of the crura into the body of the clitoris, and the other below and in front. The h^dho- cavernosi muscles arise from the tendinous raphe and anterior aponeurosis of the perineum, and are separated by the vagina, around which they course, to be inserted by a thin slit into the crus of each side in front of the erector clitoridis. The outer fibers of the Fie 118. -Laceration of the Hvmen. 166 GYNECOLOGY. muscle wind inward beneath the erector muscle to reach the upper part of the bulb near its isthmus. A portion of the median fibers are apparently derived from the sphincter and pass up- ward to the clitoris, over the pubes, and are lost in the super- ficial fascia. Other fibers form a delicate muscular arch in front of the body of the clitoris. The action of the muscle is to compress the bulb of the vagina and to some degree act as a sphincter of the vagina, though Savage assigns the latter Fig. 119. — Muscles of the Female Perineum. — (Deaver.) function to a portion of the levator am. The relation of a portion of the fibers to the sphincter ani produces a figure- of-8 action upon the two orifices, which it is important to re- member in operations upon the sphincter. The transversus perinei muscles arise one on each side from the tuberosity of the ischium, and are attached to the anterior aponeurosis of the perineal septum, the perineal body, and the skin of the perineum in front of the anus. The sphincter ani arises from ANATOMY. 167 the tip of the coccyx and is attached in front to the tendinous raphe of the perineum, where it meets the fibers of the bulbo- cavernosi. Its fibers, closely attached to the skin, decussate in front of the anus, while some fibers appear to pass com- pletely around it. The muscle is pierced by radiating fibers from the longitudinal muscular coat of the rectum, and is in close relation with the levator ani and internal sphincter. This muscle forms the external sphincter and is voluntary in its action. The levator ani is the principal muscle of the pelvic floor. It arises from the back of the body and horizontal ramus of the pubes, the pelvic fascia (white line), and the spine of the ischium. From its origin the muscle sweeps downward and inward and is attached in the middle line from before backward as follow^s: To the vagina, to the rectum, to its fellow of the opposite side, and, finally, to the tip of the coccyx. The pubic fibers blend with the posterior half of the upper border of the sphincter vagincB. This muscle is more readily exposed from above. The vulvovaginal gland with the bulb of the vestibule are ex- posed in the dissection already described. The former is a racemose gland, of which there is one situated on either side of the vagina and posterior to its orifice. It is analogous to Cowper's gland in the male. It is also known as the vulvar gland of Bartholin, or, according to Huguier, the vulvovaginal gland. It is about the size of an almond, but varies in different individuals and even upon the two sides. Occasionally glan- dular nodules are seen, which seem to be detached from the gland and scattered in the surrounding muscle. Within, the gland is in close relation with the vagina, to which it is adherent by tense cellular tissue, while externally it lies beneath the bulbocavernosus muscle. Its excretory duct, about one centi- meter long, is directed from below upward and from without inward and opens in the angle between the hymen and the wall of the vulva. When the hymen has disappeared, its orifice is found in the corresponding angle between the carunculae myrtiformes and the wall of the vulva. It is usually difficult to detect, but sometimes presents an orifice which will admit a probe. This gland furnishes the secretion which is manifest under the influence of sexual excitement or during coition. The bulb of the vestibule is a venous mass which is situated along each side of the vagina and the vestibule. It is related within to the vagina, vestibule, and urethra, and is covered externally by the bulbocavernosus muscle. The bulbs unite beneath the clitoris by a venous connection, the pars inter- media. Kobelt says the injected bulb is nearly four centi- 168 GYNECOLOGY. meters long, one centimeter wide, and from nine-tenths to one and one-tenth centimeters thick. Its external surface is convex, its internal surface concave. The bulb is a part of the erectile tissue of the female genital organs and is analogous to the cor- pus spongiosum in the male. 261. The perineal fascia or the fascia of the pelvic floor consists of the following: 1. The superficial fascia. 2. A deep layer of the superficial fascia. 3. The triangular ligament, composed of two layers. The superficial fascia is a continuation of the general fascia of the body. It consists of two layers — an outer, more or less loaded with fat, which is continuous with the same layer over the buttocks, thighs, and abdomen; an inner, more resisting membranous investment descends from the abdomen, narrowed to the width of the pubes, but spreading out so as to envelop the anterior perineal triangle at its base — the perineal septum. The abdominal portion of the fascia is firmly adherent to Pou- part's ligament; the perineal portion to the outer margin of the ischiopubic rami and the inferior margins of the septum, while the pubic portion is attached along a curved line of the bone, which indicates the origin of muscles of the anterior part of the thigh. A tubular prolongation extends backward from the margin of the external inguinal ring on each side of the vagina, nearly to the posterior vulvar commissure, and is known as the pu- dendal sac. With its fellow of the opposite side, when envel- oped with their cutaneous coverings, the two sacs form the labia majora. The pudendal sac contains more or less fatty tissue, and the terminal fibers of the round ligament of the uterus are also lost in it. The sac may be the seat of hydrocele from a patulous canal of Nuck, or a hernia may develop by a descent of a section of gut or omentum through this canal. The in- jection of air into the sac gives a similar appearance to that induced by hernia. The fascia passes around the transverse perineal muscles to form the anterior layer of the triangular ligament. This union forms the ischioperineal ligament — a very firm aponeurotic band attached to the outer ends of the rami of the ischii in front of their tuberosities. The deep fascia, or triangular ligament, has two layers — an anterior, or superficial, and a posterior, or deep. The super- ficial is attached to the rami of the pubes and ischium, and to the so-called transverse hgament of the pelvis, which lies immediately behind the subpubic ligament, from which it is separated by an opening for the dorsal vein of the clitoris. ANATOMY. 169 Behind, it is united with the superficial, as well as with the deep, layer of the pelvic fascia. The deep layer is also attached to the rami of the pubes and ischium, and joins the obturator fascia covering the lower portion of the anterior surface of the levator ani muscle. In front it is continuous with the vesicorectal fascia; and behind, with the dense anal fascia which covers the under surface of the levator ani muscle. The junction of the three layers of fascia behind forms the ischioperineal ligament, which marks the boundary -line be- tween the urogenital and anal regions. The upper surface of the levator ani muscle is covered by a fascia called the pelvic, which is a continuation of the iliac. The pelvic fascia is attached to the iliac portion of the ilio- pectineal line and to an oblique line upon the posterior surface of the pubic bone, from above and within the obturator foramen, to just below the symphysis. It covers the inner surfaces of the ilium and ischium about halfway down the pelvic wall, until it reaches the so-called tendinous arch, which extends from the spine of the ischium to the pubic bone and below the obturator canal. This portion covers the obturator muscle, and is known as the obturator fascia. A thinner prolongation extends back- ward, and is known as the pyriform fascia. The pelvic fascia splits into two layers at the tendinous arch — an upper, called the vesicorectal fascia, which extends over the levator ani muscle, and a lower layer, which follows the obturator internus muscle to the inner edge of the ischio- pubic branches, and retains the name of • obturator fascia. Below the insertion of the levator ani muscle is given off an investment, which is called the anal fascia. In conjunction with the portion of obturator fascia below the tendinous arch it serves as a lining for the ischiorectal fossa. The vesicorectal fascia, from its insertion upon the pelvic wall, passes inward and downward and covers the upper sur- face of the levator ani to the base of the bladder, the vagina, and the rectum. In front, near the middle line, a thicker part of this fascia forms the anterior true ligaments of the bladder, or pubovesical ligaments. A ligament of the rectum arises from the ischial spine and is attached to the side of the rectum. It presents a double layer of fascia with intervening loose connective tissue, and permits a sliding movement of one part over another. A study of the relations of the pelvic structures to the la3^ers of the fascia results in the following, according to Hart and Barbour : 170 GYNECOLOGY. r Superficial hemorrhoidal vessels and Between the skin and superficial fascia : ^ nerves. ( Superficial perineal artery and nerve. Trans versus perinei. Bulbocavemosus. Erector clitoridis. Between the deep layer of the super- i Transverse perineal blood-vessels and ficial fascia and the anterior layer / nerves, of the triangular ligament: ) Venous plexuses. Bulbs of the vagina. Pudendal sacs. Dorsal artery and vein of clitoris. C Compressor urethrae. Between the layers of the triangular ) Vagina, in part, ligament: j Urethra, in part. V- Pudic vessels and nerves. 262. Pelvic Diaphragm. — The structures already described as the soft parts, consisting of the pelvic fascia and the muscular structures, constitute the pelvic diaphragm, of which the most important structure is the levator ani. (Fig. 120.) The origin and insertion of this muscle have been given. It is generally described as two muscles, the levator ani and the coccygeus, but as there is practically no separation, this* seems an unnecessary distinction. Savage divides it into three, the pubococcygeus, the obturator coccygeus, and the ischiococcygeus, but this division seems inappropriate when we recognize the fact that none of the muscular fibers arising from the pubes reach the coccyx. The anterior portion of the muscle is covered by the muscles and structures of the external genitalia. The posterior portion is enveloped with the fascia and covered with the following additional layers: the skin; the adipose tissue filling up the ischiorectal fossa, and known as the ischiorectal fat. The boundaries of this irregular triangular space are the levator ani, covered by the anal fascia on the inner side, and the obturator internus muscle, covered by the obturator fascia on the outer side. The lower surface is bounded by the anterior edge of the gluteus maximus muscle and the greater sacrosciatic ligament behind, the trans- versus perinaei muscle in front, and the sphincter ani upon the inner side. The apex of the triangle is at the spine of the isch- ium. Behind, the two fossa communicate by the loose adipose tissue back of the rectum, and also by the pelvic fascia. In front, the fossa is limited by the line of junction' of the super- ficial and the deep fasciae. The posterior fibers of the levator ani pass behind the rectum and are continuous with those of the opposite side. Other fibers are attached to the tip and side of the coccyx. Action. — The pelvic diaphragm strengthens the pelvic floor, and, in association with its two enveloping layers of fascia, ANATOAIY. 171 forms a strong support for the uterus and bladder. Obser- vation of the movements of the floor, with the employment of Sims' speculum, reveals a rhythmic movement synchronous with respiration. The anterior pelvic segment goes down- ward and backward during inspiration and upward and for- ward with expiration. The muscle serves to raise up the rectum during defecation and draws the anus toward the symphysis. Fig. 1 20. — The Under Surface of the Levator Ani Muscle. — (Deaver.) The fibers between the rectum and vagina influence the size of the vaginal orifice. 263. Perforations (Fig. 121). — The pelvic floor is perforated by three slit-like openings, two of which, the vagina and ure- thra, have axes parallel with the conjugate diameter of the brim. The rectum for a part of its course is similar, but turns backward at the lower part, where it is separated from the vagina by the perineal body. The axis of the anus is at right angles with the plane of the brim. Transverse section of the pelvis through the middle and lower third of the vagina shows it folded in the shape of a letter H, with a short lateral and 172 GYNECOLOGY. a long transverse bar. The urethra presents a transverse slit, and the rectum an anteroposterior fold. 264. Internal Genitalia. — The internal genitalia are: The vagina, the uterus, the Fallopian tubes, the ovaries, and the parovarium. 265. The vagina is a musculomembranous canal, lying be- tween the bladder and the rectum, and extending from the vulva to the uterus. It is fbced below by its attachments to the pelvic floor, and above surrounds the cervix, with which it is continuous. The direction of the vagina varies with the position and the condition of the adjoining organs — the bladder Fig. 121. — The Upper Surface of the Levator Ani Muscle. — (Deaver.) and the rectum. In the erect position it forms an angle of about 60 degrees with the horizon, and is parallel with the conjugate diameter of the brim of the pelvis. (Fig. 122.) Its walls are irregularly triangular, with the widest point at the upper part, where the uterus enters, which in the nullipara measures 3 or 4 cm. ; in multiparse, 6 or 7 cm. The anterior wall is the shorter, 5 cm. long, while the posterior is 7.5 cm. In the normal condition and with the bladder empty, the cervix enters the vagina at a right angle. This angle is rendered more obtuse by distention of the bladder or by an accumulation of feces within the rectum. The vagina is attached to the cervix about 1.5 cm. from the external os, and forms with ANATO:\IY. 173 the cervix a sulcus front and back. The former is known as the anterior, and the latter as the posterior, vaginal fornix. The anterior and posterior vaginal walls lie in contact, and, Fig. 122. — A Mesial Section; the Body Erect. — (Deaver.) Upon mesial section, present a slit with a slightly convex line directed anteriorly. Transverse section is represented by an H-shaped slit, the lateral arms of which are convex upon their inner aspect, with the horizontal limb bending shghtly anterior. 174 GYNECOLOGY. The vagina in multiparse is capable of wide distention, and is of quite variable shape. The anterior vaginal wall is united with the posterior surface of the bladder by loose connective tissue, which permits its dissection, though separation rarely occurs. The urethra is more intimately associated with this wall; however, it presents no difficulty in dissection. ANATOMY. 175 The mucous membrane of the anterior wall is thrown into numerous folds or projections, called the rugae, which are more marked toward the vulva and decrease in size as the upper end of the canal is approached. There are also temporary foldings, which disappear as the vagina is distended. The rugse consist of a series of transverse ridges, which extend Fig. 124. — Arteries and Nerves of the Female Perineum. — (Savage.) Internal pudic. 2, 3. Inferior hemorrhoidal. 4. Transverse perineal. 5. Superficial perineal or vulvar. 7. Profunda branch to the clitoris. 8. Artery of the bulb. 9. Dorsal artery to the clitoris. 10. Inferior hemorrhoidal nerve to sphincter and lower rectum. 11. Posterior super- ficial. 12. Posterior muscular. 13. Trunk of the nerve. 14. Anterior superficial branches to the vulva. 15. Anastomotic. 16. Pudendal branch of (17) the smaller sciatic. 18, 18. Continuation of pudic ending in nervous sheath for the clitoris. 19. Outer terminal branch of the ilio-inguinal nerve. A. Anus. M. Urinary meatus. C. Clitoris. L. Greater sacro- sciatic ligament. V. Vagina. O. Coccyx. A. Gluteus maximus. b. Superficial sphincter, c. Anterior edge of ischiococcygeus. d. Superficial transverse muscle. e. Bulbocavemosus muscle. /. Slip of anterior aponeurosis of perineal septum, g. Upper portion of erector clitoridis muscle, y. Adductor magnus, k. Gracilis muscle. T. Nerve-fibrils to integument. obliquely upward and outward from the longitudinal stem, known as the anterior column. The transverse projections are composed of secondary ridges, covered with papillae . The anterior column generally begins behind the meatus, and disappears in the upper third of the vagina; occasionally, its lower portion is divided into two 176 GYNECOLOGY. parts by a longitudinal groove, the opposite halves of which subsequently unite. The rugae are especially marked in young children and virgins, and largely disappear in the multipara. The posterior wall also presents a column with transverse rugae, but less marked than upon the anterior. The upper part of the vagina presents, when distended, a dome-like appearance, in which the posterior fornix is twice the depth of the anterior, owing to the higher attachment upon the cervix. The lateral fornices have no especial depth, and only connect the anterior and posterior. As the patient advances in years the vaginal walls atrophy and the rugae gradually disappear. The wall of the vagina consists of three layers : tissue layer ; muscular fiber ; and an inner, of mucous membrane. The exterior layer binds the uterus to the surrounding structures and supports the plexus of vessels and lymphatics. The muscle structure con- sists of longitudinal and circular fibers, intricately interlaced. A bundle of striated muscle-fibers is described by Luschka as surrounding the lower end of the vagina as well as the urethral orifice, which he calls the sphincter 2 — an external connective- a middle, of unstriped The mucous membrane, which ex- tends from the free edge of the hymen to the cervix, over which it is reflected to the external os, varies in thickness from I to I J mm. It is of a rosy-red color, but may vary from a light pink to a dark-purple or slate color. The latter color is especially characteristic of pregnancy. The mucous membrane is closely attached to the subjacent muscular layer, and is thrown into the already mentioned rugas. The surface is covered with numerous papillae, which are greatly increased in size by pregnancy. The mucous surfaces are covered with an acid mucus, which is also markedly increased during pregnancy. The thickness of the vaginal wall is greater below, where it is about one centimeter, while at the upper part it is not over u Fig. 125. — Anterior Wall of Vagina, Showing Columnae Rugarum. — (Byford, after Savage.) I, 2. Anterior columns of the vagina, U. Ure- thral orifice. M. Cer- vix. ANATOMY. 177 five millimeters. The difference in thickness is due to the varia- tion in the muscular wall. A microscopic section of the vaginal wall presents an ex- ternal layer of fibrous tissue, enveloping large veins, which belong to the A^aginal venous plexus. These are surrounded by bundles of smooth muscle-fibers suggestive of erectile structure. Accom- panying the veins are large lymphatics, some of which are^ dis- ''&''-"• ^ iVi. i/ 'C -^1 '■■■ '■■■ ^^_JS^>' ' ' V(L b 1, )^V ^^ ^ ' ~-^ :3: ^ _ C I -^1 ' ' , ^M, Fig. 126. — Horizontal Section of the Vagina and Urethra of an Infant. a, a. Skene's glands. 6, 6, h, h. Urethral glands; the analog of Littre's glands in the male. tended to form sinuses. A middle or muscular layer is also present, in which the outer fibers seem divided transversely, the inner ones being longitudinal. The mucous membrane consists of a firm basement mem- brane in which are numerous elastic fibers. It is covered by several^ layers of stratified pavement epithelium. (Fig. 126."^) In addition to the large folds into which the mucosa is thrown, 12 178 . GYNECOLOGY. it forms secondary elevations, or papillae, in each of which is a capillary loop. These loops are single near the fornix, but present a more complicated network near the introitus. The rugce consist of large venous plexuses surrounded by bundles of muscle-fibers, as in cavernous tissue. The lymphatics are abundantly supplied to the mucosa. Lauenstein has described lymph-follicles similar to those in the intestine. The existence of mucous follicles or glands in the vagina is denied; the mucus is believed to be an exudation from the vaginal surface. The nerves ramify throughout the walls, communicate with one another and with the ganglia, and terminate in end- bulbs beneath the epithelium. 266. The uterus, or womb, is a hollow, thick-walled, mus- cular organ, of a truncated shape, which occupies the upper part of the cavity of the pelvis and projects by a portion of its cervix into the vagina. It is situated between the bladder in front and the rectum behind. The fundus is usually just below the level of the plane of the brim of the pelvis, and about two centimeters in front of the sacrum. The position of the uterus is dependent upon the condition of the surrounding organs. When the bladder is empty and the rectum undis- tended, the uterus is slightly anteflexed, and occupies a posi- tion at a right angle to the axis of the vagina. The fundus is directed forward and upward, and the cervix downward and backward, toward the rectum. A distended bladder raises the fundus and decreases the uterovaginal angle. A similar change of position is induced by rectal accumulations which push the cervix forward. It necessarily is difficult then to determine between a physiologic and a pathologic position. We may call any position abnormal in which the organ becomes fixed and its range of mobility lessened. The uterus presents, from above, a pear-shaped appearance, slightly flattened from before backw^ard, and the posterior surface is the more convex. The length of the virgin uterus is from 5 to 7.5 cm.; its breadth at the orifices of the Fallopian tubes, 5 cm. ; and its walls are about i cm. thick. The weight of the nonimpreg- nated uterus is from about 300 grains to i-J ounces. The organ is divided into two portions — the body and the cervix. The body, pyriform in shape, about 4 cm. long, is surmounted, above a line drawn through the orifices of the Fallopian tubes, by a rounded portion — the fundus. The cervix, oCylindric in form, is about 3 cm. long and terminates below in the vaginal portion. Schroder divides the cervix into three parts — the ANATOMY. 179 upper and lower, called the supravaginal and infravaginal por- tions, which are separated by an intermediate portion — a division which is of significance in the study of uterine dis- placements. The attachment of the vagina to the uterus is much higher behind. When the patient occupies the dorsal position, with the limbs well drawn up, the vagino-uterine junction is upon a 'plane vertical to the horizon. The infravaginal portion of Fig. 127. — Median Section of Uterus from Side to Side through the Fallopian Tubes. Mode of Junction of Vagina and Uterus. — (Savage.) a. Uterine cavity, b. Cervical canal, showing folding of its mucous membrane. d. Internal uterine (mucous) coat. c. Os externum uteri, e. Uterine aperture to Fallopian tube. f. Fallopian tube near uterus, g. Round ligament. V. Vagina. the cervix is especially interesting to the gynecologist, as it is the only part of the uterus which is visible upon inspection, and fully accessible to palpation. It varies extremely in size and shape, according to the age and sexual relations of the individual. In the virgin it presents a conoid projection, nearly one centimeter long, with an opening in its apex, known as the external os, or os tinc^. The os is a transverse sht, about two or three millimeters lon^:, and it divides the cervix ISO GYNECOLOGY. into an anterior and a posterior lip. The anterior lip is the longer. With the adA^ent of sexual activity the cervix changes. In the nulliparous married woman it becomes softer and larger, the conoid shape is less marked, and the os stands more widely open. In the multipara, even when lacerations have not oc- curred, the cervix is large and soft, and the os presents a trans- verse slit — more frequently an irregular opening. Inflam- matory lesions cause the cervix to become still larger, with e version of the mucous membrane, erosion of the surface, en- largement of the papilla, and an irregular opening. With the cessation of menstruation, and especially in women who have borne a large number of children, the vaginal cervix disappears and the os is flush with the fornix of the vagina. The junction of the triangular body and conoid cervix is called the isthmus. The anterior surface is flattened; the posterior, quite convex. The upper border of the uterus is rounded, and forms the fundus. The lateral uterine borders are obscured by the folds of the peritoneum, known as the broad ligaments. The upper part of each ligament is occupied by the Fallopian tube; below^ this, the round ligament; and still lower, the ovarian ligament. The arteries, veins, and lymphatics of the pelvis pass through the broad ligament. The uterine canal in the virgin (Fig. 128) is about five centi- meters long; slightly longer in the multipara. The cavity of the cervix is cylindric, wider in the center and narrower at each end, with the external os below and the internal os above. The cavity of the body is triangular from side to side, but the anterior and posterior surfaces lie in contact. At the apex of each angle of the triangle is found an opening, on each side the orifices of the Fallopian tubes, and below the internal os. The uterine wall has a thickness of a little more than one centimeter. The uterus has three layers — an external (serous) , a median (muscular), and an internal (mucous membrane). The serous or peritoneal covering is not complete, and, there- fore, will be considered with the peritoneum. The muscle-fibers are best studied in the pregnant uterus, and may be divided into three layers. The external is most distinct, and consists of a fine, thin layer over the anterior and posterior surfaces, from which prolongations are sent off into the broad ligament. The posterior fibers form the ovarian ligament, and the anterior the round ligament. Some of the fibers also furnish the longitudinal muscular structure of the Fallopian tube. These fibers are wanting upon the sides^of ANATOMY. 181 the uterus. The middle layer is by far the thickest, and con- sists of interlacing fibers, transverse and longitudinal, which are continuous with those of the vagina. This la^^er com- prises the principal part of the wall, and contains the blood- vessels. The latter are embedded in a network of fibers, and may be recognized with the naked eye upon cross-section. Their intimate relation to the muscle and tissue is recognized by their remaining open when divided transversely. The inner layer consists of circular fibers, which are most s^kW^'^ rv marked at the internal and "^mwW^f^J: external os, where thev form c'"^ '^ .■•/..-... -.^^ Fig. 128. — Virgin Uterus, Median Section. — {Byford, after Sappey.) I. Anterior surface. 2. Vesico-uter- inepouch. 3, 3, 4, 5, 6. Posterior surface. 7. Cavity of corpus. 8. Cavity of cervix. 9. Os in- temvim. 10, 11. Vaginal por- tion of cervix. 12, 12. Vagina. Fig. 129. — Mucous Membrane of Uterine Body Showing Folli- cles. — {Mann.) d, d, d. Simple or double culdesac of these follicles, a, a, a. Thin cup-shaped orifice upon the mu- cous membrane. a sort of Sphincter, and at the cornu of the uterus, from which they are extended into the Fallopian tubes. The connective tissue of the uterus is thickly interspersed between the muscle-fibers, and especially along the course of the vessels. The mucous membrane of the uterine cavity rests directly upon the muscle layer without any intervening submucosa, and its glandular structure projects between the muscle-fibers. In the cervical cavity, where the mucosa is thrown into folds, a distinct areolar layer intervenes between it and the muscular wall. The uterine mucosa is one milli- 182 GYNECOLOGY. meter in thickness at the fundus, but becomes thicker near the center of the cavity. It is smooth and velvety, of a grayish-red color, and presents no folds, unless in the imme- diate vicinity of the tubal opening, and there but a slight folding. Under a glass can be seen numerous small depressions or openings — the orifices of the glands. The free surface of the mucosa is covered with a single layer of columnar epithelial cells, V5V:f'^:>^:./.^^<.,;;: -;?^/^? •■^. "rj^i'kW 4^V^y l^Vr'M^^ Fig. 130, — Section of Normal Endometrium. Note two glands to right some- what enlarged. a, a. Glands penetrating muscular substance. which are supplied with cilia. The mucosa is filled with glands of the tubular variety, which penetrate its entire thickness, and frequently their external extremities are embedded in the muscular layer. (See Fig. 129.) The direction of these tubules is more or less oblique. They often exist as sinuous or spiral single tubes, but more frequently divide into two or more ANATOMY. 183 branches near their lower ends. Upon longitudinal section they exhibit a basement membrane lined by a single layer of prismatic ciliated cells with single large nuclei situated near their bases. (See Fig. 130.) These glands largely increase with the approach of puberty, and become elongated during menstruation, and especially in pregnancy. The mucosa is supplied with large plexuses of capillaries and lymphatics. The latter, in the form of lymph-spaces, are directly connected with the lymph-sinuses and vessels of the deeper layer. The termination of the nerve-filaments in the mucosa has not been determined, but the action of the glands indicates their reception of nerve-filaments, as in similar structures of other parts of the body. The cervical mucosa, thicker than that of the body, is thrown into several folds, known as the arbor vitas, or plicae palmate, and is separated by a submucosa from the muscular wall. This arrangement of the mucosa ends sharply at the internal os, and is best observed in the virgin cervix. The mucosa differs from the lymphoid structure of the body in hvaing a firm, fibrous basement membrane, sur- mounted by cylindric epithelial cells. These cells, according to De Sinety, are ciliated only upon the summit of the ridges, while the epithelium covering the intervening surfaces is nonciliated. The glands are of the racemose variety, consisting of branching ducts. They are lined with nonciliated cuboid epithelium, resting upon a struc- tureless basement membrane. They open upon the free surface^ upon and between the folds, and secrete a clear, viscid, alkaline mucus. The ovula Nabothi are those glands of Naboth which have formed small cysts after occlusion of their ducts. The structure of the cervical wall differs from that of the body in the increase of fibrous tissue, which is intimately inter- woven with the muscle-fiber, and in the lessened supply of blood- vessels. The external os presents a sharp line of demarcation separating the one-layered cylinder epithelium of the cavity from the multiple- layered pavement epithelium of the vaginal portion. Fii i3f' Virgin Os and Cervix. — {Sappey.) 184 GYNECOLOGY. 267. The Fallopian tubes, or oviducts, are two tortuous canals which arise from each side of the fundus uteri. They vary- in size and length, occupy the upper margin of the broad liga- ment, and extend outward almost to the pelvic brim. The length of the tube is from 7.5 cm. to 12.5 cm., the right tube usually being the longer. They are first directed outward, then backward, and finally inward, giving the appearance of a shepherd's crook. The tube presents for our study: i, in the uterine cavity a narrow, funnel-like opening, the ostium uterini tubag; 2, the section of the canal found in the uterus, pars uterini; 3, the narrow portion proximal to the uterus, the isthmus tubae; 4, a wider, longer, more tortuous portion, the ampulla tubae, which ter- minates in, 5, a distinct trumpet-shaped end, the infundibular tubag, provided with numerous fimbriae, and, 6, a distinct open- ing from the ampulla, the ostium abdominale tubag. The line of differentiation between the pars uterini, isthmus, and am- pulla is not sharply defined. The isthmus is the narrowest portion and is about two centimeters long. The diameter of the isthmus is about two millimeters, and its lumen will scarcely admit a bristle. The ampulla is the more widened part; it extends outward and backv\'ard, has an external di- ameter of from six to eight millimeters, and its lumen a diameter of two or three millimeters. The fimbriated extremity — also called the pavillion, or in- fundibulum, from its funnel shape, and the morsus diaboli (devil's mouth) — is a trumpet-shaped opening, surrounded by primary and secondary fimbriae, which resemble the tentacles of the sea anemone. The primary fimbriae are the larger proc- esses, four or five in number, from which arise the eight or ten secondary processes. The longest fimbria (fimbria ovarica) anchors the tube to the ovary and has a furrowed groove, which facilitates the passage of the ovum to the tubal orifice. The broad ligament is continued to the lateral wall of the pelvis by a small fibrous band, known as the infundibulopelvic ligament. The tube, upon repeated section, will be found to have varying dimensions, and frequently its course is tortuous — almost convoluted. It has two openings — the uterine and the abdominal. The latter is more distensible than the remain- ing portion of the tube, is somewhat trumpet-shaped, and affords a communication with the peritoneal cavity. The tube consists of four coats or layers: the external, a serous, which is separated from the muscular by a subserous coat, the tunica adventitia; next a muscular; and lastly the internal — ^the mucous membrane. ANATOMY. 185 The external serous covering is incomplete, that portion of the tube toward the broad ligament being incomplete for the inner two -thirds of the tube. The remaining third is sur- rounded by the peritoneum, which covers the external surface of the fimbrise, while the internal is lined by the mucosa. The tunica adventitia envelops the muscular layer, allowing the peritoneal to slip over its abdominal end. The muscular coat consists of longitudinal and circular fibers. The former is continuous with the outer; the latter, however, is predominant and the continuation of the inner muscular layer of the uterus. The muscular structure is more largely developed at the prox- imal than at the distal end of the tube, and the circular fibers Fig. 132. — Section of Fallopian Tube through the Isthmus. a, a, Shows the firm and compact structure of the longitudinal folds in this portion of the tube. are particularly well marked at the isthmus, where they form what is called the sphincter tubas. The tubal mucosa is quite thick, thrown into longitudinal folds, very vascular, and of a bright red color. In the isthmus the mucosa presents simple folds, which become more complex in the ampulla. Hennig has counted from three to five primary folds, which have be- tween eight and ten smaller plicae between each pair of the former. The secondary folds are less marked near the abdom- inal extremity, where the longitudinal folding is apparent to the naked eye. The mucosa has a single layer of ciliated columnar epithe- lium upon two or three layers of supporting cells, which are 186 GYNECOLOGY. round or pyriform. The cells abruptly terminate at the ends of the fimbriae, where the margin between the columnar and pavement epithelium is distinctly marked. The tubal mucosa, like the uterine, has no distinct submucous layer, but unlike the latter, it is without glands, and is covered with a thin layer of grayish mucus of a distinctly alkaline reaction. 268. Ovaries. — The ovaries, the germ-bearing organs of the woman, and the analogues of the male testicle, are a pair of small bodies, situated one upon the posterior surface of each broad ligament, below the tube and at each side of the uterus. The ovaries occupy a position at the level of the brim of the pelvis, or partly below and partly above its plane. Fig. 133- — Section of the Fallopian Tube through the Ampulla near the Isth- mus, Showing Extensive Folding of the Mucous Membrane. The axes of the ovaries lie obliquely to the pelvis, with a slight inclination forward. In the erect position they rest upon the posterior surface of the broad ligament. The Fallopian tube is situated in the broad ligament above the ovary and partly encircles it, while the round ligament is in front and occupies the anterior fold of the broad ligament. In front of the ovary, between it and the tube, is the parovarian structure, or the organ of Rosenmiiller. The inner or uterine extremity of the ovary is connected with the uterus by some muscle-fibers, about three centimeters long, known as the ovarian ligament; the outer or tubal extremity is connected, ANATOMY. 187 above, with the end of the tube through the fimbrias ovarica, and below, with the infundibulopelvic Hgament. The ovary presents a flattened, ovoid appearance, with its broad end directed externally and the pointed end toward the uterus. The anterior, straight or flattened surface of the ovary is flxed by a short serous duplication, the mesovarium, to the posterior surface of the broad ligament. The posterior convex margin is free. Its size varies with the age of the in- dividual, the functional activity of the organ, and the occurrence of menstruation or pregnancy. The ovary attains its greatest size about six weeks after parturition (Hennig), and never reaches its former size in the subsequent involution. Following the menopause, it shrinks to one-half or one- third of its dimensions during active sexual life. Luschka gives its dimensions as: length, 4 cm.; width, 2.2 cm.; thickness, 1.3 cm. It weighs from 60 to 135 grains. The color of the ovary is a pinkish-gray, becoming some- what darkened as menstruation approaches. Immediately after ovulation a dark swelling follows, due to the accumulation of blood. As absorption progresses the color changes and the mass becomes yellow, and later presents only a whitish cicatrix. Before puberty the ovary is smooth, but subse- quently it becomes irregular, from the cicatrices following repeated rupture of cysts, or nodular, from the presence of matured follicles that have failed to rupture. Following the menopause, the ovary becomes a pearly- white, irregular, almost cartilaginous mass, about one-half or one-third its former size. The ovary is situated upon the posterior surface of the broad ligament, with its pointed end connected with the uterus by the ovarian ligament. The ovary, by its pointed end, is directed toward the ligament, and its stroma extends inward upon the latter, while the external ovarian end is blunt and large. The posterior surface of the ovary projects through the peritoneum and is uncovered by it. The tmion of the columnar epithelium of the ovarian surface with the pavement epithelium is readily recognized as a white line, and is called the white line of Farre. Sections of the healthy ovary show two kinds of tissue, a. central or medullary and a cortical or peripheral portion. The latter covers the entire surface of the ovary bounded by the line of Farre, but projects to its greatest depth (two to three millimeters) at the central portion of the convex surface. The central structure has a pinkish-gray or rosy color, is of soft consistence, and has a moist, glistening appearance. It is of a white or grayish-white color, more or less firm in con- sistency, and contains numerous small vesicles. The smaller 188 GYNECOLOGY. vesicles are situated near the surface, while larger cysts are situated deeper. Some of these reach the size of a pea, and may project more or less beyond the free surface. The sac- wall is frequently so thin that the vesicles rupture under the slightest pressure. This layer also contains numerous depres- sions or scars, the result of repeated ovulation. The cortical layer of the ovar}-, or that part which projects through the peritoneum, is covered by a single layer of short, Fig. 134, — Section of Ovary, Showing Graafian Follicles. — (Wyder.) columnar epithelium, called by Waldeyer the germinal epithe- lium. This terminates abruptly at the white line, where the pavement epithelium of the peritoneum begins. Before puberty young ova are represented by large spheroid cells, with marked nuclei, which form in the columnar cells. Ingrowths of the germ epithelium into the underlying stroma are occasionally seen, which form the ovarial tubes of Pfliiger. Immediately beneath the epithelial layer, and quite insepa- rable from the underlying stroma, is the tunica albuginea — a ANATOMY. 189 thin, dense layer of fibrous tissue, which contains a few smooth muscle-fibers. It is not completely developed until the third year, and undergoes changes Avith age and inflammation until it becomes thickened and of almost cartilaginous hardness, which renders its rupture exceedingly difficult. Such alterations from inflammatory changes are a cause of the formation of retention cysts, and of the development of that condition known as cystic disease of the ovaries. The structure of the ovary, as already noted, is divided into a cortical and a medullary portion, although they differ but little in structure except that the latter is softer and more vascular. In the cortical layer lie the Graafian follicles, embedded in connective tissue inter- spersed with some muscle-fibers. A large number of these follicles, variously estimated at from 36,000 to 400,000, are found in each ovary. Whether so large a number exists is difficult to determine, but it remains evident that nature has amply provided for the reproductive function. The ovarian stroma is the framework or bed in which the follicles rest and are nourished. Each Graafian follicle has a wall, which consists of a tunica fibrosa of thin fibrous tissue, within which is a more delicate membrane, called the tunica propria; the latter contains many granular cells and a fine network of capillary vessels. This tunica propria is lined with several layers of epithelial cells, called the membrana granulosa. These cells are separated from the tunica propria by a struc- tureless membrane. These epithelial cells form a thickened mass upon one side, which projects into the cavity — ^the discus proligerus. The cavity of the follicle is filled with a clear, serous fluid, called the liquor folliculi. It is formed by lique- faction of the cells of the membrana granulosa. The Graafian follicle, when mature, is one millimeter in diameter. Embedded in the discus proligerus is found the ovum, which has been called the typical cell; it measures from 0.2 to 0.3 mm. It is a yellow, spheroid body, enveloped by a thin, delicate membrane, — the vitelline membrane, or zona pellucida, — doubtless formed from the innermost cells of the discus proligerus. Within this membrane is contained the vitellus, a network of granular, fibrillated protoplasm containing numerous fat-globules. In the outer portion of this network is a light spot, which consists of fine, fibrillated protoplasm, which contains in its meshes a granular material inclosed in a distinct membrane. This structure is known as the nucleus, or germinal vesicle. AVithin this is contained a small, highly refracting, granular body, known as the nucleolus, or germinal spot. The Graafian follicle is surrounded by a vascular network; 190 GYNECOLOGY. as it matures, the liquor foUiculi increases, the cyst becomes tense, approaches the surface, and the tunica albuginea be- comes thinned and finally ruptures, permitting the ovum to escape. The cavity of the follicle fills with blood, which coag- ulates and forms a clot. Later, this clot presents an external yellowish color, while its center is of a reddish- gray hue. The clot gradually becomes or- ganized, contracts (by which it is thrown into folds), and is gradually absorbed. The clot thus formed is known as the corpus luteum. The ovary of a normally menstruating woman will be found to contain a number of corpora lutea in various stages of retro- gression. The structure generally disappears by the end' of the twelfth week, excepting a small cicatrix, which remains. When pregnancy oc- curs, the corpora lutea do not continue to form, but the one corresponding to the last menstruation be- comes much larger and remains longer. It con- tinues to increase, and after the first month forms a large yellow clot, which gradually be- comes decolorized and more highly organized, resulting in a white, fibrinous clot surrounded by a yellow ring. The corpus luteum of pregnancy is known as the corpus luteum verum, while those which occur with ordi- nary ovulation are called corpora lutea spuria. Later in the pregnancy, the time of which is not exactly known, it becomes contracted, and at its termination forms a mass about 0.5 cm. in diameter. Fig. 135. — Large Corpus Luteum in Associa- tion with an Ovarian Dermoid. Re- moved from an Unmarried Woman Who Had Never Been Pregnant. — (Sutton.) • I. Twisted pedicle. 2. Corpus luteum. 3. Old clot. 4. Integumentary surface of dermoid. ANATOMY. 191 When the corpus luteum has lost its color and most of its blood-vessels, and is mainly composed of a n;iass of fibrous tissue, it is called a corpus albicans. Frequently, from the retention of pigment, it is dark in color, and is known as a corpus nigricans. Clark has shown that the corpus luteum finally disappears by the process of hyahne degeneration. Extravasations of blood, or apoplexy of the ovary, we shall see later, are not infrequent, and occasionally may result in the complete destruction of the organ and the formation of a blood-sac — an ovarian hematoma. 269. The Parovarium. — Between the outer end of the tube and the ovary is situated a triangular group of small tubules, known as the parovarium, or the organ of Rosenmiiller — a remnant of the Wolffian body. The structure corresponds to the epididymis in the male. The apex of the triangle is directed toward the ovary. This organ is of especial importance to the gynecologist, as it can be the seat of a number of growths. It consists of from six to thirty spiral tubules, which at their base open into a single transverse tube. This transverse tubule corresponds to the canal of Gartner in the lower animal. Cysts are frequently found associated with the tubules; the most common is the hydatid of Morgagni, or appendix vesiculosa, the pedicle of which arises in a point of the mesosalpinx, near the fimbria ovarica. The occurrence of this cyst is the rule rather than the exception, and it consists of a tough, connective-tissue wall with a well-developed vascular system, and is lined with pavement epithelium. It has a pedicle one-third centimeter long and contains clear fluid. The parovarium is entirely a rudimentary structure and has no function. 270. Urinary Organs and Rectum. — Our knowledge of the relations of the pelvic organs will be incomplete without a study of the analogy of the urethra, bladder, and ureters, as well as of the rectum and anus. 271. The urethra is a canal, from 2.5 cm. to 4 cm. long, which forms the outlet to the bladder. It lies embedded in the anterior vaginal wall, from which it can readily be separated. It is slightly curved upward, with its concavity forward. Upon cross-section the urethra presents a transverse slit near its vesical end and a stellate folding toward the external meatus. The diameter of the urethra is 0.6 cm., and it is quite distensible. When not distended, the urethral mucous membrane is more or less corrugated throughout its length, owing to the sphincter- like action of the surrounding muscle-fibers. The urethra is attached to the pubic arch by the pubovesical ligament, and penetrates the triangular ligament, between the layers 192 GYNECOLOGY. of which it is surrounded by the fibers of the compressor ure- thras, or muscle of Guthrie. It is also, together with the vagina, influenced at its lower end by the bulbocavernosu^ muscle. Its external opening is known as the external meatus, and close inspection of its orifice will reveal a number of small openings about it — the orifices of the glandulae vestibulares minores. Within the meatus are two small openings — the orifices of the tubules, described by Skene. They correspond to the lacuna magna in the fossa navicularis of the penis. They are described by Skene as tubules which extend for a distance of nearly one centimeter parallel with the urethra. As a result of inflammation they can be so dilated that they will admit a No. i probe, and even the point of a catheter. The urethra is nearly parallel with the bladder, but when the woman is erect, it is nearly vertical. The urethral mucous membrane, like that of the vestibule, is of the pavement variety. The glands are lined at their mouths with pavement epithelium, which soon changes into the columnar variety. 272. The bladder is situated in the anterior part of the pelvis, between the symphysis pubis in front and the vagina and uterus behind. Its shape is constantly changing with the accumulation and evacuation of the urine. When empty, the urethra forms the stem of a Y, the anterior limb of which is the longer. Between the urethra, the anterior surface of the bladder, and the symphysis is a triangular space filled with the retropubic fat. The bladder, when moderately distended, becomes rounded; and when full, oval. The female bladder holds less than that of the male, and dift'ers from it also in having the transverse diameter longer than the vertical. The bladder is divided into three portions: the body, the base, or fundus, and the neck. Skene defines the first as that portion which lies above a plane formed by the ureteric openings and the center of the symphysis pubis. The portion below is the fundus, or base, which includes the trigone, or space between the orifices of the ureters and internal meatus, and the bas fond, the space immediately behind the ureters. The thickened surface about the urethral orifice is the neck, which is the most dependent portion when the body is erect. The bladder-wall consists mainly of muscular structure. The wall, dependent upon the amount of distention, varies from 0.5 to I cm. The muscular structure consists of lon- gitudinal and circular fibers, the former mostly confined to the anterior and posterior surfaces. They may be traced from the vesical neck and pubes in front, where they are called ANATOMY. the musculi pubovesicales, to the summit, where some fibers accompany the urachus. The circular fibers are more marked near the vesical where they form the sphincter vesica. 193 of the orifice, Fig. 136. — Vesicovaginal Septum and Base of Female Bladder. Anatomic Relations of Ureters at Their Entrance into the Bladder. Contents of Alar Ligament. — (Savage.) I, I. Ureters. 2, 2. Uterine artery. 3, 3. Uterine veins. 4. Dotted line indicating the vaginal end of the uterine cervix. 5. Internal meatus urethrae. 6. Ligamentous process of fascia of pubococcygeus muscle and vesicopubic muscles. 7, 7. Pubococcygeus muscle. U. Uterine body. O. Ovary, utero-ovarian muscular ligament, and grooved Fallopio-ovarian fimbriae. T. Fallopian tube and fimbrias inverted. M. Parovarium. P. Pubic arch. V. Body of bladder. The muscular layer is partly covered externally by the peritoneum, which will be discussed later, and internally by the mucous membrane, with which it is loosely connected by 13 194 GYNECOLOGY. a layer of fibrous and elastic tissue. Because of this loose connection the mucous membrane is thrown into folds when the bladder is empty, except at the trigone, where it is more intimately connected with the submucous layer and is much thinner. The mucous membrane in life presents a rosy pink appear- ance, and is continuous with that lining the urethra and ureters. Its epithelium consists of three or more layers of epithelium resting upon a basement membrane. The superficial cells are squamous, but are smaller than the vaginal. The inferior layer is composed of columnar epithelium with long processes, while the middle one is made up of pyriform cells. The mem- brane is supplied with a rich plexus of fine capillaries and nerve- fibers; the latter are not marked in the trigone. The bladder is but poorly supplied with lymphatics, and they communicate with the glands near the internal iliac artery. 273. The ureters are the urinary ducts through which the urine is carried to the bladder. Their course, previous to crossing the iliac arteries, is nearly parallel. The left ureter lies behind the sigmoid flexure of the colon. In their subse- quent course the ureters extend downward, backward, and outward, along the lateral walls of the pelvis. At the spine of the ischium they bend downward, forward, and inward to the bladder, passing behind the uterine arteries, and about I to 1.5 cm. on each side of the cervix. The distance between the ureters where they enter the bladder is 5 cm. They pass obliquely through the vesical wall and enter the bladder 2 cm. below and external to the cervix, where their orifices are still 4 cm. apart, but united by a prolongation of the longitudinal fibers of the ureter, known as the interureteric ligament. This ligament forms a transverse ridge between the two orifices, and serves as the base of the vesical triangle. 274. The Rectum. — The rectum is the lower extremity of the large intestine, and begins with the termination of the sigmoid flexure, at the level of the third sacral vertebra, to end with the anus. The rectum in its course from the third sacral vertebra is directed downward and forward behind the cervix uteri and vagina, parallel with the latter, until it turns directly backward at the anus. The relation of the rectum to the pelvic structures naturally divides it into two portions, the pelvic and the perineal portion. The pelvic portion begins opposite the third sacral vertebra and ends at the insertion of the levator ani into its wall. The perineal portion lies between the muscle and the anus. The space formed by the deviation of the rectum from the line of the vagina is occupied by the perineal body. The portion of the rectum involved in this deviation, which is about 2.5 cm. long, is known as the anus. ANATOMY. 195 The entire length of the female rectum is twenty centi- meters. The canal is less curved than in the male, and its caliber is greater. The longitudinal muscular bands so characteristic of the colon are absent. The rectum, artificially distended, shows a very large sac, immediately above the anus, which decreases as the sigmoid flexure of the colon is approached. This very ^dilatable portion is called the ampulla, and when empty, the anterior surface lies in contact with the posterior, so that upon transverse section it presents a transverse slit. The anal orifice is quite dilatable. The anus forms an aperture which closes with its lateral surfaces in contact. The orifice is further obstructed by eight or ten longitudinal folds of the mucous membrane. These folds are called the ' ' columns of Morgagni," and the depressions between them, the "sinuses of Morgagni." These corrugations are produced by the con- traction of the sphincter, and disappear when the anus is dis- tended. Above the anus are three ring-like zones which are superimposed over each other. The first is the zone of the rectal columns and the intervening sinuses. The mucous membrane upon the surfaces of the columns is covered with pavement epithelium, while in the depressions cylindrical epithelium similar to that of the bowel above is found. Lie- berkuhn's crypts are seen only in the upper portion of this zone. Its boundary is often recognized as a distinct line, the linea ani rectalis (Hermann). The middle zone has a smooth, bright mucous membrane covered with pavement epithelium and small papilla. The lower zone is the cutaneous zone. This has the horny epithelium well supplied with pigment and also the connective-tissue sublayer characteristic of the skin. We find here papillae, hair, and sebaceous glands, ad- joining the large convoluted glands of the intestine. The submucous layer consists of a structure of quite dense con- nective tissue, in which are situated the blood-vessels, nerves, and lymphatics. Its laxity permits the mucous membrane to glide over it. The mucous membrane of the rectum above the anal canal has three or four large permanent transverse or ob- lique semilunar folds which often project quite a distance into the lumen of the bowel. These folds, according to Gant, are crescent-shaped, capable of some vertical motion, and extend about one-half to two-thirds the circumference of the rectum and project into its lumen from three-fourths of an inch to an inch and a half. They are situated obliquely to the long axes of the bowel. They are slightly cup-shaped with the con- cavities looking upward. With the bowel distended the free margins of these valves are prominent and readily seen through 196 GYNECOLOGY. the proctoscope. They are called Houston's valves.^ ' The number of them is variable; usually there are three. In ex- ceptional cases there may be five, six, or even seven. Their location is fairly constant. The upper valve is situated at the junction of the sigmoid and the rectum on the left rectal wall. The middle, which is the most prominent, occupies the right anterior wall opposite the base of the bladder and is RECTUM URETER (behind PERITONEUM) LOOP OF SMALL INTESTINE VERMIFORM APPENDIX, CECUM (displaced UPWARD) FUNDUS OF UTERUS FIMBRIATED EXTREMITY OF FALLOPIAN TUBE SIGMOID FLEXURE (DISPLACED UPWARD) LOOP OF SMALL INTESTINE TEEP EPIGASTRIC A. OBLrTERATED HYPOGASTRIC A. EXTERNAL ILIAC A. (BEHIND PERITONEUM) APPENDICULO-OVARIAN LIGAMENT ROUND LIGAMENT FALLOPIAN TUBES URACHUS Fig. 137. — Superior View of the Pelvic Cavity. — (JDeaver.) three inches or more above the anus. The lower valve is situated on the left side and a short distance below the middle valve. With the patient in the knee-chest posture and the rectum well inflated one can often see, by the aid of the proctoscope, all these valves at the same time. They generally form a sort of spiral stairway which gives a rotatory motion to the fecal mass as it progresses toward the anus. ANATOMY. 197 The rectal wall is composed of three coats — the peritoneal, the muscular, and the mucous membrane. The arrangement of the serous coat will be considered with the peritoneum, but it should be remembered that a portion only of the rectum is enveloped by peritoneum. The mus- cular layer consists of longitudinal and circular fibers, but the former are more generally distributed, and not collected into bands, as in the colon. The circular fibers are deeply situated, and are more marked just above the anus, where they form a distinct ring, nearly half an inch in width, which is rec- ognized as the internal sphincter. The submucous layer consists of a layer of quite dense connective tissue in which are situated the blood-vessels, nerves, and lymphatics. Its laxity permits the mucous membrane to glide over it. The mucous membrane is continuous with that of the intestine, although much thicker and more movable than that of the colon, and its great vascularity causes it to have a bright pink or even red color. The mucous membrane is lined with columnar epithelium, and contains a large number of Lieberkuhn's follicles, but no villi. The mucous membrane at the anus abruptly changes from the columnar to the pavement epithelium of the skin, which forms the so-called white line. 275. Pelvic Peritoneum. — That portion of the serous lining of the abdominal cavity which is situated within the pelvis, and envelops the pelvic organs, is known as the pelvic perito- neum. Upon examination of a mesial section it will be seen to leave the anterior abdominal wall about three centimeters above the symphysis and be reflected upon the fundus of the bladder. It covers the posterior surface of the bladder to the level of the internal os, and as much of the lateral surface as lies behind the obliterated hypogastric arteries. (Fig. 138.) From the bladder it crosses over to the uterus, the anterior stir- face, fundus, and entire posterior surface of which it invests. (Fig. 139.) Laterally from the anterior surface it extends outward upon a plane perpendicular to the pelvic brim, and is attached to the lateral wall of the cavity, thus forming the anterior fold of the broad ligament. The peritoneal investment posteriorly extends over the uterus and upon the upper part of the vagina, nearly three centimeters below the uterovaginal junction. The lateral prolongation of this portion forms the posterior border of the broad ligament. The broad ligament contains the round ligament in its anterior fold; the Fallopian tube in its superior border, between the anterior and posterior folds; and its continuation from the termination of the tube is known as the infundibulopelvic ligament, the integrity of which is 198 GYNECOLOGY. of importance in maintaining the ovary, and even the uterus^ in position. Resting upon and projecting from the posterior fold, when the patient is erect, is the ovary, which is attached to the uterus by the ovarian Hgament. The anterior and posterior leaflets of the broad ligament are separated, in addition to the structures named, by considerable loose, vascular, con- Fig. 138. — Curved Dotted Line Shows Covering of the Anterior Uterine Wall by Peritoneum. — (Winter.) nective tissue, and afford entrance for the ovarian and uterine arteries and nerves, and egress for the veins and lymphatics, while its base is penetrated by the ureter on its way to reach the bladder. From the vagina the peritoneum is reflected backward, to be attached to the anterior surface of the rectum Fig. 139. — Posterior Surface of Uterus Showing Extent of Peritoneum; also Fallopian Tubes, Ovaries, and Ovarian Ligaments. — (Winter.) and to the tissues in front of the sacrum. Above the promon- tory of the sacrum it is continuous with the posterior abdom- inal peritoneum. The reflection of the peritoneum over the uterus and its extension as the broad ligaments upon each side divide the ANATOMY. 199 pelvis into two culdesacs — the anterior, or vesico-uterine, and the posterior, or uterorectal. The posterior culdesac is further divided by a prolongation of muscular structure from the sides of the uterus backward to the iliosacral synchondrosis, over which the peritoneum is reflected. This forms a deep, cup-shaped cavity directly behind the uterus, which is known as the pouch of Douglas. This pouch dips deeper on the left side, and sometimes extends to the upper border of the perineal body. When the bladder is empty and the nonpregnant uterus lies forward, the coils of small intestine usually occupy this pouch, except at its very lowest point, and intra-abdominal Fig. 140. — Vertical Transverse Section of the Pelvis, Showing Peritoneal Pouches. — {Luschka.) I, I. Levator ani muscle. pressure sometimes causes its dissection downward until a distinct hernia occurs behind the uterus. On either side, ex- ternal to the uterosacral ligaments, is a fossa, which is known as the para-uterine pouch. This has been called by Polk the retro-ovarian shelf. On the side wall of the para-uterine pouch the ureter may be seen beneath the peritoneum. This space is occupied by the small intestine. During pregnancy the para- uterine pouch is lifted up to the pelvic brim, while Douglas' pouch remains unaffected. From before backward, we may find the following pouches or depressions: first, the pubovesical; 200 GYNECOLOGY. second, the vesico-abdominal, which is seen only during dis- tention of the bladder, and varies in depth according to the point at which the serous lining of the abdominal wall is re- flected. The vesico-uterine pouch is bounded in front by the bladder; posteriorly, by the uterus. This pouch varies less than the others, on account of the firm attachment of the perito- neum to the anterior surface of the uterus. In the empty bladder the bottom of this pouch is about three centimeters distant from the anterior culdesac of the vagina, and the pouch rises somewhat as the bladder falls. The study of the female peritoneum renders it evident that it differs from that of the male in not being a closed sac, as it communicates with the uterine mucous membrane through the orifice of the Fallopian tubes, and is again perforated by the ovaries, which project through it. The close relation of the peritoneum to the pelvic viscera renders any change in this structure perilous to the normal situation and relation of these organs. Inflammatory changes result in thickening and cicatrization, which produce temporary, if not permanent, displacements. The fixation of the uterus, compression of the ovaries, and obstruction of the orifices of the Fallopian tubes are necessary sequels of such alterations. The peritoneum, according to Luschka, serves as a sort of diaphragm, dividing the pelvic cavity into two portions : the one above may be called the intraperitoneal space, and that below, the subperitoneal. In the latter is situated the greater part of the pelvic connective tissue. 276. Pelvic Connective Tissue. — The pelvic connective tissue is a loose cellular tissue, which acts as a padding for the support and safety of the pelvic organs. This structure is continuous with that which exists in other portions of the body. It appears in the pelvis in two varieties: first, as a loose tissue, distributed in an irregular manner around and between organs and between the layers of the broad ligaments, where it acts as a support to the blood-vessels and folds of the peritoneum; second, as firm, well-defined laminae or planes entering into the formation of the pelvic floor. These have already been described under the name of pelvic fascia. The connective tissue is continued behind the symphysis as the retropubic fat, and there lies in front of the bladder. Between the base of the bladder and the vagina it is rather firmly connected. On the posterior surface of the vagina there is a very loose layer connecting it with the rectum. A large mass is found on each side of the cervix uteri, forming under the broad ligaments what is known as the parametrium, which is united in front and behind by a much thinner layer. Over the body of the uterus the connective tissue is very slight and con- tains no fat. The rectum and vagina are embedded in consider- ANATOMY. 201 able masses of this tissue. From the uterus and the parametrium. a thin layer extends between the leaflets of the broad ligament, and serves as a support for the vessels. The chief mass of this tissue is situated around the cervix, and extends downward aroimd the vagina to the insertion of the levatorvani muscle. The distribution and relation of the pelvic connective tissue have been studied in different wa^^s. The most valuable method is by the examination of frozen or spirit -hardened pelves, by which the position of the tissue, its amount, and its distribution are recog- nized. Injections of air, water, and plaster-of -Paris -have been made beneath the pelvic peritoneum in order to determine the lines of cleavage in the pelvic connective tissue and the directions in which pus would be likely to burrow. Konig made investiga- tions upon the bodies of women who had died shortly after labor from nonpuerperal disease. When an injection is made between the layers of the broad ligament, high up in front of the ovary, it first passes into the tissue at the highest part of the side wall of the true pelvis ; then into the iliac fossa, lifting up the peri- toneum; follow^s the course of the psoas, and passes but slightly into the hollow of the iliac bone; finally, it separates the peri- toneum from the anterior abdominal w^all some little distance above Poupart's ligament, and from the true pelvis below it. Second, when the injection is made beneath the base of the broad ligament and in front of the isthmus, the deep lateral tissue becomes filled first ; then the peritoneum is lifted from the anterior part of the cervix uteri. Separation extends to the tissue in the bladder, and ultimately along the round ligament and the inguinal ring, where it separates the peritoneum along the line of Poupart's ligament and enters the iliac fossa. Third, an in- jection at the posterior part of the base of the broad ligament fills the tissues around Douglas' pouch, and then follows the course as first described. 277. The Vascular Supply. — The pelvic organs and perito- neum are supplied through the ovarian, uterine, vaginal, and internal pudic arteries. The ovarian arteries, analogues of the spermatic in the male, arise from the abdominal aorta just below the renal branches and pass downward over the psoas muscles beneath the ureters, enter the broad ligaments, and pass to the side of the uterus, near which each divides into two branches. The upper supplies the fundus uteri, and the lower anastomoses at the side of the uterus with the anastomotic branch of the uterine artery. In its course the ovarian artery gives off branches to the ampulla of the Fallopian tube and to the isthmus, and also numerous branches to the ovary. A smah branch is given off to the round ligament. The uterine artery springs from the anterior diA'ision of the internal iliac, passes downw^ard 202 GYNECOLOGY. and inward toward the cervix uteri, then upward between the layers of the broad ligament in a very tortuous course, and anastomoses with the lower branch of the ovarian. This portion is sometimes called the anastomotic branch, or the puerperal branch, as by its tortuous course it permits the vessel to be straightened out during the enlargement of the uterus in preg- nancy. The primary branches given off by the uterine artery are separated from the peritoneum only by a thin layer of muscle- fibers. These give off secondary branches, which penetrate the muscular wall in a direction at right angles to its mucous layer. They anastomose freely and end in capillary loops in the mucous membrane. The vaginal branches spring direct from the ante- Fig. 141. — Distribution of the Uterine and Ovarian Vessels. rior trunk of the internal iliac, but sometimes are given off from the uterine or the middle hemorrhoidal. A special branch of the uterine artery to the cervix joins with its fellow of the opposite side to form the circular artery of the cervix, and with the vaginal branches forms the azygos artery of the vagina. Ex- tensive anastomoses take place between the vessels of the oppo- site sides. The entrance of the vessels by the broad ligament enables us in extirpation of the uterus to control hemorrhage by ligation of the latter. The anterior division of the internal iliac also affords the blood-supply to the bladder and rectum. The perineal region is supplied by branches from the internal ANATOMY. 203 -25 -20 22 Fig. 142. — Arteries of the Female Pelvic Organs. — -(Savage.) Vena cava inferior, receives right and left common iliac veins. 2, External iliac vein. 3. Abdominal aorta. 4. Inferior mesenteric artery. 5. Right common iliac artery. 6. External iliac artery. 7. Epigastric artery. 8. Obturator branch of epigastric artery. 9. Internal iHac artery, crossed in front by h, the ureter. 10. Uterine artery. 11. Obtu- rator artery; its course is along with and below m, the obturator nerve. L. Round ligament. 12. Inferior vesical artery. 13. Vaginal branch from it. 14. Uterocervical artery. 15. Artery of the Fallopian tube. 18. Vaginal artery. 17, 17, 17. Spermatic arteries. 19. Pudic artery. 20. Superior vesical artery. 21. Inferior hemorrhoidal artery, joined at 22, another inferior vesical branch. 23. Posterior division of internal iliac artery, terminates in (24) iliolumbar lateral sacral, and (25) gluteal. 26. Sciatic arteries. B. Bladder, u. Urachus. V. Vagina un distended, resting on R, the rectum. O. Ovary. T. Fallopian tube. 15. Fallo- pian branch. U. Uterus. L. Round ligament. S. Sacral articular sur- face of sacro-iliac symphysis. P. Pubic symphysis, articular surface, a. Pyriformis muscle, b. Gluteus maximus muscle, c. Obturatococcygeus muscle, p. Spine of the ischium. f. Psoas muscle. g. Linea alba. h, h. Ureters, i, j, k, 1. Trunks of sacral nerves resting on the pyriformis muscle, m. Obturator nerve, q. Peritoneum covering the transversalis fascia 204 GYNECOLOGY. pudic artery — a branch of the anterior trunk of the internal iliac. It passes out through the greater sciatic notch and enters through the lesser, passing around the spine of the ischium. In its course it lies upon the internal obturator muscle, and is inclosed with the pudic nerve in a canal formed for it by the obturator fascia. It gives off the following branches: The in- ferior hemorrhoidal; the transverse perineal; the superficial per- ineal or vulvar artery, which is much larger than the corre- Fig. 143. — Distribution of the Pudic Artery to the Structures of the Perineum. — (Deaver.) sponding branch in the male — the artery of the bulb ; the profundi branch to the crus clitoridis ; and the dorsal artery of the clitoris. The round ligament receives a small branch from the epigastric artery, which anastomoses with the branch from the ovarian. The venous distribution of the pelvis is very abundant, and occurs in the form of numerous plexuses, which freely communicate with one another. These veins are provided with valves. Con- sequently hemorrhage from an injured part will be very profuse ANATOMY. 205 when the whole pelvic vascular system is engorged, as, for instance, during pregnancy. Dissection discloses a vesical plexus which lies external to the muscular coat of the bladder. At the lower part of the rectum the hemorrhoidal plexus is found situated beneath the mucous membrane. The dis\;ribution of the veins of the labia is similar to that of the arteries. From the superficial portion they drain into the pudic, which com- Fig. 144. — Relation of the Urethral and Vaginal Venous Plexuses to the Veins of the Clitoris and Bulb, .The Right Side of the Pelvis Removed by a Section in Front, through the Pubic Body, about an Inch from the Symphysis, and. Behind, through Sacro-iliac Joint, — (Savage.) B. Bladder partially inflated, and b (vis), ureter cut just before it enters the bladder, V. Vagina distended, P. Section of pubis, R. Rectum, C. Clitoris, S. Sacrum, i. Bulb. 2. Its urethral venous process, 3, Lower efferent veins. 4. Dorsal vein of the clitoris, 5. Urethral venous plexus. 6. Commencement of vaginal venous plexus, 7, 8, 9, 10, Sciatic and gluteal veins corresponding to arteries, 11. Uterine veins assisting to form the uterovaginal venous plexus, 12. Obturator vein, 13, Internal iliac vein. a. Pyriformis muscle, b. Larger sciatic ligament, c. Pubo-, obturato-, and ischio-coccygeal muscles, d. Suspensory ligament of the clitoris. e. Bulbovaginal gland. /, /, /, Roots of sacral plexus of nerves. municates with the common iliac vein. The large veins from the labia minora open into the pars intermedia above. The blood returns from the glans and body of the clitoris through the dorsal vein of the clitoris, which communicates with the vesical plexus. The vaginal plexuses are situated, one in the submucous tissue and the other external to the muscular coat. They com- municate with the hemorrhoidal and vesical plexuses, receive the 206 GYNECOLOGY. blood from the veins of the bulb, and empty into the internal iliac vein. The uterine plexus is very complex, and empties into the ovarian veins. The right ovarian vein enters the inferior Fig. T45. — Veins and Erectile Venous Plexuses of the Female Pelvis. — (Savage.) B. Bladder. R, Rectum. L. Round ligament. U. Uterus. O. Ovary. V. Vagina. S. Sacro-iliac articulation. K. Kidney. T. Fallopian tube. P. Pubic symphysis, a. Pyriformis muscle, b. Gluteal muscles. c. Ischiococcygeus muscle, d. Internal obturator muscle, e, e. Psoas muscles, f. Linea alba, g, g. Ureters, h. Obturator nerve, i. In- ternal inguinal ring, site of canal of Nuck. i. Abdominal aorta. 2. Inferior mesenteric artery. 3, 3. Common iliac arteries, 4. External iliac artery. 5. Vena cava. 6. Renal veins. 7, 7. Common iliac veins. 8. External iliac vein. 9. Internal iliac artery. 10. Gluteal. 11. Ilio- lumbar. 12. Sciatic. 13. Pudic. 14. Obturator. 15, 16. Epigastric veins. 17. Uterine vein. 18. Vaginovesical venous rete. 19. Spermatic veins. 20. Bulb of the ovary. 21. Vein to round ligament. 22. Fallo- pian veins. ANATOMY. 207 vena cava; and the left, the left renal vein. The right ovarian vein has a valve where it pierces the coat of the inferior vena cava, while the left has none. To this arrangement is attributed the greater frequency of pain and disease in the left ovary. The ovarian or pampiniform plexus lies between the folds of the Fig. 146. — Erectile Organs and Veins of the Female Perineum. — (Savage.) g. Crura clitoridis. i, 2. Bulb of the vagina. 3. Vestibular intercom- municating branches. 5. Superficial perineal and obturator veins. 6. Veins of communication with superficial epigastric veins. 8, 9, 10. Pudic vein and primary branches. M, Urethral orifice or meatus. V. Vaginal aperture. A. Anus. T. Tuberosity of ischium. O. Coccyx. G. Vulvo- vaginal gland. broad ligament and communicates with the uterine plexus. The ovarian plexus opens into the inferior vena cava. At the hilum of the ovary is situated the collection of veins known as the bulb of the ovary. The vesical, hemorrhoidal, and vaginal plexuses, with the pudic veins, empty into the internal iliac vein, which joins the inferior vena cava. From the hemorrhoidal 208 GYNECOLOGY. plexus there is a commtimcation with the portal system through the superior hemorrhoidal vein. 278. The Lymphatic System. — This comprises: first, the lymphatic glands; second, the lymphatic vessels. The lymph- Fig. 147. — The Lumbo-iliac Lymphatics and Glands. Lymphatics of the Gravid Uterus and Appendages. — (Savage.) 1,2. Superior lumbar glands. 3, Inferior lumbar glands. 4. Sacral lymphatic glands. 5. External and internal lymphatic glands. 6. Common iliac glands. 5, 7. Spermatic lymphatic plexus, a. Left renal vessels, b. Left renal vein. c. Left spermatic vein. d. Left spermatic vessels, covered by their lymphatic plexus, e. Aorta, f. Common iliac trunks. g. Ascending cava. h. External iliac artery and vein, m, n. Ureters. o. Right common iliac vein. p. Iliacus muscle, s. Psoas muscle. O. Ovary reversed, showing lymphatics between it and its bulb. atic glands are: (A) the inguinal glands, which lie parallel to and just below Poupart's ligament ; (B) the pelvic glands. (Fig. 147.) These comprise: (a) a gland situated at the isthmus uteri ; (b) the hypogastric or iliac glands, which lie beneath the perito- ANATOMY. 209 neum, in the space between the internal and external iliac vessels ; (c) the sacral glands, situated on the lateral aspect of the anterior surface of the sacrum and the mesorectum ; (J) a gland or small collection of glands at the obturator foramen, known as the obturator gland of Guerin. All these glands discharge into the lumbar glands, which lie in front of the lumbar vertebra, and finally into the thoracic duct. The lymphatics of the external genitals form an extensive network on the internal aspect of the labia majora, over the labia minora, around the vaginal and urethral orifices, the vestibule, and the clitoris, and all these discharge into the inguinal glands. As a consequence, syphilis or cancer affecting the vulva or lower fourth of the vagina causes involvement of these glands. In the upper three-fourths of the vagina and cervix uteri the lymphatics open into the hypogastric glands. This is true not only of the lymphatics of the upper three-fourths of the vagina and cervix, but also of the lymphatics of the bladder. The lymphatics of the uterus pass through the broad ligaments with those of the ovary and tube and enter the lumbar glands. Some of the uterine lymphatics pass along the round ligaments to the glands of the groin. Leopold, in investigating the lymphatics in the unimpregnated uterus, re- gards the mucous membrane of the organ as a lymphatic surface consisting of lymph-sinuses covered with endothelium. The lymph passes from these spaces into the vessels of the muscular coat, and flows into the larger vessels which enter the broad ligaments. The distribution of these vessels and their extensive character account for the rapidity with which septic matter is absorbed from the uterine cavity and explain the various routes by which bacteria can pass through lymphatic canals or penetrate the blood-vessels. The lymphatics of the rectum lie in the mucous and muscular layers and communicate with the glands of the mesorectum or the sacral glands. Nerves. — The nerves distributed to the pelvic organs are derived from the spinal and sympathetic. The branches from the spinal nerves consist of the inferior hemorrhoidal branch of the pudic, from the fourth and fifth sacral, and of the coccygeal nerves. These nerves supply the levator ani, sphincter, and coccygeus muscles ; the muscles of the perineum and clitoris are supplied by branches from the internal pudic, which nerve ter- minates in the nervous plexus of the glans clitoris. (Fig. 148.) The hypogastric plexus, derived from the sympathetic, lies be- tween the common iliac arteries, and distributes branches, which are reinforced by others from the lumbar and sacral ganglia and sacral nerves, to form the inferior hypogastric plexuses, one of which is situated on each side of the vagina. These 14 210 GYNECOLOGY. plexuses distribute filaments to the vagina, uterus, Fallopian tube, and ovary. The pelvic, splanchnic, and hypogastric nerves are motor and sensory to the bladder ; the pudic is motor Fig. 148. — Nerves of the Unimpregnated Uterus with the Nerves of the Clitoris. — (Savage.) I. Hypogastric plexus. 2. Rectal branch of inferior mesenteric plexus. 3. A lumbar ganglion of the sympathetic. 4. Spermatic plexus, supplies Fal- lopian tube, ovary, and part of the uterus. 5. Branches from third and fourth sacral, aiding to form 6, 7, right inferior hypogastric plexus. 8. Uterine filaments. 9. Vesical plexus and branch. 10. Trunk of great sacrosciatic nerve. 11. Muscular branch of the fourth sacral nerve. 12. Trunk of pudic nerve. 13. Continuation of 12 into dorsal nerve of the clitoris. R. Rectum. U. Uterus. B. Bladder. D. Transversus perinei muscle cut across. S. Section of ilium. P. Section of symphysis. ANATOMY. 211 to the sphincter; and all the nerves of the vagina and clitoris are sensory to the skin of the perineum, and especially so to the mucous membrane of the glans clitoris. The terminal filaments in the uterus are found in the nuclei of the unstriped muscle. Those of the mucous membrane are said to end in ttie ganglia. End-bulbs have been found in the clitoris and vagina. In the ovary the nerves pass to the Graafian follicle and to the walls of the membrana granulosa. 279. Consideration of the Pelvic Organs and Structure Studied as a Whole. — In the upright position the plane of the brim of the pelvis is at an angle of 60 degrees to the horizon. The fundus of the uterus lies just below this plane, with its axis at right angles to it, and consequently at right angles to the vagina, which is parallel to the brim of the pelvis. In the upright position the internal abdominal pressure is directed against the symphysis and the posterior surface of the fundus of the uterus when in its normal situation. The uterus, as we have seen, is freely movable — swung in its position in the pelvis by the ligaments. The broad liga- ments maintain it in the center of the pelvis, and by their position and relation serve to assist in maintaining it in an antefiexed position. The round ligaments are an additional stay, and when of normal resiliency, draw the fundus forward. The other ligaments are the uterovesical and the uterosacral. The former are formed by the reflection of the peritoneum from the bladder to the uterus; the latter, while consisting of folds of peritoneum, also contain muscle-fibers, which are derived from the superior muscular layer of the uterus. The function of the latter filaments is to hold back the cervix, while the intra-abdominal pressure maintains the fundus forward. De- viations from the normal inclination of the pelvis, from the normal resiliency and tone of the ligaments, from the proper relations and support of the vagina, increase in the weight of the uterus, and increased intra-abdominal pressure, are all factors in the production of uterine displacements, especially that form characterized by descent. The plane of the outlet of the pelvis when the patient is erect forms an acute angle in front with the horizon. The urethra, the vagina, and in the upper part of its course the rectum, are parallel to the plane of the brim of the pelvis. The lower portion of the rectum turns acutely backward and forms an axis at right angles to that of the vagina. This portion, the anus, looks backward and downward; consequently the introduction of the finger or of the nozle of a syringe must be directed forward and up- ward, or directly toward the vagina, and after passing into the anus, is carried upward and backward. On median vertical 212 GYNECOLOGY. section the vagina will be seen to be a mere slit, slightly S- shaped, the lower part of which presents the convex surface of its posterior wall anteriorly. The pelvic floor is consequently divided into two segments, the anterior and upper of which rests upon the more fixed posterior segment. The rectum at the anus is found to form an anteroposterior slit. Intra-abdominal force first causes pressure of the anterior segment upon the posterior, and then a sliding backward of that portion of the inferior segment in front of the anterior wall of the rectum. PHYSIOLOGY. 280. Functions. — The important functions of the genital organs are the processes associated w4th reproduction. These comprise the alterations in the organs by which menstruation is established, repeated monthly, and finally discontinued; the relation of the sexes in copulation; the fecundation of the ovum, its subsequent nutrition, and the procedure by which the matured product attains a separate existence. 1. The transition from child to woman, indicated by the appearance of menstruation, is denominated puberty. 2. The completion of development, which fits the individual for the processes of maternity, is called nubility. 3. The deposit of the vitalizing principle of the male within the body of the female occurs through the act of copulation, and its union with the ovum is known as fecundation. 4. The nutrition of this vitalized structure and its subse- quent course of development are recognized as gestation. 5. The processes by which the matured product is afforded a separate existence are known as parturition. The first three of these divisions and their variations from the normal comprise the field of gynecology. 281. Puberty. — The completion of the developmental proc- ess that results in the establishment of menstruation and ovulation has been called puberty. It marks the transition from the child to the w^oman, and occurs betw^een the thirteenth and fifteenth years. The age of the individual differs under varying circumstances. Puberty occurs earlier in the natives of hot chmates than in those of the north, and earlier in the Latin races than in the Anglo-Saxon. City girls mature at an earlier age than those raised in the country, and those raised in affluence sooner than the poor. The occurrence of the phe- nomena of menstruation prior to the age of thirteen is called precocious puberty. Such instances are not infrequent. Iso- lated cases occur in which it appears at a very early age. Rein PHYSIOLOGY. 213 reports the case of a girl of six years whose pubes were covered with hair and who menstruated regularly for a year. The *'New York Medical Record," i6, xi, 1895, presents a report of a girl who gave birth to a child when ten years of age. Retarded or delayed puberty is caused by chlorosis, plethora, or some congenital condition of the genital tract. Numerous cases are recorded where women have given birth to children prior to the establishment of menstruation; in other words, ovulation occurs without the usual manifestation. The advent of puberty is manifested by other characteristics than menstruation. The figure becomes more rounded, from an increase of adipose tissue. The breasts enlarge and fre- quently become painful. Hair grows upon the mons veneris and labia majora. Under this process occurs increased blood formation, the development of glandular structure, particularly in the uterus and the mammary gland, and, especially, marked changes in the nervous system. "There is," Christopher Martin says, " a remarkable transformation in the psychic, emotional, and mental life of the girl. The current of her thoughts is mysteriously changed. Hopes and yearnings un- known before thrill and agitate her, and life acquires a new and deeper meaning. These profound and subtle changes are not so difficult to understand if we accept the view that puberty means the sudden bursting into activity in the midst of the nervous system of a hitherto dormant center." The glandular development of the mamm^ may be so rapid and at times so irregular as to simulate a tumor. The period of life should prevent error. 282. Nubility. — The advent of puberty indicates that the conditions and functions are established that will permit pro- creation, but the structures are not sufficiently developed to render the individual suited for favorable reproduction. Experience has demonstrated that the mortality is much greater among those who come to the completion of gestation prior to the age of twenty. Women coming to early maternity mature early, reach the menopause at an early age, and are prematurely aged. 283. Menstruation and Ovulation. — Menstruation — also called the menses, the monthlies, the courses, the turns, the sickness, and the periods — has been defined by Sutton as the ''periodic discharge of blood from the uterus, accompanied by the shed- ding of the epithelium of the body and fundus, as well as of that lining the utricular glands near their orifices." Ovulation is the discharge of an ovum from a matured Graa- fian follicle. These two processes are considered here in co-rela- tion, though we have no positive proof that they are co-depen- 214 GYNECOLOGY. dent. We have, however, determinative evidence that they are occasionally independent of each other. The not infrequent occurrence of pregnancy prior to the advent of puberty and sub- sequent to the climacteric is an indication that ovulation can occur without menstruation. The recent investigations of Frankel seem to justify him in the presentation of the following theory regarding the corpus luteum and its influence upon the menstrual function: i, the corpus luteum is a gland with an internal secretion capable of being always formed afresh in the (functional) ovary; 2, the corpus luteum carries psychic nutritive impulses to the uterus, especi- ally as concerns the endometrium, in the connective tissue of which it excites extreme hyperemia and hyperplasia ; 3 , it effects the adhesion of the impregnant ovum, or, failing this, it excites menstrual secretion. The acceptance of the above hypotheses renders the periodical occurrence of menstruation and its varia- tions more intelligible than any other which has been presented. Menstruation, in the majority of women, occurs every twenty- eight days, and the flow lasts from two to eight days. The intervals may vary from twenty-one days to five or six weeks. It does not always occur at an absolutely definite date in the same individual. The quantity of blood lost is diflicult to determine. The average amount is estimated at from three to five ounces. It has been mentioned that the flow varies in duration from two to eight days. A flow shorter than two or longer than eight days in duration indicates an abnormal condition. Absent or greatly decreased flow is known as amenorrhea. The prolonged or ex- cessive flow is called menorrhagia. When the function is asso- ciated with severe pain, it is pronounced dysmenorrhea. The menstrual discharge is not pure blood, but consists of a dark bloody fluid, thin and slimy in character, which contains, as revealed by the microscope, blood-corpuscles, leukocytes, epi- thelium, and stroma. The normal menstruation is not clotted, due to the admixture of the secretion of the uterine and cervical glands. It is only when the flow is excessive or the gland secre- tion deficient that clots are present. Menstruation occurs only in women and in certain monkeys ; it is apparently limited to those animals that maintain the erect position. Menstruation involves between thirty and thirty-five years of the life of the woman, known as the period of active sexual life, beginning from the thirteenth to the fifteenth years and continuing from the forty-fifth to the fiftieth. The final cessa- tion, like its advent, may be advanced or retarded by various causes. Each menstrual period is generally preceded by some PHYSIOLOGY. - 215 premonitory symptoms, a sense of Aveight, pressure, or uneasi- ness extending down the limbs, a sense of exhilaration, an in- creased vascular tension, and, Belfield asserts, an increase of weight which may exceed one pound an hour for several hours, the woman gaining seven to nine pounds in twenty-four hours. This increment, he says, is due, i, to increased absorption of oxy- gen, and, 2, to decreased elimination. With the establishment of the flow she suffers from depression, languor, malaise, dis- inclination for exertion, either physical or mental, and, according to Belfield, decrease in weight. Alany women will exhibit a tendency to the occurrence of gastro-intestinal disturbance, formation of toxins developing an autointoxication, which will produce migraine, aggravate nervous manifestations, chorea, epilepsy, and will cause delusions. Epilepsy and insanity are frequently so marked and recur so regularly Avith the menstrua- tion as to lead the family and physician to believe the disorders are the result of diseased conditions of the pelvic organs. During the menstrual process the uterus and pelvic viscera be- come engorged Avith blood; the uterus is enlarged, turgid, and sensitive; the capillaries rupture, some upon the surface and others Avithin the mucous membrane. The uterine epithelium be- comes desquamated ; during the process of engorgement the glands have become filled with epithelium, which is discharged from the external portion of the gland. Many of the cells are lique- fied, increasing the quantity of mucus. With the establish- ment of the floAv the engorgement is relicA^ed and the general disturbance subsides. After the termination of the period the mucous surfaces are gradually regenerated from the epi- thelial tissue remaining in the glands, until, at its culmination, the process is again rencAA^ed. According to Napier, this des- quamation and regeneration of the structures from the utric- ular glands, and the accumulation of glandular products in the uterine glands and the OA^aries, stands in a causative relation to menstruation. The menstrual discharge is suppHed by the entire cylindric epithelium-lined mucous membrane. ]\Iy own researches, confirmed by those of many others, are sufficient to demonstrate that the Fallopian tubes as aa^cU as the uterus take part in the menstrual flow. It is not unreasonable to sup- pose that the presence of bloody fluid in the tube is of value in promoting the nutrition of the fecundated ovum and that the consequent distention of the tube facilitates the passage of the ovum to the uterus. Many ingenious theories for the recurrence of menstruation haA'e been advanced, but Avhether we accept the hypothesis advanced by Frankel or not, it can not be denied that the ovaries are its cause, for the following reasons: i. The ovary furnishes the ovum, which it is the function of the uterus 216 GYNECOLOGY. to retain and nourish until its product is ready for a separate existence, hence the producer rather than the retainer should dominate the function; 2, the entire removal of ovarian struc- ture invariably results in the cessation of menstruation; 3, the removal of the ovaries is general^ followed a couple of days later by the occurrence of a vaginal discharge which can not be distinguished from the ordinary menstruation. The discharge is undoubted^ due to the pressure of the ligature upon the nerves which supply the ovaries; 4, Strassman's experiments of in- jecting the structure of the ovary with sterilized water were Fisf. 149. -Changes of Uterine Mucous Membrane During Menstruation. (Wyder.) follow^ed two days later by a discharge from the uterus which in every way resembled menstruation. The occasional occur- rence of bloody discharge after the removal of both ovaries has been held to negative our second proposition, but my experience leads me to doubt the regular recurrence of menstruation after the complete removal of both ovaries. An occasional bloody discharge from the genital tract after the extirpation of both ovaries means nothing more than that there has been some local congestion which has been thus relieved. PHYSIOLOGY. . 217 It is only when the ovaries and utricular glands attain a development that renders their secretion capable of exerting a dominating influence upon the general economy that puberty occurs, and the process continues until these structures begin to atrophy and cease to exert their governing course. Napier denies the probability of the period being induced by ovulation, and cites the occurrence of the latter without menstruation, and the continuation of menstruation after the removal of both ovaries, as presumptive evidence. Many other theories are advanced for the periodic occurrence of menstruation. Johnstone believes in a special menstrual nerve plexus, situated near the cornua of the uterus; but this structure has not been recognized by any other observer. The alteration of the uterine mucosa which occurs during menstruation prepares it for the reception and nutrition of the fecundated ovum. The fact that gestation occurs with- out an intervening period is no contravention of this supposition, but only a demonstration that the preparation can occasionally occur without the shedding of blood. The nen^e influence leading to the increase of the liquor foUiculi, and the liquefaction of the cells of the membrana granulosa, promote the multiplication of cells in the mucosa which is followed by menstruation. The coexistence of these processes is seen in the formation of a corpus luteum syn- chronous with menstruation. The course of menstruation is averted by pregnancy. Menstruation continues during pregnancy only with the rarest exceptions, and the functional activity of the ovaries is suspended during lactation. Neither ovulation nor menstruation is likely to occur during lactation. Many women prolong the period of lactation for the purpose of render- ing themselves less susceptible to fruitful coition. Menstruation, it is seen, is one of the imiportant functions of the genital tract, hence diseased conditions of the internal geni- talia generally manifest themselves by disturbances of this function. The disturbances of the menstrual function are: amenorrhea, dysmenorrhea, menorrhagia, and metrorrhagia; and, we may add, vicarious menstruation. Amenorrhea is a term applied to an almost or complete cessation of bloody flow. Occasionally the vascular tension is insufficient to result in the rupture of vessels and the discharge of blood, but causes increased secretion from the uterine glands which, with the desquamated epithelium, produces a profuse leukorrhea that supplants the menstrual flow. Amenorrhea is congenital when puberty is much prolonged beyond the period of its usual occurrence, and is due to defective 218 GYNECOLOGY. development, chlorosis, anemia, or mechanical obstruction; constitutional, when profound blood changes exist or diseased conditions are present which are calculated to reduce vascular tension; mechanical, when an obstruction, congenital or ac- quired, exists to prevent its exit ; due to disease of the ovaries, when these organs have become destroyed or their function has been arrested. Finally, it is a symptom of the existence of preg- nancy. Chlorosis and anemia, as factors in the production of amenor- rhea, are generally easily recognized by the appearance of the patient. Blood examinations will be of special value, however, to determine the degree of anemia and the extent and gravity of the defective development or the degenerative changes in the blood-corpuscles . Chlorosis generally occurs in the young. The patient may present an appearance of full flesh, but is white or greenish- white ; the lips are pale, and the ears transparent ; the pulse is rapid, and she breathes rapidly upon the slightest exertion. The menstrual flow is supplemented by the profuse leukorrheal discharge al- ready mentioned. Chlorosis and anemia may frequently be the precursors of tuberculosis, hence the wide-spread dread of this symptom upon the part of the laity. Disease of the ovaries, in the form of glandular cystoma of both ovaries, will sometimes result in this symptom. I say some- times, for it is only when the entire structure of the ovary has be- come disorganized that it occurs, and menstruation may con- tinue to be regular and pregnancy may occur when both OA^aries are the seat of cystomata. Another change in metabolism, due to ovarian disease, the pathology of which has not as yet be- fully recognized, results in an early menopause. The woman ceases to menstruate at thirty years or younger. She looks well She will give a history of rapid gain in flesh, thirty or forty pounds in a year, and of a gradual decrease in, or sudden arrest of, the menstrual flow. She may have had one or two childen or never have been pregnant. That the condition is not always as- sociated with destroyed function of the ovaries is evident from the fact that in some of these patients under regulated diet and suitable treatment the menstruation returns and the sterility is overcome. When amenorrhea is produced by mechanical causes, it may be primary or acquired, and the obstruction may occur at any part of the genital canal, although when in the tube it may not preclude an external flow, while resulting in a partial retention. Such a patient will present the appearance of good health, will exhibit periodically menstrual molimina, and later an abdominal swelling may become visible. In the primary form the patient PHYSIOLOGY. 219 has never had a visible menstrual flow; in the acquired, there usually is a history of a diiScult or instrumental labor or some injury to the genital tract, after which there was no visjble flow, though efforts to menstruate had recurred. In both classes of cases the possibility of pregnancy should be considered and may be suspected, but in the primar}^ the patient should be given the benefit of doubt until examination has rendered pregnancy certain. The diagnosis will be difficult only when the obstruction is at the internal os. Even in such cases the distention of the uterus is likely to be more spherical, and the uterine wall thinner and yet more tense, than when the distention is due to pregnancy. Should the examiner be uncertain, he may postpone the diag- nosis for another month. The amenorrhea of pregnancy is generally easily recognized by the healthy appearance of the patient and the usual physical signs associated with pregnancy. Dysmenorrhea, as a symptom of pelvic disease, is the most frequent disturbance of the menstrual function, and, possibly, as a result of the training and manner of life of our women, is becoming more frequent. It indicates painful flow, consequently the expression of intermenstrual dysmenorrhea is a misnomer. We commonly make the classification into congestive or in- flammatory, obstructive or mechanical, ovarian, and nervous dysmenoiThea, but such an arrangement is misleading. It is very doubtful whether obstruction ever is much of a factor in its production. Some of the cases in which I have found dys- menorrhea most marked were in women in whom the uterus was very patulous and a sound could be carried to the fundus Avith- out any difficulty. On the other hand, Avomen with uncompli- cated antefiexions of marked degree have menstruated without pain. To appreciate fully the significance of this symptom we must remember that the uterus is an erectile organ, whose walls are subject, as in all other involimtary muscle structure, to rhythmic contractions. Any inflammation of this organ, whether in its mucous membrane, muscle-wall, or serous covering, must to a certain degree render the performance of the menstrual function painful. In cases in which the canal is patulous in the inter- menstrual inter\^als the myometrium is undoubtedly the seat of the inflammation, and the painful spasm resembles the oc- currence of chordee in the male. This symptom is provoked or aggravated by faulty or defective development of the uterus, by flexions, chronic metritis, perimetric inflammation, rheumatism, gout, and neurasthenia. Its existence demands careful investi- gation for its cause, and it should not be forgotton that frequently 220 GYNECOLOGY. much more will be accomplished by the treatment of the con- stitutional condition than by local applications. The experienced physician has recognized that the neurasthenic patient will often perform none of her functions painlessly, and it can be readily appreciated that such a patient will require but little disturbance of the pelvic organs to occasion pain during the course of menstrua- tion. Ovarian dysmenorrhea is hardly an appropriate term, for the reason that the ovarian pain is usually felt with greatest in- tensity some days or a week prior to the flow, and should be considered as an indication of chronic inflammation of those organs. Recently much attention has been directed to the theories of Fleiss and Schijff as to the nervous or reflex dysmenorrhea attributed to what are denominated the genital spots in the nose. The mere fact that cocain solution can be applied to the nasal mucous membrane and afford relief is not proof positive that the surface thus touched was the cause of the symptom. Cocain given internally or hypodermically would be equally effective, but is not a safe remedy for frequent employment. Membranous dysmenorrhea is a form of painful menstruation in which a more or less well-defined cast of the uterus is discharged. It is usually associated with pain as intense as if the woman were undergoing an abortion. The cast contains the epithelial layer of the endometrium, often showing partial casts of the gland tubules, and also contains a croupous exudate. We need but to recur to the phenomena of menstruation with its desquamated epithelium to appreciate that this condition is the result of a more severe and chronic inflammation. The condition is recognized by the association, with labor-like pains, of the discharge of shreds of membrane or an entire cast of the uterine cavity. The false membrane may occur but occa- sionally or at every period. Its occurrence indicates lowered vitality and a profound neurotic state. Menorrhagia and metrorrhagia are terms used to indicate, respectively, excessive menstrual flow at the regular periods and bloody flow without any periodicity. The symptom may begin as menorrhagia and end in metrorrhagia. It may occur at any time between puberty and the menopause, and metrorrhagia may follow the latter. The symptom may be the result of con- stitutional conditions interfering with vascular tension, either locally or generally, as in hepatic, cardiac, or renal disease, caus- ing obstruction in the zymotic fevers, scurvy, and other con- stitutional conditions. It may be produced by pelvic conditions outside the uterus, as in cystic degeneration of the ovaries, in- traligamentary cysts, flbroid growths, ectopic gestation, or peri- uterine inflammation; from uterine involvement, as in threat- PHYSIOLOGY. 221 ened abortion, retained fetal products after labor or abortion, interstitial inflammation of the uterine mucosa, interstitial or submucous myomata, malignant conditions, such as epithelioma of the cervix, adenocarcinoma of the cervix or body, endothelioma, sarcoma, or chorioepithelioma. Vicarious menstruation indicates a discharge of blood from some other surface than the uterine endometrium. It may occur from the nose, ears, anus, or nipples, or as petechia or purpura beneath the skin. Its occurrence is readily understood when we consider the preparation for the menstrual flow characterized by increased vascular tension. The vessels which are weakest are the first to rupture, and the released tension prevents the rupture of the endometrial vessels, hence the absence of the genital flow. The symptom is recognized by its periodicity and the absence of regular menstruation. 284. Menopause. — The conclusion of menstrual activity is recognized as a critical period in the woman's existence. It is variously denominated the menopause, the climacteric, and the change of life. The menstrual life of the woman lasts, upon an average, nearly thirty-five years, so that the menopause should occur between the forty-seventh and the fiftieth years. Its occurrence may be accelerated or retarded by various causes. Premature menopause occurs prior to the age of thirty-two, and may be induced by shock, severe illness, prolonged anxiety, overstudy, mental affections, disease of the ovaries, — such as destruction of the ovarian stroma by double ovarian tumors, — sepsis, chronic disease of the appendages, and some forms of metritis. Early menopause occurs between the ages of thirty-two and forty-two. It occurs early in the virgin, and earlier in blonds than in brunets. Fat women reach the menopause early. A rapid increase in adipose tissue is associated with some cases of premature menopause. Occasionally the menopause occurs at an early age without any assignable cause. Retarded or Delayed Menopause. — The occurrence of the meno- pause is distinctly affected by heredity. It may be delayed by child-bearing, by the presence of uterine growths, and by the presence of malignant degeneration. Rob- ertson reports the case of a woman who ceased to menstruate for twelve months at the age of fifty, when the flow returned and continued until her death at seventy. Saxonia speaks of a nun who had a return of her menstruation at the age of one hun- dred, which continued regularly until she died three years later. The term menopause is employed to designate the period of the change. The average duration of the menopause is about two and one-half years. A few fortunate persons continue to 222 GYNECOLOGY. menstruate regularly until a certain period, when the flow dis- continues, never again to recur. Others continue irregular for six months, when it ceases. Generally a patient will notice that the periods are getting more scant, until finally she misses one or two periods; then menstruation recurs for a while, to again subside, thus continuing irregularly for one or two years. The irregularity may be prolonged over a period of four or five years. While, as a rule, the intervals are longer, the periods may occur more frequently, with intervals of but twenty-one or even fourteen days. The flow may be increased, and occasionally hemorrhages occur without any assignable cause. Excessive or prolonged bleeding should always be a cause of anxiety, and should lead to a careful examination in order to determine its cause. The cause should not be assigned to change of life until careful investigation has eliminated every other source. The occurrence of menstruation is attended with the elimination of certain materials from the blood. Chemic changes in the blood and tissues are constant, and the elimination of the albuminoids during menstruation is demon- strated by a more marked alteration of the blood following menstruation than the mere blood-loss would produce. When menstruation is arrested by anemia or pregnancy, we see in the skin marked deposits of pigment and other materials that would be eliminated by its occurrence. When the menopause occurs suddenly, the retained products produce an intoxication which results in various nervous per- versions. It is a very usual occurrence to witness various vaso- motor disturbances, such as sudden sensations of heat; flushings; waves of blood rolling up to the face, accompanied by a sensation of giddiness, suffocation, or oppression; cold, clammy perspira- tion ; shooting neuralgic pain ; headaches ; fullness of the vessels of the head and neck ; palpitations ; gastric irritation ; diarrhea ; irritability of temper; melancholia; and disturbed mental bal- ance. In sudden production of the climacteric after radical opera- tions the vasomotor disturbances are frequently so distressing as to render the condition for which the operation was performed preferable. Treatment. — The more distressing vasomotor disturbances can be ameliorated by the employment of tonics, good food, rest, massage, and the application of the galvanic and Faradic cur- rents; the administration of the bromids, asafetida, and other nerve sedatives ; the regulation of the bowels ; and the promotion of digestion. Picrotoxin in -^-grain doses three times daily seems to exert a specific influence in some cases. MALFORMATIONS. 223 285. Copulation is that act of union of individuals of the two sexes by which the vitaHzing principle of the male is depos- ited in the genital organs of the female. The sexual desire of the woman is much less marked than that of the man. Fre- quently she has no sexual sensation, and the act is even repug- nant, but she yields to the man's embrace from her wish to gratify his desire. Such a woman, mated to a man of impetuous inclination, often becomes a sexual slave. The clitoris and the tissues about the vestibule are erectile, and take part in the orgasm, during which a secretion is ejected from the vulvo- vaginal glands. Imperfect or unsatisfactory coptilation is a prolific source of disease. Efforts to avoid the legitimate results of copulation, like all violations of nature's laws, visit their penalty upon both the offenders, but most heavily upon the woman. 286. Fecundation. — The union of the spermatozoid with the ovum and the successful fertilization of the latter are known as fecundation. Its occurrence does not require that the woman should share in the pleasurable sensation of copulation; indeed, it can follow in spite of the fiercest resistance upon her part. The spermatozoids, the active fertilizing agents from the man, require no assistance from the woman, but by a vermicular motion can make their way to the ovum in the internal organs. There has been much discussion over the probable point at which fertilization occurs and as to the ability of the sper- matozoa to penetrate the narrow isthmus of the Fallopian tube against the waving cilia, the function of which is to pro- mote a current toward the uterus. The demonstration that they do overcome these obstacles in the sheep and other lower animals, and are found swarming over the ovary, and the fre- quent occurrence of ectopic gestation in the woman, should be accepted as a sufficient demonstration that they make the voyage. It is most probable that fecundation results in the tube, from which the vitalized ovum passes into the uterus, which is prepared for its reception. Impregnation is more likely to occur during or immediately following menstruation; less likely, immediately preceding the flow ; and the woman is least susceptible in the mid-interval. Independent of organic conditions, there is a marked differ- ence between individuals as regards their susceptibility to im- pregnation. MALFORMATIONS. 287. Classification; Definition. — A genital malformation is any deviation from the normal form and structure of the fe- 224 GYNECOLOGY. male reproductive organs. As the processes of development are not completed until puberty, such deviations may arise from the arrest or distortion of growth at any one of the periods we have already considered in the study of the formation of these organs. As the majority of instances of abnormality are due to prenatal causes, they are justly considered, there- fore, as congenital. In a former edition I considered the various lesions of parturition under the head of acquired malformations, but will now discuss them under the designation of traumatisms. 288. Bifidities. — The development of the uterus and vagina from the coalescence of the two Mullerian ducts naturally Fig. 150. — Degrees of Division of the Genital Tract. Fig. 151. — Uterus Bicornis. leads, upon arrest or faulty continuation of the process, to a -partial or a complete separation of these organs into two canals. Such a bifid development may be either equal or unequal. This double development may result in the formation of two canals by a simple partition or septum through what seems one body, or a partial or complete separation into two bodies. 289. The Degrees of Division. — The most frequent form of malformation is the presence of a more or less complete septum between the two sides of the uterus and vagina. This partition or septum in the uterus may, according to its extent, consist of five degrees. The first (I, Fig. 150) will present MALFORMATIONS. 225 a mere outline which projects from the fundus. Such a con- dition is rarely recognized during life, unless opportunity is afforded for digital exploration of the uterine cavit3r: In the second degree (II, Fig. 150) a septum extends through the body to the internal os. This form can be recognized following delivery or abortion, but otherwise may give no indication of its presence. The occurrence of pregnancy may cause its destruction. In the third degree (III, Fig. 150) the body and cervix are divided by the septum into two distinct canals. The fourth degree (IV, Fig. 150) affords a septum, which is incomplete only in the vagina, and the fifth (V, Figs. 150 and 158) presents a complete uterovaginal septum, forming two Fig. 152. — Uterus Bicomis Unicollis. canals. The one canal may be readily overlooked, or coition may occur in either side indifferently. 290. Double Uterus. — The division of the organ into two portions may be more or less complete, and consequently may form three classes : • First, the division of the fundus by a groove and two lobes, known as the uterus bilobularis, uterus bicornis arcuatus, or uterus bicornis unicollis (Fig. 151), the latter especially when but one cervical canal exists (Fig. 152). Second, the body divided into two distinct portions, the double uterus bicornis (Barnes) — uterus bifidus; it may have a single or two cervical canals (Fig. 153). Third, two separate organs exist, each with one tube and ovary, uterus didelphys (Fig. 154). The bodies diverge, each 15 226 GYNECOLOGY. half being held to the corresponding side by the short broad ligament Fig. 153. — Uterus Bitidi Fig. 154. — Uterus Didelphys. 291. Unequal Development of the Two Sides. — The two canals of Muller may be incompletely developed, and thus MALFORMATIONS. 227 produce asymmetric organs of varying form. The one canal may be completely atrophied, while the other presents a well- Fig, 155. — Uterus Unicornis. developed horn — the uterus unicornis. (Fig. 155.) Generally, the absence of one horn is associated with absence of the corre- sponding tube and ovary. The horn may be rudimentary or partly developed, per- mitting the occurrence of menstruation and even pregnancy. Such a horn is not generally prepared for the maintenance of the fecundated ovum to the completion of gesta- tion, and may result in rupture prior to the sixth month. In some cases the occurrence of such a pregnancy is quite as dangerous to life as a tubal gestation, from which it can not, pre- vious to operation, be differentiated. I have seen instances in which a one-horned uterus had passed successfully through more than one pregnancy and the ab- normal condition was only discovered by accident. Atresia in the canal of a rudimentary or partly developed horn may exist, and lead to an accumulation of the menstrual secretion and the Fig. 156. — Atresia of Rudimentary Horn with an Accumulation of Menstrual Blood. 228. GYNECOLOGY. formation of a tumor. (Fig. 156.) The diagnosis of such a con- dition is exceedingly difficult, and can be determined only during an operative procedure. The accumulation may rupture into the vagina, but usually at such a height as to leave a portion of the sac dependent and undrained, and, therefore, likely to become infected and lead to septicemia. When the condition is recog- nized, the treatment should be that for retained menstruation, which will be described later. The development of a one-horned uterus may be associated with a double cervical canal, — uterus biforis, — a condition which may cause embarrassment during labor. The septum when discovered may be pushed to one side, or, if necessary, be cut ^ ^^v between two sutures (Pozzi). flw '^9 When torn, it has caused ^Ki^ /^jlL severe hemorrhage. |H^^^ /^f^^i ^9^* Absent Uterus. — En- «|H^^^|^^^>'h^ .^^ "f tire absence of the uterus is ^S^gH^HpB rare, and is almost always ^^^W^^^^ associated with absence of i / the other genital organs, : / ^ particularly of the vagina. A' i^ The determination of the " ^ , jl' condition is difficult. V i '^ 9 I ^^^ introduction of the I I 5 B y index-finger of one hand into I > the rectum, and that of the other or of a catheter into ^ the bladder, enables the op- S'- erator to explore thoroughly •^ ^^ the pelvis. Failure to recog- nize the organ may be due to its rudimentary condition or Fig. 157.— Uterus Bipartitus or Duplex, i^s displacement to One sidc, and we can assert its entire absence only when we liaA^e been able to explore the pelvis through an abdominal incision or during an autopsy. 293. A rudimentary uterus may exist in the form of a sHght thickening over the surface of the bladder, as two undeveloped canals in the form of a T, — the uterus bipartitus (Fig. 157), — when the vagina is frequently absent or may be partly developed, deepened by coition, or may exist as a small culdesac continuous with the urethra, which has been dilated by repeated efforts at coition. Menstruation is generally absent; ovulation may occur without molimina, or there may be the occurrence of hematometra. When the vagina is well developed and menstruation occurs. MALFORMATIONS. 229 the condition may remain undiscovered. The rudimentary character of the organ can be determined by bimanual palpation or by palpation through the rectum and the bladder, as has been described. The occurrence of painful molimina may require castration. 294. Fetal and infantile uteri are instances in which the organ has been arrested during the fifth stage of its development. The uterus is small, the cervix two or three times the length of the body, and an acute anteflexion of the body probably exists. The infantile uterus differs from the fetal in that the arbor vitag arrangement of the mucous membrane no longer extends to the fundus. Menstruation rarely occurs, and sexual desire may be absent. The external genitals may be poorly or well ^ developed. The breasts not -^17 ^^-^ infrequently are normal. Treatment. — The existence of a malformation is an indica- tion of defective development and presents a condition in which the function of the af- fected organ must be more or less impaired. The presence of a septum through the uterus and vagina may be a cause of dyspar- eunia, due to the diminished size of the vaginal canal. It need not produce distress or danger during gestation, but not infrequently the cervical and vaginal septa may cause dystocia. The vaginal septum should be cut through its entire length and the edges of each wall sutured to prevent readhesion. The division of the septum by the thermocautery has been advo- cated as saving the time necessary for suturing. The cervical septum can be crushed by forceps, which should be left in place to produce necrosis of the compressed tissues. Such septa do not generally withstand the first gestation, but are broken dowm in the course of labor. I have twice seen a bridle of tissue attached to the lower portions of the anterior and posterior vaginal walls, which were without doubt remnants of an originally more complete septum. The division of the uterus into two equally developed por- Fig. 158. — Uterus Biseptus. 230 GYNECOLOGY. tions does not usually call for treatment. The investigation of a large number of such cases demonstrates that pregnancy has frequently occurred without appearing to produce difficulty in parturition. This necessarily depends upon the development of the separate cornua. In one patient upon whom hysterectomy was done for inter- stitial myomata her history revealed that she had given birth to two children, apparently without any unusual phenomena. The operation disclosed that she had a rudimentary horn upon one side, which had its own cervical canal and opened into a blind pouch for a vagina, which was situated between the existing vagina and the bladder. It is my purpose upon the next opportunity to split the adjoin- ing cornua of a partially bifid uterus, and after coaptating their edges, suture the surfaces so as to establish one cavity. It may be questioned how such a reconstructed organ will endure the course of a gestation, but if pregnancy can go to full term in one horn of the uterus, the organ thus formed should be more capable of performing its physiologic functions. Where the uterine cornua are unequally developed, the danger is from conception occur- ring in the rudimentary cornu. The recognition of the exist- ence of such a pregnancy should be considered ample justifica- tion for its extirpation by operation. Where both cornua are rudimentary and the patient suffers from menstrual molimina, the abdomen should be opened and the ovaries removed. Simi- lar advice is proper when the uterus is absent. The fetal and infantile uteri frequently present conditions in which the function of menstruation is performed irregularly and attended with severe pain. The probability of the patient becoming pregnant and carrying the fetus to full term is depend- ent upon the degree of development. Under the stimulation of the marital relation such uteri occasionally increase in size. More frequently the individual complains of irregular and painful menstruation and is sterile. 295. Congenital prolapsus uteri is an exceedingly rare con- dition, and is usually associated with other forms of defective development, as spina bifida. 296. Accessory or trifid uteri have been reported. Hollander, in 1894, found a second uterus lying in front of the normal organ, between it and the bladder. It was a simple cervix with two orifices, having neither adnexa nor round ligaments. Depage describes a trifid uterus which probably arose from a diverticulum of one of the ducts of Miiller. 297. Absent or Rudimentary Tubes. — Absence of the Fal- lopian tubes is a rare occurrence, and is associated with a similar condition of the ovaries and uterus. The absence of one tube is MALFORMATIONS. 231 of more frequent occurrence; a unicornate uterus is generally found. A rudimentary tube is generally the result of an attack of fetal peritonitis. The tube may be a simple cord and yet have well-developed fimbria. The fimbria may be independent of the openings. 298. Accessory tubal ostia are frequent. Ferraresi found six openings upon one tube, all of which were surrounded by fimbria. These openings are generally near the end, but may occur near the middle of the duct. They are probably due to failure in closure of the groove in the germinal epithelium or to splitting of the Mtillerian duct after it has closed. 299. Anomalies in Length. — The normal tube is from ten to twelve centimeters long; in ovarian or broad-ligament cysts and in ovarian hernia one tube may be found from sixteen to eighteen centimeters long. 300. Absent or Rudimentary Ovaries. — Absence of ovaries is an exceedingly rare condition, requiring an inspection of the abdominal cavity to confirm the suspicion. Absence of one is less rare, and is associated with a unicornate uterus, and occasion- ally with absence of the corresponding kidney. The rudi- mentary state is more frequent, and may be fetal or adult. It may contain no glandular tissue, or the presence of unclosed Pfiiiger's tubes may lead to a suspicion of a testicle. The con- dition may be produced by oophoritis or peritonitis during fetal or adult life, or by the twisting of a pedicle. 301. Supernumerary ovaries are very rare. Von Winckel found a third ovary in front of the uterus. Tufts of ovarian stroma have been described. The occurrence of menstruation, and even of pregnancy, after the supposed removal of both ovaries has been reported, but it is more probable that in all such cases there has been failure to remove the entire structure of both glands. 302. Accessory or constricted ovaries are more frequent. A portion of the ovary may depend from the main body by a more or less well-marked pedicle; as many as two or three have been found associated with one ovary. 303. Displacements. — The descent of the ovary may have occurred, and the organ may be situated above the brim of the pelvis. The presence of the ovary in the sac of a hernia is a lesion often difficult of accurate recognition and productive of serious distress. 304. Defects of Round or Broad Ligaments. — Absence of the round ligament is generally associated with absence of the uterus in whole or in part. I saw one patient in whom the muscular structure of the round ligament was completely ab- sent. The fold of the broad ligament, in which the round 232 GYNECOLOGY. ligament would lie, presented a thin, corrugated margin. The persistence of the canal of Nuck results in the formation of a hydrocele, which may attain to considerable size in the labia majora. The broad ligaments may be absent, extremely short, or unequal in length and thickness. They may contain cysts, which are relics of the parovarium. 305. Complete Absence or Rudimentary Development of the Vagina. — In complete absence of the canal no trace of vaginal tissue will be found between the rec- tum and the bladder. These tw^o organs lie in contact, with connective. tissue only intervening. (Fig. 159.) In the rudi- mentary vagina a fibrous cord may exist, indicat- ing the site of the ducts of M filler, the develop- ment of which has been arrested in an early stage of fetal life. We may have a complete absence of one of the segments of the vaginal canal, with an incomplete develop- ment of the other. In these cases of absent or rudimentary vagina the uterus may be entirely absent, reduced to a rudi- mentary nodule, or more or less defective in its de- velopment. Rarely will a well-developed uterus be found associated with . absence of the vagina. In some patients normal ovaries: are present without any manifestation of menstrual moli- mina. Occasionally, there are periodic pains at the times of ovula- tion. Cases have been reported of vicarious hemorrhages from dif- ferent portions of the body, associated with extreme pains at the supposed menstrual periods, when a well-formed uterus was present. The vulva may also be absent, but is more frequently well formed, presenting a funnel-shaped depression behind well-developed nymphae. The hymen may be perfectly normal Fii 159- -Absent VaRina. MALFORMATIONS. 233 and the urethra at times may be dilated by the efforts that have been made to effect coition. It is difficult to determine why it should be the lower portion of the vagina that most frequently is present in cases of arrested development. It is probably due to an abnormal elongation of the vestibular canal. This pouch, in the absence of the vagina and uterus, has been found to be two or three centimeters in length and sufficiently wide to admit the finger. These dimensions are very considerably increased by sexual efforts. The opening is generally closed by a pearly, reticulated membrane with a cicatricial appearance. The central portion of the vagina may be absent, or the two por- tions may be separated by a membrane of variable thickness, Avhich at times is perforated. One patient came under my ob- servation in whom there was a membrane dividing the upper and lower halves of the vagina, and a small opening situated at one side, which permitted the menstrual discharge to escape. The incision of this membrane exposed a good-sized cavity above, and by cutting out a por- tion of this septum, the two mucous membranes of the upper and lower halves were sutured together, to form a good-sized vagina. In patients w4th absent vagina the condition should be determined by a finger in the rectum and a catheter or a sound in the bladder. Combined rectal and vesical touch enables us to rec- ognize the presence of the uterus and its degree of development. Treatment. — x\bsence of all or a part of the vagina affords different indications according to the development of the uterus. If the latter organ is normal and the symptoms of menstrual molimina have existed, with a uterus increased in size, the presence of hematometra should be suspected, and interference should be employed. If there is no uterus and well-developed ovaries are present, associated with painful sensations, the condition may be considered a sufficient indication for cas- Fig-. 1 60 Line of Incision for For- mation of Flaps. Flaps from labia minora which are split and used to line the vagina. 234 GYNECOLOGY. tration. Absent vagina renders the person sexually incom- petent, and it becomes a serious question as to whether a vagina shall be established for sexual purposes. The operation for the formation of a vagina was first performed by Amus- sat. It is performed by making an incision through the vul- var surface, using chiefly the fingers in the division of the soft parts, and proceed- ing step by step with tearing and dissecting combined. The finger of the operator or of an assistant should be kept in the rectum and the sound in the bladder. These organs can be thus readily recognized and their injury avoided. When a depth of from six to eight centimeters has been reached, or the peritoneum opened, the second step of the opera- tion should be performed, which is the investment of the funnel thus estab- lished with integument to prevent cicatricial con- traction. The skin and mucous membrane of the adjacent parts may be employed for this pur- pose. When the labia minora exist, they may be split and utilized for the lining of the anterior portion of the canal, while flaps may be taken from the vulva and inner side of the thighs to line the pos- terior walh (Figs. i6o and i6i.) After the sutures are applied the cavity is packed with iodoform gauze, and the packing is retained or renewed until cicatrization is complete, when the canal may subsequently be kept open by a glass plug. (Fig. 162.) In some cases attempts have been made to establish cicatrization over a glass plug in the newly created canal, without any attempt to line it with mucous membrane. Such a canal, how^ever, is ex- Fi 161. — Flaps outlined in Fig. i6o Sutured in Place, and Denuded Stufaces which Have Furnished Flaps to line Posterior Wall. MALFORMATIONS. 235 ceedingly difficult to keep open, because it is liable to contrac- tion even though an obturator is constantly worn. The lining of such a canal has been accomplished by following the opera- tion by one upon another patient for redundant vagina, and utilizing the vaginal tissue removed to form a lining membrane for the newly created vagina. The tissue should be sutured over a glass plug (Fig. 162), or, preferably, over the end of a slightly distended bivalve speculum, which is introduced into the canal with the prepared hood of membrane, and as the speculum is withdrawn, some iodoform gauze is lightly packed through it, keeping the membrane in place. During the preparation of the vaginal lining the cavity should be packed with gauze, and the packing introduced with the hood should be removed at the end of a week. If the tissues by this time have united, it should be irrigated, removing any tissue which has not retained its vitality. In the patient represented by Figs. 160 and 161, after forming the wall of the anterior portion by splitting the labia minora, I transplanted a flap from the posterior part of each thigh, which fortunately became attached, and a very satisfactory vagina was formed. In making the dissec- tion for the vagina, no hesitancy should exist in opening through the peri- toneum. By making such an opening the presence and size of a rudimentary uterus are more readily determined and the latter organ affords a safe point for the fixation of the flaps to line the constructed vagina. I have no question that the employment of a portion of the sig- moid or ileum, as advocated by Baldwin, of Ohio, will prove the most efficient vagina. Such a procedure requires necessarily an abdominal incision, as the culdesac of the bowel must be restored by the anastomosis, throwing out the loop utilized for the vagina. 306. Unilateral vagina is due to arrest of development in one of the ducts of Miiller, the other forming the vagina. Such a condition may be suspected when the canal is extremely narrow. In cases of double vagina there may be incomplete development of one of the ducts. 307. Double Vagina (Fig. 163). — In this condition the septum divides the entire vagina, when the uterus is also double or divided. Occasionally, the septum in the uterus does not ex- tend through the external os, while that of the vagina terminates below it. The hymen may have two openings, simulating double Sims' Glass Dilator. 236 GYNECOLOGY. vagina. Coition generally occurs through the larger of the two conduits ; occasionally it takes place in either one. When the partition of the vagina is partial, the superior portion of the septum will be lacking. When the uterus is double, the upper portion of the vagina is often found to contain the septum, while fusion has been complete below. The septum is usually thick and fleshy, resembling the rectovaginal partition, or it may be very thin, and even perforated in places. Partition of the vagina is not incompatible with normal labor. Dunning has reported cases in which the two vaginae were separated by a septum that be- gan just above the vulva and extended to the interval between the two small cervices. The separation of the uterus into two parts was demonstrated by the use of the sound. Pregnancy occurred upon the right side, and as the uterus en- larged, the septum dis- appeared. During labor the vaginal por- tion was torn from top to bottom and only the lower portion per- sisted. An incomplete septum may form an obstacle to the passage of the child's head. When it does so, it should be incised. In one patient under my observation there had been a vaginal septum, which was destroyed during a previous labor, and there remained a bridle extending from the anterior wall of the vagina back to the posterior commissure, which hung below the vulva. Twice have I cut through the septum the entire length of the vagina, and sutured the surfaces on each wall, so that a single canal was formed. This course I ■^*^ Fig. 163. — Double Ya.gma.— (Photograph taken from patient of Dr. J. M. Fisher.) MALFORMATIONS. 237 considered wise, as it decreases the discomfort during coition and removes a cause of dystocia in the event of pregnancy. 308. Atresia of the genital canal is either congenital or acquired. The latter will be discussed farther on in these pages. Congenital atresia may affect any portion of the canal, but is more likely to occur within the vagina or near its orifice at the junction of the vagina and vestibular canal. Next in frequency is the atresia of the internal or external orifices of the cervical canal, although the congenital closure of these orifices is comparatively not nearly so frequent as is the ac- quired. Vulvar atresia is not un- common. It is produced by im- perforation of the hymen or ag- glutination of the labia minora or majora. In the latter there is usually an orifice in front through which the urine and menstrual flow can escape. Such conditions are often unrecognized until after the establishment of puberty, when the occurrence of periodic distress in the pelvis, colic-like pains, sensa- tion of weakness, bearing dow^n, and irritability of temper indicate an effort to establish the menstrual flow. The continuance without discharge, and later the develop- ment of a tumor in the median line, should awaken the suspicion of the attendant to the possibility of obstruction to the menstrual dis- charge and of its accumulation within the genital canal. The mere inspection of the parts discloses the imperf oration of the hymen. (Fig. 164.) A tumor will protrude from the vulva ; there is difficulty or abnormal frequency in micturition, more or less obstruction in evacuating the bowels is experienced, and a smooth, purplish sur- face is seen at the vulvar orifice. If the obstruction is situated in the vaginal canal, the vulvar protrusion will not be so marked. The introduction of the finger into the canal, however, dis- closes the accumulation. It is more definitely determined by the finger in the rectum, when the globular tumor encroaching upon that organ is recognized. Pressure over the abdomen causes a sensation of elasticity or indistinct fluctuation. When the vagina is absent, the accumulation forms in the upper part. ^ Fig. 164. — Imperforate Hymen. 238 GYNECOLOGY. of the vaginal canal or within the uterine cavity. An accumu- lation in the vagina is known as a hematocolpos ; in the uterus, as a hematometra ; in the Fallopian tube, as a hematosalpinx; in both uterus and vagina, as a hematocolpometra ; and when the distention also involves the tube, it becomes a hematocolpo- metrasalpinx. The symptoms are : absent menstruation, although the patient experiences each month discomfort, a sense of fulness or engorge- ment in the pelvis, with the usual nervous manifestations which awaken the anticipation that menstruation is about to make its appearance. A symmetrical enlargement of the lower abdomen appears, which from its contour has been mistaken .by the care- less observer for preg- nancy. The history of the case, with a careful physical examination of the patient, should establish the diagnosis. When the obstruction occurs at the internal OS with a normal cer- vix and roomy vagina, the diagnosis becomes more difficult. The mere fact that a girl has never menstruated does not exclude the possibility of preg- nancy. In the latter will be found mam- mary changes, an en- larged and softened cervix, increased va- ginal secretion, swell- ing, and a dusky appearance of the vagina and vulva. In the accumulation of blood these symptoms are absent and the cervix remains small, rather firm, and hard. As the accumulatin increases the cervix becomes softened, the uterus thinner, form- ing a thin- walled sac which affords distinct fluctuation. Treatment. — Operators were formerly very much averse to evacuating the fluid of such a collection. The fluid is thick, chocolate colored, and quite slimy, due, of course, to the retention of the blood and mucous secretions of the canal. It formerly was advised that a small pinhole orifice should be made through the opening in the hymen, to allow the dis- charge to continue slowly for several days. Such a procedure ' '^W'^^'^^V^KKKK'^' '% -Hematocolpos. MALFORMATIONS. 239 almost surely resulted in infection of the material and produced an inflammatory condition of the genital canal which not in- frequently caused the death of the patient. The enormous dis- tention of the tissues renders them extremely anemic, and the removal of the pressure naturally permits an engorgement, which can readily result in inflammation. The most satisfactory method of treatment, however, consists in a free incision to evacuate the contents of the cavity ; remove the stringy mucus with the finger, and then thoroughly irrigate with a weak antiseptic solution, such as a two per cent, sodium bicar- bonate, three per cent, sodium chlorid, bichlorid of mercury (1:4000), or formalin (1:1500). A large quantity of the solu- tion should be em- ployed ; the irrigation to be followed, when of the two latter so- lutions, by a douche of normal salt solu- tion. Finally, when the quantity of fluid evacuated is large, the cavity should be lightly packed with iodoform gauze to af- ford moderate pres- sure upon the sur- face, to prevent en- gorgement, and to give the structures something upon which to contract. When the accumula- tion occurs above an obliterated or absent vagina, a trocar can be employed to reach the fluid, guided through the intervening structures with a finger in the rectum. The opening made by the trocar is then enlarged to permit a free evacuation, and the treatment already advised should be employed. When the accumulation occurs in the uterus from obliteration of the external os, it will often be diffi- cult to . determine the site of the latter. The cervix should be exposed, and if we can not determine the situation of the former OS, a puncture should be made with the trocar, which opening should subsequently be enlarged in order to permit the evacua- tion of the uterine contents. The cavity is then irrigated and packed with gauze. If the obliteration has developed at the internal os, the remaining cervical canal affords a passage Fig:. 166. — Hematometra. 240 GYNECOLOGY. through which the puncture can be safely made. The canal having been dilated and the cavity thoroughly irrigated, the latter should be lightly packed with gauze. In all cases in which the obstruction is found in the uterine or cervical wall, measures should be instituted to secure subse- quently a patulous canal, otherwise the obstruction will be re- produced. The better plan of procedure will be to suture the internal and external surfaces of the uterus. The one element of danger in these operations occurs when the Fallopian tube is distended with an accumulation and is fixed by extensive adhesions. The dragging upon the thin tube which occurs from the contraction of the empty uterus i Fig. 167. — Hematocolpometra. may cause its rupture and the escape of its contents into the peritoneal cavity. Extreme care should be exercised in a hematosalpinx not to make much pressure upon the abdominal surface while the sac is being emptied. Whenever the sac has disappeared with insufficient discharge from the uterus, or when it has disappeared before the opening into the collection has occurred, an immediate abdominal incision should be made to cleanse the peritoneum and remove the offending sac. 309. Lateral Atresia. — Atresia may take place in one-half of a divided vagina or uterus. When it occurs in a portion of the vagina, a lateral tumor will project into the vaginal canal, which will be so elastic and obscure as to render doubtful the fact whether it is a pelvic cyst or a lateral hematocolpos. Such I MALFORMATIONS. , 241 cases are less dangerous than atresia of the entire half of the vagina, as the accumulation will probably rupture into and discharge through the existing vagina. The opening, how- ever, will be high, permitting serious symptoms from infection and the development of a pyocolpos. It is generally advised to make a free incision and pack such a cavity with iodoform gauze, but I much prefer to excise a large section of the wall and unite the mucous surfaces of its cut edges so that the two chambers become one. When, the atresia has occurred in one half of the uterus, the diagnosis is difficult. It is not always situated to one side of the developed horn, but may curve about it. The accumulation may then be accessible through the vagina, or may be exceedingly difficult to reach. When accessible, it should be opened through the vagina. When inaccessible below, the tumor should be removed by an abdominal incision, as for pyosalpinx. 310. Absence of the vulva is generalH^ associated with a similar condition of the vagina and uterus, although this de- fect may exist with a normal development of the other genital organs. It then probably results from coalescence of the labia majora. The latter are generally absent in exstrophy of the bladder, and may also be found so in other malformations. The nymphas can be absent and the clitoris so imperfectly developed that the site of the vulva presents a mere slit or flattened surface, upon which the urethral orifice opens. 311. Infantile vulva is found in weak, sickly women, who have suffered from prolonged ill health prior to puberty, and is generally associated with an imperfect development of the uterus and tubes. The mons veneris and labia majora will be bereft of, or sparsely covered with, hair. 312. Defects in Nymphae. — Absence of the nymphse is in- frequent, and is accompanied by incomplete development of the clitoris. More frequently they are thin, flabby, elongated, and pointed. Occasionally they are perforated by small open- ings. Hypertrophy of the nymphse is much more frequent. The nymphae project beyond the labia majora; in the Bush- women of Africa they form large folds, which reach nearly to the knees, and are known as the Hottentot apron. 313. Defects of the Clitoris. — The clitoris may be so enor- mously developed as to cause the sex of the individual to be questioned. In exstrophy of the bladder and absence of the symphysis it may be bifid or rudimentary. It is rarely absent. Frequently, from congenital conditions or from neglect of cleanliness, the smegma is retained beneath the prepuce, pro- ducing such irritation and adhesions that the glans clitoris is compressed and prevented from attaining its normal size. The 16 242 GYNECOLOGY. \ adhesions become so firm as to render tlieir separation difficult. The existence of adhesions and the retention of smegma are capable of producing quite as marked nervous phenomena as the analogous condition in the male, some of which are: irritable bladder, nervous disturbances, masturbation, absence of sensa- tion, and convulsions. The occurrence of such symptoms should direct attention to the clitoris as a possible cause. Treatment. — When the clitoris is so large as to interfere with coition, a portion of it may haA'e to be removed, but the operative procedure should, if possible, be so designed as to retain the glans as the seat of sensa- tion. If the glans is covered by an adherent prepuce, it should be thoroughly exposed by pushing back the prepuce. The adhe- sions can readity be broken up with a probe or a grooved director. When the prepuce is so long as to form a hood and com- pletely envelop the glans, it should be retracted by removing an elliptic piece of integument about half an inch above the clitoris, with the long diameter of the ellipse parallel to the cleft of the vulva. This denuded portion should be closed by sutures intro- duced in its long axis. The length of the denuda- tion necessary depends upon the projection of the prepuce. The prepuce may be dissected away and the cut edges sutured so that the glans subsequently remains exposed. A better procedure is to remove the margin of the prepuce around the glans. The cut edges should then be united with catgut sutures. 314. Defects of the Hymen. — The hymen is composed of tissue analogous to the corpus spongiosum in the male. It partly closes the vaginal orifice, and has upon its superior surface the foldings of the mucous surface of the vagina. It is generally ^ .;^ Fis:. 1 68. — Enlaro-ed Clitoris. MALFORMATIONS. _ 243 crescentic (Fig. 112), with the concave margin anterior. It can present an annular opening (Fig. 113); two openings, sepa- rated by a septum (Fig. 116); or a number of openings (Fig. 117) — the cribriform. It sometimes resembles in appearance the infantile form, when it is infundibuliform (Fig. 115), or its edges may be dentated (Fig. 114) or serrated. Its normal situation is just within the vulva, where it is exposed by sepa- ration of the labia. In the colored race its situation is higher. Its opening in the marriageable woman will easily admit the tip of the finger. Atresia has been described. (Section 308.) Supernumerary hymen have been reported, but these are prob- ably congenital bridles in the vagina. A congenital absence of the hymen must be questioned. The hymen is generally a thin membrane, which ruptiu'es during the first coition (Fig. 118) and sloughs away after confinement, leaving as remnants the carunculae myrtiformes. The laceration may be central pos- terior, triangular, or stellate. After a single coition the torn surfaces may unite. I have seen two patients in whom the hymen was so firm as to form an actual barrier to coition, re- quiring incision to render the act possible. Cases are reported where it did not rupture during labor, or offered such an ob- stacle to delivery as to require incision. Its laceration is not usually attended with bleeding, but occasionally it is, however, followed by severe, and even dangerous, hemorrhage. Incision is made with bistoury or scissors, while the labia are widely separated. Two posterior lateral incisions are preferable to a single posterior. Hemorrhage, if severe, should be controlled by a vaginal tampon, or, preferably, by a suture. 315. Hermaphroditism is a condition in AA^hich there is a real or apparent union of the two sexes in the same individual. It is doubtful whether the organs of both sexes exist complete in any one individual, although there are numerous instances in which the penis has been found well developed, with a testicle upon one side, while within were found a uterus and an ovary upon the other side of the body. The case represented in figure 169 presents characteristics of the two sexes, but, like many other such cases, requires a microscopic examination to demon- strate the presence of both ovaries and testicles in the same individual. Pseudohermaphroditism is a condition in which there is such an apparent union of the sexual organs of the two sexes, or such a malformation, or defective development of the male organs or excessive development of those of the female, as to render the determination of the sex of the individual during life difficult, if not almost impossible. Pseudohermaphroditism is divided into masculine and feminine, according to the pres- 244 GYNECOLOGY. ence of testicles or ovaries. The females resembling men form a class known as the gynandria, while the man resembling the female is classed as an androgynus. Fig. 169. — Apparent Hermaphroditism. — {'^American Journal of Obstetrics.") 316. Gynandria. — The external organs of the female re- semble those of the male. The clitoris is large, with possible fusion of the labia majora, not infrequently of the labia minora. Fig. 170. — External Genital Organs of Madame Le Fort. — (Auvard.) simulating the scrotum and concealing the vulvar opening. This resemblance is still miore striking when there is associated an ovarian hernia into the labium ma jus. The internal organs MALFORMATIONS. 245 may be irregularly developed. The hypertrophy of the cHtoris does not necessarily change its form, and may arise in women who are addicted to masturbation. The labial fusion may be so firm as to require incision. An example of this class is ]\Iadeline Le Fort (Auvard) (Fig. 170), who was declared to be a female by Beclard when she was six years of age. The clitoris was very large; a groove upon the under surface led to a depressed urethra in the cleft of the vulva. The vagina w^as replaced by a small conduit, from eight to ten centimeters long, bordering upon a well- Fig. 171. — Outline of Internal Organs of Madame Le Fort. — (Auvard.) formed uterus. (Fig. 171.) ]\Ienstruation occurred at the eighth year, and escaped from an orifice situated at the root of the clitoris. Her general appearance was strongly masculine, and she was sexually indifferent. 317. Androgyna. — ^This class predominates, and its individuals are frequently monorchid or crypt orchid males, presenting ex- ternal characteristics of the female, such as enlarged breasts. The penis may be perfect, but the nondescent of the testicles and a median depression in the scrotum resembling the labia majora will give a distinctly feminine aspect. Arrested devel- 246 GYNECOLOGY. opment of the penis, hypospadias, and fissure of the scrotum greatly increase the resemblance. (Fig. 172.) Such persons are generally dressed, reared, and educated as girls, and have been married without being aware of their true sex. The determination of sex is of great importance. It re- quires careful consideration of the size, shape, and general configuration of the body. The testicle may be small, and be retained within the abdominal cavity. The seminal secre- tion is generally sterile. The breasts resemble the feminine, as do also the buttocks and thighs. The larynx is not promi- nent and the beard is scanty or absent. The rectal touch, with the catheter in the bladder, may fail to reveal either uterus or prostate. The mental condition is generally feeble or poorly balanced. When careful examination fails to render the sex certain, the individual should be classed as a male. Independent of increased freedom and larger opportunities for acquiring a live- lihood, the imperfect male is less likely to enter upon the marriage relation. When the sex of the individual is in doubt no operation for correction of the condition should be done, unless preceded by an ab- dominal section to ascertain the character of the internal genital organs. 318. Atresia of the urethra and vagina has been noted, but a fetus with this condition is nonviable. 319. Hypospadias is much more rare in the female than in the male. The vestibule is absent and the orifice of the urethra is not visible to inspection. Generally, the apparent hypospadias is really a persistence of the urogenital sinus. The urethra can be wholly absent, and the bladder ma}^ present a crescentic opening into the vagina. It is often associated with prolapse of the bladder-wall, and incon- tinence is usually present. 320. Epispadias is still more rare. It presents four varieties: (i) The corpus spongiosum is divided, and the urinary sinus is situated in the posterior surface of the clitoris; (2) added to the former condition there is a partial defect of the anterior urethral wall; (3) the anterior wall of the urethra is entirely absent, the clitoris is bifid, and the labium minus is attached on either side to a portion of the glans clitoris, while the pubic symphysis may also be defective; (4) exstrophy of the bladder, in which the anterior wall of the abdomen, with that of the Fig. 172 . — Androgy na. — (Pozzi.) I MALFORMATIONS. 247 bladder, is absent and the posterior vesical wall protrudes. The ureters open upon the surface, and the parts are constantly soiled with urine. The first form of epispadias is very rare, the last most fre- quent. While vesical ectopia is prone to result in disease and Fig. 173. — Imperforate Anus. Communication between Rectum and Vagina^ Fig. 174. — Congenital Defect of Vagina. Communication with the Rectum. obstruction of the ureters, which lead to hydronephrosis and early death, nevertheless histories of patients have been re- ported who have reached old age. The occurrence of epi- spadias and associated incontinence is not inimical to the oc- 248 GYNECOLOGY. currence of conception, and cases of pregnancy at full term are recorded. Treatment. — The urethra may be established by denuding and suturing the surfaces, but failure to secure a good result is frequent. Ectopia of the bladder is difficult of correction. Fig. 175. — Congenital Absence of the Urethra. Communication of Bladder with the Vagina. Fig. 176. — Communication of Rectum and Bladder with the Vagina. It is preferable not to attempt an operation during infancy, owing to the friability of the tissues and the probability of sutures cutting through. Transplantation of the ureters into the rectum probably affords the most satisfactory solution of the problem. 321. Duplication of the bladder has been found associated with a similar condition of the genitalia. MALFORMATIONS. 249 322. Open Urachus. — Permeability of the urachus and dis- charge of urine from the umbihcus are a result of congenital closure of the urethra, but sometimes occur independently. It is much more frequent in boys than in girls. 323. Irregular Exit of Ureter. — Opening of the ureter into the vagina has been described, but these are probably cases in which the supposed vagina is really a rudimentary bladder. I had an opportunity to examine a young woman in whom the bladder was rudimentary and the vagina formed a receptacle in which urine accumulated and prevented incontinence becoming complete. Baum describes an accessory ureter which opened at the side of the urethra. He operated by making an incision above the symphysis, cutting through the bladder upon the Fig. 177. — Suprapubic Opening of Vagina and Urethra. ureter, which he divided, tying the distal end, while the other was brought into the bladder. The procedure overcame the incontinence. 324. Abnormal Communications. — Errors in development may produce imperforation of one of the canals which per- forate the pelvic fascia or result in the union of tAvo or three of them. In any case the cause is analogous: i. e., failure to accomplish the union between the superficial and deep organs. Imperforations of the anus and urethra are vital, calling for prompt attention of the surgeon. Imperforation of the vagina has been considered. (Section 305.) The communications may be: I. Rectovaginal. (Fig. 173.) The vagina and urethra are normally developed. The anus is imperforate and, therefore, the fecal material is discharged by a rectovaginal opening through the vaccina. 250 • GYNECOLOGY. 2. Vaginorectal. (Fig. 174.) The rectum and urethra are normally developed, excepting the opening into the former from the incomplete vagina. 3. Vesicovaginal. (Fig. 175.) The rectum and vagina are normal in appearance, but the urine escapes through the latter, the urethra being absent. 4. Rectovagino vesical. (Fig. 176.) The rectum and bladder both communicate with the vagina. The urethra is generally absent. The anus may or may not be perforate. 5. Suprapubic opening of vagina and urethra. (Fig. 177.) This condition is extremely rare. TRAUMATISMS. 325. Injuries of the genital organs of sufficient gravity to produce temporary or permanent structural changes, to in- fluence the subsequent health and comfort of the patient, are, for the most part, limited to lesions of the vulva, vagina, and cervix. The causes productive of such conditions may usually be assigned to one of three general classes, viz. : 1. External violence. 2. Coition. 3. Parturition. 326. External Violence. — The cases of injury from external violence are comparatively infrequent. They occur in a variety of ways. A woman standing upon a chair or step-ladder falls astride the back, or upon the post or round of the chair. Bovee reports the case-history of a young girl who fell from her bicycle upon the lamp bracket and sustained a complete laceration of the perineum. Lacerations may be produced by sliding down bannisters and striking against the newel post, by sliding from a haystack or haymow, falling upon the handle or prong of a fork or upon a hay-knife. Howe men- tions a young woman who thus slid upon the handle of a fork, which entered the vagina and penetrated the abdominal cavity twenty-two inches, and from which she ultimately recovered. Curran cites the case of a patient in whom the horn of a goat entered the anus and tore through the vagina. Girls have been impaled upon barrel staves, fence palings, or the sharp stump of a sapling. A chamber or slop- jar breaking under the patient has been the cause of injury. The fracture of a glass-ball pessary in the efforts at its removal has produced vaginal laceration and even fistula. Royster reports two cases TRAUMATISMS. - 251 of complete laceration of the perineum in young girls, which were caused by the finger of the obstetrician while they were yet within the body of the mother. The injury may be a free incision, a ragged laceration, or a severe contusion. The in- cision may be produced by striking upon a blunt object, the sharp edge of the rami cutting through the overlying tissues. Large vessels may be ruptured without the skin being broken, when a severe hemorrhage will occur into the tissues. In the former case the hemorrhage w411 be open; in the latter, concealed. Treatment. — The injury of vessels and the resulting hemor- rhage into the tissues are called pudendal hemorrhage (see Vulvar Hematoma). This may demand evacuation, and the resort to measures for the control of the bleeding vessels. Severe hemorrhage following an injury should demand an inspection of the injured part and the resort to measures for its control. Where a good-sized vessel is bleeding, the wound, if necessary, should be enlarged and the vessel ligated. Frequently the hemorrhage can be controlled by the sutures which are employed to close the wound. General oozing from a ragged opening is often best controlled by gauze pressure. The w^ound must be carefully cleansed and maintained in an aseptic condition. 327. Coition, as is well known, causes a rupture of the mem- brane — the hymen — which guards the vaginal opening. Lacera- tion of this structure is usually central and posterior. It may, however, be bilateral. Occasionally, as has been seen, the hymen is so firm as to resist all attempts at coitus, and, there- fore, will require incision before the act can be accomplished. The entire vaginal canal is more or less dilated by the repe- tition of the sexual act, as is evidenced by the enlarged and roomy canal which distinguishes the nulliparous from the virgin vagina. Severe lacerations of the vulva and vagina the result of sexual intercourse are rare, except when produced by rape of young girls. Instances are reported, however, in which injuries of gravity have been produced, as the tearing off of the hymen, the perforation of the posterior vaginal wall, the rupture of the perineum, the formation of rectovaginal fistula, and perforation of the posterior vaginal fornix. Such injuries are more likely to occur in those who come to the first coitus late in life, or in whom there have been premature atrophic changes. Skrobanski, however, cites a young peasant, aged twenty-two years, in whom the first coitus caused a rupture of the perineum, two centimeters in depth, but without enter- ing the rectum. R. i\brahams reports the history of a woman,. 252 GYNECOLOGY. twenty-six years old, in whom a rectoperineal fistula was produced which permitted the introduction of two fingers. Occasionally the first coitus is followed by a hemorrhage so active as to endanger the life of the woman. The bleeding is best controlled by the introduction of a suture to include the spurting- vessel. Treatment. — Injuries resulting from the sexual act are rarely of sufficient importance to demand surgical interference. Fig. 178. — Knives for Denudation. Fig. 179. — Curved Scissors. Fig. 180. — Retractor, If severe, the treatment will depend upon the character and extent of the injury. An extensive laceration should be sutured. The sexual act should be discontinued until the injured parts have fully recovered, and it then should be practised with the utmost gentleness and care. 328. Parturition. — Maternity is not without its penalty. The great majority of the injuries to which the genital organs are subject occur during or as the result of labor. The in- juries are due to faulty anatomic conditions, as distorted pelves, TRAUMATISMS. 253 rigid, unyielding muscles, inflamed and undilatable cervices, abnormal positions of the fetus, disproportion between its size and that of the pelvis, violent uterine contractions, long-delayed and feeble contractions, and premature or too long postponed instrumental or manual interference. The long-continued pressure of the fetal head impacted in the pelvis is probably even more disastrous than the pre- mature delivery by the application of forceps. Indeed, vesico- Fig. 182.— Needle-holder. Fig. 183.— Needles. Fig. 184. — Needle with Loop for Suture. vaginal fistulae, which were of frequent occurrence prior to the educated use of the forceps, now rarely come under ob- servation. The injuries are of great variety, and affect the uterus, — both body and cervix, — the vagina, the vulvar out- let, and particularly the perineum. 329. Injuries of the body of the uterus may occur in the form of lacerations of the anterior or posterior wall, in a vertical or transverse direction, and may be slight or sufficiently large 254 GYNECOLOGY. to permit the escape of the fetus and placenta. After an abor- tion, the softened uterine wall is occasionally perforated by the curet or placental forceps or both, and through such a per- foration loops of intestine have entered the uterine cavity, been drawn through the os, and subjected to serious injury. Injuries of this structure are not confined to parturition alone, but the walls of the inflamed or flexed nonpuerperal organ are frequently perforated by the use of the sound or bougie. In removal of fibroid growths, the weakened wall can be ruptured and the tumor projected through it, or the fundus uteri can become inverted and be incised during the removal of the growth. Treatment. — For the proper course of treatment in rupture of the uterus during labor the student is referred to one of the text-books on obstetrics. Perforation of the uterus in the effort to evacuate decomposing placenta or membrane follow- ing an abortion should demand careful subsequent observation. In such cases the danger of perforation is so great that the retained fragments should be removed, if possible, by the finger, and placental forceps should only be used with the finger as a guide. Evidence of perforation as presented by bringing a coil of intestine to the os should require careful replacement of the knuckle of the intestine and a certain determination that it has been pushed entirely through the uterine wound, after which the uterus should be packed with iodoform gauze. Any appearance of shock, disturbance of temperature, or continued and severe irritation of the stomach should be recog- nized as an urgent indication for abdominal section. Perfora- tion of the uterine wall by sound or bougie, unless associated with infection, has but little significance. Care should be exercised, however, not to irrigate with irritating fluids, and drainage of the uterus should be secured by gauze. The lacera- tion of the uterus during removal of fibroid growths should be considered an indication for immediate suturing of the wound through an abdominal section. 330. Injuries of the cervix uteri are described under the term laceration. Laceration of the cervix is the most frequent lesion of labor. It is exceedingly rare for a w^oman to undergo her first parturition without tearing of one or both sides of the cervix. The tear may vary from a slight fissure, which com- pletely disappears during convalescence, to an extensive lacera- tion, extending to or into the vaginal fornices. Lacerations of the cervix are unilateral, bilateral, stellate, and through the anterior or' posterior lip. The bilateral is the most frequent. The unilateral is more frequently found upon the left side, owing to the greater preponderance of the left occipito-anterior position. Lacerations can occur into the TRAUMATISMS. 255 cellular tissue laterally, or into the bladder in front, and in the latter cause a vesico-uterine fistula. (See Section 353.) The cicatrization of a lateral tear may produce a band or bridle which tilts the fundus uteri to the opposite side. 331. Symptoms. — Laceration of the cervix presents no special or specific indications of its existence. The symptoms are those produced by the complicating conditions. The lesion causes subinvolution and a consequent increased weight. A bearing-down sensation, discomfort in standing or walking, and pain in the sacrum and iliac regions are common. The lower level maintained by the organ and the traction of the vaginal wall upon its lips lead to separation of the latter, e version of the cervical mucous membrane, thickening of the tissue from its exposure, and fixation of the everted lips. Ir- regular or excessive menstruation, or metrorrhagia, is not Fig. 185, — Slight Fissure of Cervix. Fig. i86. — Extensive Laceration of Cervix. — (Munde.) infrequent. Bleeding is excited by locomotion, coition, or sexual excitement. The endometritis causes a profuse leu- korrhea, which constitutes a double drain. The cicatricial bands and the everted lips not only permit a depression of the uterus in the pelvis, but produce either lateral version or retro- version, according to the unilateral or bilateral character of the lesion. With cicatrization of the lacerated surfaces, not infrequently the scar tissue in the angles of laceration causes pressure upon the nerves, producing profound neurotic or reflex phenomena. Not infrequently the presence of neu- rasthenia may be created by pressure of the cicatricial tissue upon the nerve filaments. Pressure with the finger against •such indurated tissue aggravates the reflex phenomena. 332. Diagnosis. — A laceration of the cervix is readily recog- nized by the finger, but its apparent presence must not be 256 GYNECOLOGY accepted as proof positive of previous pregnancy, for a congenital fissure can exist which will permit as marked an eversion of the lips as would be produced by a deep bilateral tear. The finger will disclose the condition of the lesion, the extent of the cicatri- Fig. 187. — Bilateral Laceration of Cervix. — (Munde.) Fi: [. 1 88. — Slight Stellate Laceration of Cervix. — {Munde.) zation, the eversion of its lips, the presence of erosion (dis- closed by its soft, velvety feel), or the existence of eversion of the cervical mucous membrane. Inflammation and obstruc- tion of the glands of Naboth will be revealed by small, shot-like masses studding the cervix. As the finger is passed upward the Fig. 189. — Extensive Stellate Lacera- tion of Cervix. — (Munde.) Fig. 190. — Laceration of Cervix with Hypertrophy and Eversion of Cervical Mucous Membrane. — (Munde.) lips will be found to spread out, like the top of a celery stalky but hard, dense, and fixed. The bivalve speculum, in drawing upon the anterior vaginal wall, aggravates the eversion. The tubular speculum flattens the surface, removes all trace of the fissure, and leads to its being TRAUMATISMS. 257 mistaken for granular erosion. The Sims or some retraction speculum affords the best exposure. Seizing each lip with a tenaculum and drawing them together discloses the extent of the tear. (Fig. 192.) The surface of the tear is covered with exuberant granulations, which bleed upon the slighest touch (Fig. 190), and the profuse discharge renders the differentiation from epithelioma sometimes exceedingly difficult. The diagnosis may be established by the results of treatment. 333. Treatment. — Immediate examination after labor to ascertain the extent of laceration is generally impracticable, be- cause the cervix is so drawn out and thinned that it is difficult to determine the lesion. The majority of small lacerations close spontaneously under the employment of ordinary antiseptic pre- cautions. The existence of severe arterial hemorrhage should require an examination to ascertain its source, and when found, is best controlled by suturing the lacerated surfaces. Not every laceration demands an operation, and if not done within a week, three months should pass before it is repaired. I quite agree with Dickinson that the period of choice for operation is five to seven days following the occurrence of the lesion, for at this time involution has taken place sufficient to permit the lesion to be disclosed, and operation at this stage favors normal involu- tion thereby, and lessens the danger of the occurrence of endome- tritis and other complications. Small fissures which are in- clined to close or have cicatrized do not require an operation. When the lesion is complicated with endometritis, the latter should be treated. Operation in slight cases is to be condemned, as it obstructs drainage and may cause the extension of disease to the tubes and pelvic peritoneum. Repair is indicated in deep laceration, in eversion with hypertrophy and cystic degen- eration of the mucous membrane, in cicatricial formation at the angles of the fissure producing reflex phenomena, and in sub- involution and endometritis. In addition to slight lacerations- and those which have cicatrized, surgical interference confined to this lesion is contraindicated in tubal or peri-uterine disease. 334. Complications. — The presence of endometritis, associated with marked eversion and hypertrophy of the mucous mem- brane, requires treatment prior to the operation for laceration. The patient's diet should be regulated, constipation corrected, and appropriate measures instituted to relieve the accompany- ing anemia ; she should be permitted to take a vaginal douche of hot water containing an ounce of rock-salt to the quart twice daily. The cervix should be scarified or punctured, thus securing depletion. All obstructed Nabothian glands should be punc- tured and the gland cavity painted with Churchill's tincture of iodin, a combination of tincture of iodin and creasote (2: i), 17 258 . GYNECOLOGY. iodin crystals dissolved in 95 per cent, carbolic acid solution, silver nitrate (5j to f§j), zinc chlorid (3j to f 5 j), solution of argyrol, or pyroligneous acid. The superfluous material should be sponged away and a tampon of gauze and cotton applied be- neath the uterus. By raising the organ to a higher level the sensation of weight or heaviness is removed and the circulation is improved. The tampon may consist of plain sterilized gauze and cotton or medicated gauze (iodoform, carbolic or boric acid, or thymolized). Sublimated gauze should not be used, because it causes pruritus. The tampons may be medicated with preparations of glycerin, R. Alum ^j Acid, carbolic, ^iv Glycerin ,^ xij a fifty per cent, solution of boroglycerid, the official iodoform ointment, or a ten per cent, solution of ichthyol. In place of the glycerin the tampon may be medicated with an ointment, such as twenty-five per cent, of ichthyol in lanolin. The local treatment, followed by a tampon, should be applied twice a week, Fig. 191. — Blunt and Sharp Curets. and the latter removed at the end of forty-eight hours, to be followed by a vaginal douche of half a gallon of hot salt water (temperature from 110° to 120° F.) twice daily. The douches are preferably given with a fountain (gravity) syringe, while the patient is in a recumbent position on a bed-pan; although in those cases in which the cervix and the neighboring tissues con- tain a large amount of inflammatory exudate the bulb (David- son) syringe, by force of its current, exercises a salutary influence in promoting absorption. A profuse discharge of glairy mucus from the surface should be removed with a blunt curet. The curet presses the mucus-collections from the cervical glands and permits the application to come directly in contact with the diseased surface. The medicament may be applied by means of a cotton-wrapped probe, or be carried into the canal with a pipet. (Fig. 89.) Intracervical applications should not be made, however, unless the cervical canal is quite patulous, so that the fluid or increased serous discharge can readily escape. If the canal is obstructed by hypertrophied and everted mucous membrane, gauze packing (Section 90) or the use of a laminaria I TRAUMATISMS. 259 tent (Section 85) will render the application more effective and safe. Irregular bleeding or profuse leukorrhea should indicate the use of the sharp curet (Section 91), after dilatation (Section 87). The uterus should be irrigated during or following curet- ment with a disinfectant solution, bichlorid, 1:3000; formalin, 1 : 1000, a hot soda solution, 4 drams to 2 pints, or preferably with normal salt solution, and swabbed with a saturated solution of iodoform in ether. If for any reason there is much bleeding following the procedure, the uterine canal should be packed with iodoform gauze. 335. Trachelorrhaphy (that is, neck-sewing), or hystero- trachelorrhaphy (that is, womb-neck sewing), is the operation devised by Emmet for the relief of laceration of the cervix. Patient, prepared (Section 182) and anesthetized (Section 190), is placed upon a table in the lithotomy position, with a perineal pad beneath her buttocks to carry the irrigat- ing fluid into a slop-jar at the end of the table. Each leg is held by an assistant or secured by a leg-holder. The following sterile instru- ments (Section 174) have been placed in a tray upon a table at the operator's right : a scalpel or bistoury ; curved scissors ; long, rat -toothed dis- secting forceps; two double tenacula; a retraction spec- ulum (Edebohls') ; six pres- sure forceps ; a needle-holder ; four strong needles, curved and bayonet-pointed, each threaded with a loop of silk to serve as a suture carrier. A smaller tray will contain the suture material. i\Iy preference for sutures is chromic catgut, which has the advantage that it does not have to be removed (Section 176). The nurse at the operator's left should have charge of the sponges. These should pref- erably be sterilized gauze, though absorbent cotton wet with sub- limate solution, I : 2000, can be employed. A fountain syringe, filled with hot normal salt solution or some disinfecting fluid, should be suspended, so that the field of operation can be sub- jected to constant irrigation. The final preparation of the patient (Section 182) completed, the cervix is exposed with a speculum, and each lip so seized with a double tenaculum as to turn in the everted edges when the lips are apposed. (Fig. 192.) The Fig. 192. — Edges of Laceration Turned by Tenaculum Hooked into Each Lip. 260 GYNECOLOGY. assistant upon the operator's left holds the anterior lip by the tenaculum and controls the irrigation tube; the one upon the right attends to the necessary sponging. The posterior lip is held by the weight of the tenaculum. With the knife the operator cuts through the cicatricial angle, and in a bilateral Fig. 193- -Denudation of Lacerated Cervix. 'ig. 194- -Surfaces Denuded Ready for Union. laceration with scalpel and forceps denudes a corresponding surface upon each lip, first upon the left, then upon the right. The knife is preferred to the scissors, as the denudation can be made more evenly and with less bruising of tissue. The de- nudation is, of course, limited to one side in a unilateral tear. A strip of undenuded mucous membrane, one centimeter wide, should be left in each lip for the future cervical canal (Fig. 193), Fig. 195. — Sutures Introduced. Fig. 196. — Sutures Tied. and the precaution should be exercised not to encroach upon the vaginal surface of the cervix in the removal of the tissue. In deep lacerations the circular artery may be opened in the denudation. It should be seized with pressure forceps, and the first suture should be so introduced as to control it. TRAUMATISMS. 261 The sutures are placed by introducing the needle about three millimeters from the vaginal edge of the wound, bring- ing it out at its cervical margin, introducing it at a similar point in the other lip, and bringing it out in the vagina. Or- dinarily, three sutures will be sufficient upon each side. Occa- sionally the laceration will be so deep that the angle suture 1^ W Fig. 197. — Double Flap Amputation of the Cervix. — (Auvard.) Fig. 198. — Sutures Introduced. (Atward.) can not be properly placed by passing the needle as we have just described. It is then preferably introduced from within outward, which can be done by carrying the ends of the suture, by means of the carrier, through first the posterior and then the anterior lip, or with two need- les threaded with carriers, each passed from within outward, the one ante- rior and the other posterior. One carrier is passed through the loop of the other and drawn out. The loop thus carried through serves to carry the suture. The sutures are tied, super- ficial sutures are introduced, if needed, and the vagina is thoroughly irrigated. If bleeding should continue, a suture should be introduced well above the denudation to control the bleeding vessel. Avoidance of subsequent hem.- orrhage is particularly desirable if a plastic operation is also to be performed upon the vaginal outlet. 336. Amputation of the cervix is to be preferred when the cervix is much elongated and hypertrophied, when the mucous membrane has become extensively hypertrophied and everted, and when cellular proliferation justifies the suspicion of incipient malignant degeneration, although when the latter condition is ig. 199. -Wound Closed. 262 GYNECOLOGY. established , completehy sterectomy would be the better course to pursue. The amputation can be made by the double or single flap method for each lip. The instruments and preparations are similar to those given in the previous section (Section 335). Double Flap Operation. — The lips of the cervix are seized and separated by double tenacula; an incision is made in each angle to the point at which it is desired to make the amputation. A wedge-shaped piece is removed from each lip, forming cer- vical and vaginal flaps. Two sutures are then introduced in each lip, uniting the cervical and vaginal mucous mem- branes. On each side a su- ture is passed in through the anterior vaginal and cervical flaps, out through the similar posterior flaps, and external to this such sutures as are inserted are necessary to bring in ap- position the raw surfaces. The sutures are tied and superficial sutures intro- duced, if necessary, to adjust the edges of the wound nicely. The more accurate the adjustment, the less will be the subse- quent contraction. Single Flap Method. — Schroder's operation con- sists in making the denu- dation at the expense of the internal or cervical portion of each lip. This operation is preferable when the cervical mucous membrane is so diseased and h^^per- trophied as to render its retention for the formation of a flap undesirable. In this, as in the former operation, a lateral incision is made and the lips are everted. Instead of a cervical flap a transverse incision is made into the lip from within outward, at the level of the lateral incision, cutting half through the lip ; then a vertical incision to the junction of the cervical and vaginal mucous membranes. Two sutures unite the end of each flap to the corresponding cervical mucous membrane, and the remaining raw surfaces are adjusted by lateral sutures. Fic -Schroder's Single Flap Opera- tion. TRAUMATISMS. 263 337. After-treatment. — The after-care does not differ in the various operations upon the cervix. In the use of the chromic catgut suture no provision is made for its removal, but it is important to preserve it from becoming infected. Un- less the vaginal outlet is to be the seat of an operation, the vagina should be loosely packed with gauze, which should be removed in two or three days. The patient is kept in bed for two weeks, and then gradually permitted to resume her ordinary duties. Any pain should be relieved by the application of an ice-bag to the abdomen. The patient should void her urine, and the catheter should be used only when it is impos- sible for her to empty her bladder while in the recumbent pos- ture. Secure an evacuation of the bowels at least each alter- nate day. Avoid vaginal douches for the first forty-eight hours, affording the plasma opportunity to glue the appos- ing surfaces ; then use a douche of hot sublimate solution (i : 3000), formalin (i : 1500), or a I per cent, saline solution twice daily. Direct the patient to avoid worry or much exercise during the next menstrual period, and not to resume the sexual relation for one month. 338. Lacerations of the Vagina. — Small tears of the anterior, posterior, or lateral wall of the vagina are not infrequent, and result in ci- catrices which produce more or less disturbance of the pelvic functions. Separation of the muscular wall can occur without lesion of the mucous membrane. Not infrequently the entire vagina is crowded away from its muscular attachments, so that it subsequently appears as a relaxed sac, falls into folds which drag upon the cervix, displace the uterus, or, when it is fixed, produce hypertrophic elongation of the cervix. The most frequent lesions are at the vaginal outlet, and involve that por- tion of the pelvic floor known as the perineum. These lesions of the vagina are so intimately associated with, and dependent upon, the condition of the perineum that their treatment will be discussed with the lesions of the latter, under the head of in- juries of the pelvic floor. Lesions of the genital canal, especially of the cervix and vagina, may be induced by long-continued pressure of the head of the child during a protracted labor. The 1 i -»1 / 1] r ^'ii r'^T^lBIB ■^TJj Fic 201. — Schroder's Operation Com- pleted. 264 GYNECOLOGY. loss of tissue vitality will necessarily be dependent upon the severity and duration of the pressure. It may involve only the superficial structures, as an erosion or superficial sloughing, when the tissues may be regenerated or, if more extensive, there results contraction and stenosis or partial or complete obliteration of the canal, known as ac- quired atresia. Acquired atresia most frequently follows in- juries occurring during parturition, but it can be produced by irritating injections and severe inflammations. Atresia vaginse often occurs as a sequel of senile vaginitis. In one patient I found the entire vagina obliterated. The symptoms of such a condition are necessarily dependent upon the time of life at which it occurs. When it follows senile vaginitis, it often produces no symptoms outside those of marital inconvenience. During the menstrual life of the woman the symptoms are similar to those of the congenital variety. The patient suffers from menstrual molimina and a pelvic tumor follows. When the vagina is the seat of atresia, the condition is easily recog- nized, as is the uterine accumulation, if the obliteration occurs at the external os. W^hen the obliteration occurs at the internal OS, however, and the cervix is apparently normal, the diagnosis is more difficult, and the disorder may be confounded with fibroma uteri, malignant disease, or pregnancy. The careful analysis of the patient's history, associated with the examination, should aft'ord a reasonable suspicion as to its character. 339. Fistulas. — Deep sloughs involving a portion of the genital tract occasionalh^ lead to perforation of one of the ad- joining viscera, and we then have a fistula. The anterior wall is the most frequently aft'ected, and, consequently, results in a urinary fistula, which may involve urethra, bladder, or ureter, and be associated with extensive destruction of vagina and cervix. Fistulae are divided into urinary, fecal, and genital. The genito -urinary fistulas are: 1. Urethrovaginal. \ 2. Vesicovaginal. ) 3. Vesico-uterine. j (Fig. 202.) 4. Ureterovaginal. \ 5. Utero-ureterine. / The fecal fistulae are: 1. Anovulvar. ^ 2. Rectovaginal. V (Fig. 202.) 3. Entero vaginal. J 340. Etiology. — Genital cervicovaginal fistulae are most fre- quently caused by the accidents of labor. These lesions are of less frequent occurrence than formerly, the result of improved methods of delivery, by which the progress of the fetus is expedited TRAUMATISMS. 2G5 and the maternal parts are saved from long-protracted pres- sure. Fistulae are rarely the result of tearing, but generally follow a slough. Awkward use of instruments can result in per- foration of the bladder or the rectum, but such lesions present a marked tendency toward spontaneous recovery. Other causes of fistula are cancer involving the anterior or posterior vaginal walls, tuberculous disease, surgical opera- tions, ulceration from the presence of a vesical calculus, the pres- sure of a pessary, and abscesses or phlegmons. 341. Symptoms. — The presence of a urinary fistula is recog- nized by incontinence of urine and by the appearance of urine in the vagina. A fecal fistula will permit the discharge of liquid feces and gas. A few days subsequent to her confine- ment the patient com- plains of being unable / ^ to retain her urine, or - - '* ' possibly it may come with a gush, following the partial or complete separation of a large slough. The parts are afterward continually bathed with urine, the skin becomes reddened and irritated, and the salts of the urine are deposited, increasing the irritation. The clothing of the patient is saturated with de- composing urine, caus- ing a disgusting odor. Partial continence may be present when the opening is small, when it is situated high in the vagina, or when it affects but one ureter. The in- fluence of a fecal fistula depends upon its size and situation. A small opening may permit the escape of the contents of the intes- tine only when they are liquid. The odor of the vaginal secre- tion is exceedingly offensive, so that the patient suffers an enforced retirement. 342. Diagnosis. — Incontinence should at. once awaken a suspicion of a fistula. Large fistulae are readily recognized by vaginal palpation. Small fistula, associated with cicatricial contraction of the vagina, are often difficult to expose. The entire surface of the A^agina should be exposed with retractors or with a Sims speculum under a good light. If the opening Scheme Showins; Various Fistulae. 266 GYNECOLOGY is small, it will be revealed by injecting the bladder or rectum with milk or other colored liquid, when the opening will be observed as the liquid escapes into the vagina. This procedure affords a means for differential diagnosis between ureteric and vesical fistulas and between the rectal and enteric. The escape of clear urine into the vagina when the bladder is filled with a colored liquid demonstrates the ureter as the origin of the fistula. The introduction of a ure- teral catheter into the sinus and of a sound into the bladder permits the recog- nition of the intervening septum. If the opening is small and not visible, dry the surface and apply blot- ting-paper while the blad- der is being filled. The paper will be moistened at the side of the fistula (Pozzi) . The same object can be attained by packing the vagina with sterile gauze and injecting the bladder with colored fluid. The staining of the gauze will indicate the situation of the opening. In enteric fistulae the vagina is constantly bathed with liquid feces, and the appearance of the discharge is not affected by rectal enemas. There is an offensive vaginitis and the patient suffers from inanition. In supposed uretero-uterine fistula the position of the ureters should be examined by Sanger's method. (See Section 158.) It has been suggested that the patient urinate, then sit two hours upon a vessel, when a catheter is used; and if the quantity thus secured is equal to that in the vessel, there is a ureteric fistula. The collection has been obtained from separate kidneys. A fistula of one ureter may be inferred when, in spite of the periodical passage of urine through the urethra, the vagina Fig. 203. — Large Vesicovaginal Fistula with Prolapse of the iVnterior Vesical Wall through the Opening. TRAUMATISMS, 267 is constant^ bathed with urine ; a vesical fistula near the neck may permit of no accumulation of urine, while a small one in the upper part of the vagina may allow soiling of the latter canal only when the patient is recumbent. In the upright posi- tion the desire to evacuate occurs before it reaches the level of the fistulous opening. The most ready method of recognizing the ureteric fistula is by injecting the bladder with colored fluid. The con- tinuation of uncolored fluid in the vagina demonstrates that we are not dealing with a vesical opening. No operation should be attempted for rectal fistula without exclusion of rectal stricture. 343. Prognosis. — The curability of a fistula de- pends upon its cause, situa- tion, size, and duration. Those produced by cancer are a part of the progress of the disease, and are incur- able unless the disease can be removed. Spontaneous recovery of a punctured or incised fistula is prone to occur under proper cleanli- ness, but an old sinus with hard, cicatricial edges re- quires surgical interference. An opening in the base of the bladder is more readily relieved than one in the upper part of the vagina Fig. or one in the urethra. Vesico-uterine fistula are particularly difficult, and the uretero vaginal and uretero-uterine fistulce are most trying. 344. Treatment. — The methods of treating vaginal fistulas as now recognized may be considered as : 1. Cauterization. 2. Denudation and suture of the edges of the fistula. 3. Flap-splitting, fiap-sliding, and suture. 4. Flap-formation and sutures. 204. -Denudation of the Edges of the Fistula. 268 GYNECOLOGY. 345. Cauterization is applicable only to fistulse of small size and where but little cicatricial tissue exists. The thermocautery is the preferable means, although caustic potash, chlorid of zinc, or one of the stronger acids can be employed. 346. Preliminary treatment is important, whatever the method of operative procedure. The urine should be rendered non-irritat- ing by the administration of benzoin salts or salol. K . Ammon. benzoat. ^iij Tinct. hyoscyami, f ^iss Ext. buchu, r ad f 5 ij. M. SiG. — f 3 j in water three or four times daily. This prescription should be accompanied by the ingestion of large quantities of water. Salol, gr. ij-iij, may be given with a glass of hot water three or four times daily. Hot or soothing vaginal douches should be freely employed, such as a solution of sodium hypo- sulphite (oiv, aq. Oj) or weak solutions of the lead salts. If there is an incrus- tation of the lime salts about the orifice and over the vagina, employ a solu- tion of dilute nitric acid (gtt. j, mucilage water fSj). Cicatricial bands should be incised and stretched; the vaginal walls should be in- cised, to diminish traction upon the edges of the fistula when sutured. The cica- trization may be overcome by having the incisions heal while a Gariel pessary or a colpeurynter is worn. Bozeman employed vaginal obturators of plated cop- per, which, when worn, distended the vagina and The intestinal canal should % / Fis:. 20 s. — Sutures Introduced. gave more room for operation, be thoroughly evacuated. 347. Vesicovaginal Fistula. — Injuries of the vesicovaginal septum are the most frequent undoubtedly because the tissues are more likely to be compressed between the advancing head TRAUMATISMS. 269 and the pubic symphysis. The operation of vivifying and sutur- ing the edges was revived, perfected, and rendered successful by Sims. After thorough cleansing and disinfection of the vagina and the bladder the patient is placed in the semi- prone position, upon her back, with her limbs well flexed, or in. some cases the fistula may be rendered more accessible by placing her upon the abdomen and elevating the pelvis. The perineum is retracted and the edges of the opening are rendered tense by suitably applied double tenacula, which are held by assistants. The denudation is performed with knife or scissors, pref- erably the latter, as the tissues bleed less. The den- udation is accomplished at the expense of the vaginal surface, exercising care to avoid injury to the vesical mucous membrane. The mucous membrane is seized with forceps at one side and the denudation is performed with the attempt to com- plete the circuit with the one strip. Having secured an equal denudation upon all sides, about one centi- meter in Avidth, the sutures are introduced. They are inserted about one centi- meter apart, introducing and bringing them out about five millimeters from the edges of the denudation without permitting any su- ture to penetrate the vesical mucous membrane. The sutures may be introduced anteroposterior, transverse, X or Y shaped, according to the opening, that direction being chosen which will produce the least traction upon the tissues . The sutures may be silk, catgut, sillavorm-gut, or silver wire, preferably the latter two. After the sutures are all in place the bladder should be irrigated in order to remove all clots, and the sutures should be tied, twisted, or secured with perforated shot, exercising care not to draw them tight enough to strangulate the inclosed tissues. Fio;. 206. — AVound Closed. 270 GYNECOLOGY. After securing the sutures it is well to inject the bladder to make sure that no small opening remains. In large fistulae care must be taken not to injure or constrict the orifice of a ureter. These canals may open upon the surface of the fistula, when the vesical surface of the ureter should be split several days before the opera- tion and the surfaces be kept open by the frequent use of a probe. 348. Flap-splitting or Flap-sliding. — The loss of structure by denudation in large fistula is not infrequently a serious sacrifice of tissue, and has led to the practice of secur- ing fresh surfaces by split- ting the edges of the fistula. The vesical and vaginal sur- faces are divided through the cicatrized margin to any required depth, according to the size of the fistula. AVhen the opening is small, it can be closed by a purse- string suture. The suture of sillavorm-gut or silver wire is passed through the vagi- nal flap within the vesico- vaginal septum, and brought out in the vagina directly op- posite its point of entrance, reintroduced near its exit, and made to traverse the remaining side of the open- ing, and brought out near the original entrance. This suture, tied, turns the vagi- nal flap outw^ard and the A^esical inward. When the size of the opening renders it desirable to close it upon a line, the vesical flaps are closed with animal sutures, preferably of catgut. The vaginal flaps may be closed with silk or silkworm-gut. Walcher advocates first cutting away the cicatricial tissue, then separating the vaginal and vesical surfaces. This procedure secures greater mobility of the internal flaps, which are closed with catgut by the Lauenstein stitch. The needle is introduced on the raw surface and brought out on the line of demarcation, midway between the raw surface and the vesical mucous mem- Fig. 207. — Method of Suturing to Decrease the Tension upon the Sutures. TRAUMATISMS. 271 brane, and the reverse in the opposing vesical flap. After these sutures are tied, closing the bladder, the vaginal flaps are sutured. E. R. Corson (Savannah, Ga.) expedites the formation of the flaps and the introduction of sutures by the use of a portion of an india- rubber ball. A strong silk cord is passed through the shank of a shoe-button which has been made to pierce the center of a portion Fig. 209. — Wound Closed. Fig. 208. — Showing Continuation of Suturing to Close Fistula with Incisions to Decrease Tension with Suture Introduced on Left Side to Close the Secondary- Opening. of a rubber ball ; this, folded, is carried by forceps through the fistu- lous opening. Traction upon the string draws down the opening, exposing its edges. The ease with which the vaginal and vesical portions of the septum can be separated renders flap-splitting a very ready method for closing large fistulas. This separation can be done with impunity, because the circulation of the two surfaces is not interdependent. The incision through the vaginal portion 272 GYNECOLOGY. is preferably made upon a Fig. 2IO. — Fistula Preparatory to Split- ting into Vesical and Vaginal Flaps. vertical line. Beginning at one side of the fistula, one blade of a suitably curved scissors is in- serted between the two layers as exposed by the vertical in- cision (Fig. 2ii) and carried completely around the fistu- lous opening, and the walls are separated by blunt dissection. The dissection may be made with the knife, first by a ver- tical incision through the fis- tula and then dissecting up a. large flap upon either side. The separation may extend to and even through the peritoneum, where necessary, to secure addi- tional tissue to close the opening. In closing a large fistula the sutures in the vesical wall are pref- erably introduced upon a transverse line, and as they are buried they should, therefore, be of chromic catgut or of fine silk. The edges of the fistula should be inverted into the bladder. Each extremity should be se- cured by a suture, the end of which, left long and used as a tractor, permits the intervening portion to be rapidly closed with a continuous suture. These sutures should not pierce the epithelial surface of the vesical mucous mem- brane. The closure of the vesical wall should be followed by distention of the bladder with a warm saline solution to make sure that it is tight. The vaginal wall should then be closed by a vertical line of suturing, which may be continuous or interrupted 1 i \ ^v( \ r Fig, 2 11, — Demonstration of Flap-splitting, as the II TRAUMATISMS, 273 operator prefers. In introducing these sutures the bladder sur- face should be included, to prevent the accumulation of serum or blood between the surfaces. The fact that the vagina has been so destroyed that it will not afford material to cover the vesical wall need not deter the operator from emplo3^ing this method, as flaps can be taken Fig. 212. — Suture Introduced into Vesical Flap. Fig. 213. — Suttire Tied in Vesical Flap Introduced in Vagina. from the labia or from the inner side of the thighs to complete the vaginal wall. M. C. i\IcGannon, of Nashville, very ingeniously closed a fistula in a woman who had a laceration of the rectovaginal septum half-way to the cervix, and the anterior vaginal wall and base of the bladder were gone. He dissected the bladder away from the uterus and pushed the peritoneum off until he could bring the flap down to the lower segment, and closed it with fine catgut. After closing the bladder, the surface was cov- ered as much as was possible with the remaining portion of the vagina. A large sur- face was left uncovered for cicatrization. The left ureter had been included in the bladder, but the orifice of the right was situated so high in the vagina that it was inaccessible, but was subsequently conducted to the bladder by an artificially con- structed conduit. A year later her condition was good, with perfect control of the urine. In extensive fistulse Trendelenburg advocates making a trans- verse incision ten centimeters long through the abdominal walls, and a transverse incision through the bladder, just below the peritoneal junction. The upper edge of the vesical wound 18 Wound Closed. 274 GYNECOLOGY. is temporarily stitched to the corresponding abdominal, and the lower edges of the bladder are held open with sutures. The edges of the fistula are trimmed and the sutures so introduced that their ends can be brought out and tied from the vagina. The anterior vesical wound is closed around a drainage-tube, gauze is placed in the prevesical space, and both are brought through an opening in the abdominal wound, the remaining por- tion of which is closed with sutures. Fig. 215. -Sutures Introduced to Close Vesical Surface, as Suggested by Walcher. Bardenheuer formed a flap by transplantation. He per- formed suprapubic cystotomy, and through the abdominal wound dissected the bladder away from the peritoneum as low as the fistula, separated the adhesions and cicatricial tissue, denuded the edges of the fistula and sutured them from the vagina, while the edges of the fistula were pressed together by the finger passed into the bladder through the suprapubic wound. The TRAUMATISMS. 275 abdominal wound is plugged with gauze and left open. By- utilizing a vesical flap the operation can be performed through the vagina, as described above. 349. Flap formation is a procedure practised by Ferguson, of Chicago, and E. Stanmore Bishop, of Manchester, England. Ferguson made an incision with a scalpel through the vaginal mucous membrane three to six millimeters from the margin of the fistula. (Fig. 216.) This incision completely encircled Fig. 216. — Flap-formation as Suggested by Ferguson. the opening and extended to, but without injuring, the vesical wall. The wotmd was kept free from blood by a stream of sterilized water. This procedure formed a circumferential flap, hinged by the vesical mucous membrane, which, ttimed into the bladder, formed a roof for the raw surface and was held in that position by a continuous fine chromic catgut suture so inserted that it did not pierce the mucous wall of the organ. 276 GYNECOLOGY. (Fig. 2 20.) The narrow strip of vaginal tissue, which from its density retained the stitches well, became a part of the bladder-wall. The fistulous opening was thus closed and made water-tight. The operation was completed by suturing the vaginal walls with silkworm-gut or silver wire. (Fig. 181.) Bishop ingeniously inserts four sutures into the edges of the flap as constructed by Ferguson, and with a pair of forceps passed through the urethra drags these sutures, previously Fig. 217. — Flap Turned in and Vesical Opening Closed, knotted, out through that canal. The funnel thus formed is closed with a suture from the vagina and the vaginal walls are sutured over it. The advantages justly claimed for this plan are: first, there is no loss of tissue; second, a broad surface is secured for apposition; third, there is a projection into the bladder at the site of the opening which decreases the danger of leakage and infection; fourth, in case the ureter opens into TRAUMATISMS. 277 the fistula, it affords an opportunity to turn it into the bladder; fifth, it decreases the danger of primary and secondary hemor- rhages ; sixth, in large openings it affords the best opportunity to secure relaxation by incision or sliding flaps; seventh, it is applicable to fistulse of the bladder, urethra, or rectum. 350. After-treatment. — The vagina, thoroughly cleansed, should be lightly packed with iodoform gauze, which should remain for two or three days. Continuous drainage should be Fig. 21S. — Introduction of Vaginal Sutures. secured by the introduction of a self-retaining catheter into the bladder. This should be removed daily, for the purpose of cleansing. At the end of eight days it should be removed permanently; but the patient should be catheterized four times daily for the next week. The vagina should be irrigated with an antiseptic solution twice daily after the third day, and this should be continued for the greater part of three weeks. The sutures should be removed on the fifteenth dav. 278 GYNECOLOGY. 351. Closure of the Vagina. — Colpocleisis. — Episiostenosis. — Large fistulas in which the base of -the bladder is destroyed Fig. 219. — Section Showing Projection upon Vesical Surface. Fig. 220. — Self-retaining Catheter. Fig. 221. — Vesico-uterine Fistula. may be indirectly obliterated by closure of the vaginal orifice, thus making the vagina a part of the urinary reservoir. ^ A ring of tissue two centimeters broad is removed from the vaginal TRAUMATISMS. 279 orifice. In the dissection the parts should be kept on the stretch and the tissue should be dissected from above down- ward. A sound in the urethra and a finger of an assistant in the rectum will greatly facilitate the denudation of the anterior and posterior walls of the vagina. The sutures should be passed from below upward and from above downward, exercising the greatest care that neither rectum, bladder, nor peritoneum shall be perforated by the sutures. The denuded surfaces should be brought in ac- curate apposition and the overlapping of freshened surface with mucous mem- brane or skin should be strictly avoided. This pro- cedure, while it affords a means of relieving inconti- nence of urine in otherwise desperate cases, has many disadvantages. Impregna- tion is no longer possible; coition can be practised only when obliteration has occurred high in the va- gina. The menstrual blood not infrequently excites violent cystitis, resulting in pyelonephrosis and the for- mation of vesical calculi. The urine may cause metri- tis or tubal, ovarian, and even peritoneal inflam^ma- tion. Rectovaginal fistula has been made to supple- ment this operation when the neck of the bladder has undergone such injury as to render the patient unable to retain the urine. The majority of such cases have been unsuccessful, owing to the irrita- tion of gas and feces and the inclination of the fistula to close. The fistula is very rare which cannot be closed by flap-sliding, as the vesical and vaginal surfaces are easily separated and the vaginal wall when deficient can be replaced by flaps from the vulva, and inner sides of the thigh. 352. Urethrovaginal fistula is very infrequent. It is char- acterized by the discharge of urine into the vagina during; Fig. -Colpocleisis. 280 GYNECOLOGY. micturition. The flap-splitting operation affords the most satis- factory method of closing it. 353. Vesico-uterine fistula permits the escape of urine through the external os. It may result from a slough follow- ing a tedious labor, and from lacerations of the cervix when the tear has extended through the anterior lip. The tear may have been incomplete, not extending through the os, or the Fig. 223. — Closure of Fistula after Its Exposure by Incision through Anterior Vasfinal Fornix. fissure may have healed with the exception of the communica- tion between the bladder and cervix. The only condition with which such a fistula can be confused is the uretero-uterine. The latter fistula is rare. Upon injecting the bladder with a colored fluid (a solution of pyoktanin) its emergence from the OS demonstrates the presence of a vesical fistula; the con- tinuance of clear fluid, a ureteral. In an opening of consider- TRAUMATISMS. 281 able size the sound will pass directly into the bladder, where it can be recognized by another inserted through the urethra. Treatment. — The fistula may be exposed by dilating the cervix with a laminaria tent. In a uretero-uterine fistula this procedure would be accompanied with renal pain, nausea, and vomiting, due to the obstruction of urine from the kidney con*esponding to the affected ureter. The fistula may be denuded and closed from the cervical canal, but the opera- tion is attended with difficulty. The preferable procedure is to cut through the anterior fornix of the vagina and dissect the bladder from the cervix, when the opening can be exposed and sutured ; the vaginal wound is subsequently closed with silk or catgut. It is desirable that the peritoneum should not be opened, though its incision, with proper Fig. 224. — Fistula Closed into Va- gina. Uterine Opening Re- mains, Which Will Close of Itself. Fig. 225. — Section Showing Sutiire for Hysterocleisis. precautions, does not materially affect the result. AVhen the bladder-wall is thin, Herr advises cutting through the cervix and reinforcing the bladder- wall with cervical tissue. Sanger split the cervix of a patient in whom the sinus opened laterally, sutured the side on which the fistula occurred, as in an Emmet operation, and then sutured the other side. 354. Hysterostenosis or hysterocleisis (Fig. 227), the denu- dation and suturing of the cervix, is possible, but the menstrual flow may produce serious cystitis, and contraction of the fistula may result in severe pain and distress during menstruation. Both tracts will be subject to irritation and descending infection, producing upon the genital side, endometritis, salpingitis, and 282 GYNECOLOGY. peritonitis; upon the urinary, ureteritis and pyelitis. When we consider that the opening can be exposed by dissecting the bladder from the cervix, one can hardly conceive the selection of hysterocleisis as ever justifiable. 355. Vesico-uterovaginal (Cervical) Fistula. — A portion of the cervix, with a considerable portion of the vaginal septum, may be destroyed, and the remaining walls may be so thin as to render its closure difficult or dangerous, owing to proximity of Fig. 226. — Closure of Fistula within Cervical Canal after Splitting Cervix. the peritoneum. In such cases the anterior lip of the cervix (Fig. 228) may be denuded and turned into the bladder, using it as a plug to fill up the opening. When the fistula has developed at the expense of the anterior cervical lip to such an extent that it will not afford sufficient structure to close the opening, the posterior lip may be freshened and utilized. (Fig. 229.) This procedure necessarily X->roduces- TRAUMATISMS. 283^ disturbance because of the continuance of menstruation. A preferable method is to separate the vesical wall from the cervix and secure sliding flaps, which can be closed as in figure 230. 356. Ureterovaginal-ureterocervical Fistulas. — Lesions of the ureter are less frequent than the other forms of fistulas. Par- ticipation of the ureter in the vesicovaginal opening is much more frequent. Uretero vaginal fistulas are more frequently the result of injuries sustained during the performance of hys- # Fig. 227. — Hysterocleisis. terectomy. The diagnosis has been considered. (See Section 342.) The cervical fistula is very rare. The thickened ureter can generally be traced to the cervix by the finger in the vagina. Treatment. — Relief from the discomfort produced by these fistulae may be accomplished by resort to one of several methods,. viz.: 1. Anastomosis through the vagina. 2. Anastomosis through the abdomen. 284 GYNECOLOGY. 3. Ligation of the ureter. 4. Introduction of the ureter into the rectum or colon. 5. Nephrectomy. Anastomosis through the vagina may be accomplished by first establishing an artificial vesicovaginal fistula alongside the ureter. This opening, and the ureter opened for the distance of nearly two centimeters of its intraparietal border, are prevented from closing by the subsequent daily use of the sound. After perma- nent cicatrization has taken place, the vesicovaginal fistula, which now includes the ureteral, is closed by denudation and suturing the new surfaces (Simon). The vesicovaginal fistula may be formed by an oval incision. A small elastic catheter can be passed into the bladder, through the urethra, from it through the fistula into the vagina, and then into the orifice of Fig. 228. — Anterior Lip of Cervix Utilized to Close the Fistula. Fig. 229. — Vesico-uterovaginal Fis- tula in which the Posterior Lip of the Uterus is Utilized to Close the Opening. the ureter. With the patient in the genupectoral position the vaginal mucous membrane is denuded around the fistula. To close the opening, the sutures are placed parallel to the catheter, which is left in place for several days (Landau) ; or a buttonhole incision may be made, removing two centimeters of the vesical mucous membrane in the direction of the ureter ; the vesical and vaginal mucous membranes are sutured to prevent closure, and a catheter is introduced into the bladder through the urethra and into the orifice of the ureter through the vesical fistula. An annular denudation is made about the fistula, leaving immedi- ately about it a zone of mucous membrane three millimeters in diameter. After suturing, the fistula with intact mucous mem- brane is turned into the bladder, where it forms a gutter-like TRAUMATISMS. 285 depression, into which the ureter opens (Schede). X. O. Werder, in a case of double ureterovaginal fistula following hysterectomy, made a transverse incision through the anterior vaginal wall into the bladder. The vaginovesical edges of the upper portion were sutured together, while the inferior border was united to the posterior vaginal wall, making a diverticulum to the bladder which controlled leakage. All these methods employ the formation of an artificial vesicovaginal fistula, which must ultimately contract. As the ureter is a distinct canal, capable of being dis- sected out of its bed, there seems no reason why it should not be loosened from cicatricial adhesions, drawn down, and introduced through an opening in the vesicovaginal septum. This procedure is applicable to either vaginal or cervical fistulse of this canal. In order to prevent compres- sion of the ureter a portion of the bladder-wall should be excised. The ureter is introduced into the bladder, the wound is carefully closed with sutures introduced to fix the wall of the ureter and thus insure its reten- tion. Care should be exer- cised that the ureter is not compressed, nor much, if any, of its surface left un- covered in the vagina. In ureterocervical fistulas the cervix should be split until the orifice of the ureter is exposed, when that structure can be drawn down and union accomplished in the manner just des- cribed. Obliteration of the vaginal orifice has been done after the establishment of a vesicovaginal fistula, but such a course is both unnecessary and undesirable. Anastomosis through the abdomen may be preferable in a nar- rowed cicatricial vagina, or when the lower extremity has under- gone inflammatory changes or is so embedded in exudation that it Fig. 230. — Vesical Wall Loosened and [Su- tured. Vaginal Wall Sutured in Oppo- site Direction. ■286 GYNECOLOGY. can not be readily brought down. Through the ordinary incision for abdominal section the intestines are drawn aside, exposing the line of the ureter. In ureterovaginal fistula its situation •can the more readily be recognized by the introduction of a catheter prior to the abdominal incision. The peritoneum is opened, the ureter is raised, its proximal portion is tied and dropped back, and the central end is introduced through an incision into the bladder and secured by sutures, as in the vaginal method. The anastomosis with the bladder should be on the corresponding side of the pelvis, and with as little tension upon the canal as possible. Should the ureter be so short as to cause tension in reaching the bladder, the latter should be drawn up and anchored by a few stitches to the side of the pelvis, so that no traction shall be made upon the ureter. In recent injury an anastomosis can sometimes be made between the di- vided ends of the ureter. The proximal end should be introduced into the distal one and secured by sutures. (Fig. 234.) If the ends of the ureter are unfavorable for this procedure and the renal portion too short to permit of its introduction into the bladder, the ureter may be tied with a double ligature and dropped back. The urine accumulates in the pelvis of the kidney until the pressure equals that of the blood, when secretion ceases. The ureter may also be intro- duced into the rectum or colon. The ureter should pass through the bowel obliquely. However, this procedure is very likely to be followed by serious conditions in both the urinary tract and the intestine. In the former, infection and suppuration of the pelvis of the kidney are prone to follow. The presence of urine frequently causes irritation and inflammation (colitis or proctitis) of the intestine. Nephrectomy is advisable when the long duration of the fistula has resulted in extension of infection to the pelvis of the kidney, and careful examination has disclosed that the other kidney is capable of carrying on the work of both organs. Fig. 231. — Operation for Fistula. Ureterovaginal TRAUMATISMS. 287 357. Accidents of the Operation and Results. — Primary hem- orrhage of a serious character may result from an unusually large uterine artery, from vascular walls, or from injury of the vesical Fig. 232.— Vaginal Implantation of the Ureter into the Bladder. mucous membrane. Either compression or suture is the best means for its control, but its occurrence imperils the result of the operation. Secondary hemorrhage may take place between the third and fifth days, and should be controlled by the tampon. It may ( 288 GYNECOLOGY. occur into the bladder, and may be discovered only after that organ is filled with clot. It gives rise to violent tenesmus, and its decomposition will be extremely prejudicial to the success of the operation. When it can not be removed by irrigation, inject a solution of pepsin or enzymol. If this procedure fails to afford relief, the urethra should be dilated and the clot broken up and removed with a blunt curet. If hemorrhage continues, Fi< 233- -Abdominal Transplantation of Ureter for Ureterovaginal Fistula. B. Bladder. it will be necessary to remove the sutures and search for the bleeding vessel. IncUision of a ureter will cause nausea, vomiting, lumbar pains, and fever. The suspected suture should be immediately removed. Peritonitis may result from injury during the denudation or suturing, or from infection, when proper precautions have not been observed, or when there is coexisting pyelitis or cystitis. Calculi and calcareous concretions have formed upon silver wire, silk, or even catgut sutures. The results of the operation are generally most satisfactory. Death is of very infrequent occurrence. TRAUMATISMS. 289 358. Rectovaginal Fistula. — The methods of treatment sug- gested (Section 344) are equally applicable to the fecal fistulas. The last two methods, flap-splitting and flap-formation, are probably effective and most generally applicable in the great majority. In a small fistula a curvilinear or triangular trap-door may be raised, including the fistulous orifice; the opening in the Fis. 234. -Ureteral Anastomosis. rectal wall is closed by very fine (eye) silk, which has been previously sterilized, or by chromicized catgut; one or several Lauenstein sutures may be used, being careful not to enter the rectum. The vaginal flap is then secured with sillavorm-gut sutures. In large fistulse a sagittal incision with lateral flaps is most satisfactory. The sutures are introduced as previously described. Flap-formation is very serviceable in closing rectal 19 290 GYNECOLOGY. fistulas of considerable size; fiap-transplantation is rarely suc- cessful. 359. An ano vulvar fistula can be closed from the vagina or perineum. Such a fistula is incised through its track, cureted, and the entire sinus closed by sutures. It is generally better to extend the incision to, but not through, the sphincter, and to close the rectal or anal surface with sutures from the perineal side, when failure to unite will not endanger the future value of the sphincter and will enable the operator to secure union by granulation through gauze packing. Small fistulas near the vulvar outlet can be closed as a part of the operation of perineorrhaphy. / \ / L,.. ... N / *^ ■PM. iiwm^.- / M^ L \ V Fig. 235. — Sagittal Incision for Fig. 236. — Lauenstein Suture in Recto- Rectovaginal Fistula. vaginal Fistula through Rectal Wall. 360. Preliminary and After-treatment. — The bowels should be thoroughly evacuated by repeated purging for two or three days. During the same period vaginal douches should be given, and a thorough scrubbing of the vagina with a solution of creolin and soap should immediately precede the operation. However, no operative procedure for closing a fistula should be entered upon until careful rectal examination has demon- strated the absence of a possible rectal stricture as its cause. For several days prior to the operation, and for at least a week subsequently, the patient should be kept upon an animal broth diet, and the use of milk should be prohibited. The opera- tion should be preceded a few hours by thorough irrigation of the rectum, and continuous irrigation should be practised TRAUMATISMS. 291 during it. After the third day the bowels should be moved each alternate day. The sutures of silk should be removed upon the eighth day; silkworm-gut or silver wire may be per- mitted to remain for fifteen days. The patient should be con- fined to bed the greater part of three weeks, and the bowels should not be permitted to become constipated for a month. 361. Entero vaginal fistulas have been cured by cauteriza- tion or by denudation and suture from the vagina, but closing the fistulous intestine through the open abdomen is preferable, when the vaginal opening will need no further consideration. 362. Cervicovaginal Fistula. — A cervicovaginal fistula is one which arises as a result of rup- ture of the cervix during labor from a longitudinal tear, or the lower margins of which have become reunited. The tear may be a perforation of one lip of the cervix through which the fetus is extruded, and occurs where the cervix is hard, rigid, and unyield- ing. Such a condition of the cervix is sometimes the cause of the entire cervix being torn away. A fistula may also arise from faulty methods of repair of the lacerated cervix. I have seen such openings on both sides of the cervix where trachelorrhaphy has been attempted. The fis- tula doubtless sometimes arises from the use of sharp instruments in attempts at abortion. The opening of such a fistula is ex- coriated and filled with mucus. Treatment. — The correction of the condition is not always an easy procedure. The pref- erable plan is to incise the cervix through the opening, denude the margins, and close as in an ordinary operation of trachelor- rhaphy, but this is not always practicable and in some cases the amputation of the cervix may be demanded. 363. Lacerations of the pelvic floor are a frequent lesion of parturition, and can occur from within outward through the vagina and vaginal portion of the perineum, leaving its in- tegumental covering intact. The injury is a separation or tearing-off of the muscular fibers from the sides of the vagina. Fisf, 237. — Rectal Wall Closed by- Transverse Line of Sutures; Va- ginal by Vertical Line of Sutures. 292 GYNECOLOGY. Generally, the tear takes place through the integument of the perineum; sometimes it may extend through the entire struc- ture, the sphincter, and up the rectovaginal septum. Not infrequently it will be found that the injury has been quite as deep, but on one side of the rectum and anus, and leaves both intact. Less frequently it will thus extend on both sides of the anus. Naturally, the influence upon the subsequent appearance and function of the parts must vary with the extent and direction of the lacera- tion. A slight laceration, which involves only the anterior portion of the peri- neum, may heal without producing much, if any, de- formity. A deeper lacera- tion, by the action of the trans versus perinei muscles, permits the vaginal orifice to stand open, and presents a triangular appearance. The failure of the bulbo- cavernosi muscles longer to antagonize the coccygeus permits the anus to be drawn back. Laceration through the sphincter necessarily causes loss of control of the bowel- contents. (Fig. 239.) The deep laceration to one side of the anus leaves the levator ani unantagon- ized, and the parts are drawn to the opposite side ; when the tear extends upon both sides, the anus is de- pressed and drawn backward. The vulva stands open, and we can look into the vagina from three to five centimeters. 364. Causes. — Injuries of the pelvic floor may arise, first, from conditions inherent in the mother; second, in the child; and third, in the course and management of the labor. Of the first class may be — (a) too great or too slight an inclination of the pelvis, which renders the mechanism of the fetal head imperfect; (b) sl small vulvar orifice with rigid muscles, or a Fig. 238. — Rccl<:)vai^inal Fistula Closed Operation of Perineorrhaphy. TRAUMATISMS. 293 large amount of fat in the perineum ; (c) high or a nterior situation of the vulva, making a long perineum, over which the child's head must be extended. Second, laceration may result from excessive size of the fetal head and shoulders or from relative disproportion to the size of the mother. Third, laceration may result from — (a) either too rapid or too tedious labor ; (b) vertex presentations when rotation occurs Fig, 239. — Rupture of Perineum into Rectovaginal Septum. into the hollow of the sacrum and an occipitoposterior position presents a longer diameter of the head at the outlet; (c) face presentations, in which the longest diameter of the fetal head presents ; (d) either incomplete or excessive flexion ; (e) faulty manual or instrumental interference. 365. Degree or Extent. — Lacerations of the pelvic floor may be incomplete or complete, and are generally divided 294 GYNECOLOGY. into four degrees: First, a tear through the fourchet and to a sHght extent in the perineum; second, to the sphincter. These form the incomplete lacerations, while the complete are: third, the tear extending through the sphincter; and, fourth, up the rectovaginal septum. A rare form of laceration is the central rupture, in which the fetus passes through the perineum with- out tearing either the sphincter or the vulva. 366. The results of the injury are necessarily dependent Fig. 240. — Cvstocele. upon its extent. The immediate effects are induced by the action of the injured or antagonistic muscles. The cicatricial tissue produces certain reflex nervous phenomena, which, however, are insignificant compared to the mental influence exerted by fecal incontinence. The laceration causes defective involution of the vagina and uterus, the defect in the muscular junction of the pelvic floor weakens the action and consequent TRAUMATISMS. 295 resistance of the pelvic diaphragm. The constantly varying pressure of the bladder and rectum, the increased abdominal pressure consequent upon straining at stool, and the abnormally heavy uterus lead gradually to displacement downward of that organ, or, if it is fixed by the condition of its pelvic attachments, to extrusion of the anterior and posterior walls of the vagina, and their consequent weight will produce hypertrophic elon- gation of the cervix. Thus Ave have cystocele (prolapse of the ^^^I: Fig. 241. — Rectocele. anterior vaginal wall, and with it the bladder), rectocele (pro- lapsed posterior wall), partial or complete prolapse of the vagina, with elongation of the cervix, or procidentia, consequent upon the increased weight of subinvoluted organs and the diminished support resultant from the lesion under discussion. [ 367. Treatment. — The proper course of procedure is to" so repair the injury as to restore as nearly as possible the normal 296 GYNECOLOGY. condition of the pelvic floor. In slight lacerations restoration will be secured by keeping the patient quiet and the parts clean. The operative treatment may be primary, intermediate, or sec- ondary. 368. By primary operation is understood the immediate repair of the laceration, or at least within twelve hours. The tear pre- sents a large, raw surface, and is frequently found with ragged, irregular edges. The vagina may have been torn and the soft parts pushed oft' until the perineum has split either through the sphincter or to one or both sides of the anus. The method of repair will depend upon the nature and extent of the lesion. The necessary instruments will be found in an ordinary pocket case — scissors, dissecting forceps, a needle-holder, and long and short curved needles. The suture material may be silkworm-gut, catgut, silk, or silver wire. The patient should be placed upon her back across the bed or upon a table, while an assistant holds each leg, flexed upon the abdomen. As the parts are benumbed by the stretching to which they have been subjected Fig. 242. — Right and Left Curved Scissors. an anesthetic may be omitted; but if the patient is very nervous, one should be employed. A rubber pad or a piece of mackintosh should be placed beneath the patient to prevent soiling of the bed and to direct the current of irrigating fluid into a receptacle upon the floor. Compress the uterus and cleanse it and the vagina of clots; cleanse the external surface with a disinfectant fluid, after having trimmed the vulvar hair in order to keep it from embarrassing the procedure. Place a pad of gauze or ab- sorbent cotton beneath the cervix to keep the vagina free from blood. Trim smooth the ragged edges of the tear and proceed to suture. Fine chromicized catgut is preferable, because it will not have to be removed, and it produces less annoyance during the care of the patient than does either silkworm-gut or silver wire. In slight lacerations and vaginal tears the use of the con- tinuous suture is satisfactory. In extensive laceration inter- rupted sutures oft'er advantages. Precautions should be exer- cised to leave no dead spaces in which blood may accumulate, TRAUMATISMS. 297 become infected, and produce sepsis. In a double tear which extends upon both sides of the rectum the needle should be entered from above, brought out in the sulcus, reentered, and carried upward through the vaginal mucous membrane, so that each suture lifts up the tissue. Care should be exercised to restore the position of the levator ani muscles by bringing their torn ends back in position. So far as possible the sutures should be brought out in the vagina, as they thus produce less pain. Fh 243. — Incomplete Rupture of the Perineum. Fis:. 244. -Simon-Hegar Method of Denudation. The necessary perineal suturing may be with continuous suture, inclosing but little of the skin. In laceration of the sphincter make sure that the ends of the divided muscle are secured and coaptated by the suture. When the tear has extended into the rectovaginal septum, the sutures may be brought out and tied in the rectum, or, what is probably preferable, the Lauenstein suture may be employed, with buried catgut. 369. The advantages of the primary procedure are : first, if the operation is successful, the patient is spared the necessity of 298 GYNECOLOGY. a subsequent operation; second, with proper precautions she is much less hkely to suffer from infection, and convalescence is expedited; third, the sequelae of unrepaired injuries are avoided. 370. Contraindications. — The primary operation is contra- indicated when the patient has been exposed to a prolonged labor and the tissues have undergone extensive fraying or bruising through prolonged manual or instrumental interference. It is also contraindicated when there is reason to believe that the wound has been exposed to some virulent infection. Even in such cases, when the laceration extends through the sphincter. Fig. 245. — Sutures Introduced to Close the Wound. the anus and rectal wall should be sutured, in order to afford security to the contents of the bowel. 371. The intermediate operation is performed any time from twelve hours to a week following the labor. The delay may be occasioned by want of proper material at hand, or it may be due to the condition of the patient, who is suffering from such profound shock that it will seem unwise to resort to any imme- diate procedure. Probably the fifth day after labor is the most favorable period for repair of lesions of the pelvic floor, for the TRAUMATISMS. 299 uterus has at this date sufficiently contracted to render evident any lesion and any loss of vitality of the structures of the pelvic floor or exposure to infection. The genital tract should be care- fully cleansed, the raw surfaces wiped with a gauze sponge, any ragged surfaces trimmed, and the surfaces sutured as for the primary operation. 372. Secondary Operation. — This operation is preferably not performed for at least two months subsequent to delivery, in Fig. 246. — Garrigues' Modification of the Hegar Operation. order to permit involution and cicatrization to become accom- plished. In preparation, particularly when the tear is complete, the bowels must be thoroughly evacuated. Castor oil, a saline, or compound licorice pow^der should be given several days or a week before the operation and repeated at intervals of from twenty-four to forty-eight hours, in order to insure thorough evacuation of all hard, scybalous masses. The diet should con- 300 GYNECOLOGY. sist largely of animal broth, while milk should be absolutely excluded. The evening and morning before the operation the lower bowel should be cleansed with large enemas. The last enema should be given at least three hours before the time fixed for the operation. Patients should be prepared (Section 182), and the following instruments sterilized: a scalpel; right and left curved scissors, as well as scissors curved on the flat ; three double tenacula; eight pressure forceps; one long, rat -toothed dissecting forceps; a needle-holder; and two long and two short Fig. 247. — Upper Part of Wound Closed; Last Stitures Introduced. Fig. 248. — Wound Completely Closed. curved needles, all threaded with carriers. The suture material may be silk, silkworm-gut, catgut, or silver wire. In extensive laceration the silkworm-gut is preferable, for the reasons, first, that it, being more pliable, causes less pain during convalescence than wire, and, second, it is much less likely to become infected than either silk or catgut. Incomplete laceration (Fig. 243) may be repaired by a simple denudation of the torn surfaces (Fig. 244). As cicatrization has TRAUMATISMS. 301 resulted in contraction, it is necessary to extend the denudation of the vagina above the scar tissue. The further backward the rent extends, the higher into the vagina the denudation must be carried. The hne of denudation extends posteriorly from the junction of the mucous membrane and skin at the top of the old posterior commissure across in front of the anus to a corresponding point upon the opposite side, while an angle ex- tends up the vagina above the tear. The completed denudation Fig. 249. — Lauenstein Suture, Fi< o. — Rectum and Vagina Closed with Lauenstein Suture. presents a resemblance to the body and wings of the butterfly, and is designated the Simon-Hegar denudation. (Fig. 244.) The sutures are introduced about three millimeters from the margin of the wound, buried beneath the denuded surface, and brought out at a corresponding point upon the opposite surface. The sutures in the vaginal angle are first secured, and then the perineal. (Fig. 245.) The sutures when tied produce less discom- fort than if secured by compressing perforated shot upon their 302 GYNECOLOGY ends. The quill or bar suture was formerly much favored. It consisted of a quill placed in the loop of a double suture upon one side, the ends being tied over a second quill upon the oppo- site side, or the ends of a suture were passed through openings Fig. 251. — Hildebrandt's Method of Suturing. in a bar and secured by shot. The two quills or bars served for call the sutures, while the skin edges were united by super- ficial sutures. The suture caused so much pain that it has been largely discontinued. TRAUMATISMS. 303 A slight exaggeration of the denudation just described can be applied to the restoration of a complete laceration. The sutures must then be vaginal, rectal, and perineal. The latter are intro- duced after the former are placed. The rectal sutures of catgut are brought out into that canal. Care must be exercised in the introduction of the first perineal suture that it shall accurately bring the ends of the sphincter ani in apposition. Garrigues modified the Hegar operation by the following procedure (Fig. 246): According to the extent of the laceration and relaxation of the vagina and perineum the vagina is seized with a double tenaculum at a point in the median line more or Fig. 252. — Hildebrandt Suture Closed. less removed from the cervix. A point upon each labium ma jus is secured at such a distance from the clitoris as to permit of coition. The parts are rendered tense, the points are connected by an incision, and the intervening triangular surface is denuded. This denudation is carried downward to the margin of the skin and mucous membrane. With the vulva separated the denu- dation presents a triangular surface. The denudation is most rapidly accomplished by introducing one blade of curved scissors beneath the membrane at the point determined upon in the one labium and carrying it around the vaginal outlet to a similar position opposite. The central part 304 GYNECOLOGY. of this incision is picked up with forceps, cicatricial bands cut, and the finger pushed beneath this flap to the desired height. The tissues are pushed off laterally, and the triangular section is removed. It has the advantage that it is more than a denu- dation. It is a resection, and, therefore, permits the more accu- rate union of fascia and muscular structure. The sutures are introduced from above downward, about six millimeters apart, deep and superficial alternating, the latter Fig. 253. — Heppner's Figure-of-8 Suture. passing only through the edges of the mucous membrane. The four upper sutures are transverse; the remainder dip down- ward at the central portion, and, when tied, lift up the relaxed wall. The sutures are thus introduced and tied one after another until the remaining denuded surface forms an ellipse, the upper and lower borders of which are of equal length. (Fig. 247.) Then a silkworm-gut suture (10) one centimeter above the posterior commissure is carried deeply beneath the wound TRAUMATISMS. 305 two-thirds the width of the denudation, and emerges at a similar point upon the opposite side. A second suture (ii) is inserted midway between this suture and the outer margin; passing beneath the denuded surface it emerges upon the vagina to the left of the median line, is reintroduced, and comes out equally distant from the first suture upon the right side. The last suture, introduced near the extremity of the denuded surface, appears in the vagina midw^ay between the second suture and the external denuded angle, reenters upon the op- Fig. 254. — Martin Suture to Close the Rectal Opening. Fig. 255.- -Martin Suture Con- tinued. posit e side, and emerges upon the right labium. These three sutures are all introduced and the surface is irrigated, when they are secured. In my judgment, the employment of the continuous chromic catgut suture is far more satisfactory. It can be so introduced as to lift up the pelvic floor, and should include the edges of the levator ani muscle and the overlying fascia. If the floor is much relaxed, the muscle and fascia can be sutured sepa- rately and the mucous surfaces be closed over it with a con- 20 306 GYNECOLOGY. tinuous suture. This method of suturing greatly expedites the operation and has the advantage that it leaves no sutures (fig- 255) to be removed. '^Lauenstein's Method of Suturing. — This method of intro- ducing the sutures was devised to prevent their infection by the rectal and vaginal discharges. The sutures, of catgut or fine silk, are introduced in the denuded surfaces, including about five millimeters of the tissue intervening between the Fig. 256. — Denudation for Freund's Operation. borders of the rectal and vaginal mucous membranes respec- tively. (Fig. 249.) These are necessarily buried sutures. The remaining portion of the denuded surface is closed by silver wire from the perineum. (Fig. 250.) Hildehrandt makes the denudation trefoil in shape. (Fig. 251.) The sutures are, for the most part, cutaneous. The vaginal sutures are first introduced ; next the rectal, and, finally, TRAUMATISMS. 307 the perineal. 12^^ (Fig. 252.) This method of suturing obliterates dead space and decreases the danger of abscess. Fig. 257. — Sutures Inserted in Rectal Wall and Lateral Vaginal Angles. Fig. 258. — Vaginal Angles and Rectal Wall Closed. Suture in Place for Perineum. Fig. 259. — Denudation Completely Closed. Heppner accomplishes the same object with a figure-of-8 suture, which closes both vaginal and perineal surfaces. (Fig. 253-) 308- GYNECOLOGY. Martin more rapidly, and with a less complicated pro- cedure, meets the difficulty. (Fig. 254.) He, with a con- tinuous catgut suture, unites the intestinal wound from the rectal surface; when he reaches the anus, with the same suture in a contrary direction he superimposes a layer up to the superior angle of the vagina, and, if the denudation is deep, a third layer before the vaginal and perineal surfaces are united. (Fig. 255.) Freimd has emphasized the necessity of securing such a Fig. 260. — Emmet's Operation. Surface Denuded and Lateral Sutures in Place. denudation as would reproduce the original appearance of the tear. This, if there is a cicatrix, which presents the appear- ance of 00, the laceration from which it has contracted may be represented by figure 256. He incises the posterior column of the vagina at a certain distance from the scar and carries the bistoury backward along the sides of this column, circum- scribing the cicatrix in the vagina and upon the labia majora TRAUMATISMS. 309 (Figs. 257, 258, and 259), and completes the denudation as in an ordinary operation. The Hne which corresponds to the rectum is sutured, then each edge of the posterior vaginal column is united to the external margin of the denuded surface. The union of the lines forms the vulvar and perineal surfaces. Emmet's operation is of especial value in relaxation of the posterior vaginal wall, and its purpose is to expose the fascia and so to introduce the sutures as to fold in the slack and lift -^ Fig. 261. — Emmet's Operation. Lateral Angles Closed and Perineal Suture Introduced. Up the perineum, bringing the parts more completely under the control of the levator ani muscle. AAath the labia separated by the hands of assistants the summit of the protruding recto- cele is seized with a double tenaculum; two other tenacula are placed one upon each of the caruncula, and a fourth upon the commissure of the vulva. When these are separated, they constitute a quadrilateral surface. These instruments are employed to render the parts tense, and the lines between 310 GYNECOLOGY. them are employed as the boundaries of the denudation. The intervening surface is completely denuded. (Fig. 260.) The sutures are then introduced in triangles, beginning in the sulcus Fig. 262. — Emmet's Operation Completed. Fig. 263. — Emmet's Operation for Com- plete Laceration. Fig. 264. — Suture to Unite the Ends of the Sphincter. TRAUMATISMS. 311 upon either side. The sutures introduced form a double triangle ; a suture joins the summit of denudation upon each side with the apex of denudation of the posterior column. This is called the crown stitch. (Fig. 261.) A number of perineal sutures are then used. By this method the majority of the sutures are within the vagina. The tying of the sutures lifts up the pelvic floor and brings the posterior segment of the pelvic floor more closely in contact Avith the anterior. (Fig. 262.) Noble modifies this operation by carrying his denudation higher upon the posterior column, by splitting the fascia and exposing the levator ani muscles. In suturing, he pulls out the muscle and secures it with not only the lateral, but also the central, sutures, or those below the crown suture. This brings the muscles in contact in front of the rectum and insures a strong support to the pelvic floor. 312 GYNECOLOGY. Emmefs operation for complete laceration has for its first and principal aim the restoration of the sphincter ani. The first suture is introduced and brought behind the ends of the torn sphincter, which have been carefully exposed in the denudation. (Figs. 263 and 264.) As the suture is drawn up and secured, the precaution is taken to draw up and place in position the ends of the sphincter, so that they may be firmly secured. The remaining sutures appose the denuded surface of the perineum. -* Fis:. 266. — Cleveland's Suture. Fig. 267. — Dudley's Operation with Interrupted Sutures. Outerbridge modifies Emmet's operation in that he uses but three sutures. The first, of medium-sized catgut, by means of a needle threaded with a carrier loop, is passed from the end of the central undenuded portion to the summit of the lateral denudation upon either side. It is throw^n over the pubes and a silver-wire suture is passed from the highest point of the denudation upon one labium ma jus beneath the whole wound across to the corresponding point upon the opposite side. (Fig. 265.) The catgut suture is now tied and its ends are passed TRAUMATISMS. 313 downward to penetrate the skin upon each side one centimeter from the lowest point of the denudation. This suture tied, the silver wire is secured. The latter suture is removed upon the eighth day. Cleveland uses a figure-of-8 suture of catgut. (Fig. 266.) The first suture enters the skin six millimeters from the wound margin and midway between the posterior commissure and the summit of the denudation in the left labium, passes deeply across Fig. 268. — Dudley's Operation Com- Fig. 269. pleted. -Denudation for Martin's Operation, between the denuded surface and rectum, embracing the muscles, and emerges upon the right labium six millimeters from the wound margin and, midway between the posterior commissure and the point corresponding to its entrance, is reintroduced at a similar point upon the left labium, and emerges upon the right, directly opposite its original entrance. The second suture follows a similar course. It enters the left labium near the summit of denudation, is buried beneath the 314 GYNECOLOGY. edge of the denudation to the center of the vaginal column, then passes downward, and emerges upon the right labium midway between the summit of denudation and the exit of the first suture. It is introduced upon the left labium at a corresponding point, passes across its former course, follows the border of the right sulcus, and emerges beneath the right summit. A suture of wire or silkworm-gut, for support, is passed through the left labium, about eight millimeters above the Fig. 270.— Vaginal Surfaces United Perineal Sutures in Place. ig. 271 ■Bischoff's Operation. denudation, and about the same in the anterior vagina and the right labium. A. P. Dudley made a quadrilateral denudation with angles at the summit of the rectocele, laterally at the caruncula, and at the posterior commissure. The denudation removes only the mucous layer, preserving the submucous. (Figs. 267 and 268.) The fino^er is introduced into the anus and the first suture is TRAUMATISMS. 315 passed downward and forward to the median line, where it is brought out, reintroduced three milHmeters from its exit, and carried upward and back^vard to emerge upon the other side of the vagina. This suture is tied, and acts as a fixed point from which to work. The remaining sutures, of juniper catgut, are made over and over and are introduced in a direction similar to the first, taking care to push up the rectocele with a director Fig. 272. — Splitting Vaginal Wall Preparatory to Sutnre.— {Andrews.) as each stitch is tightened. As the outlet is approached the angle of the sutures is decreased, until, when abreast of the hymen, they are passed transversely. At this point the inside work is finished and the suture is made fast. A number of buried sutures are passed through the fibers of the separated central tendon. These extend to the extremity of the rent, Avhen, with a con- tinuous suture, they return to the point where the deep sutures began. After examination of the wound for bleeding points or 316 GYNECOLOGY. gaping of the surfaces the wound is dusted with iodoform, and is not disturbed for four days. Martin, in extensive relaxation of the pelvic floor, supple- ments the operation upon the vulvar outlet by a denudation of the lateral columns of the vagina, leaving a tongue-shaped, undenuded strip in the median line of the vagina. (Figs. 269 and 270.) Each lateral denudation is obliterated by continuous Fig. 273. — Introduction of Suture in Retracted Flap. — {Andrews,) suture, after which the outlet is closed with transverse sutures. (Fig. 270.) Bischoff dissects up a flap from the posterior vaginal wall, which he utilizes in covering over the line of vaginal union. The perineal sutures are passed deeply beneath the flap. (Fig. 271.) In the incomplete lacerations with relaxation of the pelvic floor the aim of the operative procedure is to take up the slack in the vaginal wall and restore the support to the pelvic TRAUMATISMS. 317 viscera. Andrews, of Chicago, does this by first dissecting a small triangle pointed below by a line drawn across the vagina between the carunculee myrtiformes and below by the muco- integumental border; second, at the outer angle of this triangle on each side a finger is pushed beneath the mucous membrane to just beneath the cervix. This line is incised on each side, permitting the central flap to contract (Figs. 272, 273, 274); third, from the side of the cervix a suture is introduced through Fig. 274. — Suture Tied; the Remaining Surface to be Closed by Transverse Sutures. — {^''^drews.) the wall, carried as a submucous stitch around the central flap already designated, and tied. This folds the flap beneath and behind the cervix. This suture straightens or smooths out the posterior vaginal wall. The remaining portion is united by transverse sutures. Harris, of Chicago, seeks to utilize the puboperineal portion of the levator ani to hold the posterior segment of the vagina against the anterior by dissecting down 318 GYNECOLOGY. upon the muscle upon each side, excising a section, and uniting the cut surface. The fascia has been denuded over the posterior segment and sutures are at once inserted posterior to the re- tracted muscle. Flap Operations. — Tail's operation is the representative for the various flap operations. In incomplete tears the rectum is tam- poned with a sponge or with cotton or iodoform gauze covered Fig. 275. — Incision for Tait's Operation for Incomplete Laceration. with vaselin and furnished with a thread. While an assistant separates the vulva, two fingers are passed into the rectum, ren- dering the posterior wall tense. To form the flap, Tait uses pointed angular scissors. The point of one blade is inserted in the median line at the mucocutaneous junction, and the recto- vaginal septum is split to the depth of two centimeters, first to the left and then to the right, and is carried forward upon TRAUMATISMS. 319 each side to the point at which he wishes the posterior com- missure to be. (Figs. 275, 276, and 277.) This forms a semi- circle following the mucocutaneous junction. The flap is drawn up by tenacula and further separated to the required depth. On the borders the incision is carried deeply into the cellular tissue of the perineum and labium ma jus. Bleeding is controlled by forceps, and later by the pressure of the sutures. Fig. 276. — Line of Incision for Tait's Operation for Complete Lacera- tion. Fig. 277. — Appearance of Surface after Formation of Flaps. The sutures are passed with the fingers in the rectum as a guide. They pass transversely across the wound, the skin not being included. Four sutures are generally sufficient. The sutures are secured after the wound has been washed with sublimate solution (i : 1000) and the tampon has been removed. Sanger closes the skin edges with superficial sutures. In complete laceration the rectovaginal septum is split, form- ing a rectal and a vaginal flap, depending in extent upon the 320 GYNECOLOGY. depth of the tear. Sanger advises that it be made with the bistoury. These flaps are loosened at either extremity by pro- longing the incision upward just within the labia, and down- ward alongside the anus, thus forming a letter H, the trans- verse bar of which is formed by the split in the septum, and is at the lower part of the letter. These flaps, when separated, form a quadrilateral. Great care must be exercised in the Fig. 278. — Outline of Flap to be Turned Down to Form Raw Surface for Union. Flap thus Formed to Protect from Fecal Infection. — (Risttne.) introduction of the first suture, which must include the ends of the sphincter ani. Ristine, of Knoxville, Tenn., in complete laceration of the perineum, begins in the vagina and dissects a flap downward to the rectovaginal margin of the tear. This flap is made sufficiently long to insure its projection beyond the anus. The divided ends of the sphincter ani are exposed and united with TRAUMATISMS. 321 silkworm-gut sutures. (Figs. 278 and 279.) The flap is fastened over the Hne of union and serves to protect it from infection. This flap can be cHpped off at a later date after it has com- pletely served the purpose for which it was constructed. The same object is secured by Noble, of Atlanta, who loosens and draws down the anterior wall of the rectum. The tag of tissue thus formed subsequently contracts. I Fig. 279. — Flap Turned Down. Sphincter Closed and Sutures Introduced. — {Ristine.) Simpson's method is somewhat similar to Tait's in the manner of forming the flaps, but they are sutured separately, form- ing the anterior wall of the rectum and the posterior wall of the vagina, while the intervening funnel-shaped raw surface is united by sutures. (Figs. 280 and 281.) Frttsch's procedure still more closely resembles Tait's in the splitting of the flaps. (Figs. 282 and 283.) He detaches 21 322 GYNECOLOGY. the rectum from the vagina, adds a lateral incision for the sphincter when its ends are retracted, and unites these with a provisional stitch, which serves during the operation to restore the shape of the orifice and to permit the accomplishment of reunion. He unites the rectum with catgut, using the Lauen- stein suture. The same suture is used to close the vagina, Fig. 280. — Outline for Simpson's Operation. and the perineum is completed by suture in superposed planes or by continuous catgut sutures in terraces. Alexander Duke, after introducing the left index-finger nearly its entire length into the rectum, with a double-edged bistoury penetrates the septum a distance of six centimeters; as the knife is withdrawn he enlarges the incision laterally to fiYQ centimeters. (Figs. 284, 285, and 286.) As the lateral TRAUMATISMS. 323 ends of the incision are pressed toward each other a lozenge- shaped opening appears. The sutures are introduced with a strong, sickle-shaped needle with eye in point, and silver wire is preferred for the suture. The needle is introduced just beyond the end of the incision, and, guided by the finger into the rectum, is made to encircle the incision, to be brought out beyond its opposite end. Drawing up this suture will give an idea of the % Fig. 281. — Sutures Introduced in Simpson's Operation. number of additional sutures required. The sutures secured, the distance betAveen the anus and the posterior commissure is considerably increased, with the formation of a thick perineal body. 373. After-treatment. — Immediately after operation cleanse the vulva with alcohol and water, equal parts, dry and apply a sterile gauze pad which should be retained with a T-bandage. The nurse should be directed to sponge the parts with the same 324 GYNECOLOGY. solution, whenever soiled. The patient is unlikely to suffer pain, unless the laceration has been complete, when a suppository of opium extract, gr. j, and hyoscyamus extract, gr. ss , can be employed. The urine should be evacuated spontaneously and the parts subsequently sponged, as already advised. The position of the patient may be changed, but she should be discouraged from making severe efforts. In incomplete lacera- tions the diet will not require careful scrutiny, but in the com- Fig. 282. — Denudation for Fritsch's Operation. plete it should be limited during the first week to animal broths,, and subsequently for another week it should be restricted to^ articles that are easily digested. Secure an evacuation of the bowels upon the third day, and at least each alternate day subsequently. Exercise care that excessive purgation shall not occur. The sutures, if of silk or silkr^^orm-gut, can be removed in from eight days to two weeks. Catgut sutures need not be disturbed. Observe care in the removal of the TRAUMATISMS. 325 sutures; the patient is preferably placed upon her side before a good light, and an assistant gently separates the buttocks, exposes the ends of the sutures, and facilitates their withdrawal. Keep the patient in bed fully three weeks. After the fourth day the vagina may be irrigated once or twice daily with a disinfectant solution — sublimate (i : 2000) or formalin (i : 1500). Advise her to do but little walking for -a month, and interdict coition for two months. im &-^f Fig. 283. — Catgut Sutures for Union of the Rectal Wall. Fig. 284. -Incision for Duke's Op- eration. 374. Choice of Operation. — It should be understood that no operation is applicable to every patient. The operation should be adapted to the special condition. In incomplete tears, without rectocele, the Simon-Hegar operation is satis- factory. In patients with rectocele, Emmet's or Dudley's operation will serve an excellent purpose. In cases of complete laceration, without much relaxation of the pelvic floor, no 326 GYNECOLOGY. procedure presents so many advantages as that described by Tait and modified by Sanger. If the tissues are redundant Fig. 285. — Incision Separated in Fig. 2 86. -^Incision United by Trans- Vertical Direction. verse Sutures. and there is need to afford support, the operation of Emmet for complete laceration is the most acceptable. INFLAMMATIONS. 375. The recognition of the development of the genital tract from the coalescence of the Mullerian ducts makes it evident that it is a continuous canal Avhich must be especially vul- nerable to infection and its manifestation, inflammation. In experience it is rarely found that the alterations due to infection are confined to a single portion of this tract. It must be admitted, however, that the special structure of certain portions of the canal renders it more susceptible to the infiuence of special micro-organisms and their products. The cyhndric epithelium of the cervical canal is more vulnerable to gonorrheal infection than is the pavement epithelium lining the vagina. The recognition of the almost continuous uniformity with which the different parts of the canal become involved from the struc- ture primarily infected, and the frequent difficulty in isolating the primary site, have caused me to depart from the usual order in the consideration of this subject, and to discuss infection and the resulting inflammation as affecting the entire genito- INFLAMMATIONS. 327 urinary tract, and subsequently to consider the features of its local manifestations. 376. Micro-organisms as a Cause. — The most important ex- citing cause in the production of inflammation of the genito- urinary tract is the influence of micro-organisms. Inoculation of a mucous surface with a micro-organism may result in an imme- diate inflammatory reaction, which may subsequently extend to the neighboring structures by one of three ways: the mucous membrane, the lymphatics, or the blood-vessels. The original site of inoculation may be the vulva, vagina, utei^us, urethra, or the bladder sirrfaces, which are more or less exposed to external contact, or even the entire tract may be involved. 377. Natural Protection against Infection. — The situation of the genital tract, the injuries to which it is exposed, and the opportunities for its infection by various germs render the com- paratively infrequent occurrence of inflammatory attacks sur- prising. The immunity against infection is to some degree secirred by the difference in the character of the uterine and vaginal secretions. It will be remembered that the uterine secretion is alkaline, while that of the vagina is acid; conse- quently micro-organisms which would readily flourish in the one canal are unfltted for the invasion of the other. 378. How Immunity is Lost. — Any condition, then, which causes these secretions to be less antagonistic, or which leads the one greatly to preponderate, permits the activity of the germs and their products to become manifest. Lowered' vitality, exposure to cold, menstruation, the increased flow after par- turition or abortion, all render the secretion more alkaline and establish a more uniform soil for the development of micro- organisms. Apparently normal conditions may be overcome at once when the tract has been inoculated with some virulent poison. 379. Inflammation and its Varieties. — Inflammation has been deflned as an expression of the eft'ort made by a given organism to rid itself of, or to render inert, noxious irritants arising from within or introduced from without. Inflammation may be acute or chronic, diftuse or circumscribed. It is denominated as acute when associated with pain, heat, burning, more or less swelling of the tissues, profuse discharge, and constitutional symptoms. Inflammation is chronic when the condition is somewhat pro- tracted ; the pain less severe or but slight ; the discharge less in amoimt and less irritating to the surrounding structure, and with but slight constitutional reaction. Diffuse inflammation may involve the entire genital tract, as in streptococcic or gonococcic infection, either of which may extend the entire length of the genital canal, involving vulva, vagina, uterus, and tubes, and 328 GYNECOLOGY. even the ovaries, peritoneum, and cellular tissue. The last form of infection may simultaneously invade the urinary tract, but circumscribed or local irritation confined to a portion of the tract is much more common. 380. The causes of inflammation should be divided into pre- disposing and exciting. The predisposing causes are those which produce congestion and disturbance of the normal equilibrium of the tract and, consequently, promote a favorable condition for the inception of infection. They may arise from disturbance of menstruation, involution, and traumatism. The first in- cludes the improper hygiene of menstruation, exposure to cold, fatigue, overexercise, and excessive sexual relation during the congestion immediately preceding or following menstruation. Not infrequently persons, to avoid the inconvenience of men- struation, will take a cold bath, with a view to its arrest. A prolific cause is neglect or imprudence following abortion, miscarriage, or parturition. The natural congestion consequent upon these periods is enhanced by exposure, which permits infection by various micro-organisms, with the resultant inter- ference of the normal physiologic results in inflammation and interference with the normal processes and the subsequent development of inflammatory changes. Uncleanliness or want of care upon the part of physician or nurse in a manipulation during or following labor or an abortion, or in the use of the uterine or vaginal douche; upon the part of the patient in handling the parts with unclean hands ; the act of masturbation or the employment of unclean instruments ; the retention within the uterus or vagina of portions of placenta, decidua, or blood- clots following abortion or labor ; the presence of foreign bodies, such as tampons, tents, stem pessaries, and especially soft- rubber pessaries, which are very prone to become foul, can properly be considered as causes. Traumatisms, including lacerations of the perineum, vagina, and cervix, from the un- skilful management of abortion or parturition, rough or unskilful examination, careless use of the sound or intra -uterine manipula- tion, without asepsis, and excessive or violent coition, are also contributing factors. Chefnic and vegetable poisons, such as phosphorus and the essential oils, may cause acute metritis. A patient suffering with chronic inflammation may have acute attacks which are excited by overexertion, sexual excess, opera- tions, or rough examinations. Inflammation may be promoted by the presence of uterine displacements, pelvic or uterine tumors, or profuse inflammatory exudates or morbid processes. The exciting causes are the pathogenic micro-organisms and their products. They are the gonococcus, the streptococcus pyogenes, the staphylococcus pyogenes aureus and albus, the INFLAMMATIONS. 329 bacillus coli communis, the bacillus tuberculosis, and the sapro- phytes from the bladder, rectum, and colon. Inflammation of the vulva and vagina can be produced by the passage through them of a septic discharge from a slough- ing fibroid, by malignant disease of the cervix or uterine body, by the contents of a pelvic abscess or pus-tube, or by being con- stantly bathed with feces or urine escaping through fistula. Of the various exciting causes named, the most prolific is gonorrhea. In woman gonorrhea is far more dangerous than syphilis, for when infection once occurs, the entire genito- urinary "tract may become involved, and the individual sub- sequently suffers from chronic inflammation of the uterus, sup- puration of the tubes, inflammation of the peritoneum and ovaries, as well as cystitis, ureteritis, and inflammation of the pelves of the kidne3^s. She not only loses through its influence her power of reproduction, but develops inflammatory con-, ditions which, if they do not cause a fatal termination, pro- duce sucl\ destructive changes in the pelvic organs as to neces- sitate their removal in order to prolong life or render it endur- able. While the recurrence of gonorrhea may not in many cases cause sterilit}^ its existence renders the soil favorable for the development of sepsis subsequent to abortion, parturition, or rough and unskilful manipulation. Careless examination, the introduction of the sound, and other intra-uterine manipulation without thorough asepsis are too frequently the causes of ex- tension of serious pelvic inflammation. Acute exacerbations are readily produced by overexertion, fatigue, cold, or rough manipulation when the pelvic organs are the seat of chronic inflammation. 381. Characteristics of Inflammation. — It should be well understood that inflammation, in the great majority of cases, is primarily a product of infection, and, consequently, is not necessarily to be regarded as a reprehensible process, but, on the contrar}^, as an effort to guard and preserve vital structures from injury and invasion. Its first aim, then, is defensive; the second, constructive and reparative. These processes are often so intermingled as to render differentiation difficult. The defensive element is more marked in the acute process, and is associated with proliferation, degeneration, and de- struction, dependent in degree upon the virulence of the in- fection and the capabilities of resistance. Efforts are set in opera- tion to establish a retaining wall. Blood stasis, cell proliferation, and exudation occur; degeneration and destruction follow. Such a process causes pain, a burning sensation, elevation of temperature, extreme sensitiveness, swelling, and more or less constitutional reaction. The process may terminate in resolution or go on to suppuration. 330 GYNECOLOGY. Acute and chronic inflammation are ofttimes mere stages in the infective process, and the one insensibly fades into the other. In the latter, defensive action is slight and not marked by an extensive limiting wall. Naturally, the symptoms are less severe, and, as the constructive elements predominate, as seen in hyperplastic conditions, the neuropathic disturbances are more marked. The inflammatory process may begin with a chill, or with repeated rigors, associated with elevation of temperature and with tenderness over the pelvic organs, often so great as to render the contact of the clothing or bed-clothes quite unen- durable, especially when the peritoneum has become involved. Increased secretion and discharge is an invariable symptom, necessarily dependent upon the seat and character of the in- flammation. Disturbance of the functions of the genital organs also necessarily occurs. In acute attacks the organs are so sensitive that a digital examination is frequently attended with agonizing pain. The menses may be arrested (amenorrhea) or be greatly aggravated (menorrhagia), while not infrequently there is profuse irregular bleeding (metrorrhagia). Increased or ir- regular flow is more likely to be associated with involvement of the peritoneum and cellular tissues, because the resulting exudate obstructs the pelvic venous circulation. The bleeding occasionally is internal. More frequently, however, there is a transudation of serum and plasma into the cellular tissues, which forms the condition known as parametritis or pelvic cellulitis. 382. Classification of Inflammation. — Frequently inflam- mation will begin in one portion and rapidly involve the struc- tures of the entire genito-urinary tract; therefore it is diflicult to specify any particular organ as its primary site. Further- more, in other cases the virulence of the micro-organisms may be so great and the defensive power of the patient so slight that general infection takes place, and localization, if it occurs, may be in organs remote from the site of original infection. The gonococcus is an example of the former, while infection with the streptococcus illustrates the latter. In the majority of cases inflammation preponderates in a portion of the genital canal or pelvic structure, and is named for the part mostly affected. Inflammation of the vulva, vulvitis. " " ducts and glands of Bartholin, Bartholinitis " " urethra, urethritis. " ** bladder, cystitis. " " vagina, vaginitis. ■' uterus, metritis. tubes, salpingitis. " ovaries ovaritis or oophoritis INFLAMMATIONS. 331 A still more minute classification of inflammation is made in relation to the particular structure or portion of the organ involved, as the mucous membrane, the muscular structure, or the periphery. Thus, with the vagina we may have an endo vaginitis, a parenchymatous vaginitis, and a peripheral or perivaginitis. The uterus furnishes an endometritis, a parenchymatous metritis, a perimetritis, the last involving the peritoneal covering, and an inflammation of the cellular tissue, known as parametritis or, better, pelvic cellulitis. The tube is aff'ected by endosalpingitis, parenchymatous salpingitis, and perisalpingitis. Inflammation of the serous covering of the uterus, as announced, is called perimetritis. It is, however, rare to find this portion of the peritoneum alone involved. More frequently, the entire pelvic peritoneum, including that of the uterus, broad ligaments, and tubes, is inflamed, so that the term pelvic peritonitis affords a more accurate description. Inflammation of the pelvic peritoneum rarely occurs without more or less inflammation of the cellular tissue. It can not be denied that we may have cellular inflammation without very extensive involvement of the enveloping peritoneum. When this occurs, it is known as pelvic cellulitis. 383. Vulvitis and its Varieties. — Inflammation of the vulva varies in degree from a slight erythema to a very severe and destructive involvement which may result in the formation of an extensive abscess, or in the destruction of a large portion of the labium. It is usually divided into simple or catarrhal, follicular, venereal, eruptive, phlegmonous, and diphtheric. 384. Causes. — Vulvitis is generally produced by infection. Its development is favored by neglect of cleanliness. The decomposition of the sebaceous and sudoriferous glandular secre- tion and of the smegma, which accumulates between the labia majora and labia minora and beneath the prepuce of the clitoris, will often cause an attack of inflammation similar to balanitis in the uncleanly male. In obese women the decomposing per- spiration, frequently associated with vaginal discharges, will keep the surfaces constantly irritated and produce an extremely offensive odor. The tendency to inflammation is enhanced by the gouty, rheumatic, and scrofulous diathesis, and by intemperance in eating and drinking, especially the latter. Vulvitis is often produced by uterine and vaginal discharge, from malignant disease or from discharging abscesses. The continual soiling of the vulva with the urinary and fecal discharge associated with fistula is productive of vulvar inflammation and often erosion of the surfaces. Vulvitis is excited and aggravated by masturbation and excessive 332 GYNECOLOGY. coition, from the pruritus occasioned by the presence of pin- worms, ants, and pedicuH. The various eruptive diseases, as eczema, herpes, acne, furuncle, warts, and venereal sores, are productive causes. A severe form of vulvitis is generally associated with eczema, and intense pruritus is caused by the presence of the torulag cerevisiae in diabetic urine. Inspec- tion will reveal whitish tufts over the surface, which arise from the spores of the oidium albicans. Severe vulvitis with eczema should always lead to examination of the urine in order to exclude the presence of sugar. Vulvitis is a frequent complica- tion in the eruptive and infectious diseases of childhood, such as scarlatina and diphtheria. It may arise from the extension of inflammation from the anus or bladder. 385. Vulvitis — Simple or Catarrhal. — In the acute stage of vulvitis the labia minora, the clitoris, and the fourchet are swollen and thickened. The parts are red, angry, and dry; later, they are covered with a profuse purulent discharge of an extremely offensive odor. This discharge is produced by an increased secretion of the sebaceous glands mixed with desquamated epithelium and pus-corpuscles. Pruritus, as in all forms of vulvar inflammation, is a marked symptom, and is at times so severe as to prevent sleeping and force the patient to abjure society. The temptation to scratch or rub the parts becomes almost irresistible. The contact of the urine causes smarting or burning. As the disease be- comes chronic, the surface is not so bright a red; it becomes abraded; at points, small ulcers form, the skin is greatly thick- ened, the papillse become hypertrophied, bleed easily, and are red; often the surface presents points of excoriation, which extend upon the vulva into the groins and the inside of the thighs, when the itching is intolerable. The glands in the groin often become swollen, and may even undergo suppuration. 386. Follicular Vulvitis. — The follicular inflammation is limited to the hair-follicles or originates in the sudoriferous and sebaceous glands. (Fig. 287.) The surface of the vulva is studded with small round protuberances the size of a millet-seed or hemp-seed. These elevations begin as papules, which may suppurate, forming pustules, which burst and shrivel, or they may remain as small indurations. The intervening skin is unaffected. 387. Venereal Vulvitis. — Venereal inflammation of the vulva is produced by gonorrhea, syphilis, and chancroid. The former is the most prolific source. Gonorrheal vulvitis is much more intense than the catarrhal. It particularly involves the ves- tibule and smaller labia. The latter are very red and ede- matous, while the external meatus of the urethra and the ori- INFLAMMATIONS. 333 fices of the ducts of Bartholin are generally red and swollen. Small excoriations frequently occur which bleed easily. The disease is attended with a very profuse purulent secretion, in which the gonococcus is found. The microscope shows the subepithelial tissue exceedingly vascular and infiltrated with solid groups of round cells. The epithelium will be seen in varying stages of granular degeneration and desquamation. Gonococci penetrate the epithelium and are found in the under- lying tissues. The inflammation extends to the vagina, not Fig. 287. — Follicular Vulvitis. infrequently through the urethra to the bladder, and often Bartholin's glands are inflamed, occasionally resulting in abscess formation. Llicturition is followed by intense burning. Vul- vitis due to syphilis occurs in the form of a single sore with indurated base and excavated surface, which is situated upon the large or small labium or in the neighborhood of the clitoris. In the secondary stage there are mucous patches similar to 334 GYNECOLOGY. those found in the mouth. Chancroids produce a more or less extensive ulceration, generally involving adjoining sur- faces; syphilis causes indurated enlargement of the inguinal lymphatic glands, while chancroid is characterized by their inflammation and suppuration, causing the condition known as buboes. 388. Eruptive Diseases of the Vulva.— Skin diseases mani- fest the same characteristics when situated upon the vulva as in other portions of the body. The most important, be- cause the most frequent, are eczema, erysipelas, and herpes. Eczema generally begins upon the labium majus or upon the mons veneris, from which it extends to the thighs, peri- neum, anus, and over the buttocks. In the acute stage the surface becomes red and swollen, burns, and is covered with transparent vesicles the size - of a pinhead. It is associated with fever, gastric irritation, and rheumatic symptoms, and becomes chronic by the end of the second week. Chronic eczema generally appears in the form of eczema rubrum, and the surface is covered with pus, dry scales, or crusts. Fissures form at the fourchet and anus and in the genitocrural folds. All the symptoms are greatly aggravated at the menstrual periods. Pruritus is intolerable. The occurrence of eczema of the vulva is generally associated with the appearance of the disease upon other parts of the body. It is a frequent consequence of diabetes mellitus, owing to the irritation of the sugar-containing urine. It is also an outcome of the rheu- matic diathesis. Erysipelas may occur as a primary affection of the vulva in the new-born, when it is a very serious disease, frequently proving fatal. It occasionally occurs periodically with the catamenia, or may even take the place of the latter. Its oc- currence during the puerperal state is generally an indication of serious infection. Herpes manifests itself by the appearance of small trans- parent vesicles, from the size of a pinhead to that of a pea, which may be few or multiple, discrete or confluent; rarely, as a single erosion of large extent. The advent of the disease is characterized by heat, smarting, and an area of redness, which is covered with agminated vesicles. These vesicles may fuse and form a large bulla. The vesicles dry; the edges of an ulcer are scalloped and its surface is covered with a crust, beneath which cicatrization is completed within from eight to fifteen days. The inguinal glands are engorged and pain- ful, but do not suppurate. Causes. — Accidental herpes may be caused by syphilis, gonor- rhea, filth, and constitutional conditions. Congestion is a predis- INFLAMMATIONS. 335 posing cause. In some women it occurs each month two days in advance of menstruation; also during pregnancy. 389. Phlegmonous Vulvitis. — Phlegmonous inflammation of the tissues may result from the catarrhal or may be the result of violence. It affects the deeper structures and subcutaneous tissues, resulting in serpiginous ulceration, which may form a permanent fistulous tract, or the inflammatory area may be so extensive as to result in the formation of an abscess. 390. Diphtheric Vulvitis. — Diphtheria may, but rarely does, affect the vulvar mucous membrane. The so-called diphtheric vulvitis is an exudation found upon lesions of the vulva and vagina, produced by parturition, and is the result of septic infec- tion. Such exudations are also found in grave constitutional disorders, such as scarlatina, smallpox, and typhoid fever. In a woman who succumbed to sepsis subsequent to the delivery of an intra -uterine sessile fibroid, whom I saw prior to death, the vulva, vagina, and uterus were lined with a diph- theric exudate. 391. Diagnosis of Inflammatory Disease of the Vulva. — The diagnosis, especially the differential diagnosis, of the inflam- matory disorders of the vulva is of great practical' importance. Gonorrheal vulvitis is evident from the greater intensity of its symptoms. It is characterized by an increased burning dur- ing micturition, profuse purulent discharge, and redness of the meatus and oriflces of the ducts of Bartholin. It has a tendency to extend to the tubes, ovaries, and peritoneum, as well as an in- creased inclination to involve the urinary tract. Its recognition is rendered certain by the discovery of the gonococcus, and the known fact of exposure to the virus. The absence of the gono- coccus is not proof positive against the specific character of the disease, as the germ may have disappeared. Late investiga- tions seem to show that the gonococcus is capable of assuming amorphous forms and resuming its original form and virulence under irritation. Thus are explained the recurrences of the dis- ease after a debauch, excessive venery, or exposure to cold in individuals who are apparently cured. (For method of dis- covering the gonococcus see Section 90.) The production of vulvitis in the virgin by masturbation is suspected when the smaller labia and the space between them and the hymen are covered with small, pointed excrescences ; the nymphae are elongated; the clitoris or its prepuce is irritated; swelling of the shallow groove between the orifice of the urethra and the clitoris exists ; clear, abundant secretion from the ducts of Bartholin occurs ; and associated with these phenomena there is abnormal sensibility ; exaggerated prudery ; and distinct hysteric symptoms. Discontinuance of masturbation may be assumed 336 GYNECOLOGY. when the hypertrophied nymphas become soft and no longer show any indication of inflammation. Eczema can be recognized by the similarity of its symptoms to those of the disease when it occurs in other portions of the body. Finding the cervix covered with whitish tufts should arouse suspicion of the presence of torula cerevisias, which is confirmed by the microscope and the discovery of sugar in the urine. It is a good plan carefully to examine the urine in every case of eczema of the vulva. Herpes is frequently confounded with chancroid, from which it is distinguished by its early his- tory. The formation of a vesicle is followed by its rupture, leaving a raw surface without a thickened inflammatory base and without loss of substance. The burning is more acute and the inflammatory symptoms subside more quickly. The lymph- atic glands of the groin -may become inflamed, but do not suppurate. The duration of herpes is from eight to fifteen days. In chancroid the sore has an uneven, fissured base, the edges of which are sharply defined, and its surface is covered with a greenish discharge. It presents points of abrasion, and generally the apposed surface becomes inoculated. Bubo develops in the groin. 392. Treatment. — In all forms of vulvitis absolute cleanliness is essential. In the simple acute variety, absolute rest and the administration of salines are indicated. Tincture of aconite can be given in drop doses every one or two hours to decrease inflam- mation. In all varieties thorough local cleanliness must be observed. In the simple and follicular forms cleansing and isolation of the inflamed parts will frequently be sufficient to establish a cure. The cause of the inflammation, if possible, should be determined, and, when practicable, remedial measures should be directed to its removal. Vaginal discharge should be arrested, and the inflamed surfaces should be protected from its contact. The rheumatic, gouty, and scrofulous diatheses and improper habits must be corrected by proper hygienic and con- stitutional measures. The food should be carefully regulated and all stimulating and indigestible articles avoided. Alcohol in any form should be interdicted, excepting in the diphtheric and phlegmonous varieties. In the acute stages a bland diet or exclusive milk diet may be advisable. Catarrhal and Gonorrheal Vulvitis. — The treatment of these forms is of great importance, as in the latter infection may lurk in the diseased tissues for years. Cleanliness is secured by the employment of the hot sitz-bath several times daily, by anti- septic fomentations, such as gauze pads moistened with sub- limate solution, I : 2000 or i :iooo; carbolic acid, i : 20; boric solution, I : 50; equal parts of boric-acid solution, and of a solu- INFLAMMATIONS. 337 tion of siibacetate of lead, or 5 per cent, solution of antipyrin, placed over the vulva and covered with oiled silk or rubber dam. In very acute conditions the distress will be much more quickly ameliorated by the application of lead-water and laudanum. This application may be kept cold by an ice-bag placed over it. These applications, whether antiseptic or emollient, should be frequently changed, the parts protected from vaginal discharge by a tampon, and the inflamed surfaces painted several times daily with a solution of Monsell's salt, i : 8, in glycerin or 20 to 40 per cent, solution of argyrol; on each alternate day silver nitrate, gr. x to the fluidounce, or compound tincture of iodin in water, i to 2, should be used. Protargol, largin, argyrol, and argonin have been especially advocated as valuable in the gonorrheal form; alumnol in 2 per cent, solution has also been advocated. Ramon Guiteras highly recommends mercurol in 2 per cent, solution. These agents are more effective in the gonorrheal form. The sides of the vulva should be separated with absorbent cotton, surgeon's lint, or prepared cotton. After the subsidence of the more acute stage the surfaces should be dusted with zinc oxid, bismuth subnitrate, iodoform, boric acid and acetanilid in equal parts, lycopodium, starch, talcum, or one of the various combina- tions of these powders. Iodoform and tannin in equal parts are very efficient. Equal parts of alum and sugar afford relief in pruritus. Buboes and abscesses should be promptly incised and their cavities sterilized. In chronic vulvitis, astringents or caustics may be employed, the latter with the purpose of promoting sufficient metabolism to take up inflammatory ex- udate which has led to thickening of the tissues. Benzoated zinc ointment is a soothing application. The surfaces may be dusted with calomel or bismuth subgallate. Gonorrheal vulvitis is usually secondary. In chancroid the parts should be kept clean by frequent washing, the inflamed area isolated by gauze or lint, and drying powders should be employed, such as iodo- form, iodoform and tannic acid in equal parts, aristol and desic- cated alum, 4 to I , calomel and zinc oxid or bismuth subgallate and acetanilid. In herpes keep the surfaces clean and separated. Drying powders should be employed. In follicular vulvitis, in addition to strong antiseptics, alkaline' solutions are efficient. It may be necessary to shave the parts and to puncture and cauterize the individual follicles, or, in rare cases, to excise the affected surface. The ointment of ammoni- ated mercury, diachylon ointment, or ichthyol in lanolin (J-i 14) may be useful. Phlegmonous and diphtheric vulvitis require cleanliness, antiseptics, removal of sloughing tissue, and, in the latter, cauterization of the infected surfaces with strong carbolic acid. 22 338 GYNECOLOGY. Eczema, when acute, must be treated with emolHent appli- cations or starch poultices, and the surfaces should be carefully cleansed. The bowels should be regulated and constitutional measures employed for the correction of any disordered condi- tion. When eczema is associated with diabetes, compresses of hyposulphite of soda, half an ounce to the pint, should be kept in contact with the inflamed surfaces. In chronic eczema the parts should be thoroughly washed with strong potash soap and hot water. By this measure all crusts and scales are removed. Where the surfaces are too much irritated, cracked, and fissured for this plan of treatment, a starch or slippery-elm poultice may be applied. After thoroughly cleansing the surfaces, the apphca- tion of the following ointments will prove of value : H . Hydrarg. ammoniat., 3 ss Lanolin, 5 ij. M. Ft. ungt. H . Iodoform. , 5 j Zinc, oxid .^ ij Lanolin, 5iij. M. Ft. ungt. B . Acetanilid, 5 j Menthol, 3 ss Lanolin 5 j. M. Ft. ungt. Or diachylon ointment or one of the tar preparations may be employed. If the irritation is apparently kept up by a vaginal discharge, use a vaginal tampon. Laxatives should be given to regulate the bowels, and constitutional measures should be em- ployed for the correction of arthritic, scrofulous, or diabetic con- ditions, from any one of which the disease may have originated. 393. Edema and Gangrene. — Edema of the vulva is fre- quently associated with pregnancy. It is common in ascites as a result of various obstructions of the circulation. It may follow labor and also result from varix of the external pudic vein. When one side of the vulva only is involved, infection should be suspected. Incisions of the vulva or spontaneous fissures permit the fluid to escape, but increase the danger of erysipelas, and may be followed by gangrene and slough- ing of the labia. The swelling in general anasarca is very great, and may render urination or the use of the catheter very difficult. A hard edema of one labium can occur from and persist after chancre. When it appears in the nymiphag or praeputii clitoridis, it resembles elephantiasis. The condition is known as syphilitic hypertrophy of the vulva. Gangrene of the vulva may be produced by traumatism, septicemia, and occur in weak and scrofulous infants. This INFLAMMATIONS. 339 form of gangrene in young children is known as noma. It is infectious, and presents a reddened, infiltrated labium and an ichorous discharge. A vesicle appears, which rapidly be- comes gangrenous. The treatment of edema is the same as that of the condition from which it arises. That of gangrene or noma consists in early excision, disinfection, and the exercise of measures to secure effectual nourishment. 394. Bartholinitis {Inflammation of the Glands of Bartholin). — These glands — also known as the vulvovaginal, Duverney's, and Cowper's glands — are racemose glands the size of a bean, situated in the labia majora at the junction of the posterior and middle thirds. The duct, two centimeters in length, opens in front of the hymen, with an orifice the size of a pinhead. Catarrh of these glands is rare, but hypersecretion is not in- frequent. It is indicated by redness about the opening of the duct, which may be either dilated or closed, in the latter case forming a retention cyst. The secretion from these gland may be thrown off in par- oxysms, not infrequently in noc- turnal emission. The secretion is particularly discharged during erotic excitement. Inflammation can occur in either the gland or the duct. It is gener- ally due to specific infection, but may arise from streptococcic or staphylococcic forms. In very severe cases it is apt to be a mixed infection. It is most generally due, however, to gonorrhea. Gonorrheal inflammation having been lighted up in the gland, it may subsequently remain dormant, and afford material which may not only again infect the patient, but others coming in contact with the secretion. Inflammation, according to its virulence, may either produce a C3^st or result in the development of an abscess. Cysts are either single or multi- locular, ovoid, with a smooth surface, and seldom transparent; the contents are viscid and are colorless or yellow. From mix- ture with blood they may become chocolate colored. (Fig. 288.) The cyst varies in size from that of a nut to that of an egg, is gen- erally unilateral, and is most frequently situated on the left side, Fis:. Cyst of Bartholin's Gland. 340 GYNECOLOGY. elongated in the axis of the greater Hp, and nearer the mucous sur- face. It seems elastic and compressible rather than fluctuating ; gives rise to discomfort in. walking and during coition, and can become inflamed and suppurate. Superficial cysts involving the duct may attain to the size of a nut ; they are usually situated at the base of the labium minus, and may project into the vagina beneath the mucous membrane. A cyst of the gland is deep, is generally larger, and is located behind the labium ma jus ; it elevates both labia and its duct is impermeable. The diagnosis is readily determined. In either solid or fluid tumors fluctuation is absent, and the transparency is insufficient. But when the diagnosis is doubtful, it can be ascertained by puncture. The conditions with which it may be confounded are: first, sacculated cysts of old hernial sacs; second, hydroceles in the canal of Nuck; third, a cyst in front of a hernia. From hernia, which may be an epiplocele, an enterocele, or ovarian, it is distinguished by the absence of succussion in coughing and by the determination of the con- nection of the mass with the abdomen. Hydrocele may fre- quently be displaced by pressure, is a larger tumor, gives more sensation of fluctuation, and is more translucent. Abscess may be secondary to the cyst or may originate from primary inflammation. Swelling and edema are marked over the pos- terior part of the vulva and about the anus, and the pain is acute and lancinating. The patient may have more or less fever; frequently, the urine is retained; fluctuation is distinct, and, if the abscess is not opened early, its contents may escape through several openings; pus is abundant and fetid. Fistulae may persist, and may result in a recto vulvar fistula, or a large ulcer may be present, associated with purulent secretion or a hypertrophic induration of the gland, with profuse discharge of milky, greenish pus. The gland is the last refuge of gonorrheal inflammation, and is a frequent source of unsuspected infection for men. It may be confused with anal abscess, phlegmon of the labium ma jus, or furuncles. In anal abscess there is more rectal disturbance, a more widely diffused inflammation, and the mass does not encroach to the same degree upon the labium. In phlegmon of the labium ma jus the inflammation is more external, and encroaches upon the cutaneous rather than upon the mucous surface. Furuncles are more sharply defined and present an indurated base. Treatment. — In early inflammation of the duct the pus may be evacuated by pressure and injected with a two per cent, sterile solution of ichthyol or a one per cent, solution of silver nitrate. The duct may be opened with a lacrimal knife, and a crayon of silver nitrate or a solution of zinc chlorid (i : 50) INFLAMMATIONS. 341 may be introduced. In cysts, when the contents are evacuated by puncture, they quickly reappear. Obliteration of the cyst may be secured by injecting ten drops of a solution of zinc chlorid (i : lo) after the contents have been removed by as- piration, or the cyst may be incised and packed with iodo- form gauze. A preferable procedure would be extirpation. In order to overcome the difficulty of removing the cyst when collapsed, it may be punctured, emptied, irrigated with hot water, and injected with melted paraffin, and the latter hard- ened with ice, after which the mass thus formed is easily dis- sected. The wound produced by the removal of a cyst should be closed with sutures. In abscess early free incision at the junc- tion of the skin and mucous surface is important. To ex- tirpate the gland, wash the cavity with carbolic solution and pack with gauze. In fistula it may be wise to extirpate the gland, dissect out the fistulous track, and close the cavity with catgut sutures. 395. Pruritus Vulvae. — Pruritus is a symptom of all forms of inflammation of the vulva. It results from the presence of pediculi, pin-worms, eczema, trichiasis; from hemorrhoids, disease of the kidneys, ureters, bladder, and urethra; from congestion of the pelvic organs and masturbation; and from acrid vaginal discharges. It is associated with pregnancy, menstruation, the menopause, old age, the gouty diathesis, and general nervousness. It is directly caused by lice, acrid discharges, and diabetes. In addition to the sources given, there is a form of pruritus in which the origin remains undeter- mined. This is designated as an idiopathic pruritus. It is, however, very questionable whether careful examination will not disclose a demonstrable cause of the disorder. Seeligman, in an investigation of a large number of cases, found in all a diplococcus which resembles the gonococcus in appearance, but differs from it in its process of growth, and, besides, it takes the Gram stain. Symptoms. — Pruritus produces intense itching, and, as a result of the scratching induced, excoriations are present, and the hair is often worn off the mons veneris. The patient avoids company, becomes melancholy, has loss of appetite and sleep and increased sexual desire, masturbation is excited, and she may become insane. Itching is continuous or occurs only at intervals it is increased by heat and is much worse at night or following any exertion. The relation of masturbation to pruritus is not always readily determined. The habit produces certain abnormal alterations as a result of the irritation: changes in the endometrium, glandular hypertrophy, ovarian irritation, increase of secretion, irritation and manipulation 342 GYNECOLOGY. of the vulva. A bad circle is engendered; irritation causes masturbation, and this aggravates the inflammation. There are cases, however, in which most careful examination fails to disclose inflammation of the vulva as a source of the intense pruritus. These conditions are know^n as idiopathic pruritus, and are supposed to be due to nerve irritation. Such cases do not properly belong under the term inflammation of the vulva, but they are so rare, and the symptoms are so prominently associated with vulvitis, that their consideration seems more appropriate here. Prognosis. — The relief of the condition depends entirely upon its cause. In some cases it is exceedingly obstinate. The removal of the cause, as filth, pedicuh, or pin- worms, results in the removal of the disorder. The prognosis in mas- turbating alterations is by no means favorable. It may be exceedingly difficult to overcome the evil habit. Treatment. — The first aim in the treatment should be to discover and remove the cause. Upon the recognition of ped- iculi the parts should be shaved, and blue ointment should be applied. A strong sublimate solution, however, is the most eft'ective agent. The surfaces should be painted with a solu- tion containing one grain of corrosive sublimate to the ounce each of alcohol and water. Unless the parts are shaved, this application must be repeatedly made, for it is necessary to destroy not only the lice which are present, but also the spores. If the pruritus arises from the action of the ascarides scabiei (the itch insect), sulphur ointment or one consisting of thirty- five grains of betanaphthol in one ounce of vaselin are eflicient applications. Of course, in the latter condition, the application must be made to the entire body. The methods of treatment of eczema and vulvitis have already been given. When it is evident that the pruritus has been produced by pin-worms, the parts should be kept clean and the patient given fluidextract of senna and spigelia in half -ounce doses; a rectal injection of infusion of quassia, two ounces to the pint ; half a grain of sublimate to eight ounces of water; an injection of lime-water or a suppository of five grains of santonin, are also efficient measures. Hemorrhoids, glycosuria, and other causes should be recognized and treated. The diet is important. Alcohol and spiced food should be- excluded. The use of coffee will often cause severe pruritus. Milk is an excellent basis for the diet. The general health should be carefully considered. Tonics, such as arsenic and quinin, should be administered. When the patient is unable to rest, sleep should be secured by the administration of bro- mid of potash, 5j-5ij daily, or tincture of cannabis indica, gtt. INFLAMMATIONS. 343 xx-xxv, thrice daily. When the measures just named are insufficient to secure sleep, sulphonal or trional should be given in preference to opium. Local vaginal injections of hot water; carbolized, sublimated, or borated cotton tampons; or fomentations of lead-water and laudanum can be employed, or a saturated solution of bromid of potash may be painted over the surface several times daih^ Local applications of chloroform in glycerin (i:8), hydrocyanic acid, two or three drops to the ounce, or a one per cent, solution of cocain may be used. A solution of carbolic acid, or a strong solution of silver nitrate, followed by cold compresses, may be employed. Seeligman advocates the use of an ointment containing lo per cent, of guaiacol in vaselin, and when this is not effective, it should be increased to 15 to 20 per cent. An ointment con- taining acetate of lead, chloral, camphor, or chloroform (a dram to the ounce), combined with vaselin, menthol, or a solid stick of nitrate of silver, is advised. The following formula may be employed : I^. Menthol, oss Lanolin, o j- M. Ft. ungt. In very obstinate cases the affected skin may be excised. Tam- pons containing equal parts of sulphurous acid and boroglycerid sometimes afford relief. The irritated surfaces may be painted with a solid stick of silver nitrate or a galvanic current can be employed. The employment of the :i:-rays has been advocated. The resort to tobacco smoking has afforded relief when all other means have failed. 396. Kraurosis vulvae is an obscure form of disease, first rec- ognized by Breisky, which consists of an atrophy of the smaller labia. (Fig. 289.) The skin of the vulva undergoes essential changes. The capillaries of the corium become dilated, the rete mucosum gets thin and disappears, while there is a substitution of a thick horny layer of epithelium, which lies directly upon the corium. The papillse disappear, the undulating character of the skin is lost, and it becomes stiff and sclerosed,' with here and there points of small cell infiltration. As the disease progresses the sebaceous and sweat-glands are entirely destroyed. It is called chronic inflammatory hyperplasia of the connective tissue with inclination to cicatricial shrinking (Peter) . Mars divides kraurosis into tw^o stages: (i) The stage of edema, characterized by more or less inflammatory reaction; (2) the atrophy of elastic and connective-tissue skin layers with the formation of scar tissue; but Heller says it may be independent of the inflammatory process. He attributes it to some chemic irritation or a direct disease of the medullated 344 GYNECOLOGY. nerves, which leads to atrophy of the muscles, fat, and glands in the deeper layers of the skin, while a hypertrophic process, especially a hyperkeratosis, occurs in the superficial layer. Causes. — The cause is unknown. It has been attributed to gonorrhea and pruritus. A preceding inflammatory stage exists (Martin). Breisky found it more frequently in the pregnant; Martin and others, in the nonpregnant. Symptoms. — The surfaces become contracted, presenting a Fig. 289. — Kraurosis Vulvas. smooth, cicatricial appearance, devoid of glands, with reddened, inflamed points, not fully cicatrized. Pruritus is intense and causes severe burning and pain upon urination. The surface is dry, smooth, contracted, often flssured. The labia minora entirely disappear, and the clitoris becomes a mere papule. The vulvar orifice is contracted, and causes coition to be ex- ceedingly painful, often impossible. Childbirth results in exten- sive laceration. INFLAMMATIONS. 345 Diagnosis. — The scratching of this disease should be sepa- rated from that of onanism and pruritus. The gratification induced by masturbation and the absence of cicatricial changes distinguish it. In pruritus the tears and superficial injuries are more marked and the disease is not so general, while in kraurosis the border of disease is more sharply defined toward the healthy skin. Prognosis. — Its spontaneous recovery is very doubtful. That carcinoma occasionally develops from it is exceedingly probable. Treatment. — The disease is exceedingly intractable to treat- ment. The application of cocain adds to the discomfort. Re- lief has been afforded by applications of strong carbolic acid, or of pledgets w^et with a solution of lead acetate. The thermo- cautery has been applied. The most effective treatment is the excision of the affected tissue, accomplishing union of the healthy tissue by sutures. Care must be exercised to prevent narrowing of the urethra. 397. Vaginismus is a term employed to represent an abnor- mal hyperesthesia of the external genital organs which pro- duces muscular spasm. It is common in young, nervous, or hysteric women, and occasionally occurs without our being able to discover any source of irritation. Generally, a care- ful examination will disclose an irritable spot in the fossa navic- ularis; an inflamed and thickened hymen, which has failed to rupture, or, when it has ruptured, irritable carunculse myrti- formes; fissures in the fourchet or around the orifice of the vagina; small ulcerations Avithin the hymen; fissure of the anus; urethral caruncle or an irritable urethra. Nervous irritation of the vulva may be engendered by association with an impotent or partly impotent man. Symptoms. — Dyspareunia, or painful coition, and sterility are the m.ost marked symptoms. The slightest touch, or even the approach of the male, may cause powerful spasm of the sphincter vaginas muscle. I have seen similar spasm occur at every attempt at urination in a very hysterical woman. The suffering is so intense as to lead the patient at once to seek medical advice, or through a sense of delicacy she may endure the distress until it becomes intolerable. She becomes careworn, anxious, and even hysteric. The ordinary vaginal examination is often extremely painful. I have, however, observed patients in whom the pain seemed confined to the attempts at coition, and they apparently experienced no un- usual discomfort during a careful pelvic investigation. Be- fore attempting digital examination it is well carefully to in- spect the surfaces and to push the labia apart, when possibly 346 GYNECOLOGY. the cause will be discovered. Hildebrandt has described a form of vaginismus due to spasm of the levator ani muscles, known as superior vaginismus, which is responsible for that unpleasant complication, penis captivus. It must not be over- looked that dyspareunia is occasioned by pathologic lesions of the floor of the pelvis, such as prolapsed, inflamed ovaries and tubes, inflammation of the cervix, pelvic cellulitis, or peri- tonitis. Prognosis as to cure is good. Treatment. — The first essential in treatment must be the removal of the cause. When the hymen is thickened and sensitive, it may be necessary to cut it completely away. Its mucous surfaces, however, should be sutured, in order to pre- clude the formation of cicatricial tissue. In irritable fissure the base should be divided, as in fissure of the anus, or touched with the thermocautery. Local applications are often effec- tive, of which one of the best is iodoform in powder or oint- ment. Its disagreeable odor, which often precludes its use, may be overcome by rubbing up a few drops of oil of eucalyptus with each ounce of the powder. Pledgets of cotton soaked in a four per cent, solution of chloral or in a two per cent, solu- tion of carbolic acid are useful. Ointments of opium, bella- donna, or ichth3^ol often afford relief. Neuromata, irritable carunculag myrtiformes, and urethral carunculas should be snipped off. In fissure of the neck of the bladder the urethra should be overstretched and cocain filaments or pencils should be used. In obstinate spasm glass dilators or plugs (see Fig. 163) should be worn for an hour night and morning. The pain caused by the introduction of the plug soon ceases, and it can be decreased by anointing it with a medicated ointment. These instruments should gradually be increased in size. When the dilator can not be worn, recourse should be had to opera- tion. Sims divided the superficial fibers of the sphincter vagina — the bulbocavernosus muscle. With the patient anesthetized, two fingers of the left hand are passed into the vagina to stretch the ostium. An incision about two inches long is made on each side of the fourchet, extending from half an inch above the ostium to the raphe of the perineum. The ostium is thor- oughly plugged with gauze, which is kept in position by a T- bandage. This plugging is important to prevent hemorrhage. The gauze is removed the following day, after which the glass plug should be worn a portion of each day for several weeks. For incision, forcible stretching may be substituted. This is accomplished by introducing the thumbs (Tilt) or several fingers of each hand (Hegar) and forcibly separating them INFLAMMATIONS. 347 until the muscular fibers yield under the traction. This pro- cedure affords the advantage that it is bloodless and that it leaves no granulating wound to cause a cicatrix. The gal- vanic current has proved beneficial. Constitutional treatment should always be combined with the local measures. Quinin, arsenic, and strychnin should be given. Outdoor exercise and change of scene should be encouraged and complete sexual rest enjoined. 398. Vulvovaginitis is an inflammation of the vulva and vagina, most frequently found in young girls, and, in the great majority of cases, is believed to owe its origin to the presence of the gonococcus. Robinson,* in fifty-four cases of vulvitis in children, mostly under five years of age, was able to find cocci in the pus-cells which corresponded to the gonococci in forty-one. It may also be induced by want of cleanliness, by the decomposition of the natural secretions, and by the entrance of pin-worms where proper cleanliness after stool is neglected. The importance of the condition is too frequently underestimated. The infection can extend to the uterus and even pelvic peritoneum, producing changes which condemn the individual to suffering all her menstrual life and often render her sterile. The principal symptoms are pruritus, painful micturition, and a profuse yellowish, watery discharge, which constantly soils the clothing of the child, and keeps the vulva irritated. The intense pruritus may readily generate the habit of masturbation. The infection may be spread by the hands, towels, linen, and bath. In children's asylums it is not uncommon to find large numbers of girls thus affected. The condition is frequently complicated by ophthalmia, peritonitis, and arthritis. Treatment should be energetic. In the acute stage it con- sists in rest in bed, a light diet, and free evacuation of the bowels. The urine should be rendered bland, and cold applications should also be employed. Severe pain and burning can be obviated by local applications of cocain, several hot sitz-baths, and careful irrigation two or three times daily. In irrigation, cocain may be first applied. This can be followed by alkaline or antiseptic agents, potassium perman- ganate (i 14000 to I : 1000), silver nitrate (i : 2000), protargol (0.5 to I per cent.), or a ten per cent, solution of argyrol. The irrigation should be made through a soft -rubber catheter intro- duced into the vagina. If the vagina does not drain well, the hymen should be stretched, to remove any obstruction. After * "Trans.. Lond. Obst. Soc," Jan. 4, 1898. 348 GYNECOLOGY. irrigation, the parts should be dried and a mild ointment applied. The vulva should be covered with a sterile dressing, which should be burned upon removal. The child and her attendant should be impressed with the danger of carrying the infection to the eyes. 399. Vaginitis, elytritis, or colpitis is an inflammation of the mucous membrane of the vagina. The mucous membrane of the vagina closely resembles the structure of the skin, having few, if any, submucous glands. It consists of connective tissue surmounted by papillae covered with several layers of squa- mous epithelium. A longitudinal ridge is formed upon the anterior wall, from which rugas, or folds, like the teeth of a comb, extend upon each side. This formation is less distinct upon the posterior wall. The central projections are known as the anterior and posterior columns. The former generally terminate below in a rounded protuberance, called the vaginal tubercle, situated immediately above the meatus urinarius. Sometimes the anterior column is divided by a furrow into two portions. The rugae aid in promoting sexual excitement, and probably contribute to A^aginal enlargement during preg- nancy and parturition. They disappear toward the upper part of the canal. The vagina receives its blood-supply from the vaginal, uterine, internal pudic, and vesical arteries — branches of the anterior division of the internal iliac. The vagina is surrounded by a venous network or plexus, which communicates with those of the vulva, bladder, rectum, uterus, and broad ligament, and finally empties into the internal iliac veins. The lymphatics of the lower fourth communicate with the superficial lymphatic glands ; those of the upper three-fourths, with the internal iliac glands. The nerves are derived from the sympathetic, and form upon each side of the vagina a plexus which communicates with the inferior hypogastric. The arrangement of the epithelium and the absence of glands render the vagina much less vulnerable to infection than either the uterus or vulva. We have already referred to the normal secretions of the genital tract. Doderlein distinguished between the physio- logic and pathologic secretions of the vagina. The former is markedly acid, dependent upon the presence of a bacillus which produces lactic acid. The latter may be feebly acid, neutral, or alkaline, and contain a variety of micro-organisms — saprophytic and pathogenic. Probably fifty per cent, of preg- nant women have this pathologic secretion, in which germs flourish, and from which auto-infection is possible. The demon- INFLAMMATIONS. 349 stration of the truth of this assertion greatly simplifies the study of the processes of infection. The vaginal discharge becomes alkaline during the menstrual period, during the puerperium, and in many cases of leukorrhea — a condition which is more favorable for the growth of micro- organisms and the infection of the genital tract. Doderlein's assertion, however, does not correspond with the results of the researches of i\lenge, Kronig, and Walthard. Kronig's investigations were confined to pregnant and puerperal women, and consequently are not a proper subject for consideration under gynecology further than to note his conclusion that the distinction between the physiologic and pathologic secretions is not determinable. He asserts that all secretions alike contain no pathogenic germs. All secre- tions are equally germicidal, though the vitality of the germ differs. It takes twice the time to kill the staphylococcus that it does to destroy the streptococcus. The vagina infected with germs will become aseptic in two or three days. The cause of this bactericidal power is as yet undetermined. It is not chemic, because it occurs whether the secretion is faintly or strongly acid; it is not believed to be due to a special bacillus, although some micro-organisms are known to be antagonistic to others. If it results from leukocytes, it must be due to a property independent of their contractile power, for the action continues after their subjection to a heat which would destroy the latter. The want of oxygen in the vagina will not explain it, for the staphylococci and streptococci are anaerobic — i. e.y grow independent of oxygen — and yet are killed. It is not mechanical, because particles of carbon and mercury are re- moved much more slowly. Possibly all these factors may unite to establish germicidal action. Kronig presents a very important practical observation, which is that a solution of corrosive sublimate for irrigation destroys the germicidal action, probably by precipitation of albumin, while plain water but lessens it. A necessary inference is that prophylactic injec- tions of corrosive sublimate are prejudicial when the secre- tion is normal. Alenge, in his investigations upon the non- puerperal, introduced pyogenic micro-organisms into the vagina in eight women, and found that the vagina cleansed itself from these organisms in periods varying from two and one-half hours to three days. The factors which compass this germi- cidal action are various forms of bacteria and their products, an acid secretion, possibly serum action, and the absence of oxygen. This activity is weak in infants, and is lessened by menstruation and by increased secretion from either the cervix or the bodv of the uterus, or even from the vaccina. It is de- 350 GYNECOLOGY. creased when the vulva is patulous or the uterus prolapsed, and at the menopause. Walthard has directed attention to the influence of change of pabulum in restoring the lost virulence of micro-organisms. He inoculated the streptococcus into the ear of a rabbit with- out unfavorable results, unless the ear was ligated to lessen tissue resistance, when a streptococcus from the vagina became as virulent as those found in puerperal fever. It is possible that an innocuous streptococcus may thus be restored by the tissues during the puerperium, and similarly in gynecologic operations in which there is bruising of all the tissues, as in the enucleation of fibroids. 400. Varieties. — Vaginitis may be divided into simple and specific (gonorrheal). The latter is exceedingly important because of its intractability and its tendency to extend. The distinction between acute and chronic is merely one of degree. Special varieties named are emphysematous, exfohative, dys- enteric, phlegmonous, diphtheric, and senile, but these are un- necessary distinctions. The etiology and pathology have undergone some con- sideration in our discussion of the action of micro-organisms. Of these, the gonococcus is most important, for upon its dis- covery will frequently depend the diagnosis. It was discovered and described by Neisser. The recognition of its presence in the secretion is diagnostic, but its absence can not be consid- ered a positive indication that the secretion is of other than gonorrheal origin. 401. Pathology. — In simple vaginitis slight elevations of the mucous membrane occur, producing a granular surface. The granulations are produced by groups of papillae, which are infiltrated with small cells; as a consequence, the papillae swell up and push before them the stratified squamous epithelium. Superficial layers are shed. Later, the surface becomes more level, from thinning of the superficial covering. With the vaginitis of pregnancy not infrequently an emphysematous condition of the mucous membrane is associated. These ele- vations have been described as cysts containing a gaseous fluid. The gas consists of air and trimethylamin. Ruge says the gas is situated in the cellular tissue, Zweifel says the masses are vaginal glands the ducts of which have become closed. A similar condition has been observed following the climacteric. The exfoliative, dysenteric, or diphtheric vaginitis presents localized patches or an inflammation of the whole vagina. In the latter condition the mucous membrane becomes so swollen that it is with difficulty the finger can reach the cervix, which is also thickened and covered with an exudation. INFLAMMATIONS. 351 Senile Vaginitis. — After the menopause the epithehal tissue is desquamated, the papilla atrophy, and the raw surfaces cause obhteration of a large portion of the vagina. It often causes curious constrictions of the upper vagina, rendering the canal frequently cone-shaped, with the small end above, which discloses the cervical opening as a mere dimple. Bands of contracting scar tissue are often seen, which divide the vagina into loculi. Desquamation of the epithelium occurs. This is probably produced by defective nutrition, and, later, granu- lations develop. A loss of elastic tissue also occurs, with an increase of connective tissue, which results in cicatricial con- traction. The same process can cause occlusion of the cervical canal subsequent to the menopause. Specific Vaginitis. — The most important cause of vaginal inflammation is gonorrheal infection. This produces an in- tractable form of vaginitis, which may continue for months, or even for years. It may extend over the mucous membrane of the uterus to the tubes, ovaries, and peritoneum, produc- ing endometritis, salpingitis, pyosalpinx, ovaritis, and pelvic peritonitis. 402. Etiology. — Vaginitis is produced by gonorrheal infec- tion; irritating discharges from the uterus; the contents of perivaginal abscesses; the contact of urine or feces from fis- tula; vaginal injections, too hot or too cold, or those contain- ing injurious chemic agents; badly fitting pessaries; decom posing tampons; efforts to produce abortion or awkward at- tempts at sexual intercourse ; and the exanthemata ; and it may complicate typhus fever, smallpox, and scarlet fever. Diphtheric patches have been observed in a number of diseases, particularly in the puerperal state. Localized patches are seen in fistulas, in carcinoma, and about badly fitting pessaries. The disease is induced by the habits of the patient. The free use of alcohol produces the granular form of the disease. The gouty or rheu- matic diathesis is a predisposing cause. 403. Symptoms. — Vaginitis is characterized by a sensation of burning, heat, and itching in the vagina; pain in the pelvic floor, increased by exercise; frequent desire to evacuate urine, with not infrequently scalding. A profuse mucopurulent leu- korrhea soon occurs. These symptoms are present in both the simple and specific varieties. In the latter the disease begins as an acute infection within from twenty-four to forty- eight hours after exposure, with itching of the urethral orifice, increased desire to urinate, a sensation of heat about the vulva, and burning and scalding upon passing urine. Generally, the tenderness and discharge are moderate ; occasionally, throb- bing is substituted. The distress is increased by walking, even 352 GYNECOLOGY. by moving the limbs, and by the shghtest touch of the finger. The urethral orifice is reddened and slightly swollen, and a drop of thick mucus or mucopus can be pressed out. After one or two days the entire urethra is exquisitely tender, and the orifice is swollen, intensely red, and bathed abundantly with pus. Pus and blood can be extruded from the vagina by pressure over the urethra. The hymen, vestibule, and labia become swollen, edematous, and eroded, and are covered with pus and exudate. At the end of a week the acute symptoms have subsided, the discharge is abundant, and when the parts are neglected, they become eczematous and cause a disagreeable odor. The vulva may regain its normal appearance in two weeks, while the discharge may continue for three or four weeks, or even longer. Infection of the vaginal follicles and of the vulvovaginal glands is not infrequent. The inguinal lymphatics become swollen, and may even suppurate. In the early part of the attack the gonococci are present to the exclusion of all other forms of bacteria, but later they may entirely disappear. The disease shows a marked tendency to invade the deeper and more important organs by the continuous mucous mem- brane. 404. Diagnosis. — Upon separation of the labia a profuse discharge is noticed, covering a reddened, thickened, and rough- ened or granular mucous membrane. The speculum reveals the vaginal mucous membrane as a red, swollen, smooth, velvety surface, from which the rugae have disappeared; or the redness, as well as the discharge, may be present only in patches. The cervix should be inspected, as the infection generally begins in it. The differential diagnosis between simple and specific vaginitis is often difficult. The history of a distinct infection would be valuable, but it is often too delicate a subject for interrogation. It may be suspected from the sudden onset of the attack, associated with urinary symptoms, a protracted course, and obstinate resistance to treatment. The inflamed urethra and ducts of the vestibule and the orifice of Bartholin's ducts, and not infrequently the formation of cysts or abscesses in the ducts or glands, with swelling of inguinal glands, afford additional confirmation. The recognition of the gonococcus by culture and microscopic investigation renders diagnosis certain. The absence of the gonococcus is not proof positive of nongonorrheal origin, for the gonococcus may disappear from the secretion. Even when the specific origin can be determined beyond peradventure, caution should be exercised in the expression of an opinion, as it may cause serious social unhappiness. The diagnosis of simple vaginitis will not be sufficient, but the INFLAMMATIONS. 353 physician should carefully examine the various structures to determine, if possible, the exact cause. Pelvic abscesses dis- charging into the vagina have been mistaken for vaginitis. 405. Prognosis. — The ease and rapidity with which vaginitis can be cured will depend upon the cause. The milder cases may be confined to the external genitalia, or may disappear even after the Fallopian tubes have become affected. In the more severe forms the entire genital tract may be rapidly involved, and portions of the tract may retain the disease and reinfect other portions. The general health is impaired in the chronic cases. The ovum, when it can enter, may find the uterus unfitted for its retention and, therefore, an abortion may result. Preexisting gonorrhea is said not to disturb the first two weeks of the puerperium, but subsequently there is a marked tendency for the germs to develop renewed virulence and to invade the healthy structure. 406. Treatment. — When the disease is in its acute stage, the patient should be kept absolutely quiet in bed. Sexual activity should be suspended, as w^ell for the interests of the patient as for the prevention of further propagation of the disease. The diet should be confined to nonstimulating articles. Alcoholic stimulants, pepper, and various other condiments, should be prohibited. Saline laxatives are advisable, and the patient should be encouraged to drink largely of emollient, liquids or alkaline waters. Local applications should consist of hot sitz-baths, alkaline douches. A saturated solution of boric acid in hot water may be given for fifteen to twenty minutes out of every two or three hours during the day, and every four while the patient is re- cumbent at night. The ordinary fountain syringe serves well, or a piece of rubber tubing weighted at one end and provided with a clip and nozle at the other. The weighted end, with the coiled tube, is placed in a basin of water above the level of the bed, the clamp applied, and the end of the tube with- drawn and introduced into the vagina. The clip opened, the water is siphoned out as long as the external end is kept below the level of the basin. When the acute SA^mptoms have sub- sided, douches should be given every three hours for the first two weeks. These douches may consist of solutions of subli- mate I : 4000, potassium permanganate i : 4000, carbolic acid, lysol, or creolin, protargol 0.5 to i per cent., mercurol 2 per cent., sodium chlorid 2 per cent., or sodium bicarbonate 2 per cent. After the period mentioned the strength of the fluid may be doubled and the frequency of the applications is lessened, now employing them four times daily. The dry treatment consists in cleansing the surface with a douche or by washing 23 354 GYNECOLOGY. the vagina through a _ speculum ; dry and pack with borated or iodoform cotton, and repeat every eight hours until the se- cretion is checked, after which it is given twice daily. A dry absorbent dressing must be applied to the vagina every two hours. Astringent douches are substituted in chronic cases and after the subsidence of the acute stage. Cleanse and dry the vaginal walls and paint with silver nitrate solution (5j : f5J), ■ followed by a tampon saturated with a solution of bismuth in glycerin, which keeps the walls separated. Fritsch recom- mends zinc chlorid (gr. ij : f.5J). A one per cent, solution of lead acetate, zinc sulphate or alum, potassium perman- ganate (i : 2000), or painting the surface with undiluted tincture of iodin, are serviceable. Acceptable powders are equal parts of tannin and iodoform, bismuth subnitrate and chalk, or boric acid and acetanilid of each equal parts re- tained with a tampon. In senile vaginitis cleanse with a satu- rated boric-acid solution. Tampons may be saturated with a 0.5 per cent, solution of lead acetate, or strips of lint may be saturated in a five per cent, solution of carbolic acid in gly- cerin or smeared with zinc ointment. Vaginal suppositories of tannin and iodoform, each, five per cent. ; zinc oxid, ten per cent.; or lead acetate, two per cent., maybe employed. When the condition is very chronic, spray through a speculum with a two per cent, solution of silver nitrate. The spray drives the medicine into the crypts and folds, and is far more effective than swabbing. I have derived more benefit from tampons anointed with ichthyol in lanolin (i 14); it causes a desquamation of the entire epithelium of the vagina and is destructive to the gonococcus. 407. Urethritis. — Inflammation of the urethra is an ex- ceedingly painful, but not an unusual, complication of pelvic abdominal procedures in which the catheter has been employed. Varieties. — It may be manifest as a simple hyperemia, an acute catarrhal urethritis, a chronic interstitial urethritis, or a granular or follicular urethritis. Associated with the ure- thral inflammation occasionally occur ulceration, fissures, and a sacculated condition of the urethra. 408. Hyperemia may result from injury during a difficult labor; from uterine displacement and uterine growths affecting the pelvic circulation; from varicose veins, irregular urination, excessive coitus, or long-continued irritation. Probably the most frequent cause of hyperemia, which may continue until inflammation results, is the repeated use of the catheter. So probable is such a result that the majority of operators prefer, if possible, to have the patient evacuate the urine unaided. INFLAMMATIONS. 355 When the employment of the catheter is necessary, the operator should have the nurse introduce the instrument for the first time in his presence, so that he can observe what precautions she employs and determine the ease with which she can accomplish the procedure. The instrument should never be introduced by touch, but always by sight. The vulva and the vestibule are generally covered with discharge, which may have decomposed and become infected by micro-organisms capable of producing serious discomfort when carried into the bladder. The labia minora should be separated and the vestibule sponged with absorbent cotton saturated with an antiseptic solution. The instrument, preferably of glass, should be per- fectly smooth, with no rough or cutting edges. It should be boiled, kept in an antiseptic solution, and previous to its use washed with sterile water. It is then anointed with carbolized vaselin and carried by gentle pressure upward and backward, without exercising any force. If the passage of the catheter is obstructed, withdraw and reintroduce it, as the instrument may have entered one of Skene's follicles. Even with the exercise of every precaution the urethra is often so irritated by the frequent introduction of the catheter that the patient may suffer more distress than from the con- dition for which the operation was performed; consequently whenever the patient can evacuate the bladder imaided, she should be encouraged to continue to do so, as the contact of healthy urine with a plastic wound, if the precaution is ob- served immediately to irrigate the latter, is less harmful than would be frequent catheterization. In operations upon the bladder Avhich require the urine to be frequently evacuated, a self -retaining catheter should be left in place several days. A soft-rubber instrument with a flange upon its vesical end is most serviceable. It can be plugged, permitting the urine to collect for two or three hours. It should not be permitted to remain longer than forty-eight hours without removal and careful cleansing. The ordinary glass catheter, with a long rubber tube attached, in my ex- perience, does equally well. 409. Acute Catarrhal Urethritis. — The mucous membrane becomes thickened; its papilla are hypertrophied and are covered with an imperfectly developed epithelium. At points the latter is desquamated and the papillae are enlarged. This may result in the formation of a polypoid mass, which pro- jects from the surface frequently by a pedicle — the urethral caruncle. The acute disease may arise from long-continued and re- peated hyperemia or from traumatism, but it most frequently 356 GYNECOLOGY. results from gonorrheal infection. The urethra is often the first point affected. Symptoms. — The onset of the acute attack is at first made known by itching or smarting of the urethral orifice, as the contact of the urine gives a sensation of a hot scalding liquid and urination is followed by intense burning along the course of the urethra. The meatus becomes red and swollen, then dark red and pouting. It is tender to the touch, and pressure along the urethra causes a few drops of mucopurulent or puru- lent secretion to be discharged. If the disease does not extend to the bladder, the symptoms soon subside or disappear. Diagnosis. — The condition should not be confounded with cystitis. Urination is not frequent. The pain and distress- are associated Avith micturition, Avhile in the intervals there is. comparative relief. The tenesmus of urethritis can be con- trolled ; it is attended with scalding, but is relieved by urination. In cystitis the tenesmus is uncontrollable, unrelieved by urina- tion, and there is no urethral burning. 410. Chronic catarrhal urethritis is very generally an inter- stitial inflammation. The membrane is thickened and the canal narrowed, not infrequently permanently so, which results in a stricture. Symptoms. — Urination is frequent. Temporary retention of urine may, however, be caused by a spasmodic stricture. The latter is greatly aggravated by frequent coition or pro- longed exercise. The thickening of the urethra is apparent upon passing the finger down the anterior wall of the vagina along its course. A small sound can be passed through the urethra, while the introduction of a large one meets with re- sistance and produces severe pain. 411. Follicular infiammation involves the follicles about the orifice of the urethra and Skene's glands. The latter are two tubules which will admit a No. i probe (French scale), and are situated in the floor of the female urethra, extending upward from the meatus about one or two centimeters. In the normal condition the orifices of the tubules are three milli- meters within the meatus, but with the urethra slightly pro- lapsed and the meatus everted, the orifices may be exposed to view. The upper ends of these canals terminate in a number of divisions, which project into the muscular wall of the urethra. (Fig. 290.) These tubules occasionally become so much enlarged as to permit the introduction of a small catheter. If such an instru- ment were forcibly introduced, it would tear through the tubule and establish a false passage. Such a passage might enter the urethra or pass beneath it into the tissue and thus enter the bladder. The follicles and tubules about the urethral INFLAMMATIONS. 357 3- ill orifice may become inflamed, with the consequent discharge of mucus and pus. The mucous membrane may become thick- ened or the orifices closed. The latter wil result in the formation of small cysts. Symptoms. — The symptoms are great tenderness ; discomfort in sitting, standing, or walking; dyspareunia; stinging pain; a sensation of heat; and frequent and painful micturition. The orifice of the meatus is partly everted, with red, puffy folds, which simulate caruncle, and with erosion of the labia minora and of the edge of the meatus. A few drops of purulent dis- charge can be extruded by pressure along the urethra. 412. Ulceration is produced as a result of traumatism, from calculi, unskilful use of the catheter, specific infection, or the presence of the diphtheric or the venereal poison. During the passage of a calculus or while in labor, injury, laceration, or over- distention of the middle portion of the canal occurs, with contraction of the mea- tus. A small quantity of urine and mucus is retained, which decomposes, and results in the development of inflammation and in the production of a condition simulat- ing an abscess. Symptoms. — The most prominent symp- tom is dysuria, which becomes chronic. The meatus is large, of a deep-red color, granular appearance, and sensitive to pres- sure. The passage of an ordinary sound is readily accomplished, but is attended with pain. Sometimes a drop of blood is discharged. The sacculated form is associated with a copious discharge of pus, particularly when pressure is made along the urethra. Even when the discharge of urine is perfectly clear, pressure will cause a considerable discharge of pus. 413. Vesico-urethral fissure holds an intermediary position between cystitis and urethritis, and strikingly resembles both. Its cause is undetermined. The fissure is situated at the in- ternal meatus, and resembles a crack in the lip or an ulcer similar to that which is found in fissure of the anus. The fissure is usually considered as being situated in the neck, but, as a rule, two-thirds of it is in the urethra. Only the upper end of it extends into the bladder. It may occur at any part of the circumference of the urethra, but, according to Skene, it is, in the majority of cases, situated upon the right side. In Fig. 290. — Urethra Laid Open with Probes, Distending Skene's Glands. Posterior Wall Divided.— (Byford, after Skene.) 358- GYNECOLOGY. length it is from six millimeters to one centimeter, and is from two millimeters to four millimeters in width at the widest part. It is deeper at either end. The deepest portion, yellowish- gray in color, resembles an indolent ulcer, while its edges are red and inflamed. Through an endoscope it looks like a fresh tear, the edges of which are abrupt, elevated, and indurated. Its situation explains the attendant discomfort. In any other portion of the urethra it produces little inconvenience beyond a smarting sensation, but at the junction of the bladder and urethra it is subject to constant though slight pressure, which causes severe and continuous pain. The portion of the fissure extending into the bladder is exposed to irritation from contact with the urine, producing a constant desire to urinate, a sen- sation of burning at the neck of the bladder, acute pain during and immediately following micturition, and severe tenesmus, causing the patient to continue straining efforts after empty- ing the bladder. The pain and burning immediately follow- ing micturition are often intense. Subsequently, it partly subsides, to return with the accumulation of a small quantity of urine. If the patient resists the inclination to urinate, the distress is greatly aggravated. 414. Diagnosis of Urethral Inflammations. — The recognition of inflammation of the urethra is often difficult, because it is frequently complicated by inflammation of the bladder. Acute catarrhal inflammation of nonspecific origin usually begins gradually, and is often preceded by uterine or vesical symptoms, while the gonorrheal variety appears abruptly, and is preceded or attended by acute vaginitis or vulvitis. In both varieties urination is painful. Sharp scalding is pro- duced by urine passing over the inflamed surface, but the desire to urinate is not so frequent or urgent as in cystitis. Often the urine is long retained, for fear of the pain occasioned by its evacuation, or started with difficulty, because of the sensation of scalding as the urine passes over the inflamed surface. Slight hemorrhage is occasionally noticed, the urethral origin of which is evident from it being unmixed with urine, a few drops oozing from the external meatus subsequent to urina- tion. Urethral discharge is common, and, except just after urination, it can be extruded from the orifice by pressing upon the urethra from the vagina. Microscopic examination of the discharge may reveal the presence of gonococci, which determines the nature of the urethritis. Absence of this germ, however, is not positive proof against the gonorrheal origin. To exclude cystitis, introduce the catheter, allow some urine to escape to wash away the mucus introduced with the in- strument, and retain the remainder, which will be found free INFLAMMATIONS. 359 from sediment. Pressure along the urethra from the vagina is painful in urethritis, while pressure over the bladder, unless complicated by cystitis, is not uncomfortable. In chronic urethritis the urethra is less sensitive, but it will be noticed as a somewhat thickened cord when examined from the vagina. In granular erosion the pain during micturition is excruciat- ing, it is associated and followed by tenesmus, and is more likely to be found in old persons. The character of the disease is assured by its history and by the appearance of the urethra. Fissure, urethritis, and cystitis are distinguished, the latter especially by examination of the urine. Fissure alone is free from all the products of cystitis. Urethritis is excluded and the fissure detected by the use of the endoscope. The endoscope is more satisfactory than the ordinary open instrument, because it exposes the sur- face of the fissure, which would be overlooked with the open end instrument. As a rule, the pain in fissure is more circum- scribed than in either urethritis or cystitis, and in many cases more acute. The maximum of pain in fissure follows urination, while in cystitis there is a sense of relief. In urethritis the most severe pain occurs during the act of urination. It then sub- sides slowly. 415. Treatment of Urethral Inflammations. — In urethral hyperemia render the urine bland and unirritating by the exclusion of acids and stimulants from the diet and by the administration of saline cathartics. Relief is enhanced by giving ten grains of benzoate of ammonia or benzoate of sodium every three or four hours, and by the employment of hot hip- baths and hot vaginal douches. Acute urethritis, whether specific or otherwise, should be treated upon the same principles as in gonorrhea of the male. The treatment consists of constitutional and local measures. Internally, salicylic acid in ten-grain doses lessens the discharge. Salol, two grains every two hours with a glass of hot water, renders the urine bland and unirritating. Douche the urethra frequently with hot water through a reflux catheter (Fig. 291), so that the current flows back from a cap on the end of the instrument. Later, inject from one-half of one to one per cent, of carbolized water; sublimate, gr. -J^, to aq., f 5j ; silver nitrate, gr. I", to aq., f§j; or zinc chlorid, gr. x, to aq. f§j; preceded, when injection is painful, by the instillation of a solution of cocain with a pipet. In making urethral applications it should not be forgotten that the canal will hold but from ten to fifteen drops. If a 360 GYNECOLOGY. larger quantity is thrown in by the pipet, it flows into the blad- der. A strong solution of silver nitrate (gr. x-xv to aq. fSj) may be applied by a pipet or applicator. The same quantity of a twenty per cent, solution of argyrol may be emplo3^ed frequently with very little discomfort and with very beneficial results. Internally may be administered those remedies which will have an inhibitory influence through the urine. These so- called blennorrhagic remedies are: copaiba, cubebs, sandal- wood oil, urotropin, and aminoform. The itching of subacute and chronic urethritis may be alle- viated by applications of different combinations of chloral or hydrocyanic acid, as in the following prescriptions : R . Chloral, J)iv Lanolin 5 j. M. Ft. ungt. R . Chloral, Camphor ^^ §.^- ^^^^ Lanolin 5 j. M. Ft. ungt. R . Acid, hydrocyan. dil 3 j Plumbi acet.^ gr. xv Glycerin f 5 j. M. These remedies may be brought in contact with the affected surface by the applicator. A suppository or bacillum of cocain in cacao-butter, or in combination with lead acetate, will give relief. These bacilla should be introduced into the urethra two or three times in the twenty-four hours, preferably after urinating. In prolonged chronic disease which has resulted in thickened walls and a more or less contracted canal, the dilatation of the urethra by bougies once or twice weekly will be beneficial. The bougie may be anointed for introduction with mercuric oleate, the official ointment of mercury, or any other medicinal agent which will have a beneficial influence upon the mucous surface. M. Julien, of Paris, applies ichthyol by dipping into it a cotton-wrapped probe, which is passed and repassed into the urethra several times. This agent has a destructive in- fluence upon the gonococcus. Granular erosion is best treated by brushing pure carbolic acid or silver nitrate (gr. xv to aq. fSj) over the surface. This should be repeated in eight or ten days. The urethra should be previously dilated. Following the subsidence of the acute symptoms, a few drops of a solution of zinc sulphate, gr. iv, fluidextract of hydrastis canadensis, f5J, aq., fSiij, may be used twice weekly with a pipet. Mercurol, 2 per cent, solution, has been found ver}^ serviceable. INFLAMMATIONS. 361 In fissure, instillations and injections do harm by increas- ing the spasmodic contraction of the bladder, and they add greatly to the discomfort of the patient. A fissure may be exposed by a fenestrated speculum, and dusted with calomel, finely pulverized iodoform, or bismuth subnitrate, or the mitigated stick of sih^er nitrate may be em- ployed. Incision of the fissure, as performed in anal fissure, is successful. The urethra should have been previously dilated. Dilatation is one of the most effective methods of treating fissure. The precaution must be exercised, however, not to overdilate the urethra and thus produce permanent incon- tinence. Follicular tirethrtiis is most effectively treated by splitting up the tubes their entire length. This may be done with the thermocautery, or they mav be cauterized with carbolic acid and subsequently treated with milder agents, as in urethritis. In such cases, however, splitting up the canal is a prerequisite to cure. 416. Cystitis is an inflammation of the mucous membrane of the bladder, and may be either acute or chronic. Fig. 291. — Reflux Catheter. Etiology. — The bladder is in intimate muscular relation with the uterus, as well as dependent upon the same nerve- centers and ganglia for its nervous distribution. A portion of the bladder lies in direct contact with the cervix, but in more close relation with the vagina. It is not surprising, then, with such intimate relations, that the condition of the bladder should be affected by disorders of the uterus. Inflammatory conditions of the bladder, if they have not originated from disorders of the uterus, are aggravated thereby. The symptoms of cystitis are more marked during menstruation and greatly aggravated by metritis. Vesical symptoms are engendered by uterine and vaginal displacements, b}^ subin- volution and hypertrophy, by tumors and pregnancy. The train of phenomena thus engendered may be enumerated as: difficulty in evacuation; retention and decomposition of the urine, producing irritation, and finally cystitis. Cystitis may be secondary to inflammation of the kidneys, ureters, or urethra. Chemic modifications of the urine mav result from indiscretions 362. GYNECOLOGY. m diet, from the administration of irritating drugs, or from affections of the central nervous system. Inflammation is produced by traumatisms, injuries from the introduction of a catheter, or the presence within the bladder of a rough calculus. Without doubt, the most frequent cause of cystitis is in- fection. This may result from the deposition of bacteria by the blood, from the extension of inflammation from neighbor- ing organs, or the introduction of infection by way of the ure- thra. The infection is generally introduced into the bladder from the employment of the catheter. A violent form of cystitis is produced by retention of urine. A pregnant retrofiexed uterus which has become impacted in the pelvis, by pressure upon the neck of the bladder, not infrequently leads to gangrene and desquamation, or to separation en masse of the entire vesical mucous membrane. Neoplasms, such as cancer, tuber- culosis, polypi, and villous tumors, will usually excite a cystitis. Pathologic Changes. — The mucous membrane becomes in- jected, particularly about the orifices of the ureters and in- ternal meatus. As the inflammation progresses the entire mucous membrane is swollen and becomes a bright red. The epithelium is desquamated and patches of ulceration or hypertro- phied papillae appear, which bleed easily. Abscesses develop in the vesical wall. The micro-organism most frequently found is the bacillus coli communis. Disease is also induced by the staphylococcus, the gonococcus, and the bacillus tuber- culosis. 417. Symptoms of Acute Cystitis. — Acute inflammation of the bladder is characterized by painful micturition; frequent desire to void urine, with only a few drops discharged at each attempt; severe vesical, and frequently rectal, tenesmus; a sensation of fullness or weight in the hypogastrium ; shooting pains in the perineum and anus; and a burning, lancinating pain, like a hot iron, in the urethra. These attacks may be almost continuous, or may, after a time, subside, to recur again in an hour or so. Examination by touch, whether over the abdomen or by the vagina or rectum, is extremely painful. The urine is scanty, highly colored, and becomes cloudy after standing. In very severe attacks the urine becomes a dark red color and contains blood and pus-corpuscles and uric-acid crystals. Constitutional disturbances are marked. These are nervous excitement, insomnia, and anorexia, followed by emaciation and loss of strength. Uncomplicated vesical inflammation does not cause elevation of temperature (Guyon). Partial or complete retention of urine is frequent. Paroxysmal pain results from vesical distention, and there may be frequent INFLAMMATIONS. 363 evacuation or continuous dribbling of urine Avithout at any time emptying the bladder — an evidence of overflow known as the incontinence of retention. The course and duration of the disease are variable: it may subside in a few days or may continue alternately better and worse for weeks. 418. Symptoms of Chronic Cystitis. — In chronic inflamma- tion the symptoms are less pronounced, though similar to those of the acute disease. Micturition is frequent and pain- ful, often difficult. The pain is pronounced at the beginning of the evacuation, thus leading to delay in starting. Exposure to cold, dampness, changes of clothing, indiscretions in diet, or constipation lead to acute or subacute attacks. The urine, after standing, becomes cloudy, and contains blood and pus- corpuscles, mucus, and uric-acid crystals. If drawn with the catheter, it is at first clear, then turbid, and toward the last pus is apparently discharged. The microscope reveals leu- kocytes, epithelial cells, tissue debris, and salt crystals. When the urine stands, it becomes alkaline, and bacteria in abundance are found. Constitutional Condition. — The patient is easily fatigued, has no appetite, loses flesh, develops a cachexia, has repeated inflammatory attacks associated with fever, repeated chills, a more or less continuous diarrhea, profuse sweating, and, finally, a fatal termination results. Such a train of symptoms and such a termination indicate the presence of an infectious pyelonephritis as a complication. 419. Cystitis of gonorrheal origin is produced by the ex- tension of gonorrheal infection from the urethra, possibly through the careless employment of the catheter, but more frequently from the continuation of urethritis to the bladder. Its principal symptoms are frequent micturition, agonizing pain in the acute stages, associated with changes in the quality of the urine; hematuria is a constant symptom, but is rarely profuse. These symptoms do not occur in the early stage of the infection. The disease is then generally much milder, characterized only by tenesmus. In the mucopus of the urine, from the associated urethritis, the gonococcus may be found. 420. Tubercular cystitis causes symptoms very similar to those produced by inflammation from gonorrhea and the irri- tation of calculi. Hematuria is a symptom in all varieties, but dift'ers in tuberculosis. It appears early in the disease, and the blood is generally mixed with the last drops of urine. The bleeding ceases as the disease advances. In common with other vesical inflammations, pain, urethral spasm, and retention and incontinence of urine are marked. 421. Diagnosis of Cystitis. — Cystitis is not difficult to recog- 364 GYNECOLOGY. nize. The frequent micturition, pain, alkaline reaction of the urine, large quantity of sediment, and mucopurulent appear- ance are ample evidence. In cystalgia and functional dis- eases of the bladder the urine will be found clear. Probably the greatest difficulty will be experienced in differentiating pyelonephrosis. Indeed, the infection from the kidney may lead to disease of the bladder and vice versd. The prognosis and method of treatment must depend upon the accurate determination of the structures involved. The existence of pyelonephrosis is recognized by finding the urine unaltered after irrigation of the bladder, while in cystitis it becomes clear. The condition of the urine from each kidney is recognized by securing the urine separately through catheterization of the ureters or by the employment of the Harris segregator. The careful investigation of the urine will often be sufficient to determine the diagnosis. Albumin is contained in the urine in either cystitis or pyelitis, but in very slight amount in the former, while it is present in quite large proportions in the latter. The presence of a proportionately great abundance of albu- min in the urine, associated with pus, should be considered as indicating the presence of renal disease. The most frequent cause is tuberculosis. The diagnosis of tuberculosis of the urinary tract is determined by the presence of the tubercle bacillus in the urine. Dr. Joseph Walsh, of Philadelphia, asso- ciated with Dr. Flick in his investigations in tuberculosis, however, informs me that the tubercle bacillus is found much more frequently in the urine of the tubercular patients than is generally supposed. The great majority of these patients will be found not to have a tuberculous kidney, though they will show a catarrhal condition of the kidneys, which is mani- fested by pains or aching in the bones, and by the presence in the urine of epithelial or granular casts, pus, and sometimes albumin. The bacilli may be found in the urine without any inflammatory symptoms. In sixty nonselected tuberculous patients whose urine Dr. AValsh examined, the bacilli were recognized in forty-four ; in thirty of these the disease was in an advanced stage; in ten it was considered marked, and in four, was only incipient. In patients in the advanced stages of the disease it is rarely that the bacilli will not be found in the urine. In five of the forty-four cases above cited tubercle bacilli were found in the urine, but not in the sputum, though the presence of a pulmonary lesion was recognizable. I have quoted Dr. Walsh fully, because his investigations seem to demonstrate that the presence of tubercle bacilli in the urine can not be accepted as evidence of the existence of a true renal INFLAMMATIONS. 365 lesion. The usually recognized difficulty of finding the bacilli in the urine is my justification for quoting here Dr. Walsh's method of examination : * ' Six fiuidounces of urine are cen- trifugated in a water motor centrifuge ; the sediment is then poured on one or two cover-glasses and allowed to dry thoroughly (twenty-four to forty-eight hours). The process is complicated by an excess of the crystalline sediment, which may render it impossible to find the micro-organism. In such cases, there- fore, the sediment secured by centrifugation should be dis- solved in water, a weak nitric acid, or a caustic potash solution, and again subjected to the centrifuge. In rare cases the sedi- ment may resist any one or all of these solutions. After dry- ing, it is fixed to the cover-glass by passing the latter through a flame two or three times, repeating this procedure twice, at intervals of a minute or two. The procedure for determina- tion of the bacillus in urine requires more heat than the corre- sponding examination of the sputum. Even after the pro- cedure for fixing given, the sediment will occasionally be washed off by the running water and the specimen thus destroyed. ' ' The specimen is stained with carbol-fuchsin for three to five minutes or longer, washed in turn with 95 per cent, and absolute alcohol for one to three minutes, decolorized, and counterstained with Gabbet's solution. The greater number of foreign elements in the urine, some of which hold the fuchsin, makes a larger experience necessary for the recognition of the bacilli than is requisite in sputum. * * The organisms must be absolutely typical to render the diagnosis certain." In examining over the abdomen of a patient suffering from tuberculous cystitis, greater pain is experienced by suddenly withdrawing the hand pressure than is produced by deep pal- pation. A cystoscopic exploration of the bladder will reveal the extent of involvement and amount of tissue destruction. Tuberculous cystitis may supervene upon the gonorrheal, without cessation of the latter. Primary vesical tuberculosis is manifested by a very ir- ritable bladder, frequent and painful micturition, followed by the passage of a few drops of blood. Such symptoms may subside, to be followed by an aggravated attack. The pres- ence of pus in the urine indicates preexisting disease, which may have been unsuspected. The progress of the disease is more rapid when complicated by the discharge of pus, the presence of a fistula, or the existence of pyelonephritis. Tlie last complication should be suspected when the urine shows the presence of a large pus sediment, inordinate quantities of albumin, and if the patient gives a history of incontinence of 366 GYNECOLOGY. urine and repeated exacerbations of high temperature. Polyuria is a most constant symptom of urinary tuberculosis. Gonorrheal cystitis is associated with evidences of infection of other portions of the genito-urinary tract, particularly the urethra, glands of Bartholin, cervix, and pelvic organs, which have preceded the vesical disease. The gonococcus can generally be found. A form of inflammation of the bladder, known as mem- branous cystitis, is a condition in which there is more or less extensive exfoliation of the bladder-wall, as in pseudo- membranous, gangrenous, croupous, or diphtheric inflamma- tion. It is always secondary to overdistention of the bladder from retention of urine. The mucous membrane is anemic during distention, but upon the removal of the bladder contents it becomes acutely congested and engorged with blood. It may be produced by any obstruction of the urethra. The most frequent causes are incarceration of a retrofiexed gravid uterus, unilateral hematometra, fibroid and ovarian tumors deeply seated in the pelvis, and loss of muscle power in low fevers and in septic conditions. The nurse or attendant may be led by the incontinence to overlook the occasionally enormous distention. The en- largement is gradual, extending above the navel, in the form of a tumor, which may very readily be mistaken for an ovarian cyst. The distention reaches its maximum when the reservoir can retain no more, and the abdominal pressure produces an involuntary discharge of the overflow, a condition which has been spoken of as incontinence of retention. Even though the bedding is constantly soaked with urine, the bladder is never completely emptied. The continuous pain, involuntary discharge of urine, a suddenly formed, gradu- ally increasing tumor, percussion dulness over its site, absence of the uterus above the symphysis, and the projection backward of the anterior vaginal wall, should make plain the diagnosis. Constant dribbling of urine should ahvays awaken suspicion of such a condition. Catheterization of such a patient by an ignorant midwife may cause the formation of a false passage, or negligence in the previous cleansing of the vulva will favor the entrance of infective agents into the bladder. No more favorable con- ditions for the extension of the sepsis could be imagined. Even if cystitis did not exist, hyperemia, infection, and traumatism, as a result of retention, would not be surprising. The enormous distention of the bladder causes anemia of its mucous membrane, thus producing disturbance of nutrition and superficial necrosis. Deep necrosis is caused by bacterial INFLAMMATIONS. 367 action. All such processes favor destruction of the mucous membrane. The inner wall of the bladder may become partially or completely detached, covered with phosphates of ammo- nium and magnesium, and penetrated with putrescent bacteria. The surface of the membrane is black or gray, contains numerous excavations, and sometimes horny concretions. The mucous membrane may come away in pieces or as a 'complete cast of the bladder. A portion of the membrane or the entire structure may lodge in front of the urethral orifice and completely obstruct the evacuation of urine. A small quantity of pus only may reward the introduction of the catheter. This pus has Accu- mulated at the lower portion of the bladder, but a more forcible pressure of the catheter may cause it to penetrate the mem- brane and permit the evacuation of the decomposing urine. Violent tenesmus is a frequent symptom of such conditions. The -urethra, dilated, will often permit the expulsion of the entire sac as a black, putrid mass. Cases have been reported in which complete exfoliation has taken place and the patient subsequently recovered good health without disturbance of the vesical functions. Neoplasms are differentiated from cystitis by the early appearance of hematuria, with absence of pain, tenesmus, or frequent micturition. The quantity of blood increases near the close of micturition ; it may continue for days or weeks, and may suddenly cease. Sometimes fragments of the growth may be discharged. Hema- turia dependent upon tumors varies with their character. If the growth is benign, its progress is slow, unless the pelvis of the kidney and ureters are involved. Cystitis due to the presence of foreign bodies, such as calculi, is characterized by severe pain, frequent micturition, violent expulsive efforts, and hematuria, after active exercise. In arriving at a correct diagnosis it must not be overlooked that very marked disturbance of the bladder may arise from the administration of various drugs, from the application of vesi- cants, especially cantharides. In such cases micturition is frequent and very painful, while tenesmus is marked. The withdrawal of the irritating cause is followed by prompt relief. 422. The prognosis of cystitis is necessarily uncertain, and must depend upon the duration and character of the disease, extent of involvement, complications, and carefulness of treat- ment. When the disease has existed for a long time, the in- flammation has extended through the mucous surface, more or less involving the muscular coat and causing contraction and distortion of the organ. It can readily be understood. 368 GYNECOLOGY. therefore, that no treatment will restore the functionating power of the organ. The prognosis is especially unfavorable when the disease has extended to the ureter, and especially to the pelvis of the kidney. Tubercular disease of the bladder also presents an unfavorable prospect for ultimate recovery, although I have seen most gratifying results when the tuberculosis was secondary to disease in one kidney and ureter after the removal of the offending organs. The favorable results in all cases will largely depend upon the carefulness of the treatment and the degree of cooperation the physician can secure from his patient. 423. Treatment. — In the treatment of inflammation of the bladder the aim should be, first, to remove or lessen its cause; second, to afford relief to pain; third, to improve the general condition of the patient. Prophylaxis. — The first indication is met most completely by prophylaxis, which, in all conditions dependent upon microbic invasion, should be the first consideration. Disinfection of the body, of the surroundings, of the hands, and of the instru- ments is necessary. The old procedure of introducing the catheter by touch is reprehensible. In the puerperal woman artificial light may be necessary. The legs should be flexed strongly, the better to bring the vulva into view. A small vessel is placed between the limbs, or the patient may be placed upon a bed-pan, and a warm disinfectant fluid poured over the vulva, which may enable her to void the urine spontaneously. If unsuccessful, the vulva is sponged with a cotton tampon and an irrigation stream is directed upon the urethral orifice. Then the catheter is taken from a disinfecting fluid and care- fully introduced, to avoid pain. Occasionally there is resist- ance at the internal end of the urethra, which is not over- come without pain. Care should be exercised in the with- drawal of the instrument, as the mucous membrane may be sucked into the eyelet of the catheter. Pushing up the instru- ment before its withdrawal will loosen it, when it can be re- moved without vesical injury. Whenever possible, the use of the catheter should be avoided, as, notwithstanding all pre- cautions, the mucous membrane of the urethra will be irritated by its frequent introduction, thus affording an opportunity for infection. Medical treatment to a limited degree meets all the indications we have assigned for the treatment of cystitis. The acidity and tendency of the urine toward decomposition are combated by the use of diuretics and by the administration of large quantities of the alkaline waters, such as Saratoga, Vichy, INFLAMMATIONS. 369 Seawright, Buffalo or Londonderry lithia, Carlsbad, or Seltzer. The salicylates are among the most efficacious remedies. Salol, 2 to 3 grains, can be given every three or four hours ; strontium salicylate, 3 to 4 grains four times daily. Some of the formalin compounds have been found very effective, as urotropin, 5 to 10 grains, four times daily. These drugs should be administered largely diluted. They prevent decomposition, remove the odor, and decrease the pain and tenesmus. They should not be given on an empty stomach. The diet, though nutritious, should exclude stimulants, acids, and condiments, except salt. Sugars and starches should be sparingly used, and in acute and severe cases it is well to restrict the patient to skimmed milk. In acute cases the patient should be confined to bed, and all exposure to dampness or cold should be avoided. In all cases care should be exercised regarding suitable clothing and protection against exposure. Pain may be so marked and micturition so frequent that measures must be instituted for its relief. Morphin or opium affords relief, but the pain soon returns. The remedy can not be repeated every two or three hours without danger of establishing the habit. An ice-bag over the bladder will frequently give comfort ; in other cases the hot- water bag is better borne. In the more distressing cases opium may be given in com- bination with belladonna or stramonium — tinctura opii deod., gtt. x-xv; tincture of belladonna, gtt. iij-v every two or three hours until relief; or suppositories of extract of opium, J- J of a grain, and extract of belladonna, |~^ of a grain, in cacao-butter — two, three, or four of these suppositories daily, according to the degree of pain. Relief is most quickly secured, however, by a hypodermatic injection of -I- of a grain of morphin with Y^Q- of a grain atropin sulphate. When opium is badly borne, cocain hydrochlorid, ^ of a grain, may be given in suppositories in combination with the same quantity of extract of hyoscyamus. When the pain is limited to the urethra, it may be delayed by injecting 30 minims of the two per cent, solution of cocain with 5 minims of solution (i : 1000) adrenalin chlorid through a syringe with bulb nozle. The openings about the bulb should be so situated as to direct the current back toward the external orifice. A celluloid is preferable to a metal syringe, because it can be used for sublimate and silver nitrate solutions. Inflammation of the neck of the bladder may be alleviated by the introduction, night and morning, of a vagina] tampon covered with an ointment containing 30 grains of extract of belladonna to i ounce of camphorated lanolin. Calculi and foreign bodies should be removed and shreds 24 370 GYNECOLOGY. of membrane and casts of the bladder should be early separated and evacuated. Gonorrheal and acute cystitis are considered as requiring diuretics, such as the alkaline salts, alone or in combination with oil of birch, buchu, or triticum repens. The following prescription is often serviceable: R . Ammon, benzoat., ^iij — or Tinct. hyoscyami, f ,5 j-ij Ext. buchu vel tritici repens, ad f ,^ ij. M. SiG. — -A teaspoonful in an ounce of water four times daily. Marsh directs: B . Acid, oxalic. , • gr. xvj Syr. aurant. cort. , f 5 j Aq. pluv., ad f 5iv. M. SiG. — A teaspoonful every four hours. Benzoic acid, gr. x, in capsules may be given three or four times daily, directing the patient to take large draughts of some bland water. Benzoic acid, gr. x, or camphoric acid, gr. xv, may be given three or four times daily with great relief. The bromid salts are often of value. ■ Free evacuation of the bowels by salines should be secured. After the severe distress and pain have subsided in acute cases and in all chronic inflammations advantage may be secured from intravesical medication. The bladder is irrigated through a return-current catheter by means of a fountain syringe: the fluid may be permitted to flow in until the discomfort is marked, when the tube is pinched and the fluid evacuated. (Fig. 292.) In the absence of a double catheter a single instrument may be used ; the bladder is filled and the fluid is allowed to flow out, and the process is re- peated until the bladder has been filled and emptied a number of times. This procedure, practised once or twice daily, gradually distends a contracted bladder and diminishes its irritability. The irrigation fluid may be hot normal salt solution; boric acid, 3ij-iv, to water, Oij ; or methyl-blue (pyolctanin) , gr. xv, to water, Oiss, night and morning. If the urine contains pus, employ a 2 per cent, solution of ichthyol five or six times daily ; the strength may be gradually increased to five per cent, after subsidence of acute symptoms. The strength of the solution at the beginning should not exceed one-half of one per cent. S. D. Powell advocates irrigation of the bladder with a solution of carbolic acid i : 30, followed by irrigation with alcohol; subsequently a 2 per cent, solution of the carbolic acid is em- ployed. Protargol i to 10 per cent., mercurol 2 per cent, (zinc acetate and aluminol 1:4), are also highly extolled. INFLAMMATIONS. 371 Lutaud advocates throwing into the bladder, after irrigation with a boric-acid solution, four ounces of tepid water, to which is added a teaspoonful of the following emulsion : Be . Iodoform. , 5 j Glycerin 3 x Aq. destil., ^v Tragacanth., gr. iv. M. This preparation should be introduced and permitted to remain. In necrotic and suppurative cases cleanliness is of prime importance. The bladder should be frequently irrigated. The frequent ichthyol irrigation is rapidly curative. Irrigation with 3 to 5 per cent, solutions of resorcin or with silver citrate (i : 8ooo to I : 4000) have been advocated. I have found great improvement following the injection of one to two drams of the 10 to 20 per cent, solution of argyrol into the bladder and allow it to remain. In tuberculosis and chronic cystitis the daily in- jection of 15-25 minims of 5 to 20 per cent, solutions of guaiacol in sterile olive oil has been advised. The cavity of the bladder may be explored by dilating the urethra and introducing one Fig. 292. — Double-current Catheter. of the vesical tubular specula used by Kelly. With a good Hght the cavity can be carefully inspected and applications, such as silver nitrate, gr. x-xxx, to aq. destillat., f 5j, made directly to the affected area. In the use of these stronger applications touching the affected or ulcerated points with a solution should be followed by irrigation with a salt solution. In subacute and chronic cystitis Clark introduces a vesical balloon of thin rubber. This balloon is connected with a thicker rubber tube, provided with a cut-off valve. Before using, it is boiled in a boric-acid solution, and its surface is coated over with a mixture of gelatin and ichthyol, 10 per cent., or bis- muth and zinc, salicylic acid, or weak bichlorid. The mix- ture is melted and poured over the bag, which has been rolled in the shape of a suppository. With a slender pair of forceps the balloon is introduced through the speculum. It is then inflated by a bulb syringe, the number of bulb pressures re- quired to fill it having been previously determined. The balloon remains in situ twenty minutes. 372 GYNECOLOGY. Guy on, in bad cases, advises that the bladder should be irrigated under anesthesia with a solution of boric acid or sub- limate (i : 10,000) and cureted with a medium-sized curet. The finger in the vagina as a guide enables him to go over the base and sides, while the hand over the abdomen aids in reach- ing the anterior surface; lastly, the urethra is scraped, the irrigation is repeated, and a self -retaining catheter is intro- duced and retained some fifteen or twenty days. Camero reports twenty-nine cases thus treated, of which nineteen were successful. Le Clerc-Dauday follows cureting by irrigation with a solution of chlorid of iron, and later by instillation of a i per cent, solution of silver nitrate. In serious tubercular cases in which pain and tenesmus are very marked cystotomy may be employed. It places the bladder absolutely at rest. A sound or bougie is passed through the urethra and used to depress the anterior vaginal wall, w^hile an incision is made through the septum. The vaginal and vesical surfaces are united by sutures to prevent the opening from closing. This procedure deprives the patient of control of the bladder contents, and requires the provision of an apparatus or receptacle for the urine. In septic conditions, where a large portion of the vesical mucosa has become necrotic, the removal of the gangrenous mass should be followed by irrigation of the bladder with a boric-acid solution (4 : 100) or a formalin solution (i : 5000). A graduated irrigator is preferably employed, and not more than three or four ounces should be injected at one time. This may be pressed out, and the fluid again allowed to flow in, repeating this twenty times. The irrigation should be performed four times daily. It is sur- prising in these cases of extensive septic inflammation to note the subsequent power to retain the urine. 424. Ureteritis is inflammation of the ureter, and may be acute or chronic. It generally begins in the mucous mem- brane, extending through the wall of the canal, so that the ureter presents the palpable sensation of a thick, rigid cord. Causes. — The disease, according to Mann, is produced by a number of causes: first, injuries during parturition; second, from previous disease of the bladder; third, gonorrhea; fourth, suppuration in the pelvis of the kidney; fifth, pelvic disease, such as pelvic peritonitis, cellulitis, and tumors; sixth, abnormal conditions of the urine; seventh, tuberculosis, to which may be added an eighth — the passage of calculi. 425. Acute ureteritis is often mistaken for intestinal colic, pain from renal strain, catarrhal appendicitis, or acute catarrhal salpingitis. The patient has a sudden attack of abdominal pain in which the distress is limited to, or more pronounced INFLAMMATIONS. 373 Upon, one side, or but slight upon the other. The pain is in- termittent, with not infrequently severe paroxysms. General abdominal tenderness is probably absent, while there is notice- able tenderness upon deep palpation upon the affected side, which in the beginning is more marked near the pelvis of the kidney. The site of most marked tenderness may be situated at ]\IcBurney's point. As the inflammation subsides the pain disappears, and may be recognized at a point an inch above Poupart's ligament. Originating in the back, it can not be differentiated in the early stage from colic occasioned by renal strain. When complicated by intestinal disorder, it may be recognized by its characteristic progress from above down- ward, the appearance of vesico- ureteral tenderness, and the urinary disturbance. When occurring upon the right side, its symptoms are sometimes attributed to appendicitis. The con- dition may terminate in recovery or may result in the chronic form. 426. Chronic ureteritis is characterized by frequent desire to urinate, which is more marked while erect, especially when standing, and is not wholly relieved by retaining the recumbent position. The patient is obliged to arise from one to many times a night; the discharge may or may not be painful. Fre- quently, the desire to evacuate the urine will be imperative, and the urine will gush forth before she can secure privacy. In some cases she complains of bearing down, greatly increased by standing, which disappears after a few hours' rest in bed. Palpation may afford no sign, except a slightly thickened cord, or a rigid mass almost the size of the finger, pressure along which will cause a discharge of urine with such power as to drive it some distance from the urethral orifice. The necessity for a cystoscopic examination of the bladder will depend upon the severity of the attack; when attended with much pain, it should be made. An alteration of the vesical mucous mem- brane in and about the orifice of the ureter will be recognized. This alteration may vary from a slight eversion and gaping of the orifice to one in which the orifice is an oval opening upon the summit of a mound of angry-looking mucous membrane. The mucous membrane in the immediate vicinity may be normal, but is generally red and injected, even roughened and eroded. The urea is said to be decreased upon the affected side. The urine may be secured for examination by catheterizing the ureters or by the introduction of the Harris double catheter. Treatment. — General treatment consists in the careful regu- lation of the diet, from which should be excluded strawberries, asparagus, and stimulants; tomatoes, onions, and cabbage should be used sparingly and with caution. The food should be largely 374 GYNECOLOGY. albuminous, of which skimmed milk may often with advantage form its base. Large quantities of water, alkaline diuretics, or the alkaline waters are useful. In acute and subacute con- ditions the patient is best in bed. The nutrition should be maintained by general massage. Local applications are advantageously made to the inflamed orifice of the ureter and to the eroded surface about it. A solution of silver nitrate (gr. x-xxx to foj) produces good results. It should be applied through a speculum directly to the affected surface, after which the bladder should be irrigated with a normal salt solution. When the inflammation of the canal is extensive, the dis- ease may be treated by irrigation through a ureteral catheter. In tuberculous disease, which is generally secondary to disease of the kidney, the affected kidney (the other having been demonstrated to be healthy) should be extirpated, and with it the ureter. INFLAMMATION OF THE CERVIX AND BODY OF THE UTERUS. 427. Classification. — The classification of uterine inflamma- tion has been and still is a difficult and perplexing problem. Various views have been presented. The existence of in- flammation of the endometrium, except in acute conditions, has been denied. The so-called chronic inflammation is de- nominated catarrh and uterine congestion, and is frequently attributed to peri-uterine inflammation. This statement would seem a distinction without a difference, and results from failure to appreciate the varying character of inflammatory changes in different tissues. The continuous mucous membrane is exceedingly vulnerable to the possibilities of infection. The irri- tation thus produced results in the production of inflammation. Its violence and extent will depend upon the virulence of the poison and upon the resistance of the patient. It may vary from a sHght inflammation which involves the cervix only to one which extends to the entire uterine cavity with infiltration of the sub- mucous structures ; may become interstitial or parenchymatous, and not infrequently in virulent attacks passes through the wall to its surface and causes perimetritis. In our early classi- fication we spoke of metritis, in a sense of inflammation of the entire organ; when it predominates in the lining membrane, it is called endometritis. When involvement of the deeper struc- tures occurs, it is known as parenchymatous or interstitial metritis, and as perimetritis if the peritoneum becomes involved. The latter condition is generally described as pelvic peritonitis, because, although inflammation can reach the peritoneum INFLAMMATIONS. 375 as described, it more frequently does so by the progress of the inflammation through the tubes, and the inflammation ex- tends to other structures than those immediately enveloping the uterus. The anatomical arrangement of the cervical mucous mem- brane makes it evident why inflammation can be confined to the cervix, although in puerperal women it is very prone to extend to the body. The various classifications are based upon clinical phe- nomena, pathologic changes, and causal relations. The ideal classification is that of Doderlein, into two divisions: first, inflammation produced through the influence of micro-organisms ; second, inflammation independent of their influence. The former is subdivided into: (a) septic and saprophytic; (6) gon- orrheal; (c) tubercular; (d) syphilitic; {e) diphtheric. The brevity of our knowledge of the influence of micro-organisms makes a careful differentiation difficult, but we are scarcely in a position to assert that there is any inflammation that is absolutely independent of bacterial production. My experience as a teacher has led me to discard the classification based upon the clinical phenomena, because it is difficult to associate there- with the pathologic relations. For this reason I propose to present the simpler and more frequently employed classification into acute and chronic, the latter subdivided into cervical catarrh, or endocervicitis, endometritis, and metritis. Acute endometritis affects both body and cervix. The chronic in- flammation can be localized in the cervical mucous membrane. The classification of uterine diseases is still further complicated by the physiologic changes which occur in the uterus as a result of menstruation. Thus, the uterine mucosa undergoes a periodic hypertrophy and degeneration, and it is often difficult to differentiate between the physiologic condition and early pathologic processes. 428. Endocervicitis — Ghronic Cervical Catarrh. — Cervical en- dometritis is an inflammatory process which aff'ects not only the cervical canal, but the entire cervix. The symptoms and appearance of the disease differ greatly in the unmarried or nulliparous and the multiparous woman, and it .manifests itself as inflammation of the portio vaginalis or of the cervical canal. In the former, the connective tissue of the vaginal portion of the cervix shows decided small-cell infiltration; the blood-vessels, especially the capillaries, become dilated and turgid with blood. Sometimes they become so distended as to form varicosities resembling hemorrhoids. Immediately beneath the epithelium the connective tissue is found rich in cells, Avhich later become converted into granular tissue. The squamous epithelium of 376 GYNECOLOGY. the surface is in many places infiltrated with leukocytes, and it undergoes hypertrophic changes from the increased blood- supply. Numerous papillae are formed and become covered with a single layer of epithelium which permits the red color to show through and the surface to present the appearance of an erosion. (Fig. 293.) Such a condition is generally recognized as simple erosion, and it generally involves the squamous epithelium of the vaginal portion of the cervix. When the external os has been lacerated, the lips w^ll often be widely separated and gaping. The mucous membrane is everted and presents irregular granular patches which protrude beyond the os. Such a condition was formerly regarded as ulceration. The microscopic examination Fig. 293. — Simple Papillary Erosion Fig. 294. — Simple Papillary Erosion of the Cervix. with Enlarged Follicles. of such a surface reveals the apparently denuded portion covered with epithelium. The increased blood-supply and the infiltra- tion of the tissue with lymphoid cell cause the cervical lining to become everted and project from the os like a fungus. Such a reddened, everted surface is sometimes known as granular or pap- illary erosion. At first the glandular structure is not involved, but eventually hyperplasia of the glandular epithelium results and there is an increase in the number and size of the glands. (Fig. 294.) The latter condition is more hmited to the super- ficial structure, which seems to be taken up with glandular tissue, to the almost complete exclusion of the connective. In the former, the glands enlarge and project through the structure of the cervix, sometimes even lifting up the squamous layer. INFLAMMATIONS. 377 The accompanying hyperplasia of the connective tissue may cause more or less constriction of the gland-ducts, and in certain places they may be completely closed, thus resulting in the distention of the glands and the formation of cysts. These cysts are known as retention cysts or ovules of Naboth. (Figs. 294 and 295.) They form nodular projections around the external os or can project deeply into the cervical tissue, becoming prominent Fig. 295. — Extensive Cystic Disease of the Cervix. Glands dilated with secretion, b. Large nodule formed by union of many glands and distended with fluid. Upon the vaginal surface at quite a distance from the external os. As the vaginal portion in the normal condition possesses no glands, it is evident these have been either extruded from the os with the hypertrophied mucous membrane, or have pushed through the structure of the cervix in the manner already described, and may lead to an extensive cystic degeneration of its structure. In one patient recently under observation change in the struc- ture of the cervix was so marked as to lead to the diagnosis of 378 GYNECOLOGY. sarcoma by myself and others, but the subsequent investigation disclosed that the condition was benign, though the cervix was entirely taken up with the cystic change. Infection may re- sult in the formation of abscesses, or the gradual distention may lead to a rupture of the cyst, producing what is known as follicular erosion, in which the greater portion of or the entire cervix may be involved. The increased glandular secretion, mixed with the transudation from the eroded surface, produces a very profuse leukorrheal discharge. The protruding struc- ture often is so extensive as to render its origin uncertain, but it evidently is produced by proliferation of the epithelial lining >^ Fig. 296. — Chronic Endocervicitis. a. Dilated gland forming cyst of Naboth. b. Detachment of glandular epi- thelium after absorption of fluid. of the cervical glands. Chronic inflammation of the connec- tive tissue occasionally causes such hyperplasia as greatly to increase the size of the cervix. In the nulliparous the cervix forms either a rounded mass, which increases the size of the cervix in all directions, or the latter may become so elongated as to produce a condition resembling prolapsus, and hence known as pseudoprolapsus. In previous laceration of the cer- vix only one lip may have undergone this hyperplasia, or both lips may be involved, when they will be widely everted and turned outward and baclavard, reminding one of the top of a celery stalk. The glands over such a surface are Hkely to INFLAMMATIONS. 379 become obstructed and produce retention cysts, which are recognized as firm, pea-like masses beneath the finger. Occa- sionally such cysts form abscesses or rupture, and with the proliferating epithelium present an extensive raw surface which can be mistaken for carcinoma. A number of cysts in close approximation may become united through the absorption and breaking-down of the intervening septa and thus form one large cyst. Puncture of the cyst permits the escape of a large quantity of viscid fluid rich in corpuscles, with subse- quent contraction and obliteration of the cavity. From the discussion it can be readity inferred that the inflammation involves all the structures of the cervix, the epithe- lium, the glands, and the connective tissue, and thus varies in its form and manifestations according to the predominance of the structure involved. When the glands are extensively involved, the cervix presents what is known as cystic degeneration. The increase of connective tissue results in what Thomas has so aptly described as areolar hyperplasia or cervical sclerosis. 429. Causes. — Inflammation of the cervix arises from exten- sion of inflammation from the body of the uterus, the vagina, and the vulva, as a result of excessive coition, laceration, in- juries during instrumental and digital examination and manipu- lation, and from puerperal and gonorrheal infection. The cylindrical lining of the cervix is particularly vulnerable to infection, especially after laceration, when exposed to friction against the walls of the vagina, and to injury during the act of coition or examination. It is rare to have inflammation of the body of the uterus without involvement of the cervix. The latter is prone to occur because the uterine discharges flow over the cervical mucous membrane and irritate it. Endo- cervicitis is particularly likely to be produced by congestion of the uterus in association with flexions, and especially retro- flexion. In retrodisplacements and in anteflexion separation of the lacerated surfaces is favored, and the delicate cervical mucous membrane is to a greater degree exposed. 430. Symptoms. — The principal symptoms of cervical in- flammation are leukorrhea, pain in the back and loins, ag- gravated by exercise or standing, irregular menstruation, and sterility. Leukorrhea is the most important symptom. The normal secretion from these parts is insufficient to attract attention. When it is excessive, it becomes known as leu- korrhea, or, in popular language, the whites. A temporary discharge — a transparent leukorrhea, like white of egg — not infrequently occurs preceding and following the menstruation, due to temporary congestion. The secretion from the cervical glands is clear and viscid, resembling white of egg. It be- 380 GYNECOLOGY. comes white when mixed with mucus-corpuscles, and yellowish when pus-corpuscles are present. Not infrequently it is tinged with blood, which escapes from the delicate vessels of the newly formed vascular tissue. Pain is aggravated by walking, stand- ing, riding, or anything which increases the friction between the cervix and the vaginal walls. i\Ienstruation is irregular and there is generally an increase in the quantity of the flow, probably produced by an extension of the inflammation to the endometrium. Sterility is often present. In the nullip- arous woman suffering from endometritis the cervical canal is filled by a plug of mucus, which may afford a bar to con- ception. In the multiparous woman the presence of cervical inflammation may render the woman less susceptible to preg- nancy, but it is not, however, considered an absolute obstacle to conception. 431. Physical Signs. — The appearance and outline of the cervix differ in the nulliparous and in the multiparous woman. In the former it is puffy and large, the os being soft and velvety. The patient will complain of pain when the cervix is moved or pressed. In the multipara the cervix is generally lacerated; its margins are soft, velvety, and eroded, or hard, presenting pea- like nodules, polypoid projections, cystic masses; or the os may be gaping, so as to permit the introduction of the finger nearly to the internal os. The one lip may have undergone involu- tion, w^hile the other is enlarged and elongated. The mucous membrane is irregular, not infrequently presenting longitudinal ridges. Digital examination affords an idea as to the position and relation of the cervix, and as to its condition, w^hether lace- rated or otherwise. The digital examination should be supple- mented by the use of the speculum, the latter being used to con- firm suspicions which have been engendered by the digital exami- nation. The Sims speculum is preferable, as it aff'ords less dis- placement to the parts and permits more thorough and complete inspection. In the nullipara the os will be filled with a plug of tenacious mucus surrounded by a patch of excoriated tissue, par- ticularly upon the posterior lip, from which the outer layers of the epithelium have been desquamated. In the multipara a lacera- tion will probably be seen. Its presence is often overlooked, be- cause the fissures are filled up with indurated cicatricial tissue. The use of tenacula to turn in the surfaces demonstrates its existence. The bluish-red ovula Nabothi may be readily seen as nodular projections upon the surface. 432. Diagnosis. — Cervical catarrh is readily determined from vaginal inflammation by the use of the speculum. In the former a plug of mucus will flll up the cervical canal and pro- ject from it, being so viscid and tenacious that its removal INFLAMMATIONS. 381 is accomplished only with difficulty. To thoroughly remove the mucus from the surface it miay be necessary to use a curet. The mucus in the interior of the dilated glands should be removed by puncture and digital pressure. When the cervical dis- charge is insufficient to render it visible, Schultze's method may be employed. He gives the patient a vaginal douche, introduces a speculum, thoroughly cleanses the surface, and places a tampon soaked with a solution of tannin against the external os. This applied at night and removed through a speculum the following morning, the character and quantity of the discharge from the cervix can be noted. The differen- tiation between endocervicitis and endometritis is still more difficult. In many cases, indeed, we may not be able to say definitely that a cervical catarrh is not associated with more or less inflammation of the endometrium. The enlargement and thickening of the cervix demonstrate that it is the seat of inflammation. It is sometimes difficult to differentiate be- tween inflammation and malignant disease of the cervix. In the former the hypertrophy is more general and uniform, the tissues are more or less firm, but not hard, and show no in- clination to friability. In malignant disease the cervix may at points be hard and indurated from the presence of an in- filtrate which is more or less localized. An excavated ulcer may be present, covered with friable, easily broken-down tissue, which will crumble and become detached under the finger, while the base is hard and resisting. Hemorrhage and a profuse, foul- smelling discharge are prominent symptoms. When the condition is such as to leave one in doubt, a test excision should be made a.nd the excised tissue subjected to microscopic investigation. 433. Prognosis. — The curability of endocervicitis is de- pendent upon the general health of the patient, the duration of the disease, and the extent of involvement. Not infre- o^uently it will be found that these patients have passed through the hands of a number of physicians, and, therefore, extreme care must be exercised as to the prognosis. The result is less favorable when there is a large amount of secretion and ap- parently but little glandular degeneration. 434. Treatment. — First, constitutional: The patient should be encouraged to take outdoor exercise, and not infrequently change of air will prove of decided value. Tonics, such as quinin, iron, strychnin, arsenic, and the bitter tonics, will be of advantage. Indigestion should be corrected, regular action of the boAvels secured, and sexual rest advised. Second, local treatment: In the nullipara it is advisable to give hot vaginal douches through a fountain syringe under moderate pressure for ten to fifteen minutes each night, having 3S2 GYNECOLOGY Fig, 297. — Lines of Incision for Contracted or Pinhole Os. the patient preferably in the recumbent position. Doubt- less in some cases the hot water thrown with force from a bulb syringe against the cervix will have a more marked modifying influence upon the hy- perplastic process and, therefore, it should sup- plant the fountain syr- inge. The temperature of the water should be from 110° to 115° F., and the patient should be advised to remain in bed following the douche. Astringents can be added, such as a solution of zinc sul- phate (5j-ij-water Oij), powdered alum (5j~ Oij), lead acetate (5j- ij-Oij), or the latter and zinc sulphate may be combined. ]\Iild so- lutions of antiseptics may be substituted for the astringent, as hydrargyri bichlorid (1:4000), formalin (1:2000), but these agents present no special advantage over the douche of sodium chlorid, Bj, water Oij. The OS, when narrow and contracted so that drainage is ineffective, should be notched bilat- erally with scissors, to permit the escape of the mucus. The lips should be trimmed, making a funnel-shaped opening. (Figs. 297 and 298.) When the secretion con- tinues, local applications, such as tincture of iodin or carbolic acid, a satu- rated solution of iodin crystals in carbolic acid, p-, 95 per cent., can be em- ployed; the former in mild, the latter in more severe, cases. Heywood Smith advises acid nitrate of mercury ; De Sinety, chromium trioxid. Better results —Union of Vaginal and Mucous Membranes. Cervical INFLAMMATIONS. 383 are secured from the employment of the milder agents, as zinc sul- phate or chlorid gr. x, aqua f § j, silver nitrate gr. x-xv-5 j, or so- lution of argyrol (20-40 per cent.). In making an application, the mucus should first be removed from the canal with a cotton- wrapped applicator or a blunt curet. When the mucus is very tenacious, its removal is greatly facilitated by throwing in a few drops of hydrogen dioxid by means of a pipet, after which it is more readily removed with the blunt curet. This step is im- portant to prevent the application being coagulated by the mucus without reaching the affected surface. After the ap- plication any surplus fluid should be removed, and a tampon of cotton or of gauze saturated with glycerin should be placed beneath the cervix. A 25 per cent, solution of ichthyol in glycerin, or ichthyol in lanolin, of the same strength, may be applied to the cervical canal with a cotton-wrapped probe, or a small pledget of gauze or cotton anointed with it may be carried into the dilated cervix, or a tampon medicated with it may be applied to the eroded cervix. Ichthyol is advisable because of its germicidal action. The application of such a tampon will not infrequently result in the desquamation of an epithelial cast, followed by a regeneration of the epithelium and restoration of a healthy appearance of the cervix. The application of a saturated solution of iodoform in ether is ad- vised. Ether stimulates contraction of the glands and forces out the secretion, while the iodoform remaining acts as an antiseptic. In the multipara endocervicitis is not infrequently complicated by retroflexion, subinvolution, or laceration of the cervix. The first consideration should be to relieve conges- tion by scarification of the surface, puncture of retention cysts, employment of hot astringents or antiseptic douches, and the use of medicated tampons. Some form of glycerin medication upon the tampon is especially efficacious in causing profuse depletion. The displacement should be corrected and the organ should be maintained in a proper position by a tampon or by the use of the pessary. When the cervical mucous membrane is much everted and the lips are widely separated by laceration of the cer\dx, the relief of the engorgement and congestion can be over- come by the employment of Emmet's operation. The uterine congestion may be greatly decreased by local depletion through scarifying or puncturing the cervix. Such depletion is of special valtie where a number of glands of Naboth have become obstructed and have formed retention cysts. Evacuation of the cysts and the introduction of tincture of iodin or carbolic acid into their cavities produce a sufficient amount of inflammation to obliterate them and relieve the pressure. In very obstinately chronic cases destruction or removal of the diseased 8:landular 384 GYNECOLOGY. tissue is imperative. It may be accomplished by the use of the PaqueHn thermocautery or by various caustics. Skoldberg recommends zinc -alum sticks, which are made by running together into molds equal parts of zinc sulphate and alum, forming a small stick, which is carried into the cervix and retained by a plug of gauze in the vagina, which also re- ceives the discharge. Silver nitrate in solid stick was formerly much used for this purpose. The latter method of treatment is required only in exceedingly severe cases, and its application should be extremely limited. It cures by destruction of the mucous membrane and glandular structure, substituting for them cicatricial tissue. It should not be used where there is danger of the cervical canal becoming so contracted as to interfere with drainage from the uterine cavity. Colpe, finding that an inflammation of the cervix did not yield to the use of astringents and caustics, examined the secretion and found present mycotic spores, after which he used lactic and salicylic acids, with immediate relief. Electricity has its advocates — the negative pole is introduced into the cervix, while the positive pole is placed upon the abdo- men. It is questionable, however, whether this plan of treat- ment has any advantage over other caustic measures. The use of the sharp curet not only removes the glands from the cervical canal, but, as advocated by Thomas, scrapes away the arbor vitse from the internal to the external os. This measure not infre- quently has to be repeated a second or even a third time before relief is complete. When there is very marked eversion or an eroded, deeply fissured surface, Schroder's operation should be performed. This consists in the formation of a single flap in each lip. The method of procedure has been described. (Sec- tion 336.) Martin removes a larger amount of the cervix, and combines amputation with excision. He splits the cervix into two lips, cuts through the cervical mucous membrane on the posterior lip above the diseased portion, then removes as much of the lip as is necessary, and stitches it. The anterior lip is treated in the same way. 435. Acute Metritis and Endometritis. — In acute inflamma- tion the pathologic changes are not confined to the endometrium, but rapidly involve the entire organ. In the nonpuerperal uterus they are excited by infection from gonorrhea, or follow trauma, induced by exploratory operative procedures, or result from exacerbations of the chronic state. The nonpuerperal cases are rare and scarcely ever fatal or sufliciently threatening to require hysterectomy. Such an inflammation is generally brought on by an infection which has occurred during parturition or abortion, and, consequently, is more an obstetric than a gynecologic condition. INFLAMMATIONS. 385 Infection is favored: 1. By protracted labor during which the tissues have been subjected to bruising or laceration. 2. Through want of skill or of cleanliness in the practice of manual or instrumental procedures. 3. From the retention of clots or of portions of placenta or decidua after labor or abortion. 4. By the presence of septic germs in the genital canal prior to the occurrence of gestation, by their introduction during the process of delivery or in the subsequent convalescence. 436. Pathologic Alterations. — The infection is originally im- planted in the degenerated mucous membrane, the blood-clots of the uterine sinuses, the site of the placenta, or in retained portions of the placenta or decidua. Intense hyperemia results, with alterations in all the tissue elements. The gland lumina are dilated by the increased secretion and proliferation of the glandular epithelium. Inflammatory infiltration takes place into the tissues, with subsequent degeneration and destruction of the cellular elements. The mucous membrane becomes greatly swollen and edematous. The epithelium is found granular and desquamating. The blood-vessels become engorged and thrombosed. Inflammatory material is poured into the cellular tissue, which may terminate in abscess formation, either in the wall or sinuses or both. These pus -pockets, at first small and localized, increase in size, the intervening walls break down, and an abscess of con- siderable size may form, which may rupture into the uterine cavity and thus terminate favorably, or a large portion of the uterus may become gangrenous, causing serious detriment to the health, and even loss of life. In an autopsy upon a patient who died under my care in the Philadelphia Hospital the entire fundus was found to have been completely destroyed. 437. Varieties and their Source. — The symptoms will be found to depend upon the character of the infection, and this can be divided into sapremic and septicemic. Sapremic infec- tion is induced by the action of the saprophytes upon retained blood-clots and portions of the decidua or placenta, which cause decomposition of the retained tissue, with the subsequent absorption of the decomposing products. Decomposed material, when undisturbed, presents a soil favorable for the implantation of septic infection. Septicemia, however, occurs much more frequently as a primary disorder induced by the entrance of pathogenic germs through fractures of the mucous membrane of the uterine body, cervix, vagina, or vulva. We have already asserted that inert pathogenic germs which inhabit the vagina can, by changed conditions, be stimulated into activity, but 25 386 GYNECOLOGY. they are, however, more frequently introduced from without, through failure of the physician or nurse to observe proper antiseptic or aseptic precautions. 438. Symptoms. — Sapremia occurs ' in from three or four to ten days subsequent to delivery. The onset of the trouble is rather sudden, and is manifested by elevated temperature and repeated rigors. The patient may have severe chills, and daily temperature varying from 102° to 105° F. The lochial dis- charge may be absent, or, if present, is exceedingly foul. The patient generally manifests but little tenderness upon pressure. Manipulation over the uterus may be followed by contraction and the expulsion of a large offensive mass, after which the patient will improve, or she may have quite profuse bleeding. Digital examination discloses the presence of retained masses and affords evidence of their decomposition. The onset of septicemia is more insidious, but the symptoms occur earlier. The reaction induced by septicemia will depend upon the condi- tion of the patient, the time of the infection, and the virulence of the infective poison. As early as the second or third day, not infrequently upon the first, the patient will exhibit an elevation of temperature, which gradually increases. She suffers from pain or tenderness in the lower abdomen, which may be so marked as to confine her to the dorsal decubitus, with her limbs flexed and unable to exercise the slightest muscular action, because of pain. Not infrequently the bladder becomes greatly distended; the pulse is rapid, varying from no to 140; respirations frequent, and the temperature displays a 'range from 101° to 107" F. The lochial discharge is arrested or free, and may be mucous, mucopurulent, ichorous, or sanguinolent. It may have a stale, sickening smell or be almost free from odor. The cervix and vagina, upon inspection, may appear normal or highly inflamed, swollen, and covered with glairy mucus, or exhibit patches of diphtheric exudate. The uterus is likely to be smooth, swollen, and exceedingly tender to pressure. The cervix will appear lacerated and boggy. The entire organ will be found enlarged, edematous, and flabby. When the inflammation is confined to the uterus, the organ will be tender -and enlarged, but not so sensitive as to preclude palpation. If, however, the peritoneal coat is involved, the pain and tender- ness will be very acute; the limbs are drawn up to protect the abdomen from pressure of the clothing and to relieve the traction upon the abdominal wall. The progress of the disease will depend upon the virulence of the poison and the resistance of the patient. In the sapremic condition the source of origin of the disease may be expelled and the patiently rapidly pro- gress toward recovery. A patient suffering from septicemia INFLAMMATIONS. 387 may be so fortunate as to secure immunity against its further progress and slowly recover. The disease may become localized and a pus-collection be spontaneously or artificially evacuated, or the general system may become so infected that, notwith- standing every therapeutic procedure, the patient succumbs. An unfavorable prognosis is indicated by a persistent high temperature, a pulse-rate continuously above 130, and the absence of localized foci. If the serious symptoms subside and the general condition of the patient improves, but a rapid pulse-rate continues, associated with an evening temperature of 100° F. or over, the patient should not be regarded as out of danger. This disorder was formerly known as puerperal fever and supposed to be due to some obscure poison charac- teristic of the condition. The investigations of Semmelweis and others demonstrated that it was analogous to surgical fever and due to a similar cause. The disorder is hydra -headed in its manifestations, and makes its invasion by one of three routes: through the continuous mucous membrane of the body of the uterus and Fallopian tubes to the peritoneum; through the blood-vessels or the lymphatics. Thus we may have inflammation of the structure of the uterus, the Fallopian tubes, the ovaries, the pelvic cellular tissue, or the pelvic perito- neum, or even all combined. Any of the veins of the body may become involved in the septic phlebitis, but the condition occurs most frequently in those of the lower extremities, caus- ing the condition formerly known as milk-leg, which we now recognize to be an infective phlebitis. It may manifest itself also by a severe lymphangitis. The disease may rapidly in- A^olve the general system, giving rise to profound symptoms of septicemia without any special localization. 439. Diagnosis. — The early differentiation between sap- remia and septicemia is very important. The former, being associated with retained decomposing products, manifests itself several days after delivery. Symptoms develop suddenly in a patient who seemed to be undergoing a normal convales- cence. The lochial discharge, where present, is exceedingly offensive. A digital examination discloses a clot, a portion of placenta, or a portion of decomposing membrane within the uterine cavity. These products, when removed, have a very offensive odor, and with their disappearance the symptoms rapidly subside. In septicemia the symptoms occur more insidiously, and at an earlier date following delivery, unless, however, the infection should have been implanted late. The occurrence of elevation of temperature following a delivery should be regarded as a danger-signal, Avhich should cause the attendant to make a careful investigation of the history 388 GYNECOLOGY. of the case, together with a judicious interrogation of the phy- sical signs. The condition of the breasts should be ascertained, for not infrequently women have a high temperature con- comitant with the establishment of lactation. The breasts become greatly distended, caked, and hard. The temperature of the patient reaches 105° F. or over. Not infrequently the nipples may be the source of infection, which may lead to the occurrence of a mammary abscess. Typhoid fever and malaria are frequently mistaken for sepsis and vice versd. The possibility of these conditions should be excluded by a careful examination of the blood; finding in malaria the Plasmodium and in typhoid fever the securing of a positive Widal reaction and the examination of the urine are considered sufficient evidence to establish the diagnosis. Furthermore, the typhoid bacillus may be found in the urine and also occasionally in the blood. A digital examination excludes sapremia when it reveals the walls of the uterine cavity smooth and free from any decomposing products. Intoxication from morbid prod- ucts in the intestinal tract may sometimes closely simulate septicemia. It was quite recently my privilege . to see, with two young doctors, a young woman who was suffering from a very high temperature with some abdominal distention, in whom there were no signs of any localization of sepsis. The patient had been delivered a week prior to the manifestation of symptoms. Examination disclosed the uterine cavity free from any decomposing material, and absence of tenderness over the uterus. The woman had had some fifteen foul-smelling stools during the preceding twenty-four hours. It was her first confinement, and there was a history of her having undergone a curetment some three years before. She had been very care- fully managed during her confinement, with every aseptic precaution, and had been cared for by a well-trained nurse. The inference of the attendants w^as that she had had some local accumulation in a tube prior to her delivery, from which this infection had developed. But as I found the uterus free from any tenderness or undue enlargement, no sign of in- fection in the vagina, and she had what seemed to me no tender- ness or swelling about either tube or ovary, I reasoned, there- fore, that if such local cause had existed, it should still show evidence of its presence, and in view of the very evident in- testinal disturbance, I ascribed the symptoms to an intestinal infection, and suggested measures for its correction. The rapid subsidence of the symptoms and recovery of the patient confirmed the diagnosis. Having reached a diagnosis in septicemia, by exclusion, it is then desirable to recognize and treat the local manifes- INFLAMMATIONS. 389 tations promptly. These we determine by the size and evidence of laceration of the uterus, the existence of patches of diphtheric exudation in the vagina or uterus, and the possible form and prog- ress of the infection. Metritis will be indicated by a large, swollen, more or less tender and boggy uterus; perimetritis or pelvic peritonitis by extreme tenderness in the lower portion of the abdomen, pain and anxiety of the patient, with a fre- quent, rapid, wiry pulse, and high, sometimes low, and even subnormal, temperature; the latter symptoms, moreover, rather increasing the danger. Phlebitis will be recognized by tender- ness over the femoral and saphenous veins, as these are the ones in which the disease most frequently manifests itself. Lymphangitis is often indicated by the existence of inflammation of the cellular tissue and by pain and tenderness over the lumbar or inguinal regions. 440. Prognosis. — Sapremia is a condition w^hich usually terminates favorably. The removal of the putrid products soon results in the subsidence of the constitutional intoxication. It should not be forgotten, however, that the putrid material affords a favorable soil for the development and propagation of septic germs, so that when a patient comes under obser- vation she may have been subjected to mixed infection. Under proper management this condition generally terminates in recovery. Septicemia is an exceedingly dangerous disease; its manifestations are so various that often when the patient survives she may be in a condition which cripples her for life and at the expense of serious sacrifice of important organs. The condition demands the most careful scrutiny of the prog- ress of the disease, with the resort to radical procedure when it is manifest that local foci are continuing its propagation. 441. Treatment. — Prophylaxis is the most important treat- ment, but is so closely associated with the work of the obstet- rician that we will not consider it. A woman who develops symptoms leading one to suspect the occurrence of a septic process should at once be subjected to careful investigation. This careful scrutiny is advised in order to eliminate the possi- bility of other conditions being confounded with sepsis. Finally, a pelvic exploration should be made, and all decomposing products, such as blood-clots, portions of placenta, or remnants of decidua should be removed. The patient should be placed across the bed; if the abdomen is tender, an anesthetic should be given, and two fingers introduced into the uterus, which, with the hand over the abdomen, will permit the entire uterine cavity and wall to be thoroughly explored and all products and debris removed. The procedure not only removes the debris and contents of the uterus, but favors the pressing out 390 GYNECOLOGY. of infected clots from the blood-vessels and uterine sinuses. This manipulation should be followed by intra-uterine douches of sterile normal salt solution, or, better still, a i per cent, saline solution, made up of 2 J grains sodium bicarbonate to 7 J grains of sodium chlorid to the 1000, or formalin solution I : 1 500-1000, or sublimate solution i : 3000. When the uterine cavity is clear of decomposing masses and other causes are excluded, we are justified in accepting the diagnosis of septic infection, as distinguished from putrid intoxication. In septicemia, intra-uterine manipulation often will be unpro- ductive of any favorable result. The micro-organisms have already penetrated beyond the reach of any local measures. Curetment, by affording fresh avenues for infection, is harm- ful. The uterine cavity should be irrigated through a double- current tube three, four, or more times daily with a hot i per cent, saline solution or solutions of formalin or bichlorid. The latter solution (i : 3000) should be followed with normal salt solution to avoid the danger of mercuric poisoning. The removal of decomposing products, irrigation of the uterus, and the internal administration of salines in sapremia, or putrid intoxication, usually establishes early convalescence. Not infrequently, however, there will be a marked rise of tem- perature after such a procedure, but it soon subsides. Sepsis, on the other hand, is caused by micro-organisms which have entered the blood, and kill, not so much by their presence, as by the toxins or poisons which they generate. Researches have seemed to demonstrate that these toxins, obtained from pure cultures of the organisms and injected into the circulation of some of the lower animals, soon generate an antitoxin which acts as an antidote to the original poison. My early experience in the treatment of sepsis by the administration of the anti- streptococcic serum was such as to lead me to place greater reliance upon its efficacy in affording prompt immunity than the later experience of myself and colleagues would seem to justify. In severe cases as much as ten cubic centimeters (two and a half drams) in twenty-four hours should be employed. In less severe cases smaller doses, three to six cubic centimeters, can be employed. The dose should be administered daily until the abnormal symptoms subside. The advocates of the employment of serum-therapy in the treatment of puerperal sepsis are doubtless correct in their demand that the serum must be fresh. The want of success may have been due to this cause, as many have employed the imported serum of Marmorek. A requisite to accuracy is the careful bacterial investigation of the secretions, for it would not be reasonable to expect a satisfactory result by the employment of anti- INFLAMMATIONS. 391 streptococcic serum in a staphylococcic infection. To be most effective, it is most important that the serum should be ad- ministered early and in good dose. The strength of the patient, and her consequent ability to fight the disease, should be main- tained by the administration of supporting remedies, by a nutritious, easily digested diet, and by the judicious use of stimulants. Ouinin may be given in suppository (gr. v-x) three or four times daily; strychnin, atropin, tincture of digitalis, digitalin or adrenalin chlorid solution (i : looo) should be administered hypodermically, as the indications demand. Action of the bowels should be secured by the proper use of salines, which facilitates the elimination of the infective products, though care should be exercised to avoid undue depletion. Intravenous Injections. — The intravenous injection of normal salt solution has been of great service to the surgeon in over- coming shock and in carrying patients over a critical condition. It has been demonstrated, also, that this procedure is service- able in low septic conditions by increasing the volume of the blood, thus diluting toxic material, promoting secretion, and the consequent elimination of poisonous products. The com- bination of chlorid of sodium with bicarbonate of sodium, making a i per cent, saline solution which should be in the proportion of 7 J parts of the chlorid of sodium to 2 J parts of bicarbonate of sodium, has proved especially efficacious in septic conditions, as it increased the phagocytes and the con- sequent ability of the patient to resist the progress of the in- fection. The brilliant results achieved by Professor Baccelli, in 1889, in the treatment of pernicious malaria, by the intra- venous injection of hydrochlorid of quinin, has directed the attention of the profession to the intravenous injection of germicides. Baccelli later instituted the intravenous injection of corrosive sublimate in the treatment of syphilis, after the administration of mercury by other methods had failed. His experiments on the lower animals demonstrated the fact that albuminate of mercury, which was first formed, was redissolved in an excess of albumin. As it is known that the micro-organisms enter the blood, the introduction of germicidal agents into this fluid to render it an unfavorable soil for their multiplication is a plan which naturally appeals to the scientific mind. The difficulty has been to secure some agent which shall prove destructive to the specific germ in the hemal circulation, without inducing degenerative changes in the circulatory fluid. Carbolic acid, sublimate, and formalin have all been recommended as suit- 392 GYNECOLOGY. able agents for this purpose. In a ■ recent case in which the conditions were such as to make it evident that death was imminent unless the poison could be arrested, I injected ^ of a grain of sublimate in 500 centimeters of normal salt solution. The patient the following day developed an in- farct which cut off the circulation in the end of the nose, and she died at the end of forty-eight hours. As air, however, had entered, due to the faulty apparatus employed, it is not justifiable to condemn the bichlorid as the cause. Formalin has been especially commended of late, particularly by Barrows, of New York, and Maguire, of London. The latter, in his experiments, has injected solutions as strong as i : 500 into himself. This was followed by hematuria, albuminuria, cramp- like pains, and faintness. I have applied gauze, wet with formalin solution (i : 1500-2000), to the peritoneum, with com- plete destruction of the endothelial covering of the involved surface, so that I should regard the injections of solutions of formalin, therefore, under i : 5000, as extremely dangerous, and as it has been claimed that it is germicidal in solutions of I : 200,000, a weaker solution still would seem preferable. As the simple injection of water into the blood-vessels causes degenerative changes in the blood-corpuscles, it would seem much wiser that these injections should be made in combina- tion with normal salt solution. In cases, then, in which it is evident that the patient will succumb to the disease unless it can be arrested, we should feel justified in proceeding to extreme measures with the hope of affording relief; and with our present knowledge of conditions, I should favor the formalin in combination with a normal salt solution as being the least deleterious of the agents we can employ. I would advise against it being given in greater strength than i : 10,000. The beneficial results from the intravenous employment of this drug have not been sufficiently brilliant to compensate for its well-recog- nized disadvantages. Localization of infection may result in abscess formation in the uterine wall, in the pelvic cellular tissue, in the tube, in the ovaries, or in multiple abscesses in various portions of the body. The manifestation of such a local collection should be deemed an indication for prompt surgical inter- ference. The treatment necessarily must depend upon the site and extent of the lesion. If an exudate or inflammatory collection can be reached by a vaginal incision, through which the contents of the cavity can be evacuated, its sac enucleated and removed, or the cellular tissue opened up and drained, more serious destruction of tissue can often be avoided. Where the uterus remains large and extremely tender, or presents INFLAMMATIONS. 393 indications of localized peritonitis or localized abscess formation, and the condition of the patient will permit, the abdomen can be opened and hysterectomy performed. It should be capable of demonstration that the uterus is the seat of irreparable dam- age or a focus for the continued distribution of infection before it is removed, because I have been consulted as to its removal in women who have recovered without operation, and even subsequently given birth to children. In doubtful cases the uterus can be explored by an incision through the posterior vaginal fornix, and in many cases the opportunity thus granted for peritoneal drainage will afford the required relief. The ex- ' c- /I t- a. — — ^ * -'. • .J ' ' ''■■' L'l ' '-^M '%^,. ^ ■^ Fig. 299. — Interstitial Endometritis. a. Free uterine surface. 6, 6, h. Hyperplasia of connective tissue. c,c,c,c. Obliteration of glands, d. Choking of gland from increase of fibrous tis- sue, e, e. Glands occluded and somewhat dilated. cision of a section of an infected vein has been successfully per- formed, but one must be satisfied that the condition is not dif- fuse before resorting to such a procedure. When the temperature is elevated, the skin hot and dry, associated with tympanites and repeated vomiting, the most effective plan of treatment is to irrigate the stomach with hot normal salt solution, followed by intercolonic irrigation. The latter should be continued over several hours, or a quart of normal salt solution should be injected into the bowel every hour. The better plan is to elevate the foot of the bed and through a double rectal tube subject the rectum to more or less 394. GYNECOLOGY. continuous irrigation with a one per cent, salt solution. The administration of large quantities of salt solution promotes elim- ination. The tongue and skin become moist, the secretion of urine increased, the pulse increases in volume, and the tempera- ture becomes reduced. 442. Chronic endometritis is an inflammation of the mucous membrane of the body of the uterus. It rarely, if ever, is the consequence of acute endometritis, but more frequently follows subacute processes and long-continued hyperemia. It is divided by Ruge into glandular, interstitial, and mixed, according to the structure of the mucous membrane most extensively involved. In all varieties of inflammation the ^M h-^' ^7 Fig. 300. — Hypertrophic Glandular Endometritis, showing Increase in Size and Numbers of Glands, a, a. Glands dilated and containing secretion, h. Infiltration of leukocytes. entire structure of the membrane is necessarily more or less affected. With thickening of the mucous membrane the glands become elongated, dilated, bent, and tortuous. Cells become swollen and proliferated, resembling those of the decidua. The vessels of the deeper portion of the mucosa are dilated and in a state of congestion. The mucous membrane is not infrequently several times its normal thickness, soft, spongy, and easily scraped away. The surface presents vegetations or growths, which, according to De Sinety, are of three forms. In one, the tissue consists of dilated blood-vessels; in the second, of dilated, hypertrophied glands (Fig. 301); in the third, of INFLAMMATIONS. 395 embryonic tissue containing but few blood-vessels and only traces of glands. With these conditions are associated three kinds of discharge — sanguinolent, leukorrheal, and mucopuru- lent. As a result of the changes in the mucous membrane, ^f^>f^-?\ 0s%"'''"<' <-0.} -'f'hr]3 ^X 4/^ Fig. 301. — Hypertrophic Glandular Endometritis. Vertical Section through the Mucous Membrane. a. Blood-vessel distended with blood-cells, h. Gland penetrating muscular wall. not infrequently portions project as polypoid masses, which consist of either glandular or vascular structure. (Fig. 302.) In this condition the mucous membrane is thickened and granu- lar in appearance, and the state has been called villous de- 396 GYNECOLOGY. generation, or endometritis fungosa. With cell-proliferation in its connective tissue and the subsequent contraction of the gland its structure is compressed and obliterated, so that the surface is almost free from glands. Or, again, the orifices of the glands' ducts in places become occluded and cysts result. The hyperplasia of the uterine mucosa in some cases results in the desquamation of the epithehal layers at each menstrual period. This desquamation may take place in the formation of shreds or in a complete cast of the uterus, in which the orifices of the Fallopian tubes and the internal os are recognized. This condition is known as exfoHative endometritis, membranous dys- menorrhea, or, probably better, menstrual decidua. (Fig. 303.) Fig. 302. — Polypoid Masses Associated with Chronic Endometritis. a. Glands greatly dilated, with destruction of the intervening septum. 443. Symptoms. — The disease arises after abortion or labor, as a result of an attack of uterine inflammation, or an attack of gonorrhea. Occasionally, it may begin insidiously and without any sign of a cause. It occurs more frequently in the muciparous, and is more common in the later menstrual life. Nulliparae are not exempt; CA'^en virgins are sometimes affected — a condition known as virginal endometritis. This especially occurs in narrowing or stenosis of the external os. A form of the disease occurs subsequent to the climacteric, when it is known as senile endometritis. Endometritis is characterized by the following symptoms: leukorrhea and menorrhagia. The discharge from the body of the uterus INFLAMMATIONS. 397 is less viscid than that from the cervix. It may be clear, but more generally is mucopurulent; occasionally it is tinged with blood, so that the patient imagines herself continuously un- well. The discharge flows freely or there is an apparent ac- cumulation. Retention of the discharge and its evacuation in considerable quantity occur when endometritis is complicated by retrodisplacements or when the os is small. The discharge may have an offensive odor and be so irritating as to give rise to extensive excoriation of the vulva. Excessive menstrual flow, or menorrhagia, may or may not be present. Occasionally, it will be so profuse as to occasion a suspicion of malignant disease and cause a profound anemia. The resulting loss of Fig. 303. — Membranous Dysmenorrhea. vasomotor tonus results in increased tendency to hemorrhage. Dysmenorrhea, or painful menstruation, is not so common as in disease of the appendages or in chronic metritis. It is especially marked when accompanied by the discharge of a menstrual decidua. The influence of endometritis upon con- ception is not fully determined, but the increased frequency with which women become pregnant subsequent to a curet- ment renders it evident that it has a restraining influence upon the occurrence of conception. Endometritis is a prolific cause of abortion. 444. Diagnosis. — The existence of leukorrhea or of irregular 398. GYNECOLOGY. and profuse menstruation, associated with enlargement of the uterus for which no explanation external to the uterus can be found, justifies the suspicion of endometritis. The history of abortion, or prolonged convalescence subsequent to labor, con- firms the suspicion. The use of the curet is of incalculable advantage in determining the diagnosis. Portions removed with the curet will show small-cell infiltration of the entire glandular tissue, without glandular hyperplasia, or marked hyperplasia of glands with proliferation of the glandular epithe- lium. The epithelial cells become enlarged and granular, lose their cylindrical shape, and resemble the decidual cell. Endo- metritis, when uninterrupted, extends to the deeper structures, producing metritis. It predisposes to malignant change. When permitted to pursue an undisturbed course, it may involve the peri-uterine covering. Deposits occur in the cellular tissue about the ovary or around the orifice of the Fallopian tube, or the disease involves the pelvic peritoneum. Neglected cases result in cellulitis, salpingitis, ovaritis, peritonitis, the for- mation of abscesses, the destruction of tissue in the organs, and not infrequently, alas! in loss of life. Senile endometritis is associated with retention of secretion which decomposes, producing an exceedingly offensive odor, and arouses the sus- picion of malignant disease (Dunning). The examination of such a uterus reveals its walls thinned; the mucous membrane consisting of a thin layer of connective tissue covered with a single layer of flattened epithelial cells. 445. Treatment. — Constitutional treatment is of marked value, and will be discussed with chronic metritis. Prophylaxis will require rigid asepsis during labor or abortion, as well as in making gynecologic examinations. A rise of temperature or the suspicion of the retention of a portion of placental debris should be considered as indicating the necessity for thorough use of the curet, free irrigation, and, in many cases, gauze pack- ing. Laceration of the cervix or of the pelvic floor should have early repair. All suspicious discharges must be removed by treating the cause. Before the third or fourth day an en- dometritis of gonorrheal origin is best treated by frequent irrigation with antiseptic solution, such as permanganate of potash (i : 3000-2000), mercurol (i to 2 per cent.), protargol (0.5 to I per cent.). If the acute symptoms have subsided, paint the cervix, and where the os is patulous, the cervical canal, with 50 per cent, solution of ichthyol in water, or glycerin, and later, if the condition persists, curet and pack with iodoform gauze. Careful antiseptic or aseptic cureting is the proper form of treat- ment in all forms of endometritis, w^hether complicated or un- complicated. In serious cervical lesions, with much eversion INFLAMMATIONS. 399 and thickening of the mucous membrane, cureting should be associated with Schroder's operation upon the cervix. Drainage is of incalculable advantage in endometritis when complicated with slight catarrhal salpingitis. It will also prove serviceable in mild forms of peri-uterine inflammation. Cureting should be considered contraindicated in well-established pathologic changes in the adnexa and in chronic peri-uterine inflammation unless immediately followed during the anesthesia by an abdominal incision for the correction of the pelvic lesions. In addition to curetment, intra-uterine treatment consists in the employ- ment of antiseptics and caustics. Free drainage should be con- sidered as a prerequisite to all intra-uterine treatment. The inflamed uterine canal is similar to a sinus. Unless the pent-up discharges have free vent, the irritation is aggravated. When the canal is patulous, large injections of a feeble antiseptic solution such as formalin (i : 2000), normal salt solution, or a two per cent, solution of bicarbonate of soda through a re- turn-current catheter can be employed. The latter solutions, when used, are as salutary as the more distinctly defined germicidal agents. If the cervical canal is insufliciently large, it should be dilated with laminaria tents, after which irri- gation should be practised. In mild cases the canal may be swabbed, by means of a cotton-wrapped applicator, with tinc- ture of iodin; in more severe cases, with carbohc acid. When the mucous membrane is thickened and tends to bleed or to furnish a profuse discharge, more active agents may be em- ployed: silver nitrate, gr. xxx, to aq. destil., 5ss-j; zinc chlorid, 3j-iv to f 5j ; chromium trioxid, gr. x-xxx, to f 5j ; fuming nitric acid, acid nitrate of mercury, tincture of chlorid of iron, pencils of silver nitrate, zinc chlorid, zinc sulphate, copper sulphate, or formalin. When strong caustics are used, precautions must be practised to protect the healthy vagina from con- tact with the solution. Indeed, in my judgment the employment of the strong caustics is very infrequently required. Much more is to be gained where a strong effect is desired by the use of the curet and the subsequent applications of the milder agents, as argyrol (10 to 50 per cent.), protargol (5 to 10 per cent.), or the ordinary tincture of iodin. A mass of absorbent cotton should be placed beneath the cervix prior to the appHcation, and the superfluous caustic should be removed by sponging before the pledget is withdrawn. Pencils are objectionable in that they produce sloughing of the cervical mucous membrane and cause the development of atresia. Tampons. — Intra-uterine treatment should be supplemented by placing beneath the cervix a tampon, preferably saturated with a preparation of glycerin, a 50 per cent, solution of boro- 400 GYNECOLOGY. glycerid in glycerin, a lo to 15 per cent, solution of ichthyol in glycerin, or a 25 per cent, ointment of ichthyol in lanolin. The following prescription is an excellent astringent and anti- septic : B . Pulv. alum f ^ j ^ Acid, carbolic ^vj Glycerin., Oj. Various ointments, either astringent or alterative, with lanolin as a base, may be used upon the tampon. A tampon improves the circulation by raising and maintaining the uterus at a higher level. The antiseptic tampon may be retained from twenty-four to seventy-two hours, according to its character. When the tampon is not used, or after its removal, a vaginal douche of two or three quarts of hot salt water (110° to 120° F.) should be used twice daily, with the patient in the recumbent position. When using very hot injections cover the vulva and perineum with vaselin, to prevent burning. The employ- ment of rock-salt, an ounce to the quart, in a douche, promotes its efficiency. Scarification under continuous irri- gation will often prove of advantage, and is more effective than leeches. An iodoform gauze tampon should follow. Intra- uterine injections have been employed for endometritis, but should never be used unless the canal is sufficiently patulous to permit the escape of the superfluous fluid. The preferable plan is to employ a pipet or syringe by which one, two, or three drops may be introduced. Occasionally, even this small quan- tity will cause violent uterine colic. These attacks are not necessarily dangerous, but they are not calculated to encourage the continuation of treatment. The treatment par excellence in chronic endometritis is the use of the curet. In senile endometritis the important consideration is drainage; to insure this, it may sometimes be necessary to employ a tube. The cavity should be frequently irrigated with an antiseptic solution. 446. Chronic Metritis. — Chronic metritis is an inflammation in the muscle-wall of the uterus, leading, when long continued, to increased connective-tissue formation. The term metritis is used in a comprehensive sense, and comprises conditions which have been described by different writers under such terms as chronic parenchymatous inflammation (Scanzoni) ; subinvolution (Simpson) ; diffuse proliferation of connective tissue (Klob) ; infarction (Kiwisch) ; hyperplasia of flbromuscular tissue, similar to fibroid tumors (Virchow) ; diffuse interstitial metritis (Noeggerath) ; irritable uterus (Gooch). The term may be criticized from a pathologic standpoint, as there is INFLAMMATIONS. 401 no chronic inflammation of the muscle-fiber of the uterus, but an increased amount of connective tissue, out of proportion to that of the muscle-fiber. Clinically it is satisfactory, as it enables us to comprise under one term a variety of conditions which may be developed from different causes but produce a similar group of symptoms. It has been objected to this term that, by inference, there has been a profuse acute inflam- mation, which is not the case, as chronic inflammation of the uterus does not follow the acute. It is more correctly described as an increased tissue formation, dependent on long-continued congestion. The term chronic is applied to analogous forms of inflammation in other organs and structures of the body, as cirrhosis of the liver, which describes a condition similar to that which is found in the uterus. Subinvolution is, in some English books, described separately, though it is due to the same cause. The differential diagnosis between subinvolution and chronic metritis is impossible, and the treatment of the two conditions does not differ. The altered condition of the uterus will vary with the period at which the patient comes under observation. In the early stages the organ is enlarged, hyperemic, and soft. Later, it may decrease in size, though it is still large, and then becomes hard, indurated, and anemic. The enlargement of the organ is uniform, so the shape is not altered. Upon open- ing the abdomen of such a patient the peritoneal surface will present a normal color, or patches of extravasated blood may be present. On section, in the early stages the tissues will be soft, hyperemic, easily incised; later, firm, cartilaginous, presenting a whitish color, the walls thickened, and the cavity of the uterus enlarged. Not infrequently the organ will be found as firm and dense as a mature fibroid growth. During the first period, De Sinety says, the dominant lesion is the presence of a large number of embryonic elements through- out the thickness of the muscular wall. These are more par- ticularly situated around the blood-vessels, . or they may form islands more or less separated from one another. The second period is characterized by two changes: first, marked dilatation of the lymphatic spaces; second, localized hyperplasia around the blood-vessels. We raay find it difficult to determine whether the muscular tissue remains normal, or is present in decreased quantity. Fritsch examined uteri removed for cancer, and found associated evidences of chronic metritis, in which the following pathologic changes were noticed: The arrangement of the muscular fiber and connective tissue is less regular than in the normal, and the latter is greatly increased in quantity. Blood-vessels are more numerous and tortuous. The vessel 26 402. GYNECOLOGY. lumen is contracted, its tunica media is thickened, and the contour of the vessel is masked by the degeneration of the con- nective tissue in its wall. The lymphatic spaces, instead of being narrow clefts, are gaping; the peritoneum is thickened. Both Corneuil and Snow-Beck described an increased num- ber of round and oval globules with amorphous tissue in the uterine walls. The increase in the size of the organ is due to the presence of this rather than to the increase of muscle-fiber. 447. Etiology. — The causes of chronic metritis are divided into two classes : the predisposing and the exciting. The former may be divided into: (a) Those which operate by interference with the normal involution of the puerperal uterus; (6) those which are due to the production of repeated or protracted congestion. The first class comprises: first, retentions within the uterus of portions of placenta, membranes, or blood-clots; second, cervical lacerations; third, pelvic inflammations subse- quent to labor; fourth, too short convalescence following de- livery; fifth, nonlactation ; sixth, repeated miscarriages. Two factors are essential to the accomplishment of involution: first, fatty degeneration of the muscle-fiber; second, removal of the products of degeneration. Now, subinvolution or failure of the uterus to undergo complete involution is due not to want of degeneration of muscle-fiber, but to substitution of con- nective tissue for the products of this degeneration. Metritis, then, is generally found in women who have borne children, and it has been asserted that involution is retarded by the removal of- the ovaries, although a patient of mine who completed her gestation after the removal of both ovaries did not manifest any failure in the process of involution. Any irritation in or about the uterus will cause a chronic metritis, and this explains the effect of retention of portions of the placenta or membranes, of lacerations of the cervix, and of the existence of peritonitis or cellulitis, as these conditions interfere with the circulation, which is also aftected by premature getting up following labor. The organ is heavy, and the increased weight leads to its being displaced to a lower level, producing passive congestion. Passive congestion is decreased by any cause which increases uterine contractions; the physiologic stimulus of nursing excites contraction reflexly through the mamm^ and favors involution. Abortions are especially in- strumental, for the reason that the patients do not take so much care of themselves as they w^ould subsequent to a labor, and the stimulus of lactation is absent. After an abortion con- ception is likely to occur before the process of involution is complete, and this favors the recurrence of abortion. The second class of cases, which operate through production INFLAMMATIONS. 403 of repeated or protracted congestion, includes displacements of the uterus, the presence of tumors in or near it, and causes that produce increased flow of blood to the uterus, such as endometritis and the free use of caustics. To this class also belong malformation, incomplete development, congenital ante- flexion, conic cervix, stenosis of os, improper clothing, expo- sure to cold, and masturbation. Metritis is favored at each menstrual period, by exposure to cold, especially when the uterus is displaced or the cervix is contracted or lacerated, by excessive copulation or its practice during menstruation, and by gonorrheal infection from an incompletely cured husband. Chronic contusions from the use of a pessary may engender the inflammation. The intra-uterine stem-pessary is capable of doing the most injury. 448. Symptoms. — In the large majority of cases the patient will date her trouble from a confinement. Not infrequently she will report repeated abortions, and that she subsequently regained her health very sloAvly. The symptoms are not characteristic, but are similar to those found in cancer, fibroma, displacements, and other local disorders. They are: weakness; pain or aching over the lower lumbar and sacral regions; a sensation of weight and bear- ing down, as if the pelvic organs were to be extruded; an ap- parent loss of power in the limbs; points of anesthesia over the anterior surface of one or both thighs; painful contractions of the uterus; irritable bladder; constipation; loss of all plea- surable sensation during the sexual relation; pricking pain in the eyes and weak sight; photophobia; occipital pain, but more frequently pain over the coronal suture ; and disturbances of menstruation, as dysmenorrhea, abnormal bleeding, menor- rhagia, or metrorrhagia. In weak patients are found amen- orrhea, leukorrhea, hydrorrhea, hydrorrhoea gravidarum, puer- peral hydrorrhea associated with retention of portions of placenta and clots. Not infrequently there are loss of appetite, nausea, dyspepsia, and enfeebled assimilation. The patient is pale, anemic, and exceedingly weak, with dark circles beneath her eyes. She suffers from palpitation and a sense of oppression, and is exceedingly despondent and profoundly melancholic. Acute mania, epilepsy, hysteria, and neurasthenia are occasion- ally induced, and are always aggravated by the existence of chronic metritis. The diseased condition under discussion is responsible for the majority of cases of semi-invalidism. The patient is continuously conscious that she has a uterus; the distress is increased by exercise and lessened by rest. The constipation and digestive disturbances are aggravated and increased by dread of pain and by her sedentary habits. The 404 GYNECOLOGY. patient can suffer from acute exacerbations, with diarrhea and rectal tenesmus, as a result of extension of the inflammation to the rectum. Menstrual disturbances are common, largely induced by the accompanying endometritis, called, from the bleeding, hemorrhagic endometritis. The hemorrhage is probably quite as often due to the dimin- ished contractile power of the organ as to the substitution of connective tissue for the muscle-fiber. The associated disease of the mucous membrane adds to the dysmenorrhea, which may precede, be simultaneous with, or follow the period. It is generally continuous with the period, in the form of in- creased backache, pressure, and pelvic discomfort. Leukorrhea is produced by alterations of the uterine mucous membrane. In the aged not infrequently a hydrorrhea de- velops, with a periodic discharge so offensive as to lead to the suspicion of the development of malignant disease. Sterility is a natural consequence of the prolonged existence of chronic inflammation, not only from alterations in the struc- ture of the wall and mucosa, but probably much more from the superadded changes in the pelvic peritoneum, affecting the tube and ovaries. The escape of the ovum may be pre- vented by extensive adhesions fixing the ovary, or through thickening of the ovarian tunica albuginea, which prevents its exit from the maturing Graafian follicle. The Fallopian tube may furnish the obstacle, through closure of its abdom- inal or uterine end, or by stricture along its course. In the earlier stages of the inflammation the susceptibility to pregnancy may be engendered by the conditions, while the existing changes unfit the internal uterine surface for the complete nutrition of the developing embryo, and abortion or premature discharge of the contents follows. The sub- stitution of connective for the muscular tissue, through the consequent uterine inertia, when gestation is completed, renders delivery tedious and increases the danger of postpartum bleed- ing. Chronic metritis is responsible for a large proportion of the sofa and bath-chair population — the nervous, debilitated, dyspeptic women who wander from physician to physician or crowd the watering-places during the summer. The con- dition is frequently unrecognized and untreated, and the patient is condemned to suffer deeper and deeper wretchedness. 449. Physical Signs and Diagnosis. — The uterus is large, without a change in shape. The walls are firm and rigid — in later stages almost as resistant as a fibroid tumor. The organ may have a normal position, may be situated 1 INFLAMMATIONS. 405 at a lower level, or may be displaced. It may be freely movable or more or less fixed; readily outlined or fixed in a mass of pelvic exudate. The organ is sensitive to pressure. Differential Diagnosis. — Pregnancy in the early stages pre- sents a history of cessation of menstruation and of increased discharge. The uterus is enlarged, the cervix soft, while the body bulges like a jug and is not resistant. Cancer usually involves the cervix, though the body may be the site of origin. In the latter the bimanual examination will disclose points of increased resistance. Bleeding results from severe manipu- lation, and an offensive, thin, and serous discharge will prob- ably be present. Pain is a frequent symptom, and occurs most severely toward evening. The use of the curet or digital exploration after dilatation with tents may be required to confirm the diagnosis. The cureted tissue in cancer will be friable from infiltration, exhibiting under the microscope the characteristic cellular structure. Small fibroids are frequently difiicult to recognize, especially when interstitial or submucous. The irregular enlargement, well-defined points of resistance, and frequently intermittent pain are diagnostic. Digital exploration of the uterine cavity determines the presence, size, and situation of the growth. Salpingitis is often associated with metritis, when it may be difiicult to determine which predominates. A small ovarian tumor may be the cause of hemorrhage. Rectal disease may produce symptoms simulating chronic metritis. The general health may be so affected as to cause the local manifestations to be overlooked. Thus, the patient may complain of persistent cough, difficult breathing, or pro- gressive emaciation, or the stomach may be the source of trouble, causing loss of appetite, fiatulence, and gurgling, and present- ing evidences of dilatation. She may have precordial anxiety, palpitation, or cardiac and vascular murmurs. It is a good rule to make a careful uterine examination in all cases of chronic disease. 450. Course and Prognosis. — Metritis in all forms is obsti- nate and rebellious. The mucous membrane, muscular wall, and serous covering in turn are affected, followed by uterine sclerosis, cyst formation, and, finally, chronic metritis. In alterations of structure we can not hope to cure in the sense of restoration of altered tissues; we can hope only for arrest of the process, relief of congestion, and amelioration of unpleasant symptoms. 451. Treatment. — The best treatment is preventive. It consists in thoroughly emptying the cavity of the uterus after labor; in early repair of lacerations; in the relief of inflam- 40Cr GYNECOLOGY. matory conditions existing about the uterus; in stimulating involution of the organ by hot vaginal douches; in the ad- ministration of ergot and of remedies that will facilitate the contraction of its muscle-fibers ; in the exercise of such measures as will diminish congestion; in preventing the patient from rising too early from bed after pregnancy or abortion, and, when the condition subsequently exists, obliging her to remain in bed several hours daily, and to avoid sedentary occupations and long standing. While it is important that the patient should have sufficient rest, it is equally desirable that this should not be excessive. A certain amount of exercise in the open air is as desirable as rest. Tight clothing should be ex- cluded. If the abdominal muscles, however, are very much relaxed, a snugly fitting abdominal binder affords great com- fort and relief. This relaxation of the abdominal muscles is not infrequently associated with relaxation of the vaginal walls, when the use of a ring-pessary gives comfort. The circulation of the pelvis should be stimulated by vaginal douches of either hot or cold water. The latter are more stimulating, but few patients can employ them. Patients should take a hot douche containing rock-salt, at a temperature of from 103° F. to 120° F., for ten or fifteen minutes before retiring. These douches are more eft'ective when the patient is in the recumbent position. She can lie across the bed with her pelvis upon a basin or rubber pad, which should drain into a pail below, while her feet rest upon chairs. A douche bag, con- taining at least three pints, should be placed three feet above the level of the patient. Prior to its use the vulva and peri- neum should be coated with vaselin, to protect from the heat. The tube should be introduced to the cervix, and from three to ten pints of fluid should be used with each douche. Occa- sionally, warm baths should be used simultaneously with the vaginal douche. A cold hip-bath in the morning will be of great service. Medicated baths and waters are often of value. A course in hydrotherapy will frequently be serviceable. In catarrh or in scrofulous and chlorotic patients iron waters are beneficial. In nervous patients the character of the water is unimportant, but the patient should be encouraged to take large quantities. With dyspeptics, alkaline waters are desir- able. In the lymphatic and scrofulous cases waters impreg- nated with chlorid of sodium are very efficient. These are also of value in some forms of chronic metritis where engorge- ment of the uterine body predominates. Patients not infre- quently derive great advantage from change of air or scene, new surroundings, new relations, or a visit to the seashore or country. Constipation should be combated, preferably INFLAMAIATIONS. 407 with foods, such as vegetables, Graham bread, and prunes; often effectively with other agents, as a teaspoonful of w^hite mustard in water at meals ; enemas to which glycerin is added ; the administration of mineral waters — ^the Friedrichshall water, Carlsbad salts, or Hunyadi Janos. The Carlsbad salts are of particular value in bilious patients. A teaspoonful should be dissolved in a glass of water and drunk in repeated sips during the morning. Friedrichshall and Hunyadi act best Avhen mixed with equal quantities of hot water. A good mixture is a tablespoonful of the f olloAving preparation : R . Magnesii sulph. , • • • 3 "^j Quinin. sulph gr. xxiv Acid, sulphuric, dilut., Tinct. capsici, aa f ;5 j Aqua, ad f J vj. M. SiG. — Tablespoonful three times daily. Contraction of the uterine muscles may be increased by the administration of ergot, Avhich should be given in doses of gtt. XX to f 5j of the fiuidextract t. d. When the condition is complicated with menorrhagia, extract of hydrastis canadensis may be combined. An effective prescription would be a mixture of ergot and hamamelis. (Section 224.) Potash salts are especially beneficial in chronic inflammation of the uterus. Chlorate of potash is highly recommended by Tait. lodid of potash, however, is equally eft'ective, and, when the patient is nervous and restless, may be combined with a bromid, giving of the iodid, gr. v, wdth bromid, gr. x, largely diluted with water, three times daily. Potash salts may be administered in the bitter tonics, as in compound tincture of cinchona or compound tincture of gentian. In the anemic and debilitated, iron, strychnin, quinin, arsenic, cod-liver oil, and malt extracts will prove beneficial. The general health should be carefully w^atched and any deranged condition of the various organs, should be corrected. During the menstrual period patients should be confined to the sofa. When the pelvic distress is marked, or when the metritis is complicated by inflammation in the surrounding structures, benefit will be derived from the use of counterirritants, in the form of small blisters over the inguinal region, or the use of iodin or of croton oil. A good mixture is croton oil, one part ; tincture of iodin, two parts ; sulphuric ether, five parts, which can be painted over the hypo- gastric and iliac regions until a crop of pustules arises. The application should then be discontinued until they have healed. Exercise care not to allow the application to be made in the groin. Blistering fiuid may be applied to the cervix and to the vault of the vagina, or tincture of iodin, or' a combinatio.i 408- GYNECOLOGY. of tincture of iodin and glycerin, may be thus used. Scanzoni advocated this appHcation: R . Potass, iodid., gr. iv Glycerin., it^xxx. When cervical catarrh complicates the condition, punctur- ing or scarifying the cervix, under an antiseptic stream, will be beneficial. Considerable depletion can thus be effected and the patients relieved. After the bleeding has stopped, a tampon of cotton and gauze, saturated with one of the prep- arations of glycerin, will prolong the depletion. A tampon raises the uterus to a higher level and improves its circulation, while, medicated with glycerin, it has a depletive or cholagogue effect upon the vessels of the cervix, causing a profuse watery discharge. The patient may be instructed how to introduce these tampons, and may use them daily. A tampon saturated with a 50 per cent, solution of boroglycerid in glycerin, a 10 to 20 per cent, solution of ichthyol in glycerin, or carbolic acid (i : 16) may be kept in place for one to tw^o days. A tampon anointed with one part of ichthyol to four of lanolin is valuable when more or less irritation of the vagina is associated with the uterine lesion. In laceration of the cervix, where it has subsequently become hypertrophied, Emmet's operation is of service in relicAdng the congestion and promoting involution of the organ. If the cervical mucous membrane is much everted, with papillary projections and eroded surfaces, amputation of the cervix by the single -flap method advocated by Schroder (Section 336) will be more effective. Any disturbances of menstruation, such as dysmenorrhea and menorrhagia, should receive treatment suitable for endometritis. (Section 434-) For this condition, as well as for the chronic metritis, dilatation and curetage of the uterus are of value. The dilatation is pref- erably done with Pratt's dilators, as these instruments gradually stretch the uterine canal without danger of tearing, unless the dilatation is excessive, which may occur in the use of the parallel-bar dilators. After preparation of the patient (Section 181) she is placed upon her back, the uterus is exposed by the Edebohls speculum, "the cervix is seized and fixed with a double tenaculum, prefer- ably with two, when there will be no tearing out under the strain of dilatation, and the bougies are introduced, thus gradually dilating the cervical canal. The dilatation is followed by the use of the curet. This instrument may be blunt or sharp; the latter is preferable, if carefully used. The handle of the in- strument should be perforated, so that the surfaces can be irri- gated as the cureting is done. The instrument is held lightly INFLAMAIATIONS. 409 between the thumb and finger, and is passed into the uterus and drawn down on all sides of the organ in long sweeps, paying par- ticular attention to the angles of the body and to the orifices of the Fallopian tubes. The use of the curet in this manner does not remove the entire mucous membrane; even though it did, the mucous membrane would be regenerated from the portion of the glandular structure which penetrates the muscular wall. The curetage may be followed by swabbing out the cavity of the uterus with tincture of iodin, with a combination of tincture of iodin and carbolic acid, perchlorid of iron, or preferably a saturated solution of iodoform in ether. When any of these agents, except the last, are used, the irrigator should be in- troduced, again washing out the cavity of the organ, thus Fig. 304. — Uterus Dilated with Graduated Bougies. removing any clots and superfluous medicine. If the discharge of blood is slight, the uterine cavity need not be packed. If there is considerable discharge, it should preferably be packed with iodoform gauze. Gauze packing is serviceable in that it first acts as a tampon, decreasing the danger of bleeding or of the formation of a clot of blood, which might become in- fected and give rise to extension of inflammation to surround- ing structures. Second, by its pressure upon the surface it favors the throwing-out of exudation and shuts off the en- trance of septic material into the uterine sinuses; third, by its capillary action it affords a limited amount of drainage; fourth, by its presence as a foreign body it stimulates uterine contraction and facilitates the process of involution. The 410 GYNECOLOGY. vagina is carefully cleansed and a gauze pad is placed within it, thus raising up the uterus. This gauze dressing may be per- mitted to remain two or three days. After its removal the vagina should be irrigated once or twice daily with a bichlorid or formalin solution. When the uterine cavity has been the seat of extensive inflammation, with a predisposition to hem- orrhage, the removal of the gauze may be subsequently fol- lowed by uterine irrigation through a double-current catheter. In hydrorrhea or pyometra in the aged it is very important to make sure that drainage is complete. The accumulation of fluid within the uterine cavity results in the formation of ^i§- 305.— Uterine Cavity Packed with Gauze after Dilatation. a sac of this organ, the contents of which may become infected and produce an occasional profuse discharge, which may cause the greatest alarm on the part of the patient. Drainage in such cases should be insured — when necessary, by the intro- duction of a drainage-tube, through which the cavity is well irrigated and cleansed. Remedies should be applied to the uterine cavity which will establish a healthy inflammation and arrest the abnormal accumulation. When the uterus is displaced, associated with hydrometra or pyometra which a pessary fails to correct, the advisability of extirpation of the uterus should be considered, particularly if the woman has passed the climacteric. Uterine adhesions or peri -uterine INFLAMMATIONS. 411 inflammation need not necessarily contraindicate curetage, as not infrequently the increased drainage thus secured will result in the relief of the peri-uterine disease. In patients who have suffered for a great length of time, who have become exceedingly nervous, hysteric, with general health destroyed, suffering from delusions or illusions, exceedingly irritable tem- per, a source of worry and distress to the family and to them- selves, no better plan of treatment can be instituted than that advocated by Weir Mitchell as proper for neurasthenic patients. This treatment consists in placing the patient in bed; at first upon a distinct milk diet, with careful regulation of the bowels, correction of disordered condition of the alimentary canal; and, later, forced feeding, with as large a quantity of food as the patient can properly digest. She is under the control of a discreet, careful nurse, who allows her to take no exercise — nor even to move without assistance. In place of exercise she is given, once daily, thorough massage, thus carrying for- ward the blood-current, stimulating the absorption of waste material, and causing the introduction into the uttermost parts of the body of blood containing oxygen. The anemia which characterizes such patients is thus rapidly overcome, the number of red blood-corpuscles greatly increases, while the elimination of waste material is promoted. Once a day she is given an application of the faradic current — general faradization. She is isolated from the members of her family, and during this period of isolation is brought under careful mental discipline, which aims to stimulate her ambition, to over- come the condition to which she has become subjected, so that by the end of six weeks or two months the patient under- goes a complete physical and mental change. 452. Inflammation of the Fallopian Tube. — Inflammation of the tubes is a frequent result of infection, and the gravity of the physical changes is directly in proportion to the viru- lence • of the poison. Gonorrhea and sepsis are the most fre- quent forms of infection which invade these organs. The invasion may occur through the uterus by the continuous mucous membrane, or through the blood-vessels or lymphatics, the former being the more frequent. The inflammation may involve the mucous membrane, the muscular w^all, and even the peritoneum. It may be catarrhal or suppurative. Gon- orrheal infection, most frequently reaches the tube by the continuous mucous membrane of the uterine body, and is more prone to involve the tubal mucosa, resulting in either catarrhal or suppurative salpingitis. It may, however, pass rapidly over the surface epithelium into the deeper structures of the tube, and causes profound destruction. Other avenues for the 412 GYNECOLOGY. entrance of infection are an inflamed or diseased appendix, es- pecially upon the right side, through adhesions to a knuckle of intestine, especially where the tube contains a collection of blood, and, finally, through the peritoneum, in which case, how- ever, the infection is generally tubercular. The entrance of infection into the tube is foUoAved sooner or later by evidences of inflammation. The epithelium becomes swollen, edematous, and granular, with the infiltration of inflammatory materials into the deeper layers. Serous effusion takes place into the tubal canal. (Fig. 306.) Loss of the cilia from the epithelium also Fig. 306. — -Acute Salpingitis. a. Swollen and edematous fold. h. Inflammatory exudate vessel, d. Desquamation of epithelium. Disintegration of longitudinal fold. c. Dilated blood- . Infiltration of leukocytes. /. occurs, especially upon the free surface, while they may be re- tained upon that portion between the folds. The epithelium will be found well preserved upon the surface of the tubal mucous membrane even when suppurative processes exist. (Fig. 307.) The irritating discharge from the tube early leads to irritation of the peritoneum and agglutination at the abdominal end of the tube, while the swollen structures obstruct the uterine orifice. The exudate which collects in the tube may be serous or purulent, according to the virulency of the infection and the resistive force of the patient. In either case the exudation is likely to increase, forming a clear serous collection in the INFLAMMATIONS. 413 one case, which is known as hydrosalpinx or sactosalpinx, while the more virulent process (Fig. 308), which results in a more or less extensive pus-collection, is called a pyosalpinx. Fig. 307. — Chronic Salpingitis showing Agglutination of Folds. a. Union of folds forming gland-like areas, b. Thickened and retracted fold. c. Desquamation of epithelium, d. Hyperplasia of tubal wall. Fig. 308. — Extensive Pus-collections with General Adhesions. 414 GYNECOLOGY (Fig. 309.) Occasionally the excessive hyperemia or a partial twisting of the base may cause rupture of the blood-vessels with an intratubular accumulation of blood. This condition is denominated hematosalpinx. The latter condition, how- ever, is more frequently associated with the retrogressive pro- cesses of ectopic gestation. As a result of the inflammatory process the tube ma}'" assume the form of a simple sac, which gradualhr becomes distended until it attains a large size, and presents as a thin-walled cystic tumor. If the peri- toneal w^all has not been involved, the tumor may remain freely movable, whether it contain serum or pus. Such a sac may, oc- casionally, become twisted upon itself until the venous circulation is partially or completely obstructed, and then rapid increase in size results from the hemor- rhage, which takes place not only into the sac, but also, occasionally, into the peritoneal cavity. A young girl recently came under my observation in whom there had been an apparent acute exacerbation. Examina- tion revealed a large mass upon either side, that on the left side being situated above the uterus, and that on the right posterior to and below the fundus. An op- eration was advised and subsequently performed. This revealed so much blood as soon as the abdomen was opened as to arouse the suspicion of an ectopic gestation. The hemorrhage in this patient came from the tumor of the left tube, the neck of which was twisted near the uterus. The tubal sac was dark (Fig. 312), and covered with clotted blood, which also filled that side of the pelvis. The right sac was clear and free from blood. Both sacs were found to contain pus, the left being mixed with blood. Both tubes were free from adhesions. Sometimes the distention of Fig. 309. — P3'osalpinx. INFLAMMATIONS. 415 h - '^2 ^} the tubal sac overcomes the swelling of the mucous membrane of the uterine end, and, therefore, its opening remains patulous and permits its contents to es- cape, after which the sac attains a favorable posi- tion. Such a con- dition may lead to occasional dis- charges of a considerable quantity of fluid through the uter- us, giving rise to the phenomenon 'Z^ known as hy- drops tubas pro- >"*- fluens, or inter- •5 mittent hydro- ^^^ ,^. T~^ salpinx. Inflam- — b 7r t^ -•i 7^ Fig. 310. — Section from Wall of Pus-tube. , a. Folds matted together forming gland-like spaces, h, h. Folds undergoing dissolution, c. Shows complete desquamation of epithelium covering folds. d, d. Blood-vessels distended with blood-cells, e. Leukocytic infiltration. Fig. 311. — Single Fold from Wall of Pus- tube, enlarged. Line through upper por- tion shows area of extensive hypere- mation of the tube involving its muscular wall causes a shortening of its longitudinal muscular fibers, which, owing to the mobility of the subserosa, permits the fimbria to be drawn into the 416 GYNECOLOGY. tube and the peritoneum to be pushed over it like the pre- puce over the glans penis in phimosis. (Fig. 313.) The peri- toneal edges coming in contact are agglutinated, and the tube is sealed up. If the fimbrice are not completely withdrawn, the protruding fimbriae may serve as an avenue for leakage in sub- sequent distention of the sac and thus cause recurring attacks of localized peritonitis. ^m^^SS^ (Fig. 314.) The tubal inflam- mation, instead of forming the cystic tumor already des- cribed, may result in extensive small-cell in- filtration and thicken- ing of the longitudinal folds, which necessa- rily decreases the cali- ber of the tube. Fur- thermore, in places the edges of the folds lose their epithelium, be- come more or less adherent, and upon microscopic section present the appearance of distended glands. Such a condition has been called salpingitis cysto-adenosa, but this term, like salpingitis follicularis, pachysal- pingitis, and other designations, is an un- necessary distinction. The inflammatory in- filtration frequently involves the folds and wall of the tube, pro- ducing such hyperplasia of these structures as almost to obliterate the tubal canal and to form a large sclerosed mass. The contrac- tion of the circular fibers may cause the formation of a series of small sacs, each one of which is independent of the other, and for which the only relief is afforded by the extirpation of the tube. In the more virulent forms of infection the peritoneal surface of the tube becomes involved by an extension through its ab- Fig. 312. — Distended Pus-tubes Removed from Young Girl. A. Tube whose pedicle was twisted. Sac filled with blood and pus, B. Right tube filled with pus. INFLAMMATIONS. 417 dominal end or through its walls, and extensive adhesions unite the organ to coils of the intestine, the uterus, the ovary, or the pelvic peritoneum. The enlarged and swollen tube drops down into the retro-uterine culde- sac, and generally becomes adherent to the sigmoid flexure or side of the rec- tum. As the sac becomes more and more distended the union thus formed may permit the establishment of a communication with the lumen of the bowel, through which the tubal abscess drains. The tube of one side, dropping into the pelvis, may become adherent to the extremity of the other and form a common pus cavity, which may attain a large size. (Fig. 315.) By a rupture of the tube, infection of Douglas' pouch may occur, thus filling the entire pelvis with a walled-off abscess. The intimate association of the abdominal orifice of the tube with the Fig. 3^3- -Convoluted Fallopian Tube from Perisalpingitis. Fig- 314- -Incomplete Inflammatory Closure of the Fallopian Tube, of Fimbrise Unretracted. Portions ovary causes frequent adhesions between these organs, result- ing in intimate fusion of the involved structures, and rendering it sometimes difficult to differentiate between the two organs. 27 418 GYNECOLOGY. Occasionally they appear as a tubo-ovarian tumor or a fused inflammatory mass, which may contain serous fluid or pus. 453. Symptoms. — Tubal inflammation has no characteristic symptoms. If a patient has had an acute pelvic inflammation, characterized by extreme tenderness in either pelvic region, and aggravated by motion, it is justiflable to conclude that the possible pelvic peritonitis has had its origin in a tubal in- flammation. When each menstrual period is followed by Fig. 315. — Double Tubo-ovarian Collection. pain and tenderness in the inguinal regions, tubal inflammation is very probable. A normal tube is not usually palpable. In diseased conditions, however, especially when the tube has become thickened by salpingitis or parenchymatous inflam- mation, it may be recognized as a more or less thickened cord which slips under the finger and is quite sensitive. When hyperplasia of its connective tissue occurs, the tube is felt as a INFLAMMATIONS. 419 contracted, distorted, nodular mass, closely associated with the uterus and frequently firmh^ fixed in the pelvis. When the abdominal end is closed, it may present an enlargement increas- ing from the uterus outward, something like a bell-retort or gourd in shape, or resembling a sweet potato or sausage or sausage-like links. 454. Diagnosis. — When the uterus is bound down, with evi- dence of extensive peritoneal inflammation upon either side of the pelvis, in the majority of cases the tubes will be found to have been the source through which the infection has reached the peritoneum. In a normal condition, unless the patient is very thin, the tubes are not palpable. Inflammatory change, however, which renders the tubes resistant and causes them to be stiffened, leads to their recognition, so the determination of a cord-like structure running out from the side of the uterus is evi- dence of tubal inflammation. Where the tubes become occluded at their abdominal ends and filled with secretion, they become more and more retort- shaped, being larger at the external portion and narrowing toward the uterus. A tumor pre- senting such a shape as this, and quite movable, is most frequently a hy- drosalpinx. (Fig. 316.) It is true that pus-tubes may at times be free from Fig. 3 1 6 .—Hydrosalpinx, adhesions, but in the majority of cases the infection which is so virulent as to lead to the formation of pus causes a perisalpingitis, which leads to agglutination of the surrounding structures, and not infre- quently to absolute fixation of the pelvic structures. Where the tube is free from adhesions, it is likety to drop into Douglas' pouch. Here the change in the circulation not infrequently leads to it becoming adherent to the posterior surface of the uterus, the sides of the rectum, or the ovary and tube of the opposite side, forming a large mass filling up the pelvis. (Fig. 315.) These conditions are readily recognized by bimanual palpation. In practising this procedure, however, it is very important that it should be done with great precaution, re- membering that not infrequently these sacs may be so thinned that undue pressure may lead to their rupture with the escape of their contents into the peritoneal cavity, causing a general infection, to be followed subsequently by peritonitis. The association of the ovary in a mass of this kind, forming a tubo- 420 GYNECOLOGY. ovarian abscess, is not always readily recognized. A tubo- ovarian cyst is more readily determined by the increase in size, by the greater spherical character of the external end of the sac, associated with a bell or retort -like shape as we ap- proach the uterus. 455. Prognosis. — Tubal inflammation should always be con- sidered a source of danger. Even its mildest forms should necessitate resort to treatment, in order, if possible, to arrest Fig. 317. — Double Pyosalpinx, Showing Adhesions to the Rectum, to the Uterus, and, on the Right, to the Appendix. the progress and limit the extension of the inflammation. When associated with pelvic peritonitis, the extensive infection, especially the streptococcic form, is one of the most dangerous lesions with w^hich we have to deal. When associated with disease of the ovaries and extensive suppuration of the tube, the cure of the patient, in the sense of restoration of her func- tions, is absolutely impossible. While the patient may recover her health and comfort, she is subsequently crippled for life, because her powers of procreation are destroyed. INFLAMMATIONS. 421 Treatment. — (See Section 459.) 456. Inflammation of the Ovary. — Inflammation of the ovary occurs in two forms: oophoritis, inflammation of the structure of the organ; peri-oophoritis, where the inflammation is confined to its surface. A hyperemia or congestion of the ovary may arise as a result of infection. This may be so ag- gravated as to lead to rupture of vessels. The occurrence of hemorrhage into the structure of the ovary produces small collections of blood-clots in the organ, known as ovarian apo- plexy, or a large collection of blood, an ovarian hema- toma. The latter may destroy the ovary and even rupture its coat, and result in a serious internal hemorrhage. Oopho- ritis is an interstitial inflammation of the ovary, which may be either acute or chronic, septic or gonorrheal. It is char- acterized by all the signs of inflammation, hyperemia, swell- ing, increase in size of the vessels, extravasation of blood, and later pus-formation. The latter may involve only a small portion of the ovary or the entire organ may become the seat of an abscess. The origin of the infection not infrequently arises in a corpus luteum, so we have what are known as corpus luteum abscesses. In these cases the walls of the abscess may be recognized by the wavy elevations of the inner wall on micro- scopic section. The acute form of the disease is most frequently the result of infection ; the latter gains admission through lesions of the vagina, of the uterus subsequent to labor or abortion, sur- gical operations, or an accidental injury. Infection may reach the ovary through the continuous mucous membrane of the tube or by way of the lymphatics or blood-vessels. In fatal cases the ovary will often be found very much enlarged, soft, and sloughing, and containing small extravasations of blood or pus, or small collections of pus will be found in the con- nective tissue and structure of the ovary, or a single large abscess may exist, equal in size to a hen's egg or even larger. The larger abscesses may be produced by suppuration of an ovarian cyst. Suppurating ovaries generally become adherent to the neighboring structure, and, if the walls are thick, the pus may remain quiescent, thus being the cause of a chronic state of ill health. However, the pus may escape by rupturing into the bowel, bladder, or vagina. The cavity thus emptied may shrink and ultimately disappear, while a state of chronic ill health will still continue. An inflamed or cystic ovary, ad- herent to the inflamed tube, frequently loses the intervening wall and forms a concavity, which is known as a tubo-ovarian cyst or tubo-ovarian abscess. Coalescence of both ovaries and tubes in such a sac may result in the formation of a tumor which fills up the pelvis. The formation of an abscess in the 422 * GYNECOLOGY. ovary is not always associated with peri-oophoritis. Some years ago I saw a patient in consultation, and subsequently operated upon her, in whom, some three weeks folloAving her delivery, her temperature rose to 104° F. Careful examination failed to reveal any increase in the size of the uterus or anything to indicate that the uterus was the seat of disease. Some en- largement of the ovary upon the left side, which, however, was free from adhesions, led me to open the abdomen. After enter- ing the abdominal cavity the left ovary w^as found the size of a small orange ; it was free from any adhesions, but had a small flake of lymph on one side, which corresponded to a similar flake in the orifice of the tube. The tube itself was not enlarged nor did it show any signs of an inflammatory condition. The ovary was afterward removed and, when opened, contained within a thin shell some thick, greenish pus. The subsequent convalescence of the patient was uninterrupted. In chronic oophoritis there is a great increase in the connective tissue, which results in contraction and thus causes destruction of the follicles and compression and arrest of development of the stroma, while the epithelium of the free surface is the longest preserved. This may present extensive fissures, the result of the contraction. In chronic inflammation the tunica albu- ginea becomes greatly thickened, so it does not readily rup- ture with the development of the Graafian follicle. The con- sequence is that the follicle increases in size, and such an ovary may present a large number of cysts, producing the condition known as cystic degeneration of the ovary. Another form of chronic inflammation of the ovary has been denominated oophoritis serosa. In this form the inflammation is chronic in development and duration, and in the majority of cases it is curable if properly treated. It may be a sequel of fevers, sometimes it is associated with mumps, and it may follow a passive gonorrheal infection. The ovaries become swollen, exceedingly tender, and frequently prolapsed. In advanced cases they are greatly swollen, quite smooth, shiny, and almost translucent. Folds and cicatrices are completely obliterated. Cirrhosis is a term which has been applied to various changes in the ovary. I have frequently seen ovaries which were pro- nounced cirrhotic, but which I could not regard otherwise than as physiologic. The term is only applicable to those cases in which the ovary has undergone contraction to such a degree as to result in the destruction of its glandular tissue and decided decrease in size of the organs. Peri-oophoritis is a condition characterized by the deposition of inflammatory material upon the surface of the ovary. The surface epithelium is destroyed and it is likely to be followed INFLAMMATIONS, 423 by a true oophoritis. This condition, hke simple oophoritis, is frequently a part of a widely extended inflammatory process, which may involve uterus, oviducts, ovaries, pelvic peritoneum, and cellular tissue. (Fig. 318.) It is generally consequent upon an extension of infection from the tubal orifice to the pelvic peritoneum, although it may follow an abscess of the ovary. The end of the tube is usually associated with the ovary in this form of inflammation, and it may be the forerunner of a tubo-ovarian abscess. The inflammation varies from a few bands of adhesions which bind down the ovary and tubal orifice, possibly occluding the latter, to a mass of exudation which Fig. 318. — Peri-oophoritis. Tube and Ovary Encysted. completely obscures both and forms so intimate a fusion as to render difficult the line of demarcation between these organs. The chief function of the ovary, apart from any supposed internal secretion, is to provide a site for the perfect develop- micnt and maintenance of healthy ova, and to permit them, under circumstances as 3^et undetermined, to pass into the mouth of the oviduct. Peri-oophoritis necessarily interferes with this process, by the presence of adhesions about the ovary or the consequent induration of its tunic. An ovum escap- ing from a matured Graafian follicle will be barred from en- trance into the oviduct by adhesions which fix the fimbriated orifice or so envelop the ovary as to prevent it reaching the oviduct. Such adhesions are a cause of severe suftering, espe- cially when they limit the free mobility of the ovary and fix it 424. GYNECOLOGY. subject to pressure, as behind the uterus or over the rectum, or where intestinal adhesions subject it constantly to dragging and tension by intestinal peristalsis. An ovary fixed in the retro- uterine pouch, with an overlying retro verted uterus, is a con- stant source of distress. Its position, independent of the ad- hesions, causes congestion from the obstructed circulation, while the pressure of feces and the impinging male organ during coi- tion augment the discomfort. 457. Symptoms. — Oophoritis exhibits no characteristic symp- toms. Even in cases of acute septic poisoning no symptoms will be present which can be said to be absolute indications of an ovarian lesion. In the less severe form of inflammation we may recognize symptoms which we could justly attribute to ovarian disease, but they are so intimately associated with those caused by disease of the oviducts that it becomes difficult to differentiate them. Pain is the only constant s^^mptom in all varieties of pelvic inflammation, and the site to which it is referred bears no constant relation to the affected organ. The entire pelvic region may be the seat of pain, but we are, however, unable definitely to distinguish the exact origin of pain and say whether it is due to affections of the tube, ovary, peritoneum, broad ligament, body of the uterus, cervix, or in- dependent of disorder in any of them. We can readily appreciate this when we remember that the nervous distribution of the vari- ous organs is derived from a common sympathetic center. As in any inflammatory condition, pain is aggravated by pressure, so in inflammatory processes of the pelvic structures pain is magnifled by pressure and motion. The pain is distinguished from that of true dysmenorrhea by the fact that it is an exagger- ation of the distress and is felt between the periods, while true dys- menorrhea is purely a menstrual pain. Not infrequently patients will assure us that the only time they are free from discomfort is during the menstrual flow. Pain may persist subsequent to coi- tion as a result of congestive tension. When produced by intra- abdominal pressure and increased by standing, pain is greatly relieved by assuming the recumbent position. Ovarian pain is directly aggrav^ated by pressure over the organs through the va- gina or rectum, as during coitus, an examination, or the passage of large fecal masses. The various symptoms of pelvic disease, such as amenorrhea, menorrhagia, or leukorrhea, are not char- acteristic of oophoritis. Peri-oophoritis causes pain which is more or less distinctly localized at the pelvic brim, and extends down the thigh of the affected side. Not infrequently pain is experienced in the corresponding breast. The inflammation may extend from the surface of the ovary into its substance and cause changes in its stroma, dropsy of its follicles, or hem- INFLAMMATIONS. 425 orrhage, producing a condition, in the one case, known as cystic degeneration of the ovary, and, in the other, as ovarian hema- toma or ovarian apoplexy. The wide distribution of neurotic symptoms must not be overlooked. The local pelvic lesion may be a minor one. To oophoritis or uterine displacement are often attributed symptoms which are the result of fissures of the cervix, mobility of the kidney, enteroptosis, gastroptosis, or even central lesions of the nervous system, which will per- sist after the supposed local lesion has been cured or removed. Such experiences are a source of great disappointment to the medical practitioner. At times relief is obtained, at others pain and distress continue or are even aggravated. 458. Diagnosis. — Inflammatory processes of the ovary do not present a constant characteristic clinical picture. The infection rarely confines itself to the ovary, consequently the sympto- matic phenomena are modified by the circumjacent inflamma- tory changes. The recognition of a tender body, somewhat enlarged, yet retaining the shape of the ovary, by vaginal or rec- tal palpation, adds certainty to the diagnosis. The presence of adhesions or exudate will render its determination difficult and make it doubtful how much the swelling is due to the ovary, the tube, or the exudate. In acute conditions or in hyperesthetic patients an anesthetic will prove of value. Where the obscurity of the condition can not be overcome, a preliminary vaginal or abdominal incision may be necessary in order to determine the proper operative procedure. 459. Treatment of Inflammation of the Appendages. — In the great majority of chronic inflammations of the uterine appendages the treatment of diseased conditions of the tubes is similar to that of diseases of the ovaries, or, in other words, the tw^o conditions are so closely related that I deem it better to consider their treatment under the one section. The first aim in the treatment should be the preservation of the function of the affected organs. The second, the restoration of health to the patient. Treatment may be either medical or surgical. The medical or nonoperative treatment consists in rest in bed and in keeping the patient absolutely quiet. Free purgation should be established by the use of salines in order to make the in- testines drain the peritoneal cavity and relieve the congestion. The diet should be restricted and cold should be applied to the external surface. In the acute stage the application of cold in the form of the ice-bag is of value, and this should be kept more or less continuously applied. The ice-bag decreases the congestion, limits the exudation, lessens the danger of suppuration, and promotes absorption, xlfter the more acute symptoms have subsided the treatment may still further be 426, GYNECOLOGY. promoted by the application of pressure, using three to five pounds of shot in a bag, which is appHed over the inflamed, indurated tissues; the pressure is increased and its position changed as the condition may demand. Unless suppuration has occurred, resolution will probably be accomplished. The absorption may be still further promoted by the use of counter- irritants, such as small blisters, painting with iodin, the use of croton oil, or inunctions of dilute ointment of the iodid of mercury or a dram of the official ointment to an ounce of lanolin. Occasionally ice will be very uncomfortable to the patient, while heat will be more grateful. A flaxseed poultice may be ap- plied, or, what is probably much more agreeable to the patient and more easily applied, would be to take a piece of spongio- pilin, wring it out of hot water, and place it over the abdomen, and over this a dry cloth. This should be changed as frequently as may be necessary. The changing may be made less frequent, however, by the application over it of a hot-water bottle. Ich- thyol in lanolin, one or two drams to the ounce, may be rubbed into the lower part of the abdomen, and this supplemented by the pressure already suggested. Hot vaginal douches should be employed, and benefit will frequently be obtained from the use of hot rectal enemas, using a pint to a quart of hot water and directing the patient to retain it as long as possible. This is more eft'ective than hot vaginal douches, for the reason that the heat comes more nearly in contact with the infiamed surfaces and can be retained for a greater length of time. In- ternal medication during this time, aside from the application mentioned, should be largely supporting. The patient should be carefully protected from any possibility of exposure or overfatigue. During the menstrual period it is preferable that the patient should be confined to bed. The more acute stages having subsided, in addition to the douches and enemas recommended the patient ma}^ take a hot sitz-bath for fifteen to thirty minutes daily. With the further subsidence of the acute symptoms and in those cases in which it is evident that suppuration has not occurred, the adhesions binding down the ovaries and tubes may be overcome by the employment of pelvic massage. The structures are lifted up with one or two fingers within the vagina and manipulation over the ab- domen employed, gradually pressing the fingers in so as to follow lines of cleavage and to lengthen the bands of adhesions or promote their absorption by stretching and irritation. The congestion and pain in chronic inflammation of the ovary may frequently be very greatly lessened by the administration of fluidextract of gelsemium, giving five drops three times daily. In these conditions great prudence must be exercised INFLAMMATIONS. 427 in the administration of anodynes. A patient suffering from pelvic pain as a result of attacks of peritonitis, with binding down of the pelvic viscera, may very easily be led into the habit of taking morphin or opium until, instead of it simply being a servant, it attains the position of master, and the patient finds herself enslaved to a drug from which emancipation is very difficult. While it may be necessary, in an acute attack, to administer a dose of morphin in order to allay the violent pain, yet, in the majority of cases, the early and continuous administration of salines, associated with the application of the ice-bag, will be effective in arresting the severe pain, or at least in making it endurable. The measures Avhich we have already discussed are in the line of what we have denominated the first aim in the treatment of lesions of the uterine appen- dages — that is, to maintain the functions of these organs. Surgical Treatment. — The surgical treatment does not neces- sarily exclude the object which Ave have considered as the first aim in treatment, but may, indeed, assure its accomplishment, especially when early and efficiently established. Delay, how- ever, would almost certainly favor the development of conditions which would necessitate more serious procedures. Operative treatment, with a view to maintenance or restoration of func- tion, is known as conservative treatment. AVhere the sacrifice of the appendages is considered necessary, in order to save life or insure good health, the procedure is known as a radical one. Conservative treatment may consist in the breaking up of adhesions, the reopening of the orifice of the tube, sal- pingostomy, or the partial resection of the tube itself, thus shortening it and permitting the removal of those portions which are prejudicial to health. (Figs. '319 and 320.) This procedure also comprises the resection and removal of any diseased portion of the ovary, with the endeavor to retain a sufficient portion of the organ to insure the continuance of ovulation and menstruation. In chronic oophoritis with marked thickening of the tunica albuginea and the development of small cysts in the ovary, a resection of the ovar}^ or removal of the more diseased portion will frequently result in such metabolism as to restore the remaining portion of the ovary to a more normal condition. Wherever conditions will permit, a portion of the ovary should be retained; its retention will insure the continuation of menstruation and ovulation and have a marked influence upon the general morale and nervous condition of the patient. The retention of the whole or a part of the ovary is desirable even though it may be necessary to remove both tubes, because it insures the continuation of ovulation and menstruation. This has a marked influence 428 GYNECOLOGY. Upon the nervous system of the patient. In surgical opera- tions we are obHged to be governed by the physical condition of the organs under consideration. The abdomen should not be opened unless palpable disease of the uterine appendages by physical examination can be determined. Operations for • tube: OVAR^ :W-, Fig, 319. — Resection of Tube. Fig. 320. — Operation of Resection of Tube Completed. pain in the region of the ovary, without ovarian enlargement, will most frequently be attended with no favorable result. Where the disease is extensive and ovaries and tubes have undergone destruction, the removal of these organs will often- times be the only procedure that will afford any hope for res- toration of the comfort and health of the patient. In sup- INFLAMMATIONS. 429 purative conditions where the ovary is also involved in the inflammatory process the better plan of procedure will be the removal of the ovary and tube complete. In a patient upon whom I recently had to operate the left ovary and tube were so extensively involved that their removal was indicated. The right tube was considerably enlarged, its wall was several times its ordinary thickness, and the cavity of the tube contained pus. In this case, the left tube and ovary having been re- moved, the right tube was dissected out from the cornua of the uterus and the opening in the broad ligament was closed with a continuous catgut suture, thus controlling hemorrhage. The ovary, as it presented no marked abnormal change, was permitted to remain. In these cases the operation is some- times exceedingly difficult, as on opening the abdomen we will find the tube and ovary, with the fundus of the uterus, matted down in the pelvis in close association with coils of intestine, the omentum, and the parietal peritoneum. Where the condition is one of recent sepsis, it may sometimes be neces- sary to consider the advisability of removal of the uterus as well as of the appendages. When there is occasion to open the abdomen, the structure should be carefully inspected and examined by touch. The adhesions should be broken up and proper care be exercised to insure control of hemorrhage. In some patients the broad ligament will be so contracted from the inflammatory changes that we will be unable to lift the ovary and tube out of the wound. In such cases the broad ligament should be resected with the ovary and tube. This may be accomplished without the application of ligature, seiz- ing the bleeding vessels as we proceed, and holding them with hemostatic forceps, after which the wound in the broad liga- ment can be closed with a continuous catgut suture, so intro- duced that each turn or second turn shall lock the preceding stitch, and thus secure against hemorrhage and prevent the broad ligament from being distorted. After operations in some of these more critical cases, and sometimes prior to operation, the patient may be very greatly benefited by the employment of the rest treatment — the plan of treatment introduced by S. Weir Mitchell. It consists in the isolation of the patient, careful study of her condition, and the improvement of her general nutrition. The patient should be kept absolutely in bed ; she should have her secretions made normal and her diet restricted, possibly at first to milk, and, later, feeding should be forced. Graduated exercise should be advised, supplemented by the employment of massage and electricity. By these means the elements of the blood are restored and the patient gradually regains her strength and health. 430 GYNECOLOGY. 460. Pelvic Inflammation. — The term pelvic inflammation is a comprehensive one. It is necessary, at the outset, to limit it to the conditions which we intend it shall include. In- flammation of the individual pelvic viscera has been discussed, so this term will be confined to inflammation which involves the cellular tissue and the peritoneum. It consequently includes those affections described as pelvic cellulitis and pelvic peritonitis. These conditions have been designated as peri-uterine inflammation; by some writers of .distinction, notably Virchow and Matthews-Duncan, the terms parametritis and perimetritis have been used — the former to indicate inflammation of the cellular tissue; the latter, of the peritoneum. These terms are objectionable for the following reasons: First, they are so nearly alike in sound that it is difficult for the student to avoid confusion in their use, and the subject is rendered more difficult of com- prehension. Second, a difference in the anatomic relations of the peritoneum and cellular tissue to the uterus is implied which does not exist. The pelvic connective tissue and the pelvic peritoneum are in equally close contact with the uterus. It is distinctly objectionable, therefore, to consider one as an inflammation around the uterus and the other as an inflamma- tion near it. Third, the conditions are described as associated with the uterus, while they may exist in all the tissues of the pelvis, and are not necessarily uterine in their origin. Careful investigation of the pathology of these conditions by autopsy, and their more extended study during abdominal procedures while in active stages of disease, have demonstrated how easily such erroneous views could arise. Bernutz and Aran, of France, many years ago demonstrated the true nature of pelvic inflammation, which has been abun- dantly confirmed in the practice of abdominal surgery, where the opportunity has been afforded for comparing physical signs with the actual existing pathologic changes. 461. Varieties. — Pelvic inflammation, as we have described it, is properly divided into inflammation of the cellular tissue (pelvic cellulitis) and inflammation of the peritoneum (pelvic peritonitis). It must not be understood in these definitions that the demarcation between these aff'ections is sharply de- fined, for, in practice, we do not find inflammation confined to the single or specific structure. Their use indicates simply that the infiammation predominates in the structure named. 462. Pelvic cellulitis, parametritis, or peri-uterine phlegmon is an infiammation of the pelvic cellular tissue. It may be either primary or secondary: i. e., it may have originated in the cellular tissue or may have reached it by extension from the neighboring structures. The primary inflammation is an INFLAMMATIONS. 431 acute infective disease which differs in no respect from acute inflammation of the connective tissue in any other portion of the body. Chronic pelvic celluHtis is ahvays a secondary affection, and may or may not have been preceded by an acute attack. The pehdc connective tissue is not a special structure, but a portion of that wide system of mesoblastic connective tis- sue which surrounds the great vessels of the trunk and accom- panies their branches from origin to termination. It is found in the pelvis, partly in the form of a loose areolar network, partly in the more condensed form of fascia. It surrounds all the blood- vessels, nerves, and lymphatics, as well as the uterus, and serves as investing sheaths for them outside the pelvic cavity. It is closed off from the perineum and ischiorectal fossa by the pelvic fascia, a strong aponeurosis, which is attached to the pelvic wall between the pubic bones and bodies of the ischia, and along that thickening of the obturator fascia known as the white line. It passes as a continuous layer over the levator ani and coccygeus muscles to the vagina in front, and to the rectum and coccyx behind. It closely blends with the vaginal orifice, behind the pubic symphysis, as the triangular liga- ment. Inflammatory exudations of the female' genital organs above the vulva are situated above this strong fascia. The cellular area with such a boundar}^ below has the peritoneum for its superior limitation. This boundary, however, is less abrupt, as it is continuous with the subserous connective tissue of the parietal peritoneum of the abdomen. With the ex- ception of the fundus of the uterus, it forms a layer beneath the entire pelvic peritoneum — both parietal and visceral. The so-called uterine ligaments contain more or less of it between their peritoneal folds, and in certain situations it is abundant; for instance, around the supravaginal portion of the cervix, and along the base of the broad ligaments and between the bladder and symphysis pubis. In the latter situation it con- tains a varying quantity of fat in its meshes. Its oflice in the pelvis, as elsewhere, is to protect and sup- port the other tissues, performing a passive mechanical function. It affords a cushion which prevents injury of the viscera (Schae- fer). The connective -tissue layer, between the vagina and peritoneum posterior to the uterus, generally does not measure more than | of an inch in thickness, but in pregnancy its thick- ness is greatly increased. During the progress of develop- ment of a pregnant uterus the broad ligaments are gradually drawn upward, until at the completion of the pregnancy they lie in the iliac fossa, above the brim of the pelvis, while no peri- toneum dips into the lateral parts of the pelvis. The space thus vacated is filled with connective tissue, which during 432 GYNECOLOGY. the later months of pregnancy is enormously increased. Freund describes a form of cellulitis which affects more particularly the fat less connective tissue, or fascia, which he calls para- metritis chronica atrophicans circumscriptum et diifusum. Cellulitis is a very common complication of pelvic peritonitis involving particularly the uterosacral ligaments and peritoneal folds. Schultze calls this parametritis posterior: uterosacral cellulitis is more accurate. Cicatrization of the ligaments follow- ing such inflammation causes traction upon the upper part of the cervix, and is a very common cause of dysmenorrhea and ster- ility. As a result of the contraction of the tissues the uterus may be antefiexed and draw^n to one side or backward, thus pro- ducing a pathologic anteflexion. By compression of the vessels and nerves the uterus and ovaries may become atrophied. Cellulitis may exist with or without suppuration. When sup- puration does not occur, an exudation results in the connec- tive tissue, which becomes edematous, and subsequently more or less organized, firm, and hard, causing pressure upon the vessels and nerves which pass through it. The changes in this structure are similar to those which take place in cirrhosis of the liver or of the kidney. 463. Etiology. — Primary pelvic cellulitis is always a re- sult of sepsis. Ready entrance for septic material is afforded through lacerations of the cervix uteri. These injuries may be caused by the use of forceps, and, if kept aseptic, readily heal. In the nullipara cellulitis may arise from the same causes as pelvic peritonitis, such as exposure to cold during men- struation, being then generally associated with pelvic peri- tonitis, and from surgical operations which open the connective tissue, as in the removal of large uterine polypi, affording an opportunity for cellulitic infection. The danger is especially great when the gro\\i;hs are expelled or removed while in a state of necrosis. A certain amount of lymphangitis is then associated, with which the lymphatic glands may be implicated. Cellulitis may develop from disease in the bladder. As a re- sult of such irritation thickening occurs in the connective tissue outside the bladder, which thickening passes outward and for- ward, and in ultimate atrophy may cause uterine displace- ment in the opposite direction. From the rectum, the causative irritation may be dysenteric. A pelvic cellulitic abscess is not infrequently so situated as to render it more than probable that the hypogastric glands are involved. Inflammation occurs much more rarely in the cellular tissue than in the pelvic peri- toneum. With the advent of suppuration an abscess follows, which is generally of large dimensions, although occasionally several abscesses may be found in close apposition. INFLAMMATIONS. 433 464. Symptoms. — In puerperal cases the cellulitis is gener- ally ushered in about the second or third day, with a rigor or chill, although it may occasionally occur later. In nonpuer- peral cases the interval between infection and the first mani- festation of symptoms is rarely more than one or two days. The occurrence of the chill has produced the belief that the inflammation arises from exposure to cold; simultaneously with the chill occurs an elevation of temperature, a rapid pulse, but rarely pain, unless the peritoneum is involved. When suppu- ration occurs, the most marked symptom is the progressive emaciation associated with pallor or earthy sallowness of the skin. The skin is harsh, dry, and covered with branny scales from the fine desquamation. Peritonitis may complicate the condition and will be indicated b}^ the frequent vomiting of a dark-green fluid. Vomiting will be excited by the ingestion of the smallest quantity of anything, even liquids. The patient looks ill, loses her appetite, and suffers from marked debility and severe mental depression. She becomes very irritable. If the exudation extends to the fascia over the iliacus and psoas muscles, and particularly if the connective-tissue elements between these muscles are involved, the patient will lie upon her back with the leg of the affected side flexed and the thigh bent upon the trunk. The symptoms are those of a subacute form of septicemia. Pain and local signs may be so slightly marked as to lead to the condition being unsuspected or over- looked. 465. Physical Signs. — In the early stages of an acute attack the physical signs are but slightly marked. All that will be noticed by digital examination is that the vagina is hot and its vessels are pulsating. In a few hours there are indications of an inflammatory exudate. There is a doughy sensation and fullness on one side of the uterus and in the iliac fossa. This may extend partly around the cervix, and subsequently become hard and indurated. If the poison has entered through a wound in the cervix, the latter becomes less movable. The supravaginal tissues on the affected side are tender, more or less hard, and unyielding. There is a bulging at the side of the uterus, and the lateral fornix on that side is apparently obliterated. (Fig. 321.) We rarely find both sides of the uterus affected at the same time, but occasionally the whole supravaginal portion of the cervix may be embedded in a thick collar of indurated tissue, which more or less completely sur- rounds it. Generally the disease spreads laterally along the base of the broad ligament to the tissue beneath the reflection of the peritoneum on the anterior abdominal wall. AVhen this occurs, a uniform hardness or resistance is felt in the abdominal 28 434 GYNECOLOGY wall beneath the muscles. This may assume the form of a broad band, from J of an inch to 2 inches or more in width, which lies along the upper border of Poupart's ligament. Occa- sionally the exudation spreads upward and outward from above Poupart's ligament into the iliac fossa. This exudation may extend in one of two ways : (a) it follows the course of the lymph- atics which run from the uterus outward beneath and be- tween the layers of the broad ligament to the glands and lumbar region ; (b) by lines of cleavage in the cellular tissue of the pelvis. In the latter form it not infrequently passes backward, pro- ducing an exudation in the tissue of one or both uterosacral ligaments in the tissue surrounding the rectum, and lines the posterior pelvic wall beneath the peritoneum. In these cases Fig. 321, — Exudation in Broad Ligament from Pelvic Cellulitis. the rectum will be felt wholly or partly surrounded by a belt of exudation, which forms a bridge or an arch. If suppuration does not occur, the exudation becomes absorbed, and in un- complicated cases the hardness may so far disappear as to leave no subsequent trace. In not a few cases pelvic cellulitis results in the formation of an abscess. The situation of the abscess and the direction in which it may be expected to extend depend upon the situation and the extent of the inflammatory exudation. If the inflammation is seated in the base of the broad ligament and passes forward beneath the peritoneum, where it is reflected on to the anterior abdominal wall, an area of induration may be noticed above Poupart's ligament. Sup- puration can be recognized by the occurrence, over the indurated INFLAMMATIONS. 435 area, of edema in the skin, which pits on pressure; by deep- seated fluctuation, especially recognized by bimanual examina- tion ; and by the eventual pointing of the abscess a little above Poupart's ligament. The pus can often be detected before it reaches the surface by passing the tip of the finger carefully over the induration, when a softened point will be recognized in the surrounding hardness. As we have already noticed, pelvic cellu- litis may unfortunately extend backward instead of forward, when, if suppuration follows, an abscess forms beneath the peri- toneum covering the back of the pelvis. Such an abscess has no direct access to the free surface, relief is much longer delayed, and extensive burrowing follows. It can extend into the ihac fossa and the loin, particularly when the posterior wall is the seat of the abscess. It may point at the iliac crest, or may sometimes leave the pelvis by the sciatic notch and follow the course of the sciatic or gluteal vessels. Again, it appears in Scarpa's triangle, having followed the side of the femoral vessels. By whatever route the abscess leaves the pelvis it will follow the prolongation of the connective tissue upon the blood-vessels or the ureter, rather than that of the nerves or tendons. When matter burrows along the psoas muscle, it comes, not from cellulitic abscess, but from dead bone, and this is an important fact to keep in mind. I saw with the late Dr. Kappes a patient who had been con- fined about six weeks previously, and she was suffering from what was apparently a subacute attack of septicemia. She was lying Avith her limbs drawn up, complaining of severe pain in the abdomen, extending into the groin. On examination, induration could be recognized extending from the left lumbar region into the groin. Vaginal examination disclosed the uterus freely movable, with no induration about it nor in the pelvis, until the finger was passed well above the brim, when the indurated psoas muscle was recognized. On investigating the history of this patient it was found that she had suffered Fig. 322. — Exudation of Cellulitis over Rec- tum, 436 GYNECOLOGY. from a fall about the third month of pregnancy. She was walking on stilts in her back yard to amuse her children, when she tripped and fell in a sitting position. She suffered more or less discomfort during the entire remainder of the pregnancy. An incision w^as made on the left side over the crest of the ilium and the peritoneum was pushed forward, when the tissue of the psoas muscle was found infiltrated with purulent material. It was hoped that the vent thus afforded would give the patient relief. She improved for a few days, when pain occurred upon the opposite side, where a similar condition was found. We not infrequently hear of cellulitic abscesses opening into the rectum, vagina, or bladder, but these cases, when considered in the light of the pathology of pelvic inflamma- tion, are doubtful, and are more than likely cases of intra- peritoneal suppuration which has originated either in dis- ease of the Fallopian tubes or of the ovaries. An abscess will usually point between the seventh and twelfth weeks. In discussing pelvic disease we should not overlook a peculiar malignant form of inflammation, mostly occurring in puer- peral women, in which, associated with other lesions significant of the virulence of the infection, multiple abscesses in the con- nective tissue are found. Many of these abscesses are so small as easily to elude detection. The condition is known as diffuse pelvic suppuration, and has all the characteristics of phleg- monous erysipelas. The tissues become edematous and of a livid hue. Suppurating thrombi are found in the veins and the lymphatics are acutely inflamed. Occasionally, the ovaries may be found in a state of suppuration. Associated with this condition are all the symptoms of acute infection in its most virulent form. 466. Diagnosis. — The absence of pain not infrequently permits considerable progress before the existence of the con- dition is suspected. Puerperal women, because of the tender- ness of the external genitals and the presence of the lochial discharge, are very averse to vaginal examination. If the puerperium pursues a normal course, this aversion should be respected, but it can not be too strongly asserted that examina- tion should be made whenever symptoms of pyrexia supervene and the ordinary course of convalescence is interrupted. A temporary disturbance of temperature and of pulse-rate may result from such causes as constipation, excitement, and mam- mary engorgement. Unless such conditions can be recognized as provocative of the disturbance, or if the abnormal symp- toms are persistent, and especially if the lochia is offensive, a thorough examination not only of the vagina, but of the in- terior of the uterus, should be made. During the first ten INFLAMMATIONS. 437 days subsequent to delivery the uterus can be readily explored without artificial dilatation. If a portion of placental tissue or a decomposing blood-clot is found, it should be removed, and the uterine cavity should be cleansed and disinfected. Ordinarily the symptoms will be promptly relieved. If they are not, the examination will have revealed the probable cause of the disorder, and simultaneously will permit any swelling or other morbid condition of the pelvic tissues to be detected. A few days after the onset of the attack the physical signs of cellulitis will be so marked as to render the diagnosis cer- tain, and a laceration of the cervix or of the vagina will be disclosed as the probable gateway for the entrance of the in- fection. Occasionally the first indication of cellulitis will be an impaired mobility of the cervix upon one side, on which tenderness and, swelling will be marked. Later, this infiamed structure becomes stiff, and passes to well-defined hardness. The cellulitis may be situated to one side of the cervix or may extend along the base of the broad ligament of the aft'ected side. The lateral fornix of the vagina will be completely ob- literated. When the inflammation extends back\A^ard, vaginal examinations of the posterior wall will reveal a diffuse fullness and hardness on the affected side, which is still further dem- onstrated by rectal examination. In the rare cases in which the broad ligament itself is affected the diagnosis is determined by finding the mobility of the body of the uterus impaired, and a more or less flattened mass of induration upon one side, which is continuous with the uterus. Excepting the plane of tissue between the cervix uteri and the bladder, the cellular area of one side of the pelvis is practically shut off from that of the other. Hence, we flnd pelvic cellulitis is, for the most part, unilateral. The differential diagnosis of pelvic peritonitis will be discussed later. (See Peritonitis.) The only other conditions with which cellulitis can be confounded are hematoma of the broad ligament and myoma of the uterus. In hematoma there is an effusion of blood into the connective tissue, which forms a slightly movable, somewhat flattened tumor along- side of and continuous with the uterus. The history of the case and the absence of symptoms of severe illness will generally serve to distinguish it. It occurs suddenly, from rupture of a pregnant tube or of a varicose vein in the broad ligament. In either case the onset is marked by violent pain, faintness, syncope, and usually vomiting. In pregnancy of the tube one or two menstrual periods will have been passed, and the pain will be situated in the lower part of the abdomen, generally on one side, with irregular uterine bleeding. The effect of such an outpouring of blood upon the temperature and pulse 438 GYNECOLOGY. . is transient. The temperature is not elevated. If infection occurs, suppuration results, and the symptoms then are similar to those of pelvic abscess from cellulitis. Myoma can rarely be mistaken for cellulitis. Only in those rare cases in which the myoma develops laterally between the layers of the broad ligament and forms a more or less hard tumor directly con- tinuous with it is error possible. Should the myoma be com- plicated by a localized peritonitis, or the tumor become in- flamed or gangrenous, the diagnosis may be difficult. In the posterior wall error is scarcely probable, for large inflammatory exudations into the connective tissue behind the uterus are extremely rare. In the anterior wall the signs of cellulitic exudation between the bladder and the upper part of the cervix are well marked and characteristic. 467. Prognosis. — The disease usually terminates in recovery, except in the very diffuse variety, in which it is a part of a general septic process. With the subsidence of the fever the exudation is gradually absorbed, and under favorable circum- stances entirely disappears in a few weeks. Cellulitis un- complicated by peritonitis leaves no unpleasant results, no adhesions nor displacements. Its existence, consequently, is no bar to subsequent pregnancy. If fever continues longer than five or six weeks, suppuration has probably resulted. The duration and progress of the illness will largely depend upon the direction the pus takes. Generally it points above Poupart's ligament, where it can be easily and satisfactorily opened. Such cases invariably do well. In the rare cases when it occurs at the back of the pelvis, pus is longer in reach- ing the surface, and may burrow in dift^erent directions. Such cases often last a long time, and are likely to be complicated by extension to the peritoneum. When resolution and the absorption of the inflammatory processes are slow, the exudate will become organized, and cause cicatricial contraction and resulting displacement of the uterus. Such contractions also lead to atrophy of the uterus and ovaries. The obstruction of the circulation produces localized congestion and even inflammation, and causes disturbances of menstruation, such as menorrhagia, dysmenorrhea, and sterility. It is neces- sary, then, to be guarded in our promises of complete recovery. 468. Treatment. — A description of the disease and of its causes emphasizes the importance of preventive treatment. This consists in careful attention to the principles of asepsis or surgical cleanliness in all midwifery cases and in surgical manipulations. If freedom from infection could be insured, pelvic cellulitis would disappear. When the disease is once developed, medication, either internal or external, has but INFLAMMATIONS. 439 little influence. The most important indication is to avoid doing the patient harm. Particular care should be exercised in the administration of opium and antipyretics. The former agent is generally given as a matter of routine. Opium adds to the disturbance of the already obstructed digestive functions and aggravates one of the difficulties which it is important to obviate — viz., constipation. Opium or morphin should be given only in cases complicated by peritonitis, in which it is absolutely necessary to afford relief. Similarly, antipyretics should be reserved for the rare occasions when the temperature is so high as to constitute in itself a source of danger. A simple saline mixture, potassium citrate, or small, frequently repeated doses of magnesium sulphate should be given until the bowels are freely evacuated. Care should be exercised to avoid fecal accumulation. ■ The question of feeding is of equal impor- tance: farinaceous diet in the acute stages, with meat, eggs, and easily digested food in the later period of the disease. The tendency to emaciation calls for generous feeding. In the early stages of the inflammation an ice-bag over the abdomen will limit the congestion and the amount of inflammatory exudate. When the ice-bag is uncomfortable or causes dis- tress, hot fomentations should be applied. Hot vaginal douches, at a temperature of from iio° F. to 115° F., are advocated by Emmet, although the influence they exert is doubtful. When pus forms, the case should be dealt with according to recog- nized surgical principles. The abscess should be opened as soon as fluctuation is detected or there is the faintest indication of pointing, and drainage should be instituted for a few days. If the abscess points in the vagina, it must be opened there. Most of the fluctuating swellings felt through the vaginal roof are not cellulitic abscesses, but come from an entirely different direction. While it is not generally recognized as the proper plan of treatment, yet, without question, the course of an abscess can be shortened or suppuration prevented by making an incision into the infected cellular tissue through the vagina as soon as the swelling about the uterus can be recognized. The infected area should be broken into with the finger, and a gauze drain inserted which will afford vent for the discharge. The drainage thus se- cured will frequently obviate the occurrence and danger of sup- puration and prevent the extension of inflammation to the pelvic peritoneum. If the patient lies with the thigh flexed on the body, the limb should be exercised by lifting the foot with the hand under the heel two or three times a day sufficiently to straighten the knee. This will prevent permanent contrac- tion and stiffening of the joint. Chronic pelvic cellulitis, as already asserted, does not exist 440 GYNECOLOGY. as an independent affection. It not infrequently follows puru- lent salpingitis or other intrapelvic suppurative inflammation, and involves only the parts immediately contiguous to the in- flamed structures. The induration which it causes, for a time, of course, introduces an element of obscurity into the diagnosis of deep-seated inflammatory lesions of the pelvis. It is rarely attended with cellulitic abscess, and is characterized chiefly by edema and small-cell infiltration of the connective tissue. Its absorption and the mobility of the uterus may be promoted by the practice of pelvic massage. (Section 231.) When cellulitis has existed sufficiently long to result in atrophy of the uterus or ovary, treatment exerts but little effect. 469. Pelvic peritonitis, perimetritis, perisalpingitis, or peri- oophoritis is an inflammation of the peritoneum situated with- in the pelvis. It occurs much more frequently than pelvic cellulitis; indeed, more frequently than any other form of in- flammatory disease within the pelvis. In the great majority of cases it is an infective process, due either to the presence of micro-organisms or to the effect of their chemic products. In the main its action may be regarded as beneficial, it being one of nature's efforts to resist or to do battle with the invad- ing foe by erecting barriers around the diseased area. These barriers serve to narrow or to confine the field of invasion, and shield the neighboring structures from damage. Treves asserts that the purpose of peritonitis is to save and not to destroy life. Unfortunately, the poison may be so virulent, exist in so large a quantity, or the resistive powers of the patient be so en- feebled that we are neither able to limit nor to guide the inflam- matory process to a successful issue. 470. Etiology. — Pelvic peritonitis probably never occurs as a primary disease, but always as a complication of a pre- existing disorder. Occasionally, however, it is the first recog- nized expression of such disease. The symptoms of peritonitis are so severe that attention is at once aroused, while the con- dition from which it originated may have been so insidious as to have been overlooked. From want of knowledge, then, of the previous condition we are often compelled to ignore the exciting condition, and to say that the patient suffers from pelvic peritonitis. Is it surprising that the original condition was formerly unrecognized and the disease denominated idio- pathic peritonitis, the result of a slight injury or of exposure to cold? It is true there are still cases in which we are un- able to discover the preexisting disease, but the number of such cases has become less and less frequent, and failure to determine the cause of pelvic peritonitis is the result of de- fective observation and of want of knowledge. INFLAMMATIONS. 441 The most frequent cause is sepsis ; next, gonorrheal infection. The micro-organisms principally concerned in the develop- ment of infection are the streptococcus, the staphylococcus, the gonococcus, the bacillus coli communis, and the bacillus tuberculosis. The propagation of these infectious micro-organ- isms is favored by parturition, abortion, instrumental ex- amination, and surgical interference. Other causes are in- flammations of the appendix, intestinal perforations, abdominal lesions, rupture of an ectopic gestation, hematocele, ovarian abscess or hematoma, and malignant disease. Infection generally reaches the peritoneum in one of three ways: first, by the continuous mucous membrane through the uterine cavity and tubes; second, by the blood-vessels; third, by the lymphatics. Tubal disease is the most common cause of pelvic peri- tonitis, and should receive first consideration. The mucous membrane of the Fallopian tube is continuous with that of the uterus, and at its abdominal end opens into the peritoneal cavity. The continuity of the tubal mucous membrane with that of the uterus and vagina subjects it to continual danger of in- fection. The tendency of every acute infective endometritis, whether septic, gonorrheal, or tubercular, is to extend to and involve the tube. The relation of the tubal mucous mem- brane to the peritoneum, in infection of the former, favors its extension to the latter. This risk is further aggravated by the anatomic position of the tube in woman. No other mucous membrane is similarly situated. The uterine cavity, when inflamed, naturally drains into the vagina through the external os; but the tube has its most constricted portion toward the uterus, where the lumen of the canal is but large enough to permit the passage of a bristle. A very slight amount of swelling will be sufficient to close the uterine end, when the only outlet of the tube is into the peritoneum. The ab- sence of a suitable outlet for morbid secretions of the tube and the continuity of its mucous membrane with the perito- neum render inflammatory affections of the canal of especial importance and make pelvic peritonitis so frequent a conse- quence of salpingitis. A prompt result of peritonitis from tubal infection is closure of the abdominal ostium of the tube by adhesions or by in- flammatory changes in the fimbriae. The tube then becomes filled with retained secretion, and is the center for an inflamma- tory process which extends through the w^all to the neighboring tissues, especially the peritoneum. If this extension is not an immediate occurrence, the tube is subject to frequently recurring 442 GYNECOLOGY. inflammatory attacks from slight causes. When the retained secretion consists of pus, the liability to recurring attacks of pelvic peritonitis is much greater than when the accumulation is serous or mucopurulent, to which liability is added the danger "of ulceration and thinning of the tube-Avall and the possibility of pus escaping into the peritoneal cavity by perforation or rupture. Frequently the ovary becomes infected from the tube, suppurates, and affords a fresh source of danger. Both inflamed tube and ovary may act as further sources of peritonitis, but sometimes the tube, after infecting the ovary, recovers and is no longer a focus for infection. Infection of the ovary is very prone to occur when the latter has been the site of cystic disease or when a Graafian follicle has recently ruptured. The most frequent mode of in- fection is through a cyst -wall which has become adherent to a diseased tube. Sometimes the infection occurs through an ul- cerative process which permits the tubal contents to enter the cyst suddenly by perforation of the cyst -wall. Tubo-ovarian abscess is thus explained. Such an infection may produce an attack of peritonitis more violent than any preceding. A more alarming attack of peritonitis is engendered by the escape, through ulceration, of the contents of a suppurating tube or ovary into the peritoneal cavity. Fortunately, such an occurrence is rare. The thinned wall of such a collection is a menace which places nature upon her guard and stimulates her to form adhesive barriers which will limit the space into which the rupture occurs and favors the formation of an intra- peritoneal abscess. Such an abscess may rapidly enlarge, and, if the patient survives, may burst into one of the neighbor- ing viscera, into the peritoneal cavity, or externally, accord- ing to its situation. Suppuration of an ovarian cyst may be independent of infection through the tube; occasionally, it more than probably occurs from the proximity of an inflamed growth to the rectum or intestine. The cyst is more vulner- able to such infection when it has been exposed to injury or subjected to bruising, as in labqr. Peritonitis may be favored by twisting of the pedicle of an ovarian cyst. This accident can result in strangulation, intracystic hemorrhage, inflammation, or necrosis of the growth, according to the amount of strangulation. The accident is particularly prone to occur during parturition. The presence of puerperal sepsis should be regarded as de- manding careful investigation. New pelvic growths, by their mere presence, may engender peritonitis. This is common in ovarian tumor. The tumor varies greatly in the prob- ability of its producing peritonitis. Uterine fibromata may attain a large size without adhesions unless degenerative proc- INFLAMMATIONS. 443 esses set in, while a papilloma of the ovary, or tube, dermoids, and malignant diseases are usually associated with extensive peritonitis. Severe septicemia may follow abortion, parturition, or sur- gical manipulations, and, instead of being confined to the uterine mucous membrane, can at once be carried by blood-vessels or lymphatics to the peritoneum, and generate a diffuse septic infection in the pelvis. Such a peritonitis may become localized in the pelvis or may rapidly prove fatal by its extension to the general peritoneum. Clinical experience has demonstrated that injury alone will cause peritonitis only when the hand or instrument in- flicting the injury is surgically unclean. The truth of this assertion is illustrated by the infrequency with which exten- sive operative manipulation within the peritoneal cavity is followed by inflammation, and by the frequent attacks of virulent and fatal peritonitis following slight injuries in efforts to produce abortion. It is, without question, a mere prob- lem of infection. The operator in the latter is usually ignorant or reckless. Complications during parturition may cause peritonitis. The shape and size of the normal pelvis is adapted to the pas- sage of the normally constructed child at full term, and is with- out extra accommodation. Any encroachment upon the pelvis by tumor, growth, or malformation affords an obstacle which renders passage through the canal possible only at the expense of injury or bruising, which may result in loss of vitality of tissue or gro^^^th, and thus render the structures more suscep- tible to the influence of pathogenic micro-organisms. Pelvic cellulitis, it has been said, is generally secondary, but still it may precede the peritonitis. This is particularly true of suppuration. Pelvic hematocele is a source of peritoneal inflammation. The irritation induced by the blood diffused into the perito- neal cavity causes exudation and adhesive peritonitis. The blood-serum may be roofed in beneath adherent omentum and coils of intestine, when the peritonitis limits effusion and promotes its subsequent absorption. Inflammation of the vermiform appendix, or appendicitis, is a not infrequent cause of pelvic peritonitis. Its normal situation is in the right inguinal region, just above the brim of the pelvis, but instances have occurred in which it was found lying within the pelvis. In right-sided inflammation of the pelvic peritoneum an inflamed appendix should always be regarded as a possible source of the infection. An abscess formation may follow, which Avill fill up Douglas' pouch. In 444 GYNECOLOGY. many cases it is difficult to determine whether the appendix or the right tube is the original source of infection. 471. Pathologic Anatomy. — Inflammation of the peritoneum may be serous, adhesive, or suppurative, and acute or chronic. As it most frequently originates from infection through the tubes, the tubes and ovaries are, therefore, implicated. It begins as a congestion or hyperemia of the serous surface, with cloudy swelling of the endothelium. The membrane, instead of being smooth and glistening, becomes dull, dry, clouded, and slightly roughened with plastic lymph, w^hich is poured out between its adjacent surfaces. The adhesions thus produced are its most characteristic feature. In recur- rent attacks we find additional adhesions. Serum exudation becomes encapsulated, is found in the meshes of the connective tissue, may fill the culdesac or pelvis, posterior to the uterus, or it may be encysted to one side. Such collections may simu- late a cyst. When the exudation thrown out is considerable, it may form a distinct coating, which may be peeled from the surface of the peritoneum. These lymph coagula are also found floating in the serum, and, as the fluid becomes absorbed, this coating stiffens the peritoneum, and, with the induration in the subjacent cellular tissue, causes the hardness wdiich is one of the striking characteristics of chronic pelvic peritonitis. These indications of inflammation are usually most strongly marked about the fimbriated ends of the Fallopian tube, and diminish as they pass from it. When the inflammation has originated from some other cause, such as an inflamed appen- dix, the alteration and adhesions are most dense at the seat of origin. Thus, a Fallopian tube, when it becomes inflamed and increases in weight, drops from its original position, so that it is found upon the floor of the lateral fossa of the pelvis, in the pouch of Douglas, or adherent by its flmbriated end to the ovary or to the side of the pelvis. Occasionally the two tubes meet, and the distal ends become adherent to each other behind the uterus. At other points the direction of the tube may differ in two sides of the body. One side is bent like a horseshoe, while the other terminates against the lateral wall of the pelvis, to which it is adherent by its abdominal end. If the uterus is lifted out of the pelvis by pregnancy, the tube may be found situated above the brim, close to the border of the psoas muscle. The ovary is generally found implicated in the mass of inflammation which has extended from the tube. When this inflammation has existed for some time, we generally find the ovary in a cystic state, and con- siderably enlarged. These changes result from the effect of the surrounding peritonitis. INFLAMMATIONS. 445 In chronic cases the peritoneum, in places, is lifted up by circumscribed collections of serous fluid in its meshes. These swellings vary in size from a pea to a large orange. They possess no pathologic importance, but often increase the diffi- culty in arriving at an accurate diagnosis. A mass formed by an inflamed tube, ovary, and broad ligament not infre- quently is found adherent to the posterior pelvic wall and rectum. Sometimes a coil of intestine or a portion of omentum may intervene, when the parts are so entangled in an extensive mass of exudation as to cause great difficulty in outlining and determining their relations. The body of the uterus is envel- oped in a mass of adhesions or is completely free. Whe.n the lesion from which the peritonitis has originated is puru- lent, peritonitis is also apt to be purulent, and, instead of an accumulation of serum, pus or intrapelvic abscesses are found. Occasionally, suppurative peritonitis exists. The latter occurs only in cases of exceptional virulence, or from sudden bursting into the peritoneal cavity of a pus-collection which was situated in an ovary or tube. Intraperitoneal abscesses may be single or multiple. They generally originate by the rupture of a suppurating Fallopian tube or by the discharge through' its abdominal ostium of pus into Douglas' pouch or into a space bounded by adhesions. Both tubes may thus discharge into a common receptacle, which is most generally Douglas' pouch. A tense, fluctuating swelling is formed, easily felt through the depressed vaginal roof, which, by pressure against the intestine, causes more or less obstruction. Purulent inflam- mation of the tube leads early to closure of the abdominal ostium, when the pus is confined within the tube, and forms what is known as a pyosalpinx. An intraperitoneal abscess or general peritoneal infection may then be induced by in- fection through the tubal wall, or by the bursting of the pyo- salpinx from ulceration Avithin, or by the spread of infective processes to the ovary, causing it to suppurate. An intraperitoneal abscess walled in by adherent viscera may run an acute course or may be retained for a long time, causing few, if any, indications of its presence. One of two things is likely to occur, how^ever: either the abscess gradually dries up and disappears, or its walls undergo ulceration and its contents escape into the bowel — usually the rectum, sig- moid flexure, or colon — or into the vagina, the bladder, the general cavity of the peritoneum, or some part of the abdom- inal wall. The most frequent exit is through the intestine. The other routes are exceptional. Such abscesses differ very markedly from cellulitic abscesses, and will quickly disappear when they have once found an outlet. The latter discharge 446 GYNECOLOGY. their contents imperfectly. A troublesome sinus remains for years, producing serious ill health. Among the secondary changes resulting when salpingitis is unilateral is an exten- sion of the peritonitis to the other side of the pelvis, involv- ing the healthy uterine appendages in a mass of adhesions which complicate the function of both tube and ovary. Such a condition may be followed by hydrosalpinx. Hydrosalpinx may result as a sequel of salpingitis, but is less frequent than pyosalpinx. Effusion of blood within the tube (hematosalpinx) often arises as a consequence of tubal gestation, but occasionally may be independent of the latter. 472. Symptoms. — The first characteristic of acute pelvic peritonitis is pain in the lower part of the abdomen, which is sudden in its onset. For a few hours it is extremely severe, associated with fever, with increased rapidity of pulse, and often with vomiting. An early symptom is more or less intes- tinal distention, which may be general or localized. Follow- ing the acute pain, movement is attended with great suffering, because of the tender, inflamed parts, and the patient is gen- erally obliged to remain in bed for a length of time dependent upon the severity of the attack. Rigors are infrequent, unless the condition is part of a diftuse septic inflammation or the re- sult of intraperitoneal rupture of a pyosalpinx or a suppu- rating ovary. Constipation is usual. Pain precedes defecation and micturition, owing to the contiguity of the inflamed part to the rectum or bladder. Not infrequently the pain is greater at the completion of micturition. The patient generally assumes the recumbent posture, with the limbs flexed, and guards the abdomen against the pressure of clothing or contact with the hand. In subacute or chronic cases pain in the back and inability to undergo physical exertion are experienced. Menstruation is more profuse than normal, often painful. Very trifling causes will result in recurrence of the attacks. This is particularly true when the chronic pelvic perito- nitis is maintained by the presence of pelvic suppura- tion. Recurrence of pain and abdominal tenderness are more reliable indications of the presence of pus than is elevation of temperature. Not infrequently a large quantity of pus may be found in the pelvis of the patient who has either a normal or a subnormal temperature. Patients in whom ex- tensive suppuration exists are found emaciated and incapac- itated for work or exercise. In the worst cases the patient will be bedridden. The amount of suffering depends upon the nature and extent of the disease and upon the social posi- tion of the patient; in other words, upon the demands that INFLAMMATIONS. 447 are made upon her activity. In an acute attack the abdominal muscles are kept rigid over the affected parts. This rigidity is due to muscular contraction, and is beyond the control of the patient. Occasionally, by abdominal palpation a definite swelling can be recognized. This is particularly true when the mass is situated above the brim of the pelvis, has attained a large size, or presents an encysted exudation of serum or pus in front of the uterus or against the pelvic wall. Occasion- ally the abdominal enlargement will be due to the presence of serous fluid. When depression of the vaginal roof occurs, it will not be lateral, but central, because the accumulation of effusion, serous or purulent, is in Douglas' pouch. Upon vaginal examination the parts may be very tender, with a sense of resistance, or the uterus is pushed forward. After subsidence of the acute symptoms a careful bimanual examina- tion, for which an anesthetic may be required, Avill often re- veal in the posterior fossa of the pelvis the presence of a fixed, irregular, tender swelling. This begins at the uterine cornu as a cylindric body, equal in thickness to a lead-pencil; it may be rolled between the fingers, but may suddenly become thicker a short distance externally; it curves itself, may completely reverse its direction, and- finally ends behind the cervix uteri in the pouch of Douglas. A Fallopian tube can be adherent to the ovary, which is embraced within the concavity of its curve, and surrounded on all sides by a thickened, adherent peritoneum. The uterus is not always displaced, but is often found retro verted or retrofiexed, and adherent in its abnormal position. Again, it may be pushed forward by a mass of effusion in Douglas' pouch. The shape and consistence of the swelling vary in different cases, as the tube may be soft, sausage-shaped, particularly when its abdominal ostium is occluded, or it may be distended mostly at the outer end, which gives it the shape of a retort. Occasionally it is irregular, distended from sac- culation, thrown into knuckles or prominences, bent upon itself with sausage -like convolutions produced by intervening constrictions. Its consistence depends upon the extent to which the walls of the tubes have become thickened and upon the induration of the surrounding peritoneum. 473. Diagnosis. — Peritonitis may be confounded with hema- tocele and cellulitis. Pelvic hematocele is readily distinguished by its clinical history, slight febrile disturbance, history of a possible tubal gestation, severe pain attending the rupture of the latter, and the subsequent bloody discharge from the uterus. The distinguishing features between peritonitis and cellulitis are as follows: 448 GYNECOLOGY. Peritonitis. 1. Inflammation is chiefly confined to the pelvic peritoneum. 2. Inflammation is bilateral. Cellulitis. 1. Inflammation principally affects the pelvic cellular tissue. 2, Inflammation is unilateral. Differential Diagnosis. — Peritonitis. 1. Its onset is sudden, with severe pain, 2. Both legs are drawn up. 3. A firm, flat effusion surrounds the uterus or a mesial bulging is pro- duced by serous effusion in Douglas' pouch; the vaginal por- tion of the cervix is of normal length. 4. The inflammation does not extend along the round ligament and iliac fossa, but it may affect the entire peritoneum. 5. The uterus is displaced forward or backward. 6. Vomiting is frequent. Cellulitis. 1. Its onset is insidious, pain not marked. 2. One leg is drawn up. 3. A firm effusion bulges usually into the fornix of the one side; the cervix is apparently shortened on the affected side. 4. Exudation, or pus, spreads in definite directions, and is usually localized. 5. The uterus is displaced to one side. 6. Vomiting is infrequent. 474. Prognosis. — The mortality of peritonitis is much higher than that of celluHtis. Even when the patient recovers, the after-effects are more troublesome, and not infrequently the sequels are sufficiently serious to entail a life of chronic in- validism. The disease from which the peritonitis originates remains after the subsidence of the acute attack, and con- stitutes a focus from which subsequent attacks are likely to result, either from changes in the diseased tissues or from ex- ternal agencies. Recurring attacks of peritonitis are much more likely to occur when associated with the presence of pus, either in the form of pyosalpinx, suppurating ovary, or intra- peritoneal abscess. The damage done to the uterus, ovaries, and Fallopian tubes, particularly to the latter, by the obstruc- tion of the abdominal ostium, necessarily causes sterility. If the gradual absorption of the morbid products permits the occurrence of conception, the continuation of pregnancy to full term may be rendered impossible by the inability of the organ, from extensive adhesions, to becom^e enlarged. It is not possible, however, to say that pregnancy can not occur, for experience has demonstrated that even after the most virulent peritonitis the parts may so recover themselves as to permit of a subsequent conception. The discreet prac- titioner will consequently hesitate positively to assert that the patient can not give birth to children. Another effect of pelvic peritonitis is interference with the normal action of the intestinal canal. INFLAMMATIONS. 449 The termination must depend upon the condition of the individual patient. 475. Treatment. — The first and most important aim of treat- ment is prevention. The large majority of nonpuerperal cases of pelvic peritonitis originate from a preexisting gonorrheal salpingitis; consequently the treatment should consist in the arrest of the infection before it has extended beyond the reach of local application. Unfortunately, gonorrhea is very frequently regarded as an unimportant affection, although it probably destroys the health of a larger number of women than does the much more dreaded poison of syphilis. The earlier symptoms of the disease usually pass unregarded. They are attended with but little pain — often none, if the urethra is not in- volved — and the signifi- cance of the purulent discharge is not realized. Medical advice, conse- quently, is unsought until the infection has produced serious results or has inflicted life-long damage. Even when advice is obtained, the disease is seldom re- garded seriously, and vigorous treatment is not employed. A puru- lent vaginal discharge in a recently married woman should always be regarded with grave suspicion, and its treatment should be undertaken with a due sense of responsi- bility. The object of treatment should be to prevent the extension of disease to the tube and the development of septic salpingitis. Its occurrence means a focus for the continuous distribution of infection and a cause for frequently recurring attacks of peri- toneal inflammation. Such invasion, as would naturally be inferred, is a frequent consequence of gonorrhea, but its avoid- ance requires rigid adherence to the rules of aseptic surgery and midwifery in the management of abortion, parturition, and surgical manipulation. Care should be exercised in the 29 Fig. 323. — Induration from Peritonitis. 450 ' ^ GYNECOLOGY. examination of patients, and particularly when such investigation is to be intra-uterine. When the patient has once been the victim of pelvic peri- tonitis, it is extremely important that all causes likely to pro- voke a relapse should be avoided. She should be careful in her dress, should not be exposed to cold or damp, especially during her menstrual period, and exhausting exercise or over- fatigue should be guarded against. Prolonged standing is as disastrous as excessive exercise. She should be advised to secure sufficient rest, and the state of her bowels should be carefully watched. Intestinal adhesions naturally increase the tendency to habitual constipation. The fecal accumulation favors the development and migration through the coats of the intestines of pathogenic micro-organisms, so the tendency to constipation should be overcome by suitable aperients, or by enemas of glycerin or of soap and water. The medical treatment is very similar to that employed in pelvic cellulitis, with the exception that opium and its derivatives may be neces- ^SiSSii*^^ sary in some cases of peritonitis. Their administration, how- ever, should be regarded as an unavoidable evil, and only small doses should be given, and these discontinued as early as pos- sible. Constipation should be prevented by appropriate aperi- ents or enemas, or both. Accumulation of scybala is more harmful than active purgation. During an acute attack the patient should rest in bed, and the diet should be restricted to liquid or easily digested food at regular intervals. The pain should be relieved by the application of the ice-bag, or, if this is uncomfortable, by hot fomentations. Intestinal dis- tention is relieved by the use of enemas. The patient will probably be tormented by thirst and by the desire for ice or to drink effervescent waters. She will find much greater re- lief from frequent sipping of hot water. Ice should be avoided, as, when once employed, it increases the thirst, and the patient will be constantly demanding it, with the result, if granted, that the mouth and tongue will soon suffer from a severe attack of glossitis. If the enemas fail to give relief, an aperient INFLAMMATIONS. 451 should be administered — doses of calomel, castor oil, or, what is more efficient, sulphate of magnesium. The last may be given in one- to two-dram doses, dissolved in syrup of ginger and cinnamon- water, every two or three hours until the bowels are freely evacuated; subsequently three or four times a day, as the condition may demand. The state of the pulse is a more correct guide to the condition of the patient than the temperature, and will indicate the need for stimulants. If the pulse shows signs of flagging, becomes thin, feeble, and intermittent, brandy or whisky should be given in regular doses, diluted with five or six times the quantity of water, its effect being carefully watched, the dose to be increased or diminished according to its influence. Stimulants should not be allow^ed to take the place of food. The indications of collapse — coldness of the extremities, sunken features, flagging pulse, subnormal temperature — should be further combated by the application of external heat and by the hypodermatic inj ection of strychnin and atropin or digit alin. The intensely depressing effect of intestinal distention should be kept in mind, and this condition should be relieved by the use of ene- mas or by the introduction of a soft -rubber rectal tube with the patient turned upon the side. Not infrequently, as suggested by Keith, an injection of quinin, gr. vj, whisky, foss, and water, fSij, repeated every hour until three doses have been given, stimulates the nerve-centers and increases peristalsis. The most effective enema is an ounce of powdered alum dissolved in a quart of hot water. This is best given with the patient lying either upon one side or upon her back, with the hips elevated. This enema promotes peristalsis, and, consequently, is of service in tympanites. Where peritonitis is established and the patient is ejecting a dark- green fluid from the stomach and is unable to re- tain even liquids, the stomach should be irrigated through the stomach-tube with a normal salt solution. This should be re- peated if the vomiting returns. No food, not even water, should be allowed to enter the stomach. Peristalsis should be quieted by injection of gr. J -J morphin hypodermatically, followed by gr. -^Q 1^2 of the same agent every three hours. The nutrition should be maintained by rectal feeding, administering normal salt solu- tion three ounces, bovinine one ounce, every three or four hours, and, where necessary, hypodermoclysis or intravenous injections normal solt solution may be employed. The occurrence of peritonitis should lead to a careful examina- tion of the pelvis, and any indication of tenseness in Douglas' pouch or about the cervix should be considered an indication for immediate vaginal incision to break up the tissue and per- mit the fluid to escape. The opening should be kept patulous by the introduction of a gauze drain. Such a course will not 452 GYNECOLOGY. infrequently arrest or limit the progress of the inflammation. The mere removal of the tension affords great relief. If an intraperitoneal abscess exists, such interference not only affords relief, but may anticipate its bursting into the rectum and establishing a troublesome sinus. Unless such conditions can be determined, however, it is wiser to defer surgical inter- vention until the acute symptoms have subsided. If the attack is the first the patient has had, and the swelling is so slight as to indicate a possibility of a probable nonpurulent inflammation, operative interference should not be advised. If the patient has repeatedly had similar attacks, and swell- ing of such a size is found as to render it probable that in its midst there is an occluded, distended Fallopian tube or an enlarged, cystic ovary, operation should be urged. Such a mass, with the recurring attacks, almost positively indicates the presence of pus; and where pus is present, surgery is ab- solutely indicated. It is impossible, of course, to lay down positive rules: every case must be personally decided. A woman from the laboring-class can not afford to spend as much time in invalidism as a woman in better circumstances. When operation has been decided upon as necessary, the method of procedure still remains undetermined. Abdominal section being the older and more generally adopted procedure, it will be first described. (For the preparation of the patient see Section 187.) The patient is placed upon the operating table, preferably one by which the Trendelenburg posture can be secured, and an incision from 2^ to 3 inches long is made in the median line, beginning an inch above the symphysis pubis. The operator must remember the possibility of adhesions be- tween the intestines, the omentum, and the anterior abdominal parietes, and should proceed carefully as he approaches the peritoneal cavity. Generally the omentum is adherent to the mass in the pelvis, over the surface of the uterus, the tubes, or the ovaries. The first step is to separate these adhesions and to free the omentum and any coil of intestine which may be adherent. The omentum and intestines are drawn upward to expose the matted contents of the pelvis beneath them. When the patient is lying fiat, we have to be guided almost entirely by the sense of touch. In the Trendelenburg posture we are aided in our manipulations by sight. Following the fundus of the uterus as a guide, the operator endeavors, with the tips of the first two fingers, to enucleate the diseased uterine appen- dages from their adherent surroundings. The fundus of the uterus may be free or implicated in the adherent mass. In the latter case its identification may be exceedingly difficult, rendering it necessary for an assistant to pass one or two fingers INFLAMMATIONS. 453 into the vagina to elevate the uterus by pressure against the cervix. The fundus is thus identified. The affected tube, on one side, is traced out from the uterine cornu and made to serve as a guide when searching for planes of cleavage. If it turns backward and becomes lost in the adherent mass, the safest way is to keep the fingers close to the posterior sur- face of the uterus, and to trace the adherent mass downward to Douglas' pouch. In breaking up the adhesions it is neces- sary to separate the mass from the walls of the bowel, includ- ing the anterior wall of the rectum. It is often advisable to have an assistant pass his forefinger into the rectum, partly to facilitate the separation by steadying the bowel, partly to ascertain where the bowel is and whether the manipulation is in dangerous proximity to it. The separation of these adhesions in Douglas' pouch is generally the most difficult part of the operation. Indeed, I know of no operation more difficult than to have to break up adhesions which have existed for a long time between knuckles of intestine and the fundus of the uterus or the ovaries and tubes. The separation is to be continued posteriorly from below upward. When the mass has been cleared from its posterior and inferior attachments to the uterus and to the uterine appendages of the opposite side, there still remain adhesions to the back of the broad ligament, which has become more or less folded over the diseased parts, and forms a deep, concave surface on its posterior aspect. This concave surface has to be unfolded in order to permit the mass to be brought into view and the broad ligament below it to be transfixed. This separation can be accomplished by working from below upward, and should be continued until the ovary and tube remain attached to the uterus and broad ligament by their anatomic connections only. The pedicle is then tied in the same manner as in the removal of the normal ovary and tube for the relief of myoma. The appendages on the opposite side are examined, and are removed or left, according to their condition. If merely adherent, the operator may content himself by simply separating the adhesions. During such manipulation it is not infrequent to find an escape of pus, which may be independent of any fault of the operator. It is often difficult to accomplish without rupture the separation of adhesions around the ostium of a suppurating tube or the enucleation of a suppurating and adherent ovary the wall of which is thinned and nearly ready to burst. For- tunately, unless the pus is unusually virulent, no serious harm results. However, we should always exercise care, in such cases, to wall off the general peritoneum and intestine with several layers of gauze pads, to prevent their being soiled. 454 GYNECOLOGY. (Fig. 325.) Occasionally, in severe cases, when the patient is much depressed, the persistence required for the separation of extensive adhesions would so prolong the operation as to endanger the life of the patient. It may be necessary then to content ourselves with mere emptying and draining of the suppurating cavity. The greater the experience of the operator, however, the less frequent will be the incomplete operation. Separation of adhesions between different parts of the intestinal canal other than the rectum should be made as much as possible under the eye, and any injuries to these structures should be Fig. 325. — Intestines Held Back by Gauze. Patient in Trendelenburg Posture. immediately repaired. The inexperienced operator should be careful not to mistake a thickened and adherent intestine for an inflamed Fallopian tube. This mistake may be avoided by following the tube toward the uterus before an effort is made toward its separation. During the performance of these operations the general peritoneum should be carefully protected by drawing back the intestines and omentum, and retaining them with gauze or gauze sponges, so that they shall not be soiled by rupture of an abscess cavity. When the operator and his assistants have been unable INFLAMMATIONS. ■ 455 to protect the intestines from the contact with the contents of the abscess, I think it better to irrigate the abdomen with hot normal solution, 105° to 112° F., and thus complete the peritoneal toilet rather than to attempt to accomplish it by dry sponging. In such cases the belly cavity may be left filled with the salt solution. Drainage must be decided by the indications of the individual case. The larger the experience of the operator, un- less he is particularly prejudiced, the less frequently will he be likely to use drainage. Even in the most virulent cases, with ex- tensive adhesions, irrigation of the cavity with a large quantity of normal salt solution, repeating it before the cavity is closed and leaving a considerable quantity of fluid within the abdomen, dilutes any poison that may remain and renders it less active and less likely to produce deleterious effects. In this way drainage may be avoided. In suppurative peritonitis McCosh suggests intra -intestinal injections of saline cathartic. He cleanses the peritoneal cavity thoroughly with irrigation instead of sponging. Through a hollow needle between one and two ounces of a saturated solution of magnesium sulphate is introduced into the small intestine at a point as high as possible in the jejunum or ileum. The needle-puncture is closed by a Lembert suture. The action of the saline produces free watery discharges, and thus makes the intestine act as a drainage-tube for the peri- toneal cavity. When drainage is used in suppurative cases, the gauze or wick drain, in which a number of strands are in- troduced into different parts of the abdominal cavity, is the preferable method of drainage. If the ends are carried well around the side of the body and are surrounded by cotton and gauze at a point below the level of the internal ends, we then secure a siphon-like action, which more effectually drains the cavity. Postural drainage was suggested by Clark, who thus utilized the healthy and unirritated portion of the peritoneum for ab- sorption. He recognized that, in the ordinary positions of the body, fluids, serum, and blood were likely to accumulate on those portions of the peritoneum which have been injured and con- sequently was less able to take care of them, and in which there were possibly still remaining tissues impregnated with pathogenic germs and the culture fluid was thus maintained in contact with the germs at a most favorable temperature. Such a misfortune can be avoided by elevating the foot of the bed thirty-six inches. The patient could be occasionally turned from one side to the other, so that no fluid would accumulate in the pelvis, but be thrown upward upon the healthy peritoneum, which was better able to take care of it. Other advantages for this posture were that a decreased amount of blood was sent to the injured part. 456 GYNECOLOGY. lessening the amount of pain from which the patient suffered subsequent to the operation ; that it permitted immediate closure of the wound and greatly decreased the danger of a weak ventrum and a consequent hernia. The procedure suggested by Fowler, to elevate the body of the patient so that the drainage may ac- cumulate in the most dependent portion of the abdomen, whence it can be siphoned by a gauze wick emerging from the lower angle of the wound or into the vagina, has appealed to the profession as the more satisfactory procedure. In closure of the wound we must endeavor to utilize measures that will bring to- gether and hold in apposition the tissues, so that firm union may be secured and the risk of hernia lessened. Various methods of procedure have been employed to accomplish the purpose — ^the in- troduction of a double row of sutures or of a series of sutures, one in the peritoneum, another in the aponeurosis, and another in the skin. The difficulty in the introduction of rows of sutures, how- ever, is that not infrequently there are left dead spaces, in which Fig. 326. — Three-pronged Vulsellum. an accumulation of fluid occurs. This later becomes infected and results in the formation of an abscess, which necessarily weakens the wall. I endeavored to obviate this difficulty by the employment of the figure-of-8 suture. The suture was made to cross just in front of the aponeurosis or that portion of the abdominal wall which it is most important should be main- tained in apposition. The figure-of-8 suture was designed to accomplish the same purpose as a double row of sutures, but affording the advantage that the suture could be removed. It was found to have the disadvantage, however, that in order to secure apposition of the tissues, the suture was likely to be drawn so firmly as to result in a slough, which produced a stitch abscess. I have experienced the greatest satisfaction by a com- bination of continuous chromic catgut suture with interrupted silkworm-gut sutures. Beginning at either angle of the wound, the catgut suture is introduced external to the aponeurosis upon one side of the wound, brought out in the peritoneum and fascia of the opposite side, and then through the edges of the peritoneal wound until the other angle of the wound has been reached, INFLAMMATIONS. 457 when it is brought out above the aponeurosis. The silkworm- gut sutures are now introduced, including all the tissues above the peritoneum, the wound is cleansed, and the catgut suture continued, uniting the edges of the aponeurosis, when the wound is carefully dried before the introduction of the last turn and the tying of the knot. Again drying the wound, the silkworm-gut sutures are tied. This procedure gives secure Fig. 327. — Vaginal Incision for Pus-collection in the Broad Ligament. union of the peritoneum, aponeurosis, and skin with but one buried knot. When twenty-day catgut is used, the wound should be firmly secured against subsequent weakness. The silkworm-gut sutures serve as supports to the wound, and should be tied only closely enough to hold the surfaces in apposition. The after-treatment is similar to that of other abdominal operations. (Section 206.) The combined crescent 458 GYNECOLOGY. and vertical incision (see Fig. 79), where large masses do not have to be removed, has given me great satisfaction and greatly lessens the danger of hernia, while it affords an opportunity to conceal an unsightly scar beneath the pubic hair. Vaginal Section and Uterine Castration. — Many clinical observers have appreciated that the infected uterus, from which the disease had been transmitted to the peritoneum Fig. 328. — Incision through Vagina with Thermocautery in Vaginal Excision of the Uterus. and appendages, has continued to be a cause for discomfort and ill health after the secondary foci of infection — the ap- pendages — have been removed. Pean, in 1886, to insure relief in such cases, advocated the removal of the uterus through the vagina as a routine pro- cedure in all cases in which that organ had been involved in an infectious process. This operation he designated as uterine INFLAMMATIONS. 459 castration. The procedure was subsequently popularized by the advocacy of Segond and Jacobs. The diseased appendages may or may not accompany the uterus in its removal. In preparing for this operation the following instruments should be sterilized: Three double tenacula; four vaginal retractors; a knife; one pair of straight scissors and one pair curved on the fiat; four large and twelve small pressure forceps; an angiotribe; Deschamps ligature-carrier; needle-holder; needles, threaded with silk loops; chromic catgut, sizes o and 2. The Fig. 329.— Clamp Forceps for Securing the Broad Ligament. operator may also have at hand the thermocautery and a large number of sterile gauze sponges. The steps of the operation are similar to those in the performance of the ordinary opera- tion of vaginal hysterectomy. The patient is prepared as directed in Section 182. She is placed in the lithotomy position, and the uterus is exposed by the vaginal retractors, one anterior, a second posterior, and one on each side. These retractors are held by two assistants. The cervix is seized by a vul- Fig. 330. — Deschamps Needle Ligature Carrier. sellum or double tenaculum, dragged down, and a circular incision made through the vaginal walls, which will be nearer the OS externum anteriorly than posteriorly. Behind, the incision extends for half an inch or more above the os, and, if required, additional room can be secured in the vagina by lateral incisions in the vaginal wall which extend for half an inch outward from the circular incision, and parallel with the broad ligament. The incision about the uterus is often made 460 GYNECOLOGY. with the thermocautery, which has the advantage that, in addition to decreased bleeding, the burn prevents the surfaces from immediate union and affords better opportunity for drain- age. After cutting through the vagina the tissues are pushed away from the cervix with the finger, the separation between the bladder and the cervix is accomplished by blunt dissection with the finger or some blunt instrument, or by successive snips of the scissors. The late Joseph Eastman inserted the Fig. 331. — Drawing Down the Fundus. scissors, closed, near to the cervix and then separated the blades, which facilitated the dissection. The dissection can be more rapidly accomplished posteriorly, as there is but little danger of injuring the rectum. The dissection is completed front and back by opening the peritoneal cavity when the uterus is held by the broad ligaments, through which pass the uterine and ovarian arteries. The tissues upon each side are divided with successive snips of the scissors, and the uterine artery is seized with forceps as soon as exposed, or immediately when INFLAMMATIONS. 461 cut. The fundus of the uterus can then be tilted forward through the anterior fornix of the vagina. This permits the cervix to be carried upward. With the fingers passed over the fundus of the uterus the ovary and tube are followed upon the tense surface of the broad ligament and dragged down, when a pair of clamp forceps can be placed upon the broad ligament to secure it. This is usually done first upon the left side, after which the broad ligament is cut between the uterus and the forceps. This permits more ^ ready access to the right tube and ovary , as the fundus of the uter- us is turned out of the way. This tube and ovary are brought down in a similar manner, the broad ligament clamped external to them, and the mass cut away. We have now the bleeding vessels secured by the pressure for- ceps. If the condi- tion of the patient is such as to make an expeditious op- eration desirable, it may be completed by simply packing the vagina with gauze between these forceps, carrying the gauze well over the ends of the forceps in order that the intestine shall not impinge against them and become injured. The forceps and vulva are covered with a sterile dressing and the patient put to bed. The forceps should be allowed to remain for forty-eight hours, the gauze for four or five days. The clamp method, while expeditious, has the disadvantage, however, that the tissue enclosed in the grasp of the forceps undergoes necrosis and Fig. 332. — Application of the Clamp Forceps to the Lower Portion of the Broad Ligament. 462 GYNECOLOGY. causes a disagreeable odor for two or three weeks subsequent to the operation. This condition is a w^orry to the patient, nurse, and physician. There is ahvays a possibihty of the infection of the structures and of the peritoneal cavity, so that the majority of operators prefer to employ the ligature. The upper part of the broad ligament, that in the grasp of the upper clamp, may be crushed with the angiotribe and ligated with chromic catgut in the groove. The angiotribe, however, should not be employed if the tissue has undergone inflammation Fig. 333. — Ligation of the Broad Ligament in Vaginal Hysterectomy. and contains more or less exudate. The angiotribe crushes this tissue, indeed, almost bites it off, and, therefore, does not preclude the possibility of bleeding. Care must be employed in the use of the ligature to make sure that it is firmly' tied and that it does not slip. The uterine arteries, if they are in the grasp of the small forceps, may be ligated with catgut. These, if they have been picked up separately, do not require a large mass within the ligature. In the employment of liga- INFLAMMATIONS. 463 tures in the pelvis, the catgut should be preferred, although it has the disadvantage of being more likely to slip. The liga- ture here is very likely to become infected, consequently, if it is a silk ligature, it leads to a profuse discharge, to the for- mation of extensive granulations, and to a condition which is uncomfortable to the patient and a source of worry to the physician. Therefore, the chromic catgut should be employed in preference to the silk, which is almost certain to become infected. The ideal method of operating is that in which the electrothermic angio- tribe is employed, as devised by Dr. A. J. Downes. This cooks the tissues to such a degree that hem.or- rhage is effectually controlled, and hence no ligature remains to act as a source of irritation. When the inflammatory exu- date in the pelvis has been extensive and has gone on to suppuration, so that we have pus- sacs in the broad ligament or in Douglas' pouch, the preferable plan of procedure is that the incision should be made through the poste- rior culdesac, the pus sacs opened, evacu- Fig. 334. ated, and irrigated before the general peritoneal cavity has been opened and disturbed. Gauze may be packed into the pelvis temporarily during the remaining steps of the operation. In some cases the uterus is so bound dowm by inflammatory exudate that the dissection through the ante- rior fornix of the vagina is somewhat difficult. In these cases the operation may be expedited by splitting through the an- terior lip of the uterus, holding each side of the organ with -Upper Portion of the Broad Ligament Secured by Clamp Forceps. 464 GYNECOLOGY. the double tenaculum, and drawing it down while the cervix is being split. This affords a better opportunity to observe the relation of the bladder and the uterus, and to keep within the layer of connective tissue in the septum. Splitting the cervix and making traction upon its sides enable us to see the relation of the bladder and, consequently, to avoid injuring it. Another modification is the amputation of the cervix after the lower part of the broad ligament has been cut through. This permits the more ready rotation dowmvard of the fundus through the anterior fornix, as it has a shorter arc through which to rotate. The fundus of the uterus may be rotated through the posterior fornix, but the anterior is preferable, Fig. 335.— The Introduction of Gauze after Removal of the Uterus. for the reason that it puts the broad ligament more readily upon the stretch and enables us the better to find the lines^'of cleavage between the tube and ovary and the other adherent viscera. If the ovary and tube are not readily brought down, or if the patient is suffering from chronic hyperplasia of the tubal and ovarian structures, by which these organs are often largely obliterated, we may apply the clamp on either side of the uterus prior to its removal. After the removal of the uterus we can then proceed in our effort to remove the ap- pendages upon each side; but should we fail in this or if the adhesions are very firm, these structures may be permitted to remain, taking care, of course, that all pus-pockets have INFLAMMATIONS. 465 been thoroughly broken up and packed with iodoform gauze. The great majority of these cases have been infected. It is certainly preferable to keep the wound open by packing it with iodoform gauze rather than to close the vagina and peri- toneal surfaces. Landau advocates and practises the bifur- cation of the uterus through the anteroposterior line as a pre- liminary. One half of the organ is pushed upward, the other is drawn down. This procedure affords much more room for Fig. 336. — Closure of the Vaginal Wound by Sutures. the manipulation necessary in the application of forceps, the use of the ligature, or in crushing with the angiotribe. It affords better opportunity, also, for dealing with the infected tube and ovary. As a preliminary, the peritoneum can be protected by packing with sterile gauze before we proceed to enucleate or separate the ovary and tube. In the employment of pieces of gauze it is very important, however, that the end 30 466 GYNECOLOGY. of the gauze should be fixed with a pair of hemostatic forceps, as the gauze is very readily worked upward into the peritoneal cavity by intestinal peristalsis, and may readily get beyond the reach of the surgeon. Nothing is more annoying than to ex- peditiously perform an operation and subsequently have to Fig. 337. — Landau's Method of Delivering the Uterus after Its Complete Median Section. lose valuable time in hunting sponges. The nurse who dis- penses the sponges should do nothing else, and should keep an accurate account of the number of sponges she has given out. These should be accounted for before the operation is considered completed. DISPLACEMENTS OF THE PELVIC ORGANS. 476. Changed Relations of Structures of Vulva. — The re- lations of the structures of the vulva are modified and dis- torted by hypertrophy, by varicose veins, by inflammatory exudates and deposits, by edema, and by hernia and tumors, but they are, however, so intimately connected with the deeper DISPLACEMENTS OF THE PELVIC ORGANS. 467 structures that they are not subject to anything like displace- ment. All the other pelvic structures ^ are capable of more or less marked displacement; still all are so closely relg^ted to and dependent upon uterine deviations that we will proceed to the consideration of the uterus and its displacement as a primary subject. 477. Physiologic ^Movements of the Uterus and the Forces by Which It Is Sustained. — The uterus is a freely movable organ. It is suspended in the pelvis, with its fundus at or a little above the level of the brim of the pelvis, by the action Fig. 338. — Uterus Displaced by Distended Bladder. of the uterosacral, the uterovesical, and the inferior portion of the broad ligaments, and occupies the axis of the pelvis, with its cervix directed toward the last sacral vertebra. The supports of the uterus are not ligaments in the ordinary sense, but consist of connective tissue, into and through which run prolongations from the uterine muscular structure, so that the organ is virtually sustained by muscular action. That the uterus is supported by muscular action is evident from the fact that the organ moves upward and downward with every respiratory excursion, changes its position with that of the body, and is influenced by the distention and condition 468 GYNECOLOGY. of the surrounding viscera. In the normal position the uterus rests forward upon t^e bladder, in a position of slight ante- flexion, while the cervix is directed almost at a right angle to the axis of the vagina. Such a position is markedly changed by the distention of the bladder, which raises the fundus and decreases the angle between the uterus and the vagina until it becomes exceedingly obtuse (Fig. 338),, and in marked dis- tention, indeed, the uterine axis becomes nearly parallel with that of the vagina. The cervix is pushed forward by disten- tion of the rectum. (Fig. 339.) When the rectum and the bladder are both distended, the organ is elevated, and no longer Fig. 339. — Uterus Displaced by Impacted Rectum. finds room between these two viscera. It will be seen that the muscles, arranged as just mentioned, support the cervix. The movements of the body of the organ are influenced by the broad ligaments on each side, which prevent it from un- dergoing lateral change of position, and by the round ligaments, which act as stays to prevent it from falling backward, or to draw it forward, when the bladder is emptied. The round hgaments are, of course, an insignificant force, but it must be remem- bered that the uterus weighs less than an ounce, and we can understand, therefore, how they serve to maintain the uterus far enough forward to permit the intra-abdominal pressure DISPLACEMENTS OF THE PELVIC ORGANS. 469 to be directed against its posterior surface. So long as the intra-abdominal pressure continues upon the posterior surface of the uterus, it is held forward against the bladder. It is also important for the maintenance of the uterus in its normal place that the muscular structure of the pelvic floor shall re- main in normal condition. Relaxation of the vaginal walls and of the muscular structure, occasioned by injury to the pelvic floor in which the perineal muscles are torn through, — and, particularly, the levator ani, — withdraws a support, which sooner or later favors displacement. The normal condition of the peritoneum is a factor. This structure is certain to be Fig. 340. — Scheme of Dislocated Uteri. — (Dudley.) affected by loss of muscular tone and of muscular support. It is not one factor, then, but several, which combine to maintain the uterus in its normal relations. 478. Pathologic Changes and What Constitute Them. — From what has been said of the physiologic changes of position in the situation of the uterus it can readily be perceived how difficult it is to draw the line of demarcation between physi- ologic and pathologic changes. It may be said that when the uterus undergoes such changes in its structure or in its envelopes that it becomes stable in a position which is at times regarded 470 GYNECOLOGY. as physiologic, it becomes pathologic and is known as displace- ment. Thus, the uterus may be pushed forward by a distended bladder, which will increase the angle between its axis and that of the latter ; but if it does not follow the bladder forward when that organ is emptied, the position becomes abnormal. These changes may result from : I. Neglect of hygiene on the part of an individual, either in permitting the bladder to become habitually overdistended or the rectum to be loaded with fecal matter until the uterus is so driven back that the intra-abdominal pressure is no longer directed upon its posterior, but falls upon its fundus or an- Fig. 341. — Uterus Pushed up by Tumor in Douglas' Pouch. terior surface, which will lead to changes productive of an abnormal fixation. 2. Inflammatory changes in the uterus, leading to increased weight of the organ, straightening of the body, loss of its normal curvature, and, by the w^eight, displacement of the organ for- ward, by which pressure is exerted against the fundus of the bladder; or, again, the increased weight produced by inflam- matory conditions causes relaxation of the pelvic ligaments and consequent displacement of the uterus downward and backward, while the body is bent upon the cervix. This bend- ing may take place forward, backward, or laterally. 3. The presence of inflammatory material in the cellular tissue and in the structures surrounding the uterus causes DISPLACEMENTS OF THE PELVIC ORGANS, 471 its displacement by the volume of exudation, and subsequent displacement in the opposite direction takes place by the re- sulting inflammatory contraction. The uterus may be dis- placed as a whole, while its axis still remains parallel to what it was before, causing a change of location; or, again, it may be turned upon its axis forward, backward, or laterally; may be bent upon its own axis; may be depressed downward; and may undergo torsion. 4. The presence of growths, either of uterine or external origin. 479. Classification of Displacements. — As may readily be in- Fig. 342. — Uterovaginal Prolapse. ferred from what has been stated in the previous section, the uterus is capable of displacement upward, downward, back- ward, forward, and laterally, and of being twisted upon its axis. Upward displacement is known as ascent; downward, as descensus or prolapsus uteri. (Fig. 340.) The location of the uterus is subject to change: thus, when it is situated toward the back part of the pelvis, hugging closely the hollow of the sacrum, it is known as a retrolocation ; close to the sym- physis pubis, as an antelocation ; and toward one or the other side of the pelvis, as a dextro- or sinistro -location, according to the side on which it is situated. When the direction of the axis 472. GYNECOLOGY. of the organ is changed, it is known as a version ; with the fundus well forward, it is an anteversion; the fundus turned back- ward, a retroversion; and toward either one or the other side, a dextro- or sinistro-version. The organ may be bent upon its axis, in which event the cervix and fundus approach each other. This bending may take place forward, backward, or laterally, giving rise to the terms anteflexion, retroflexion, and dextro- and sinistro-flexion. Finally, it may be twisted upon itself, producing a torsion. 480. Ascent is the least frequent form of displacement. Those conditions which increase the weight of the organ, natu- Fig. 343- — Vagino-uterine Prolapsus. rally, by force of gravity, depress it. It is only when the organ has attained a size so great that it is no longer accommodated within the pelvis that ascent occurs. This is recognized as a physiologic ascent in pregnancy, and occurs after the fourth month, when the uterus becomes so large that it can no longer be retained within the pelvis, and rests upon the brim. A similar state develops when fibroid growths are situated in the organ and become large. (Fig. 341.) The uterus is drawn or pushed up by growths which may have developed in the DISPLACEMENTS OF THE PELVIC ORGANS. 473 pelvis and become adherent to it. As they increase in size and rise out of the pelvis, they drag or push the uterus up with them. Ovarian tumors, extra-uterine pregnancy, extensive pel- vic exudation, hematocele, and retro-uterine gro\-\i:hs may bring about an elevation of the uterus. 481. Diagnosis. — The elevation of the uterus is readily de- termined by digital examination. The cervix is absent from its usual position in the vagina; frequently so elevated as to be with difficulty reached behind or even above the symphy- sis; often a growth or mass fills the pelvis, over which the Fig. 344. — Vagino-uterine Prolapsus with Hypertrophic Elongation of the Cervix. cervix can not be reached. Greater difficulty is sometimes experienced in determining the condition which has caused the displacement, and this is more important than the treat- ment, for the latter is entirely dependent upon the cause pro- ducing the displacement. 482. Descent, or Prolapsus.^Descent or prolapsus of the uterus varies in degree. By this term is understood a down- ward displacement of the organ, which is generally associated with retroversion, so that retroversion is often considered as the first degree of prolapsus. The uterus is situated at a 474 GYNECOLOGY. lower level, with the os directed in the axis of the vagina. The second degree of prolapsus is w^hen a portion of the organ pro- trudes through the vulvar orifice, and the third degree when the entire uterus is outside of the vulva. This term includes a partial or complete prolapsus or inversion of the vagina. Pro- lapsus is also divided into complete and incomplete, according to the situation of the uterus. When the organ is .still situated within the vagina or only a portion protrudes from the vulva, it is known as incomplete prolapsus, but when the entire uterus is external to the vulva, it is called a complete prolapsus. The term procidentia is also applied to prolapsus, but only when the entire uterus is external. Prolapsus is further divided into three Fig- 345- — Uterus Detached, Showing Hypertrophic Elongation of the Cervix. varieties, according to the relation of the uterus to the vagina. Thus, it is called uterovaginal prolapsus (Fig. 342), when the prolapsus begins in the uterus, which is extruded through the vagina with only partial inversion of the latter; (2) vagino- uterine prolapsus, when the prolapsus begins in the vaginal walls and more or less extensive protrusion of the vagina precedes the prolapse of the uterus (Figs. 343 and 346). In such cases the prolapsus of the uterus may be incomplete, while the vagina is inverted, and a hypertrophic elongation of the cervix exists (Figs. 344 and 345). The third variety is pseudo-prolapsus. DISPLACEMENTS OF THE PELVIC ORGANS. 475 In this condition a large portion of the cervix projects into or through the vulva, while the fundus retains its normal position and the vaginal walls are unaffected (Figs. 347 and 348). In the latter case the hypertrophic elongation takes place in the vaginal portion of the cervix. 483. Etiology. — The causes of prolapsus may be classified under three heads: first, decreased support; second, increased weight; third, increased intra-abdominal pressure. These con- ditions can exert their influence separately, but they usually act in conjunction. Decreased support is characteristic of individ- uals who have given birth to one or more children, and in whom the pelvic structures have been in- jured during the process of parturition. Lacera- tion of the perineum or removal of the support of the posterior segment of the pelvic floor per- mits a protrusion of the anterior wall of the vagina and the bladder during the distention of the latter organ. This protrusion of the ante- rior segment of the pelvic floor, because of the close attachment of the blad- der to the cervix, drags upon the latter, and, unless the uterus is fixed by firm ligaments or inflammatory adhesions, the entire organ is gradu- ally brought into the axis of the vagina, with its fundus thrown backward, and the intra-abdominal pres- sure will subsequently be directed upon it or its anterior surface. The decreased support to the posterior wall of the vagina permits protrusion of this segment with the recttun, and the cervix is drawn upon by both the anterior and posterior vaginal walls. Decreased support may exist in women who have not given birth to children, where, owing to want of normal muscular development, to ill health, or to too straight a sacrum, the support is lessened and the muscles of the pelvic floor are Fig. 346. -Vulvar Appearance uterine Prolapsus. of Vagino- 476 GYNECOLOGY. greatly relaxed. If, in such cases, intra-abdominal pressure is increased, extensive displacement results. Prolapsus may thus be produced in the unmarried. In marked relaxation and want of pelvic support, which have resulted from lesions of parturition, the tendenc}^ to prolapse is increased b}^ enlargement of the uterus or by failure to complete the process of involution. The uterus remains heavy, so that these two forces, decreased support and increased weight, acting in conjunction, lead to descent. It is true, we may have prolapsus when the uterus is small; thus, in cases in which, subsequent to the climacteric, the patient loses Fig. 347. — Pseudoprolapsus. Cervix Within the Vagina. flesh, the absorption of the fatty cushion decreases the amount of support, and, with enfeebled muscular action, permits a small uterus to be driven through the pelvis. This is a cause of pro- lapsus in the aged. Increased intra-abdominal pressure may arise from want of hygiene in clothing, where tight corsets and heavy skirts fastened about the waist afford insufhcient room in the abdomen for the viscera, which are driven downward into the pelvis. Neglect of the evacuation of the bowels and of the bladder increases the tendency to displacements. Prolapsus is DISPLACEMENTS OF THE PELVIC ORGANS. 477 favored by straining at stool, by lifting and carrying heavy weights. Not infrequently a patient will give a history of having lifted a weight or of violent straining, after which a protrusion was noticed at the vulvar orifice. In such cases the condition has existed for some time, and in the majority has been aggravated only at the time of the extra effort. The presence of growths within the abdominal cavity — fibroid tumors, ovarian cysts — which press upon the uterus may force it down. In relaxation of the pelvic floor it is not unusual to observe a prolapsus of the uterus, which has been produced by the increased intra-abdominal pressure incident to the presence of a new-growth. Fig. 348. — Pseudoprolapsus. Cervix Protruding from Vulva. 484. Symptoms. — In the early stages of prolapsus of the uterus there are no symptoms characteristic of the condition. The patient complains of a sensation of weight, pressure, dis- comfort in the bladder, a feeling of burning in the rectum, and dragging sensation while walking or standing — all of which may be associated with other conditions. As the prolapsus pro- gresses, the patient will notice a protrusion from the vulvar orifice, which is increased by straining and lifting. As this pro- trusion increases, the close association of the bladder with the cervical wall causes the uterus to be dragged down. The bladder, 478 GYNECOLOGY. with exceedingly rare exceptions, accompanies the displacement. Occasionally, however, the peritoneal fold may be driven down between the bladder and the uterus, and a prolapsus thus occur without the bladder being associated with it. With the continu- ation of the prolapse the anterior wall becomes more and more everted, and, not infrequently, forms a considerable-sized tumor, which projects anteriorly, is increased by straining, and forms a tumor with a smooth, globular surface. This protrusion of the anterior wall of the vagina and bladder is known as a cystocele. (Fig. 349.) The posterior wall of the vagina may be likewise protruded, though less frequently than the anterior. In cases of inversion of the vagina the posterior wall is generally associated, although even then not to the same degree as the anterior. (Fig. 349.) The posterior protrusion is known as a rectocele. The uterus is separated from the rectum by a prolon- gation of the peritoneum which extends below the rectum on the posterior wall of the vagina. In the inversion of the posterior wall of the vagina to form a rectocele, the intestine may or may not be associ- ated with it. Occasionally, the want of support of the anterior rectal wall permits it to be pushed downward, and form a diverticulum considerably below the anus, which renders the evacuation of the bowel difficult, and at times impossible, unless it is pushed up with the hand, when the scybalous masses situated in the pouch can be extruded. In complete prolapsus of the vagina with the formation of an extensive cystocele a portion of the bladder is situated below the level of the internal orifice of the urethra, and as this protrusion extends, the bladder is incompletely evacuated, the retained urine with mucus in this reservoir undergoes Fig. 349. — Anterior and Posterior Colpocele. DISPLACEMENTS OF THE PELVIC ORGANS. 479 decomposition, forming an ammoniacal urine, which irritates the mucous membrane of the bladder and produces a cystitis. In this diverticulum, with a plug of mucus as a nucleus, a calculus of considerable size can form; indeed, one weighing an ounce has been found in such a sulcus. With the protru- sion the distress of the patient is greatly increased, because of Fig. 350. — Cystocele. the bladder irritation and the friction of the protruding tumor against the clothing and limbs of the patient. The urethra, instead of passing upward and backward as in the normal situation, passes backward and even downward. The pro- truded vagina in a complete prolapsus may form a large tumor extending half-way to the knees, in which tumor is situated a 480 GYNECOLOGY. portion of the bladder, the uterus, ovaries, tubes, and prolapsed intestines — an extensive hernia (Fig. 352). The mucous mem- brane of the vagina loses its moistened, reddish appearance, and instead becomes pale, thickened, and covered with flakes of epithelium, and resembles the appearance of the skin. Bathed with urine and fecal matter, irritated by the clothing and by friction against the limbs, and congested from the decubitus, ulceration is produced upon the external os and upon the sides Fig. 351. — Prolapsus with both Rectocele and Cystocele. of the tumor, which, at times, causes extensive loss of structure and adds greatly to the discomfort of the patient. In the early stage of the displacement the menses are increased, possibly irregular, and occur at shorter intervals. Leukorrheal discharge is present, often profuse, as a result of the congestion of the organ. As the prolapsus becomes still more extensive and approaches nearer to complete prolapsus, menstruation is likely to be decreased and the leukorrheal discharge disappears. The displacement does DISPLACEMENTS OF THE PELVIC ORGANS. 481 not necessarily interfere with conception, as pregnancy has often occurred with complete prolapsus; but in the later stages the patient is more likely to be sterile. 485. Diagnosis. — The patient considers every protrusion from the vulva to be a prolapsus or falling of the womb. The diagnosis would seem self-evident, but it must be conceded that not every such protrusion is necessarily a prolapse of the uterus, and it is important to determine the degree, the form of prolapsus, and the structures involved. This knowl- edge is obtained by inspection, while the patient is directed to increase the displacement by straining and bearing down, and is further confirmed by touch. A protrusion from the Fig. 352. — Irreducible Prolapsus. The Tumor Contained Uterus and a Large Pyosalpinx. Ulceration of Cervix. « anterior part of the vulva, which, on separating the labia, is found to be continuous with the urethra and anterior wall, is a cystocele. It is the most frequent protrusion from the vulva, and may be accompanied in part or wholly by the uterus. Cystocele is recognized by the finger entering the vagina be- hind the protruding mass, which can generally be replaced with ease. The cervix, when accompanying it, will be situated at its posterior surface. A protrusion of the posterior wall of the vagina is recognized by its continuity with the peri- neum, and the finger enters the vagina in front of it. Con- siderable protrusion of the vaginal walls may occur without much, if any, displacement of the uterus. The degree of displace- 31 482 GYNECOLOGY. ment of the anterior and posterior walls of the vagina is recog- nized by the introduction of the finger around the uterus. Thus, the cervix may protrude from the vulva without there being any shortening of the posterior, and but slight shortening of the anterior, wall of the vagina. With inversion, or com- plete prolapse of the vagina (Fig. 351), the summit of the pro- trusion is occupied by the cervix, which may appear as the normal-sized opening, or external os; or, when laceration of the cervix has occurred, the lips may be widely everted, and show an irritated cervical mucous mem- brane. When prolapsus is complete, the uterus is situated in the tumor, external to the vulva, generally in the position of retroversion or retro- flexion ; rarely it is ante- flexed. The uterovaginal form of prolapsus is de- termined from the vagino- uterine variety by the lessened involvement or association of the vagina with the protrusion. In the uterovaginal form (Fig. 353) the uterus is driven through the vagina, drags with it the upper part, and finally results in partial inversion of the canal. A¥hen the prolapsus is complete, the uterus is likely to be small and its cavity short. In the vagino-uterine variety the prolapse begins at the lower segment of the vagina by a rolling outward of the anterior and posterior walls. The thickened and everted vaginal walls drag upon the cervix, and lead to displacement of the uterus; or, where the fundus is fixed by the condition of its ligaments or by inflammatory disorders, the cervix is drawn out, and causes a very marked elongation of the uterus. This condition is determined by placing the fingers of one hand Fig. 353- -Prolapsus without Protrusion of Vaginal Walls. 1 DISPLACEMENTS OF THE PELVIC ORGANS. 483 in front of, and those of the other hand behind, the protruding mass, when we determine the situation of the fundus of the uterus. (Fig. 354.) The protruding tumor can be grasped between the thumb and fingers of one hand, when the fingers will distinguish the uterus outside the vulva, or the cord-like cervix protruding into the vagina, when hypertrophic elon- gation of the cervix exists (Fig. 355). The situation of the fundus can still further be recognized by the introduction of the finger into the rectum. By dragging upon the cervix with a tenaculum while passing the finger into the rectum the at- y / f/. K Fi&- 354- — Determination of the Position of the Uterus by Bimanual Palpation. tenuation of the neck is determined, and the situation of the fundus is recognized (Fig. 356). In pseudoprolapsus the fundus is but little displaced from its normal situation. There is a protruding mass from the vulvar orifice, and the introduction of the finger into the vagina shows that the vaginal walls are not displaced; this elongation has taken place in that portion of the cervix which is situated below the vaginal attachments. It generally results from enlargement and increased weight of the cervix. The anterior segment of the vagina is attached to the cervix at a lower level than the posterior. Occasionally, 484r GYNECOLOGY. we find a protrusion of the anterior wall of the vagina, and at its posterior surface the cervix, while the introduction of the finger into the vagina shows that the posterior vaginal wall is not displaced. (Fig. 357.) In other words, the elonga- tion has occurred in that portion of the cervix situated be- tween the attachment of the anterior and the posterior vaginal walls. In considering the differential diagnosis we must concede the possibility of the protrusion having arisen from a cyst in the anterior wall of the vagina, a hernial protrusion through the posterior fornix, a fibroid polypus, and an inversion of the uterus, associated w4th inversion of the vagina. Cyst of the Fig. 355. — Recognition of Uterus with Thumb and Fingers of One Hand. vagina is recognized by bimanual palpation. A catheter or sound introduced into the bladder, and a finger into the vagina, will reveal an abnormal thickness of the anterior wall, and the character of the condition will be readily disclosed. The bi- manual examination can reveal a fibroid polypus protruding from the orifice of the cer\^ix by a more or less distinct pedicle. Traction upon the timior and the introduction of a finger into the rectum will disclose the position of the uterus. Displacement of the rectum is not generally associated with prolapsus of the vaginal walls, and, when so, is less intimately connected. DISPLACEMENTS OF THE PELVIC ORGANS. 485 Inversion of the uterus is recognized by a protruding tumor, which does not present an external os, is more sensitive, under careful examination shows the orifices of the Fallopian tubes, and is a globular, well-shaped tumor, which can, still further, lead to an inversion of the vagina in which the relation of the cervix to the tumor and the vagina is readily determined. Enterocele, or hernia through the posterior fornix of the vagina, is a rare condition, although I have seen two such cases in which the hernia extended to the vulva. (Fig. 358.) The Fig. 356. — Diagnosis of Position of the Uterine Body by Rectal Touch. tumor is generally more elastic and is greatly distended. The absence of the uterus, in association with it, is 'recognized. On reduction of the hernia the opening into the posterior fornix, through which it had passed, is readily recognized. 486. Prognosis. — The results of treatment must generally depend upon the stage of development, the existing compli- cations, and the manner of life the patient is required to live. The earlier the displacement comes under observation, the less radical will be the means required to maintain the organ in its replaced position. When both uterus and vagina are 486 GYNECOLOGY. prolapsed, changes have taken place which are beyond our skill to restore to the previous condition. While much can be done for the comfort of the patient in all cases, still in some, however, it may be necessary to sacrifice the uterus and part of the vagina. The irritation to which the vagina is subjected will sometimes lead to the development of an epithelioma. (Fig. 359.) Not infrequently we will find gravity sores and extensive ulcerations as a result of friction and the interference with the circulation. The restoration and maintenance of the pelvic organs in their proper place will depend upon the Fig. 357- — Hypertrophic Elongation of the Cervix. Anterior Vagina Everted, while Posterior Retains Its Normal Position. complications which may be associated with the displacements. The most frequent complication is the sequel of inflammatory changes, in which the displaced organs are more or less fixed by extensive exudation and adhesions. In procidentia the protruding sac or hernia, in addition to the uterus and part of the bladder, is likely to contain the ovaries and tubes, and even a large portion of the large and small intestines. In- flammatory changes in such a condition may lead to an ir- reducible hernia, which must necessarily add very much to the distress and discomfort of the patient. Such a patient can neither sit nor stand with comfort. In one patient (see DISPLACEMENTS OF THE PELVIC ORGANS. 487 Fig. 352) a large protruding sac contained the uterus, ovaries, and tubes, the latter having become infected, and resulted in the formation of a quite considerable-sized abscess. For- tunately, the condition was irreducible, for otherwise the re- duction of such a mass into the abdominal cavity might readily have resulted in rupture of the tube and general infection of the peritoneum. In one instance I was obliged to remove the uterus because of a partial necrosis of its structure. Or- dinarily, hysterectomy would not be the operation of election, as the removal of the uterus leaves an open space, which it is difficult thoroughly to close, and favors the subsequent develop- ment of a vaginal hernia, which is difficult to remedy. With Fig. 358. — Enterocele through the Posterior Vaginal Fornix. the retention of the uterus and its proper anchorage in the pelvis it serves as a plug and obstruction to the redevelopment of a hernia. It is self-evident that the patient who is enabled to live a luxurious life need not be subjected to the same treat- ment as the woman who must maintain herself, and, possibly, the members of her family, by laborious industry. The former, by rest and proper hygiene, may be able to prevent the develop- ment of the prolapsus, consequently an operative procedure may be delayed or mechanical means employed to overcome the condition, while the woman who must earn her living at the washtub or by continuous maintenance of the upright position will be required to subject herself to operative interference in order to prevent a more extensive displacement. 488 GYNECOLOGY. 487. Treatment. — The treatment of prolapsus uteri must necessarily depend upon the extent of the displacement, the involvement of the vagina, the distention of the vaginal orifice, and the age and physical condition of the patient. The most important treatment is prophylaxis. This consists in the care- ful management of the woman during labor and the puerperium ; the early repair of lacerations of the cervix and perineum; the examination of the patient subsequent to her delivery to determine the condition and situation of the uterus. The advent of inflammatory conditions should be followed by judicious treatment, such as the employment of hot vaginal douches; cold applications over the abdomen; rest in bed; depletion of the uterus ; and, where endometritis exists, the use of the curet. A heavy uterus should be sustained by tampons Fig. 359. — Vagino-uterine Prolapse Complicated by Proliferating Epithelioma. or a pessary, until the process of involution has been com- pleted. The treatment of prolapsus may be divided into hy- gienic, mechanical, and operative. Hygienic treatment com- prises the wearing of proper clothing. A woman with a ten- dency to prolapsus of the uterus should not wear tight clothing. The increase of the intra-abdominal pressure necessarily ag- gravates the displacement; consequently, the clothing should be loose. Skirts should be suspended from the shoulders rather than from the waist; the bowels should be kept regular and all straining at stool avoided ; lifting and carrying heavy weights should not be undertaken ; the patient should frequently assume the knee-chest position, and, while in this attitude, separate the vulva in order that the air may enter and magnify the in- fluence of gravity in restoring the displaced organs. This position should be particularly assumed for several minutes DISPLACEMENTS OF THE PELVIC ORGANS. 489 as a last act before retiring, and patients should assume the lateral or prone position rather than the recumbent. Mechanical treatment of prolapsus consists : (i) in the reduc- tion of the displaced uterus or its return to a normal position ; (2) in the employment of means to insure that this position will be maintained. The first step, then, in treatment is to replace the displaced organs. Ordinarily this is not difficult, as the increased size of the vaginal canal readily permits the organ to be carried upward to its proper place. AVhere the displacement, however, is complicated by inflammation with extensive exudation into the pelvis, it may result in matting together the uterus, ovaries, and tubes with knuckles of intestine and portions of omentum. Such a condition will render the restoration of the organs ex- ceedingly difficult, if not impossible, without resort to operative interference. Sometimes the displaced uterus, from passive congestion or edema, will become so large and engorged that it can not be replaced through the pelvic canal. This is par- ticularly prone to occur in those cases in which the prolapse is complete and the uterus and vagina have been subjected to friction against the clothing, causing the formation of gravity sores, and swelling to such an extent that the mass is rendered too large to be returned through the pelvis. Such a tumor may sometimes be reduced in size by the application of an elastic bandage, or by keeping the patient perfectly quiet in bed, with the pelvis somewhat elevated, and cold applications applied to the swollen structures. Cloths wet with lead-water and laudanum and covered with oiled silk, over which an ice- bag is applied, will frequently be effective in relieving the en- gorgement, and after a few days' treatment will result in such a decrease in size as to permit the parts to be reduced. The organ can be replaced with much greater ease by placing the patient in the genupectoral position. While the patient is in this position the tumor can be drawn down, compressed with the fingers, and gradually pushed up to its normal site within the pelvis. A mass too large to permit of its replace- ment with the patient in the dorsal position can generally be returned while in the knee-chest posture. When the uterus is fixed by inflammatory exudate, the patient should be put to bed, the parts subjected to pelvic massage, and in the in- tervals the uterus supported as high as possible by tampons of cotton and gauze, or, probably still better, lamb's wool saturated with medicinal agents, in which glycerin shall form an essential part. This treatment should be alternated with hot vaginal douches. Inflammatory adhesions may also be overcome by the employment of continuous weight or pressure. This is rather difficult to apply within the pelvis, because of 490 GYNECOLOGY. its being the most dependent portion of the trunk. The patient can be placed upon her side, with the pelvis somewhat elevated. Pressure is then obtained by introducing a small rubber bag, containing mercury, into the vagina. The continued pres- sure thus directed upon the surface will promote the absorp- tion of the exudation, and, by change of position, the uterus can be gradually worked free from the exudate. Thus, tampons, Fig. 360. — Ring Pessary. Fig. 361. — Disc Pessary. douches, massage, and pressure should be employed until the uterus becomes freely movable and its reposition is accom- plished. This, of course, is desirable as a preliminary to the employment of such a mechanical stipport as the pessary. In cases of prolapsus the pessary acts by so distending the upper part of the vagina that the levator ani and the muscles of the pelvic floor form a support for the instrument, and thus prevent the displacement. Consequently it is necessary that Fig. 362. — Smith-Hodge Pessary. Fig. 363. — Munde Pessary. the pessary shall be of sufficient size to accomplish this dis- tention. The pessaries most frequently employed are the ring (Fig. 360), the bulb, the disc (Fig. 361), the Smith-Hodge (Fig. 362), or Thomas or Munde (Fig. 363) modification of the latter. Numerous other pessaries are employed, such as the soft-rubber pessaries (Fig. 364), the Zwank or bat-like pessary (Fig. 365), the Gehrung (Fig. 366), the double curved pessary, the saddle or Graily Hewitt (Fig. 367), according DISPLACEMENTS OF THE PELVIC ORGANS. 491 to the purposes intended to be accomplished by their designers. In the employment of many of these pessaries, however, it is absolutely necessary that the pelvic floor shall afford a point of resistance to the intra-abdominal pressure. In cases in which the pelvic floor has been lost, or where the prolapsus is of the vagino-uterine variety, the pessary, having no point of resistance, is at once extruded when the patient makes a Fie. 364. — Hoffman Soft-rubber Pessary. Fig. 365. — Zwank Pessary, straining effort, or even upon standing. In such cases a pessary may be employed with an external support. This is in the form of a cup with a stem attached to straps which are fastened to a belt around the waist. Such an instrument, however, is exceedingly uncomfortable ; the stem and straps are irritating to the delicate external surfaces. The cup may cause ulceration and abrasion of the cervix and vagina. The employment Fig. 366. — Gehrung Pessary. Fig. 367. — Hewitt Cradle Pessary. of a pessary in prolapsus can only be palliative ; it has no power to restore function to the part. However, a patient came under my observation who had worn a pessary for twenty- six years. This had produced such marked abrasion and irritation of the vagina that granulations had sprung up which enveloped the greater part of the instrument with new tissue. The pessary was cut with bone-pliers, and each half removed 492 GYNECOLOGY. separately, leaving undisturbed the mass of cicatricial tissue by which the uterus was subsequently supported. I have seen, in several instances, the bulb or glass-ball pessary worn for a long period of time, until it resulted in cicatricial changes in the vagina, which formed the support for the atrophied uterus. The maintenance of the uterus by the establishment of cicatricial tissue has been attempted by the injection of quinin and other irritating materials into the broad ligaments. This was done in order to establish a cellular inflammation, which should cause such contraction of the connective tissue as to retain the uterus in position. Such a plan of treatment, however, is attended with too much danger to justify its employment. The operative treatment affords the only means which can be considered radical, or as giving hope for the restoration of the structures and their maintenance in normal position. In the employment of such measures I wish to direct your attention to the three causes which have been assigned for the development of prolapsus. These are, increased weight of the uterus, decreased pelvic support, and increased intra- abdominal pressure. The malposed uterus is rendered heavy by a condition of subinvolution or chronic inflammation, which has in part resulted from obstruction to its circulation. Not infrequently will we find that the cervix has undergone hyper- trophic elongation, and that the vaginal walls are dragging upon this elongated portion of the organ. The first step, then, in the restorative process, should be the amputation of the cervix. This decreases the size of the uterus, not only by the amount of the cervix removed, but by the favorable metabolism thus engendered. The amputation may be free or the double- flap or single-flap method can be employed (see Amputation of CeWix, § 336), according to the particular pathologic con- dition present. In performing this operation we would suggest that the cervix be sutured with chromic catgut, as such sutures can be allowed to remain; moreover, the stretching of the newly united surfaces consequent upon the removal of sutures is thus avoided. The second indication is met by narrowing the vaginal canal and reconstructing the pelvic floor. Early in the history of gynecology various operations were devised to secure this object. Sims did a triangular denudation upon the anterior wall, the surfaces of which were united and the canal thus reconstructed. The method of freshening the surface will largely depend upon the character and form of the prolapsus. The protrusion of the anterior wall of the vagina, for which these procedures are considered, is known as cystocele. Furthermore, the maintenance of the uterus in position by narrowing the vagina will be especially DISPLACEMENTS OF THE PELVIC ORGANS. 493 applicable to the correction of the cystocele. In cystocele we have to deal not only with the protrusion of the vaginal wall, but also with an accompanying prolapse of the bladder; a por- tion of the bladder is consequently oftentimes below the level of the internal orifice of the urethra. The portion thus dis- placed, as we have seen, affords an opportunity for ammoniacal fermentation and decomposition of the urine. In the sulcus or depression thus formed, not infrequently calculi are devel- Fig. 36S. — Anterior Colporrhaphy. iVnterior Vaginal Wall Removed. oped, which further aggravate and add to the distress of the patient. Any operative procedure, then, should comprise not only the contraction of the anterior vaginal wall, but the elevation of the bladder to a higher level. This change of the bladder position is accomplished by an incision through the anterior vaginal wall into the connective tissue between the vaginal and vesical surfaces. The edges of this incision are held with forceps, while, by blunt dissection or with sue- 494 GYNECOLOGY. cessive snips of the scissors, the vesical surface is dissected off; this dissection is extended upon either side to a degree sufficient to permit the removal of the relaxed tissue of the anterior vaginal wall. The bladder should then be pushed away from the cervix, up to or even through the peritoneum. (Fig. 368.) This dissection is followed by tucking the bladder up from below, and stitching it fast to the cervix at a higher level. This method renders the posterior surface of the bladder more tense. Some operators have advocated anchor- ing the bladder to the anterior parietes through an abdomi- nal incision, but such a procedure will be necessary in but few cases. The traction upon the bladder and its fixation to the anterior surface of the uterus will decrease the pressure against the reconstructed vaginal walls. The vaginal incision should be united from near the cervix, and the suturing extend outward, the cervix being pushed as we proceed. In this man- ner a strong anterior segment of the pelvic floor is established. (Fig. 369.) The su- turing should be done in a vertical line with a continuous chromic catgut suture, which should be locked at every second turn, in order to prevent puckering of the wound. The aim of the operator should be- to make a long anterior wall, to hold the cervix backward, and, consequently, tilt the fundus uteri forward. In greatly relaxed vaginal walls the excision may be made circular, and the wound closed with the Stolz's suture. (Fig. 370.) This, however, contracts the vagina in every direction and, therefore, is less favorable in the majority of Fig. 369. — Wound Closed. DISPLACEAIEXTS OF THE PELVIC ORGANS. 495 cases than the method of anterior colporrhaphy already de- scribed. The ordinary method of performing the operation, known as anterior colporrhaphy, consists in making a denuda- tion which does not penetrate the entire vaginal wall. When suttired, such a denudation forms a wall of connective tissue, which is not so durable as the method we have described. The operation upon the anterior vaginal wall should be supplemented by one upon the posterior. This may be slight or extensive, ^ig- 370- — Stolz's Purse-string Suture. according to the amount of relaxation. The restoration of the posterior segment may be accomplished by performing the operation known as the modified Garrigues-Hegar, or the operation designed by Emmet. For a description of the method of performing these operations see Section 372. The decrease in the size of the uterus, the restoration of the pelvic floor, as described, will, in some cases, prove effective in maintain- ing the uterus in its proper position. In others, however, 496 GYNECOLOGY. in which the uterus is large and does not maintain its proper axis, but drops backward, the intra-abdominal pressure will tend to drive it through the newly united canal and reestablish the hernia. It is consequently important that the uterus should be anchored within the abdomen, to prevent such an occurrence. This anchoring of the uterus may be accomplished by the operation known as ventrosuspension, or, still better, ventrofixation. For the description of this operation and its indications and contraindications see page 541. The same purpose can be effected by one of the operative procedures which utilize the round ligaments, as in the Alexander, the Gil- liam-Ferguson, the Ries, or other modifications, which will be described later. The aim, of course, of the operative pro- cedure is to maintain the fundus of the uterus forward. This can be accomplished by vagino-uterine fixation or by shortening the round ligaments through the vagina. These operations can readily be done in association with those upon the anterior wall of the vagina, as in the procedure we have already described. When the bladder is pushed away from the cervix, it is very easy to enter the peritoneal cavity through an anterior colpotomy and employ the opportunity thus afforded to break up adhesions, to treat ovarian and tubal disease, and to restore the uterus to its normal position. The incision through the posterior vaginal fornix is also employed for shortening the uterosacral ligaments. It will readily be understood that if the cervix is carried upward and backward, the fundus will necessarily fall forward. The contraction of the uterosacral ligaments, or the tissue in which they are usually situated, is of special value in marked prolapsus, for if the ventrosuspension or fixa- tion, or one of the operations upon the round ligaments alone, is done, we would have the uterus hanging and dragging upon its anchorage. Shortening the uterosacral ligaments, however, lifts up the cervix and, consequently, throws forward the fundus, thus making the uterus serve as a plug to obstruct the egress through the pelvis. Where the utero-sacral ligaments are short- ened as a part of the general procedure, they should be exposed before the sutures are tied in the operation upon the anterior vaginal wall. Bovee advises that the ligaments be exposed by a vertical incision from the posterior surface back toward the rectum, which shall extend to but not through the peritoneum. The latter is pushed off on either side until the thickening in- dicating the position of the ligament can be determined. Each ligament should be seized with a hemostat about its middle and drawn downward, while traction upon the cervix is discontinued. Each loop should be transfixed by a suture which is tied and the end of the doubled ligament secured just behind the cervix, near DISPLACEMENTS OF THE PELVIC ORGANS. 497 •' the normal attachment of the ligament. This course applied to both ligaments results in holding the cervix at a higher level and may in many cases obviate the necessity for opening the ab- domen. The sutures for closing the wound in anterior colpor- rhaphy should have been introduced and secured by hemostats before the incision to expose the uterosacral ligaments, and after the latter are secured, as we have indicated above, the former should be tied and by this course no traction is made upon sutures after they have been secured. These measures may be further supplemented by the retraction of the posterior vaginal wall or pelvic floor. When the ligaments have been se- cured, the vaginal inci- sion for their exposure should be united by con- tinuous catgut suture, leaving a vent through which gauze drainage can be employed. Freund advised in aged women, in whom the prolapsus was marked and the condition of the patient unfavorable for a radical operation, that silver wire sutures should be passed so as to form successive rings beneath the uterus. The introduction of the sutures should begin im- mediately beneath the cervix, so as to push up and maintain the organ at a higher level. He directed that they be drawn moderately tight and fixed by twisting ; the ends are then cut off and pushed into the vesicovaginal septum. The silver wire thus secured forms successive, bands or hoops around the restored vagina, which it was thought would maintain the uterus in place. My own experience, however, is that upon very slight exertion 32 Fig. 371. — First Stage of Dudley's Bilateral Denudation of the Vaginal Walls for Pro- lapsus. 498 GYNECOLOGY. the entire condition is reestablished. Moreover, the silver wire sutures are likely to cause irritation and possibly the formation of abscess, which will ultimately require their removal. Attempts have been made to maintain the uterus within the pelvis by in- flammatory changes in the broad ligaments. Injections of quinin hypodermatically have been employed for this purpose, but such procedures must be futile, inasmuch as they meet but a part of the required indications. Wiggins endeavored to accomplish the same by an intraperitoneal purse-string suture in each broad ligament. In prolapsus of large uteri, complicated by inflamma- tion of the tubes and ovaries, with bands of adhesion fixing omen- tum or coils of intes- tine to the uterus and bladder and with the subsequent cicatricial changes, the prefer- able plan of proced- ure, in my judgment, is the partial or com- plete removal of the organ. Even so radi- cal a procedure should be supplemented by a plastic operation upon the vagina, in order to narrow the canal and afford better support to the abdominal viscera. Such patients, even though old, bear op- eration fairly well. Where the condition of the uterus will permit of its retention, the organ should not be sacrificed. We have already cited reasons why hysterectomy should not be the operation of election. In hypertrophic elonga- tion of the cervix it may be difficult, by simple amputation of the cervix and fixation of the uterus, to sufficiently elongate the vagina to prevent recurrence of the hernia. In such cases, especially where the woman has passed the climacteric, the supravaginal amputation of the fundus uteri, through an abdom- inal incision, followed by suturing the stump, covered with peri- toneum, to the broad ligaments upon each side, as advocated by Baldy, will be effective, or, when the vagina is very much Fig. 372. — Dudley's Operation, Showing Denuda tion upon One Side of the Vagina. DISPLACEMENTS OF THE PELVIC ORGANS. 499 relaxed, we may sew the stump of the cervix directly to the abdominal parietes, as advocated by Noble. E. C. Dudley asserts that the part of the vagina most resistant to displace- ment is its lateral surface, and that, instead of narrowing the vagina on the anterior and posterior walls, the preferable plan of procedure would be to denude an elliptical surface upon either lateral fornix, with the long diameter anteroposterior. The edges of newly made surfaces are apposed and secured with sutures through the long diameter. From this a lateral denudation is made upon either side, in which the sutures are introduced from behind forward and from above downward, in such a way as to lift up the anterior wall of the vagina. (Figs. 371 and 372.) Even in marked cases of prolapsus sutures may be introduced so as to in some degree serve to anchor the lateral sur- faces of the vagina. .488. Urethrocele. — The urethra, in extensive cystocele, is generally more or less involved. As has already been rec- ognized, the intimate connection of the bladder and urethra with the anterior vaginal wall necessitated their associ- ation in any prolapsus of the latter structure. When a segment of the bladder is situated below the internal orifice of the urethra, the upper part of the urethra, as a consequence, becomes prolapsed. The lower segment of the urethra, however, generally retains its normal situation. Occasionally we may have a protrusion from the central portion of the urethra, which forms a sac-like projec- tion (Fig. 373) at the lower portion of the anterior wall of the vagina. This latter condition is independent of any uterine or vaginal displacement. This projection, on the introduc- tion of a catheter, is found to be a part of the urethra. It is at times so large as to form a kind of diverticulum, over which the urine flows, without entering it, or enters it only to a limited extent. Pressure over the urethrocele causes a discharge of quite profuse purulent material, although pus has not previously been found in the urine. The treatment consists in dissecting out the sac, a catheter having been previously introduced as a Fig. 373. — Urethrocele. 500 GYNECOLOGY. guide. The opening in the urethra is closed while the catheter is in place. The vaginal wall is then sutured over this wound, and the urine is subsequently evacuated through a permanent catheter for two or three days. 489. Dislocation of the uterus is a displacement in which there is but slight change in its axis. These dislocations may be forward, backward, or lateral. The organ is more or less fixed in the abnormal position by inflammatory changes, fre- quently in the form of inflammation of the cellular tissue. In p,nte position the uterus is situated close to the symphysis, gener- ally above it, and the condition is produced by growths or by accumulations in the pelvis which push up the uterus. The organ, once fixed in the abnormal position, remains. In retro- position the uterus is situated at a lower level, and close to the hollow of the sacrum. It results from inflammatory changes which contract and fix the organ; thus, a hematocele in its earlier stages may push the uterus forward into a state of anteposition, but later, as the collection becomes absorbed and organized, contractions occur which draw the organ back- ward. When the contraction involves the region of the folds of Douglas or the uterosacral ligaments, the fundus of the organ will be pushed forward, and an anteflexion will be es- tablished. It is only when the organ has previously been the seat of metritis and has become so rigid that it resists the tendency to flexion that it retains the retroposed position. Lateral position, either right or left, is generally due to inflammation in the cellular tissue of the broad ligament. In the acute stage of inflammation the organ may be pushed to the side opposite to that on which the exudation occurs. As the condition becomes chronic, the inflammatory material con- tracts, and the uterus is drawn to the affected side. These displacements cause no special symptoms. The symptoms, when present, are due to the complications or conditions which have produced the displacement and are a consequence of the displacement. 490. Diagnosis. — The situation of the displaced organ is recognized by bimanual examination. The fixed position and situation are usually sufficient to establish the diagnosis. In lateral displacement the organ is not in a median position, and on manipulation moves more readily toward the affected side. In a woman whose abdomen is very fat or the abdominal wall quite rigid, the posterior dislocation is often difficult to differentiate from retroversion. The introduction of the sound would afford information, but the advantage derived from determining the position is insufficient to compensate for the danger from its use. An assistant dragging upon the cervix DISPLACEMENTS OF THE PELVIC ORGANS. 501 with a tenaculum or vulsellum, while either the vaginal or rectal bimanual is practised, will generally afford a definite deter- mination as to the character of the malposition. 491. Torsion. — Torsion is generally associated with either a retroposition or a lateral position, and is due to an irregular contraction of the portion of the broad ligament which has been subject to cellular inflammation. This contraction twists the uterus upon its axis, so that the cornua may be turned anteroposterior instead of being situated laterally. The entire uterus can be thus twisted, so that, upon inspection, the os. Fig. 374. — Anteversion of the Uterus. instead of being transverse, will present an oblique or nearly anteroposterior line. Torsion also results from the presence of growths in one or the other broad ligament or of an ovarian tumor to which the tube is adherent. As the tumor enlarges it drags upon the uterus and twists it. This lesion is frequently overlooked, and presents no symptoms of special importance. (Treatment, see page 547.) 492. Anteversion. — In anteversion, the uterus is found with its fundus forward and the cervix directed backward or upward and backward. (Fig. 374.) The organ m.ay be fixed in the abnormal position by complications, such as inflamma- 502 GYNECOLOGY. tion, which may cause adhesions between the fundus and an- terior parietal peritoneum, or more frequently in the cellular tissues about the uterus, the cervix, or in the uterosacral liga- ments. An inflammatory process of the uterosacral ligaments with a normal uterus will produce flexion, but when the latter organ is stiffened by long-continued inflammation, it causes anteversion. The uterus is considerably increased in size; its walls are thickened and often rigid and firm. The normal flexion has disappeared, and the canal is perfectly straight. This position of the uterus is caused by increase of weight, and in severe versions the fundus will lie forward upon the bladder or against the symphysis, while the cervix may be directed upward and backward. 493. Etiology. — Any disorder which increases the weight of the uterus increases the tendency to an antedisplacement. When the uterus has been the site of previous inflammation, particularly a metritis, this displacement is necessarily an anteversion. Metritis, subinvolution of the uterus, pelvic cellu- litis, occurring in the posterior portion and in the utero-sacral ligaments ; flbroid growths in the fundus ; ovarian growths — all may cause this form of displacement. 494. Symptoms. — Anteversion presents no characteristic symptoms. The symptoms are those which are associated with the complication by which it is produced. The patient may complain of a sensation of distress, from pressure upon the bladder, of frequent micturition, and of pain or a dull ache over the region of the symphysis. 495. Diagnosis. — Anteversion is readily determined by bi- manual palpation. The cervix is situated high posteriorly, and often reached with some difficulty, while the uterine body can be traced forward and is found to rest upon the bladder. Not infrequently the fundus lies well against the symphysis. The situation of the fundus in the anterior portion of the ab- domen, the absence of any angle in the uterus, and its size, weight, and more or less immobility, definitely differentiate it. 496. Treatment. — As we have already seen, anteversion is a symptom or sign rather than an actual disease. It is a develop- ment that arises as a natural consequence of increased weight of the uterus, and the treatment must necessarily be that which is applicable to the existing complication. The most common complication is inflammation, causing hypertrophy or hyper- plasia of the uterus, an irritative infiltration and proliferation of the tissue element. The inflammatory condition may exist with or without adhesions. The treatment of the condition, then, in the great majority of cases, is that of existing inflam- mation — hot vaginal douches, tampons medicated with agents DISPLACEMENTS OF THE PELVIC ORGANS. 503 which are expected to exert an influence in decreasing the size of the uterus. This decrease can frequently be accom- plished, to a considerable degree, by thoroughly dilating the uterine cavity with laminaria tents, and after their removal, swabbing the interior of the organ with tincture of iodin, a sat- urated solution of iodin crystals in 95 per cent, carbolic acid, or a saturated solution of iodoform in ether. Following such an application the decrease in size of the uterus may still further be promoted by packing the organ with iodoform gauze and by placing a tampon of iodoform gauze beneath it. This raises the organ to a higher level and promotes its circulation. Furthermore, the uterus can be dilated with gradu- ated bougies, its cavity cureted, and applications made as suggested. Where the uterus is free from ad- hesions, it may be sup- ported by a pessary. The pessaries which were de- vised for the purpose of elevating the fundus have not proved satisfactory. The retroversion pessary in some cases of heavy uteri is particularly ser- viceable, although it may seem a paradoxical instru- ment to employ in ante- version, but it does, how- ever, afford relief by hold- ing the uterus at a higher level. Pelvic massage em- ployed daily is of special value in promoting drainage, in facilitating metabolism, and in decreasing the size of the uterus. Operations upon the cervix, amputation, or the repair of a laceration of the cervix will establish a process of metabolism which will decrease the size of the uterus. When the uterosacral ligaments have not become shortened through inflammatory processes and thus caused an irremediable displacement, the operation devised by Sims may be practised. This consists in making a transverse ^^S- 375- — Sims' Operation for Anteversion. 504 GYNECOLOGY. denudation upon the anterior lip, another upon the anterior vaginal wall at a suitable distance from it, and uniting these two surfaces by sutures (see Fig. 375). As a result of this operation the cervix is drawn toward the vulvar outlet, the fundus is tilted upward, and a more correct position is secured. When the uterus is fixed by adhesions, in addition to the treatment already suggested, pelvic massage will prove beneficial. Two fingers in the vagina are hooked behind the cervix and press the fundus of the organ upward; while the external hand is rotated over the fundus, the fingers pressing down along its sides and in front of it, push the fundus backward. While the fundus is pushed backward with the fingers of the external hand and drawn forward with the fingers in the vagina, bands of adhesion are put upon the stretch and are manipulated to such an extent that their absorption is promoted. The manipulation of the uterus promotes absorption of inflammatory exudate within its walls, and thus assists in decreasing its size, so that by the time the adhesions are stretched and loosened, the uterus is so reduced in size that the patient is much relieved. In some cases, where a boring pain is experienced over the symphysis, the wearing of a cincture or belt (Fig. 376) will support the abdomi- nal viscera and relieve the degree that the ache or dis- Fig. 376. — Abdominal Belt. intra-abdominal pressure to such a comfort will disappear. 497. Retroversion.— In retroversion the uterus is turned with the fundus backward. (Fig. 377.) The cervix is directed forward against the posterior wall of the bladder. This displacement varies in degree according to the relations of the cervix and uterus to the axis of the vagina. The maximum degree is a backward displacement in which the fundus lies low in the hollow of the sacrum, with the cervix directed upward. Retroversion is recog- nized as an early stage of prolapsus. With this displacement the intra-abdominal pressure is directed upon the fundus or upon the anterior wall of the uterus, which favors downward displace- ment, so that we usually find retroversion associated with a •certain amount of descent of the uterus. 498. Etiology. — The most frequent cause of retroversion is a lesion of pregnancy. Retroversion occurs in the unmarried or sterile woman, but much less frequently. It is produced by decreased support of the ligaments, particularly of the DISPLACEMENTS OF THE PELVIC ORGANS. 505 uterosacral, which permits the uterus to sag downward and to be rotated backward; the latter action is occasioned by a distended bladder, until finally the ligaments lose their mus- cular tone and the organ does not regain its normal position. Retroversion can be produced by traumatism, as when the person falls from a height and strikes upon the feet or, par- ticularly, upon the buttocks, and by the presence of growths in the uterus or in the ovaries. 499. Symptoms. — Retroversion causes few symptoms. The discomfort in the majority of cases arises from complications. Patients may have marked retroversion without experiencing Fig. 377. — Retroversion. any inconvenience or being aware of the condition until it is brought to their knowledge. Inflammatory complications pro- duce a sensation of weight or dragging, as if everything were about to protrude when the patient stands or walks. The menstrual flow is increased, producing menorrhagia; occasion- ally there is an irregular, bloody discharge, or the intermen- strual intervals are shortened, or, as a result of the coexisting catarrh, the patient will have a profuse leukorrhea. The pro- jection baclavard of the fundus and pressure of the cervix against the bladder cause a more or less frequent desire to 506 GYNECOLOGY. urinate. Not infrequently there is an extension of the inflam- mation to the vesical mucous membrane, which produces cystitis. Pressure of the uterus upon the rectum increases the tendency to constipation, interferes with the rectal circulation, and develops hemorrhoids and fissure of the anus. An injury of the anus or rectum under these circumstances is slow to re- cover, which makes it important, in cases of rectal disease, to ascertain the condition of the uterus before we resort to any operative interference. 500. Diagnosis. — Digital examination discloses the cervix uteri in the axis of the vagina, or looking forward and sometimes upward. Through the posterior vaginal fornix the examining finger recognizes a mass which is continuous on a straight line with the cervix. The bimanual examination discloses the absence of the fundus from the anterior fornix. The rectal bimanual affords an opportunity to explore the fundus and even the anterior surface of the uterus. (For treatment see Retroflexion, Section 571.) 501. Lateral Version. — Lateral version is a form of dis- placement in which the fundus is situated to one side of the pelvis, while the cervix is directed toward the other. This condition is produced by cellulitis in the broad ligament and by intraligamentary growths, either fibroid or ovarian; in marked cases of inflammation contraction can occur in the base of one broad ligament and in its upper part on the op- posite side. This produces a fixation of the uterus directly transverse to the pelvis, not unusually with a certain amount of torsion. The lateral version causes no special symptoms, and is readily recognized by a bimanual palpation. 502. Anteflexion. — In anteflexion the uterus is bent upon its axis, with the fundus forw^ard, while the cervix lies more or less in the axis of the vagina. The flexion may be slight (Fig. 378), but little more than normal; indeed, any flexion which is fixed is an abnormal one, even though it may not be greater than the ordinary bending of the uterus. From a slight flexion we may have a very acute one (Fig. 379), in which the fundus and cervix seem to lie upon each other at a very acute angle. The anterior wall of the uterus, at the point of flexion, undergoes a change in which there is a substitution of fibrous tissue for the muscle-wall. The posterior surface becomes exceedingly thinned where it bends over the anterior. (Fig. 382.) The anteflexion ma}^- be mobile or immobile. The former results from a heavy fundus when the cervix is in a more or less fixed position. Raising the fundus, we can tilt it backward, and leave the uterus in a position of retroflexion, so that at times the organ is anteflexed; at others, retroflexed. Not infre- DISPLACEMENTS OF THE PELVIC ORGANS 507 pig^ 278. — Slight Degree of Anteflexion. Fig. 379. — Acute Anteflexion. 508 GYNECOLOGY. quently a diagnosis of anteflexion will be made, and at a subsequent examination by another person the uterus is found retroflexed. If the fact that the organ is mobile is not remem- bered, an error in diagnosis will be attributed to the first investi- gator. In the immobile uterus the flexion is fixed. Anteflexion, again, may be regarded as physiologic, pathologic, and indifferent. A physiologic anteflexion is one which corresponds to the normal condition of the uterus; a pathologic, one in which the flexion is more or less fixed or is greater than normal ; while in an indif- ferent anteflexion the bending causes no symptoms. 503. Etiology. — Anteflexion is probably next to the most frequent form of uterine displacement, and it occurs less fre- quently in the married than do the retrodisplacements. It occurs with greater frequency in the unmarried or nulliparous woman, and is a result of congenital conditions, or, rather, those which are associated with the earlier development of the uterus. Anteflexion may be ascribed, first, to the long cervix of the puerile organ, the situation of which, in the vagina, necessitates the fundus bending forward over it. Second, inflammation in the uterosacral ligament or in the cellular tissue posterior to the uterus, which draws the cervix upward (Fig. 383), promotes, in a flexible body, its falling forward, and the angle between the body and the cervix is increased. Third, the displacement arises from localized inflammation at the site of the placenta, when situated upon the posterior uterine wall. Involution is more rapid in the anterior, and the shorter wall becomes the string of the bow which bends the uterus forward. Fourth, anteflexion is produced by growths in the fundus of the uterus. 504. Symptoms. — The symptoms most frequently attributed to anteflexion are sterility and dysmenorrhea; but when un- complicated by inflammation, neither of these symptoms is necessarily present. The patient with marked anteflexion generally suffers from chronic vesical distress. Pain occurs when the bladder is moderately distended, micturition is fre- quent, and generally there is a sensation of distress and annoy- ance which follows the evacuation. These symptoms, how- ever, are not infrequently produced by inflammation in the bladder, so that, as a rule, the urine should always be carefully examined. Dysmenorrhea has been attributed to an obstruc- tion of the canal from which there is an accumulation of material within the uterine cavity, and the organ has to go into labor to expel it. As flexion does not cause dysmenorrhea when the lesion is uncomplicated by inflammation, it is evident that the latter is the cause of the symptom, and that the hyperemia prior to and coincident with menstruation produces pain during DISPLACEMENTS OF THE PELVIC ORGANS. 509 the distention of the inflamed surfaces rather than an obstruc- tion of the canal. Even in the congenital conditions the dys- menorrhea does not occur with the first menstruation, but later, when there is distinct evidence of the development of in- flammatory trouble. 505. Diagnosis. — Anteflexion is recognized by digital and bimanual palpation. The cervix is situated in the axis of the vagina, and, by carrying the finger in front of it, a body is felt in the anterior fornix of the vagina, between which and the cervix a distinct angle is recognized. During bimanual palpation this angle can to some degree be straightened, and the relation of the flexion to the cervix and body is more distinctly recognized. The flexion is particularly determined by passing the index-finger into the lateral fornix, first upon one side and then upon the other; by pressing from above we are able to recognize the lateral borders of the uterus and the absence of an}^ growth. We can be in doubt as to whether the mass found in front is the fundus uteri or a fibroid growth attached to the anterior wall. Each condition may afford an equal-sized angle. The method we have already described, of passing the finger along the lateral aspect of the uterus, will enable us to differentiate them. By changing the position of the organ and pressing it well forward with the hand over the abdomen, we can outline the posterior surface of the fundus, and determine that its size and relations correspond to those of the cervix to the fundus, rather than to a growth. When the uterus is fixed, bimanual palpation is difficult. The posi- tion of the organ can be determined by the introduction of a uterine sound into the canal. The use of the sound, however, under these or any other circumstances, is fraught with so much danger that it is preferable to administer, if necessary, an anesthetic for the further practice of the bimanual, rather than to make an intra-uterine exploration. Rectal palpation with the digital finger, while the thumb of the same hand is placed in the vagina against the cervix, and the other hand over the abdomen, enables us to bring the uterus definitely under observa.tion. 506. Treatment. — Anteflexion requires treatment only when it is associated with symptoms, and these are usually the re- sult of complications. The symptoms may be caused by com- plications incident to changes in the structure of the uterus itself, as inflammation either in the wall of the organ or in the surrounding structures. It may be incident to the various constitutional conditions, as a rheumatic or gouty diathesis, the effect of neurasthenia, but in such cases the treatment may be constitutional or a combination both of constitutional 510. GYNECOLOGY. and local measures. The most frequent symptoms associated with this displacement are those of dysmenorrhea or painful menstruation, and sterility. That these symptoms, however, are not necessarily the result of anteflexion alone is evident, from the many cases in which the patients with marked ante- flexion have both menstruated painlessly and given birth to children. Patients suffering from dysmenorrhea associated with anteflexion should be encouraged to live an outdoor life. Hygienic measures are particularly important. The clothing should be suitable, and the extremities be warmly clad. Very frequently women who suffer from d^^smenorrhea while in our northern climates, will be absolutely free from this symptom when residing in the South or in the Bermuda Islands. Meas- ures should be instituted to improve the general nutrition, to obviate the sluggish circulation, to regulate the bowels. Such patients are often improved by bicycle-riding, playing golf, and anything which leads to an outdoor life. Pelvic Fig. 380. — Thomas Anteflexion Pes- Fig. 381. — Stem-pessary, sary. or uterine congestion should be decreased by the administration of iodids and bromids, the employment, particularly, a few days to a week before the menstrual period, of gelsemium or Pulsatilla, taking five drops of the fluidextract of gelsemium or ten drops of tincture of Pulsatilla, three or four times in the twenty-four hours, until the patient exhibits signs of its physi- ologic action. Thyroid extract has proved of value in these cases, when the drug is given in doses of three to five grains two or three times in the twenty-four hours. Douches, tam- pons, painting the vault of the vagina with tincture of iodin, gauze packing, and pelvic massage are all of service. The pessary, particularly the Graily-Hewitt (Fig. 367) or the Thomas anteflexion pessary (Fig. 380), which tilts up the fundus of the uterus, have had their advocates. Their efficacy, however, is somewhat doubtful. Pelvic massage is of special value in these cases, as the manipulation of the uterus serves to straighten the organ and promote a healthy condition of its circulation. DISPLACEMENTS OF THE PELVIC ORGANS. 511 When the patient is not improved by douches, tampons, or constitutional measures, the uterus may be dilated by the in- troduction of a laminaria tent. This procedure should be done under most thorough aseptic precautions, with the vagina thoroughly cleansed, the cervi- cal canal rendered as aseptic as possible, and the tent itself ster- ilized, preferably by dry heat. However, the tent may be placed for several minutes in a solution of iodoform and ether, in equal parts of alcohol and car- bolic acid, or, better, in iodin tincture prior to its introduction. The cervix should be seized with a double tenaculum, sponged with a solution of formalin, and by traction straightened so that the tent can be the more readily introduced. As large a tent as the caliber of the cervical canal Fig. 382. — Section Showing Thinning of Cervical Walls at the Angle of Flexion. Fig. 383. — Anteflexion Associated with Contraction of Uterosacral Ligaments. will allow should be employed. The tent is removed in from twelve to fourteen hours, after which the uterine cavity is irri- 512 GYNECOLOGY. gated, if necessary cureted, swabbed with a saturated solution of iodin in carbolic acid or of iodoform in ether. The canal may or may not be packed with iodoform gauze. The dilatation with tents may be repeated at intervals until the tendency to displacement appears to be overcome and the complicating involvement of the uterus has subsided. Inflammation in the cellular tissue about the uterus, or in the tubes and ovaries, as evidenced by their being enlarged and fixed in the pelvis, should be considered a contra-indication to the employment of tents. The dilatation can be accomplished by graduated bougies and their employment followed by curetment. Twenty- five years ago the employment of the stem-pessary was a favorite method of overcoming an anteflexion. The stem was one- eighth of an inch shorter than the uterine cavity; the patient was required to wear it for a considerable length* of time. (Fig. 381.) The objection to the stem-pessary is that it is a source of irritation, affords constant danger of infection to the uterine mucosa, and may lead to the development of more serious trouble. W. Gill Wylie advocated the employment of a grooved stem of hard rubber or glass which should serve as a drainage- tube. He and others still practise this method of overcoming the dysmenorrhea incident to acute anteflexion and claim marked improvement in many cases. The favorite treatment of Sims was a bilateral incision — occasionally one through the posterior lip. Unless precautions are taken to prevent union, the parts are reunited. Even when precautions are employed, cicatricial tissue forms, which subsequently causes distress, some- times greater even than the preexisting condition. The pos- terior lip can be split up to the angle of flexion and its cervical and vaginal lining membranes united by sutures, to prevent re- union. Occasionally, after such an operation, the cervix spreads out, owing to the intra-abdominal pressure, and the more delicate cervical mucous membrane is thus exposed to pressure and irritation, resulting in endometritis and formation of cysts of Naboth, which will require continuous treatment. Splitting the anterior lip has been advocated. This is performed by dissecting the bladder from the anterior wall of the cervix to the level of or above the point of flexion. A grooved director is then introduced into the uterus and the cervix is incised. As the incision approaches the os it is carried around to the side of the cervix. The cervical mucous membrane is united to that of the vaginal wall. This enlarges the opening from the front and prevents obstruction, but is subject to the same objection made to the posterior operation, in that it exposes delicate surfaces to irritation and subsequent inflammation. E. C. Dudley has devised an ingenious operation, in which he DISPLACEMENTS OF THE PELVIC ORGANS. 513 splits the posterior lip beyond the vaginal attachment; the surfaces are held apart by tenacula and the incision is deepened upon the cervical side with a knife. A wedge-shaped piece is removed from each side, and the sutures are so introduced as to unite the edge or apex of the incision on each side with the base. By this method eversion of the cervical mucous membrane is prevented. (See Fig. 384.) The anterior lip Fig. 384. — Dudley's Operation for Anteflexion, by Incising and Suttiring the Posterior Lip. of the cervix is then amputated, and the wound closed with transverse sutures, which push back the cervical orifice and straighten the canal. (See Fig. 385.) Nourse, recognizing that the flexion corresponded to the shorter wall, made a bi- lateral incision to the level of or a little above the angle of flexion. Traction is then made upon the posterior lip, which results in straightening the canal. The new surfaces are apposed and secured with sutures, leaving the posterior lip longer. When 33 514 GYNECOLOGY. the latter is half an inch or more in length, it is amputated by the flap method, thus making it the same length as the anterior lip. The raw surfaces are united b}^ suture. (Figs. 386 and 387.) When the . elongation is short, it is left to contract. C. A. L. Reed advocated opening the abdomen and removing a wedge-shaped piece from the posterior wall of the uterus opposite the angle of flexion. This surface is closed by vertical Fig. 385. — Completion of Dudley's Operation, by Transverse Denudation and Suturing of the Anterior Lip. sutures and restores the organ to normal position. Burrage advises, in proper cases, incision of the uterosacral ligaments and the performance of a ventrosuspension, thus raising the fundus of the organ upward. 507. Retroflexion. — In retroflexion the fundus is bent back- ward upon the uterine axis, and, according to its degree, lies toward the rectum (Fig. 388) or is forced well down into Douglas' DISPLACEMENTS OF THE PELVIC ORGANS. 515 pouch. (Fig. 389.) The cervix is in the axis of the vagina. The retroflexion may be mobile or immobile, may be pathologic Fig. 386. — Nourse's Operation by Splitting the Cervix and Resuturing the Incisions. Fig. 387. — Operation Completed. or indifferent, but can never be said to be physiologic. This form of displacement is very frequently a sequel of version. The uterus becomes retroverted and the abdominal pressure 516 GYNECOLOGY. then drives the fundus downward, bending it upon its axis, forcing it into Douglas' pouch. (Fig. 390.) 508. Etiology. — Retroflexion is produced by metritis; sub- involution; inflammation of the placental site, in the anterior wall of the organ; fibroid growths in the fundus or anterior uterine wall (Fig. 391), parametric inflammation, or cellulitis of the anterior segment of the pelvic floor, which draws the cervix forward; localized peritonitis; or contraction following hemato- Fig. 388. — Retroflexion of Slight Degree. cele (Fig. 392), by which the fundus of the organ is drawn back- ward. 509. Symptoms. — Retroflexion, like the other forms of dis- placement, when uncomplicated presents no special symptoms. It produces a sensation of weight and pressure, not infre- quently pain in the region of the anus, an uncomfortable sen- sation down the posterior surface of the lower extremities, points of anesthesia over the thighs, congestion, partial ob- struction of the rectum, obstinate constipation, and not infre- quently a sensation that the intestine is so obstructed that the DISPLACEMENTS OF THE PELVICXORGANS. 517 Fig. 389. — Retroflexion of Extreme Degree. Fig. 390. — Retroflexion Following Version. 518 GYNECOLOGY. bowel can not be evacuated. Development of hemorrhoids, anal fissures, and more or less prolapse of the rectal mucous membrane not unusually follow. Menstruation is irregular and profuse, or the menstrual intervals are shortened, and leukor- rhea is quite profuse. 510. Diagnosis. — Digital examination discloses the cervix Fig. 391. — Retroflexion Produced by Fibroma of Anterior Uterine Wall. BLADDER. Fie. 39: -Retroflexion the Sequel of Inflammatory Adhesions. situated at a lower level in the pelvis, occupying the axis of the vagina or directed a little anteriorly; the finger in the pos- terior fornix recognizes a body slightly above, or even below, the cervix, which is rounded, may be movable or fixed, and somewhat larger than the normal fundus. Between it and the DISPLACEMENTS OF THE PELVIC ORGANS. 519 cervix is a distinct angle, though the structures can be traced from one to the other. The finger in the anterior vaginal fornix ^' Fig. 393. — Retroflexion Simulated b}^ Posterior Uterine Myoma. Fig, 394. — Retroflexion Simtflated by Small Ovarian Cyst in Posterior Culdesac. and the other hand over the abdomen discloses the absence of the fundus uteri from its normal position. The flexion is 520 GYNECOLOGY. apparently increased by pressure upon the cervix, and the fundus is driven more deeply into the culdesac. By pressing the finger upward on either side of the uterus and cervix the lateral margins can be determined. Digital examination through the rectum enables us to pass directly over the fundus and to feel to some degree its anterior surface, which now becomes posterior. Retroflexion of the uterus can be confounded with fibroid growths (Fig. 393) situated in the posterior uterine wall, adherent ovarian growths (Fig. 394), and pelvic inflammatory exudation. (Fig. 395.) The introduction of the sotmd into the uterine canal, and its passage backward into the mass, would be definite evidence that a retroflexion exists; but, as Fig. 395. — Anteflexion and Retroflexion Simulated by Pelvic Exudation. in other uterine conditions, this procedure is fraught with so much danger that it is preferable to make the diagnosis with- out it, and, if necessary, even to leave it uncertain. With a careful bimanual examination, as has been advised, by the rectum, the vagina, or both, we are generally able to deter- mine the relations of the uterus to the surrounding parts, and absolutely to fix the diagnosis. When the existence of pelvic exudate or immobility of the uterus and a resistant or thick abdomen prevent its accomplishment, the patient should be given an anesthetic. 511. Treatment of Retroversion and Retroflexion. — As retro- flexion is simply a bending of a version, we will, therefore, con- DISPLACEMENTS OF THE PELVIC ORGANS. 521 tsider the treatment of these two conditions together. As the majority of the other displacements are not characterized by symptoms, unless complications are present, so, in these •conditions, symptoms are not manifest without the existence •of complications. The organ, however, in maintaining a retro- position, interferes with its circulation, which results in con- gestion and subsequently in more or less inflammation. There- fore the treatment of the complications is ineffective so long .as the displacement remains. The relief of the inflammatory ■condition is expedited by maintaining the uterus in a correct position. Treatment largely depends upon the duration of the displacement, the changes which the structures have under- Fig. 396. — The Retro verted Uterus Replaced; Patient in Dorsal Position. :gone, and the ability of one to replace and maintain the organ in proper position. No means for maintaining the uterus in position are effective until it has first been accurately replaced, after which it can be supported with relief of many of the dis- tressing symptoms. Three methods are generally recognized as proper for replacing the organ. These are: (i) The bimanual. The patient is placed in the dorsal position with her limbs flexed. Two fingers are introduced into the vagina, while the fingers of the other hand are placed over the abdomen (Fig. 396). The middle or long finger is passed into the posterior fornix of the vagina to press up the fundus, while the index- finger is carried in front of the cervix to push it backward. 522 GYNECOLOGY. The pressure against the lower end of the lever carries the opposite end, the fundus, forward, until it can be grasped by the external hand and brought into a position of ante version. In some cases the fundus of the uterus is caught beneath the promontory of the sacrum and can not readily be dislodged. If the cervix, however, is grasped with a double tenaculum or vulsellum, and drawn down, while the fundus is pushed up with the finger in the vagina or rectum, the fundus uteri is readily displaced from beneath the promontory and the cervix can then be carried backward. The second procedure con- sists in placing the patient in the genupectoral position and the employment of the Sims speculum to open the vagina. The atmospheric pressure balloons the vagina and the uterus is Fig. 397. — Schultze's Method of Replacing an Adherent Retroverted Uterus. carried to the upper part of the canal. This procedure, how- ever, does not of itself correct the position, as the uterus, though elevated, may still be retroflexed or retroverted. The posi- tion, when uncomplicated, may be readily corrected by seizing the cervix with a tenaculum or vulsellum, and drawing it to- ward the vaginal orifice, and then carrying it backward and upward. The fundus is thus dislodged and the position corrected. A third procedure consists in the employment of the uterine sound. With the patient in the dorsal position, two fingers are introduced into the vagina and the sound, carried between them, enters the os and is introduced to the fundus and then rotated. The external end of the sound is carried through a wide arc so as to do as little injury to the internal mucous membrane as possible, while the handle of the sound is de- DISPLACEMENTS OF THE PELVIC ORGANS. 523 pressed and the finger in the posterior fornix pushes the fiindus upward. This combined movement carries the fundus for- ward until it can be controlled with the external hand. In spite of the most careful precautions, the uterine mucous mem- brane will be injured by this method of procedure. It is ex- ceedingly difficult to avoid the danger of the introduction of infectious material into the uterus, which necessarily favors the development of further complications. For such reasons, the sound should not be employed, especially as every purpose attained by its use can be readily accomplished by the employ- ment of the dorsal manipulation or with the patient in the genupectoral position. Various jointed sounds have been Fie -Second Step in Replacing Uterus by Schultze's Operation. devised for the purpose of replacement of retrodisplaced uteri, but these instruments are open to the same objections offered to the use of the ordinary sound. In adherent uteri none of these methods of procedure will accomplish the restoration of the displaced organ. When the adhesions exist between the posterior uterine surface and the anterior rectal wall, the intestine may be dragged up with the uterus and apparently permit it to assume its normal posi- tion; but as soon as the supporting force is removed, the uterus is drawn back and, if mechanical efforts are employed to main- tain it in position, the fundus is bent backward and the retro- flexion is greatly increased. If adhesions are present and they 524 GYNECOLOGY. are not too firm and of too long duration, pelvic massage affords a valuable method for overcoming their baneful influence and promoting their absorption. The massage should be supple- mented by the use of tampons. In some cases the pressure of an air pessary within the vagina stretches the bands of ad- hesions, promotes their absorption, and supports the uterus. Schultze advocated a procedure which is very effective in over- coming recent adhesions. The patient is placed in the dorsal position, with the muscles well relaxed by an anesthetic. Two fingers are introduced into the rectum, while the thumb in the vagina against the cervix steadies the uterus until the rectal fingers, one on either side of the fundus, can invert and draw down the bowel and separate it from the uterine surface (Figs. 397 and 398). As the adhesions are separated and the uterus is set free, the external hand grasps the fundus and draws it forward, after which the remaining bands of adhesion are broken up. Care must be exercised in carrying out this procedure not to employ too much force, otherwise the intestine may very readily be injured. There is more danger, however, of injuring the tubes or ovaries, when these organs are adherent. An adherent tube may be torn and -liberate poison at the seat of inflammatory trouble, which, particularly if of a purulent character, would be followed by a violent attack of pelvic or possibly general peritonitis. With purulent inflammation or pus collections in the tube excluded, the absorption and loosen- ing of the adhesions of the ovary, tube, and uterus can be effected by pelvic massage. If the adhesions are extensive and the vagina tender, especially when its posterior fornix is more or less obliterated by the long duration of the displacement, the uterus can be temporarily supported by the employment of vaginal tampons, medicated or not, as the conditions require. The employment of continual pressure over the abdomen or within the vagina may be effected by shot-bags or the employ- ment of rubber bags containing mercury. Three to five pounds or ,more of shot may be applied over the abdomen to make pressure over a mass of exudate and thus promote its absorp- tion and the setting free of an adherent uterus. The absorp- tion of the vaginal exudate may be expedited by the use of mercury, applied in a rubber bag. Such a weight introduced into the vagina, with the position of the patient changed from time to time in order to subject different portions of the exudate to the weight, promotes its absorption and the consequent loosen- ing of the uterus and pelvic structures. When the uterus is free from adhesions and, consequently, can be readily replaced, we can at once resort to the use of a pessary. Some of the more prominent retrodisplacement pes- DISPLACEMENTS OF THE PELVIC ORGANS. 525 saries are the Hodge (Fig. 362), Thomas, Munde (Fig. 363), and the Schtdtze (Fig. 399) instruments. The various modi- fications of the Hodge pessary consist of a posterior bar with converging side bars which are united by a shorter bar anteriorly. Laterally, the pessary has the shape of a letter S- The posterior bar is carried behind the cervix into the posterior fornix. In its modification by Thomas and Munde, the posterior bar is thick- ened, which makes a larger mass in the fornix. The pessary does not support the body of the uterus on its posterior bar, but it so drags upon the posterior vaginal fornix as to ptdl against the cervix and lift it up, until the other end of the lever — the fundus — is held so far forward that the intra- abdominal pressure is directed upon the posterior uterine sur- Fig. 399. — Schultze Pessary. Fig. 400. — Proper Position of the Pessary. face. This pulley-like action of the pessary is readily seen in Fig. 400, which shows the proper position of the pessary in relation to the uterus and vagina. It has already been emphasized that the pessary does not support the body of the: 526 GYNECOLOGY. uterus, and that the position of the organ must be corrected before the introduction of the instrument. The result of an attempt to employ the pessary to correct the position of the uterus can be seen in Fig. 401. It is very important that the pessary should not be unduly long. When too much pressure is produced, ulceration of the vagina occurs, rendering the pa- tient unable to retain it, or, if the instrument is too long, it may project from the vulva and cause irritation about the urethra or neck of the bladder, and much discomfort in sitting. The proper length of the pessary is readily determined by the intro- duction of two fingers into the vagina to measure the distance Fig. 401. — Faulty Position of the Pessary. between the distended posterior vaginal fornix and the internal margin of the symphysis. The proper width of the pessary is appreciated by determining the extent to which the fingers can be separated without undue lateral presstire in the vagina. The proper size of the instrument to be employed is thus as- certained. While a pessary too long produces the conditions we have already mentioned, one too short allows the fundus of the uterus to fall backward over its posterior bar and in- creases the retroflexion and adds to the distress of the patient. It is difficult to maintain the pessary in place where the vagina is much relaxed. If the uterosacral ligaments are much elon- DISPLACEMENTS OF THE PELVIC ORGANS. 527 gated, and the posterior fornix distensible, the pessary will fail to maintain the uterus in its normal position, and, more- over, it will permit the organ to drop back and rest upon the instrument. (Fig. 401.) Schultze designed the pessary known as the figure-of-8, which is very effective for such cases. This pessary laterally is similar in shape to the Hodge instrument, forming a letter S. The lateral bars of this pessary are twisted to form a figure-of-8, the upper loop of which surrounds the neck of the cervix and carries it upward, while the inferior loop is so broad that it receives support from the vagina and does not incline to prolapse. Should the figure-of-8 prove un- satisfactory, the sledge pessary of Schultze may be efficient. (Fig. 402.) Its posterior end has a bar curved forward, which rests in front against the cervix and holds it back, while at the same time traction is made upon the cervix through the dis- tention of the posterior fornix by the upper part of the instru- ment. The pessary should be sufficiently broad to impinge against the side walls of the vagina to prevent it being displaced downward. It distends the vagina in three direc- tions — in length, laterally, and in the anteroposterior direction. When adhesions are present, the pessary is badly borne and is harmful. It is at all times a foreign body and produces a certain amount of irritation in the vagina, which, to many patients, is Fig. 402.— Schultze's Sledge a source of much discomfort; besides. Pessary. it is not always efficient in maintain- ing the uterus. It must be worn for months or even years to secure sufficient contraction to maintain the organ, consequently many patients prefer to submit to operative interference. The pessary may be employed in retroversions due to sub- involution of the uterus subsequent to a recent delivery. In such cases the pessary will maintain the uterus at a higher level, promote the process of involution, and thus favor the maintenance of the organ in a replaced position after it has reached its normal size. It may be employed after adhesions have been broken up, by the Schultze method, or when we have been able to accomplish the loosening of the uterus by pelvic massage. Where retrodisplacement has existed for some time, the posterior fornix of the vagina may be so shortened that the pessary can not be worn. Such a condition will re- quire treatment by douches and tampons until the posterior vaginal fornix is stretched. They are also of little value in those cases in which the vaginal portion of the cervix has been des- 528 GYNECOLOGY. troyed by amputation or as a result of repeated labors. As the pessary is a foreign body, it is therefore important that explicit directions should be given regarding its management before this subject is dismissed. Directions have been given for the determination of a suitably sized instrument, and I would again emphasize the fact that the instrument should be neither too large nor too small. The former will cause pressure upon the surrounding parts, producing irritation, ulceration, loss of structure, and open avenues for the entrance of infection. A smaller instrument is easily dislodged from its position, does not serve any useful purpose, and may only serve to aggravate the condition. The patient should be directed APONEUROSIS E;(T. OBLIQUE ROUNJ) LIGMT. 3UB-CUTANE0U5 FAT H mcvmi N. Fig. 403. — Alexander Operation; Round Ligament Exposed. to remove or have the instrument removed if it gives rise to increased discomfort, and return to the physician within a week at least after its introduction. He can then determine definitely whether the instrument is serving its proper purpose or causing any irritation. In neurotic patients too much at- tention must not be given to the instrument, otherwise the patient, will manufacture a long train of distressing symptoms and attribute them to its presence. The instrument is likely to increase the vaginal discharge, and for this reason it is im- DISPLACEMENTS OF THE PELVIC ORGANS. 529 portant that it should be kept clean. It is undesirable, how- ever, to employ mineral astringents in the douche for this purpose, as they are likely to become deposited upon the sur- face of the pessary, thus rendering it rough and, therefore, more likely to serve as an irritant. A properly fitting instru- ment can be worn by the patient without her being aware of its presence, but even though it causes no annoyance, the patient should be advised of the importance of having it removed at Fig. 404. — Round Ligament Being Drawn Out. stated intervals, not exceeding three months, for cleanliness, and to make sure that it is producing no irritation. These rules apply to the hard-rubber instrument. Where the in- strument is of the soft-rubber variety, it should be removed much more frequently, as the discharges to some degree enter into the rubber, decomposition takes place, and a foul odor arises which is very annoying to the patient and to those with whom 34 530 GYNECOLOGY. she is associated; moreover, it ma}^ give rise to systemic infection. The operative procedures for the correction of retrodisplace- ments of the uterus consist of the extraperitoneal and intra- peritoneal shortening of the round ligaments, by abdominal or vaginal incision, and the construction of artificial ligaments, as in such operations as ventrofixation or ventrosuspension. il;. 405. — Round Ligament Sutured. Besides these, there are also numerous vaginal operative methods for correcting retroplaced uteri. Extraperitoneal Shortening of the Round Ligaments. — Shorten- ing of the roimd ligaments is an operation which was performed by Alexander in December, 1881, and two months later by Adams, although the latter contributed the first publication. The operation had, however, been advocated by a Frenchman DISPLACEMENTS OF THE PELVIC ORGANS. 531 named Alquie, as early as 1840. The operation requires two incisions, and each consists of four stages: (i) An incision six centimeters long, a little inside the pubic spine and above and parallel to Poupart's ligament, is made through all the tissues to the aponeurosis of the external oblique. (Fig. 403.) (2) Exploration for the round ligament. This is disclosed by a small ball of fatty tissue which covers its end between the pillars ot the external inguinal ring. Pressure upon the side causes the mass to pro- trude. A hook passed beneath this mass en- ables the operator to raise up the ligament. (Fig. 404.) It is then detached by a direc- tor, from the posterior adherent fibers which maintain its relation to the inferior part of the canal, after which it is seized with a pair of forceps and drawn out. Upon the com- pletion of the first and second stages, on both sides, we proceed to the third, which con- sists in shortening and fixation of the liga- ments. The ligaments are drawn upon until the fundus is brought under the pubes. This movement can be facil- itated and rupture of the fibrous filaments avoided by previously placing the uterus in anteflexion, either by the sound or preferably by the aid of the fingers of an assistant. The ligaments are drawn out from four to ten centimeters, according to the resistance. When they become tense, they are maintained by an assistant, while a needle charged with silk, silkworm-gut, or catgut is made to traverse the external pillar, theligament, and next the internal pillar. (Fig. 405.) Three sutures are thus introduced, one centimeter apart. (Figs. 406 and 407.) (4) The wound is closed with silk or silkworm-gut Fi 406. — Continuous Catgut Suture Uniting In- ternal Oblique Muscle to Poupart's Ligament. 532 GYNECOLOGY. sutures, dressed with gauze, and the parts are so secured by bandaging as to prevent the wound from becoming exposed by the movements of the patient. The employment of a Hodge pessary for two months following the operation is advisable, though some prefer the tampon. Various modifications of this operation have been devised. Edebohls splits the entire length of the inguinal canal, draws the ligaments out at the internal RD.LIGnT. Fig. 407. — Return Layer of Suture Bringing External Oblique Muscle in Apposition. ring, and closes the wound as in the Bassini operation. New- man makes an incision directly over the internal ring, draws the Hgament straight out, and secures it in the wound. Franklin Martin and Buret, of Lille, do not use sutures, but pass a pair of dressing forceps beneath the skin and subcutaneous tissue from one wound to the other, draw the ligament through, tie the two ligaments together in a knot, and close the tissues over DISPLACEMENTS OF THE PELVIC ORGANS. 533 the union. Cassati joins the lower ends of the lateral wounds with a curved incision, in which the crossed ends of the liga- ments are united by continuous suture. Doleris employs the same method, uniting the two ligatures with catgut sutures, after pulling theiji through, as in the method suggested by Martin. Goldspohn attempts to extend the usefulness of the Alexander operation by stretching the internal ring and open- ing through the peritoneum, so that the finger can be passed into the pelvis and break up adhesions about the uterus, ovaries, and tubes. By this method a tube or ovary can be withdrawn and subjected to necessary treatment. The advantages claimed Fig. 408. — Wylie's Operation for Shortening the Round J^igaments within the Abdomen. for the Alexander operation are: (i) The incisions being super- ficial or extraperitoneal, the risk of infection is less; as it is local, the danger of peritonitis is decreased; (2) the method of maintaining the uterus forward has less injurious influence upon a future pregnancy; (3) it imitates the natural support, in that the natural ligaments are employed; and (4) no intraperitoneal adhesions can form. The disadvantages are: (i) That two incisions are reqmred. (2) The operation is limited in its ap- plication. It is only in those cases in which the uterus is mobile that we can practise this procedure. Consequently it has the further disadvantage in that we are not always able to deter- mine definitely the existence of adhesions between the uterus and the anterior wall of the rectum. Should such adhesions exist, the uterus drawn forward by the round ligaments is sub- 534 GYNECOLOGY. ject to forces which tend to render the operation nugatory. The procedure of Goldspohn seeks to overcome this objection; nevertheless, the objection still remains, for the operation to break up adhesions and treat the pelvic organs is done through so small an opening as to render it more or less a blind proce- dure. Besides, severe injuries may occur and be readily over- looked. (3) The roimd ligaments are sometimes so attenuated as to be of little use in maintaining the organ. In an operation of mine the ligament on one side was apparently entirely absent. I found no vestige of it in the canal. I therefore opened into the peritoneal cavity and found that the round ligament had disappeared. (4) In cases of infection the infected ligament may slip back and carry infection beneath the peritoneum, Fig. 409. — Mann's Operation for Intra-abdominal Shortening of Round Liga- ments. where it w411 be difficult to reach, and, consequently, render the operation, as has been proved, not altogether free from danger. Intraperitoneal Shortening of Round Ligaments. — The round ligaments are shortened within the peritoneal cavity by making an incision through the abdomen in the median line. This procedure permits the uterus to be drawn up, the condition of the appendages examined and treated, if necessary. Existing adhesions can be broken up and the round ligaments shortened by folding them. (Fig. 408.) Wylie suggests that from two to four inches of the ligament be doubled up on each side and united by sutures, so that the shortened ligament draws and holds forward the fundus. Mann grasps the broad ligament about the junction of its middle and outer third and folds the ligament in three parts which are united by sutures. (Fig. 409.) By this DISPLACEAIENTS OF THE PELVIC ORGANS. 535 method the Hgament is well shortened on each side. A. P. Dudley, of Ncav York, performed an operation which he called desmopycnosis. (Fig. 410.) This is accomplished as follows: The abdomen opened, an assistant introduces two fingers into Fig. 410. — Dudley's Operation of Desmopycnosis. the vagina and pushes the uterus as high as possible in the pelvis, while the operator brings the organ through the ab- dominal incision. An oval denudation is made upon the ante- rior uterine wall, making sure that the bladder is not injured; Fig. 411 ■Dudley's Operation Completed. then each round ligament is brought up to the portion of the peritoneal covering on the inner side, denuded to correspond with that on the uterus, and the three denuded surfaces are then united with catgut sutures. The sutures must be so adjusted as to pass sufficiently deep in the uterine tissue to secure against. 536 GYNECOLOGY. their cutting out before union has occurred. (Fig. 411.) This procedure holds the uterus forward in a position of anteversion. Ries cuts a sHt through the anterior surface of the fundus, through which a loop of the round ligament, drawn out of its sheath, is carried and fastened on either side. Bissell excises a portion of the round ligament and unites the cut ends with cat- gut sutures. Webster picks up a loop of the round ligament, carries it through the broad ligament beneath the Fallopian tube, and secures it to the posterior surface of the uterus. This pro- cedure has been modified by Baldy, who ligates the uterine end of the round ligaments, incises each ligament external to the liga- ture, and carries the free end, rather than the loop, through the broad ligament and fastens it to the posterior surface of the uterus. All these operative procedures, however, act upon the Fig. 412. — Gilliam-Ferguson Operation. Round Ligament Seized through Stab Wound. strongest part of the ligament, leaving the weakest portion, that which occupies the inguinal canal, to be stretched out. Gilliam devised a procedure (Fig. 412) which consists in picking up the ligament, three or four centimeters from its uterine end, and carrying a loop of it through a stab wound in the lower part of the rectus muscle on either side, and there securing it. (Fig. 413.) This procedure divided the lower part of the abdomen into three apertures, through two of which coils of intestines were capable of being pushed and compressed to a greater or less degree. To ob- viate such danger Ferguson modified the operation by quilting to- gether the peritoneal surface external to the point transfixed by DISPLACEMENTS OF THE PELVIC ORGANS. 537 Fig. 413. — Round Ligament Drawn through the Abdominal WaU. % ^ Fig. 414. — Section Showing Position of the Uterus with Completion of the Operation. 538 GYNECOLOGY. the loop of round ligament. This ligature, when tied, closes up the gap in the peritoneal cavity external to the point through which the loop of the ligament is brought out. With these parts secured, the uterus is held forward by a loop of the strongest part of the round ligament. (Fig. 414.) Simpson, through a median incision about one inch from the uterus, passed a suture through three- fourths of the round ligament, threaded both ends of this suture into a carrier, and through the slit made in the anterior layer of Fig. 415. — First Step in My Modification of the Gilliam Operation for Securing- Round Ligament Support. the broad ligament passed it directly forward beneath the peri- toneum of the vesico-uterine pouch to a point upon the anterior abdominal wall one and one-half inches external to the median line, and carried both ends into the peritoneal cavity, one end threaded into a sharp curved needle and thrust into the muscular structure, emerged upon the peritoneum, where it was secured by tying with the other end. I have combined the Simpson and DISPLACEMENTS OF THE PELVIC ORGANS. 539 Gilliam operation as follows: A cun-ed incision, when possible, within the pubic hair line is made through skin, superficial fascia, and aponeurosis. The aponeurosis is loosened from the pyra- midalis muscles and drawn upward (see Figs. 78 and 79), the recti muscles separated, and the peritoneum divided in the ver- tical line. After freeing adhesions and giving proper attention to the condition of the ovaries and tubes, a suture is passed be- Fig. 416. — Second Step, Showing Ligament Fixed with Hemostat while Tem- porary Ligature is Carried Beneath Anterior Leaflet of Broad Ligament with a Deschamps Needle. neath each roimd ligament, one inch and a half external to the uterus. (Fig. 415.) The ends of the suture upon one side are threaded into the eye of a Deschamps needle having a rather long arm. (Fig. 416.) The round ligament external to the suture is seized with a hemostat and giA'en to an assistant with the direction to keep it taut. An opening is made into the an- terior layer of the broad ligament, just below the insertion of the suture, and through this opening the needle carr^dng the ends of 540 GYNECOLOGY. the suture is introduced and carried outward between the layers of the broad ligament until the parietal peritoneum is reached, when the latter is drawn inward and the point of the instru- ment plunged through the abdominal parietes, emerging upon the aponeurosis. The suture ends upon each side, are withdrawn from the Deschamps needle, and the ends secured by a hemostat. Seizing the suture upon one side and drawing upon it to make it Fig. 417. — Operation Completed; Differs from Gilliam-Ferguson in Having No Internal Sutures. tense, a pointed scissors, closed, is thrust alongside the ligature and the blades separated, when, in the majority of cases, the trac- tion causes a loop of the ligament to follow the withdrawal of the scissors. Where it does not at once follow, it can be teased through by pressing back the tissues as traction is being made. (Fig. 417.) Having thus brought a loop of each ligament through the wall, the loop is secured to the aponeurosis by catgut sutures. Pre- vious to securing the protruded loop see that the uterus is in DISPLACEMENTS OF THE PELVIC ORGANS. 541 proper position. If it is not, the portion of ligament next to the uterus can be pulled upon to the necessary degree to accomplish the object. The ligaments secured, the wound is closed by a con- tinuous chromic catgut suture in the peritoneum and muscle edges. This suture should be drawn over firmly enough to hold in apposition the peritoneal surfaces and not strangulate the muscle structure. A second suture closes the aponeurosis and the third the skin surfaces. The greatest care must be exercised to prevent the accumulation of blood above or beneath the aponeurosis, for such an accumulation is readily infected and the formation of an abscess will result in a weakened ventrum — pos- sibly in sloughing of the aponeurosis. Bleeding vessels should be Fig. 418. — Sutures Introduced for Ventrosuspension. ligated, and where there is a tendency to oozing, drainage should be employed. This m^ethod of treatment possesses the advan- tages that: I, it affords ample opportunity for the recognition and treatment of diseased conditions of the pelvic structures; 2, no opportunity is added by the operation for the formation of disturbing pelvic adhesions; 3, the natural condition is more closely imitated and the uterus maintained in position by liga- ments capable of evolution and involution. Ventrofixation and Ventrosuspension. — These terms are ap- plied to the operation devised by Olshausen, and modified by Kelly, for establishing an artificial ligament for the purpose of maintaining the uterus forward. The operation consists in an 542 , GYNECOLOGY. incision in the median line, through which the uterus is exposed and its fundus sutured to the parietal peritoneum at the lower angle of the wound. Two or three buried sutures of silk, silk- worm-gut, catgut, or silver wire are generally employed. (Fig. 418.) The first suture is passed through the peritoneum about one centimeter from the w^ound margin, through the fundus uteri near its center, and brought out through the peritoneum of the opposite side of the wound. A second suture is similarly placed about eight millimeters behind the first. To prevent the peritoneum from being dragged away from the abdominal wall it is included in the abdominal suture. Since the first edition of this book I have modified my method of performing this operation by introducing a silkworm-gut suture through the fundus of the uterus and the abdominal walls, which is sub- sequently tied externally. A needle, carrying a chromic catgut suture, is introduced through the aponeurosis of the lower angle of the right side, through the fundus of the uterus, near the silk- worm-gut suture, and brought out through the peritoneum of the opposite side. Two subsequent turns of the suture are passed through the edges of the peritoneum and the fundus of the uterus, after which the peritoneal wound is closed with the remaining suture. Following the introduction of silkworm-gut sutures through all the tissues above the peritoneum, this same catgut suture is carried back through the aponeurosis and tied at the lower angle of the wound. Therefore the uterus, peritoneum, and aponeurosis are all held by the one suture, and only a single buried knot remains in the incision. Silkworm-gut sutures, in- cluding the one through the fundus uteri, are then tied, which would bring in apposition and secure the skin edges. The stay or lower suture of silk^vorm-gut may be tied over a pledget of gauze to prevent it cutting the skin, and should be permitted to remain for two weeks. This operation establishes a ligamentous band between the uterus and parietal peritoneum, which is suf- ficiently strong to maintain the uterus fonvard and yet not inter- fere with its mobility. Where it is preferable — as, for instance, after the climacteric, or in patients from whom both ovaries have been removed — that the uterus should be more firmty fixed to the abdominal wall, it is better that the peritoneum should be pushed back so that the sutures bring the muscle structure directly in contact with the fundus of the uterus. Such a course secures a firmer union and, therefore, the uterus is held more closely to the parietal wall. The procedure we have described permits thorough exploration of the pelvic cavity, the separation of adhesions, and the fixation of the uterus through a single incision. The procedure has been greatly modified. By some, the sutures are placed in the anterior uterine DISPLACEAJENTS OF THE PELVIC ORGANS. 543 wall. The majority of operators insert them in the fundus — the first suture in the line of the Fallopian tubes, and the second a little behind it, thus throwing the uterus forward in slight anteflexion. The purpose of the operation of ventrosuspension is to establish a ligamentous union, which will permit a certain amount of uterine mobility. Consequently the uterus is attached only to the peritoneum, rather than to the muscle wall. To avoid the buried suture, F. Martin has suggested using the urachus, and Avhen it is not well defined, a loop of peritoneum is carried from below upward through a buttonhole slit in the fundus and included in the sutures closing the wound. Bovee employs a portion of muscle aponeurosis. These modifications, however, have no special advantage. The fixation has been accomplished through a transverse incision above the symphysis. This incision only divides the skin and superficial fascia. A vertical incision is then made through the aponeurosis, muscle wall, and peritoneum. The uterus is brought forward and se- cured by two silkworm-gut sutures through the fundus. These are brought out through the muscle wall and segment of integu- ment below the transverse incision. The remaining portion of the vertical wound is closed with catgut and the transverse in- cision in the skin with a continuous intercut icular stitch of silk. The suspensory stitches are tied over a gauze roll and permitted to remain two weeks. Ventrosuspension has the advantages already suggested, that it permits the inspection of the con- dition of the peritoneal cavity, the treatment of diseased appen- dages, the separation of adhesions, and the fixation forward of the uterus in a position which is unlikely to give distress. It has the following disadvantages : (i) That it has been found to inter- fere to some degree 'with subsequent gestation and labor, the patient complaining of more or less pulling and distress during the progress of gestation, sometimes so marked as to cause abor- tion or premature labor. When the band of fixation is short, large, and firm, it may prevent enlargement of the uterus and produce thinning of the posterior wall, which will increase the danger ■of rupture and afford obstacles to the normal progress of par- turition. A firm band of adhesion, during pregnancy, after the performance of ventrofixation, may cause a condition simulating a bifid uterus. I have, in several instances, opened the abdomen during pregnancy and cut the band in order to permit the uterus properly to develop. Furthermore, I have seen patients in whom I felt that such a procedure was advisable. In one instance I Avas called in consultation to see a woman who had had a ventro- suspension performed and who was in labor at full term. The anterior wall of the uterus and cervix were apparently' doubled up, forming a shelf upon which the fetus rested with an arm protrud- 544 GYNECOLOGY. ing. The attendants, after vigorous efforts to turn the child, had cut off this arm. The fetus was lying in a transverse position,, and a part of the body had engaged. After considerable difficulty I succeeded in passing a cephalotribe upon the body of the child, with which I crushed the spine and delivered first the lower ex- tremities, and then the trunk and head. (2) That the operation is not free from danger. I had the misfortune to have one patient in whom a large portion of intestine slipped below the band of adhesion immediately following the operation. This became strangulated and caused death. Similar cases have been reported by Lindfors, Jacobi, Olshausen, and others. The accident in my case occurred almost immediately after the operation, and, although the patient suffered greatly, it was attributed by her attendants to hysterical excitement following the anesthetic, and, when recognized, the condition of the patient was such as to preclude any hope of recovery. It would not require great stress upon the imagination, when one sees these bands of adhesion, to appreciate the possibility of strangu- lation occurring at periods more remote from the operation, and numbers of such instances are recorded. (3) The buried sutures of silla\^orm-gut, silk, or silver wire may become a source of irritation, either from immediate infection or later inflamma- tory changes, and cause a sinus to extend through the abdominal wall and give rise to an unpleasant discharge. Such a sequence, of course, annoys both patient and surgeon until the offending cause — the buried sutures — have been removed or have become disintegrated. Such a sinus may keep up for months or even years. The sutures can occasionally be fished up and removed. For this purpose I know of no instrument better adapted than the hook of the ear-spoon devised by the elder Gross for the removal of hardened wax from the ear. If this instrument is ineffective, the surgeon may find himself obliged to reopen the wound, and frequently the offending ligatiu-e will be found deep in the pelvis, at the end of the band of adhesion. For the pur- pose of avoiding this difficulty I have employed the chromic catgut suture with a single knot. Burrage has advised ventro- fixation for the treatment of immobile anteflexion. Through an abdominal incision he divides the uterosacral ligaments close to the uterus and secures the fundus to the abdominal wall. Schmidt, of Cologne, frees the anterior uterine wall from the bladder by dissection, excises a wedge-shaped piece with its point directed toward the cervical canal, and unites the surfaces by sutures. This draws the uterus forward in a position of anteflexion. Vaginal Operations. — The ease with which the pelvis can be entered through the vagina has led to the adoption of various DISPLACEMENTS OF THE PELVIC ORGANS. 545 Operative procedures through this canal for the purpose of maintaining the uterus in proper position. One of the earhest operations performed through the vagina is that known as the Schiicking. This consists in passing an instrument, curved, for an acute anteflexion, to the fundus, from which a concealed needle is driven through the anterior vaginal fornix. This needle carries back the ligature, which, when tied, fixes the uterus in a position of anteflexion. Care must be exercised in its employ- ment to avoid injuring the bladder by pushing this organ to one side. Injury of the intestine has also occurred. The ligature is permitted to remain for two or three weeks, when the resiilting inflammatory changes will maintain the uterus in an anteflexed position. The procedure is objectionable in that it is a blind operation, and injury, therefore, may be unavoidable. In- struments have been devised to push the uterus against the anterior abdominal wall and thrust needles carrying ligatures from its cavity, by which the fundus can be fastened ; but these are open to the objection already assigned — that they are blind procedures. Vaginal fixation devised by Diihrssen, subse- quently practised and modified by Mackenrodt, consists in making a vertical incision through the anterior vaginal wall to the cervix, when the bladder is pushed off until the peritoneum is reached. Without opening the latter a suture is introduced, and by it the uterus is pulled forward. A second suture, placed higher, near the fundus, is employed to maintain the uterus forward by bringing its ends through the edges of the vaginal incision. Mackenrodt modified the operation by opening through the peritoneum and introducing the sutures at a higher level, thus securing the fundus or anterior wall to the vaginal incision. The peritoneal and vaginal wounds were then closed. This operation for a time was very largely practised, but it was soon recognized that it was likely to cause much distress and discom- fort during the progress of gestation. Moreover, it often pro- duced profound dystocia, which imperiled the lives of both mother and child. For these reasons the operation is now rather infrequently practised. Vineberg and Wertheim, through a similar incision, seize the round ligament some three centi- meters from the fundus uteri, pass a ligature beneath it, and bring the ends of this ligature out through the vaginal walls on either side of the vertical incision. The ligature is then tied. This holds the round ligament down against the vagina, and, consequently, fixes the uterus forward. The round ligaments have also been shortened through the vagina by performing the Wylie or Mann operation upon them. I have sutured the round ligaments to the anterior surface of the uterus through the vaginal opening. The operation of Ries consists in pulling 35 546 . GYNECOLOGY. a loop of the round ligament through a slit in the anterior wall of the uterus. This method has been described under abdominal procedures, but was devised to be performed through the vaginal incision. Through a posterior colpotomy by a vertical incision, Freund and Gottschalk shortened the uterosacral ligaments. The incision was made from just behind the cervix downward, toward the rectum. The peritoneal cavity was opened and a ligature introduced on each side to separate the surfaces. From this opening a ligature w^as carried through the middle of the uterosacral ligament, and one end of it through the posterior surface of the cervix. The ligature thus introduced on each side was tied, which drew the cervix upward and backward. Con- sequently the other end of the lever, the fundus, was thrown forward. A modification of this procedure has been extensively practised by Bovee, of Washington, who shortens the ligament without opening the peritoneum, and is quite an enthusiastic ad- vocate of it. Pry or advocated a transverse incision in the pos- terior fornix of the vagina, through which he broke up adhesions, carried the uterus forward, and packed gauze into the posterior culdesac. Then with a tampon he pressed the cervix well up- ward and backward. The subsequent adhesion of the cervix in this position leads to correction of the malposition. 512. Lateral Flexion. — Lateral uterine bending may be dex- trofiexion or sinistroflexion. The position of the cervix is more or less fixed and the fundus of the uterus is drawn to one side by cicatricial contraction, or is pushed to the opposite by a large exudate, an intraligamentary fibroid growth, or an ovarian cyst. No special symptoms characterize the state; the diagnosis is readily determined by the methods already cited for the deter- mination of other forms of displacement. 513. Complications Associated with Displacements. — It has been noted, in discussing the individual forms of displacement of the uterus, that they rarely produce symptoms themselves, and, when it is considered that the organ involved, in its normal condition, weighs less than an ounce, that its circulation is so extrinsic that the organ can be bent forward or backward with- out injury thereto, it is difficult to see why so much stress has been placed upon these displacements. The development of a complication, however, by which the circulation is obstructed, changes the whole aspect of affairs. The most frequent complications of uterine displacements are: Endometritis. Metritis. Salpingitis. Oophoritis. Cellulitis. ] \ DISPLACEMENTS OF THE PELVIC ORGANS. 547 Peritonitis. ' Other complications are : Ectopic gestation. Ovarian or myomatous tumors. Ptosis of the aJDdominal viscera. These complications are most frequently primary as regards the production of symptoms, though, as in prolapsus, they may be secondary in the sense that the displacement lessens the resistance to infection. 514. Prognosis of Displacements. — The prognosis of a dis- placement will depend upon its degree and the existence of complications. In the earlier stage of the displacement, when the distress arises from increased weight of the organ, the mere correction of the position and the maintenance of the organ corrected will bring about a decrease in its size and afford relief from the displacement. After the displacement has existed for some time, it is complicated by chronic inflammatory changes, which will absolutely prevent any procedure from maintaining the organ in its proper position. The symptomatic phenomena, however, can be relieved and the patient be practically restored to health. 515. General Treatment. — It will be seen, from a discussion of the different forms of displacement, that I am disinclined to believe that uncomplicated displacements are likely to produce symptoms. Of course, I can readily understand that when a patient has prolapsus, with the uterus protruding from the body, it necessarily produces disturbance and is subject to unusual irritation from its abnormal location. The small size of the uterus, when normal, the manner in which it receives and discharges its blood-supply, render it difficult to conceive how the mere displacement of so movable an organ should be pro- vocative of the serious symptoms which have been frequently attributed to it. The most 'frequent complications of uterine dis- placement are inflammatory processes and their sequelae, which cause increase in the size of the organ, its flxation by extensive adhesions, and interference with the performance of the function of the adjacent viscera. The treatment, then, must largely consist in the correction of the existing complication. Expe- rience has disclosed, however, that when such complications exist, their treatment is most effective when associated with measures directed to maintain the uterus in proper position. The methods of procedure most effective to accomplish this purpose are both local and constitutional, such as massage, electricity, and mechanical procedures. The patient should be suitably clad, and wear clothing free from undue constrictions about the waist. Her skirts should be supported from the 548 GYNECOLOGY. shoulders. The bowels should be carefully regulated, and the bladder should not be permitted to become overdistended. The existence of peri-uterine inflammation and extensive exudates can be ameliorated and absorption expedited by the employ- ment of pelvic massage. This is best performed by a daily seance of five to ten minutes or more, after the more severe distress and pain have been relieved. The vault of the vagina may occasionally be painted with tincture of iodin, and in the intervals between the massage, tampons, medicated preferably with an antiseptic solution containing glycerin, should be worn. The tampon maintains the uterus at a higher level, promotes the absorption of exudation, facilitates involution, and thus favors its maintenance in a normal position. Vaginal douches, hot rectal enemas, hot sitz-baths, or the application of heat over the abdomen or pelvis in the form of hot sand or a peat bath will be found beneficial. Pressure over the abdomen, particularly where a mass of exudate is recognized, will promote its absorption. This action oftentimes causes such an exudate to melt entirely away. The pressure can be effected by the use of a shot bag, by which three to five pounds or more of shot are retained over the affected surface. When the uterus is freely movable or the adhesions have been absorbed, the organ can be maintained in its proper position by a suitable pessary. It should, however, be recognized that the physician must be able to replace the uterus in its proper position before employing this instrument. The pessary does not act as a corrective agent, but only as a crutch to support and maintain the uterus in its corrected position. The pessaries are generally made of soft and hard rubber, sometimes of wire coated with soft rubber. The soft -rubber instruments absorb the discharges from the vagina, decompose, become exceedingly foul, and cause a very disagreeable odor. During the time the pessary is worn it is important that the vagina should be' daily irrigated. Solutions of the inorganic salts should not be employed for irrigation, for they are likely to become deposited upon the surface of the pessary, cause it to be rough, and thus lead to abrasion and ulceration. Care must be exercised in the employment of the pessary that it shall not be either unduly large or too small. An overlarge instrument makes pressure upon the surfaces of the vagina, causes ulceration and the formation of granulations, which may envelop a large portion of the pessary and finally cause it to become embedded in cicatricial tissue. Too small an instrument permits the uterus to fall back over the pessary, or the pessary itself to be twisted around and thus prevent it being of any service. 516. Summary. — In anteversion and anteflexion of moderate DISPLACEMENTS OF THE PELVIC ORGANS. 549 degree constitutional measures for the improvement of the general health, the regulation of the secretions, enforced rest during menstruation, with dilatation, curetment, and the estab- lishment of proper drainage will be means sufficient to establish a symptomatic ciire. When the anteflexion is acute and dys- menorrhea is marked, curetment will generally be of only tem- porary benefit and should be followed by splitting the posterior lip and suturing the surfaces, as advised by E. C. Dudley. Retro- version and retroflexion are capable of producing marked influ- ence upon the general health, but should not be considered as indicating the practice of special procedures unless they are productive of symptoms. The correction and maintenance of the uterus in its proper position is indicated as a preliminary' treatment of any complication, and retroversion, associated with subinvolution following a recent parturition, unless com- plicated by perimetritic adhesions, should be considered an indication for the use of the pessary, but the previous replace- ment of the organ must be a sine qua non. In retroflexion, if the pessary is not well borne and the uterus is freely movable, the Alexander operation may be employed. The great frequency with which inflammation and more or less adhesion of the uterus occurs greatly limits the number of cases to which this operation is applicable. Indeed, I would prefer to make the median inci- sion, for it enables us thoroughly to examine the condition of the pelvic viscera, to break up existing adhesions, and to treat diseased conditions of the ovaries and tubes. As already seen, the great majority of operations for shortening the round liga- ments within the abdomen utilize the strongest portion of the ligament and leave the weakest undisturbed, with the probability of a redevelopment of the condition. The combination of the operations of Gilliam and Simpson, which I have employed, seems to me the most desirable, as it accomplishes all that the Alexander operation could do. Moreover, it has the advantage over the operation of ventrosuspension in that it affords no opportunity for the formation of adhesions which may serve as a trap by which a knuckle of intestine may become fixed and obstructed. My experience leads me to the performance of the operation known as ventrosuspension or ventrofixation less and less frequently. Of the vaginal operations, the ones pursued by Vineberg and Bovee are the most serviceable. The other vaginal operations have proved unsatisfactory, for many of the patients thus operated upon have experienced trouble during subsequent pregnancy. Prolapsus uteri is a condition which should receive early con- sideration. The longer the displacement is permitted to remain unantagonized, the greater are the chances that it can not be com- pletely restored. The first stage of uterovaginal prolapse can be 550 GYNECOLOGY. corrected by the employment of a suitable pessary. One should be employed Avhich will maintain the uterus in a position of ante- flexion or anteversion. The early stage of vagino -uterine prolapse should be considered an indication for the prompt retraction of the relaxed vaginal walls and the restoration of the perineum. The accompanying cystocele should be treated by an excision of the redundant vaginal portion of the septum. This surface should be sutured in a transverse direction in preference to the su- ture that is sometimes advocated, known as the Stolz suture, which shortens the vagina in every direction. The importance of having a long anterior vaginal segment is seen in its influence in maintaining the cervix at a higher level, consequently throwing the fundus forward. In the later stages of prolapsus the vaginal plastic operation should be supplemented by an abdominal pro- cedure to maintain the organ forward. This may be accom- plished by shortening of the round ligaments and of the utero- sacral. After the climacteric, especially when the uterus shows a marked tendency to descent, fixation of the organ is desirable. In very extensive prolapsus or in elongation of the supravaginal cervix the fundus uteri should be amputated, and the stump can then be secured to the upper part of the broad ligament or to the anterior abdominal wall. Very frequently the condition will be complicated by an extensive hernia through Douglas' pouch, when an extensive vaginal plastic operation, combined with a ventrofixation, will not necessarily prevent the development of this condition. The hernia may be obviated, however, by sutur- ing together the fold of Douglas over the rectum and the remain- ing part of each fold to the side of the rectum. Enteroptosis may be still further prevented by fastening the colon to the abdominal parietes. My experience has led me to condemn the Freund operation as one of no value. 517. Inversion of the Uterus. — Inversion of the uterus is that condition in w^hich its inner or mucous surface is outside and its internal or peritoneal surface within. Inversion can be partial or complete, and presents three different degrees: In a partial inversion the body of the organ is depressed and inverted until it reaches the cervix, but without dilating the latter, when it is known as the first degree, or inversion intra- uterine. (Fig. 419.) Next, the fundus protrudes through the cervix, the cervix being turned down upon the neck like a cuff, which is .the second degree, or inversion intravaginal. (Fig. 420.) In the third degree the entire uterus is inverted, and with it, not infrequently, the vagina, the uterus hanging outside the vulva, and this is known as inversion extravaginal. (Fig. 421.) Now, every degree of this form of alteration of the uterus can combine itself with a partial or total inversion of the vagina, DISPLACEMEXTS OF THE PELVIC ORGANS. 551 so the view that the third degree only is necessarily combined with prolapsus is a mistake. A trifling degree of inversion or partial turning in of the uterus is called invagination. This may be a mere depression, over which the mucous surface becomes convex, while the peritoneal surface forms a depression or con- cavity. As this depression continues, the proximity of the tubes and round ligaments to the ligamentum ovarium draws these structures into the opening. The ovaries may rest upon the funnel-shaped depression, while the tube is necessarily, for a part of its extent, drawn into the cavity. The cavity, with its Fig. 419. — Partial Inversion of the Uterus, Showing: Three Degrees. Fig. 420. — Intra vaginal Inversion; Three Degrees. enlarged opening in the peritoneal cavity, is called the inversion funnel. This funnel is usually not quite the depth of the ordinary length of the uterine cavity. If the inversion continues for some time, secondary phenomena result, from retrogressive processes, but the uterus returns to its normal size. The in- verted mucous membrane is covered with epithelium; the neck of the uterus is small, generally surrounded by a cuff of tissue, derived from the cervix, which has not been completely inverted — a cervical ring. The longer the inversion exists, the more consid- erable is the congestion, with edematous enlargement, and thick- ening which form the misproport ion between the narrow inversion 552 GYNECOLOGY. funnel and the enveloping cnff of the cervix. We not infre- quently find diseases of the adnexa. The orifice of the tube situated in the vagina can readily be the avenue for the passage of infection into the deeper structures. The uterine inner surface of the tubal mouths is exposed, the projecting mucous membrane is frequently rubbed and irritated, so this door stands open for \ J.. Fig. 421. — Extra vaginal Inversion; Three Degrees. Fig. 422. — Nonpuerperal Inversion. Fibroid Tumor Attached to the Fundus Uteri. the entrance of germs, and infection can take its way through the tubal mucous membrane or by the lymphatics to the deeper tissues, producing endosalpingitis, suppurative processes in the ovary, or purulent pelvioperitonitis by extension of infection from the connective tissue. In ordinary conditions we can have involvement of the cellular tissue from such infectious processes. DISPLACEMENTS OF THE PELVIC ORGANS. 553 Alterations in the peritoneal covering of the inversion funnel occur, which render the condition more or less fixed. 518. Etiology. — Inversion generally arises from two causes: first, from puerperal conditions, relaxation, or partial paralysis of the uterus during the process of labor, especially the third stage of labor; and, second, the nonpuerperal form, in which the uterus is displaced by the presence of a fibroid tumor at- tached to the fundus. (Fig. 422.) These two conditions are very much alike in the clinical form of an inversion, but are Fig. 423. — Palpation of an Inversion of the First Degree. very different in their manner of development. Puerperal inversions are much more frequent than those which arise from the presence of growths. They are in the proportion of nine to one. Total inversion is rare. How much more frequently the partial form occurs is difficult to determine, as not infrequently partial inversion resulting from the presence of growths is over- looked. Puerperal inversion, in some cases, is produced by traction upon the cord in the efforts to deliver the placenta ; by faulty pressure over the uterus the fundus may be inverted, and in the paralyzed condition may be grasped by the deeper struc- 554 GYNECOLOGY. tures and the inversion progress until it is completed. A short cord is an occasional cause for inversion. The traction is made upon the cord at a time when the uterus is relaxed and least resist- ant. The traction upon the fundus and the subsequent uterine contraction very rapidly complete the displacement. Inversion rarely occurs spontaneously. The overdistention of the cervix by a large fetus frequently causes such relaxation as will permit in- Fig. 424. — Palpation of an Inversion of the Second Degree. version to occur readily. It will be a matter of interest to know w^hether, in the cases in which inversion has occurred, the placenta has been attached near the fundus of the uterus. 519. Symptoms. — Inversion causes characteristic symptoms. The patient generally complains of severe pain, which is con- tinuous, sometimes for days; sometimes a pulling sensation is felt in the vagina. Immediately following the dislocation a severe hemorrhage occurs. This continues in noteworthy strength the DISPLACEMENTS OF THE PELVIC ORGANS. 555 first day of the puerperium, and does not completely disappear, but may continue much longer. Later, it appears intermittent, but the suspension of discharge rarely corresponds in its duration to the normal intermenstrual interval. During the interval there is a profuse mucous discharge from the genitalia. The profuse blood discharge may cause the death of the patient from acute anemia, or later from septic infection. In some cases sponta- neous reinversion may take place in the course of the year. The condition may be suspected from these phenomena. Fig. 425. — -Appearance of Inversion of the Third Degree. 520. Diagnosis.— Inversion will be suspected from the severe pain, the more or less continuous hemorrhage, and the absence of the fundus uteri when the hand is placed upon the abdomen. Digital examination discloses a globular mass which fills up the vagina and is encircled by a cuff -like ring at its upper part. This ring is situated at the external os. (Fig. 424.) Placing the hand over the abdomen and making deep pressure, the fundus 556 GYNECOLOGY. of the uterus is found to be absent from its normal situation, and, instead, a funnel-shaped excavation is recognized, which is ordinarily sufficient to determine the diagnosis. (Fig. 425.) In the chronic condition the uterus resumes its normal size, presents a globular or pear-shaped mass in the vagina, sur- rounded at its upper part by a distinct cuff or ring, and the sound will pass into this the same distance on all sides. Bimanual examination discloses above a funnel-shaped depression. This depression can be more readily determined by drawing upon the fundus of the uterus and introducing the finger into the rectum, when it can pass over the neck and directly into this funnel. Fig. 426. — a. Inversion of the Uterus, b. Fibroid Polypus, pus, with Stenosis of the Cervical Canal. c. Fibroid Poly- The ovaries and tubes are recognized near it or upon its margin. By investigation with the speculum the vaginal tumor is smooth, glistening, highly reddened, and sometimes at its lower angles the openings of the tubes can be recognized. While a vaginal examination may afford a suspicion of the character of the dis- order, the diagnosis is incomplete without a bimanual investi- gation which involves the rectum and belly cavity. When the abdominal walls are very thick and palpation is not readily determined, the introduction of a sound or a catheter into the bladder and of a finger into the rectum enables us to determine definitely the presence or absence of the uterine body. Inver- DISPLACEMENTS OF THE PELVIC ORGANS. 557 sion of the uterus is sometimes confounded with fibroid polypus which has been extruded into the vagina. (Fig. 426.) A fibroid polypus may have a broad-based pedicle and the tumor may present a shape very similar to that of an inverted uterus. As it is covered with rj;iucous membrane, the superficial similarity may be marked. Of course, a fibroid tumor will show no orifice of the Fallopian tubes, but the latter are not always distinguished. Sensation in the fibroid is a little less marked than in the inverted uterus, but is not sufiiciently definite to afford a foundation for diagnosis. The sound carried around the cuff of the inverted uterus passes on all sides an equal distance. With fibroid tumor it would pass into the uterine cavity at one side. (Fig. 426, b.) Occasionally, however, the cavity of the uterus may be so stenosed Fig. 427. — a. Submucous Fibroma, b. Partial Inversion, c. Partial Division- of the Uterus. that the sound will not enter, and the diagnosis may then be uncertain. (Fig. 426, c.) If we grasp the mass and draw it down, the finger in the rec- tum will disclose, in the one case, the cup-shaped depression of the inverted uterus ; and, in the other, the body of the uterus lying above the neck of the growth. In a partial inversion, associated with fibroid growth, we may not be able definitely to determine the condition until we proceed to operation for the removal of the mass. (Fig. 427.) 521. Treatment. — There is a difference in the treatment of the two forms of inversion. In the puerperal condition all that is necessary is to replace the uterus, when it will remain, while- 558- GYNECOLOGY. in the nonpuerperal form it is necessary to remove the growths which have occasioned it. Reinversion is comparatively easy in recent cases. Pressure against the fundus with the hand or Fig. 428. — Prolapsus Uteri without Inversion. Fig. 429. — Inversion of the Uterus — Extra vaginal. DISPLACEMENTS OF THE PELVIC ORGANS. 559 fingers in the shape of a cone will be frequently sufficient to carry the hand directly into the cavity of the uterus and to accomplish its complete reinversion. After the puerperal condition be- comes chronic we then have to resort to various methods for re- placement of the organ. These methods consist in manual treatment — instrumental and operative. In the manual treat- ment the fingers exercise a veritable taxis on the inverted organ, just the same as in hernia, and the tw^o hands are necessary for treatment, in which they play an essentially distinct role. The left hand over the abdomen maintains the uterus, while the Fig. 430. — Central Taxis. right replaces the inversion. Courty introduces one or two fingers into the rectum and hooks them over the end of the uterus, which fixes it more solidly. The other hand is intro- duced partly or totally into the vagina. The method of taxis is exercised in various directions; thus, it is central, lateral, or peripheral. The taxis is called central when the pressure is made against the fundus, or median part of the organ (Fig. 430) ; lateral, when it is exercised at the level of one or the other uterine cornu (Fig. 431) ; and peripheral when the pressure is exerted on the refiex parts (Fig. 432). The latter is exemplified when we 560 GYNECOLOGY, grasp the fundus in the palm of the hand, pass the fingers to the fundus of the vagina, and spread it out, stretching the funnel while the fundus is pushed against it. If taxis has been tried and found inefficient, we can then resort to instrumental reduc- tion. A number of instruments for this purpose have been de- vised. The air pessary of Gariel is introduced and distended. It exerts a hydrostatic or aerostatic pressure against the fundus, and pushes it upward, while the vaginal walls, by their traction, pull apart the cervix. This soft pressure in some cases may be suffi- cient to accomplish the gradual reduction of the organ. The pessary can be introduced and the bandage so applied as to Fie. maintain the pressure against the cervix (Fig. 433). A vaginal tampon of iodoform gauze for twenty-four hours is sometimes more effective than the pessary. The pressure is sometimes employed against the fundus by having an instrument with a cup-shaped end, into which the fundus fits, and a spring upon its external surface, by which an elastic pressure is induced. (Fig. 434.) This procedure is more effective when combined with Marcy's suggested insertion of two or more ligatures in the cervix, by which traction can be made upon it, while pressure is made against the fundus. Thomas advised opening the abdo- men and dilating the cervix with an instrument similar to a DISPLACEMENTS OF THE PELVIC ORGANS. 561 Fig. 432. — Peripheral Taxis. Fig- 433- — The Use of the Air Pessary to Reduce an Inversion. 36 562 GYNECOLOGY glove-stretcher, while pressure is made against the fundus. (Fig. 435.) This procedure was successful in one case and fatal in another. It has been suggested to introduce the index-finger of one hand into the rectum, and that of the other into the blad- der, hooking them into the funnel-shaped depression of the uterus, while the thumbs are pressed against the fundus. Kiist- ner advocates making a transverse incision through the posterior fornix of the vagina into Douglas' culdesac, through which he presses the index-finger of the left hand into the inversion funnel, and attempts with the thumb of the same hand to press up the fundus. If the procedure fails, he advises splitting through the posterior uterine wall, in the median line, by a longitudinal in- cision, which may extend to within two centimeters of the fundus, Fig. 434. — Reduction of Inversion with White's Apparatus. from the mucous surface to the peritoneal. (Fig. 436.) The renewal of attempts at reinversion under such circumstances is usually successful, for the reason that the resistance is removed and we are consequently enabled to replace the organ. After the uterus has been reinverted the fundus is turned down through the vaginal opening and a number of sutures are introduced to close the incision. Hirst advises a cut through the vaginal por- tion of the cervix only. Cases have been recorded of spontane- ous reduction of the inversion when the vulva has been distended with the patient in the genupectoral position. If the conditions DISPLACEMENTS OF THE PELVIC ORGANS. 563 are unfavorable for an operation of reinversion, we can proceed to total extirpation of the uterus or to amputation of the inverted fundus. When the amputation of the fundus only is made, it is very important to guard against reinversion of the stump with a resulting hemorrhage into the peritoneal cavity. The stump may be secured by three or four partial ligatures, and then the ampu- tation may be made below them. When the inversion is pro- duced by the presence of tumors, we may content ourselves Fig. 435. — Intraperitoneal Dilatation of the Uterus. simply with the removal of the gro^^i:hs and the reinversion of the organ; or when the organ is very extensively involved, it may be necessary to remove the fundus with the growth. The possibility of partial inversion should always be kept in mind in operating upon partial extrusion of groT\i:hs from the uterine cavity. Numerous cases are recorded in which a fibroid polypus or growth has been removed by the wire ecraseur, and examina- tion subsequently disclosed that a portion of the uterine wall was 564 GYNECOLOGY. removed, causing an opening into the abdominal cavity. With growths projecting into the vagina, the preferable procedure is a careful enucleation of the tumor. The tumor is depressed and held while the enucleation is performed under the eye, so that, even though an inversion has occurred, by hugging the tumor closely we prevent breaking through the wall of the uterus. 522. Displacements of the Appendages. — Displacements of the ovaries and tubes are verv common with backward uterine Fig. 436. — Incision of the Posterior Uterine Wall Preliminary to Reduction of an Inversion. displacement. Inflammatory troubles in the tubes cause them to drop down, from increased weight, and they are found behind the uterus in Douglas' pouch. (Fig. 43 7 . ) Frequently both tubes may be situated in this position, and, united at their abdominal ends, form a single tumor, which contains pus or serum. The tubes are dislocated by their attachment to growths; ovarian, DISPLACEMENTS OF THE PELVIC ORGANS. 565 fibroid, or broad-ligament cysts may draw the tube up into the abdominal cavity and almost double its length. The most fre- quent dislocation of the ovaries is downward, into Douglas' culdesac. This prolapse can occur as a consequence of retro- displacement, pr, independent of it, from elongation or rupture of the infundibulopelvic ligament. The dislocation can be occasioned by enlargement of the ovary, or the hypertrophy may be secondary to the displacement. The complication of retrodisplacement with ovarian prolapse is a source of additional distress and annoyance to a patient, as the tender ovarian struc- tures are subject to pressure from the heavy uterus and from the passage over them of the contents of the bowel. In this situation they are also subject to pain and distress during the act of coition, often rend- ering it so painful that the act is dreaded by the pa- tient. 523. Symptoms. — Prolapse of the ovary is generally associated with chronic inflamma- tion, either as a primary or second- ary condition. The symptoms from which the patients suffer are necessar- ily those which to some degree are occasioned by the chronic disorder. In addition to this fact, however, the patient suifers distress during fecal evacuation, during the act of coition, in walking, and on standing. The ache and distress are some- times so severe as to render the patient unable to assume or retain the upright position; a condition of semi-invalidism from the influence upon the nervous system is engendered similar to that present in chronic ovarian inflammation. There are no symptoms characteristic of tubal displacement. 524. Diagnosis. — Prolapse of the ovary, when freely movable, is readily determined by bimanual palpation. A mass can be felt posterior to the uterus in Douglas' pouch, which varies from Fisf. 437- Prolapsus of Ovary and- Tube behind Uterus. 566 GYNECOLOGY. the size of an almond to that of a small orange. These masses can be pushed up, and, as they rise in the pelvis, fall toward the side corresponding to the affected ovary, and drop backward as soon as the force is removed. When the ovary is enveloped with inflammatory exudate in the pelvis, it is more difficult to deter- mine its situation, and, in fact, it may not be discovered until after the abdominal cavity is opened. Tubal enlargement with adhesions can frequently be mapped out as extending around the side of the uterus on its posterior surface, and the organs are more or less fixed. 525. Treatment. — In inflammatory conditions of the tube involving the ovaries the treatment is the same as that of the diseased condition, as described in Section 468. Prolapse of the ovary associated with chronic ovaritis, in which the ovaries are very much enlarged, is best treated by extirpation. When the enlargement is simply due to prolapse, causing more or less ovarian edema, the organ should be brought up and fixed in its proper position. Frequently shortening the round liga- ments or ventrofixation will bring with it the restoration of ,the position of the ovaries. W^hen these, however, do not rest upon the posterior surface of the broad ligament, but drag backward into Douglas' pouch, the infundibulopelvic ligaments should be shortened or the external end of the ovary should be stitched to the posterior surface of the broad ligament near its upper part. Efforts have been made to maintain the ovary in its restored position by mechanical means, but in my experience they are usually ineffective. The ovary slips behind the pessary, though it have a thick bar, becomes pinched, and adds to the distress of the patient. Frequently the ovary will be caught behind the instrument, and the patient will be unable to move for a few minutes, owing to the severe pinching of the inflamed organ. GENITO-URINARY HEMORRHAGE. 526. Hemorrhage a Symptom. — The advisability of consid- ering hemorrhage under a separate heading or division, when it must be recognized that under all circumstances its presence is an indication of the existence of disease rather than the actual palpable disorder, may be questioned, but my experience has caused me to beheve that in the diseases of women the gravity of this symptom is not always fully appreciated, and that this failure will be better overcome if the subject is given the im- portance of a separate consideration. 527. Site and Varieties. — Hemorrhage may arise from any portion of the genito-urinary tract and from the vessels within GENITO-URINARY HEMORRHAGE. 567 the adjacent cellular tissue. It can occur at any age, though it takes place but rarely, except from trauma, prior to puberty. The significance of hemorrhage is largely dependent upon the age at which it makes its appearance. The hemorrhage is called open when the blood escapes from the urethra, vagina, or through external injuries; concealed, when within the abdominal cavity or in the cellular tissue. In the latter, also, it may be denomi- nated as circumscribed. A discharge of blood mixed with urine is known as hematuria. An excess of bloody discharge syn- chronous with the regular menstrual period is named menor- rhagia; while bleeding of an irregular character is named metror- rhagia; a collection of blood in the cellular tissue is known as a hematoma; when in the tissues of the vulva or vagina, it is called a vulvovaginal thrombus or hematoma; into the cellular tissue about the uterus, an extraperitoneal hematocele; an accumulation within the peritoneal cavity, which is encysted or closed in by peritoneal adhesions, is described as an intraperitoneal hemato- cele; hemorrhage into the structure of the ovary, when small, is known as an ovarian apoplexy; and when large, or frequently repeated, so the ovarian stroma is practically destroyed, and ^ the collection forms a blood cyst, it is called an ovarian hema-' toma. A collection of blood in one of the hollow organs is known, in the Fallopian tube, as a hematosalpinx; in the uterus, as a hematometra; and in the vagina, as a hematocolpos ; or when the collection is so large as to involve all, it is denominated a hemato- colpometro salpinx. Further distinctions are retro-uterine, circum- uterine, and ante-uterine hematocele, according to the situation of the blood collection — ^behind, about, or in front of the uterus. 528. Hematuria and Its Causes. — Hematuria is blood mixed with the urine, and is engendered by urethral caruncle, polypi, vegetations, fissures (the latter situated about the internal meatus) , and malignant disease of the canal. It occurs in acute and chronic cystitis, associated with more or less vesical ulcera- tion; in the aggravation of the disorder occasioned by the pres- ence of vesical calculi; and malignant growths or villous pro- jections from the vesical mucous membrane are a prolific source for the occurrence of blood in the urine. It is often produced by injury, inflammation, or malignant disease of the ureters or kidneys. Stone in the pelvis of the kidney frequently causes bloody urine. Occasionally, blood appears in the urine as a result of constitutional conditions. So frequently is it associated with malarial infection as to give rise to the term ■ malarial hematuria. 529. Symptoms and Diagnosis. — The blood may be mixed with the urine, giving it a dark, smoky, often almost black appearance, or may precede or follow the act of micturition, as a 568 GYNECOLOGY. few drops of free blood mixed with the urine or in the form of a small clot. The clots may be bright and recent, or darkened by longer retention within the urine. Unmixed blood comes from injury or disease of the urethra; frequently a few drops or a small clot will follow urination when caused by a fissure of the meatus. When the bleeding is occasioned by disease or injury of the bladder, the urine is not constantly bloody. An evacua- tion may be perfectly clear and the next be bloody. The cause of the symptom is ascertained by careful exami- nation. Disorders of the urethral orifice are recognized by in- spection of the canal, by palpation, and, if necessary, by inspec- tion through an endoscope or a urethral speculum. A fissure at the internal urethral orifice causes severe pain upon palpation of the urethra. Inflammation of the bladder — cystitis — is recognized by pain- ful and frequent micturition and attacks of profuse bleeding. The microscope reveals the cellular elements of the blood and degenerating epithelium in the urine. In growths or foreign bodies palpation discloses thickened walls, increased tenderness, and possibly the mobility of a foreign body or calculus. Micro- scopic investigation of the fluid evacuated is of great value. Not infrequently the bladder may be the seat of profuse bleeding, which becomes coagulated, and the clots interfere with the col- lection and evacuation of the urine. Disease of the ureter and pelvis of the kidney may produce bloody discharge. Irrigation of the bladder permits the char- acter of the urine from the kidney to be determined. Through the speculum the ureteric orifice will often be seen as a pouty, more or less abraded elevation, from which bloody urine is seen to issue. Catheterization of the ureter will determine the char- acter of the secretion in the respective kidneys and the existence of disease in one or both of the organs. Calculi in the renal pelvis are generally a source of pain in the region of the kidney. The pain is generally felt along the course of the ureter, not in- frequently over the distribution of the genitocrural nerve. 530. Treatment. — The treatment of hemorrhage is the same as that of the condition producing it. Hemorrhage from the bladder and urethra must be recognized as of importance. Measures for its relief (Section 409) have been described. When trouble can not be discovered in the urethra and blad- der, the treatment should be directed to the disease in the pelvis of the kidney. Before proceeding to internal measures, constitu- tional conditions should be excluded. If necessary, the blood should be examined for the presence of the malarial plasmodium. The determinaiton of malaria should indicate the use of anti- malarial remedies. Bleeding may be arrested by the employ- GEXITO-URIXARY HEMORRHAGE. 569 merit of astringents — tannic and gallic acids, hydrastis, and hamamelis ; cotarnin hydrochlorate, gr. ss-j ever^^ three hours ; ergotin, gr. j-ij four times daily; ol. erigeron, gtt. v-xx every three hours ; gelatin in lo per cent, jelly by the stomach, or 2 to 3 per cent, solution in salt solution by hypodermoctysis. Tyson advises ferri persulph., gr. J-^, as very effective. Continuation of bleeding associated with renal calculus should indicate operation for its removal. Operation will be a conserva- tive course, for the continuance of the disorder necessarily results in renal degeneration and destruction. 531. Genital Hemorrhage or Bleeding. — This term is em- ployed to distinguish bleeding which makes its exit externally, and miay arise from any portion of the genital tract. Bleeding of slight character, — a few drops, — which will occasionally soil the clothing, will be a source of great anxiety to a nervous patient and should be considered an indication for a careful investiga- tion by her physician. Such bleeding may arise from irritation of the vulva, warty growths, scratching induced by pruritus, from caruncle of the urethra, papillary growths and granulations of the vestibule or vaginal mucous membrane, lacerations, abra- sions or erosions, or beginning malignant diseases of the vagina or cervix, inflammation of the endometrium, or changes incident to gestation or parturition. ]\Iore severe bleeding or hemorrhage is induced by injuries of the vulva caused by falling and striking against a sharp object or by kicks or bloAvs ; these injuries cause very severe hemorrhage when the bulb of the vestibule is in- jured. Hemorrhage, is also incident to malignant disease of the labia or clitoris, severe injuries of the vagina, or extensive lacera- tions of the cervix. Interstitial endometritis, fibroid groT^1:hs encroaching upon the uterine cavity, and epithelioma, carci- noma, and sarcoma of the uterus are frequent causes. Hemor- rhage from the genital tract may also result from disease outside of the canal which interferes with its circulation, as, inflamma- tory exudate, cellulitis compressing the vessels of the pelvis and interfering with the return circulation, displacements, extra- uterine pregnancy, intraligamentary tumors of the ovary or of the uterus, inflammation of the Fallopian tubes, chronic inflam- mation of the ovaries, and constitutional conditions (as disease of the heart, of the kidneys, or of the liver) which affect the circulation in the uterus. The circulation is very often tem- porarily influenced by the development of zymotic diseases. Severe uterine hemorrhage may occasionally usher in an attack of typhoid fever. Disturbance of the process of gestation by hemorrhage may indicate the occurrence of abortion or of pre- mature labor, or may follow abortion or labor where the secun- dines or portions of the placenta are retained. 570 GYNECOLOGY. 532. Diagnosis. — The determination of the existence of ex- ternal hemorrhage, of course, presents no difficulty. It is exceed- ingly important, however, that we should be able to recognize its etiology and source. This will often be found a difficult ques- tion. No physician does justice to his patient who permits her to bleed without subjecting her to a careful examination in order to ascertain the cause. Not infrequently patients will object to the necessary examination. Such a patient should be plainly given to understand that the physician can not continue to treat her unless she affords him an opportunity to know the existing conditions. He will do himself less injury by absolutely refusing to treat the case than he will if he yields to the patient's objection and endeavors to palliate an unrecognized disease. Unfortunately, many patients have an idea that hemorrhage at or near the climacteric is a condition to be expected, so if free bleeding occurs at this period, they attribute it to the coming change of life and continue to endure it. Members of the medical profession, I find, are often responsible for this misconception, for frequently they advise the patient that the bleeding is inci- dent to her period of life, and that, therefore, when this has passed over, the hemorrhage will cease. Such a statement, however, only calms the patient and favors a transition from the existing to another and perhaps more serious state. Moreover, when the discovery of the actual condition is made, the time for radical measures has elapsed. The occurrence of hemorrhage incident to local or constitutional conditions makes it incumbent upon us to examine carefully every organ of the body to be certain of its cause. In every woman who suffers from hemor- rhage, where we are able to eliminate constitutional conditions, and where we can discover no disorders in the tissues about the organ or any disease of the cervix to explain the cause, the uterine cavity should be thoroughly explored. The previous history of the patient will enable us to ascertain whether the bleeding is due to the retention of products of a recent gestation. Bimanual examination will generally reveal even small growths. Such a condition will be manifested by localized areas of enlarge- ment or resistance in the organ. Some of these growths, being pedunculated, can be moved about in the uterine cavity to a limited degree. Combined palpation also affords information as to the possibility of malignant disease. The latter occurs more frequently in the cervix, and when it exists in the body, it causes more or less hardening and sense of resistance from the presence of infiltration. This, of course, depends somewhat upon the associated reactionary inflammation. If the disease involves only a portion of the lining membrane of the uterus without the infiltration extending into the wall, the bimanual GENITO-URINARY HEMORRHAGE. 571 examination will not reveal the induration. Therefore it will be necessary to explore the uterine cavity, preferably with the finger. The finger within the uterus and the hand over the abdomen enables one to outline and definitely determine the thickness and rigidity of the wall and the extent of induration as well as the general condition of the uterine mucous membrane. In the nonpuerperal uterus, however, one can not readily em- ploy digital exploration of its cavity without a previous dilata- tion. Dilatation may be accomplished by a variety of methods, one of which is the employment of mechanical dilators or of graduated bougies. This procedure affords an excellent oppor- tunity for the employment of therapeutic measures within the uterus, but sufficient dilatation of the organ can not thus be secured to allow the introduction of the finger without tearing and inflicting serious injury to the structure of the cervix. The cervix may be split on either side of the internal os with scissors or knife, after which the canal can be dilated or stretched enough to permit the introduction of the finger. Often this method of procedure is associated with an extensive laceration of the uterine structure, and, furthermore, incision of the cervix is too radical an operation for mere exploration. It is only when it is neces- sary to institute treatment for a threatening condition within the uterine cavity that we would advise cervical incision. Another method of dilatation is that devised by Vulliet, which consists in packing the uterine cavity with pieces of gauze until the cervix becomes gradually dilated, and renewing this gauze packing until the uterine cavity is so well dilated that the finger can be readily introduced. This plan is open to the objections, how- ever, that the gauze is an irritant, requires care that the patient does not become infected during the progress of the procedure, and in many cases, particularly when the cervix is the seat of infiammation and is a little rigid, the dilatation is ineffectually accomplished. The most effective method of dilating the cervix is accom- plished by the use of tents. The tents may consist of sponge, laminaria, or tupelo. Sponge tents are objectionable on account of the difficulty of rendering them sterile and because of the fact that they readily become impregnated with the discharges, which quickly decompose and predispose to infection. This danger has in some degree been obviated by the suggestion that the tent be covered with a rubber sleeve, but this requires the employment of special measures to convey the moisture to the tent. The laminaria tents are exceedingly eff'ective, preferably those which are perforated. The tent should be carried into the uterine cavity without much force, the tent and the canal having been previously rendered, as far as possible, sterile. As I 572 GYNECOLOGY. large a tent as can be introduced should be employed. When the cavity is somewhat dilated or when the first tent is not sufficiently large, and we wish for more complete dilatation, a number of tents or a nest can be employed. More rapid dilata- tion is accomplished by previously moderately stretching the canal with bougies. If aseptic precautions are observed, the danger is not thereby increased. The details of the procedure and the precautions to be exercised have been given. (Section 85.) 533. Treatment. — The treatment should be directed to the disorder which has caused the hemorrhage. We may not, how- ever, be ready, or the patient can not be subjected to radical treatment, while the hemorrhage is so severe as to necessitate the exercise of measures to save her life. Various remedies are advocated for relief of hemorrhage — agents which exercise con- tractile power upon the involuntary uterine mucous membrane, of which ergot is one of the most efficient. It not only causes contraction of the uterine muscle wall, but also decreases the amount of blood that is sent into the uterus through the con- traction of the uterine vessels. Thyroid extract and the extract of mammary gland have been highly extolled. The various astringents are of benefit, as gallic and tannic acids; dilute sul- phuric acid; iron salts, especially the persulphate of iron; ham- amelis; hydrastis and its salts, hydrastin and hydrastinin; and the tincture of cinnamon. The latter may be given with good effect in combination with either gallic or tannic acid, giving from ten to thirty grains of the acid with a tablespoonful of the liquid. Cotarnin hydrochlorate (stypticin), gr. ss-j every two or three hours, is frequently very effective in controlling hemor- rhage. The patient should be kept perfectly quiet in bed; if hemorrhage is severe, she should be prevented from rising even to evacuate the bowels or to void the urine. Cold applications may be made to the abdomen, and heat or a mustard-plaster ap- plied between the shoulders, in order to divert the current of blood from the pelvis. Local applications of various astringents, such as alum, zinc sulphate, hydrastis, or hamamelis, used in strong solution or as a douche, may be employed. Douches of hot water should be given the patient while in the recumbent posi- tion, using water at from 110° to 115° P., even 120° F. if the patient can bear it. Applications to the uterine canal by in- jecting a few drops of perchlorid of iron may be employed, or the cavity may be swabbed with it. The objection to the injection is that the uterine cavity will contract upon its contents, causing contraction of the cervix, by which the contents are forced from the uterine cavity into the tubes, and produce inflammation within them, or, worse, a localized peritonitis. Gersterberg GENITO-URINARY HEMORRHAGE. 573 employs a strong solution of formol upon a cotton-wrapped applicator. A solution of aluminium acetate has been advo- cated. When hemorrhage is severe, endangering the patient by its continuance, the uterine cavity should be tamponed, by packing a good-sized piece of gauze firmly into its cavity. This prevents the further discharge of blood and facilitates the dilata- tion of the canal until it can be explored. These measures for the treatment of hemorrhage are merely palliative. They do not correct the fault or the trouble which induced it; and the earlier radical treatment can be instituted, the better it is for the patient and the more readily is the condition controlled. Slight bleeding from the vulva and vagina is readily controlled by making applications of an astringent or a styptic, such as persulphate of iron, directly to the diseased surface. The cavity should be packed, in order to secure further improvement through pressure. When bleeding occurs from an injury to the vulva, the most efficient means is to enlarge the external injury and to secure the bleeding vessel by ligation. When a large surface bleeds, the hemorrhage is best controlled by packing with iodo- form gauze, making firm pressure upon or into the wound. When the bleeding is the result of incomplete abortion or the ex- istence of an intra-uterine growth, the offending cause should be removed. An interstitial endometritis should indicate the em- ployment of the curet. Atmocausis, or the application of steam to the uterine cavity by a special apparatus, has had many ad- vocates, but it would seem desirable to employ more controllable measures, for it is impossible accurately to regulate the amount of destruction to which the uterine mucosa will be subjected, and definitely to equalize its distribution. 534. Vulvar Hematoma or Hematocele. — ^Vulvar hematoma or thrombus is a term applied to hemorrhage which takes place into the tissues of the vulva. It arises as a result of injury sufficient to cause rupture of a vessel without a break in the in- tegument. AVhen the injury involves the bulb of the vestibule, the hemorrhage may be extensive and cause a large-sized tumor, which involves one or the other large labium. It also occurs from rupture of varicose veins or from compression of vessels during the progress of labor. The latter is the most frequent cause. The tumor may attain the size of an orange or even of the fist, and may be very tense and painful. It usually occurs suddenly, and is associated with more or less burning and pain in the region of the swelling while it develops. When the skin is unbroken and the collection does not become infected, it may be completely absorbed. 535. Vaginal Hematoma or Thrombus. — This condition, un- complicated, is of rare occurrence. It is usually associated with 574 GYNECOLOGY. hemorrhage into the vulvar tissue, forming a vulvovaginal thrombus. It usually occurs upon one side of the vagina, and is most frequently a result of injuries sustained during labor. The exciting agent is the passage of the presenting part of the child, which frequently pulls off and stretches the vaginal at- tachments. This causes rupture of the vessels and severe bleeding. The tumor may attain a very large size, compress the vagina and rectum, and cause difficulty in micturition. The physician may be in doubt, when called to see such a patient, whether it is an accumulation of blood or a suppurative process. The better plan of procedure is, of course, to make a careful examination. With the history of the patient in mind, we may be able to eliminate the probability of it being inflammatory, especially when it occurs shortly after a confinement. During the year 1898 I saw a patient, thirty-four years of age, three weeks after her first confinement, who had passed through a normal labor. She had, however, sustained a slight laceration of the perineum, which was repaired. Two weeks subsequent to her delivery she developed some elevation of temperature, with more or less distress in the pelvis, and examination dis- closed a large swelling which compressed the vagina and rectum. The mass thus formed was quite large; the right buttock was edematous and the mass protruded into the vagina to such a degree as greatly to obstruct it, as well as to encroach upon the rectum. Sensation of fluctuation was indistinct. The right buttock was so much more prominent than the left and the sen- sation of elasticity, almost fluctuation, so marked "that I decided to incise through it and thus reach the mass, rather than to make an incision from the vagina. The incision into the buttock, however, disclosed that the swelling in it was entirely edematous. Through this incision the levator ani muscle was opened, when there was at once a discharge of a large quantity of bloody fluid and clots. By pressure through the vagina the mass was readily removed, and the patient looked and expressed herself as feeling greatly improved. A gauze wick was passed through the wound into this cavity with a view to insure drainage and to prevent its premature closing. The gauze was removed at the end of twenty-four hours, and the subsequent progress of the patient was uninterrupted. Another case of this kind came under my observation in a young woman who had been delivered by forceps. The right side of the pelvis was apparently occupied by a large clot, which bulged into the vagina, protruded into the labium, and gave rise to suggillation of the entire buttock. This mass was incised from the vagina and it was found to extend up into the broad ligament of the right side. The clot was thoroughly turned out and the cavity packed with a large quan- GENITO-URINARY HEMORRHAGE. 575 tity of iodoform gauze. The patient recovered. I have ob- served one case of vaginal hematocele in which labor was com- plicated by an ovarian dermoid. The union of this growth with the uterus had been destroyed by previous torsion. The tumor subsequently became engrafted upon the omentum, from which, by a broad band of adhesion, it evidently received its nutrition. It was attached below by folds of the peritoneum, which ex- tended over and to the left of the bladder. In the latter fold, dipping down into the pelvis in front of the bladder and vagina and to the left of the latter, was an extensive collection of clotted blood, which had evidently been produced by pressure upon the inferior attachments of the tumor during the progress of labor. 536. Diagnosis. — Vulvar hematoma is likely to be confounded with edema of the labium and with labial tumors. Its devel- opment, however, is too sudden for the latter condition. Edema of the labium is generally associated with other disorders. It is not one-sided. Both labia are involved unless the edema is due to some special cause, in which there is obstruction of vessels or lymphatics on one side only. Vulvar and vaginal thrombi are usually associated, producing the condition already de- scribed as vulvovaginal thrombus. The condition generally follows difficult or complicated labors. Pus-collections are rarely found in the lateral walls of the vagina, but are most fre- quently pushed into the vagina from the posterior fornix. Thrombi, on the other hand, are frequently found upon the lateral surface and rarely affect the posterior vaginal wall. 537. Treatment. — The amount of bleeding in these thrombi is usually limited, for the pressure of the tissues into which bleed- ing occurs naturally controls it. In noninfected cases the extra vasated mass is ultimately absorbed, although in large collections it may remain for quite a long time. A patient recently came under my observation in whom an operation was required for pelvic inflammation. On examination, a mass was felt posterior to the rectum, in the neighborhood of the sacrococcygeal articulation, which had an elastic sensation. Upon inquiry, I found she had undergone her first labor six months before, with a history of an injury to the coccyx. The coccygeal injury had, however, disappeared ; the mass remained. As I had already made an incision through the vagina into the peritoneal cavity, I did not care, therefore, to attempt to open into this from the vagina, on account of the dissection required around the rectum. An incision was made into this sac pos- terior to the anus, when a teacupful of thick, pasty, reddish material, evidently the remnants of the clot, was evacuated. Gauze drainage was instituted, and the cavity gradually closed. 576 GYNECOLOGY. When the collection is small, it may, without detriment to the patient, be left to nature; but when large, the pressure produces thinning of the enveloping wall and permits the ready introduction of infecting germs, either from the rectum or the vagina. In such collections the danger of subsequent infection is decreased by free incision and the evacuation of the accumulation. Not only should the clots be removed, but measures must be employed to preclude further hemorrhage. A large bleeding vessel may be sectired by passing a ligature beneath or about it with a needle. When ligation is impractic- able, hemorrhage should be controlled by packing with iodoform gauze. The gauze should be retained for two or three days, and should be renewed with a smaller amount, in order to keep the external wound open long enough for the cavity to undergo thorough contraction. 538. Peri-uterine hemorrhage may be intraperitoneal or extraperitoneal. Intraperitoneal hemorrhage, unless preceded by inflammatory adhesions which form limitations, is free, and may be large in quantity. Extraperitoneal hemorrhage takes place into the cellular tissue about the uterus and the broad ligaments, and is limited by the pressure of the tissue. Hemor- rhage into the cellular tissue beneath the peritoneum under- goes coagulation and forms a bloody tumor, known as a hemato- cele. It is analogous to the thrombus which occurs during the progress of labor, and which we have described under the term vulvovaginal. Hemorrhage into the peritoneal cavity will form a coagulum, and subsequently a tumor, or, when very free, may remain liquid and the hemorrhage continue until the death of the patient or until surgical intervention is practised. 539. Causes. — The causes may be divided into two classes: first, hemorrhage that results from extra-uterine pregnancy, which is more important, because more frequent and more serious in its results; second, hemorrhage of nonpuerperal origin, which occurs without the existence of fecundation. The pelvis being the most dependent portion of the abdomen, hemorrhage from any of the intra-abdominal viscera, or within any portion of the peritoneal cavity, naturally gravitates into the pelvis. Thus, we may have intra-abdominal hemorrhage from traumatic injuries of the liver or spleen, rupture of an aneurysm of the aorta or of the celiac axis, rupture of varicose veins, from the ovary, regurgitation from the Fallopian tube of menstrual blood (particularly when there is obstruction of the uterine neck), rupture of a uterine or tubal collection, rupture of bands of adhesion in the pelvic peritoneum, slipping of a ligature, or the retraction of a cut vessel following an opera- GENITO-URINARY HEMORRHAGE. 577 tion. Any of these causes may lead to an accumulation of blood in the pelvis or, particularly, in Douglas' pouch, whereby the intestines containing gas are floated up and the uterus is pushed forward. Soon or later the coagulated blood causes irritation and l^ads to the formation of adhesions, by which the collection may become encysted and form what is known as an intraperitoneal hematocele. (Fig. 438.) The most fre- quent cause, however, belongs to the division of the puerperal or extra-uterine. 540. Symptoms. — Intra-abdominal hemorrhage from what- ever site or cause, unless limited by previous adhesions, will gravitate into the pelvis. The gravity of the symptoms will de- 438. — Intraperitoneal Hemorrhage. pend upon the size of the vessels injured and the rapidity of the hemorrhage. The rupture of the vessel is generally associated with pain in the vicinity of the lesion. This sensation may be intense cutting or burning. If the hemorrhage is slight, it ma}^ be slow and produce little if any constitutional evidence. When severe, the symptoms of shock are profound and may be announced by severe, agonizing pain, accompanied by syncope or repeated attacks of fainting. The skin is pale, covered with a cold, clammy perspiration, the pupils are widely dilated, pulse feeble, frequent, or absent in the radius. The mere effort to raise the head may lead to unconsciousness. The temperature is sub- normal. The syncope may be associated with such reduced 37 578 GYNECOLOGY. arterial tension that a clot is formed, which obstructs the bleed- ing vessel and becomes so firmly fixed that as the patient reacts the hemorrhage is controlled. The salts of the blood so irritate the peritoneum that a mild grade of peritonitis results, which leads to the collection becoming encysted. The watery portions of the blood are absorbed and the clot may gradually become organized and result in thickening of the peritoneum and ad- hesions as the only traces of its occurrence. More frequently the condition from which it has originated, or the stagnation from the imprisoned intestinal coils, leads to infection and the for- mation or a pelvic abscess. Unless such a condition is i r- M" ' ^ '^'^ // ^..^Sii^^ik^-^ promptly evacu- / ^^AP^ ■ ^ ' M ated, general infec- /^^ AyL:^^^-\^' JJ^^HP^Sf' ^^^^ may follow. // //'^ "^ y^^fe^>*^BF / ' // 541. Extra p e r i- toneal Hematocele. — Extraper i t o n e a 1 hemorrhage result- ing in the formation of a hematocele may be produced by puerperal or non- puerperal causes. (Fig. 439-) .The former, associated with ectopic gesta- tion, are the more frequent. The non- puerperal causes are the rupture into the broad hgament of varicose veins, and injury of an artery or its retraction from the stump when the pedicle is ligated en masse. 542. Symptoms. — Extraperitoneal hematocele in. the broad ligament is limited in its character, and causes symptoms similar to those which have already been enumerated for the intra- peritoneal variety, though in a much slighter degree. The indications of shock and collapse are much less marked, and hemorrhage, from its limitation, is much less serious in its influence. As it occupies the broad ligament, it is usually situated upon one side of the pelvis, and pushes the uterus to the opposite side. This hemorrhage may be situated either in the upper part or in the base of the broad ligament, and Fig. 439. — Extraperitoneal Hematoma. GEXITO-URIXARY HEMORRHAGE. 579 may produce different physical signs according to its situation. The hemorrhage, when low in the broad ligament, may dis- sect forward between the uterus and bladder, or backward around the uterus beneath the peritoneum, and extend to the opposite side. In the great majority of cases, however, extraperitoneal hemorrhage is one-sided. 543. Diagnosis. — Peri -uterine hemorrhage, w^hether intra- peritoneal or extraperitoneal, is determined by the phenom- ena of internal hemorrhage. It is true that similar symp- toms — a sharp pain, symptoms of collapse — might arise from rupture of a pyosalpinx or a pelvic abscess. In such accidents, however, acute agonizing pain is caused, with symptoms of peritoneal reaction which are more intense than when from the hematocele, but a tumor does not form. A retrofiexed gravid uterus may be mistaken for hematocele, but the out- line of the boundaries of the organ are more definite than those found in hematocele. In the latter the uterus is frequently inclosed within a mass or pushed forward, while by a careful examination in a retrofiexed gravid uterus the cervix is found at a higher level, either in the axis of the vagina or looking for- ward ; a distinct angle exists between it and the smooth, definitely outlined mass filling up the pelvis, which should not be confounded with hematocele. Ovarian cysts and uterine fibroids imprisoned within the pelvis possess nothing in common with hematocele. The manner of appearance and the course of development of the condition are entirely dift'erent. Extra-uterine pregnancy before rupture does not present similar symptoms, although it may be a starting-point for the later hemorrhage, and unless the examination is carefully performed, rupture may result from the methods used for diagnosis. Extraperitoneal hemorrhage is determined from intraperitoneal by the situation of the collec- tion upon one side, which is more definitely localized,, its boun- daries more sharply defined, and the uterus generally pushed to the opposite side, while in the intraperitoneal hematocele the lat- ter is surrounded by the accumulation or is pushed forward. The determination of the cause of the hemorrhage is not always easily accomplished. Previous symptoms of pregnancy, amenor- rhea, with symptoms rapidly ushered in, profound depression, and very marked anemia, should lead to the suspicion of probable rupture of a fetal sac. Symptoms of collapse or depression, of internal hemorrhage, may arise from rupture of internal varicose veins. In hemorrhagic salpingitis the condition is more insidi- ous, the progress more slight, owing to the gradual effusion of blood. Should there be any doubt of intraperitoneal hemor- rhage, the true condition can be surely determined by making 580. GYNECOLOGY. an exploratory puncture through the posterior vaginal fornix. This is a justifiable and commendable procedure. 544. Prognosis. — The affection is always a serious one. We can not be certain that death may not suddenly result from a continuation of the hemorrhage, or, when hemorrhage has apparently been arrested, that the clot may not be loosened and hemorrhage again recur. In large collections the progress of the, case is exceedingly tedious. Plastic material remains about the uterus for a long time, becomes more or less organized, is frequently a source of discomfort, and often a cause of sterility. That sterility is not invariably caused is evident from the numer- ous cases recorded in which women have suffered from hemato- cele, in whom the collection is ultimately absorbed, and the patient again undergoes an ectopic gestation, and the experience is repeated. The presence of a large collection of blood within the pelvis is a source of continuous danger, from its close prox- imity to the vagina and rectum, through either of which chan- nels infectious material may enter, to cause pelvic suppuration. Suppuration is particularly likely to occur if the individual has had previous tubal disease, from which, doubtless, the infection develops. The extraperitoneal variety is less serious in its in- fluence, much more likel}^ to undergo absorption, and leaves less evidence of its previous existence. Its situation renders it less susceptible to infective changes. When the collection is large, however, and has existed for some time, the patient will, without question, have a more favorable prognosis by the exercise of measures for its removal. 545. Treatment. — -Active interference must depend very much upon the character of the symptoms and the severity of the attack. When the symptoms are such as to indicate escape of a large quantity of blood into the pelvis, the abdomen should be opened promptly, clots removed, and the bleeding vessel secured. In profuse internal hemorrhage ligation of the bleed- ing vessel is just as certainly indicated as in hemorrhage from the radial or femoral artery. When hemorrhage has apparently been arrested and a reactive peritonitis develops, we are not absolutely certain that the clot can not be displaced and the patient suffer from a recurrence of hemorrhage, which may be fatal, or that the collection of fluid about which nature is forming its barriers may not become infected from the neigh- boring hollow viscera and cause subsequent changes, necessitat- ing its evacuation, with increased danger to the patient. In extraperitoneal hemorrhage the indications for operation are not so marked. The symptoms are much slighter, the amount of exudation is less, and the probabilities of infection are dimin- ished. In such cases we can afford to wait and trust to nature GENITO-URINARY HEMORRHAGE. 581 to absorb the effused fluid. In large collection^, however, much time will be saved by its evacuation. The method of operative procedure will depend upon the time the condition comes under observation. In an acute attack, and with an evidently bleedihg vessel, we should follow the procedure which affords the most accurate and complete exposure, with the most ready access to the field of hemorrhage. Abdominal incision meets every indication, as through it we are enabled to see and to reach the bleeding vessel. A¥hen the patient, however, comes under observation a week or more subsequent to the hemorrhage, when the peritoneal reactive processes have resulted in the blood becoming encysted, and vaginal and abdominal palpation discloses that barriers have been formed by plastic exudate between the knuckles of intestine over the surface of the hematocele, the vaginal incision is the preferable procedure. This procedure is preferable for the reason that it respects the barriers which nature has constructed to limit the collection, and affords a free opportunity for the evacuation of the clots. They are removed by the finger and by irrigation. With gauze packing and a free vaginal incision the subsequent progress of the case is much less severe and the length of the convalescence is decreased. When blood has been effused into the peritoneal cavity and clots have formed, by neither the abdominal nor the vaginal method would we be able to remove all the clotted blood. The clotted material remains adherent to the sides of the sac and pelvis, and is likely in either procedure to cause a certain elevation of temperature as a result of the fermentation taking place in the retained fibrin. When the condition has gone on to suppuration, there should be no question as to the preferable procedure of reaching the collec- tion, when accessible, through the vagina, rather than by the abdominal route. It should be remembered that not all cases of internal hemorrhage are necessarily fatal nor require opera- tive procedure. If the patient is unwilling to undergo an operation, or the conditions do not urgently demand it, the promotion of absorption should be accomplished by keeping the patient absolutely at rest in bed, by the use of the catheter to empty the bladder, and by the evacuation, of the bowels or intestines by enemas. Absolutely interdict the use of opium, keep the vagina antiseptic by repeated douches, and when it is supposed that hemorrhage still continues, or that it is in danger of being renewed, apply an ice-bag over the abdomen, introduce ice suppositories into the rectum, and thus bring the ice in close contact with the bleeding vessels. In extraperitoneal hemorrhage indications for operation are much less marked. The absorption may be promoted by keeping 582' GYNECOLOGY. the bowels regular and the patient at rest, and by the applica- tion of cold over the abdomen or of counterirritants. When operative interference seems indicated, the preferable procedure would be to make an incision through the vagina into the broad ligament, tear with the finger or a blunt instrument through the tissue of the ligament until the hematocele is reached, then enlarge the opening, turn out the clots, irrigate the cavity, and introduce gauze to afford vent for further discharge. When the collection is very large, it may sometimes be evacuated by an incision above Poupart's ligament and pushing back the perito- neum, the collection exposed, opened, and evacuated. After the cavity is thoroughly emptied, it should be packed with gauze, as alreadv advised. EXTRA-UTERINE PREGNANCY. 546. Definition. — When the fecundated ovum does not reach its normal situation, — the uterine cavity, — but undergoes develop- ment external to it, the condition is designated ectopic gesta- tion or extra-uterine pregnancy, ]\Iuch difference of opinion exists as to the point at which the union of the spermatozoon and the ovum, and its consequent fecundation, takes place. Tait very firmly asserted that in the normal condition this fecundation always occurred in the uterus. Others as em- phatically believe that fecundation may occur at any point between the internal os and the exit af the ovum from the Graafian follicle. The recognition of the fact that in the lower animals the spermatozoa in normal conditions are found in con- tact with the ovary w^ould seem to afford justification for the belief that fecundation does not absolutely occur within the uterine cavity. Fecundation in the majority of cases un- doubtedty occurs in the tube, but may occur at any point in the progress of the ovum to the uterus. The changes which follow, as a result of fecundation, produce alterations in the uterine mucous membrane which prepare it for the reception of the fecundated ovum. 547. Causes. — Much difference of opinion still exists as to the causes which lead to the occurrence of a misplaced ges- tation. Some would deny that inflammation has any part in its production, and would lead us to believe that the existence of inflammation in the tube always produces alterations which preclude the subsequent occurrence of pregnancy. Every ab- dominal surgeon of any experience, however, has seen cases in which well-marked tubal disease, and frequently of evident gonorrheal origin, has subsequently recovered, and the pa- EXTRA-UTERINE PREGNANCY. 583 tients have given birth to children. During the active inflam- mation of such tubes the abdominal orifices are closed off by exudate, which, during the following resolution, may be reab- sorbed and afford an entrance to the tube. Those who exclude inflammatory cpnditions as a cause attribute the occurrence of ectopic gestation to congenital conditions. These consist of long tortuous tubes containing numerous tubal constric- tions, and, especially, a tubal diverticulum. It is also attributed to intratubular growths, which limit the caliber of the canal, or to growths in the tubal wall, or to pressure of growths ex- ternal to the tube. The hypothesis of the migration of the ovum from^ the ovary of one side to the tube of the opposite side has been well established. i\s evidence, a history is recorded in which an intra-uterine pregnancy occurred in a woman who had lost the tube of one side and the ovary of the opposite side. It has been supposed that the ovum, having become fecundated upon its emergence from the Graafian follicle, attains too great a size before it reaches the tube of the opposite side to permit of its passage down that canal. The vegetations upon the ovum, however, which form the chorion, do not develop until the ovum has come in contact with the tubal mucous membrane, hence this cause is of doubtful application. Every- one familiar with poultry is aware that occasionally an unusually large egg will be laid. Indeed, I have seen cases in which the egg was too large to pass through the canal. It is not improb- able that similar conditions exist in the formation of the ovum, and that, occasionally, an oversized fecundated ovum may lodge on its wa}^ to the uterus. Fright and emotional conditions at the time of conception are ascribed as causes. Were the latter, however, an important factor, tubal gestation would be likely to occur much more frequently in illegitimate cases. The study of the history of ectopic gestation long ago led to the recognition that a misplaced gestation was frequently associated with prolonged sterility. It is not unreasonable to believe that a period of sterility has been one in which in- flammatory conditions have existed and which have subsequently improved. Investigations of inflammatory conditions disclose the fact that loss of the tubal epithelium is of rather rare occur- rence. The existence of the gestation is due, not so much to the presence of patches of desquamated epithelium, as to in- flammatory changes which cause the canal to become narrowed, the folds of the mucous membrane thickened, thus rendering the passage of the fecundated ovum more tedious than under normal conditions. The expedition of the ovum to the uterus is also retarded by the decreased peristalsis resulting from hyperplasia and loss of activity in the muscular wall. Gon- 584 GYNECOLOGY. orrheal inflammation seems to have a special influence in the production of ectopic gestation. Thus, Prochownik found gonorrhea in three out of eight cases, and Ahlfeld, in the few cases he has observed, also attributes the condition to gonor- rheal infection. Ectopic gestation may occur at any period of the reproductive life, as in a first pregnancy or in women who have borne a number of children. Analysis of a large number of cases will show that several A^ears of previous sterility will occur in the majority of cases. It may occur in the first pregnancy of a woman who has been married eight, ten, or twenty years, in a woman who has not given birth to a child for five or six years ; or, again, it may follow immediately after a labor or abortion. Furthermore, it may occur in the newly made bride or in the unmarried. Both tubes may be pregnant concurrently or one tube may contain a tubal pregnancy or a tubal may com- plicate a uterine pregnancy. Cases have been reported in which Fig, 440. — Tubal Pregnancy. there occurred a twin pregnancy in the outer portion of the tube, and an interstitial or single pregnancy in the uterine end, making three embryos in the one tube. Dr. Wilmer Krusen has reported a tubal pregnancy which had ruptured, and in the sac three fetuses were found. 548. Varieties. — Ectopic gestation is most frequently found to be of the tubal variety. Some undisputed cases of ovarian pregnancy have been described, but when we consider the fecun- dated ovum and the conditions necessary for its nutrition and development, it is evident that the ovum rarely develops when not in contact with the Miillerian mucous membrane. It is quite probable that many of the cases described as ovarian preg- nancy have been originally tubo-ovarian and have become separated from their tubal relation. Tubal gestation occurs most frequently in the central portion of the tube. (Fig. 440.) It may be situated toward its abdominal end, and as it de- EXTRA-UTERINE PREGNANCY. 585 velops, is extruded or partly extruded and comes in contact with the ovary, when it is known as tubo-ovarian pregnancy. (Fig. 441.) When situated within the central portion of the tube ■or ampulla, it is known as ampullar or tubal pregnancy. To- ward the uteri*ne end, or that portion which passes through the uterine wall, it is known as tubo-uterine or interstitial pregnancy. (Fig. 442.) Rupture of a tube with partial escape Fig. 441. — Tubo-ovarian Pregnancy. of the ovum, which retains its placental attachment, may sub- sequently develop, when it becomes an abdominal pregnancy. Abdominal pregnancy, therefore, is secondary and not primary. The reimplantation of the ovum upon the peritoneal surface and its subsequent development have been asserted to be an impossibility, but when we find the tube having no longer any Fig. 442. — Tubo-uterine or Interstitial Pregnancy. relation or connection with the sac, the placenta situated, as in the case of Tuholske, upon the liver, and apparently upon the folds above it, it seems impossible to explain its occurrence upon any other ground than that of reimplantation. 549. Course and Progress. — The fecundated ovum lodged in the tube finds a condition different from that of the ovum within the uterine cavity. In the latter, the mucous membrane 586 GYNECOLOGY. consists of glandular or lymphoid tissue, which becomes thickened as a preparation for the reception of the fecundated ovum, in which the trophoblast cells of the ovum enable it to sink in and become embedded. The syncytial cells in the chorion arise from the trophoblast cells, and the uterine epithelium in no sense plays any part in their production. In the tube it meets with an entirely different condition. There are no glands, and there is much difference of opinion as to the formation of the decidua. This, in the uterus, consists of a compact and spongy layer, but in the tube, of a compact layer only. The decidua cells are found not so much in immediate contact with the wall of the tube as at either end of the sac. Bandler, in his investigations on the development of ectopic gestation, divides it into three types : ( i ) The columnar type of tubal gestation ; (2) the intercolumnar ; and (3) the centrifugal, (i) In the columnar variety, at no point in the tube wall or in the mucosa Fig. 443. — Tubal Abortion. is there any decidual change or any condition representing the trophoblast cells or villi, consequently no decidua or tropho- spongia develops. The ovum is surrounded by mucous folds and only an invasion of the tubal capillaries follows. Abor- tion in these cases is easy and causes but little danger ; bleeding occurs ; the fetus dies, and further hemorrhage expels it. The tube may subsequently become normal or a hematosalpinx may follow. (Fig. 443.) (2) In the intercolumnar type one- half of the tube is normal, the other torn and infiltrated, the mucous folds are involved down to the muscularis. The ovum is situated upon the tube wall, where it compresses and destroys the folds at the situation known as the serotina. These folds are united at either side about the ovum, forming a pseudo- refiexa. Some distance on either side of the serotina, tissue resembling decidua, with closely grouped cells without capil- laries or spaces, rests upon and invades the free surfaces. The EXTRA-UTERINE PREGNANCY. 587 invasion traverses the mucosa in irregular branches or pro- jections about the blood-vessels, invading and infiltrating their muscular walls up to and into the lumen. Trophoblast cells are accompanied by sync}^ium, but at no point do the connective -tissue cells, the tubal folds, or the delicate sub- mucosa, if present, exhibit any evidence of change which re- sembles in the slightest degree those occurring in the uterine mucosa, from which the decidual cells develop. Neither is there at any point any change of a so-called syncytial character. The ovum rests upon the wall, and the tubal fold immediately beneath it will be compressed, but the epithelium may remain in the depressions. Other folds may form a capsularis, which consists of mucosa alone. An intervillous space may develop when the capsularis is formed. The villi at the placental site enter the wall, and hemorrhage follows, especially upon the invasion of vessels of the capsularis by fetal cells. The preg- nancy may terminate in abortion, complete or incomplete, the latter usually being the rule. If the abdominal end is closed, a hematosalpinx or tubal mole may follow. (3) The syncytial type. In this the tissue of the tube is invaded by villi cell groups — syncytial cells. Here again there is no evi- dence of a decidua or of any decidual reaction. When unin- terrupted, the capsularis unites with the mucosa of the envelop- ing tube wall in the same way that this process is exemplified in the uterus. The centrifugal ovum sinks into the wall of the tube, when invasion of the wall and vessels by the villi occurs. Rupture may take place at the summit or hemorrhage from invasion of the vessels entering into the intervillous spaces. Bleeding from the villi penetrates the serosa and rupture at the placental site may follow, or we may have multiple per- foration and erosions. The ovum apparently eats up the tube wall and its destruction is not the result of pressure. In such cases the perforations may be so minute as only to be revealed by a microscope. The death of the ovum may not arrest the growth of the villi. This form furnishes the majority of cases of rupture. Very frequently the hemorrhage is due not to rupture, but to the erosions from the perforating villi. The presence within the tube of the developing ovum causes the entire structure to become turgid and vascular. There is some tendency in the tube to the development and extension of its structure, but to a much less degree than in the uterus. The wall becomes stretched, attenuated, and thin. The mucous membrane is stretched and its folds effaced. As the tubes vary in length and thickness, the rapidity of thinning correspondingly differs. When the ovum is situated in the outer third, changes follow in the ostium. In the first four cases the fimbria are sw^oUen, 588 GYNECOLOGY. turgid, and the congestion extends to the adjacent muscular and serous tissue; the fimbria are gradually retracted, while the peritoneal margin of the ostium forms an irregular ring, which in four and one-half weeks projects beyond the ends of the fimbria. It finally contracts, and at the end of the eighth week is completely contracted and hermetically sealed. The occlusion, however, is not constant. Occasionally the ostium dilates. The nearer the ovum is situated to the abdominal end, the less likely will it be to become closed. As the tube dis- tends, its vessels ruptiue and hemorrhage takes place, which fills up the sac and may cause the extrusion of the ovum. The more firmly the tubal end becomes occluded, the greater the danger of tubal rupture. Its situation near the abdominal ostium favors its extrusion through the opening into the ab- domen as a tubal abortion. ]\Ioles occur in tubal as in uterine gestation; indeed, they are more frequent in the former. They vary from one to eight centimeters in diameter and are glob- ular or ovoid, assuming the latter shape in the larger varieties. The tubal moles are formed by hemorrhage, which occurs in the subchorionic diameter, between the chorion and the amnion. This hemorrhage may be gradual or sudden, and results in the death and often in the disappearance of the embryo. The puerperal origin of the condition in the absence of any vestige of the fetus is recognized by the discovery, with the micro- scope, of the chorionic villi. The outer investing membrane, the chorion, is generally shaggy, with villi, which are rendered more visible by washing the clot under a gentle stream of water. When the amniotic cavity is obliterated, doubt may exist as to the character of the mass, but section will disclose the villi in clusters as small circular bodies. Tubal abortion has been mentioned as one of the terminations of tubal gestation, when the developing embryo occupies the external third of the tube. The nearer the fecundated ovum is situated to the ostium, the greater the danger of its extrusion. As the em- bryonal sac increases to a size beyond that which the tube is able to accommodate, it is pushed out through the funnel- shaped cavity and escapes into the abdomen. This accident is denominated tubal abortion, and is frequently associated with profuse hemorrhage, which is very similar to that which occurs in uterine abortion. The mole is discharged with copious hemorrhage into the peritoneal cavity. This displacement is likely to take place during the first two months of the preg- nancy. When the ostium is closed, blood escapes from the tube only after rupture of the sac. The quantity of blood discharged is sometimes enormous and attended with all the symptoms of internal hemorrhage. This condition is one of the most EXTRA-UTERINE PREGNANCY. 589 frequent causes, of pelvic hematocele. Internal hemorrhage in such cases has been ascribed to metrorrhagia, to reflex men- strual discharge from the uterus, or to hemorrhage from the Fallopian tube. The reason why it has been associated with metrorrhagia is, that while the embryo is developing in the tube a decidua is forming in the uterus. With a tubal abortion, hemorrhage occurs from the uterus as a result of the separation and the expulsion of this decidua. This not infrequently happens near the time the patient expects to menstruate, and is, consequently, regarded as reflux menstrual fluid. Very frequently the bloody discharge from the uterus may be derived from a gravid tube in protracted tubal abortion. If the bleed- ing occurs at a time not synchronous with the menstrual flow, it is often attributed to a disorder of the uterus. In all such cases the affected tube and the bloody discharge should be carefully examined for the presence of the embryo or the chor- ionic villi. The abortion may be complete or incomplete — complete when the embryo and its envelope are discharged; incomplete when a portion remains attached to the tube. The latter is the more common. The danger is increased in these cases, owing to the fact that the bleeding is apt to recur while the mole is retained. The villi will be disclosed by careful microscopic examination of the extruded mass and are dis- covered in sections of the adherent pole of the mass. A third termination of tubal gestation is that of rupture. As the embryo develops, the tube becomes more and more thinned, until it is no longer able to resist the inward pressure, and rupture results. Rupture of the gestation sac may be considered under: flrst, primary rupture; second, secondary rupture — each of which may be intraperitoneal or extraperi- toneal. Primary rupture takes place at any time between the third and tenth weeks after impregnation, and is rarely deferred beyond the twelfth. Predisposing causes of rupture are the gradual thinning of the gestation sac by the gro^vth of the ovum or the undue distention of the membrane by hemorrhage, especially at the seat of implantation of the chori- onic villi. The perforation of the tubal wall by the villi may be excited by violence, as jumping from a train, strain- ing at stool, jarring of a carriage, vomiting, or sexual congress. Rupture may occur as a result of eft'orts to determine the diag- nosis. It was my misfortune to see a case of this kind in which the examination by myself, and subsequently by the attending physician, was followed within a few minutes by symptoms of profound collapse, which confirmed the suspicion that an extra -uterine pregnancy was present. As soon as permission 590 , GYNECOLOGY. could be secured the abdomen was opened, to find half a gallon of liquid blood within it; and although the vessel was secured, and every measure taken to restore the patient, she succumbed to the shock. The tube is enveloped in two-thirds of its circumference by the peritoneum, which forms a mesosalpinx; as the tube is enlarged by the developing embryo the mesosalpinx sepa- rates. This condition is true only of the internal two-thirds of the tube. The external third is not supplied with the meso- salpinx. The intraperitoneal rupture is three times as frequent as the extraperitoneal. In primary intraperitoneal rupture the embryo and its enveloping membranes, or a mole, are dis- charged into the abdominal cavity, and a certain amount of hemorrhage follows. The amount of blood extravasation will depend upon the period of pregnancy when the rupture occurs; when early, it may be slight. After the first month, however, it is copious — frequently sufficient to cause death in a few hours. I saw one patient who had missed her period but five days. She was taken with violent pain at night, fainted several times, and was seen and subjected to operation the following morning. She was then extremely anemic, and the abdomen was found filled with a large quantity of blood, which had escaped from a cyst not larger than a bean in the left Fallopian tube. The ligation of the bleeding vessel and the removal of the extravasated blood resulted in her restora- tion to health. Frequently the hemorrhage may be so great as to cause a fatal result in a few hours; in some cases even in half an hour.. AVhen a rupture is deferred until the seventh week, the embryo or mole is not constantly discharged through the opening. The quantity of blood which escapes may be very large, and demand immediate attention, or it may be slight in character, permitting the patient to escape the im- mediate dangers incident to the accident with but slight shock. The effused blood can undergo absorption and recovery ensue. When the discharge is not excessive, the blood collects in the rectovaginal fossa and fioats the coils of intestine, forming an intraperitoneal hematocele, as has been described. Dangers of the primary intraperitoneal rupture are: first, hemorrhage so great as to cause immediate death; second, the fatal result may be occasioned by repeated hemorrhage. In primary extraperitoneal rupture that portion of the tube not covered by peritoneum gives w^ay and permits the discharge of the ovum and the accompanying blood between the layers of the mesosalpinx. Here the blood is forced into the connective tissue between the layers of the broad ligament, and, fortu- nately for the patient, the bleeding is checked by the pressure EXTRA-UTERINE PREGNANCY. 591 from the resisting tissues, and is generally arrested before it assumes dangerous proportions. This lesion rarely causes trouble. Occasionally, the rupture of the tube is slight, the embryo partly escapes, with its membranes remaining un- injured, and tjie pregnancy will continue. Rupture affords increased space for further' development, and, the power of resistance being decreased, the ovum, as it increases in size, burrows between the layers of the broad ligament. The rup- ture may be gradual; the tube does not split suddenly, but as its walls, through the gradual distention, become thinned, they yield in the part uncovered by peritoneum until an open- ing forms and the ovum is extruded, accompanied by sudden hemorrhage. The extent of collapse and its duration will be largely dependent upon the amount of blood effused. The artificial opening gradually extends, the embryo and placenta make their way into the new area, and, unless the hemorrhage be sufficient to terminate the life of the embryo, the pregnancy is continued. This is known as a mesometric or an intraliga- mentary gestation. In this anomalous development of the ovum the placenta is liable to many changes which will vitally influence the life of fetus and mother. The tubal mucous membrane, as has been mentioned, plays a very insignificant part in the formation of the placenta. The latter is developed mainly from the fetal tissues, as the tube does not develop a decidua. With the fecundation of the ovum there are at once developed changes in the uterine mucosa in preparation for its retention and sustenance. When the fecundated ovum is arrested in its progress and prevented from entering the uterus, the uterine decidua continues to develop as if it were normally placed. This decidua, however, is rarely retained until the completion of gestation, but is thrown off during the false labor; not infrequently, when the individual suffers from symptoms of tubal abortion or tubal rupture. The oc- currence of this profuse bleeding after one or two months' amen- orrhea, with the discharge of a cast or of shreds of tissue from the uterus, which may frequently be enveloped in a large clot, leads the patient and her attendant to believe that a uterine abortion has occurred. When the individual goes to term, the uterine decidua is thrown off as a cast or in shreds during the early months of the pregnancy. When the decidua is discharged' in small fragments, it takes place without unusual pain; but en masse, the symptoms are similar to those of a miscarriage. The absence of the uterine decidua at the death of the ovum from rupture of the cyst, even in the early stages of pregnancy, is no proof that the membrane has not existed and been expelled before fetal death. When pregnancy occurs 592 GYNECOLOGY. in one-half of a bicornate uterus, the decidua is present in the unimpregnated cornu. Under no circumstances, however, either in the normal or abnormal pregnancy, Fig. 444. — Complete Rupture of a Tubal Sac. is a decidua found in the Fallopian tubes. As the destructive- changes of the mucous membrane of the gen- ital tract associated with menstruation are limited to the uterine cavity, so the true decidua is found in the same portion. It is sometimes important to avoid confounding the decidua of preg- nancy w4th the cast thrown off from the uterus in membranous dysmenorrhea. In the former it consists of a compact layer of decidual cells. In the latter, the cast is more likely to involve a portion of the glandular structure of the uterus. Rupture may be complete or incomplete. Complete rup- ture is one in which the ovum and its envelopes escape, either into the peritoneal cavity or into the broad ligament, with more or less profuse hemorrhage. (Fig. 444.) A partial rup- ture may result in the gradual thinning of the wall until it gives way in one place ; and when this takes place extraperitoneally, it is reinforced by plastic exudate, with the oc- currence of but little, if any, hemorrhage. (Fig. 445.) Successive ruptures or partial ruptures thus occur until finally the envelope becomes sufficiently distended to permit the fetus to develop as in an intra-abdominal Fig. 445. — Incomplete Rupture of Gestation Sac. EXTRA-UTERINE PREGNANCY. 593 pregnancy. At no time during such a rupture has the separation oc- curred between the placenta and the tube. In the extraperitoneal variety the embryo and placenta gradually occupy a sac formed by the expanded tube and separated layers of the broad ligament. The floor of this space is formed by connective tissue and the leva- tor ani muscle. The ultimate effects depend to a great extent upon the original situation of the placenta. When the embryo is situated above the placenta, the latter is depressed between the layers of the broad ligament until it is arrested by the pelvic floor. If the embryo lies below, and the membranes burrow between the layers of the broad ligament, the placenta is pushed up until it lies high in the abdomen. As there is no tubal decidua, the placental villi lie embedded in the decidual cells without any intervillous system existing. When the placenta is dis- placed into the tissue of the broad ligament, which occurs gradually, its structure becomes seriously damaged: the villi are less perfect in their contour, points of extravasation of blood are present, and blood-crystals are abundant. Finally, tmder the pressure, the placenta becomes gradually reduced to a mass of compressed villi ; its serotina is destroyed and is replaced by blood-crystals and by organized blood-clot. While the consequences to the placenta from its displacement into the tissue of the broad ligament are thus marked, it is not attended with nearly so much danger as when the placenta is situated above the embryo. It is then subject to extreme disorganiza- tion, forming, as it does, the roof of the gestation sac. The changes that take place in the placenta, owing to the pressure of the developing fetus, have a great influence on the sub- sequent history of the pregnancy, adding to a marked degree to the peril to the life of the mother, and are, in the majority of cases, disastrous to the life of the fetus. The constant tension to which the peritoneum covering the gestation sac is subjected leads to partial detachment of the placenta and to severe hemor- rhage, either into the gestation sac or into the peritoneal cavity. In the later stages of the pregnancy such hemorrhage is al- most invariably fatal. A w^oman with an intraligamentary pregnancy, with a placenta situated above the fetus, runs a greater risk of losing her life than she would from placenta previa. A tubal placenta which is situated above the embryo has its structure so damaged by rupture as to render it an in- efficient respiratory organ; and the constant results upon the embryo are very marked. The fetus from such a gestation is rarely a satisfactory individual. It is very unusual for the fetus to live longer than a few days or weeks subsequent to its delivery. Not infrequently it is ill formed, suffering with hydrocephalus, club-foot, spina bifida, ectopia of the viscera, 38 594 GYNECOLOGY. and other deformities. When normal in shape, it is exceed- ingly defective in size. One case is recorded in which the tubal sac contained two embryos, measuring eleven centimeters in length, which were united by a band in the thoracic region. Dr. M. Price reported a well-formed ectopic fetus which sur- vived operation and was subsequently healthy. The amount of hemorrhage in an incomplete rupture will depend much upon the situation of the placenta. If the placenta be at- tached to the peritoneal surface and rupture takes place over it, the bleeding will be excessive and will possibly result in the death of the patient unless surgical intervention prevent. If the placenta is situated on the opposite side to that on which rupture occurs, the envelopes may protrude, but little bleed- ing will follow, and the sac becomes reinforced by plastic exu- date and adhesions. The sac wall is then formed by the uterus, the bladder, the parietal or pelvic peritoneum, and the coils of intestine. Secondary Rupture. — The extraperitoneal rupture causes the formation of a secondary broad-ligament gestation sac, which increases in size and may subsequentty undergo rupture. As has already been indicated, the danger is much increased when the placenta is situated above the fetus. As the preg- nancy progresses the peritoneum becomes stretched and is separated from the adjacent parts and from the viscera. The sac extends into the abdomen, and strips the peritoneum from the anterior abdominal wall to a greater degree than would an overdistended bladder. When the posterior peritoneum is thus raised up, the rectum, as well as the posterior surface of the uterus, may be deprived of serous investment. The placenta is insinuated between these parts, and secondary rupture may result at any time between the twelfth week and the completion of term. The effects of this secondary rup- ture are dependent upon the injury to which the placenta is subjected. After the middle period of pregnancy has passed, when it involves the placenta, — as it almost certainly will, situated, as the latter is, above the fetus, — most frightful hemor- rhage and rapid death will be the consequence. Earlier in the course of the pregnancy the hemorrhage is not so severe, and may be arrested by prompt surgical intervention. Opening of the sac into the peritoneal cavity is recognized as secondary intraperitoneal rupture. If the fetus occupies the upper por- tion of the sac and the placenta is attached below, the former may escape among the intestines. Secondary rupture does not always occur. The patient may go to term, spurious labor follow, the liquor amnii be absorbed, and the placenta dis- appear. If the extra-uterine pregnancy has not been sus- EXTRA-UTERINE PREGNANCY. 595 pected and its course not disturbed, the formation of a mum- mified fetus, or lithopedion, results, which may be discovered years later. Secondary intraperitoneal rupture may occur at any time between the twelfth week and term. When it occurs at or near term, the belief is perpetuated that the fer- tilized ovum had tumbled into the peritoneal cavity, to in- graft itself upon the serous membrane and there develop. It should be understood, however, that there is no primary peri- toneal pregnancy, but that the condition originally developed in the Fallopian tube. When the pregnancy develops in the uterine end of the tube, particularly that portion which traverses the uterine wall, it is termed a tubo-uterine pregnancy. This form of pregnancy is not frequent, and can readily be confounded with pregnancy in one cornu of a bicornate uterus. The tubo- uterine gestation differs in its course, relations, and mode of termination from the purely tubal form. Primary rupture generally occurs before the eighth w^eek, and the pregnancy is rarely continued without rupture beyond the twelfth week. The tubo-uterine gestation sac may rupture in two directions: into the peritoneal cavity, causing frightful hemorrhage and a rapidly fatal result, or, resistance being slighter toward the uterine cavity, the fetus and envelopes may be pushed into the uterus and terminate as in an intra-uterine conception. The intraperitoneal rupture is much more rapidly fatal than in the tubal form, and causes more severe hemorrhage, because the uterine wall is more vascular and the sac is situated in closer apposition to larger vessels. Tubal and tubo-uterine pregnancy have the following distinctive characteristics: the tubal pregnancy is very common, the tubo-uterine rare; the tubal gestation sac is ver}^ thin, the tubo-uterine very thick. The termination can be: (a) Intraperitoneal rupture for each, or (b) rupture into the intraligamentary space. In the tubo-uterine, rupture can occur into the uterine cavity, with the discharge of the fetus through the vagina, (c) In the tubal, abortion can result, and, as in the primary rupture, date from the third to the tAA^elfth week. In the tubo-uterine, rupture occurs at any time from the fifth to the twentieth week. Ovarian pregnancy, pure and simple, is extremely rare, and while there are cases in which careful examination has disclosed ovarian structure in the sac wall, w4th the tube free and unaffected, yet we are not prepared to admit that the condition may not have originated from the tube, for it is very doubtful whether the ovum w411 develop when not attached to the ]\Iullerian structure. The majority of cases of ovarian pregnancy are undoubtedly tubo-ovarian, in which the embryo was originally situated in the orifice of the tube and has been partly extruded 596 GYNECOLOGY. without loss of its vitality. As would be readily inferred, the life of the embryo in a tubal pregnancy is necessarily pre- carious. Aitev rupture, undoubtedly the pregnancy may con- tinue until full term. Symptoms of labor set in, during which the gestation sac may burst into the peritoneal cavity, or, if this catastrophe is avoided, the fetus dies. The body re- mains quiescent or produces various forms of disturbance. Thus, the liquor amnii is absorbed; the tissues of the fetus become mummified or partly calcified, and form a lithopedion. The softer parts are converted into adipocere or undergo other forms of decomposition. The placental tissue is gradually absorbed and disappears. Mummification. — The process of mummification is attended with absorption of the fluids, while the soft parts are converted into a dried tissue similar to that which follows when a dead cat is permitted to remain under an old building, producing a dried cat. An extra -uterine fetus can be retained in the body for a long period of time. Cheston reports a lithopedion carried for fifty-two years; Barnes, one forty-two. The pos- sibility of the fetus being carried this length of time does not necessarily indicate that it can not prove a source of danger to the patient. Pathogenic micro-organisms can find entrance to the sac through the adjacent hollow viscera, and at any time produce serious trouble. Suppuration follows, and pus finds its way through the sac- wall, and penetrates the va- gina, uterus, bladder, or rectum. Through any of these open- ings fragments of fetal tissue from time to time escape, caus- ing frightful distress and necessitating operation for relief. The existence of a lithopedion or macerated fetal skeleton does not preclude subsequent pregnancy. One case came under my observation in which a woman with a good-sized and distinctly well-defined lithopedion subsequently gave birth to two children. 550. Symptoms. — The symptoms which should lead one to suspect the existence of an ectopic gestation are dependent upon the duration and course of the pregnancy. A history will be obtained of disordered menstruation, the patient having missed one or more periods. The ordinary symptoms of pregnancy are present and she has supposed herself pregnant. She may have experienced a sensation of uneasiness or distress over the region of the ovary and tube upon one side, associated with frequent and sudden attacks of colicky pains. These pains may have been of severe, cutting character, paroxysmal, and occasionally quite intense. In other cases without any premonition pain of a tear- ing, cutting character will occur, so severe and lancinating as to cause the patient to fall and become unconscious. This phenom- EXTRA-UTERINE PREGNANCY. 597 enon may be followed by repeated attacks of syncope in which the countenance of the patient becomes pale, anxious, covered with clammy perspiration, lips pale and blanched, respiration sighing, the sight obscured, sensation of darkness or even blind- ness, mind frequently AA^andering, or she may remain unconscious or pass from one attack of syncope to another. The pulse at the wrist becomes exceedingly feeble, faint, and imperceptible. The temperature is subnormal, and all the indications of approaching dissolution are present. Generally the symptoms are not so marked or the patient is weak, debilitated, shoAvs symptoms of shock or collapse, soon rallies, AAdth recurring attacks of a similar character, AA^hich indicate that the hemorrhage has again recurred or is sloAAdy continuing. In other cases the progress is insidious. A small aperture exists; the AA^alls have been stretched. Plastic exudation is throAvn out and the pregnancy ma}^ progress AA^thout further accident. The tube may rupture either intraperitoneally or extraperitoneally. The symptoms of the tAvo varieties Avill be found entirely different. The graAdty of the former is much the greater, but will depend upon whether the rupture has been complete or incomplete, and also upon the situation of the placenta. When the rupture occurs from the site of the placenta, CA^en though incomplete, hemorrhage can be so scA^ere as to cause the death of the patient if inter A^ention is not instituted. Ac- cording to the intensity of the hemorrhage, the patient may either die in the first attack, that is, AA'ithin half an hour or an hour after the first symptoms, or slightly rally and an apparent recurrence of the hemorrhage folloAA- , AA^th death AA^thin less than tAventy- four hours. Should the patient surA^iA^e tAA^enty-four hours and rally, her strength may gradually return and recoA^ery folloAA^ or a secondary hemorrhage may dcA^elop and result in a fatal termina- tion. AYhen the patient survi\^es the hemorrhage and shock, the accident is folloAA^ed by more or less tenderness OA^er the abdomen and by abdominal distention, AA^hich symptoms indicate the oc- currence of localized peritonitis. In the early stage of hemor- rhage no physical signs of its existence can be recognized. Pos- sibly a large quantity of blood in the abdominal caA'ity of a thin woman could be recognized by the sensation of fluctuation. In tAA^enty-four hours the blood aa^II accumulate in the peh^s, and AA^e then obserA^e a sensation of fluctuation and slight resistance by A^aginal palpation. Change in the position of such a patient per- mits the collection to floAV out of the peh'is, AA^hen its presence Avill no longer be recognized. If the pelvis is again loAA^ered, the accu- mulation returns. The coagulated blood causes more or less irri- tation, which results in the exudation of plastic material and the occurrence of a localized peritonitis. The abdomen becomes tender to the touch, febrile reaction occurs, the temperature instead of 598 GYNECOLOGY. being subnormal now rises to ioi° F. or even 103° F. The patient may experience distress from pressure of the mass on the rectum or against the uterus and bladder, which produces frequent micturition or even incontinence. With the advent of plastic peritonitis the collection becomes encysted; the patient will often suffer from nausea and abdominal distention. The watery portions in such a collection become gradually absorbed and the mass is more apparent and resistant. The uterus may be pushed upward and forward. The intestines are raised up and form a part of the wall of the sac. The collected mass varies in its con- sistence: sometimes it is hard, at others soft, or the same mass may have several points of softening. The uterus may be envel- oped by the collection, producing w^hat is known as an enveloping uterine hematocele ; the functions of the rectum and bladder may be greatly impaired by the compression of the mass against these organs, which may often cause symptoms of intestinal strangula- tion and retention of urine. Pressure upon the nerves of the pelvis frequently gives rise to severe neuralgia of the lower ex- tremities. Even when suppuration does not occur, irregular attacks of fever are frequently the result of peritoneal reaction. The course and progress of the disease are essentially chronic, or re- peated attacks may occur. The congestion which takes place at the menstrual periods may result in acute symptoms. Sup- purative change in such a collection is ushered in by an aggrava- tion of both the local and general symptoms, chills, elevation of temperature, profuse sweating, increased leukocytosis ; the tumor increases in size and undergoes softening; the mass may sub- sequently perforate into the rectum, causing the evacuation of dark, purulent, exceedingly oft'ensive material in the stools, which may cause more or less irritation of the rectum. These discharges are followed by cessation of or disappearance of the tumor. Perforation into the vagina or bladder may occur, though these are rare. Perforation into the abdominal cavity is for- tunately infrequent. When it does result, a violent attack of general peritonitis follow^s. The occurrence of rupture of the tubal sac is not infrequently associated with discharge of blood from the vagina and with severe uterine pain. The uterine pain or the pain from the rupture may cause the victim to believe that an abortion is impending. This suspicion may be still further confirmed by the discharge of a cast from the uterus or of shreds of tissue, associated with clots, which may lead both the patient and her medical attendant to believe that an abortion has occurred. When the hemorrhage is slight and the ovum retains its connection w4th the tube, the fetus may continue to full devel- opment, and even reach full term. A pregnancy situated pos- terior to the uterus may reach full term without causing the EXTRA-UTERINE PREGNANCY. 599 patient to suspect that an abnormal condition exists, and it is only after the beginning of labor, when an examination is miade, that the true state of affairs is recognized. Even then it is not always recognized and the spurious labor. may terminate without the discharge of the fetus and the sac may undergo subsequent changes. 551. Diagnosis. — Diagnosis comprises: (i) The recognition of extra-uterine pregnancy prior to rupture ; (2) the determination of rupture or abortion with intraperitoneal or extraperitoneal hemorrhage and death of the fetus; (3) secondary rupture; (4) continued growth of the embryo after rupture; (5) peritonitis; (6) suppuration. I. Preceding Rupture. — ]\Iost frequently the victim of mis- placed conception does not apply to her physician until the oc- currence of a violent, tearing pain, associated with rupture. The distressing symptoms are rarely sufficiently definite prior to this occurrence to demand a physical examination. Such an examina- tion is generally requested in order to ascertain the existence of the supposed normal pregnancy. The frequent occurrence of ectopic gestation, however, should lead to the careful investigation of every patient who gives symptoms of being pregnant, where there is a previous history of more or less extended sterility, of attacks of pelvic inflammation, and, especially, if the latter has originated from gonorrheal infection. Such an examina- tion is particularly indicated when the patient, having missed a period, complains of a sensation of uneasiness or distress in one side of the abdomen, associated with frequent and' sudden attacks of colicky pain. Every such patient should be sub- jected to a careful examination. Slight enlargement of the uterus, with some tenderness in the pelvis, more marked upon one side, associated with a more or less spherical or rounded distention of the tube, should increase the suspicion of ectopic gestation. This suspicion would be confirmed by finding increased vascularity in the broad ligament, causing marked pulsation of its vessels. This pulsation is distinctly recogniz- able upon the affected side, while the pulsation on the opposite side is not defined. The examination should be made with the utmost gentleness, for rough manipulation or marked pres- sure in the practice of the bimanual procedure can very readily rupture a sac which is so thin as to require only a slight amount of additional pressure. AVhere the sac is of considerable size, it is unwise to subject it to much force in the examination, un- less the operator is prepared for immediate operation should rupture occur. It has been my unfortunate experience with a patient in whom the pulsation was as distinct as if the finger were placed over the radial artery, to have the sac ruptured 600 GYNECOLOGY. by her physician, who was desirous of examining the case. The patient succumbed to the subsequent operation. Dr. J. M. Fisher, my assistant, reports two cases in which he has observed the rupture of an ectopic gestation during examination. 2. Rupture. — The rupture of an ectopic gestation sac may be suspected when the patient gives a history of having failed to menstruate for one or two periods and has exhibited the ordinary symptoms of pregnancy. She has probably had more or less discomfort upon one side, with frequent colic k}^ attacks, when suddenly, without warning, there has been an attack of most violent, tearing pain, followed by syncope, all the symptoms of internal hemorrhage, with oncoming collapse. I have seen such a patient in the space of ten minutes pass from a condition of apparent good health to one which seemed to threaten approaching dissolution. The face was blanched, pale, exceedingly anxious looking, covered with cold, clammy perspiration; pupils dilated, eyes expressionless, rolling from side to side; sighing respiration; pulse rapid, feeble, some- times almost imperceptible; patient complaining of being un- able to see, and everything appearing dark about her. Some- times marked nausea and vomiting are present. The slightest movement, even raising the head of the patient, is followed by more or less profound syncope. The occurrence of such a train of symptoms should awaken in the mind of the ob- server the absolute conviction that an internal hemorrhage is occurring, and the association of such a group of symptoms would indicate its origin from an ectopic gestation. A phy- sical examination affords very little information, for at this time the tumor is insufficiently large and without the necessary firmness to afford the sensation of resistance. The physical signs are consequently indefinite. When the bleeding is ex- tensive, the abdominal walls thinned and not very resistant, a sensation of distention may be noted and even fluctuation recognized. When the hemorrhage is not so profound as to endanger life, the watery portions of the effused blood are gradually absorbed and leave a more or less resistant clot, which can be felt as a firm mass in the pelvis. In the absence of previous history of recent inflammatory trouble or the pre- vious existence of a growth, it must be recognized as effused or clotted blood. The accumulation is generally retro -uterine. A large extravasation may fill the pelvis, push the uterus for- ward, and raise the intestines above it (Fig. 438). In other cases the uterus may be found in a state of retroversion, while a mass is situated in front and forms an ante-uterine hemato- cele; or in very large accumulations the uterus may protrude through it, producing what is known as a circumuterine hemato- EXTRA-UTERINE PREGNANCY. 601 cele. Hemorrhage dangerous to life, and productive of the most profound anemia, may arise without rupture, as in tubal abortion, or when the villi have penetrated the wall of the tubal sac and bleeding occurs from their surfaces. These per- forations may l^e so minute as to be unrecognizable by the naked eye, except for a thrombus projecting from the external tubal surface. The tubal abortion in its earliest stage causes no marked physical manifestations outside of those symptoms which indicate an internal hemorrhage. Later, however, the blood-clots in the tube, filling up the sac, produce a large, sausage- shaped mass, which may be firm and resistant. The patients in whom rupture has occurred may present successive attacks of shock and syncope. Thus, a patient bleeds until the blood pressure is greatly reduced, a clot forms, plugs the vessel tem- porarily, and the circulation is restored. If, however, injudicious ^m Fig. 446. — Ectopic Gestation Sac Ruptured, Showing Fetus. efforts are made to revive the patient by hypodermatic injections of strychnin, digitalin, or intravenous injection of salt solution, the clot is washed or driven out and hemorrhage again recurs, with a repetition of the former symptoms. Noble has reported cases in which the rupture and hemorrhage have been associated with a rather rapid and marked rise of temperature. The general rule, however, is that where hemorrhage is marked the patient shows a subnormal temperature, as would be ex- pected in cases of shock and threatened collapse. The tem- perature rarely is elevated until some days after the hemor- rhage, and then is not high. The elevation of temperature is undoubtedly due to degenerative changes in the collection, possibly from the fibrin-ferment, or more likely from partial 602 . GYNECOLOGY. infection by organisms from the intestinal canal. At the time of this elevation of temperature the peritoneal exudate is thrown out, which forms barriers and confines the blood accumulation within the pelvis. The w^atery portions of the blood become absorbed, until a more or less distinct and well-defined mass of clotted blood is perceived. In extraperitoneal hemorrhage the symptoms are much less acute. Shock or collapse is less marked, although we still have symptoms which, to a limited degree, should lead one to suspect internal hemorrhage. In such a case examination will disclose on one side of the pelvis a mass which may fill up and distend the broad ligament. The tumor may be quite tense and push the uterus to the opposite side. The condition differs from tubal disease in that the broad liga- ment is distended by it. There has been an absence of recent inflammatory trouble, and the patient does not present the characteristic symptoms of inflammation. In the intraperi- toneal variety the irritation of the accumulated blood causes certain reactive symptoms and sometimes the development of peritonitis. The temperature becomes elevated, pulse rapid, the abdomen tender and sensitive to pressure. But the symp- toms are not so acute and severe as in marked inflammation. The rupture and internal hemorrhage are usually associated with a discharge from the uterus of decidual membrane, either as a complete cast of the cavity or in the form of shreds mixed with clots. The cast may show the oriflce of the Fallopian tubes and internal os. Inquiry should be made with regard to this symptom, and, when possible, the discharged material should be carefully examined. It is important to differentiate it from the decidua thrown off in some forms of dysmenorrhea. That of pregnancy is from six to eight millimeters in thick- ness, while that of menstruation rarely exceeds two or three centimeters in length and is scarcely two millimeters in thick- ness, is translucent, is rarely passed entire, and consists of the compact layer of the epithelium. When the symptoms have been slight and the woman has considered herself the subject of an abortion, it is not until the enlarged fetal sac causes a suspicion of the continuation of the pregnancy that the patient will present herself for examination, and even then she may not consult a physician. 3. Secondary Rupture. — Secondary rupture necessarily fol- lows a primary rupture, which, in the majority of cases, has taken place in the broad ligament. The rupture has occurred in such a way as not to interfere with the vitality of the ovum. Retaining its vitality, it enlarges its implantation, and in its growth spreads out the broad ligament until the latter is no longer able to retain it, when from pressure the thinned wall EXTRA-UTERINE PREGNANCY. 603 finally ruptures and severe hemorrhage takes place into the peritoneal cavity. The history of repeated attacks of pain and distress, of symptoms of internal hemorrhage, of the en- larging abdomen, and, finally, the cutting, agonizing pain associated with rupture into the peritoneal cavity should be sufiicient data upon which to base the diagnosis of secondary rupture. Both in primary and secondary rupture the amount of hemorrhage will depend upon its relation to the site of the placenta. Where the rupture takes place over the latter, the hemorrhage may be very profound and so rapid as to re- sult in death of the woman before measures can be instituted for her relief. 4. Continued Growth of the Embryo after Rupture. — As has already been seen, this growth may take place into the broad ligament, spreading it out, or in those cases in which the em- bryo has become reimplanted upon the surface of the perito- neum, the ovary, or in a continuation of the tube, the growth advancing as it would in ordinary pregnancy. The fetal movements are recognized, the enlargement continues, and the patient imagines herself normally pregnant. On phy- sical examination of such a patient the parts are more dis- tinctly defined by bimanual palpation than if the mass were situated within the uterus, as there is less structure intervening between the fetus and the palpating hand. The recognition of the fetal heart sounds is an absolute indication of the ex- istence of pregnancy. After the completion of the normal term of pregnancy in such a patient ^ the appearance of spurious labor, the cessation of fetal movements, and the changes which come under observation months later, may greatly increase the obscurity of the condition. A patient came under my observation who supposed her- self pregnant, and who suffered from a bloody discharge, with considerable pain, at the end of the second month, which led her to think that an abortion had occurred. The supposed abortion occurred in February. Her abdomen consequently became enlarged, and in the following October she went inta labor. Pains continued for tv/o days, and after the move- ments ceased her menstrual periods returned. In April, when she came under my observation, she presented a tumor as- large as in a pregnancy at full term, over which there was dis- tinct fluctuation and marked resonance. A thin-walled sac was recognized, but there was no sign of a resistant mass. Vag- inal examination disclosed behind the uterus a tumor which filled Douglas' pouch. The uterus was enlarged and was situ- ated directly in front of the tumor. On percussion, there was resonance everywhere. No dulness could be distinguished,. 6Q4 GYNECOLOGY. although fluctuation was distinct. The diagnosis was an ectopic gestation, with death of the fetus, decomposition in the fetal sac, and the formation of gas. This diagnosis was confirmed by opening the abdomen and finding posterior to the uterus a sac which contained a macerated fetus and a considerable quantity of offensive fluid. 5. Peritonitis. — Peritonitis may take place as a result of rupture of the sac, the escape of its contents into the peritoneal cavity, the accumulation of blood from a large hemorrhage, and its irritation upon the pelvic peritoneum. Unless relief is afforded, extensive matting together of the intestines and pelvic structures occurs, which will require early operative inter- ference for relief. Peritonitis may be produced, also, by the death of the fetus and infection of the sac. Its occurrence is indicated by pain and tenderness over the abdomen, the distention of the belly, assumption of the dorsal position, dis- tress during the evacuation of the bladder or movement of the bowels. 6. Suppuration. — Suppuration in an ectopic gestation may follow its rupture, so that the contents of such a sac becomes sanguinopurulent. Suppuration also takes place in later stages of a pregnancy which has gone on to full term; the fetus has subsequently become macerated, mummified, or even a lith- opedion has formed. Suppuration may take place months or even years after the occurrence of a pregnancy, leading to the evacuation of the sac or to its rupture into the intestine, the bladder, the vagina, or through the abdominal wall. In such a case the fragments of the fetus and its bony structure will be discharged. Suppuration will be indicated by increased pain and distress, by recurring chills, sweating, elevation of tem- perature, and the ordinary symptoms associated with sup- purative processes. That the suppuration has originated in an ectopic gestation will be demonstrated by the previous history of the case. This is made absolutely certain when the bony fragments of the fetus are discharged. 552. Differential Diagnosis. — Tubal and uterine pregnancy may coexist. Uterine pregnancy may follow tubal, or re- peated uterine pregnancies may occur subsequent to the for- mation of a lithopedion. Tubal pregnancy may be bilateral. Its frequent occurrence in the remaining tube after removal of a tubal gestation sac has led some operators to advocate the removal of both appendages in every case of tubal gesta- tion. Tubal pregnancy may coexist with ovarian and tubo- ovarian tumors. In a case I saw with Dr. J. M. Fisher the symptoms justified his diagnosis of rupture of a tubal gesta- tion sac. From its outline a mass upon the left side of the EXTRA-UTERINE PREGNANCY. 605 pelvis was considered to be a large extraperitoneal hemato- cele, which I decided to evacuate by a vaginal incision. A large quantity of clotted blood w^as evacuated, above which was a smooth cyst, too large to remove through the vagina. The ruptured tubal gestation sac was upon the opposite side. The removal of the cyst was effected by an abdominal incision. The following conditions may be confounded with ectopic gestation: first, uterine pregnancy; second, pregnancy in a bicornate uterus; third, a retroflexed gravid uterus; fourth, spurious pregnancy; fifth, ovarian tumors; sixth, uterine tumors; % Fig. 447. — Large Ectopic Gestation Sac. seventh, intraligamentary tumors; eighth, accumulation of feces in the rectum. First, uncomplicated uterine pregnancy is generally more easily recognized by the change in shape and size of the organ. In ectopic gestation the jug-like shape or outline of the fundus is wanting. A sac or mass, rather sharply defined, will be found in one of the tubes, if rupture has not occurred, and the sub- jacent vessels will pulsate more distinctly than upon the oppo- site side. After rupture the condition is distinguished by more or less severe shock, profound anemia-, and the appear- ance of a large mass in the pelvis without a history of previous inflammatory phenomena. The introduction of the sound 606 GYNECOLOGY. and the use of the curet to secure decidual tissue have been advocated, but are procedures which are not free from danger. In possible uterine pregnancy and abortion the danger of in- fection must not be overlooked. The investigation for decidua may be misleading, as it may have been previously exfoliated. The tissue removed by a curet can not be certainly distinguished from that which will be caused by inflammation, and the pro- cedure endangers the development of septic processes, which will complicate a tubal gestation if any exists. Second, pregnancy in one horn of a bicornate uterus may be impossible to differentiate from a tubo-uterine or an inter- stitial pregnancy. Fortunately, the treatment of the two conditions is similar, and is almost equally urgent. A tubal gestation is situated at a greater distance from the uterus. Third, the retro flexed pregnant uterus is "recognized by palpation, in which we are able to trace the tumor back from the cervix, and the smoothly outlined fundus is capable of considerable movement. Fourth, careful analysis of the symptoms, associated with the accurate consideration of physical signs, will guide to a correct diagnosis. It is a grave error to mistake, after the ab- domen has been opened, an extraperitoneal pregnancy for sarcoma or myoma. Fifth, ovarian tumors are usually differentiated by their history. It is only when one of these growths has produced no symptoms by which its presence could be suspected, and is suddenly complicated by an acute attack, during which or subsequent to which examination discloses its presence more or less fixed in the pelvis, that error is possible. Such a train of symptoms is readily produced by twisting of the pedicle of a small ovarian or a broad-ligament cyst. A young unmarried woman came under my observation with a history of having had a severe attack of pain upon the right side, which was pronounced appendicitis. While a movable mass could be felt above the brim of the pelvis upon the right side, there was no indication of inflammatory exudation. Not- withstanding the good character of the individual, ectopic gestation was regarded as a possibility. An abdominal incision disclosed a broad-ligament cyst beyond the ovary, closely attached to the outer part of the tube, whose pedicle had twisted, causing hemorrhage into the cyst and twisted portion of the tube, with the effusion of a large quantity of bloody serum free in the peritoneal cavit}^ Sixth, when, in an extra-uterine pregnancy, the fetus is dead, the fluid portions have been absorbed, and the mass is hard and firm, with its sac closelv adherent to the side of the EXTRA-UTERINE PREGNANCY. 607 uterus, the physical signs are frequently insufficient to establish the differential diagnosis between it and an intraligamentous myoma. Seventh, intraligamentary tumors are easily confounded with ectopic gestation. Frequently the diagnosis can be deter- mined only after abdominal incision. A patient was brought to me with the following history: She had been married nine years and had never been pregnant ; six weeks before admission she was seized with severe pain in the left side, and subsequent inflammatory symptoms, which confined her to bed the greater portion of the time. A mass, quite resistant, was felt to the left and in front of the uterus, which was firmly fixed by ad- hesions. The long period of sterility, sudden onset, and more or less fixed tumor, not previously recognized, led me to sus- pect tubal gestation with intraligamentary rupture. The incision, however, disclosed an intraligamentary ovarian cyst with thick walls, which had undergone a degenerative pro- cess, and which probably explained the sudden onset. Not infrequently the diagnosis can be determined only by incision, and an ectopic gestation is found when opera- tions are performed for other conditions, and the reverse. Eighth, careful examination should exclude fecal accumu- lation; ordinarily, the latter condition is determined by the possibility of indenting the fecal masses. AVhen there is any ■doubt, an expression of opinion should be withheld until a •complete evacuation of the bowels can be secured through the employment of an active purgative, supplemented by free rectal enemas. The differential diagnosis of tubal rupture is often difficult. Rupture is simulated by lesions of the abdominal viscera, such as perforating ulcers in the stomach, duodenum, small in- testine, and vermiform appendix; rupture of a pyosalpinx; torsion of the pedicle of a small ovarian cyst; acute intestinal obstruction; renal and biliary colic. A case of tubal gestation has been brought to operation as a supposed strangulated hernia. The diagnosis of tubal rupture can always be rendered certain by a puncture through the posterior vaginal fornix, when the rupture will be indicated by the discharge of dark- colored blood. The vaginal puncture affords," in addition, opportunity for the digital exploration of the pelvic viscera. Such an investigation permits palpation of the tubes and ovaries and the recognition of existing abnormalities. The following table, modified by Greig Smith from Web- ster, presents in a convenient form a summary of the pathologic and clinical features of ectopic gestation: 608' GYNECOLOGY. A. Ampullar. — Gestation beginning in the ampulla of the tube. I. Persisting (rarely goes to full term), II. Rupture (the usual result): 1, Into broad ligament: (a) Gestation continues there. (6) Secondary rupture into peritoneal cavity. {c) Gestation terminates: {a') By formation of hematoma. {b') By suppuration. {c') By mummification. 2. Into peritoneal cavity: (a) Gestation continues, the placenta remaining in the tube, the fetus and the membranes being in the cavity. (6) Gestation terminates: (a') The patient dying from hemorrhage or shock. (60 By absorption of the mass. {c') By mummification or by adipocere or lithopedion forma- tion. III. Destruction of gestation: 1. By tubal abortion. 2. By formation of mole. 3. By hematosalpinx. 4. By suppuration. 5. By absorption after early death. B. Interstitial, when the gestation develops in the interstitial portion of the tube: I. Persisting (the gestation may go on to term). II. Rupture: 1. Into the peritoneal cavity. 2. Into the uterine cavity. 3. Into both the peritoneal and uterine cavities. 4. Between layers of broad ligament. III. Destruction of gestation and retrogressive changes in fetus and envelops. C. Infundibular, when the gestation is in the outer end of the tube. The ovary may form part of the wall of the sac. 553. Prognosis. — Extra-uterine pregnane}^- at any stage of its progress must be regarded as a condition fraught with the greatest peril to the individual. It should be regarded as just as positive an indication for treatment as would be the presence of malignant disease. If discovered before the rupture of the sac, the patient is in danger from hemorrhage. The longer the condition progresses, the more grave is the peril. After rupture, with death of the fetus, the patient is not free from danger, as the collection of blood — the hematocele — may become infected, from its proximity to the hollow viscera, and cause the formation of an abscess or the development of pyemic symptoms. If the fetus survives the rupture, its subsequent development only in- creases the danger. A secondary rupture, with escape of the sac contents into the peritoneal cavity, or the frightful hemorrhages which result in some conditions, may prove immediately fatal. The woman goes on to full term ; the fetus dies, then undergoes retrogressive processes, which may at any time, even after years of quiescence, become infected, resulting in the formation of ab- scesses, perforation of viscera, and escape of the contents of the EXTRA-UTERIXE PREGNANCY. 609 sac. As the nutrition of the fetus in the majority of cases is de- fective, from unfavorable implantation of the placenta, frequently from pressure upon it, the fetus is generally imperfectly devel- oped, often undersized, suffering from hydrocephalus, spina bifida, club-foot, ' and other deformities. The preservation of the life of such an individual should not be considered when it is recognized that the life of the mother is constantly in peril. Furthermore, the fact that, even under the most favorable circumstances, the chances for the fetus are very greatly de- creased, and that, even when delivered alive, its duration of life is short, should be taken into account. The statistics of Dunning, hoAvever, indicate that an operation for the dehver}^ of the child during life, when viable, is more favorable for the life of the mother than is the delay of the operation until after the death of the fetus. 554. Treatment. — In a condition replete with such dangers as that of ectopic gestation it does not seem the province of the physician to practise any other method than one which will afford the greatest certainty of relief and which can be accomplished with the least danger. This, in our judgment, is through surgical manipulation; but, as other methods of treat- ment have been advocated, before entering upon the considera- tion of extirpation we will consider the substitutes. The sub- stitute methods recognized are evacuation of the liquor amnii, injection of poisonous substances, elytrotomy, and the ap- plication of the electric current. The evacuation of the liquor amnii was advocated by Simp- son in 1864. He treated a case by puncturing the cyst through the vagina without killing the child, and the mother died in three days. Braxton Hicks tried a similar method in 1865, which killed the child, but the mother died of hemorrhage. Greenhalgh, in 1867, had a successful case. James, of Phil- adelphia, in 1867, had a successful case after much tribulation. This plan of treatment, owing to the great mortality, has been generally abandoned. The injection of poisonous materials into the fetus and its enveloping fluids was advocated by Joulin in 1863. Morphin is the drug most frequently used. Other remedies, such as strychnin and ergotin, have been similarly employed. In- unctions of mercury, the administration of potassium iodid, and repeated bleeding have been advocated, but it is difficult to explain why. The injection of morphin with a hypodermatic syringe is practised before the fifth month. Two injections are usually given, containing J of a grain each, at an interval of from eight to fifteen days. The treatment may result in severe hemorrhage, septicemia, and perforation of an intestinal loop, so that, while- 39 610 GYNECOLOGY. apparently a simple procedure, it is attended with greater danger than an abdominal operation. Elytrotomy, or the removal of the fetus and its contents through a vaginal incision, was instituted as early as 1817 by Dr. King, of Georgia. This operation, which has been lately revived, is not by any means a new one. In the discussion of hematocele vaginal incision has been advocated as a justifiable method of procedure when the condition has become chronic; in other words, some time after the hemorrhage has taken place, when the vessels are occluded and the fetus is more than likely to be dead. In such cases vaginal incision affords an opportunity for clearing away the debris without subjecting the patient to so serious an operation as would be that through the abdominal wall. But before rupture, or immediately following rupture, in order to arrest the hemorrhage, the ab- dominal incision should be preferred. When the patient has reached full term and the death of the fetus has occurred, but as yet without the appearance of suppuration, the vaginal pro- cedure may be chosen: (i) When the fetus presents the head, breech, or feet, so that it can be extracted without altering its position; (2) when it is certain, from the thinness of the structures separating the presenting part from the. vaginal canal, that the placenta is not situated over this part of the sac, and we are not absolutely certain that the placenta may not be inserted on the anterior abdominal wall. If it is neces- sary to turn the child in order to deliver it, the vaginal pro- cedure should not be considered. Robertson advocates dividing the perineum, septum of the vagina, and rectum, but this is an unnecessarily severe proceeding. The application of electricity for the destruction of the fetus has been practised since 1853. There is a difference of opinion, however, among electrotherapeutists as to the greater value of the faradic and galvanic currents, each having its advocates. This procedure is preferable to all those which have been named, but is advisable only in the earlier months of pregnancy. In the early stages we must take into con- sideration the fact that the diagnosis is not always certain. Without doubt, many of the cases reported to have been cured by electricity were cases which had undergone rupture, and in which the tubal mole or embryo had escaped and lost its vitality, and the electric treatment has possibly served to ex- pedite the absorption of the exudation — an absorption which would have taken place had electricity not been applied. Many cases in which electricity has been applied were undoubtedly cases of mistaken diagnosis. It is true that advanced methods of examination will more certainlv differentiate the condition, EXTRA-UTERINE PREGNANCY. 611 but the violence required to accomplish this will greatly en- danger the rupture of the fetal sac. The application of electric- ity has occasionally been found to intensify the contraction of the muscle-fiber of the tube and to result in rupture and severe hemorrha,ge. When the death of the fetus occurs the danger does not cease, and we will frequently find the placenta continuing to grow, or rupture may follow,, associated with severe hemorrhage and later with septicemia. In the applica- tion of the current one pole of the battery, generally the neg- ative, is applied through either the rectum or the vagina in the neighborhood of the ovum. The other pole or a large electrode is applied to the abdominal wall directly over the sac and an inch or more above Poupart's ligament. The cur- rent is used for from five to ten minutes, increasing it as the sensitiveness of the patient will permit. When necessary, the application should be repeated. The practice of this pro- cedure is of doubtful utility, and, as has already been men- tioned, it is not without danger. It temporizes with a condition which menaces life and may excite severe tubal contractions which often result in rupture with subsequent hemorrhage. The risks and difficulties of operative treatment will largely depend upon the stage of gestation and the condition of the placenta and gestation sac. The surgeon, to be properly prepared to meet all emergencies, should consider the following: (i) The measures to be employed before primary rupture or abor- tion; (2) the measures required at the time of primary rupture; (3) what shall be done for the patient coming under obser- vation subsequent to rupture — (a) with intraperitoneal hemor- rhage; (b) with extraperitoneal hemorrhage; (4) the niethod of treatment advisable in advanced growth of the embryo — (a) the child alive; (b) the child dead, mummified, or reduced to a lithopedion; (c) following decomposition of the fetus and suppuration of the sac. I. The Measures to be Employed before Primary Rupture or Abortion. — Cases in which opportunity is afforded to operate prior to the rupture of the sac are more frequent than form- erly, owing to our improved m.ethods of diagnosis and to the greater significance given to disorders accompanying pregnancy. Too frequently, still, the disorder will be overlooked until the danger-signal of rupture appears. When the symptoms pres- ent make it evident that an ectopic gestation exists or is ex- tremely probable, the patient should be subjected to operation at the earliest possible moment. The danger arising from rupture is so great that the patient should be considered in peril of her life until the condition is corrected. The abdominal incision is the preferable procedure, inasmuch as it affords a 612 . GYNECOLOGY. better opportunity to explore the field, to manage adhesions, and to secure bleeding vessels. The removal of the entire sac rarely affords any special difficulty. In a tubo-ovarian pregnancy it is possible that a knuckle of intestine may have become adherent to the sac. In such cases the removal of the latter must be carefully managed, because the changes which take place in the adherent intestine render it easily torn. Failure to recognize this possibility in my own experience led to the necessity of resecting a knuckle of intestine for an ex^ tensive tear. The patient, however, fortunately recovered. 2. The Measures Required at the Time of Primary Rupture. — Unfortunately, the attention of the physician is much more frequently directed to the occurrence of primary rupture or abortion than to the existence of an ectopic gestation prior to this event. Very frequently the efforts employed to arrive at a correct diagnosis may be the means of the pro- duction of this catastrophe. Therefore, I would again em- phasize the importance of delicate manipulation in a case of suspected ectopic gestation. Indeed, prior to the careful examination of a patient in whom an extra-uterine pregnancy is suspected it would be well to have ample provision for re- sort to immediate surgical firocedure, in the event of collapse or rupture of the ectopic sac. Should the disaster occur during an examination, or the physician be called upon to attend a. case in which rupture had recently occurred, he should endeavor to keep the patient perfectly quiet and free from annoyance, with her clothing loosened. The foot of her bed should be elevated and a hypodermatic injection of morphin should be administered with a view not only to quiet the pain, but to lessen the nerve irritability and restlessness. An ice-bag should be applied over the abdomen, and immediate preparations made for opening the abdomen, in order to secure the bleeding vessel. The patient should be placed under the influence of an anesthetic. If the operator is at all in doubt as to whether the condition has resulted from an internal hemorrhage, he may confirm his suspicions and satisfy all doubts by cleansing the vagina and making a puncture through the posterior fornix, which will permit the recognition of the escaping blood. In- deed, through such a puncture the tubes may be examined and the presence of the sac recognized. Moreover, a skilful operator may be able to secure the bleeding vessels through the vaginal incision. Indeed, it has been advocated that the ruptured tube should be brought down, the surfaces cleansed, and sutures so introduced as to control the bleeding vessel and close the opening, leaving the tube in place. Such a plan of procedure, however, is inadvisable. The fact that the caliber- EXTRA-UTERINE PREGNANCY. 613 of the tube is so obstructed as to have caused an ectopic preg- nancy would indicate that its retention must necessarily subject the patient to the danger of a recurrence of the condition. The abdomen opened, the bleeding vessel secured', with aseptic pre- cautions, no grdat effort need be made to free the peritoneal cavity of blood, for, if the patient is kept under proper regimen, the blood is quickly absorbed and serves in some degree to sustain and support her. The absolute indication at this stage is to arrest the hemorrhage, and this is most effectively accom- plished through an abdominal incision. As soon as the abdominal incision is made there will be a gush of blood. The pelvis will be found more or less occupied with blood-clot ; do not stop to turn out the clots, but proceed through the clotted blood to the fundus of the uterus and along either tube to discover the sac. The site of the gestation is recognized as a soft, boggy enlargement of varying size and consistency, according to whether the ovum is, or is not, m situ. The sac is brought up and examined for the rent. A¥hen the hemorrhage is marked, the pedicle is at once secured with pedicle forceps until the cavity can be cleansed and ligatures applied. After ligation the sac is cut away. If the patient is very profoundly anemic, no time should be lost by attending to the toilet of the abdo- men, but it should be simply irrigated with normal salt solution to carry away the principal clots. 3. The treatment of the patient subsequent to rupture — (a) with intraperitoneal hemorrhage. The patient, having rallied from the shock, will in very many cases recover without opera- tive interference by keeping her perfectly quiet, promoting drainage through the intestinal canal by frequent purgation, and limiting the amount of food and drink that is given. She is thus obliged to live upon her tissues, which will promote the absorption of even a large collection. As we have already seen, the tube which has been the seat of an abortion will gener- ally be found distended with clots, and the same material will fill up the retro-uterine pouch. The convalescence of the patient will generally be enhanced by the removal of the tube and the clotted blood. This is particularly true when the tube is the seat of a perforation from the villi, for frightful hemorrhage may be found, and, besides, under such conditions it is likely to continue. Even when the hemorrhage arises as a result of rupture, we are not certain that the clot which plugs the vessels may not be loosened and a recurrence of bleeding follow. In spite of every precaution that may be observed it is not infrequently found that a collection of blood in the peritoneal cavity becomes infected from its proximity to the intestine, and thus a suppurative process is engendered which prolongs 614 GYNECOLOGY. the patient's convalescence. Even should this not occur, the blood-clot, becoming organized, gives rise to thickening, extensive adhesions, and more or less crippling of the function of the pelvic organs for the remainder of the patient's life. If the patient comes under observation some days subsequent to the evident rupture, thus affording sufficient time for the vessels to become occluded by clots, and with an accumulation of blood in the pelvis, which frequently is walled off by plastic exudate from the general peritoneal cavity, the preferable plan of procedure would be to make a free incision into the vault of the vagina. Two fingers should then be introduced through this opening, the clots broken up and evacuated, the cavity thoroughly irrigated with normal salt solution and packed w4th iodoform gauze. The tube may frequently be brought down and secured by ligature or clamp between the seat of rupture and the uterus, and the mass be thus removed. This is particularly true when the tube is occupied by a large blood-clot. When the tube is situated high up in the side of the pelvis or the lower part of the abdomen, and in a position not readily accessible through the vagina, the abdominal incision is preferable, as it affords a better opportunity to inspect the condition of the pelvic organs, to remove the occluded tube, and, if necessary, the associated ovary. It has been urged that where one tube has been the seat of an ectopic gestation which has ruptured and led to operative interference, the other tube should likewise be removed in order to prevent the possible occurrence of an ectopic gestation within it. The many cases in which a normal intra-uterine pregnancy has followed a tubal pregnancy would render such advice unwise. While numerous cases are recorded in which an operation for the removal of an ectopic gestation has been followed by the occurrence of gestation in the remaining tube, this, however, is not the rule, and it would be just as logical to forbid matrimony because an occasional marriage is unfortunate. (b) Extraperitoneal hemorrhage is a result of rupture of the tube betw^een the folds of the broad ligament. A hemato- cele is thus produced which is situated in the cellular tissue between the layers of the peritoneum. The amount of hemor- rhage is necessarily limited by the size of the vessel opened, the blood pressure, and the distensibility of the structure into which the hemorrhage has occurred. Where the collection is small, it may be sufficient to treat the patient expectantly, watch her progress, and trust to nature to absorb the exudate. Even in this condition it should not be forgotten that in rare cases the embryo may survive the accident and continue to grow. The continuation of the growth of the fetus presents EXTRA-UTERINE PREGNANCY. 615 additional and more serious problems. Prior to the fourth month the embryo, tube, ovary, and adjacent portion of the broad ligament, including the placenta, can generally be re- moved. Subsequent to this period, . however, the placenta may have attained such a size as to render its removal difficult. Not infrequently the life of the patient is endangered by a subsequent rupture. The placenta extends upon the pelvic surface, covering over and surrounding the vessels and the ureter. Moreover, the intestines may aid in forming the sac wall of the developing embryo and a condition result which would render any operative interference exceedingly serious. Where the patient shows marked symptoms of internal hemor- rhage and an examination reveals a collection of large size, an immediate operation is preferable, for the depressed con- dition of the patient increases the danger of infection of the effused blood from the walls of the adjacent intestine. When infection enters the sac, suppuration will follow. This, of course, greatly endangers the life of the patient. Early inter- ference with such a collection is preferably made through the abdomen, for the reason that it affords a better opportunity of exposing and securing the bleeding vessel. Having opened the abdomen, the peritoneal cavity so far as possible should be carefully walled off with a large quantity of gauze, the blood- clots evacuated, and the bleeding vessels searched for and secured. If the blood collection has been a large one and the pelvis is covered with adherent blood-clot, an opening should be made into the vagina, through which the end of a piece of gauze sufficient to fill the cavity should be carried. When the collection has been extraperitoneal, the abdomen can be walled off with gauze before the broad ligament is opened, the clots should be turned out; the bleeding vessel secured; the cavity packed with gauze, the end of which has been carried through an opening in the vagina, thus allowing the peritoneal wound to be closed. Care must be exercised, however, in this procedure not to injure the uterine artery or the ureter. 4. The method of treatment advisable in advanced growth of the embryo — (a) the child alive. From the fourth month to the completion of pregnancy the existence of a quick placenta presents a condition which is generally regarded as the most dangerous in the whole realm of surgery. The sac has ruptured, the placenta has formed new and more extended attachments. While the condition of the patient can not be considered other- wise than grave, the immediate danger is not so great but that we can afford to wait until a later stage of the pregnancy for interference and thus give the fetus a chance for its life. The existence of the live placenta and the profound hemorrhage 616 GYNECOLOGY. which results from any effort at its removal have led many oper- ators to question the advisability of any operative procedure while the child is alive. Some have advocated securing the death of the child by injecting into its bod}^ poisonous materials, such as morphin, or, when near the completion of the pregnancy, awaiting its death. They have justified this course of action by the assertion that in the great majority of cases the product of ectopic gestation is puny, ill developed, and often malformed, and that even when it survives extraction it usually lives but a few weeks, or at most months. Therefore they claim that the life of the mother should not be endangered to insure the life of a defective child. Experience, however, has disclosed that the extra-uterine fetus may be well developed, and when it is evident that the mother- can be saved only by operative procedure, it seems cowardice that this should not be employed at such a stage as will give the other being an opportunity for continued existence. Fortunately, the investigations of Dunning have demonstrated that the maternal chances are enhanced by operation during fetal life. The recognition of extra-uterine pregnancy, then, should lead to the prepara- tion for operation at a certain definite time prior to the com- pletion of the gestation, preferably at about eight and one-half months. In resorting to operative procedure we must consider it from two additional standpoints: (i) As to the treatment of the sac; (2) the method of disposition of the placenta. The sac is composed of remnants of the expanded tube or of the broad ligament, thickened and in parts expanded. In some places coils of intestine or the adherent omentum also enter into its formation. The removal of the sac, consequently, is fraught with danger, not only to the adjacent large blood- vessels and ureters, but to the abdominal viscera in general. When the pregnancy has passed the fifth month with ample evidence of a living child, we would advise that interference be postponed until after the eighth month. It should be under- taken, however, not later than at eight and one-half months, in order to afford the fetus the best chance for its life. The operator is compelled to adapt his procedure to the con-, dition immediately confronting him. The position of the fetus has been recognized and carefully outlined. In the major- ity of cases the median incision affords the best opportunity for the delivery of the fetus and the management of the sac and placenta. Having entered the peritoneal cavity, the sac is carefully examined and efforts made to avoid injuring the placenta. Where it is situated in front, we should endeavor to open the sac on one side. After opening the sac the most available part of the fetus is seized and delivered quickly. The cord is clamped with two hemostats and cut between them. EXTRA-UTERINE PREGNANCY. 617 The fetus is then removed and given to an attendant to be cared for. We now come to the decision of the question we have already mentioned, namely, the management of the sac and the disposition of the placenta: (i) The sac, as already mentioned, is composed of remnants of the distended tube or the broad ligament, thickened and in parts expanded. In other places coils of intestine or portions of the adherent omen- tum assist in forming it. The removal of the sac, consequently, is associated with great danger, not only to the adjacent large blood-vessels, but to the viscera and ureters. The ideal plan, where possible, is to follow the delivery of the fetus by the re- moval of the sac, including the placenta; where the removal of the sac can not be safely accomplished, the operator should stitch its edges to the skin margins of the abdominal w^ound. In well-advanced pregnancy we may possibly be able to push the peritoneum from the anterior abdominal wall and to penetrate the sac without opening the peritoneal cavity, but the chief dif- ficulty would be to determine — (2) how we shall manage the pla- centa. The method employed w411 entirely depend upon its situa- tion. Its management is most promising when situated in the pelvis below the fetus. When above the fetus, the placenta may be injured and result in furious bleeding or, indeed, even death of the patient. Even prompt seizure and ligation of the uterine side of the sac may fail to arrest the bleeding. The abdominal aorta may then be compressed, the cavity packed with sponges, and an application made of perchlorid or persulphate of iron. The danger of bleeding has frequently induced surgeons to leave the placenta and allow it to slough away, employing proper measures for securing external drainage. When the removal of the placenta can be accomplished without too much risk, it should be done. In addition to avoiding the placenta in opening the fetal sac, we should exercise the precaution to prevent discharge of the amniotic contents into the peri- toneal cavity. After delivery of the fetus the operation is com- pleted in one of three ways: (i) The extirpation of the entire sac; (2) the removal of the placenta without the sac; (3) the retention of the placenta and the sac. 1. Whenever it can be safely accomplished, the entire sac should be removed. By this method the operation is more complete and convalescence is more likely to be insured. This can be accomplished whenever we can construct a pedicle and the sac wall is made up of tissue that can without disadvantage be removed. The pedicle may be narrow or broad, as in an ovarian cyst. 2. Extirpation of the Placenta with the Sac Remaining. — The placenta should be removed whenever it can be peeled out without hemorrhage, or when it is so situated that the vessels 618 GYNECOLOGY. supplying it can be securely ligated and the mass " removed, or when its position is such that effective control of hemor- rhage can be accomplished by tampons of iodoform gauze. After removal of the placenta the gauze may be removed and replaced by a large drain. 3. The Retention of the Placenta and Sac. — When the pla- centa is firmly attached or it is evident that its detachment would result in dangerous hemorrhage, it should not be dis- turbed. The operator should exercise the greatest care in the management of the live placenta, as the hemorrhage in such cases is frightful and exceedingly difficult to control. Where the placenta is partially detached, it may be necessary to proceed with its removal. This should be accomplished quickly, making firm pressure over the parts with iodoform gauze. If the attachment is of such a character as will permit, the parts should be quilted together by a ligature which is tied firmly around the base of the placenta. Where it is neces- sary to retain the placenta and the sac, one of the following methods can be practised : The sac can be fixed to the abdominal wall and the cavity drained, or the opening in the sac can be closed, covering over the placenta and shutting off the latter from the peritoneal cavity. In such cases the cord should be cut off close to the placenta, after previous ligation with chromic catgut, or the electro -angiotribe can be employed. This instrument appeals to me as an efficient means of con- trolling hemorrhage and insuring the removal of a portion of the placenta. To accomplish this, it will require a modifica- tion of the angiotribes at present in use, employing one with a more flattened surface, thus allowing a good portion of the placenta to be subjected to the slow action of heat. The pla- centa and sac should be closed and returned to the peritoneal cavity only when we have been able to secure absolute and rigorous antisepsis. The presence of a single microbe may lead to putrefaction of the placenta and suppuration. The disadvantages of the retention of the placenta are that its separation and discharge are tedious and present continuous risks of septicemia and peritonitis. Fecal fistula may form. These risks are decreased by irrigation of the sac, by the ligation of the cord close to the placenta without disturbing the latter, by carefully sponging the cavity, and then, as has been sug- gested, by hermetically closing it. Even though we are able to exclude the germs from the cavity, it must be remembered there is danger of their entrance through adhesions to the in- testines. Intestinal micro-organisms may gain access to the placenta and produce decomposition. The following rules have been formulated by Sutton: (i) When the placenta is situated above the fetus, attempt its removal; (2) if the placenta has EXTRA-UTERINE PREGNANCY. 619 become partially detached during the course of the operation, no choice is left but its removal; (3) the placenta below the fetus can be left; (4) if the placenta is left, the sac closed, and subsequently symptoms of suppuration occur, the wound must be at once laid open and the placenta removed. (6) The Child Dead, Mummified, or Reduced to a Lithopedion. — The death of the child at any stage results in very early arrest of the circulation in the placenta. The continuation of the growth of the placenta after the death of the fetus has been considered as a possibility, but this is very improbable. The placenta does not decompose, but undergoes slow and complete atrophy. The vessels in the maternal portion atrophy and dis- appear. This, consequently, leaves much less of the placental structure than would be found in an extra-uterine pregnancy. The absorption of the placenta continues until, in those cases in which the lithopedion is formed, the placenta is found to be entirely absent. Should the patient come under observation when the history would lead us to suspect that the fetus has but recently perished, it would be wise to postpone operation a few weeks later, when arrest of the circulation in the pla- centa may become complete. The sac is exposed by the ab- dominal incision, the general peritoneal cavity is well pro- tected by gauze packing, and care exercised that the contents of the sac shall be removed without soiling the peritoneum. The escape of the contents into the peritoneal cavity should be prevented by the employment of an aspirator and the sac should be carefully guarded by sponge packing before it is opened. The fetus is withdrawn and the sac then examined, with a view to its removal, if possible. Where the condition will admit, the entire sac, with the enclosed placenta, should be removed. If knuckles of intestines are adherent to the sac, the greatest care should be exercised in their separation, in order to avoid inflicting injury to them. Where the adhesion is very firm, the separation should be made at the expense of the sac wall, leaving a portion of it attached to the intestine. When a large portion of the intestine enters into the formation of the sac wall, the removal of the sac will not be feasible. In such cases the placenta should be peeled out, the cavity thoroughly sponged with carbolic acid and afterward with alcohol, dried, packed with gauze, and its edges stitched to the abdominal wound. Where the sac is dependent and in close approximation to Douglas' pouch, an opening should be made through its base into the vagina, through which drainage maybe effected and the upper part of the sac closed. The vaginal drainage of the sac should be employed whenever possible, as the drainage is from the most dependent portion and the convalescence of the patient is much shorter and 620 GYNECOLOGY. the dangers of subsequent ventral hernia greatly decreased. Following the death of the fetus marked changes occur. The fetus itself may become mummified, its watery portions absorbed, forming a flattened mass. Or, again, the entire fetus undergoes a substitution of fat for its original structures, forming a lardaceous condition; or, again, we may have the fetus and its sac filled up with calcareous deposit, causing a rather dense, hardened mass. Some of these conditions may continue for years. A lithopedion has been found in a woman of ninety. Their presence, however, always predisposes to infection, which may result in suppuration, with subsequent discharge of particles of the calcified mass. Wherever pos- sible, the entire mass should be removed. Wherever it is rec- ognized, after an abdominal incision, that the mass has formed extensive adhesions to the intestines and other structures of such a character as to preclude the probability of successful removal, the sac should be opened, its contents so far as pos- sible removed, the sac wall stitched closely to the abdominal wound, and its cavity packed with gauze. The removal of the fetus and the drainage of the sac result in its complete obliteration and the restoration of the patient to health. (c) Following Decomposition of the Fetus and Suppuration of the Sac. — Decomposition of the fetus and suppuration of the sac are indicated by symptoms of inflammation, the sac becoming tender to pressure with evidence of localized peri- tonitis. The temperature of the patient will be elevated; pos- sibly recurring chills, night-sweats, progressive emaciation, and symptoms of low continued fever will be manifest. Lique- faction of the sac by pus-formation causes thinning and even rupture of its walls, with the escape of its contents into the peritoneal cavity, the bladder, the intestine, the vagina, or through the abdominal w^alls. The rupture results in the for- mation of a sinus, through which often will be found passing fragments of small fetal bones. The existence of suppuration should be considered an indication for immediate operation. To open the sac without entering the peritoneal cavity is, of course, more satisfactory, and this occasionally can be accom- plished. If the adhesions between the peritoneal surfaces are not extensive, the opening may be a small one, and by gauze packing and other means the adhesions may be extended. Where parietal adhesions do not occur, the sac should be opened and its contents thoroughly evacuated, but the peritoneal cavity must be thoroughly protected from soiling by gauze packing. Every fragment of bone should be removed, for otherwise the obliteration of the sac will not take place and suppuration will continue as long as the irritation remains. The cavity of the sac should be thoroughly packed with iodo- GENITAL TUMORS. 621 form gauze and the sac itself be stitched to the skin edges. During the convalescence the cavity should be frequently irri- gated with antiseptic fluids. We may sometimes be able, es- pecially where the opening has taken place through the abdominal wall, to dilate the sinus and empty the sac with- out opening into the general peritoneal cavity. This method of procedure can be effectually employed in the opening through the abdominal wall and the vagina, but openings into the bladder or intestine will require abdominal operation. How- ever, efforts should be made to remove the sac, if possible, and to close the intestinal or vesical openings. GENITAL TUMORS. 555. Definition. — In the broad sense of the term any unusual swelling or protuberance of a part can be called a tumor, but the designation is properly restricted to a new-growth which is inde- pendent of the results or productive of inflammation. Such a growth is distinctly circumscribed, has a marked course, can be definitely differentiated, and is associated Avith febrile symptoms only when degenerative changes exist. 556. Classification. — Tumors of the genitalia, like those occurring in other portions of the body, are divided clinically into the benign and malignant; pathologically into neoplasms and cysts, and histologically into those which originate in adult or in embryonic tissues. The following table, prepared for me by Dr. P. B. Bland, presents the subject in a readily compre- hensive form : f Adult connective tissue < Fibroma Myoma Fibromyoma Fibro-adenoma Angioma " ^ Solid 1 i Lipoma Myxoma Chondroma Osteoma Benign ! I [ I Adult epithelial tissue Retention Neuroma Papilloma Adenoma . Cystic Congenital ^ Teratoma^ [ Vaginal cysts Malignant 0^ Embr} 'onic epithelial tissue Carcinoma Chorio-epithelioma malignum Embr> 'onic connective tissue < Sarcoma Endothelioma 622 GYNECOLOGY. When we come to analyze the arrangement into groups of these growths, we find that any arrangement must be more or less arbitrary, and the transition from one form to another is so subtle as to make the assignment of some growths very difficult and uncertain. The definition into benign and malignant is of classic origin and necessarily is of great importance. A benign tumor may be defined as one which in the course of its develop- ment inclines to remain local or confined to the structures in which it originated. It de\'elops from adult tissue, in its prog- ress is not usually destructive to life, and displays no dis- position to metastasis nor to recur when removed. The malig- nant tumor, on the contrary, is supposed to have its nidus in embryonic tissue, gradually breaks down its original barriers, invades the surrounding structures, extends by metastasis until the entire organism may become infected, and displays a marked tendency to recur after surgical intervention. The study of the structure of gro^^-ths shows a marked difference in the cellular tissue of the two classes, each having well-defined tissue changes which render them recognizable, and from which the future progress may be predicated. In the differential diagnosis it is often difficult to draw the line and assert that the benign terminates here and the malignant begins there. In some of the uterine and ovarian growths, par- ticularly the glandular varieties, we are forced to rely upon the life history of the growth in order to determine its proper classi- fication. Notable examples are the glandular and malignant adenomata of the uterus and the papillomata of the ovary. VULVA, VAGINA, AND BLADDER. 557. Characteristics of Benign Neoplasms. — The benign growths have been divided into solid and cystic, and the former, from their structure, into the connective-tissue and the epithelial tumors. The connective-tissue growths predominate among the benign, and while they may be found in all the tissues of the geni- talia, they to the greatest degree characterize those springing from the uterine parenchyma and are known as the myomata or fibro- myomata, according as the muscular or connective tissue pre- dominates, or the fibromyomata in a combination of the two. Cystic tumors are those which consist of the envelope, sheath, or sac containing thin serum, blood, pus, mucin, sebaceous material, parasites, hair, cartilage, or bone. These tumors have their origin in the ovaries, broad ligaments, vulva, and vagina, in con- genital remains, as the Wolffian bodies, the parovarian and remnants of the ducts of Gartner, and the Mullerian ducts. Cystic growths of the ovary present considerable difficulty in GENITAL TUMORS. 623 classification, inasmuch as twenty per cent, of them prove to be malignant. Even careful microscopic examination of the growth will not always enable it to be properly classified, because a malignant nodule or portion may be engrafted upon what other- wise seems a benign growth, and may be so situated that it can readily escape observation, for the examiner would be entirely unable to subject the parts of a large gro\^rth to such an investi- gation. Certain of these gro\\i:hs — ^the papillomatous variety — show a disposition to grow through the enveloping sheath or cyst wall, and when it is ruptured, their contents are infected or become implanted upon the peritoneal surface, causing a low grade of peritonitis and an extensive ascites. Such behavior at once answers to the description of malignant disease, but experi- ence reveals that in the majority of cases the removal of the origi- nal source of infection, the ovarian growth, produces atrophy and disappearance of the secondary infection of the peritoneum. In many of these growths the surgeon is compelled to deter- mine the final diagnosis between benignancy and malignancy by the subsequent clinical history of the patient. In discussing specific gro\A^hs, comparison can more readily be made by con- sidering separately the tumors, benign or malignant, which are prone to occur in each portion of the tract. 558. Unclassified. — In the former editions I discussed some conditions under genital tumors, using the term in its unre- stricted sense, which I will now consider separately. These condi- tions are hernia, hydrocele, varicose veins of the vulva, edema, elephantiasis, and urethral caruncle. 559. Hernias. — The gaseous cysts are hernias which present in the vulva in tw^o varieties — the anterior labial or inguinal and the posterior labial. The anterior labial hernia is analogous to the scrotal hernia in the male. It is formed by a portion of intestine or omentum descending through the inguinal canal and distending the large labium. (Fig. 448.) This form of hernia is comparatively rare in women. Femoral hernia is much more frequent in the female. In the latter the hernial sac emerges below Poupart's ligament and makes its exit as a lump in the groin, which, as it increases in size, pushes up over the ligament. In the sac of an inguinal hernia has been found an ovary and tube and even the fundus of the uterus. Instances have been recorded of an ovarian cyst or a tubal gestation complicating such a hernia. The posterior labial hernia (Fig. 449) is formed by the intestine driving the peritoneum through the pelvic aponeurosis and the levator ani muscle. The sac appears at the side of or projects through the vulvar orifice. Labial hernia may sometimes be difficult to difterentiate from hydrocele or a fatty tumor of the labium. A double hernia with an ovary in 624 GYNECOLOGY. each labium associated with a large penis-like clitoris may cause some doubt as to the sex of the individual. 560. Hydrocele. — A well-formed serous cyst which is con- tinuous is sometimes situated in one or the other labium ma jus, or when the canal of Nuck is patulous it may, b}^ slight pressure, be emptied back into the peritoneal cavity to recur as soon as the patient assumes the upright. This tumor is known as hydrocele, Fig. 44S. — Anterior Labial or Inguinal Hernia. and is analogous to the serous collection sometimes found in the scrotum of the male. The sac is thin walled, quite translucent, and affords a distinct sense of fluctuation. The swelling grad- ually increases in size and may become so large that it is uncom- fortable in sitting or walking, and may prove an obstacle to the sexual relation. Hydrocele is readily distinguished from solid tumors by its translucency and distinct fluctuation ; from hernia by its being more continuously distended, except in the few GENITAL TUMORS. 625 cases in which the canal of Xuck remains patulous, the more dis- tinct sense of fluctuation, its translucency, a less amount of pain or discomfort, the absence of any swelling over the line of the inguinal canal, and the failure of the protrusion to increase during coughing or straining. Treatment. — The contents can be readily removed by punc- ture, but recollect rapidly. Obliterative inflammation may be Fig. 449. — Posterior Labial Hernia. engendered after the removal of the fluid by the injection of some irritating agent, and pressing it about to bring it in contact with the entire cavity of the sac, but care must be exercised to prevent it being forced through an open canal into the peritoneal cavity. A safer and more satisfactory procedure will be to miake a free opening into the sac and pack it Avith iodoform gauze. 561. Erectile or vascular tumors are rare in the labium, but when they occur, present characteristics similar to those in other 40 626 GYNECOLOGY. portions of the body. Vascular growths about the urethra are much more frequent. Pozzi indicates that the hymen is not a simple isolated structure surrounding the vulva, but comprises, first, the masculine frsnum vestibuli; second, the ring inclosing the urinary meatus; and, third, the hymen. The structure is the undeveloped matrix tissue of the corpus spongiosum in the male, and has not become erectile. These considerations, he asserts, throw light upon the origin of some of the vascular growths of the urethra and meatus. The retention of the erectile tissue in the female, which is normal in the male, results, through efforts at micturition, in the formation and extrusion of a polypus, known as a ^ire- thral caruncle. 562. A urethral caruncle appears as a bright red, fragile looking projection from the urethral orifice. It is largely composed of dilated capillaries with a small amount of connective tissue, and is covered with pavement epithelium. In a recent study of some mi- croscopic sections of these growths I discovered the presence of glandular struc- ture quite well m.arked. The gro\\i;h is amply supplied with nerves, which are more or less exposed. The struc- ture of the growth accounts for its vascularity and great sensitiveness. (Fig. 450.) Etiology. — The growths may occur at any age. They are frequently seen in young children, are more frequently found in middle life, and have been seen in women as late as the seventy-fifth year. They occur with about equal frequency in the married and unmarried. Symptoms. — The growth usually projects from the urethral orifice and is generally situated upon the posterior wall. Sepa- rating widely, the vulva causes the tumor to be pushed forward and rendered more prominent. Its sensitiveness varies with i Fig. 450. — Urethral Caruncle. GENITAL TUMORS. 627 different individuals. In some it produces no marked symptoms, while others complain of continuous burning, a sensation of full- ness in the urethra, and marked pain during and for several minutes following urination. Occasionally the distress is so marked that the act of micturition is prevented and the employ- ment of a catheter is rendered necessary. Its extreme sen- sitiveness frequently causes it to be a barrier to the sexual re- lation, hence it is one of the causes of dyspareunia. Diagnosis. — The tumor is readily recognized by its bright red appearance, its ex- treme sensitiveness, and its fragility. A varicose condi- tion of the urethral vessels may occur, but this is char- acterized by bluish projec- tions from the urethral ori- ^ r.^^^ fice, which are plainly recog- f/f^BUL^^ I nized as distended veins, somewhat resembling hemor- rhoids about the anus. A prolapse of the urethra may exist, but this condition forms a rounded projection which partly or completely encircles the urethral orifice. (Fig. 451.) Treatment. — The only treatment that affords any hope of success is excision. This may be done under co- cain anesthesia, the mass picked up and cut off at its base with scissors, and bleed- ing arrested by coaptating the surfaces Avith a suture. It is much more satisfactorily accomplished, however, under general anesthesia, as the patient is then quiet and the manipulation can be more deliberate. The excision of the mass with scissors and the application of the thermocautery to the base are very efficient. In the employment of the thermocautery a wooden rod the size of a catheter should be previously intro- duced to preserve the urethra from destruction. Especial care must be exercised to control the hemorrhage, as I have seen frightful bleeding occur from such an operation. Fig. 451. — Prolapsus Urethras. 628 GYNECOLOGY. 563. Varicose Veins. — Varicose veins of the vulva are not in- frequent during gestation. (Fig. 452.) Holden reports a case in which the labia majora were the size of a fetal head. The pa- tient died of phlebitis. The tumor presents a bluish color on the surface of the integument, violet on the mucous surface, and gives rise to a sensation of weight in walking or when the patient is in the upright position. The rupture of such a tumor may cause serious or even fatal hemorrhage. The patient should be cautioned to wear her clothing loose, having no constriction about the waist, and the varicose parts should be supported. The most effective treatment is the excision of the principal veins. Fig. 452. — Varicose Veins of the Vulva. — {Dr. W . Krusen.) 564. Edema. — Anasarca is frequently accompanied by ex- tensive swelling of the labia. The cause is readily recognized by the associated condition. When edema exists without general dropsy, it is indicative of some obstruction to the circulation in the pelvis. Edema confined to one labium is generally the result of injury or inflammation. A hard, dense exudation in one la- bium will usually be found to be due to a hard chancre, situated upon the same side at the margin of the vagina. 565. Elephantiasis. — Elephantiasis consists in chronic inflam- mation of the lymphatics, with dilatation of their canals. It is very rare in our climate, but is more likely to exist in hot climates. The cause of the condition is unknown. The affection consists GENITAL TUMORS. 629 of more or less considerable hypertrophy of the entire vulva, sometimes localized in certain regions, as, for example, in the clitoris. The large hypertrophied labia form voluminous masses, which may exceed the dimensions of an adult head. (Fig. 453.) Three forms ate described: first, the entire derma is hypertro- phied, with A^ast dilatation of the lymph-spaces; second, the engorgement of the lymph in the capillaries and large trunks; third, the lymphatic ganglia become the seat of fibrous altera- tion. Symptoms. — The enlargement is frequently so great that walking and urination are interfered with. Friction of the sur- face leads to ulceration, which is slow to heal. The thickened tissues invade the vulva and the perineal and anal regions, and form enormous tumors. When the surface of the skin is smooth, it is called glabrous; when roughened, with warty projections, verrucous; and papillomatous when the papillas are much hypertrophied. Diagnosis is easy. The hypertrophy and swelling of lupus are always accompanied by ulceration. The papillomatous veg- etations are situated directly on the skin. In fibromata and myxomata which become pedunculated the tumors are isolated and circumscribed, while elephantiasis is diffuse. The cause of the condition is unknown, although it has been attributed to syphilis. It is due to an acute lymphangitis, with intense fever. The only effectual treatment is ablation and the suturing of the surface in order to secure union bv first intention. VULVA. 566. Tumors of the vulva are comparatively rare and com- prise cystic and solid, benign and malignant, growths. 567. Serous cysts would naturally be expected to occur in a region so well provided with glands as is the vulva. Retention cysts of the gland of Bartholin belong to this class. (See Section 394-) 568. Sebaceous cysts rarely attain to any size. They are found upon the labia majora, the labia minora, in the sulcus, between them, about the clitoris, over the mons veneris, and sometimes upon the edge of the hymen. 569. Blood cysts are occasionally found. These may origi- nate in a preexisting hematoma, through a hollow, round liga- ment (Koppe), in the sac of an old hernia, in the site of a throm- bus, or from dilatation of lymph-vessels. Cysts are also found in the hymen — Doderlein says, from fusion of adjoining surfaces; in the urethra, either from ob- literation of Skene's glandules or the dilatation of a terminal and unobliterated vestige of Gartner's duct. 630 GYNECOLOGY. Hematoma of the vulva and vagina has been described. (Section 534.) Abscess. — (Section 391.) 570. Neuroma of the vulva is a rare condition. Painful nodules are occasionally recognized, and their presence oc- casions vaginismus. Treatment would be to excise the painful spots. 571. Simple Vegetations. — Vegetations appear upon the vulva in the form of papillomata or condylomata, occasionally having the appearance of a cauliflower. They may be situated at the edge of the vulva in isolated projections, or may cover, by a voluminous growth, the whole surface of the external genitalia. The mass may extend backward around the anus, and may attain the size of a fetal head. The growth presents a pale red color, often a deep wine tint, and is situated upon the vulva, perineum, and margin of the anus, sometimes extending for- ward over the mons veneris and over the inner surface of the thighs. (Fig. 453.) A profuse leukorrheal discharge is gener- ally present, which is retained by these vegetations, and causes an extremely disagreeable and fetid odor. The decomposing discharges irritate the surface, which becomes greatly inflamed during w^alking and exercise. They are generally considered an indication of venereal infection, and are produced by either gonor- rheal or syphilitic virus. Transmission of the disease has been observed by contact. The presence of vegetations, however, is not always an indication of specific infection, as these growths arise in pregnant women from a simple leukorrhea. The sur- faces upon which they are implanted may become thickened by inflammation, undergo ulceration, and be covered by a glairy, fetid mucus which increases the resemblance to malignant disease. A vertical microscopic section of a growth, however, will reveal its true character. In the vegetations are dilated, tree- like capillaries embedded in connective tissue, and covered with several layers of epithelium, thus presenting a marked con- trast to the nests or tubular masses of epithelium embedded in connective-tissue stroma, which indicate the presence of epithelioma. Treatment. — Keep the parts thoroughly clean, irrigate with bichlorid solution (i : 2000), and dust the surface with equal parts of alum and sugar or paint it with carbolic acid and after- ward wash with alcohol. When the vegetations are very ex- tensive, the most effective method of treatment is to place the patient under an anesthetic and with scissors cut away the vegeta- tions, cauterize the base with nitric or chromic acid, or, still better, with the thermocautery, and subsequently keep the parts clean and dusted with a drying powder. The pain following the GENITAL TUMORS. 631 application of the thermocautery will be greatly lessened by painting the burned surface with carbolic acid. The convales- cence will be rapid. The existence of pregnancy need be no Fig. 453. — Vulvar Vegetations. barrier to the method of treatment indicated, as the danger to the patient from sepsis following delivery is much greater than any which could result from the removal of the growths. 632 GYNECOLOGY. General anesthesia can be avoided by saturating the parts with a ten per cent, solution of cocain. Removal of the growths by the curet has been advised, but the scissors affords a cleaner Fig. 454. — Elephantiasis of the Vulva. and more effective instrument. Excision produces less irritation of the subjacent skin. The hemorrhage may be controlled by the application of a strong solution of persulphate of iron, but GENITAL TUMORS. 633 the thermocautery will prove more satisfactory. The burn- ing of the latter can be lessened by the application of a com- press wet with a 5 per cent, solution of carbolic acid. The ap- plication of a 10 to 40 per cent, solution of formaldehyd two or three times will cause the vegetations to slough, but this is a painful application. 572. Fibroma and myxoma are tumors which are found in the large labia, though they may also develop in the nymphag or in the perineum. They are benign tumors of slow gro\\i:h, though they occasionally attain to large size. The former be- come pedunculated. The tumor may be enucleated or the pedicle may be cut without danger of hemorrhage. Figure 455 shows a fibroid tumor that occurred in the. practice of Dr. S. E. Cox, of Nashville, to whom I am indebted for the illustration. 573. Lipoma. — A lipoma is a fatty tumor of the labium which may resemble elephantiasis. Through the kindness of Dr. E. L. Reed, of Atlantic City, I was permitted to see a lipoma the size of an orange on the vulva of a woman who consulted him from the fear that it was a hernia. Lipo- mata are usually small, but Stiegel removed one that weighed ten pounds. 574. An enchondroma is an ex- ceedingly rare cartilaginous tumor which affects the clitoris. It may become as large as the fist and present calcified portions. Bartho- lin reports a Venice courtesan who wounded her paramour with her ossified clitoris. 575. Malignant Disease of the Vulva. — Alalignant disease occurs in the vulva in the form of epithelioma, sarcoma, and rarely as adenocarcinoma. Primary cancer of the vulva is rare. Epithelioma is the most frequent form and. begins in the large labium or in the cleft between it and the lesser labium, less frequently in the clitoris or the meatus. The disease origin- ates from the squamous epithelium and usually appears first as small warty nodules covered with thick layers of epithelium. Sometimes it follows irritation about the base of a preexisting papilloma or wart. It is frequently preceded by psoriasis. The epithelium covering the nodules undergoes degenerative changes and causes a discharge of thin watery fluid mixed with blood. Fig. 455. — Fibroid of Labium. 634 GYNECOLOGY. Groups of the embryonic cells fracture the limiting membrane and penetrate deeper tissues, supplanting the normal tissue and forming the characteristic epitheHal pearls. Sometimes the cells will be found in the act of penetrating the walls of the blood-vessels, thus expediting the propagation of the disease. As the infiltration advances, superficial ulcerations occur, which gradually become deeper and involve the neighboring structures. (Fig. 456.) The inguinal glands are first sympathetically in- Fig. 456. — Cancer of the Vulva. volved and later become infiltrated with the malignant cells. The disease occurs upon one side and then spreads to the oppo- site, possibly by inoculation through apposition. Adenocarci- noma results when the disease begins in the glands of Bartholin. Sarcoma occurs in the simple form as the melanosarcoma. Symptoms. — -The patient suffers from* intense pruritus, in scratching for which the nodules, previously unnoticed, are discovered. These become excoriated and cause a bloody GENITAL TUMORS. 635 discharge and an exceedingly fetid odor; not infrequent!}^ the nodule is a wart which has become irritated at its base and subsequently infiltrated. The nodules may be sessile or pedun- culated, and subsequently coalesce. When the disease occurs about the urethra, the orifice may become contracted, and the canal may appear as a hard, indurated cylinder. The ulceration presents excavated borders, with the adjacent skin infiltrated and hard, and the pubic hair may fall out. In the r 0/ 1- Fig. 457. — Appearance of the Vulva after an Operation for Cancer of the Vulva. later stages the skin and tissues for some distance around the vulva become indurated and hard, and the glands of the groin are infected. With the extensive inflammation, the discharge, loss of blood, loss of rest, and the mental anxiety produce emacia- tion, and death follows from marasmus, sepsis, or metastatic development. The latent period is a long one, the disease remaining for some length of time with but slight circumjacent or more extensive involvement. Death occurs in the second or third year. 636 GYNECOLOGY. Diagnosis. — The history of continued genital psoriasis; in- tense pruritus, with small nodules ; arrangement of the epithelial layer, which shows a tendency to break down; the irregular ul- ceration, with infiltrated base and margins ; and, later, glandular involvement, are sufficient to indicate the character. Papillary vegetations extend over a considerable surface, are comparatively free from induration, and in no sense resemble cancer. A pol- ypus or caruncle of the urethra has a base free from induration. Chancre is an indurated sore without disposition to spread, and is associated with glandular involvement, and later with the syphilitic eruption. Chancroid is a superficial ulceration without induration. The contiguous surfaces readily become inoculated. The lymphatic glands promptly go on to suppuration and to the formation of buboes. In lupus the ulceration is serpiginous, with a tendency to cicatrization in the tissues first affected, and glandular involvement is rare. The prognosis of malignant disease of the vulva is bad. The cases usually come under observation after extensive involvement, generally after the lymphatic system has become invaded by the malignant process. Operative treatment delays the progress of the disease and renders the patient more com- fortable. Treatment. — The only hope for the patient consists in total removal of the disease. Some prefer the thermocautery or galvanocautery to the knife, as affording less danger from secondary inoculation. The scissors or the knife, however, are preferable, as by their use we shorten the convalescence and leave the structures less distorted. Care must be exercised, when possible, not to injure the meatus. In peri-urethral cancer, however, the sound should be introduced into the bladder, which will aid in the dissection, and the neoplasm, if neces- sary, should be followed to the neck of the bladder. In one case I removed the urethra up to the neck of the bladder without the patient suft'ering from incontinence. The incision should ex- tend well around the disease, as far as possible within the bounds of healthy tissues. Bleeding vessels, rather frequent in this region, are secured with clamp forceps, and ligated if neces- sary with catgut ligature, or the sutures closing the wound are so introduced as to constrict the bleeding vessels. Care must be exercised that the bleeding vessel does not retract and continue to bleed. The retraction thus of branches of the internal pudic caused hemorrhage which followed the pelvic muscles backward, broke through and formed a large hematoma upon the posterior surface of the sacrum, in one of my early operations for this condition. In such a case, if the vessel can not otherwise be secured, it will be better to tie the internal GENITAL TUMORS. 637 pudic over the external surface of the spine of the ischmm. Fig. 456 illustrates the case of a woman who underwent opera- tion in which both labia and clitoris were removed, and the tissue subsequently united, as seen in Fig. 457. Any inguinal glands involved should be extirpated, as well as the principal chain of lymphatic vessels leading to them. The circumjacent fat and cellular tissue should also be removed. When the disease has progressed too far to render radical operation successful, the putrid discharge may be temporarily controlled by the use of the curet and cautery. When the disease is too far advanced for this, the surfaces may be kept sprinkled with iodoform and pure charcoal, and dressed with gauze. The surface can be dusted with the following powder: B . Salicylic acid, gr. iv Boric acid, .^ j Iodoform, ^ij Ext. eucalyptus, q. s. Kraske advises in extensive disease that the parts be thor- oughly cureted, the lacerated parts cleansed, and the surface cov- ered with flaps of healthy skin, as this procedure renders the course of the disease slower and the symptoms less painful. VAGINA. Tumors originating in the structure of the vagina are infre- quent. 576. Cysts of the vagina are very rare, and are generally formed in the remains of congenital structures. (Fig. 458.) They are found as isolated tumors in the mucous and submucous membrane, in the former usually directly beneath the squamous epithelium. Rarely more than two or three occur in any indi- vidual case; Schroder, however, removed six from one patient. They are more frequently found upon the anterior wall, and are exceedingly rare upon the posterior. They vary in size from that of a pea to a hen's egg. The contents of these cysts are serous, more or less viscid or gummy, and are sometimes found mixed with blood. The epithelial lining of the sac may be either cylindric or laminated. The epithelium of some is ciliated (Abel). The origin of these growths is exceedingly diflicult to determine. They have been attributed to the remains of Mliller's, Wolff's, and Gartner's ducts, to vaginal glands, or, according to Klebs, to dilated lymphatics. Neugebauer attri- butes most of them to remains of Gartner's canal. Hematoma of the vagina may serve as the origin for a cyst. Glands of the urethra may form retention cysts, and, as they develop, may project into the vagina. 638 GYNECOLOGY. The symptoms will depend upon the size of the cysts. Or- dinarily, they produce no inconvenience nor discomfort. Re- cently a patient underwent examination for some pelvic dis- order, when a cyst the size of a walnut was found upon the posterior wall. Diagnosis. — The condition may sometimes be mistaken for cystocele or urethrocele. The use of the catheter during the examination will demonstrate the thickness of the septum and the presence and size of the cyst. In the upper part of the vagina cysts are confounded with small tu- mors in Douglas' culdesac, such as prolapsed ovaries, a noncystic inflammatory condition of the tubes, and other inflammatory collec- tions. A second vagina, which is closed and filled with retained secretion, may simulate a cyst. Treatment. — Only the large cysts require any treatment. The cyst may be opened and the sac cauterized most effectually with the actual cautery; or it may be packed with iodoform gauze, which af- fords drainage and sets up sufficient inflammation to obliterate it; or the entire sac may be enucleated. 577. Fibroid Tumors and Polypi. — Fibroid tumors originating in the vagina are very rare. They de- velop in the submucous or deeper layers of the mucosa and push into the vagina. As they increase in size they become polypoid, and hang by a pedicle. The structure is similar to that of uterine fibroids, and the gro^vth is slow. The most common situation is the superior portion of the anterior wall. They are often adherent to the urethra, and distend the vulva. They are usually small, although they have been reported as weighing two and one- half pounds. Bandier and Gremlier report one weighing ten Fig. 45 8. — Cysts of the Vagina. GENITAL TUMORS. 639 pounds. I am indebted to Dr. John C. DaCosta for the illustra- tion (Fig. 459) of a specimen which he removed from the vagina. As these growths increase in size, they become softened and ulcerate. They are much more likely to develop during the period of sexual ' activity, although Tratz reported one in a child of fifteen months which attained the size of a man's fist, and Martin one f of an inch long in a child two days old. Symptoms. — The symptoms of the growth are largely de- pendent upon its size. If small, the tumor may remain unrecog- nized. Larger growths cause dysuria and retention of urine. They project from the vulva, and the traction produces bleeding, ulcera- tion, and erosion. Diagnosis. — The growths are readily determined by their situation, slow growth, and mechanical disturbance. The softening, ulceration, and hemorrhage may sometimes lead to a diagnosis of malig- nant disease. Treatment. — The treat- ment consists in the removal of the growth by enucleation in sessile tumors, and by sec- tion of the pedicle in polypus. Hemorrhage is controlled by ligature or suture. 578. Papillomata. — Papil- lary or warty growths are found in the vagina, gener- ally in association with simi- lar growths about the vulva. Generally they appear as small isolated projections over the walls, but occasionally the entire vagina will be filled. 579. Malignant Neoplasms. — In the vagina malignant growths of primary origin are very rare. They most frequently extend from the uterus, rectum, vulva, urethra, or bladder, in one of three forms: first, papillary; second, infiltrated or nodular, both of which are included histologically under epithelioma; third, sarcoma, either diffuse or circumscribed. They most frequently occur in the papillary form, although we may have carcinomatous Fig. 459. — Myoma of the Anterior Vag- inal Wall. — (^Dr. John C. DaCosta.) 640 GYNECOLOGY. infiltration, either circumscribed, forming a broad-based excres- cence, or a substitution of scirrhous for the normal tissue. Etiology. — Malignant disease is most frequent during middle age, and is rare in youth, although I have seen one case of cancer of the vagina in a woman twenty years of age. Hegar once saw it in a woman in whom it was attributed to the irritation pro- duced by a pessary. Epithelioma of the papillary form usually affects the posterior wall, as a broad-based excrescence which rapidly invades the culdesac and ex- tends downward to- w^ard the vulva. Epithelioma of the nodular or infil- trated form appears as nodules which become confluent, sometimes localized about the wall of the urethra. The ulceration advances rapidly, and may burrow into neigh- boring organs, pro- ducing rectovaginal or vesicovaginal fist- ula. The disease ex- tends by the lymph- atics to the pelvic cellular tissue ; when it is situated in the anterior wall, the lymphatic glands of the groin are also in- volved. Symptoms. — Va- ginal epithelioma very early causes hemorrhage, which will be aggravated by locomotion, coition, and the various procedures in examination. There is a profuse purulent discharge which is exceedingly offensive ; pain is not so marked as in disease of the uterus, unless in the later stages. The principal symptoms are the mechanical obstruction to coition and to delivery from stenosis, and the watery, bloody, and offen- sive purulent discharge. In a case recently under observation the disease had involved the anterior wall of the vagina, having Fig. 460. — Primary Cancer of the Vagina. GENITAL TUMORS. 641 apparently originated in the urethra, and formed a large scirrhus- like mass extending upward over one-half the anterior vaginal wall. The patient suffered from great inconvenience in urina- tion, having frequent attacks of retention and severe pain. Sarcoma. — Salrcoma occurs in two varieties: first, the dif- fuse sarcoma of the mucous membrane, often seen in young children; second, fibrosarcomatous growths, or melanotic sar- coma. Epithelioma, or cancer, may be distinguished from sar- coma by the use of the microscope. In the former we note the characteristic assemblage of the epithelial cells, forming the pearly bodies, and preservation of the walls of the blood-vessels; while in the latter, the cells are more or less unconfined by connective -tissue stroma and the blood-vessels appear as mere sluiceways or blood-channels. Treatment. — The thin wall of the vagina is very slightly resistant to the progress of malignant disorder, and the dis- ease is rapidly transmitted by the lymphatic vessels to the deeper cellular tissue of the pelvis, so that by the time the patient affected with cancer or sarcoma comes under observation, very little can be done in the way of treatment beyond relieving her from the discomfort produced by the accompanying symptoms. Complete recovery is rare. Eiselsberg, in a case of cancer which involved the whole of the rectovaginal septum, resected the coccyx and established an artificial anus in the sacral region after extirpating the whole of the diseased part. The patient rapidly recovered and had control of her stools. In a patient of mine, when the disease had proceeded from the rectum, involved the posterior wall of the vagina and the perineum, and extended close to the cervix, I removed the coccyx, re- sected the sacrum, excised six inches of the rectum, removed the ovaries, tubes, entire posterior wall of the vagina, and the posterior commissure of the perineum. The rectum was stitched to the sacrum posteriorly, and to the anterior wall of the vagina anteriorly, the peritoneum having been pre- viously closed. (See Fig. 530.) A colostomy had been per- formed upon the patient before she came under my obser- vation. After the patient had recovered from the pelvic opera- tion the opening in the intestine was dissected, out and the two ends of the bowel were reunited. The patient was under observation for nearly thirteen months. The contraction of the intestine at the site of the former colostomy was sufficient to give the patient warning of the passage over it of feces, so that she could prepare herself for the evacuation of her bowels and avoid soiling her clothing. 41 642 GYNECOLOGY. BLADDER. 580. Tumors of the Bladder. — Benign new-growths of the bladder are claimed to be very rare in the female; the most frequent are the villous polypi, called by Rokitansky villous cancer. Albarran declared that every tumor of the bladder was malignant. The frequent -deaths from uncontrollable hemor- rhage and relapse would seem to justify such a diagnosis, but after careful microscopic investigation of the anatomic structure of the tumor by Virchow, he asserted that it was not correct, and called the tumor fibropapilloma or villous polypus. The growth is most frequently situated on the lower surface or over the trigonum, though occasionally found upon the fundus and in vesical diverticula. It is sometimes completely pedun- culated, so that several berry-like masses are situated upon a single stem, which is easily torn. In women these tumors are more frequently pedunculated, while in men they have a broad base or present as multiple tumors. With water in the bladder they float about like a water-plant. Sometimes there are several masses of various dimensions, like grapes or raspberries, upon a single pedicle. The tumors grow very slowly. These growths absorb water, and consequently be- come very much shriveled when kept in alcohol. Microscopic- ally, they consist of a thick portion, which ends in villi of thin connective-tissue frame and many large vessels. Vessels are often so well developed that they completely supplant the frame. The epithelium is then situated almost completely upon the vessels. In other cases the connective -tissue frame is thicker, so that one would incline to pronounce it a fibro- papilloma. The under layers of the epithelium are cylindric in form, while the superficial are polygonal and the epithelium sends in no processes. We do not find nests or alveoli in the connective tissue, so the characteristic structure of cancer is wanting. The base of the bladder-wall is thickened and infiltrated, a centimeter in thickness, which forms a crust dis- tinctly recognizable during operation. The tumor itself is firm or soft, according to the thickness of its stroma. The pedicle is fre- quently so soft that, in an operation, an attempt to tie it results in the thread cutting through or tearing it off. The large blood- vessels contained in the connective-tissue frame lead to engorge- ment, and not infrequently to strong venous hemorrhage. This is the principal symptom of the villous polypi. These polypoid multiple tumors may fill the entire bladder. They may even pass through the urethra to the external orifice. 581. Mucous Polypi. — In cystitis not only enlarged papillae, but also mucous polypi, are observed. These growths have GENITAL TUMORS. 643 a smooth surface without papillomatous arrangement, and are poorly supplied with blood-vessels. Occasionally, they attain considerable size — from five to seven centimeters in diameter. 582. Myoma.-^A myomatous tumor of the female bladder is much more rare than in man. The tumors are hard, whitish upon the cut surface, arise from the vesical muscular struc- ture, and grow into the wall or become pedunculated. With the gradual thinning of the pedicle the tumor loses vitality and becomes partly destroyed. Cystic or softened myomata are also recognized. Dermoid of the bladder has been observed (Thompson). Symptoms. — The most characteristic symptom is hemor- rhage. The bleeding is very likely to occur in the night, per- haps owing to congestion from being warmly covered in bed. Bleeding takes place without any other symptom, and must be carefully investigated, as the patient will frequently assert that it comes from the vagina. The hemorrhage may sud- denly cease, and the urine the following day be perfectly clear, to continue so for a number of weeks, when bleeding again recurs. After the tumor exists for some time, bleeding will become continuous. Pain may be absent for years. Cystitis does not necessarily exist. Indeed, small tumors may have no influence upon the mucous membrane; floating in the urine, they do not injure its epithelial surface. In spite of long-existing growths, we will find the bladder surface pale from the general anemia. When hemorrhage ^ leads to the suspicion of the existence of vesical tumors, the use of the catheter must be practised with care. The touch of the instrument causes injury; por- tions of villous growths float into the eye of the catheter and are torn off. Such masses should be carefully examined. Tumors of the trigonum float into the internal urethral orifice and obstruct the flow of urine. In long-existing tumors the urine becomes progressively bloody, coffee-like, or brownish. The surface of the tumor, from which the blood arises, appears black, red, sometimes opaque, or a bright red. The continuous vesical hemorrhage leads to intense anemia, although it is sur- prising how long the patient will endure it. Gradual emacia- tion, and finally cachexia, appear. The disease may extend over a period of many years. Diagnosis. — Examination is practised by palpation with two fingers of one hand in the vagina, while the fingers of the other are placed over the abdomen. The patient lies upon a table or hard couch. If the bladder is emptied with a catheter, 644. GYNECOLOGY. one must remember its danger. The examination is made slowly, carefully, and systematically. Generally, the abdominal walls are easily depressed. When the patient is unable to relax them, an anesthetic should be given. By careful in- vestigation a tumor as small as a hazel-nut can be recognized, but pedunculated gro\^1:hs may easily be displaced to one side and elude the grasp, and leave one in doubt as to their presence. The ovaries are not unusually so situated that they may be felt, and lead to the belief that a vesical tumor is present. The cystoscope aids in clearing up doubt. Diagnosis should not be based alone upon palpation. The urine should be examined chemically and microscopically. Cylinder-like cells are char- acteristic of papilloma. The older writers placed great stress upon the character of the hemorrhage — whether fluid blood, worm-like clots from the ureters, blood only, in the first or last portion of urine, or pure blood followed catheterization. These distinctions afforded differential diagnosis between renal and vesical hemorrhage, but are now considered of little value as compared with cystoscopy. By direct investigation the relation of the tumor to the vesical wall is observed, and bloody urine can be seen flowing from the orifice of a ureter. The bladder can also be investigated by touch with a finger intro- duced through the urethra, but this should be practised with the greatest prudence, and, preferably, with the little finger only, because overdilatation may result in incontinence. Treatment. — The one treatment for vesical tumors is opera- tive. Following the diagnosis, the operative procedure should be employed as soon as the condition of the patient will per- mit. High fever, suppuration, cystitis, and marked anemia, are considered as contraindications. The removal of the growth is surprisingly easy. New loss of blood is endangered by ever^^ day's delay. Suppuration is not a contraindication. If the tumor is large, irrigation with the syringe does not secure disinfection, and suppuration ceases only after the complete removal of the mass, and thus. the danger of nephritis is lessened. The tumors may be reached through the urethra by the urethral speculum. The masses are seized with forceps and torn off, cut through by the galvanocaustic loop, cut away with scissors or forceps, or scraped off with a sharp curet. The latter instrument, however, should be used only when the finger can be introduced as a guide. Whatever method is em- ployed should be thorough. In large, broad-based, friable tumors much injury may be done by scraping or tearing. The bladder soon fills with blood, which is hard to remove and decomposes, and the necrotic masses often cause cystitis and GENITAL TUMORS. 645 suppuration. Syringing the bladder with ice-water and as- tringents is painful. If the pain, loss of blood, and cystitis are aggravated by the operation, it is hard to convince the patient that anything has been done for her relief. In extensive involvement or growths with a broad base the preliminary incision of the bladder is more effective and satisfactory, as by it the diseased structure and the field of operation are exposed to view and to more effective manipulation. Vaginal Incision. — As a guide a catheter is introduced into the bladder, upon which a longitudinal incision is made through the middle line of the vagina, about five centimeters long, of sufficient length to permit the introduction of two fingers. The incision can be enlarged with scissors or with a knife above and below, affording considerable exposure of the bladder and its morbid growths. Bleeding vessels are secured by pressure forceps. The growths are then removed with forceps, scissors, knife, fingers, the galvanic loop, or the Paquelin cautery. In copious hemor- rhage syringe with either ice-water or quite hot water; cotton sponges wet with the latter may be pressed upon the bleeding surface. Sutures can not well be used, because they cut through. The precaution must be exercised to avoid injuring the ureters. Hemorrhage is very severe in these operations and greatly obscures the view. The fistula should be closed, a catheter introduced, and the vagina tamponed to compress the bladder and decrease the bleeding. An ice-bag should be applied over the lower abdomen. The trifling mobility of the bladder in the region of the trigone renders it difficult to expose a bleeding vessel through the vaginal incision, and the bleeding renders the field but little more accessible to view than through the dilated urethra, while through the latter the organ can be tamponed even more effectively than by the vaginal incision. It has been advised that operation for removal of tumors of the bladder should be preceded by double nephrotomy for the establishment of drain- age. Such a procedure may be of value in extensive vesical operations, but the discomfort of lying continuously in a pool of urine is so great that it should be infrequently employed. Abdominal Incision. — The sovereign procedure is the high bladder incision. A transverse incision gives more room than a vertical, though the two may be combined in a T-shaped cut. The difficulty in securing firm union and thus avoid- ing subsequent ventral hernia, how^ever, precludes its practice. The vertical incision requires strong traction to be made on each side. Fritsch prefers the transverse incision, claiming 646 GYNECOLOGY. that recovery is excellent if the incision is not made too long — not over six or seven centimeters. The scar so disappears under the hair of the mons veneris that subsequently it is no more seen, even if the wound heals by secondary intention. It has the additional advantage that large vessels are not likely to be cut. He has seen a number of cases in which extensive hernia had formed above the symphysis, but these were cases in which the object of the operation had been castration, supra- pubic transverse section had been employed in the operation for castration, or cases in which the Trendelenburg posture had been employed for operations upon bladder fistula. In all these cases the scar tissue could still be seen. In twelve of these cases the incision had been twelve or more centimeters long. Such an extensive incision is unnecessary in bladder operations. If the incision is made shorter, the recti unite with a firm scar to the pubic bone. Fritsch describes the procedure as follows: The patient is placed in the Trendelenburg posture, with pelvis elevated, and the mons veneris and vagina are thoroughly cleansed. The bladder must also be thoroughly irrigated; the vagina, for the reason that the fingers may be required to be intro- duced into it, in order to penetrate the bladder from above. The bladder should be irrigated with several liters of boric- acid solution. It is better to employ a large quantity of water than a trifling quantity of disinfectant, solution. If the urine is clear or the discharge of blood quite fresh, syringing is un- wise, as it can easily cause a hemorrhage. An assistant places his hands upon the abdomen in such a way as to keep the mov- able skin fixed, while a transverse incision is made above the symphysis. The' point at which the incision is to be made should be fixed before the skin is put upon the stretch; other- wise upon drawing it up it may be found that the incision is too low. It should be made directly over the upper border of the symphysis. While one is operating in the loose fatty tissue behind the symphysis, an assistant pushes up the bladder with a thick male catheter. The projection made by the end of the catheter is readily seen, the tissue above it is picked up with a tenaculum, and the bladder-wall is cut transversely above the end of the catheter. As soon as the bladder is opened the margin on either side is seized with a pair of pressure for- ceps and the bladder is prudently drawn down so that the forceps will not tear. The catheter is removed and the incision extended right and left by scissors until a broad wound is made in the vertex of the bladder, which will permit one conve- niently to enter it with two fingers and inspect its inner wall. In this, as in all operations, it is important to proceed rapidly. GENITAL TUMORS. 647 The margin of the bladder is seized by ten or twelve pressure forceps, which hold the bladder open automatically and make its cavity visible. To sew the bladder to the margin of the wound would take more time. If the tumors are large and deeply situated, they may be discovered to the right or left by two fingers. 'The pedicle is seized between the fingers and the tumor prudently drawn up. As the structure tears easily, the bleeding point may sink back and vanish from view^; when the bleeding is copious, one may be in doubt just what shall be done. It can be controlled promptly only through tam- ponade, which takes time; consequently, it is important, if possible, not to tear the tumor. Having fixed the situation of the tumor, one must make accessible the pedicle. This not infrequently may require an enlargement of the skin and bladder section. To avoid this, an assistant seeks to enter the vagina, and presses up- ward in the region of the pedicle. Hemorrhage may be con- trolled by a Paquelin thermocautery. The smallest points should be employed, in order to avoid extensive burning of the epithelium of the bladder. The ideal procedure is the employment of the galvanocautery. In small polypi and very small tumors the galvanocaustic loop does not act so well. To tie them off is, of course, difficult, as the thread easily cuts through. Frequently the base can not be encircled, on account of the proximity of the ureters. If we pass a ligature deeply in the firm tissue, we may injure or occlude the ureter. A hot iron is not effective in arresting the bleeding, and vet this must be controlled in order to proceed. More favorable action is accomplished by long and continued direct compression of the wound from the vagina and bladder. A strong vaginal tampon has a good influence. Ice-water may be used with advantage, and influences the closed bladder still better. In the open bladder the influence is not direct on the bleeding vessels, as the bladder muscle, like that of the uterus or the placental part, contracts on the bleeding surfaces. When the pedicle is quite visible, so that with the Paquelin one can touch the proper place, we should employ the scissors to cut the growth away. The smooth, well-marked, cut surface can be compressed by the finger of the assistant, in the vagina, with a certain advantage. It may be necessary to tamponade both vagina and bladder and to apply a firm abdominal bandage. This method is effective in controlling hemorrhage. The means by which hemorrhage is to be controlled must be rapidly determined upon, whether it be the Paquelin, the application of a solution of iron, syringing with ice-water, or surrounding with needle clamp forceps. The tampon should 648 GYNECOLOGY. be prepared beforehand, and should be ready. In large, broad- based, villous grovvi:hs we should work with sharp curet and scissors. Hemorrhage is often quite considerable. If the tumor is situated in the trigonum, so that there is no danger of injury of the ureter, the base of the bladder-wall can be penetrated and ligated. The possible discharge of urine through stitch-holes is of no significance, for in Shucking's operation for uterine fixation it is probable that the needle has frequently entered the peritoneal cavity, and it is only in rare cases that peritonitis appears. The necessity of preventing hemorrhage by a tampon after the operation excludes the possibility of complete suturing of the wound. We can, of course, draw together the bladder wound somewhat, as well as diminish that in the skin by lateral sutures, but in the middle it must be kept open for the eventual renewal of the tampon. In such cases it should be the rule to sew the bladder to the skin wound, in order to make its cavity accessible and to secure the tissue behind the bladder from overlying urine and wound secretion. As the patient recovers, the bladder suture cuts through, the organ sinks back, and the wound opening is gradu- ally closed by granulations. When the opening continues too long, it should be narrowed by suture after artificial freshen- ing of the wound. A permanent catheter should be intro- duced, which is necessary in all bladder injuries. With an incision into the bladder vertex, or in bladder resection, do not completely close the bladder wound, but place a strip of iodoform gauze in the opening left in the wound. It has re- peatedly occurred that the patient accidentally or purposely has had the catheter removed, when the urine can flow from the wound without injury; but if the wound is entirely closed, the removal of the catheter would work injury to the processes of recovery. After the bladder tampon is removed hemor- rhage rarely occurs. Bloody urine disappears in from twenty- four to thirty-six hours after the removal of the tampon. While the catheter remains, the bladder should be irrigated with astringents or a weak solution of liquor aluminii acetici. This direction applies also to the external wound, and the pledget should be wet with the same solution. The upper wound has a great tendency to close. If the granulations are weak, as in anemic patients, they can be stimulated by dilute alcohol, camphor, silver salts, or tincture of iodin. The appetite, which is lost through an excessive flow of blood from the tumor, im- proves, and the patient gains rapidly in weight. The patient should be permitted to rise from bed as soon as the wound is healed. When the operation is very late in the progress of the disease, the wound remains unaltered, the patient does GENITAL TUMORS. 649 not recover from the anemia, and does not regain her appetite. Whether the patient dies from loss of blood, from loss of strength, or from the influence of the operation, is difficult to determine. 583. Carcinoma. — Klebs asserted that cancer of the bladder always began in tjie prostate. Had this assertion been correct, woman should be exempt from the disease. Primary cancer of the bladder has been described by a number of investigators. Bode alone has seen fourteen cases. Cancer appears as a harden- ing and thickening of the bladder- wall, which is covered with several layers of epithelium. Small tumors form in the per- iphery, sometimes as isolated masses, while complete infiltra- tion of the entire bladder is very rare. Following the destruc- tion of the epithelium, destructive ulceration of the cancer occurs. This takes on a malignant character if putrid germs appear in the bladder. Symptoms. — The urine smells like carrion; there is pain and vesical tenesmus. By rapid increase the carcinoma breaks through externally. High fever appears. The bladder with rapid gro\\1:h of carcinoma is fixed in contraction in the para- vesical tissue. With the peritonitic irritation there is increased sensibility. The disease extends up to the ureters, and develops pyelitis on both sides, interstitial abscesses, or nephritis. If death has not already taken place, it occurs from high fever and profound cachexia. It is found that the ureters become dilated as a result of the pressure upon those portions situated within the bladder-wall. Uterine cancer presents symptoms similar to those induced by villous tumors. If infiltration of the bladder-wall takes place, symptoms of cystitis appear. It is sometimes asserted that after extirpation of villous tumors carcinoma occurs in their place, but pathology does not seem to sustain this assertion. The existence of malignant disease does not contraindicate opera- tion, though it is necessary, in order to remove the matrix of the tumor, that a portion of the bladder-wall should be removed in order to operate in healthy tissue. In the adoption of this prin- ciple a portion of the bladder-wall, the trigonum, must be omitted. To remove it, we must remove the ureters, or at least the place at which they enter the bladder. Bardenheuer, in a case of extensive disease of the bladder, through an abdom- inal incision upon it, shoved back the peritoneum, loosened the bladder as far as possible from the perivascular tissue, raised it up, incised it longitudinally, secured.it with sutures, and drew it into the abdominal wound. The now exactly determined tumor is, with an elliptic piece of the bladder-wall, excised, and the wound margiQs are united by continuous suture, sparing the mucous membrane. Finally, the belly wall 650 GYNECOLOGY. is sutured and a continuous catheter introduced. Wassiljew reports a case of total extirpation of the bladder for malignant tumor. The ureters were secured outside the bladder and sutured in the belly wall. The patient recovered, although both ureters became necrotic in two centimeters of their course ; but the pyelonephritis improved, as well as the general con- dition. Bensa describes a case in which a greater portion of the bladder was extirpated on account of an infiltrated car- cinoma of the right bladder-wall in a woman fifty-one years old. The operation was accomplished by a median incision in the mons veneris; the symphysis pubis was separated and the bladder opened and loosened subperitoneally, except on the right side, where the peritoneum tore, but was immediately sutured again, then loosened on the left side; the left ureter was resected, and the under part of the right ureter, because it had been invaded by carcinoma. The ureters were replaced in the small remains of the bladder, which was closed by sutures. The symphysis was .then closed with silver wire sutures and the wound tamponed above and below the symphysis. The patient died the day after the operation. Bensa holds total bladder extirpation as indicated, first, in benign tumors if they are multiple and produce sufficient disturbance of the bladder function; second, in infiltrated malignant tumors if they occupy the greater part of the bladder-wall, third, in large, broad-based tumors of the base of the bladder. The entire bladder has also been resected for tuberculosis. How much advantage is to be obtained from these procedures is a question. Narrowing of the ureters in the artificial bladder and small abscesses from implantation and sutures cause dis- turbance for months, even though the case has been quoted in literature as a successful result. After extirpation of the bladder the ureters have been implanted in the vagina. While the vagina is normally aseptic, it is questionable how long it will so remain with this additional abnormal function. UTERUS. 584. Fibromyomatous Tumors. — Myofibromata are benign growths of the connective-tissue order which occur in the cer\dx as well as in the body of the uterus. Their structure consists of connective tissue or of muscular combined with connective tissue. Where the connective tissue predominates, they are designated by the term fibromata, and where the muscular tissue, as myomata or fibromyomata. The pure myomata consist only of muscular structure and exist only in the early stages. They usually appear singly and may attain rather a large size. GENITAL TUMORS. 651 The myomata are the most frequent form of uterine growths. Careful examination will disclose such a growth in 20 per cent, of all the women who have reached the age of thirty-five years (Bayle), in 40 per cent, of women of fifty years (Klob), but in the great maj6rit3^ "^^^ tumors are small. The gro\Ai:h of a tumor is very slow; when rapid increase in volume is observed, it arises, not from an increase of tumor elements, but from a dis- turbed condition of tissue fluid, which will be considered later. The most favorable condition for rapid gro^^^h is an intimate vessel union with the uterus. It is the generally accepted view that fibroid growths in- crease in size only during the period of sexual activity, and remain stationary or undergo atrophy after the climacteric. It is quite probable that no myoma ever originates in the uterus prior to puberty or subsequent to the menopause. A tumor has been reported as having been found in the uterus of a girl aged ten years, but no opportunity was afforded to demon- strate the correctness of the diagnosis by microscopic inves- tigation. Sutton has reported a childless widow, who had never men- struated, as having carried such a tumor for ten years. Peter Muller and Joseph Taber Johnson both assert that the growth sometimes continues to increase after the cessation of men- struation. Hofmeier says that such increase occurs in those myomata which stand in nutritive union with the peritoneum through organized bands of adhesion. The truth of this is especially indicated in omental adhesions, which greatly in- fluence the progress of the growth. He cites a woman in whom a thirty-flve pound myoma, w^ith numerous interstitial and omental adhesions, had continued to grow for a year after the menopause. A myoma is rarely found alone in the uterus. The dis- ease generally exists as a multiple tumor formation. Over fifty growths have been found in one uterus. J. Bland Sutton recently removed a uterus which contained one hundred and twenty myomatous growths, varying in size from a pea to an egg. They vary from a tumor the size of a pea to an enormous growth. Hunter removed, after death, a tumor that weighed 145 pounds, while the woman weighed but 95 pounds. How much the gro\^rth of myomata is influenced by the activity of the sexual organs remains difficult to determine, but the fact that myomata originate and have their greatest growth during the years most favorable for procreation can not be without significance. Myomata occur with about equal fre- quency in the married and unmarried. Observation does not justify us in the assertion that the size to which they attain or 652 GYNECOLOGY. the rapidity of their growth is influenced by the married or the single state. Some regard sterility as a cause of myomata, others as a consequence. Winckel and Schroder consider that the following conclusions are justified: 1. Fibroid growths originate without relation to marriage or to pregnancy. 2. Sexual excitement favors growth. 3. The presence of a growth inclines to prevent child-bearing. 4. Pregnancy promotes growth. 585. Pathologic Anatomy. — Whatever the origin, they are found in either the bod}^ or the cervix of the uterus, but in larger proportion in the former situation, and more frequently in its posterior wall. The consistence of the growth varies with its structure. A soft muscular mass presents, upon section, a reddish-pink color, with wavy, glistening bands running in every direction, but with a tendency to form whorls about individual centers, owing to the origin of the disorder along the course of blood- vessels. The cut surface of a fresh section presents an uneven appearance, owing to the elasticity of the fibrous tissue causing the softer muscle surfaces to bulge. The mass is enveloped by a false capsule, produced by compression changes in the uterine structure. The capsule varies in thickness according to the site of its development. If the growth has originated in the middle layer, the capsule is thick and well formed; but if immediately beneath the peritoneum or the mucous membrane, the capsule will be very thin or may even be absent. About the tumor is a layer of loose connective tissue which permits ready enucleation. Occasionally, there are numerous fibrous bands to the capsule, which render enucleation difficult, and are so frequent as to appear like a hyperplasia. The tumor is surrounded by numerous large vessels, from which it is nourished, but which do not penetrate its substance to any great depth. The vascularity of the structure is slight as compared to that of the uterine wall, for well-formed vessels are rarely found away from the circumference. In the softer variety the blood- vessels are comparatively numerous; in the harder varieties they are very scant. 586. Microscopic Appearance. — The comparative amount of muscular and connective tissues varies widely. In young and rapidly growing tumors the muscular tissue predominates and the capsule or line of demarcation between growth and uterus is ill defined. As the tumor becomes older and more GENITAL TUMORS. 653 mature, there is a substitution of connective for muscular tissue, and it becomes hard and dense. (Fig. 461.) The section differs in appearance according to its direction. A longitudinal section presents cells of an elongated shape with rod-like nuclei, while a transverse section resembles groups of round cells. Occasionally, between the muscle bundles are spores — lymph-glands lined with endothelium. They develop from cellular proliferation about the capillaries, and, with increase of connective tissue, may grow to large size. (Fig.. 462.) ' ' , ' ' - '^ / ■••■) V / ', / ■ » ; f- 1 . / ^ .^ Fig. 461. — Microscopic Section; Myoma Uteri. — {Coplin.) 587. Varieties. — Bishop follows Gusserow's classification and divides myomata into the multiple and encapsulated and the single and nonencapsulated. The former are found most largely in the body of the uterus, while the latter grow from the cervix. This division is based upon structure. The multiple growths are hard and firm. They largely consist of fibrous tissue, apparently mature, and no longer continue to grow. They are also called fibromata. The single growth is soft and elastic. It is largely supplied with vessels and is rapid in growth. In its structures the 654 GYNECOLOGY. muscular tissue will be found to predominate. They are known as liomyomata or fibromyomata. All myomata originate within the uterine wall, but upon their proximity to its inner or outer surface will depend their future progress. The most frequent classification, and that which we find most useful in practice, is a division of myomatous growths according to their situation into: (i) Submucous, intramural, or concentric (capsulated, non- encapsulated) ; (2) interstitial, mural, or centric; (3) subperito- neal, extramural, or excentric (capsulated and nonencapsulated) ; and (4) fibromyomata of the cervix. Degenerative changes which may occur in the life-history of such a growth are indicated by the terms edematous, col- loid or myxomatous, fibrocystic, calcific, necrobiotic, necrotic ; but these changes are not sufficiently con- stant to justify their employment to indi- cate a distinct classifi- cation. The same state- ment can also be ap- plied to the further division which is sometimes given: sar- comatous, adenomyo- matous, telangiectatic, ly mphangiectatic . 588. Submucous fibroids, according to the proximity of their origin to the mucous surface, present two varieties — the encapsulated and the nonencapsulated or free. The former develop in the wall and are extruded beneath the mucous membrane by the uterine contractions. The second variety, the free, originate immediately beneath the internal surface, and are not supplied with a capsule, but are closely enveloped by the mucosa. An encapsulated tumor may become free through absorption or thinning of its capsule from pressure. The encapsulated variety is much larger than the free. Nature regards such growths as foreign bodies and endeavors to extrude them from the uterine walls. Under this action a submucous fibroid may become pedunculated, when it is known as a submucous or fibroid polypus. (Fig. 463.) The Fig. 462. — Liomyoma of the Uterus ^ in. obj.; i in. oc. B. and L. GENITAL TUMORS. 655 muscular capsule may resist expulsion and prevent peduncula- tion, while the tumor bulges into the uterine cavity from a more or less broad base, and is called a sessile submucous fibroid, (^ig. 464.) The sessile and pedunculated submucous tumors enlarge the organ and increase its vascularity. (Fig. 465.) The re- peated contractions, together with the expulsive efforts, lead to hypertrophy of the muscle-wall to such a degree as to simu- Fig. 463. — Submucous Myoma (Polypoid), late pregnancy. The circulation in the entire mucous mem- brane, and especially in that portion covering the tumor, be- comes obstructed, leading to severe hemorrhages. The severe pressure frequently causes atrophy and ulcera- tion in the free variety, and the production of grave secondary changes, such as sloughing and gangrene. Compression of the neck of a polypus may cause edema, and, when acute, can produce gangrene or sloughing of the mass, and a fatal termina- 656 GYNECOLOGY. Fig. 464. — Sessile Submucous Myoma. Fig. 465. — Submucous Myoma Occupying Uterine Cavity. GENITAL TUMORS. 657 tion. In the slower form the chronic edema may often be mistaken for a cyst. Uterine contraction may lead to elongation of the pedicle of a pedunculated fibroid and cause its extrusion from the external os into the vagina, where it can be readily recognized and removed. (Fig. 466.) The elongation of the pedicle may become sufficient to permit the mass to hang from the vulva. The expulsion into the vagina may be sudden, but it generally occurs slowly. Very rapid expulsion of a tumor with a short pedicle may produce partial or complete inversion. Not infrequently the polypus may be felt projecting from the OS during menstruation, w^hile it disappears during the intervals ; this condition is knoAvn as intermittent polypus. Fig. 466. — Submucous Myoma Extruded into the Vagina. Rarely by the efforts of the uterus the tumor may be com- pletely and spontaneously separated and extruded. The pressure of the uterine or vaginal wall upon the tumor sometimes causes ulceration, from which adhesions may form and by which the nutrition is maintained. A polypus may be so firmly gripped by the cervix, as to cut off its supply of nu- trition and cause it to slough. The gangrene may spread up- ward and produce a fatal result. Such a condition can easily be mistaken for cancer. 589. Interstitial, mural, or centric fibroid growths develop in the parenchyma of the uterus, frequently attain to enor- mous size, and involve the entire structure of the uterus, when 42 658 GYNECOLOGY. they are then known as the diffuse or the gigantic fibroid. (Fig. 467.) A second variety is the circumscribed general form (Fig. 468) ; the third, the local interstitial fibroid. (Fig. 469.) In the general circumscribed variety, as described by Schroder, the wall of the uterus may be filled by a large number of growths. In the localized fibroma a single or two or three interstitial fibromata may be found. These growths are situated in the wall of the organ, surrounded by muscle-fibers and the loose connective-tissue capsule, from which they can be readily enucleated. In the diffuse form the entire structure of the uterus seems to be taken up by the grow^th, and it is difficult to fix a sharp border of limitation between the growth and Fig. 467. — Voluminous Myomata Occupying Anterior and Posterior Walls. the uterine wall. These growths, when they attain a large size, not infrequently draw out the lower portion of the uterus as a pedicle, which may be attenuated to the' thickness of the finger and twisted, as seen in one case by Kiister, where, in the twist, the torsion was two and one-half times. The cer- vical canal had been obliterated. Occasionally, the uterine body is found separated from the cervix. The muscular struc- ture of the uterus itself undergoes hypertrophy in these cases, particiilarly when but few growths occupy the wall. The uterine wall becomes thickened, its cavity is increased, and the cavity undergoes various changes in its shape and size. GENITAL TUMORS. 659 Fig. 468. — Circumscribed Interstitial Myomata Fig. 469. — Local Interstitial Myomata. 660 GYNECOLOGY. according to the development of the tumor and its projection into it. (Fig. 470.) The influence of the growth upon the endometrium is most marked.- In a large interstitial myoma it may become strongly distended, not infrequently thin and atrophied. (Figs. 471 and 472.) In other cases there is a hyper- trophy of the entire mucous membrane, occasionally only of the glands; in others, the interstitial tissue between them is in- creased. (Fig. 473.) Occasionally, the condition is complicated by malignant edema. In the great majority of cases hypertrophy of the mucous membrane is found associated with these growths. Fig. 470. — Uterus Opened, Showing Multiple Interstitial Myomata. (Fig. 474.) Indeed, the endometrium may be three or four times its normal thickness. 590. Subperitoneal growths (also called subserous, eccentric, or extramural) are generally spheric or ovoid masses springing from the external surface by a more or less distinctly marked pedicle. Like the submucous, these growths are sessile or pedunculated. While the latter class are polypi, that term is more generally applied to intra-uterine growths. The surface of the growth may be smooth or irregular, according to the contraction of the connective tissue. A division into free and encapsulated is made: the former covered by GENITAL TUMORS. 661 Fig. 471. — Sectioned Surface of Uterus, Showing Several Fibroid Tumors: a, Uterine cavity; b, large subserous fibroid. Fig. 472. — Serous Surface of Same Specimen: a, Cervix 662 GYNECOLOGY. the serous layer, which is closely attached, without capsule, to the surface of the tumor; the latter, or encapsulated, are covered with a layer of muscle -wall beneath the peritoneum. The free are hard and only attain a small size; the encap- sulated are soft and often become enormous. The pedicle of the tumor varies in length and thickness. It may be short, thick, and permit but little movement between the tumor and the uterus, or long and attenuated, affording such marked freedom as to cause doubt whether the growth is connected with the uterus. The pedicle can sometimes become so twisted Fig. 473. — Uterus Incised, Containing Interstitial Fibromyomata: a, a, Tumors; b, uterine cavit3\ as to cut off the circulation of the tumor and lead to its loss of vitality, the development of gangrene, and subsequently to septicemia or peritonitis ; or the tumor, in more fortunate cases, may become adherent to the surrounding viscera and lose its association with the uterus. Such a growth is nourished by its adhesions. Not infrequently a very movable tumor causes ascites, and thus simulates a malignant growth. 591. Fibromyoma of the Cervix. — Cervical myomata, like those of the uterine body, are submucous, interstitial, and sub- serous. These growths originate in the body of the organ, GENITAL TUMORS. 663 and, by the process of enucleation through contraction, may have been driven downward, either through the cervical canal or into its structure by splitting it externally or, as in the single noncapsulated tumor, had its origin in the cervix and grown either upward or^ downward. The latter may be either pedun- culated or sessile, and rarely attain a size larger than a goose- egg, although they may completely fill the pelvis. (Fig. 476.) They cause contraction and prolapse of the uterus, and simu- Fig. 474. — ^Uterus Incised, Showing General Circumscribed Fibromyomata : Uterine cavity. late inversion of the organ. They may be divided into two classes : (A) Those of the external os, in which the tumor is formed by a cylindric or elongated lip in the interstitial variety. (Fig. 477.) The submucous growths of the cervical canal are oc- casionally polypoid, which, like slender stalactites, descend through the cervix by the splitting process. ,(-B) Tumors from the sub vaginal portion. These are more 664 GYNECOLOGY. important when developed from the external surface and situated between the layers of the pelvic floor. They become intra- ligamentary and exceedingly dangerous by pressure upon the ureter or upon the pelvic vessels; also when posteriorly they press upon the rectum and push the uterus forward and up- ward. Occasionally, the tumor crowds anteriorly against the bladder, between it and the uterus. Most generally these tumors are found surrounded by a loose capsule, which permits of ready enucleation.' Sometimes, however, there is no line of demarcation between the tumor and the uterine structure. 592. Etiology. — These gro^\i;hs occur more frequently than any other to which women are subject. Not infrequently they may attain to considerable size without the patient being Fig. 475. — Subserous Myomata. aware of their existence, and are then recognized only by ac- cident. The causes of their development are unknown. Reck- linghausen attributed their origin to embryonic tissue, the remains of the Wolffian bodies. The irritation which char- acterizes fibromata is not a physiologic irritation, like that of pregnancy, but a diseased impetus. It is an unusual kind of local irritation, associated with a weak or debilitated con- dition of the concerned spot. This introduces Cohnheim's view of tumor origin, which was that the local irritation was brought to development by the presence of tumor germs. The influence of sexual irritation is appreciated, in that statistics demonstrate that in the majority of cases the first indications GENITAL TUMORS. 665 appear during the second half of the third decad: i. e., between the twentieth and thirtieth years. The tumor forms in the first half of the fourth decad, shortly after the thirtieth year. These growths rarely develop before or after these periods, although Biegel is, reported to have seen one in a girl ten years of age, and Leopold the beginning of a myoma in a child. There has been much discussion as to the influence of the married or single state upon the development of these growths. The in- vestigations of Moller show that 32.8 per cent, occur in virgins, 67.2 per cent, in those who are not, but one-half of the latter are sterile. Hofmeier says that the number of births does Fig. 476. — Pedunculated Myoma of the Cervix. not stand in any relation to the causal formation of the growth, while Winckel believes that the married are more predisposed, and that the myomatous formation decreases the number of births. Shoemacher, on the contrary, asserted that the un- married are more frequently so diseased. Hofmeier accounts for the relatively large number of unmarried women who suffer from myomata by the explanation that the tumor formation is one of the few causes which lead them to consult the gyne- cologist. Prochownik gives syphilitic infection as a cause, but the growths occur so frequently in individuals in whom there has been no possibility of such infection as to render 666 GYNECOLOGY. this view of little value. Olshausen and Gusserow assigned local irritation as the etiologic factor. Shoemacher also looks upon menstrual congestion as a cause, but to give these reasons for the development of the disease is equivalent to giving none, as it is necessary to seek further for the cause of the irritation. Moller, already referred to, frequently found that a myoma the size of a pin's head was separated from the uterine muscle by a distinct layer of connective tissue. Small arteries could be traced into the growths, which still retained their three coats ; consequently he doubted the theory that myomata arise from the muscular coat of the blood-vessels. The cause is Fig. 477. — Sessile Myoma of the Cervix, sometimes considered as congenital. The influence of heredity, as to whether there is a predisposition to the development of such growths in families, may be questioned. Heredity seems to be manifested in the greater apparent and comparative susceptibility of the colored race to the development of fibroid growths. It is not unusual to find several members of one family suffering from myomata. Among the various causes it is probable that sexual irritation should have the first place, and this irritation may have been engendered without the uterus having undergone the changes incident to pregnancy and labor. The abnormal irritation may be the result of mas- GENITAL TUMORS. 667 turbation, of psychic disturbances, of such unnatural processes as the evasion of maternity, of the psychic phenomena engen- dered by body-contact with man, of sexual agitation, and of other factors which may produce repeated injurious influence. It is quite possible that defective development or an abnormal position of the uterus may exert a marked influence in the development of these growths. • Mann reports a childless widow at the age of forty-three, twice married, who had never men- struated, and for ten years had had a large fibromyoma. It still remains evident, however, that in any individual myoma we can not positively assign a cause which can be considered a definite reason for its development. 593. Symptoms. — The symptoms which lead us to suspect the existence of myomata are: Hemorrhage, pain, and abdom- inal cramp, especially when associated with progressive enlarge- ment of the abdomen. The symptoms of the individual case will depend largely upon the variety of tumor present. In the subperitoneal and in the interstitial, which have not en- croached upon the uterine mucous membrane, the growth may attain to considerable size without the manifestation of any symptoms which would attract the attention of the patient. Not infrequently, especially in the unmarried, such growths attain to a size so great as to be remarked by the friends of the patient, before she is herself aware of its existence. The growth will be suspected when the patient has a history of a slow but progressive enlargement of the lower half of the ab- domen. Not infrequently one of the first symptoms will be inability of the patient properly to evacuate her urine. In- deed, there may be even complete retention, which will re- quire the aid of the physician to secure relief, during which the presence of the tumor may be for the first time recognized. It may, in such a case, be situated in the pelvis, completely filling it and pushing the uterus above it. If the growth simply presses against the bladder, it may only slightly interfere with the evacuation, or, which is more likely, cause frequent mic- turition, because of the inability of the bladder to distend. Urination may be so painful and so frequent as to lead the patient and her physician to suppose that an inflammation of the bladder exists. Such a growth may press upon the rectum, causing constipation, retention of gas, tympanitic abdomen, interference with the circulation in the lower portion of the rectum, the occurrence of hemorrhoids, prolapse, marked anal pruritus, or burning of the anus, the existence of a fissure, and not infrequently the veins of the anus as well as those of the vulva become exceedingly varicose. Such a growth, be- coming incarcerated in the pelvis, may cause severe pressure 668 GYNECOLOGY. on the surrounding structures, with sloughing and gangrene of the pelvic soft parts. (Fig, 479.) An intraligamentary tumor may push the uterus to the opposite side, and the organ may be so small compared with the tumor that its situation is with difficulty determined. (Fig. 480.) Pressure of the tumor on the pelvic nerves may produce pain extending down the posterior sur- face of the leg in the form of sciatica or a crural neuralgia over the front of the leg, or marked pain in the sacrum. While these symptoms may occur in any form of myoma, they are, however, characteristic of the subperitoneal and interstitial varieties, especially when the latter has not encroached upon the mucous membrane. In the interstitial growth, which grows toward the mucous membrane, giving rise to obstruction in its circulation and leading to engorgement and degeneration of the overlying mucosa, hemorrhage is a marked symptom. In the submucous varieties bleeding is a more or less constant and characteristic symptom. Hemorrhage may be manifested by an increase of the menstrual flow (menorrhagia) or an ir- regular bleeding (metrorrhagia) may result. Hemorrhage, as before stated, is a very prominent symptom of all submucous growths. The bleeding varies, and is not affected by the size of the gro^i:h, since a small polypoid growth will very frequently cause just as severe hemorrhage, if not greater than that which occurs from a large tumor. In these growths the menses become profuse and prolonged, resulting in marked anemia and great debility. The bleeding may be continuous and very free for a few days, then a period of brown secretion, to be again followed by profuse bleeding. Blood may be dis- charged as a bright fluid blood or in large clots. Clotting has no significance, and depends upon the size of the uterine cavity in which the accumulation occurs, or it may take place in the vagina; pedunculated polypi may be associated with severe flooding. Intermenstrual hemorrhage may alternate with periods of amenorrhea, which may continue for months, and when the patient is congratulating herself that she has recovered, another severe hemorrhage occurs. The bleeding occurs from two sources: (i) From the covering mucosa of the tumor; (2) from the general uterine surface. The former is the active primary site of bleeding and is very vascular, particularly in the free variety. In some of the smaller groAvths the tumor will be found to be quite anemic. In these the hemorrhage is undoubtedly due to the irritation of the circumjacent uterine mucosa and the production of an interstitial endometritis. Metrorrhagia from rupture of veins in the superimposed mucosa is frequently associated with a profuse watery discharge, which adds to the depression and prevents the patient from regaining her health. GENITAL TUMORS. 669 Leukorrhea, or discharge other than blood, is increased during the development of these grow^ths. The extrusion of the groT\i:h into the uterine cavity increases the normal watery discharge from the uterine glands. The interference with the circulation and the consequent hypertrophy of the glandular tissue cause a profuse secretion. This may be truly glandular in character and mixed with the desquamated epithelium. Pus-cells and blood-cells may also be found, according to the degenerative processes, which sooner or later ensue. As the cervix becomes dilated, its glands add their thick, viscid secre- tion to the abundant discharge. The partial or complete ex- trusion of the growth influences its circulation, not infrequently causing necrosis of portions of its surface or even the entire structure, according to the extent of the constriction. The discharge is often bloody, purulent, or watery, contains necrotic masses of detritus, and produces an extremely offensive odor. The patient, and not infrequently her attendant, has cause to suspect the existence of malignant disease. In all varieties of the tumor the blood supply of the growth itself is very slight, as no large vessels directly enter the tumor. Where the neoplasm is of some size, this deficient blood supply must affect the nutrition of its structure, and causes the pro- duction of toxins which have a deleterious influence upon the health of the individual. This is evident from the appearance of such patients where hemorrhage and leukorrheal discharge are not a factor. It is probable that these toxins have an influence upon the heart muscle and other structures of the body, causing conditions which are so frequenth' found associated with the presence of fibroid growths. It is probable that in these tox- ins will be found the explanation for the mental disturbance that is so frequently associated with the development of such growths and which usually clears up with their removal. It may also explain the occurrence of ascites which frequently is associated with subperitoneal gro^^^hs. Pain is not a constant symptom. It is frequently more a sensation of weight or pressure in the pelvis and upon the surrounding organs. Intense pain may characterize very small growths, but is conditioned somewhat upon their situation. K growth pedunculated or so situated upon the uterine wall that it projects into the internal os may act as a ball- valve, and be the cause of the most agonizing labor-like pains. I have seen this form of dysmenorrhea in many cases. (Fig. 478.) In one patient it was so severe as to require the administration of two grains of morphin at each menstrual period to render it endurable. Xn operation subsequently revealed that the patient had a double vagina and a bicornate uterus with two 670 GYNECOLOGY. distinct cervical canals in a common cervix. In one of these cavities was found a submucous tumor which, by a nipple- like projection, filled up the internal os, and explained the violence of the dysmenorrhea from which this patient had suf- fered. Sterility is a common SA^mptom and conception is the ex- ception. The inflammatory changes consequent upon the pres- ence of the growth render it unfavorable for the reception and retention of the fecundated ovum. More frequently than is generally appreciated, the tubes have undergone secondary changes which result in the occlusion of their abdominal ex- tremities, and thev are found to form retention cvsts. Further- Fig. 478. — Bicomate Uterus. Both Cornua Containing Myomata. more, pathologic conditions of the ovaries are sometimes found, and this fact, also, is not given the consideration it merits. Con- stipation, hemorrhoids, anal fissure, prolapse, and pain arising from pressure upon the rectum are more or less constant symp- toms and signs. Vesical tenesmus, cysts, frequent micturition, retention of urine, dilated ureter, and hydronephrosis are pro- duced by disturbance and obstruction of the urinary organs. Not infrequently the first symptom which leads to the discovery of the growth is the retention of urine, from pressure upon the vesical neck. The myomata may also be the cause of retention of urine from pressure upon the ureters interfering with the entrance of the secretion into the bladder, and, as a consequence, we may have renal dilatation even to the extent of sacculation of the kidneys. In one of my early operations GENITAL TUMORS. 671 for myoma, upon a patient who had carried a large tumor for some twenty years, death occurred very shortly after the opera- tion. The autopsy revealed that both kidneys were distended, forming thin-walled sacs, that the ureters were several times their normal size, and 'that their walls had become greatly thinned. The protracted hemorrhages, profuse discharge, severe labor- like pain, and pressure upon the neighboring viscera are prone to result in a profound anemia, which is characterized by a straw-colored appearance of the skin, often so marked as to simulate cachexia and plainly indicate the gravity of the pa- tient's condition. 594. Diagnosis of Myomata. — The existence of a fibroid growth of the uterus may be suspected when there is a slow but progres- sive enlargement of the lower part of the abdomen. It may occur in either the single or married woman, and need not be associated with any special indication of ill health. The physician should have in mind the possibility of its existence in every patient who consults him regarding a sensation of weight or pressure in the pelvis, disturbance of urination, such as frequent mic- turition, difficulty in evacuating the urine, or even sudden attacks of severe retention, which may necessitate the use of a catheter. Indeed, in every such case the condition of the pelvic viscera should be examined preliminary or subsequent to the use of the instrument. Uterine growths should be still further suspected if the patient is complaining of hemorrhoids, fissure of the anus, frequent bleeding from the bowel, pain and distress during, and difficulty in, defecation. The surgeon should never be misled into subjecting a patient to operation or treatment for hemorrhoids until he has examined the con- dition of the uterus. Only recently I was asked to operate upon a Sister of Charity for severe hemorrhoids, when examina- tion of the pelvic cavity revealed a group of subperitoneal and interstitial fibroids completely filling up the pelvis, the ex- istence of which she had never suspected. Profuse menstrual flow or irregular bloody discharge occurring in an unmarried woman or in one who does not give a history of the interruption of a recent pregnancy or abortion should lead to the suspicion of the existence of a submucous fibroid growth, particularly where this hemorrhage is associated with pain, often of labor- like character, as if the uterus were making an effort to expel a foreign body. This hemorrhage will often produce a marked anemia without emaciation, which distinguishes it from that associated with malignant disease. It should be remembered that no characteristic symptoms of myomata occur, and, there- fore, the physician is forced to rely for diagnosis and confirma- tion of his suspicions upon the physical signs. An important 672 GYNECOLOGY. factor in this recognition is the consistence of the tumor or tumors in contrast with the surrounding soft structure of the unin- volved portions of the uterus, which permits the determination and dehmitation of the growth. The alterations in the shape of the uterus, according to the situation of the tumor, are of interest. A good-sized gro\A^h may fill out the organ and give it a spherical shape. The further contraction of the uterus forces the mass into the cervix, where it may distend the en- tire organ and be palpable at the external os. An intra-uterine polypus is determined only by palpation through the cervical canal. If the os is sufficiently open, the pedunculation can be inferred by the mobility, and definitely determined by reaching the pedicle with the finger. In small fibroid growths with a long pedicle the growth may be felt through the uterine walls to move under the pressure of the finger, even though the cervix is undilated. During the menstrual period with profuse menor- rhagia, the offending growth is frequently extruded or the cervical canal is sufficiently dilated to permit its recognition by the examining finger. A growth- may be extruded during the flow and drawn back in the interval, producing what is known as an intermittent polypus. A growth filling up the pelvis may make pressure upon the large vessels and so interfere with the return circulation of the lower extremities as to pro- duce enlargement of the superficial veins in compensation for the obstructed abdominal vessels. Pressure upon the ureters causes dilatation of these ducts, hydronephrosis, dilatation of the pelvis of the kidney, not infrequently a sacculation of the kidneys with destruction of the secreting tissue, the forma- tion of renal calculi, and even the occurrence of suppurative changes. These are characterized by more or less pain and discomfort in the region of the kidney — so much so as possibly to mask the pelvic lesion. Interference with the cardiac or renal functions causes profound anemia and the appearance of cach- exia, not infrequently interference with the veins of the lower extremities, phlegmasia, blocking of important vessels by particles of coagulated tissue, and possibly the formation of pulmonary and cerebral emboli. The diagnosis is determined by the bimanual examination, the introduction of one or two fingers into the vagina or the finger into the rectum, and the other hand over the abdomen. In this way the uterus is care- fully palpated and any enlargement of its structure recognized. If such enlargement or hardening of the organ exists, its size, relation to the organ, and its resistance are carefully studied. The fibroid growth has a definite shape, is smooth in outline, is well defined, and has a characteristic resistance. It is im- portant in the study of such growths to arrive at a diagnosis GENITAL TUMORS. 673 not only as to the existence of fibroid, but also as to the character of growth which may be present. The decision, then, is made whether the growth is an intra-uterine or a submucous tumor. The endeavor is made to ascertain by palpating the cervix, when patulous, as* to whether the growth is a sessile or polypoid tumor. If the uterus is occupied by interstitial growths, their situation is determined, whether they occupy the anterior or pos- terior wall or the fundus; if subperitoneal, from what portion of the organ they spring. The latter growths are divided into three types: (i) When the growth proceeds from the fundus or the anterior wall, grows upward and in the progress of develop- ment becomes pedunculated ; (2) whether it is pushed out through the lateral wall of the uterus between the folds of the broad ligament, practically splitting and spreading this out and dis- Fig. 479. — Intraligamentary Myoma. placing the uterus to the opposite side (Fig. 479); (3) when it grows downward from the posterior wall and is beneath the peritoneum, but probably not even in contact with it. When the tumor is small and as yet nonpedunculated, it may be difficult to determine by conjoined manipulation from which wall it has originated. This can be accomplished either by the intro- duction of the sound into the uterus or, better, by the dilatation of the organ and the introduction of the finger. With one finger in the uterus and the hand over the abdomen or a finger in the rectum, the physician is enabled accurately to determine the relation of the growths to the uterine wall. The factor which should be fixed in mind as an essential one for the recog- nition of fibroid growths is their smooth, regular outline. In the fibromyomata of the cervix the tumor presents a mass which 43 674 GYNECOLOGY. is situated in the vagina, not infrequently filling it, is quite movable, and between it and the vaginal walls the finger can be easily passed. Its situation external to the cervix pre- cludes the probability of it having undergone necrosis from pressure, but occasionally inflammation may be developed in the vagina from the pressure of the growth, which will lead to agglutination between the tumor surface and the vaginal wall. The attachment of the tumor is recognized by bimanual pal- pation with traction upon the tumor. 595. Differential Diagnosis of Myomata. — An accurate diag- nosis of any condition is secured only b}^ carefully reviewing the conditions with which it may be confused. The conditions with which myomata are likely to be confounded are: Normal pregnancy. Extra-uterine pregnancy. Desmoid tumor of abdominal walls. Inversion. Carcinoma. Sarcoma. Incomplete abortion. Subinvolution with endometritis. Uterine displacements. Ovarian displacements. Ovarian cysts. Pelvic infiltrations. Sactosalpinx. Floating kidney. Normal Pregnancy. — The amenorrhea, subjective symptoms, regular growth of the uterus, absence of hardness in its walls, and a sensation of elasticity are generally sufficient to determine the diagnosis of pregnancy. We have already seen that a limited amenorrhea may be characterized by a submucous myoma, and a patient may go for months without a hemor- rhage. On the other hand, hemorrhage may occasionally com- plicate the early months of pregnancy. I formerly attended a patient who always suspected herself pregnant if the menstrual flow was especially free, and she continued to menstruate for two or three months following the occurrence of each preg- nancy. The myomata may be present as small, edematous, subperitoneal nodules, which may be mistaken for the extremities of the fetus. Calcification of a fibroid has led to the growth being mistaken for the fetal head. The existence of the tumor does not preclude the possibility of pregnancy as a complication. The occurrence of pregnancy associated with fibroids should be suspected when the growth takes on more rapid enlargement, when the rapidity of the growth is greater than that which GENITAL TUMORS. 675 usually characterizes a fibroid tumor, and when a portion of the mass presents a sensation of elasticity. The regular shape, size, and outline of the uterus under the bimanual, with the contractions of the pregnant organ, which are absent in the nonpregnant, contrasted with the more or less firm resistance, the irregular enlargement, and the smooth nodular outline, should establish the diagnosis. In diagnosis the following case very graphically illustrates, as shown in Figs. 489 and 490, that fibroid tumors under certain conditions may simulate pregnancy. The patient, about forty-two years of age, had applied to her physician because of an uncomfortable sensation attended with enlargement of the lower portion of the abdomen. On examination, he pronounced her pregnant. This diagnosis was repeated by him after a subsequent examination, and coincided in by other physicians. She came under my obser- vation some length of time after having completed the supposed normal period of her pregnancy and was referred to me as a case of delayed labor. Upon examination, the cervix presented its normal size. Above it, in front, however, could be felt very distinctly two rounded masses with a sulcus between them, which was taken by the examiners to be a fontanelle. The abdomen was enlarged, about the size of a pregnancy at six months. There was a sensation of elasticity or rather of dis- tention in the abdomen. When pressure was made against it, a mass could be felt which was pushed back on deep pressure, and could be felt impinging against the abdominal wall when the hand was suddenly removed. This sensation was taken to be ballottement of the fetal body. Bimanual examination, however, convinced me that if this was a pregnancy, it was extra-uterine, as the mass could be felt too readity through the anterior vaginal wall to be within the uterine cavity. It was found that the woman continued to menstruate, that the enlargement had increased only to a ver}^ slight extent in the last few months. The investigation of the condition caused me to pronounce it one of multinodular myomata, one of which was a large mass with a rather thick pedicle, permitting it to be pushed away, but firm enough to bring it back against the abdominal wall, and thus produce the sensation of ballottement. .The freedom of movement was accounted for by the presence of free fluid in the peritoneal cavity. This diagnosis was confirmed by operation. Extra-uterine pregnancy will present symptoms in the early stage similar to those of a normal pregnancy, as amenorrhea, nausea, mammary changes, etc., associated with a history of colic -like pains on one or the other side of the pelvis, with later a marked tearing pain, possibly attended by fainting, and symp- 676 GYNECOLOGY. toms of internal hemorrhage. Subsequently a mass will be found in the side or an increase in the size of the abdomen will take place, but this enlargement will be less symmetrical than is the case in a normal pregnancy. The examination of the patient will ordinarily reveal the uterus slightly enlarged, some- what softened, free from any irregular or nodular masses, pos- sibly displaced to one side, or crowded forward by a mass which is situated in the side of the pelvis or in Douglas' pouch pos- terior to the uterus. In the advanced stages the parts of the fetus may be felt, probably with greater ease than if the fetus was contained within the uterus. Desmoid tumor of the abdominal walls presents the same hard- ness and resistance as does a fibroid growth of the uterus, but de- veloping in the muscular structure of the abdomen it generally becomes by its weight more or less pendulous and usually does not attain to large size, so is readily distinguished from the deeper seated uterine growths. In my clinic in the spring of 1905 a colored woman of thirty years, who had given birth to two children, presented herself with a distention of the abdomen which was quite symmetrical and extended from the pelvis to beneath the ribs. Palpation disclosed a firm, hard mass, occupying the entire abdomen and quite movable. The diagnosis was made of intersti- tial uterine myoma and resort made to operation. Incision in the median line, however, exposed the tumor as continuous with the abdominal wall, and did not afford access to the peritoneal cavity until it had been carried some distance above the umbili- cus. The growth sprang from the right side of the abdominal wall, was covered upon its inner surface with peritoneum, and had no association with the uterus. (See Fig. 480.) The tumor weighed nineteen pounds. (Fig. 481.) Notwithstanding that this growth grew inward from the under surface of the muscular walls and filled the abdominal cavity, careful bimanual examina- tion should have revealed that it had no connection with the uterus and that the abdominal walls could not be moved over it. Incomplete Abortion. — The uterus may be larger than nor- mal and the patient give a history of irregularity and more or less continuous bloody discharge from the uterus. Careful question- ing will afford a history of amenorrhea and belief of the patient that she has been pregnant. The uterus will be large, softened, and when the cervix is patulous, the finger can be introduced, re- vealing the enclosed embryonic tissue. Inversion. — Inversion of the uterus may be associated with a myoma with a short pedicle, attached near to the uterine fundus. The efforts at extrusion of such a mass, after dilatation of the cervical canal, may cause a dragging upon the fundus and gradual inversion. A polypus with a moderately thick GENITAL TUMORS. 677 Fig. 480.— Large Desmoid Tumor of Abdominal Wall Weighing, upon Removal, Nineteen and One-half Pounds. a, Adipose tissue of abdominal wall; h, b, recti muscles from which tumor orig- inated; c, aponeurotic sheath of recti muscles; d, portion of tumor projecting downward into pelvic cavity. 678 GYNECOLOGY. pedicle, when extruded from the os, may be distinguished from the body of an inverted litems " with difficulty. A myoma is said to be less sensitive than the uterus, but this is not sufficiently characteristic to be of much value in diagnosis. The inverted uterus shows upon inspection the orifice of the tube upon either side. In each condition the neck of the uterus can be felt encircling the pedicle of the tumor like a cuff. The diagnosis is best established by introducing a finger into the rectum, while traction is made upon the tumor. In case of inversion the cup-shaped cavity of the inverted uterus will be felt, where in ordinary cases the uterine fundus should be situated. The exercise of recto-abdominal touch, while traction is made upon Fig. 481. — Histologic Section of Desmoid Tumor. a, Blood-vessel; b, area of specimen showing edema; c, long spindle-shaped cells; note scarcity of nuclei. the protruding mass, will afford an unfailing method of deter- mining the diagnosis. A sound passed into the uterus in a case of a cervical tumor will be found to pass at one side the entire length of the ordinary uterus. In an inversion of the organ the sound will pass an equal distance on all sides of the tumor. The diagnosis, ordinarily, however, can be accom- plished without the use of the sound. Carcinoma and Sarcoma. — Profuse bleeding, pain, and dis- charge are common to both fibroid tumors and malignant dis- eases of the uterus. In the majority of cases the offensive discharge associated with malignant disease is not found in GENITAL TUMORS. 679 myomata. The recognition of this fact has sometimes led to error in judgment ; thus, in a case where a myomatous growth has pushed through the cervix, has been for a length of time constricted by it, caries or superficial necrosis follows as a re- sult of the interference with the circulation in the tumor, from which the careless observer may be led to a diagnosis of malignant disease. A digital examination of such a patient, however, reveals the fact that the vagina is occupied by a tumor which is firm in consistence, is smooth and regular in outline, is not friable nor easily broken down, and thus differs materially from the friable necrotic mass which is found in the vagina in the cauliflower growth of malignant disease. A sloughing fibroid within the uterine cavity may afford some difficulty in the diagnosis. It causes a thin, watery discharge, which is exceedingly offensive. It may have caused repeated attacks of hemorrhage. The associated loss of blood, with the absorp- tion of the products of decomposition from necrotic tissue, produces a condition of sapremia which is with difficulty differ- entiated from malignant disease. In such cases, however, the diagnosis is determined by dilatation of the uterine canal. The necrotic growth forms a large tumor, one which is more resistant, in which fragments broken away and examined pre- sent the regular lamellated structure of a fibroid growth, but nowhere is seen the nesting or collection of epithelial masses surrounded by a connective-tissue stroma pathognomonic of carcinoma or the homogeneous mass of cellular tissue with an absence of true blood-vessels which characterizes the sarcoma. Subinvolution iviih Endometritis. — Subinvolution is a chronic inflammation of the uterine parenchyma, and when it has existed for a length of time, the uterus becomes firm and hard, indis- tinguishable from the hardness of myomata. The enlargement of the uterus is uniform, involving the cervix as well,, Avhile in fibroid growths the enlargement is pronounced only in that part of the uterus which comprises the groA\i:h. Uterine Displacements. — Flexions of the uterus are the varieties of uterine displacements most readily confounded with fibroid groA\i:hs. Indeed, it should not be overlooked that a fibroid growth may be the cause of the displacement. The growth, by its smooth outline and situation, may form such an angle as to cause one to regard it as the fundus uteri. These are the cases in which the sound can be successfully employed to ascertain whether the direction of the uterine canal corresponds to the position of the tumor. The cases are rather few, however, in which the gynecologist can not accurately locate the fundus uteri and detect the relations of the growth thereto by practising the bimanual examination 680 GYNECOLOGY. in association with the vagino -abdominal or recto-abdominal touch. Such an examination will reveal the greater consistence of the growth, its rounded, smooth outline, and the extent of its association with the uterus. In a flexion, when the organ is straightened between the internal and external fingers, the normal outline of the uterus is found restored. Displacements of the Ovary. — The ovary is likely to afford confusion of diagnosis only when it is firmly fixed to the uterus by inflammatory exudate or has become somewhat enlarged. Its situation, the inability to recognize the ovary in any other situation, and its extreme sensitiveness should reveal its true character. Ovarian Cyst.- — It is frequently difficult to differentiate be- tween a fibroid tumor with a long pedicle, which has become ede- matous, and an ovarian cyst of the glandular or dermoid variety. If the cervix is grasped with a double tenaculum, while an assistant, with the hand over the abdomen, draws up the tumor, we are enabled through a rectal examination to ascertain a more exact determination of the relation of the pedicle of the tumor to the uterus. This examination, with the patient under the influence of an anesthetic, will generally be sufficient to determine the diagnosis. It should not be forgotten, how- ever, that the existence of a fibroid tumor does not necessarily preclude the possibility of pregnancy, as we can have pregnancy complicating fibroid growths. I narrowly escaped operating some years ago upon a patient who had a history of having had a very profuse bleeding during the preceding three weeks. The right side of the uterus presented a gro^\^h, which was firm and hard, and was recognized as a fibroid. Upon the left side of the abdomen there was more sensation of elasticity or indistinct fluctuation, and it w^as believed that we had an areolar glandular ovarian growth closely adherent to a fibroid of the uterus. On the day set for the operation, on starting to cleanse the vagina, a foot and leg of a fetus were found projecting from the dilated os, and a partly macerated fetus was delivered. Upon removal of the placenta the uterus contracted and disclosed a pretty good- sized fibroid upon the right side of the uterus. The patient re- covered, and with marked decrease of the fibroid growth during the progress of involution, rendering operation for its removal unnecessary. Pelvic infiltrations are recognized by the previous history of inflammation and the irregular and undefined outline of the masses which are found. Sactosalpinx is usually preceded by a history of inflam- mation. The mass is felt at one side of, or posterior to, the uterus. When adherent to the latter, the connection is so irregular and undefined as to reveal its character. GENITAL TUMORS. 681 Floating kidney forms a tumor which is generally situated at a higher level. The fingers can be pushed between it and the symphysis and the promontory of the sacrum, and both can be palpated below the supposed growth. This would be impos- sible in a growth .connected with the uterus. The floating kid- ney can generally be pushed back into its normal situation. Fig. 482. — Myoma Uteri with Large Intraligamentary Fibromata. a, Anterior and posterior leaflets of broad ligament; h, tumor. 596. Alterations and Degenerations. — During the active prog- ress of a myoma it becomes larger, sw^ollen, and more ede- matous as each menstrual period approaches; and, following the flow, it decreases in size and becomes more firm and re- sistant. In the submucous and interstitial varieties cessation of the menstrual function or the establishment of the climacteric is delayed for from five to ten years longer than would occur in a 682 , GYNECOLOGY. woman whose uterus was free from disease. With the establish- ment of the menopause, however, the growth usually diminishes in size and undergoes a process of atrophy. The gro^1:h be- comes firm and hard, and its size remains fixed ; or it may become soft, and, with this, a process of metabolism follows, by which the gro^vth gradually disappears. In small growths the same length of time after the climacteric the tumor may have almost entirely vanished. These changes also occasionally take place during the progress of a pregnancy or in nonpuerperal cases without our being able to assign a cause. Not infrequently a patient has been alarmed at the discovery, through examination, of the presence of a fibroid growth, and some months or years later another in- vestigation reveals no indication of its existence. If the second investigation has been made by another physician, he may be inclined to believe that a misrepresentation had been made, and yet do an injustice in giving expression to such a suspicion. Edema. — Edema of large fibroids, especially of the inter- stitial variety, is not infrequent. The condition is caused by con- striction or torsion of the pedicle, through which the venous cir- culation is obstructed, while the arteries continue to pump in the blood. The decreased circulation in such growths may result in edema as a first stage of a necrobiosis. The interstices of the tumor become filled with serous fluid, so that the enlarged growth gives a sensation of indistinct fluctuation or elasticity, so marked that only the determination of the continuation of the growth with the cervix renders one able to difterentiate it from an areolar glandular ovarian cyst. After the removal of such a growth an incision into its wall will permit the discharge of a large quantity of serous fluid. I once extirpated the uterus for such a growth, when a prominent surgeon examining it asserted that it was a fibrocystic tumor. An incision through the struc- ture, however, failed to reveal a single cyst, while nearly a gallon of fluid drained out of the growth in the two hours fol- lowing its removal and incision. Fibrocystic tumors (Fig. 483) result from dilatation of the lymph-spaces in the tumor, from degeneration of a portion of its structure and the formation of a cavity, or possibly, in rare cases, from the separation of the structure of the tumor in edema. Calcification. — As the tumor matures its direct circulation is reduced and nutrition reaches its structures largely by transuda- tion. Under certain unknown chemical conditions of the blood this fluid is heavily charged with lime salts which are deposited within and upon the surface of the tumor, causing it to become enveloped in a stony shell or to form a calcareous mass. Lime salts were formerly administered to favor such formation and thus arrest further growth in myomatous tumors, but it was soon rec- GENITAL TUMORS. 683 ognized that other and more vital tissues of the body were equally vulnerable to such deposits. In the examination of gro^^i:hs which have undergone such change, the sensation given of pressure against bone renders such a tumor harder and more resistant than th$ ordinary mature fibroids. Not infrequently plates of bone will be felt to break beneath the palpating finger. Undoubtedly the cases reported of the expulsion of uterine cal- culi were myomata which had undergone this calcareous change. A submucous or interstitial fibroid so changed may subsequently Fig. 483 > — Fibrocystic Tumor of the Uterus. be expelled by the uterine contractions. Amyloid degeneration has been reported in one patient. Fatty degeneration has been evident from the macroscopic appearance of tumors I have re- moved, although it has been asserted that fatty degeneration of such growths is never confirmed by the microscope. Colloid Myxomatous Degeneration. — This condition, accord- ing to Virchow, is an effusion of mucous fluid between the mus- cular bands. The presence of a mucin proliferation of the 684 GYNECOLOGY. nuclei and small round cells permits of its being distinguished from simple edema. Inflammation, Suppuration, and Gangrene. — Inflammation of a growth may result from injury, traumatism, compression or obliteration of nutritive vessels of the tumor, and from septic infection following an exploration. Septic inflammation may follow an exploration or the delivery of a patient. The rapid changes which take place subsequent to the delivery of a patient who is suffering from a large fibroid may result in interference with its nutrition and in the development of inflammation and suppuration. Suppuration may take place external to the capsule, in the cellular tissue about it, or in the structure of Fig. 484. — Submucous Fibromyoma Undergoing Cystic Change. the tumor. This may have been preceded by mortification of a small part of an interstitial or a submucous growth. The gangrenous portions may be eliminated spontaneously, or may produce putrid infection. When a large growth has lost its vitality and is still retained within the wall of the uterus, it may gradually disintegrate, slough, and be expelled into the vagina through the cervix as a large sloughing mass, or may produce such marked symptoms from putrid infection that the life of the patient will be sacrificed notwithstanding operative interference for its removal. Such conditions are readily con- founded with malignant disease. Some years ago I saw a pa- tient who had been examined by a physician who assured her family that she was suffering from an incurable malignant GENITAL TUMORS. 685 growth, which must speedily terminate her life. The his- tory of profuse hemorrhage and of an exceedingly offensive discharge, and the appearance of profound anemia and a condition resembling cachexia, afforded apparent confirmation of the correctness of his suspicion. The finger disclosed a large mass filling the vagina, which, instead of being soft and friable, as a cauliflower gro\"s^h would be, was roughened on Fig. 485. — Myoma of the Body and Cancer of the Cervix. its inferior, but smooth upon its upper, surface, was quite mov- able, and a distinct pedicle could be recognized, which pro- jected from the cervical canal. The neck of the uterus was thin, pliable, and without any infiltrate, which demonstrated that the diagnosis of malignant disease was incorrect, and that the patient was suftering from a fibroid polypus whose sur- face was necrotic. In cases of doubt the history, more or less 686 GYNECOLOGY. firmness of the growth, the distinct arrangement of the struc- ture, even when gangrenous, and the absence of any cellular infiltrate are sufficient to afford a correct diagnosis. An abscess may develop either in the wall or within the gro^vth itself. Malignant Degeneration (Fig. 483). — Cancerous degeneration of a fibroid growth has not been demonstrated, nor is it easy to understand how it could occur, unless the gro\vth contains gland- ular tissue and is, consequently, a fibroid adenoma. The presence of the growth renders the uterus less resistant and facilitates Fig. 486. — Uterus Incised, Displaying Numerous Fibromyomatous Growths and Incipient Cancer of the Cervix. a, Shows invasion of cervix by cancer. the probability of malignant degeneration of the endometrium. The most frequent malignant degeneration, however, is the infil- tration of the fibroid growth by sarcomatous processes. 597. Mixed Growths. — Enchondroma, Sarcoma, Osteoma, and Carcinoma. — The origin of these growths is uncertain. It is possible that they must originate in one of two ways — either in transformation of the cells which produce other tissue species, or in an invasion in which the growth is penetrated by the neighboring proliferating masses. Thus, we have myochon- GENITAL TUMORS. 687 droma, myosarcoma, and myocarcinoma. The first of these is very rare. The second is less rare, and grows rapidly from a small invasion. The normal filamentous structure of the fibroid growth is soon lost in a homogeneous mass, which rapidly becomes necrotic; the tumor then forms a mere thick shell. With the necrosis of the mass, not infrequently vessels are eroded, and extensive hemorrhage may take place into the cavity. The disease is not confined to the growth, but invades the surrounding healthy tissues. The enveloping cells are large, irregular, rich in chromatin, and contain several nuclei. Sanger asserts that all myomatous growths containing irrita- tion cells are sarcomatous. Myocarcinoma arises from carcinomatous alteration of the surface of the polypus, or by development from the glandular constituents of an infiltrated adenomyoma. 598. Complications. — The study of the progress of a fibroid growth from its origin in the wall of the uterus to its subsequent extrusion, and the changes and lesions to which it may be readily subjected, will aftbrd reasonable explanation for many com- plications which are associated with it and influence the prog- ress of the growth. Of these complications, the most im- portant, because one of the most frequent, is that of inflam- mation and the resulting adhesions. 1. Inflammation, as we have already seen, may involve the structure of the growth or may influence only its super- ficial surface. The structure of the gro^^i:h can undergo in- flammation from decreased nutrition by its extrusion into the peritoneal cavity, when it becomes a foreign body, which nature, in its efforts to protect the general structure, surrounds with plastic material, from which the tumor may receive ad- ditional and necessary nutrition, and which fixes it in relation to the structures immediately about it. Such adhesions may take place with the intestine, the mesenter}^, or the abdominal wall, and may lead, through traction upon the tumor, to still further thinning or attenuation of its pedicle, and, finally, to separation from the body of the organ, so that occasionally such groT\i;hs are found removed from the original attachment and nourished through the inflammatory adhesions. The causes for inflam^matory changes may be divided into — (i ) those incident to alterations in the tumor; (2) to irritation changes in the peritoneum from the presence of the groT\i:h as a foreign body; (3) to infection. Infection may arise from disease of the ap- pendix, the Fallopian tubes, or through direct transmission from the intestinal cavity. 2. Ascites. — A second, though less frequent, comphcation of my omat a is ascites. (Fig. 489.) This is attributed to invitation 688 GYNECOLOGY. of the peritoneum from pedunculated subperitoneal growths. (Fig. 490.) It is more probable that it may be engendered by the development of a toxin from lowered vitality in the growth which makes it a foreign body and causes irritation, which pro- Fig. 487. — Myoma Uteri Complicated by* Pyosalpinx, duces ascites. i\scites is much more frequent in malignant than in benign growths, and its presence should always awaken the suspicion that very grave changes are taking place in the growth. 3. Disease of the Tithes (Fig. 487). — Disease of the Fallopian tubes as a complication of the presence of fibroid tumors is very Fig. 488. — Uterus Containing Several Fibroid Tumors Complicated by a Large Tubo-ovarian Cyst, a, a, Shows sites of fibromata ; b, round ligament. common. It may be a simple hydrosalpinx or a pyosalpinx. Adhesions may be extensive, and very greatly complicate any operative procedure. The most frequent cause of this condition is undoubtedly the result of infection which has traveled through GENITAL TUMORS, 689 the litems. The presence of the fibroid gro\\'ths favors the congestion of the pelvis, and makes the tubal mucous mem- brane a more favorable soil. Pressure of the growth upon a Fallopian tube may interfere with its circulation, cause a distention of its Ciavity, and the formation of a tubal collection. This defective drainage causes regurgitation into the pelvic perito- Fig. 489. — A Myoma Which, from the Associated Ascites, Had Been Mistaken for Pregnane V. netim from the abdominal end of the tube, which sets up a peri- toneal inflammation and produces a closure of the tube and the formation of a hydrosalpinx or pyosalpinx, according to the exposure to or absence of infection. 5. Ovarian Hematoma. — The distention of the ovary by the accumulation of blood is not an unusual complication of myo- mata. The ovarian sac is usually adherent and filled with a 44 690 GYNECOLOGY. thin, dark, bloody colored fluid. The sac wall is easily ruptured and is rarely dissected without rupture occurring. 6. Pregnancy. — The presence of fibroid growths is a cause of sterility, but does not necessarily preclude the occurrence of pregnancy. The early recognition of the compHcation is of the very greatest importance, as the progress of the pregnancy may have a marked influence upon the rapidity of the growth, while the growth may favor the premature interruption of the course of pregnancy. This complication is of so much importance that it may be studied from various standpoints. 599. (a) The Influence of the Myoma upon Conception. — Fig. 490. — Tumor Shown after Removal. It can be readily understood that the presence of a fibroid growth — for instance, of the polypoid or submucous character — renders the mucous membrane of the uterus unprepared for the retention of the fecundated ovum, and not infrequently the removal of a polypus from a woman who has been sterile for a number of years is very shortly followed by conception, even though years of sterility had preceded. The engorge- ment of the uterine mucosa, occasioned by the presence of a sessile submucous or of an interstitial growth, which encroaches upon the uterine canal, the profuse and irregular hemorrhages accompanying its progress, associated with the constant and GENITAL TUMORS. 691 excessive secretion from the glandular structure, present con- ditions exceedingly unfavorable for the fecundation of the ovum. 600. (b) Influence of Pregnancy upon the Myoma. — The in- creased congestion of the uterus incident to pregnancy causes greater nutritioil of the growth, results not infrequently in its rapid increase in size, and the growth which was situated in the pelvis is of itself raised out of it, and forms a more formidable mass. In some cases the growth is slow, adhesions may so fix and bind down the uterus that it can not rise out of the pelvis, and we may have as a result an impaction of a mass in the pelvis similar to that which occurs in the gravid retroflexed uterus. Sometimes the rise of the growth in the pelvis may be rapid, or Fig. 491. — Myoma Complicated by Pregnancy. it may be situated low in the pelvis, and not emerge from it until between the sixth and seventh months. Intraligamentary growths become altered by the pressure and cause very marked distress. The fibroid polypus or submucous tumor is sometimes extruded into the vagina, whence it may be removed without any indication of interference with the pregnancy. Marked changes in size, form, and consistence of the uterine growth may be noticed. The increase in size is often due to edema. Venous engorgement frequently occurs as a result of obstruction of the veins, while the blood is continually poured into the structure by the less readily controlled arteries. (Fig. 490.) Where a num- ber of fibroid growths are situated together in the pelvis, they not 692 GYNECOLOGY. infrequently become nonpedunculated subserous growths, and often become flattened from pressure. The circulation can be obstructed to such a degree as to result in necrotic changes. Such changes require early and prompt interference in order to save the life of the patient. 60 1, (c) The Influence of the Myoma upon Pregnancy. — An intra -uterine growth, covered as it is by mucous membrane, pre- Fig. 492. — Uterus Containing Large Fibroid Tumor and Three Months' Fetus. disposes the subject to increased bleeding. This hemorrhage and the changes in the uterine mucous membrane may be so marked as to result in premature interruption of pregnancy ; or the ovum may be lodged low in the uterine cavity, causing the formation of the placenta over the cervix, — w^hat is known as placenta prasvia, — in which the life of the mother will become more endangered as the pregnancy progresses. The situation of the tumor may favor retroversion of the gravid uterus and its im- GENITAL TUMORS. 693 paction in the pelvis, or the tumor itself may be impacted with the development of the pregnancy. The presence of a fibroid growth, with its pressure upon the tubes, may cause the develop- ment of a tubal pregnancy, which may remain unsuspected until its rupture into 'the abdominal cavity occurs, with the accom- panying peril to the patient. 602. (