Nancss MONOXI T t CHICAGO Presented by David B. Bosworth, D. 0. COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA MANUAL OF GYNECOLOGY. MANUAL OF G Y NECOLOGY B E R R Y HART, F.R.C./.E., F.R.S.E., PRESIDENT OF THK EDINBURGH OBSTETRICAL/SOCIETY ; ^- - ^ LECTURER ON MIDWIFERY AND DISEASES OK WOMEN, SFBGEONs' HAM., EDINBURGH ; PHYSICIAN, ROYAL MATERNITY AND SIMPSON MEMORIAL HOSPV/AL, EDINBURGH; ASSISTANT PHYSICIAN FOR DlgE.ltiHO or.gpMEX, ROYAL IXFIRM/RY, EDIXBITRGH; AND A. H. FREELANU BARBOUR, M.A., B.Sc., LECTURER ON MIDWIFERY AND DISEASES OF WOMEN, SCHOOL OF MEDJ1USE, EDINBURGH ; ASSISTANT PHYSICIAN, ROYAL MATERNITY- AND SIMPSON M ASSISTANT PHYSICIAN FOR DISEASES OF WOMEN, ROYAL INFIRMARY, EDINBUI PHYSICIAN FOR DISEASES OF WOMEN TO THE COWGATE AND TO THE WOMEN'S DISPENSARY, EDINBURGH. WITH FOURTEEN LITHOGRAPHS AND FOUR HUNDRED WOOOCUT8. .C.P.E., F.R.S.E., FOURTH ED I TIG N. J. H. VAIL & CO., NEW YORK. 1891. Alt riiiltt,i reserved.] TO OUR FRIEND AND TEACHER, ALEXAKDEK BUSSELL SIMPSON", M.D., F.E.S.B., PROFESSOR OF MIDWIFERY AND DISEASES OF WOMEN AND CHILDREN IN THE UNIVERSITY OF EDINBURGH. '/ A PREFACE TO FOURTH EDITION. Edition has been carefully revised and brought up to date, and New Sections on Massage and Apostoli's Method of Treat- ment have been added without materially increasing the size of the Work. The Index of Gynecological Literature gives a convenient Biblio- graphy of the important papers published since the last Edition. We have to express our thanks to Mr J. A. Melville, not only for his literary help and the work connected with the Indexes, but also for the preparation of the technical portion of the Section on Apostoli's Method. To Mr J. C. Webster, M.B., we are also greatly indebted for valuable help afforded in preparing this Edition for press. D. BERRY HART. A. H. FREELAND BARBOUR. EDINBURGH, Feb. 1, 1890. PREFACE TO FIRST EDITION. IN writing this Manual we have tried to keep before our eyes the great principle that the Anatomy, Physiology, and Pathology of the Pelvic Organs form the foundation of good Clinical work. As students we felt the want of a text-book based on this principle and embodying the most recent views from the various literatures instead of giving those of one school. This want we have endeavoured to supply. Our thanks are due to Professor Simpson for his kind advice in matters of difficulty : and specially to Mr J. A. Melville, for the literary revision of the text and the preparation of the copious Table of Contents and Indexes. Messrs W. & A, K. Johnston have executed the lithographs with their well-known accuracy and finish : and to Mr James Bayne we are indebted for the care and fidelity with which he has drawn on the wood the majority of the engravings. We have in all cases acknowledged the source of every illustration not specially prepared for this work. " D. BERRY HART. A. H. FREELAND BARBOUR. EDINBURGH, July, 1882. TABLE OF CONTENTS. PART I. ANATOMY, PHYSIOLOGY, AND METHODS OF EXAMINATION OF THE FEMALE PELVIC ORGANS. SECTION I. ANATOMY AND PHYSIOLOGY OF THE FEMALE PELVIC ORGANS. CHAP. i. General Anatomy of External Genitals and Contents of Pelvis . . . . . . .2 External Genitals as observed Clinically . . 3 The Pelvic Floor and Organs resting on it, con- sidered as a whole ..... 7 The Pelvis considered in detail ... 8 Pelvic Floor dissected from below . . 8 Pelvic Floor dissected from above . . 12 The Uterus and its Annexa ... 14 Fallopian Tubes .... 22 Ovaries ..... 23 Vagina ..... 27 Bladder 30 Rectum ..... 36 PerinealBody . . . . 38 Peritoneum ..... 39 Connective Tissue of Pelvis ... 41 CHAP. ii. The Sectional Anatomy of the Female Pelvis . . 44 Sagittal Mesial Section .... 45 Sagittal Lateral Section .... 45 Transverse or Horizontal Section ... 47 Coronal Section ..... 48 Axial Coronal Section of Pelvis ... 49 xii CONTENTS. I'AGE CHAP. in. The Position of the Uterus and its Annexa, and the Relation of the Super] acent Viscera ... 51 The Normal Form and Position of the Uterus . 53 The Local Divisions of the Pelvic-Floor Peritoneum as viewed through the Pelvic Brim, and the posi- tion of the Uterine Annexa ... 57 The Physiological Changes in the position of the Uterus ...... 58 The Relation of the Small Intestine to the Pelvic Floor and to the Uterus with its Annexa . 59 CHAP. iv. Structural Anatomy of the Female Pelvic Floor . 60 In Sagittal Mesial Section ..... 60 Pubic Segment ..... 61 Sacral Segment ..... 61 Segments Contrasted .... 61 In Axial Coronal Section ..... 63 The entire Displaceable Portion ... 63 The entire Fixed Portion .... 63 Functions of the Female Pelvic Floor ... 64 Pelvic Floor Projection ..... 65 CHAP. v. Bloodvessels of the Pelvis ..... 68 Arterial Supply ..... 68 to Uterus, Ovaries, &c. ... 68 to Perineal Region .... 69 Venous Supply ..... 70 Lymphatics of the Pelvis ..... 71 Lymphatic Glands ..... 71 Lymphatic Vessels ..... 72 of External Genitals ... 72 of Vagina and Cervix Uteri . . 72 of Uterus ..... 72 Relation between Glands and Vessels . . 73 Nerves of the Pelvis ...... 73 Spinal. ...... 73 Sympathetic ...... 73 Development of Pelvic Organs .... 74 CHAP. vi. Physics of the Abdomen and Pelvis, with special reference to the Semiprone and Genupectoral Postures ....... 75 The effect of Intra-abdominal Pressure on the Female Pelvic Floor .... 75 Results brought about by change of Posture, especially by the Genupectoral Posture . . 76 The effect on Uterine position of Digital Pressure in the Vaginal Fornices .... 80 CONTENTS. xiii PAGE CHAP. vn. Menstruation and Ovulation .... 82 Preliminary Considerations .... 83 General Phenomena of Menstruation . . 83 Local Phenomena of ,, . . 84 Ovulation ...... 84 Corpus Luteum ..... 84 Source of Discharge, and Changes in the Uterine Mucous Membrane 85 SECTION II. PHYSICAL EXAMINATION OF THE FEMALE PELVIC ORGANS. CHAP. YIII. External Abdominal Examination ... 90 Inspection of External Genitals .... 94 Vaginal Examination ..... 94 Bimanual or Abdomino-Vaginal Examination . 96 Other Varieties of Abdominal Examination . . 99 CHAP. ix. Examination per Rectum ..... 101 Simple Rectal, Abdomiiio-Rectal and Abdomino- Recto-Vaginal ..... 101 Simon's Method of passing the Hand into the Rectum ...... 103 CHAP. x. TheVolsella 104 Description of Instrument .... Methods of Use ... .104 Mechanism of Displacement it causes . . 105 Uses in Diagnosis ..... 105 in Treatment ..... 106 Contra-indications ..... 106 Sims' Tenaculum ..... 107 CHAP. xi. Vaginal Specula ...... 108 Spatular Speculum the Sims . . . 108 Tubular Speculum the Fergusson . . . Ill Bivalve Speculum the Neugebauer . . - the Cusco ... 112 Uses and comparative value of the various Specula 114 CHAP. xn. The Uterine Sound ...... 115 Nature ...... 115 Preliminaries to its use ; centra-indications . 116 Method of Use 117 Employment for Diagnosis .... 121 Treatment .... 122 Dangers attending its use .... Sound combined with Bimanual Relation of Sound to Bimanual and Rectal Ex- amination . .... 123 xiv CONTENTS. PAGE CHAP. xin. Tents and other Uterine Dilators . . . 125 Tents ....... 125 Material ...... 125 Purposes for which used . . . 126 Preliminaries to and method of use . . 127 Dangers in use and centra-indications . . 129 Hard Rubber Dilators Tait's, Hanks', Hegar's . 130 CHAP. xiv. The Curette ....... 132 Varieties 132 Cases in which useful .... 132 Method of Use ..... 133 Cautions and Dangers .... 133 Relation of Posture to Examination and Treatment 133 CHAP. xv. Instruments ....... 135 Knives ...... 135 Scissors ...... Needles ...... 136 Sutures ...... 137 Vaginal Syringes and Douches ; Uterine douche . 137 Cautery ..... 140 Anaesthetics ...... 140 Action of Chloroform .... 140 Uses of Chloroform .... 142 Method of administration . . . 143 Dangers ..... 144 Cocaine ..... 145 CHAP. xvi. Relation of Micro-Organisms to Gynecology . . 146 Antiseptics ....... 147 Activity of various antiseptics . . . 148 Directions for use in operations . . . 150 PART II. DISEASES OF THE FEMALE PELVIC ORGANS. SECTION III. THE PERITONEUM AND CONNECTIVE TISSUE. PAGE CHAP. xvn. Pelvic Peritonitis and Pelvic Cellulitis (Parametritis) 156 Preliminary considerations .... 157 Pelvic Peritonitis ...... 157 Pathological Anatomy and Varieties . . 158 Etiology ...... 158 Symptoms and Physical Signs . . . 160 CONTENTS. xv PAGE CHAP. xvn. Pelvic Peritonitis continued. Differential Diagnosis .... 161 Course and Results ..... 161 Prognosis ...... 162 Treatment of Acute ..... 163 Prophylactic . . . 163 General . . . 163 Local . - v . 165 Chronic .... 166 Tubercular Peritonitis .... 166 Malignant Peritonitis .... 167 Pelvic Cellulitis (Parametritis) .... 167 Pathological Anatomy and Varieties . . 168 Etiology ...... 168 Symptoms ...... 169 Physical Signs ..... 169 Differential Diagnosis between Pelvic Peritonitis and Cellulitis ..... 170 Course and Results ..... 171 Prognosis ...... 171 Treatment ...... 171 Effects on Uterus of Pelvic Peritonitis and Cellu- litis 172 Displacements caused by Pelvic Peritonitis . 173 Pelvic Cellulitis . . 173 Parametritis Chronica Atrophicans . . . 174 Circumscripta ..... 174 Diffusa ...... 175 Reflex Disturbances in .... 176 CHAP. xvin. Pelvic Hseruatocele and Hsematoma ... 177 Preliminary Considerations .... 177 Terminology ...... 178 Nature of Pelvic Ha;matocele . . . 178 Pathological Anatomy .... 178 Etiology : Sources of Hzemorrhage and Varieties . 181 Symptoms ...... 184 Physical Signs . . . . . 184 Diagnosis and Differential Diagnosi . . 185 Course and Results ..... 185 Prognosis ...... 185 Treatment ...... 185 At onset of Haemorrhage . . . 185 After Suppuration has occurred . . 186 New Growths in Peritoneum and Connective Tissue (Broad and Round Ligaments) . . 187 Tumours of Broad Ligament . . . 187 Hydrocele of Round Ligament . . . 187 Tumours of the Round Ligament . . . 188 Echinococci in Pelvic Organs . . . 188 Tumours of Pelvic Connective Tissue 189 CONTENTS. SECTION IV. AFFECTIONS OF THE FALLOPIAN TUBES AND OVARIES. PAGE CHAP. xix. Affections of the Fallopian Tube ... 192 Abnormalities ..... 193 Stricture and Occlusion of the Tubes . . 194 Patent Condition of the Tubes . . . 194 Inflammatory Conditions of the Tubes Salpingitis 195 Pathology and Varieties . . 195 Hydrosalpinx or Hydrops Tub* . . . 196 Pyosalpinx ...... 197 Haematosalpinx ..... 198 New Formations : Tubo-ovarian Cysts . . 199 Affections of the Parovarium 199 CHAP. xx. Malformations of Ovary . . . . . 201 Ovaritis ....... 202 Pathological Anatomy .... Etiology ...... Symptoms and Physical Signs Differential Diagnosis .... Progress and Results ..... Treatment ...... Periovaritis ....... 204 Displacements of the Ovary Hernia. . . 204 Etiology ...... 205 Diagnosis and Differential Diagnosis . . 205 Treatment ...... 205 Prolapsus ....... 205 Pathological Anatomy .... 205 Etiology ...... 206 Symptoms ...... 206 Physical Signs ..... 206 Treatment . 206 CHAP. xxi. Operations for Removal of Fallopian Tubes and Ovaries .208 Oophorectomy Battey's Operation ... 208 Nomenclature ..... 209 Nature and Aims ..... 209 Indications and Results .... 209 Methods Vaginal ..... 210 Abdominal .... 211 Conclusions ...... 212 Removal of Uterine Appendages Tait's Opera- tion . 212 CONTENTS. xvii . PAGE CHAP. xxii. Pathology of Ovarian Tumours .... 214 Preliminaries . . ... 215 Mode of Origin of Ovarian Cysts . . . 216 Varieties of Ovarian Cyst .... 219 Naked-eye Anatomy .... 219 Microscopic Anatomy .... 221 Nature of Ovarian Fluid .... 222 Solid Ovarian Tumours .... 223 Non-Malignant ..... 223 Malignant ...... 224 Parovarian Cysts ..... 225 Other Broad-ligament Cysts .... 226 CHAP, xxiii. Diagnosis of Ovarian Tumours .... 229 When Small (Pelvic in position) . . . 229 Lateral to Uterus .... 229 Posterior to Uterus .... 230 When Large, Multilocular, and Pediculated (chiefly Abdominal in position) .... 231 Symptoms ..... 231 Physical Signs .... 231 Differential Diagnosis . . . 233 When Large and Extra-peritoneal (often Papillo- matous) ...... 234 Diagnosis of Adhesions .... 235 Co-existence of Pregnancy and Ovarian Tumour . 235 CHAP. xxiv. Operative Treatment of Ovarian Tumours . . 236 Ovariotomy ....... 237 Vaginal method ..... 237 Abdominal method ..... 237 Requisites ..... 238 Preliminaries ..... 239 The Incision ..... 239 Evacuation of Cyst .... 240 Drawing out of the Cyst from Abdomen . 240 Securing of the Pedicle . . . 241 Treatment of Adhesions and Bleeding . 243 Peritoneal Toilette .... 244 Closure of Wound .... 244 Drainage . . . . 244 Dressing of Wound .... 244 After-Treatment : Treatment of Complications 245 Abdominal Method when the Tumour is Papillo- matous and Extra-peritoneal . . . 245 Enucleation ..... 245 Relation of Listerism to Ovariotomy . . 246- Ovariotomy when Pregnancy is present . . 246 Contra-indications to Ovariotomy . . . 247 Course and result of Ovarian Tumours when left alone ........ 247 Adhesions ...... 247 Torsion of Pedicle . . . 248 xviii CONTENTS. SECTION V. AFFECTIONS OF THE UTERUS. PAGE Periods during which Morbid Conditions of the Uterus arise ..... 251 CHAP. xxv. Malformations of the Uterus .... 253 Relations of Malformations to Development . 253 Pathology 254 Etiology and Classification .... 259 Symptoms ...... 260 Diagnosis . . . . . . 261 Prognosis ...... 264 Treatment . . . . . . 264 CHAP. xxvi. Small Os Externum ; Rigidity, Stenosis, and Atresia of Cervix ...... 265 Etiology and Pathology .... 265 Symptoms ...... 266 Diagnosis ...... 269 Prognosis ...... 269 Treatment ...... 269 Dilatation ' . . . . . 269 Division ...... 270 CHAP. xxvu. Atrophy of the Cervix and Uterus ... 274 Superinvolution of the Uterus .... 275 Pathology ...... 275 Etiology ...... 275 Symptoms ...... 277 Diagnosis ...... 277 Prognosis ...... 277 Treatment ...... 277 CHAP, xxvin. Hypertrophy of the Cervix : Amputation . . 279 Forms of Hypertrophy of the whole Uterus . 279 Two forms of Hypertrophy of the Cervix . . 279 Hypertrophy of the Cervix Vaginal Portion . 279 Pathology ...... 279 Etiology ...... 280 Symptoms ...... 280 Diagnosis ...... 280 Treatment Amputation .... 281 With Scissors or Knife . . . 281 "With Ecraseur or Cautery . ' . 285 Hypertrophy of the Cervix Supra-vaginal portion 286 Treatment ...... 288 CHAP. xxix. Laceration of the Cervix and its Consequences . 291 Introductory ...... 291 Pathology ...... 292 Etiology ... . . . . 293 Symptoms ...... 294 Diagnosis ...... 295 Treatment . . . . . . 296 Emmet's Operation .... 297 CONTENTS. xix PAGE CHAP. xxx. Chronic Cervical Catarrh ..... 302 Pathology ...... 302 Etiology 307 Symptoms . . . . . . 308 Physical Signs ..... 308 Diagnosis and Differential Diagnosis . . 309 Prognosis ...... 310 Treatment . . . . . . 311 CHAP. xxxi. Endometritis ....... 315 Pathology 315 Etiology ...... 321 Symptoms of Acute Endometritis . . . 322 of Chronic Endometritis . . 322 Physical Signs of Acute Endometritis . . 323 of Chronic Endometritis . . 324 Diagnosis : Differential Diagnosis . . . 324 Prognosis ...... 325 Treatment of Acute Endometritis . . . 325 of Chronic Endometritis . . 325 CHAP, xxxii. Acute Metritis ...... 331 Pathology ...... 331 Etiology ...... 331 Symptoms ...... 332 Physical Signs ..... 332 Progress and Termination .... 332 Diagnosis ...... 332 Prognosis ...... 333 Treatment ...... 333 Chronic Metritis ...... 333 Pathology . . . . . .334 Etiology ...... 336 Symptoms ...... 337 Physical Signs, Diagnosis .... 338 Differential Diagnosis .... 338 Treatment ...... 339 CHAP, xxxin. Displacements of the Uterus .... 342 Preliminaries ...... 342 Definitions ...... 344 Etiology ...... 345 Frequency ...... 346 Symptoms ...... 346 Physical Examination .... 346 Treatment ...... 347 Anteflexion ....... 347 Pathology . .... 347 Etiology ...... 349 Symptoms ...... 350 Obstruction and Congestion theories of Dysmenorrhcea ..... 351 Physical Diagnosis ..... 353 xx CONTENTS. PAGE CHAP. xxxm. Displacements of the Uterus (continued.} Differential Diagnosis .... 354 Prognosis ...... 355 Treatment ...... 355 Anteversion ....... 355 Pathology ...... 356 Etiology ...... 357 Symptoms ...... 357 Diagnosis ...... 357 Treatment ...... 358 Retroversion ....... 360 Pathology and Etiology .... 360 Symptoms ...... 361 Diagnosis ...... 361 Treatment ...... 362 Retroflexion = Retroversion + Retroflexion . . 362 Pathology ...... 362 Etiology ...... 364 Symptoms ...... 365 Diagnosis ...... 367 Differential Diagnosis .... 369 Prognosis ...... 370 Treatment ...... 371 Replacement by Bimanual . . . 371 with the Sound . . 373 by Genupectoral Posture . 374 Retaining the replaced Uterus by Pessaries . 375 by Operation 382 CHAP, xxxiv. Inversion of the Uterus ..... 384 Pathology ...... 384 Etiology and Frequency .... 388 Symptoms ...... 389 Diagnosis ...... 390 Differential Diagnosis .... 392 Course and results of Chronic Inversion . . 393 Prognosis ...... 394 Treatment ...... 394 Reposition ..... 394 with the hand alone or aided . 395 by continuous slight elastic pressure 398 Amputation ..... 399 CHAP. xxxv. Tumours of the Uterus ..... 402 Fibroid Tumours ...... 402 Pathology ....... 403 Situation ...... 403 Structure ...... 403 Mode of Growth, Varieties .... 405 Changes in the Uterus .... 409 Degenerative Changes .... 411 Fibroid Tumours of the Cervix . . . 412 Etiology 413 CONTENTS. xxi PAGE CHAP, xxxvi. Fibroid Tumours of the Uterus (continued] . 416 Symptoms ....... 416 Menorrhagia, Irregular Hemorrhages . . 416 Painful Menstruation .... 417 Sensations due to size and weight of Tumour . 418 Pressure Symptoms ..... 418 Sterility and Abortion .... 418 Progress and results ..... 419 Physical Signs : Differential Diagnosis . . 420 Of small Fibroid Tumours .... 420 Of large Fibroid Tumours .... 422 Prognosis ....... 424 CHAP, xxxvir. Fibroid Tumours of the Uterus (continued] . 425 Medical Treatment ..... 425 Treatment by Electricity .... 427 Surgical Treatment ..... 429 Removal through the Vagina . . . 429 Removal through Abdominal Walls by Laparotomy 430 Subserous pediculated tumours : intraperitoneal treatment . . . . 431 Tumours growing between layers of Broad Liga- ment or into Cellular Tissue : Enucleation . 431 Tumours growing within substance of wall . 431 Enucleation ..... 431 Hysterectomy ..... 432 The opening .... 432 Extraction of tumour . . . 432 Treatment of stump . . . 433 Intraperitoneal . . . 433 Extra-peritoneal . . 434 Removal of Ovaries or of Uterine Appendages . 442 Summary as to Operative Treatment . . 442 CHAP, xxxvin. Fibro-Cystic Tumour of the Uterus Pathology Symptoms Diagnosis : Differential Diagnosis Treatment 443 443 445 445 446 CHAP, xxxix. Polypi of the Uterus Varieties Symptoms Diagnosis Differential Diagnosis Prognosis Treatment 447 447 453 454 456 457 458 xxii CONTENTS. PAGE CHAP. XL. Carcinoma Uteri (of Cervix) .... 460 Pathology ....... 461 Classification ...... 461 Origin . , . . . . . 461 Position ...... 464 Progress ....... 46.") Extension to neighbouring Organs . . . 466 Etiology ....... 469 General predisposing Causes . . . 471 Local predisposing Causes .... 471 CHAP. XLI. Carcinoma Uteri (of Cervix) (continued} . 474 Symptoms ....... 474 Local Symptoms ..... 474 Haemorrhage ..... 474 Offensive discharge .... 474 Pain ...... 475 General Symptoms ..... 476 Diagnosis ....... Differential Diagnosis .... Prognosis ....... Causes of death ..... CHAP. XLII. Carcinoma Uteri (of Cervix) (continued) . 483 Introductory ...... 483 Treatment of Symptoms .... 484 Haemorrhage ...... 484 Offensive discharge ..... 485 Pain ....... 485 General Treatment ..... 485 Treatment of the Disease .... 486 Principles of Treatment .... 486 Application of Caustics .... 487 Scraping out of diseased tissue . . . 487 Amputation of the Cervix .... 488 Ecraseur or Galvano-cautery . . . 488 Knife and Scissors .... 491 Vaginal Amputation . . . 491 Supra-vaginal Excision . . 491 Amputation followed by caustics . . 493 Excision of the whole Uterus . . . 494 By Abdominal Incision (Freund's method) . 494 Through the Vagina .... 495 Comparison of Amputation of Cervix with Extirpation of Uterus .... 497 Comparison between Cancer of the Uterus and the disease elsewhere ..... 499 CHAP. XLIII. Carcinoma of the Body of the Uterus . . 500 Pathology and Etiology .... 500 Symptoms and Diagnosis .... 501 Treatment 502 CONTENTS. xxiii PAGE CHAP. XLIV. Sarcoma Uteri ^. . ... . . 503 Pathology ...... 503 Etiology and Frequency .... 507 Symptoms ...... 508 Diagnosis ...... 508 Prognosis . . . . . . 510 Treatment 510 SECTION VI. AFFECTIONS OF THE VAGINA. CHAP. XLV. Atresia Vaginae ...... 512 Pathology ...... 512 Atresia Hyrnenalis .... 512 Atresia Vaginalis .... 513 Etiology ...... 513 Symptoms ...... 516 Diagnosis ...... 516 Prognosis ...... 518 Treatment ...... 519 Dangers of Operation . . . 519 Operation for Imperforate Hymen . " . 520 for Atresia of the Vagina . 521 for Atresia of the Cervix . . 522 Atresia of one half of a Septate Uterus and Vagina 523 CHAP. XLVI. Vaginitis ....... 525 Nature and Varieties . . . . 525 Pathology ...... 525 Etiology 527 Symptoms ...... 528 Diagnosis ...... 528 Treatment ...... 529 Vaginismus ....... 530 Etiology ...... 530 Symptoms and Diagnosis .... 531 Treatment ...... 531 Sims' Operation .... 532 Tumours of the Vagina . .... 533 Cysts ....... 533 Fibroid Tumours ..... 535 Carcinoma ...... 535 Sarcoma ...... 536 Tuberculosis . 536 SECTION VII. AFFECTIONS OF THE VULVA AND PELVIC FLOOR. CHAP. XLVII. The Vulva : Malformations .... 540 Development ...... 540 Hermaphroditism ..... 540 True ...... 542 False . 543 xxiv CONTENTS. PAGE CHAP. XLVII. The Vulva : Malformations continued. Inflammation of the Vulva (Vulvitis) . . 544 Pruritus Vulva- ..... 545 Eruptions on the Vulva .... 547 Tumours of the Vulva .... 547 Cysts of Bartholinian Glands . . . 547 Elephantiasis ...... 548 Neuroma ...... 54!) Fibroma ...... 549 Lipoma ...... 549 Carcinoma ...... 549 Lupus ....... 550 Kraurosis or Atrophy .... 551 Pudendal Hernia ..... 551 Varix ....... 551 Hsematoma ...... 551 External Haemorrhage .... 552 CHAP. XLVIII. Rupture of the Perineum .... 553 Preliminaries and Nomenclature . . . 553 Pathology and Varieties .... 554 Etiology ...... 555 Significance ...... 555 Treatment ...... 556 Prophylactic ..... 556 Operative immediate . . . 557 deferred .... 557 for restoration of function of sphincter ani . . 558 for rupture of perineum . 562 CHAP. XLIX. Displacements of the Pelvic Floor . . . 563 Preliminaries ...... 563 Undue Yielding or Bulge .... 564 Prolapsus Uteri ..... 565 Definition ..... 565 Preliminaries ..... 565 Etiology ..... 565 Nature. ..... 566 Symptoms and Physical Signs . . 567 Mechanism ..... 567 Summary of Displacement in Prolapsus . 569 Diagnosis and Differential Diagnosis . 56! ( Treatment by Pessaries . . . 570 Treatment by Operation . . . 573 Preliminary considerations as to Opera- tive Technique . . . 574 Repair of Sacral Segment by Perine- orrhaphy, etc. . . . 574 Operations that aim at narrowing Vaginal Walls (Elytrorrhaphy) . 576 Shortening Round Ligaments . . 577 Vaginal Enterocele ..... 578 CONTENTS. xxv SECTION VIII. DISTURBANCES OF MENSTRUAL FUNCTION. PAGE CHAP. L. Amenorrhoea ....... 582 Causes, Local and Constitutional . . . 582 Symptoms ...... 582 Treatment ...... 583 Menorrhagia ....... 584 Causes, Local and Constitutional . . . 584 Treatment ...... 584 Dysmenorrhcea ...... 585 Varieties ...... 586 Treatment ...... 588 SECTION IX. DISTURBANCES OF REPRODUCTIVE FUNCTION. CHAP. LI. Sterility ....... 591 Relative ...... 592 Absolute ...... 592 Etiology ...... 593 General Causes .... 593 Local Causes ..... 593 Treatment ...... 588 SECTION X. AFFECTIONS OF BLADDER AND RECTUM. CHAP. LIT. The Bladder 596 Anatomy and Physiology .... 596 Methods of Exploring the Urethra . . . 599 Methods of Exploring the Bladder by Catheter and Sound ...... 599 Methods of Exploring the Bladder by Finger and Speculum ...... 600 Methods of Exploring the Bladder by Catheterisa- tion of Ureter ..... 603 Methods of Exploring the Bladder by Electric Endoscope ...... 604 CHAP. LIU. Affections of Urethra and Bladder . . . 605 Malformations ...... 605 Diseases of the Urethra . . . . . 605 Displacements ..... 605 Neoplasms ; Urethral Caruncle . . 606 Urethritis ..... 607 Dilatation and Stricture .... 607 Diseases of the Bladder ..... 607 Displacements ..... 607 Cystocele ..... 608 Neoplasms ..... 608 Cystitis 609 Calculi and other Foreign Bodies . . 612 Functional Diseases . ... 613 xxvi CONTENTS. PAGE CHAP. LIV. Vesico-vaginal Fistula ..... 615 Pathological Anatomy and Varieties . . 615 Etiology ...... 618 Symptoms ...... 619 Diagnosis ...... 619 Prognosis ...... 620 Treatment ...... 621 Essentials ..... 621 Operation Preparatory . . . 623 Paring of edges . . . 624 Adaptation of edges with sutures 627 After-treatment .... 632 Obliteration by Cauterisation . . 634 Closure of the Vagina : Kolpokleisis . 635 CHAP. LV. The Rectum ....... 637 Physiology ...... 637 Examination ...... 639 Diseases ...... 639 Displacements of . . . 639 Fissure of the Anus .... 640 Piles 642 Functional Disturbance of Rectum Constipation 643 Coccygodynia . . . . . . 644 APPENDIX. Abdominal Section ........ 645 Preliminaries ......... 645 Antiseptics ......... 646 The Abdominal Incision ....... 647 Exploration of Abdomen and Pelvis and Removal of Tumours . . 648 Possible Accidents during Laparotomy ..... 651 Peritoneal Toilette ; Closure of "Wound ..... 652 Electricity in Gynecology : The Apostoli Method of Treatment . 652 Introductory ......... 652 History ......... 653 Note on Electrical Terms used ...... 653 Units of Measurement ...... 655 Action of different Currents and Poles ..... 657 Action of the Galvanic Current ..... 657 Action of the Faradic Current ..... 659 Apparatus and Instruments ....... 659 The Current : its strength, duration, and frequency of operation . 660 Pathological conditions in which Electricity is used in Gynecology . 661 Results ......... 661 Systematic Treatment of Nerve Prostration .... 662 Seclusion ......... 662 Absolute rest in bed . ....... 663 Systematic extra-feeding ....... 663 Use of Massage and Electricity ...... 663 CONTEXTS. xxvii PAGE Hysteria .......... 664 Hystero-epilepsy ........ 666 Massage .......... 667 Relation of Gonorrhoea to Diseases of Women .... 669 Case-Taking ........ 671 Sources of Gynecological Literature ..... 675 Index of Recent Gynecological Literature .... 679 CLASSIFIED LIST OF ILLUSTRATIONS. To facilitate study, we have grouped the illustrations under the following heads. Anatomy naked eye Sectional anatomy. Anatomy m icr oscopic. Pathology naked eye Pathology microscopic. Charts of etiology. Gynecological examination. Instruments. Operations. ANATOMY-NAKED EYE. PLATE IV. Surface view of abdomen and thorax . ,, VI. Distribution of ovarian, uterine and vaginal arteries Fig. Page 1 External genitals .... 4 2 External genitals in section . . 5 3 Hymen of virgin with vertical slit 6 4 Hymen of virgin with oval opening 6 5 Crescentic hymen ... 6 6 Outlet of bony pelvis ... 8 7 Dissection of perineal region . 9 8 Diagram of perineal muscles . 10 9 Muscles of clitoris and bulb . . 11 10 Oblique coronal section through external genitals ... 12 11 Dissection of pelvis . . .13 12 Levator ani and coccygeus . . 14 13 Virgin uterus, from front and in section 15 14 Multiparous uterus, from front and in section .... 15 15 Diagram of divisions of cervix . 17 16 Coronal section of uterus . . 18 20 Fallopian tube, ovary and parovarium 22 23 Vagina on vertical section . . 26 24 Anterior vaginal wall and multi- parous cervix .... 27 25 Diagram of vertical mesial section of pelvis .... 28 26 Horizontal section of pelvic floor at pelvic outlet ... 29 29 Urethral glands of Skene . . 31 31 Course of the ureters ... 33 34aThe rectum inflated, showing sphincters .... 36 at p. 59 facing p. 69 Fig. Page 47 Schultze's diagram of position of uterus 53 50 Contents of female pelvis viewed through pelvic brim . . 56 51 Uterus seen through brim, with bladder distended ... 57 52 Diagram of position of uterus, according to distension of bladder 58 54, 56 Diagrams of pelvic- floor pro- jection . . . . 65, 67 57 Venous supply of uterus and vagina 70 58 Diagram of intra-abdominal pres- sure 76 59 Outline of figure in genupectoral posture 77 61, 62 Diagrams of uterus before and after menstruation ... 86 122 Diagram of structures in broad ligament 199 159 Nulliparous os uteri . . . 271 160 Multiparous os uteri . . . 271 325 Sacral segment of the pelvic floor 555 348 Bladder in systole . . .597 359 Normal relations of the cervix, the ureters, and the urethra . 617 394 Direction of rectum and of anus in relation to intra-abdominal pressure 638 SECTIONAL ANATOMY OF PELVIS. PLATE I. Position of uterus and ovaries . . facing p. 44 II. Coronal sections of left half of pelvis . ,, 46 ,, III. Axial coronal sections of pelvis . ,,48 V. Coronal section of female cadaver frozen . . at p. 59 Fig. Page Fig. Page 32 Vertical mesial section, showing Y-shape of bladder frozen . 34 33 Vertical section of pelvis, with bladder contracted frozen . 35 341 Coronal section through anus . 36 36 Vertical mesial section showing peritoneum frozen . . 38, 39 37 Vertical mesial section, with blad- der contracted, showing peri- toneum frozen . . 38, 39 CLASSIFIED LIST OF ILLUSTRATIONS. XXIX Fig. Page 38 Vertical mesial section, with ute- rus drawn back, showing peri- toneum spirit hardened . 38, 39 39 Vertical mesial section with peri- toneum dipping abnormally deep frozen . . . 38, 39 40 Vertical mesial section, at end of pregnancy frozen . . 38, 39 41 Vertical mesial section, during parturition frozen . . 38, 39 42 Vertical mesial section, with blad- der distended frozen . 38, 39 43 Lateral sagittal section spirit hardened .... 46 44 Transverse section at level of hip-joints frozen ... 47 45 Coronal section of pelvis frozen 48 Fig. Page 46 Transverse section of pelvis in line of pyriform muscles . . 57 48 Vertical mesial section with bladder distended ... 54 49 Vertical mesial section with bladder contracted frozen . 55 53 Vertical mesial section, during parturition frozen . . 62 60 Vertical mesial section of pelvis in genupectoral posture frozen . 79 280 Vertical mesial section of pelvis from a case of carcinoma uteri spirit hardened . . . 467 281 Vertical mesial section of pel- vis from a case of carci- noma uteri et vaginae spirit hardened . 468 ANATOMY-MICROSCOPIC. PLATE X. Section of Ovary and Wolffian body of a foetal lamb . ... facing p. 225 Connective tissue sprouting up and surround- ing the germ epithelium . . ,, Fig. Page 17 Course of glands of mucous membrane of uterus . . 19 18 Vertical section through mucous membrane of uterus . . 19 19 Vertical section through mucous membrane of cervix . . 20 21 Section of ovary of cat . . 24 22 Section of human ovary . . 24 Fig. Page 27 Section of posterior wall of blad- der and anterior of vagina . 29 28 Transverse section of urethra . 31 30 Epithelial cells from vesical mucous membrane ... 32 35 Perpendicular section through end of rectum .... 37 63 Mucous membrane of menstruat- ing uterus .... 87 PATHOLOGY-NAKED EYE. PLATE XI. Diagram of mode of origin and growth of multilocular and papillomatous tumours . facing p. 226 XII. Figs. 1 and 2, Erosion and Laceration of Cervix as seen in the Speculum . . 303 Fig- Page 94 Cervical canal dilated by a poly- pus 128 113 Uterus bound down by peri- tonitic adhesions . . . 161 114 Uterus retroverted and fixed with adhesions .... 162 115 Uterus drawn to one side by peritonitic adhesions . . 172 116 Vertical mesial section of a hsema- toma felt as a retro-uterine tumour in case of extra-uterine gestation 180 Fig. Page 117 Retro-uterine hsematocele, with pouch of Douglas not pre- viously obliterated . . . 181 118 Ante- and retro-uterine blood effusion 182 119 Vertical mesial section of recent hsematocele in pouch of Douglas in case of ruptured sac of extra-uterine gestation . 183 120 Sarcoma of Pelvic connective tissue 189 121 Hydrops tubse . . . .194 128 Multilocular ovarian cyst . . 219 CLASSIFIED LIST OF ILLUSTRATIONS. Fig. Page 129 Papillomatous cyst from hilum of ovary 220 133 Myoma of ovary .... 223 137 Simple broad ligament cyst . 226 143, 144 Rudimentary uterus . 254, 255 145 Uterus bipartitus . . . 255 146 Uterus didelphys . . .256 147 Uterus unicornis . . . 256 148 Uterus bicornis .... 257 149 Uterus septus .... 257 150 Infantile uterus .... 258 151 Primary atrophy of uterus . . 258 152 Foetation in detached horn of uterus 262 153 Uterus septus, puerperal . . 263 154 Normal and pin-hole os in specu- lum 265 155 Conical vaginal portion . . 266 164 Uterus and ovaries from a case of superinvolution . . . 277 165, 166 Hypertrophied vaginal por- tion of cervix . . . 280, 281 174 Hypertrophy of intermediate portion of cervix . . . 286 175 Hypertrophy of supra - vaginal portion of cervix . . . 287 176 Hypertrophy of whole uterus secondary to prolapsus . . 288 178 Single laceration of cervix . . 292 179 Multiple or stellate laceration of cervix ..... 293 200 Diagrammatic scheme of flexions 344 201 Diagrammatic scheme of ver- sions .... 345 202 Anteflexion with stenosis at os externum .... 348 203 Diagram to show anteflexion pro- duced by cicatrisation of utero- sacral ligaments . . . 349 204 Myoma of anterior wall . . 354 209 Uterus retroverted and bound back by peritonitic adhesions . 360 210 Extreme retroflexion of uterus . 362 211 Congenital retroflexion . . 364 226 Inversion of uterus . . . 385 227 Inversion of uterus+inversion of vagina, caused by a small sub- mucous fibroid . . . 386 228 Inversion of uterus . . . 388 241 Section of a large fibroid tumour, fibres round several centres . 404 242 Section of a fibroid tumour, show- ing wavy bundles of fibrous tissue 405 243 Section of a fibroid tumour, show- ing spaces between bundles of fibrous tissue .... 405 244 Pediculated sub-peritonealfibroid tumour 406 245 Uterus with elongated cavity due to presence of several fibroids 407 246 Interstitial fibroid tumour . . 408 247 Submucous fibroid tumour pro- jecting into uterine cavity . 409 248 Pediculated submucous fibroid in process of extrusion . . 410 249 Cervical polypus having appar- rently two pedicles . . . 413 Fig. Page 251 Uterus containing large fibroid tumour 417 252 Case of two-and-a-half months' pregnancy associated with two large fibroids .... 421 265 Large three-lobed fibroid from the fundus .... 444 266 Fibrous polypus laid open to show its identity in structure with a fibroid tumour . . 448 267 Intra-uterine submucous fibroid becoming vaginal . . . 449 268 Submucous fibroid which has come to be wholly in the vagina 450 269 Group of mucous polypi growing in the cervix uteri . . . 451 271 Non-malignant papilloma of cer- vix 452 272 Pediculated submucous fibroid . 454 273 Submucous fibroid which simu- lated Inversion . . . 456 276 Carcinomatous nodule . . 464 279 Carcinoma of cervix uteri pro- ducing fistula .... 467 281 Vertical mesial section of pelvis in carcinoma vaginae et uteri . 468 284 Cauliflower excrescence growing from cervix uteri . . . 477 286 Carcinoma of the cervix leading to occlusion of os uteri . . 481 287 Mode of the spreading of carci- noma 486 295 Uterus extirpated for cancer of body 500 296 Carcinoma of the body of the uterus 501 297 Sarcoma uteri with tumours in vagina 504 299 Section of sarcoma uteri, showing fibroid nodules . . . 505 300 Sarcoma uteri invading Fallopian tubes 506 303 Atresia vaginse, seen from behind 513 304 Case of double atresia . . 514 305 Atresia hymenalis . . . 517 306 Atresia vagiiice lower third . 517 307 Atresia of cervix at os externum 518 308 Atresia of cervix at os internum 518 311 Atresia in a septate uterus . 523 317 to 321 Normal development of external organs of generation . 541 322, 323 Spurious hermaphroditism . 542 324 Abscess of the Bartholinian gland 548 326 Central rupture of the perineum 556 332 Hernial nature of prolapsus uteri 566 345 Posterior vaginal enterocele . 579 346 Dysmenorrhosal membrane laid open 588 353 Caruncle at urethral orifice . 606 355 Large stone extracted by vaginal lithotomy . . . .612 356 Chief varieties of urinary fistula 616 357, 358 Deep and superficial vesico- vaginal fistulse . . . 616 360 Relation of peritoneum to a fistula 618 395 Rectocele . ... 640 CLASSIFIED LIST OF ILLUSTRATIONS. PATHOLOGY -MICROSCOPIC. PLATES IX. [ Foulis' cells, from ascitic fluid in malignant ) facing p. 217 and X. j tumour of ovary . . . j p. 224 PLATE XII. Fig. 3, Section of cervix with simple erosion p. 303 PLATE XIII. Mucous Membrane of Uterus in Eiido- metritis . . . . ,, p. 316 PLATE XIV. Microscopic Sections of Sarcoma of Vagina, and of Epithelioma of Clitoris and Labia at p. 536 Fig. Page 124 Cellular bodies the source of ovarian cysts .... 216 125 Diseased blood-vessels in ovary . 217 126 Epithelial tubes the source of ovarian cysts .... 218 127 Colloid degeneration of ovarian stroina 218 130 Papillae of ovarian cyst wall . 220 131 Round-celled sarcoma from der- inoid cyst .... 221 132 Cells from ovarian fluid . . 222 134 Cancer of ovary . . . .223 135 Spindle -celled sarcoma of ovary . 224 136 Alveolar sarcoma of ovary . . 224 184 Papillary form of erosion . . 303 185 Follicular form of erosion . . 304 186 True iilceration of the cervix . 305 187 Healing of catarrhal patch . . 310 192 Hypertrophied glands in en- dometritis .... 316 193 Mucous membrane in endome- tritis fungosa .... 317 194 Dilated blood-vessels in endome- tritis . 318 Fig. Page 195 Granulation from endometritis composed of embryonic tissue . 319 199 Section of uterine tissue in chronic metritis 270 Section of a mucous polypus of the cervix .... 275 Cancer of the vaginal portion 275*Cancer of the cervix proper 277 Section of a portion of cervix uteri with carcinomatous no- dule 278 Section of a flat cancroid of the cervix 285 Scraping from carcinoma of the cervix ..... 298 Section of mucous membrane in sarcoma ..... 301 Scraping from a fibroid tumour . 302 Scraping from a spindle-celled sarcoma 312 Granular vaginitis acute form . 313 Granular vaginitis chronic form 314 Colpitis emphysematosa . 316 Section of vaginal cyst 335 451 463 463 465 466 479 505 509 509 526 526 526 534 CHARTS OF ETIOLOGY. Fig. Page 221 Influence of age on development of fibroid tumour . . . 414 282 Influence of sex on development of carcinoma .... 471 Fig. Page 283 Influence of age on development of carcinoma . . 473 GYNECOLOGICAL EXAMINATION. PLATE VII. Female cadaver in semiprone posture . facing p. 109 ,, VIII. Female cadaver in semiprone posture, with Sims' speculum passed and uterus drawn down with volsella . . . ,, p. 110 Fig. Page 96,97 98 (54, 6;") Right hand in Bimanual 66 Left hand in Bimanual 67 Displacement of pelvic floor and abdominal wall in Bimanual . 99 68 Right hand in abdomino - recto- vaginal examination . . 102 71 Uterus drawn down by volsella . 107 77 Method of holding Sims' speculum 110 85 First stage of passing sound . 117 86 Second stage of passing sound, in retroverted uterus . . 118 87 Proper contrasted with improper method of turning the sound . 119 Fig. Page 88 Second stage of passing sound with uterus to the front . . 119 89 Sound arrested in anteflexion . 120 90 Sound combined with Bimanual 122 95 Introduction of tangle tents . 129 138 Area of dulness in ovarian tumour and ascites . . . 232 204 Diagnosis between fibroid and anteflexion .... 3o4 212 Diagnosis of retroflexion by Bimanual .... 368 230, 231, 232 Diagnosis of inversion and polypus in vagina . . 391 CLASSIFIED LIST OF ILLUSTRATIONS. Fig. Page 233, 234 Diagnosis of partial inver- sion and intra-uterine polypus 392 235 Uterine polypus + In version . 393 253 Sound used to detect pediculated submucous fibroid . . 423 Fig. Page 305, 308 Diagnosis of various forms of atresia . . . 517, 518 352 Catheterisation of ureters . . 603 396 Use of anal speculum . . 641 397-399 Diagrams for case-taking 673, 675 INSTRUMENTS. Fig. Page 55 Callipers for measuring pelvic floor projection ... 66 69 A. R. Simpson's volsella . . 105 70 Hart's volsella . . . .106 72 Sims' Tenaculum . . .107 73, 74 Sims' speculum . . . 109 75 Bozeman's speculum . . . 109 76 Battey's speculum . . . 109 78 Fergusson's speculum . . Ill 79, 80 Neugebauer's speculum . 112 81 Barnes' crescent speculum . . 113 82 Cusco's speculum . . . 113 83 Sir J. Y. Simpson's sound . . 115 84 A. R. Simpson's sound . .116 91 Laminaria tents before and after expansion .... 126 92 Tupelo tents before and after expansion .... 126 93 Tupelo tent extended . . 127 96 Tait's dilators .... 130 97 Hanks' dilator . . . .131 97AHegar's dilator . . . .131 98 Recamier's curette . . . 132 99 Simon's scoop .... 133 100 Thomas' curette, modified by A. R. Simpson . . .133 101 Martin's curette . . . .133 102 Bozeman's scissors . . . 135 103 Kuchenmeister's scissors . . 166 104 Hart's scissors .... 136 105 Emmet's needles . . .137 106 Needle-holder . . . .137 107 Higginson's syringe . . . 137 108, 109 Vaginal douche . . .138 110 Fritsch's catheter for washing out the interior of the uterus . 139 111 Cones for cautery . . . 141 112 Chloroform drop-cork . . 143 139 Spencer Well's trocar . . 240 140 Ordinary trocar .... 240 141 Nelaton's forceps . . . 241 142 Spencer Wells' clamp . . 241 156 Schultze's dilator . . .270 157 Marion Sims' dilator . . . 270 158 Sir J. Y. Simpson's metrotome . 271 162 Glass plug for cervical canal . 272 163 Conical excision of cervix . . 273 1 73 Rake for removing sutures . . 285 198 Sir J. Y. Simpson's porte- caustique .... 328 205 Greenhalgh's intra-uterine stem 355 Page 358 359 375 375 375 378 207 Graily Hewitt's cradle-pessary 208 Thomas' anteversion pessary 216 Hodge pessary .... 217 Albert Smith Pessary 218 Side view of Albert Smith pessary 221 Hodge pessary insituad naturam 222 Position and support of pessary illustrated .... 223 Position and action of pessary in vagina 224 Schultze's pessary 225 Meadow 's compound stem pessary 254 A. R. Simpson's nail-curette for fibroids 258 Pean's curved needle for ligatur- ing pedicle of fibroids 259 Cintrat's serre-noeud . 260 Keith's clamp for pedicle of fibroids ..... 261 Kaltenbach's needle for elastic ligature . . . . 274 Forceps with catch for mucous polypi 288 Simon s sharp spoon . 289 Chain ecraseur .... 309 Perforated glass plug used after operation for atresia vaginas . 310 Breisky's instruments for operat- ing in atresia with retention . 315 Henderson's vaginal spatulfe 333 Greenhalgh's pessary with trans- verse bars .... 334 Ring pessary with diaphragm 335 Simple elastic ring pessary 336 Ring pessary in situ . 337 Zwanck's pessary 349*, 350 Simon's urethral specula . 351 Skene's urethral specula . 354 Skene - Goodman self -retaining catheter 364-66 Knives for operating on fistulas 367 Sponge-holder .... 368, 369 Sir J. Y. Simpson's tubular needle and method of use 372-73 Bozeman's fork and method of use .... 626-627 377 Bozeman's suture adjuster . . 629 378-79 Coghill's wire - twister and method of use .... 629 389, 390 Sims' stationary catheter . 632 396 Anal speculum .... 641 379 380 381 381 430 435 436 437 438 458 488 489 521 522 528 570 ~>70 570 571 571 601 602 611 024 624 625 OPERATIONS. Fig. Page 123 Staffordshire knot . . .211 161 Bilateral division of cervix with Kuchenmeister's scissors . 272 163 Conical excision of cervix . . 273 167 Sims' method of passing the sutures after amputation of cervix . 282 Fig. Page 168 Marckwald's method of splitting and stitching the cervix in amputation .... 283 169 A. R. Simpson's method of ampu- tating the cervix . . . 284 170, 171 Introduction of sutures in amputation of cervix . . 284 CLASSIFIED LIST OF ILLUSTRATIONS. XXXlll Fig. Page 172 Hegar's method of passing the sutures 285 177 Amputation of hypertrophied cervix in proplasus uteri . . 289 180 Emmet's operation denuded surface ..... 298 181 Denuded surface as made by Emmet 298 182 Emmet's operation introduc- tion of sutures . . . 299 183 Emmet's operation tying of sutures ..... 300 188 Forceps dressed with cotton wad- ding for applications to cervical canal 311 189 Barnes' speculum for introducing vaginal tampons . . . 311 190, 191 Schrreder's excision of cer- vical mucous membrane . . 313 19lAj\fartin's method of excising the mucous membrane of the cervix ..... 314 196 Sound dressed with wadding for intra-uterine applications . 326 197 Curetting of uterus ... 327 206 Sims' division of cervix, lines of incision ..... 356 213 RepositioTi of retroflexed uterus by finger in rectum . . . 370 214 Reposition of retroverted uterus with the sound . . . 372 215 Reposition of xiterus with vol- sella, and finger in rectum . 374 219 Introduction of pessary . . 376 220 Pessary carried on by finger . 377 229 Drawing-down of inverted uterus with tape - noose and lines of incision for Barnes' opera- tion 390 236 Reposition of inverted iiterus with the hand . . . 395 237 Reposition of inverted uterus with White's repositor . . 396 238 Reposition of inverted uterus with finger in bladder and rectum 397 239 Emmet's method of retaining partially replaced uterus with sutures ..... 397 240 Cup with stem for gradual reduc- tion of inversion . . . 399 255 Martin's operation for enuclea- tion of fibroid from wall of uterus ..... 431 256, 257 Supra - vaginal amputation of uterus for fibroid tumour 433, 434 262 Extra-peritoneal treatment, with elastic ligature, of pedicle of fibroids 438 263 Mode of sewing-up stump in extra-peritoneal treatment of pedicle 439 264, 2646 Mode of suturing walls and peritoneum round stump . 440 290 Chain ecraseur applied to cervix in amputation .... 490 Fig. Page 291 Schroeder's supravaginal ampu- tation of cervix . . . 492 292 Sims' method of removing carci- nomatous cervix . . . 493 293, 294 Vaginal extirpation of the uterus .... 495, 496 327, 328, 329 A. R. Simpson's opera- tion for complete rupture of the perineum . . 558, 559 330aLawson Tait's operation for tear of perineum .... 560 3306, 330cOperation for rupture into anus ..... 560 330^Coronal section through anus . 560 331 Emmet's operation for ruptured perineum .... 562 335 Introduction of ring pessary . 570 338-341 Operation for repair of peri- neum .... 572-574 342 Various forms of raw surface made on posterior vaginal wall in operation for prolapsus . 575 343 Raw surface as made by Martin 576 344 Raw surface on anterior vaginal wall, as made by Sims . . 577 349 Emmet's button-hole operation on the urethra . . . 598 357 Closure of superficial vesico-vagi- nal fistula .... 616 358 Closure of deep vesico-vaginal fistula 616 360 Relations of peritoneum to ex- tensive fistula .... 618 361 Simon's method of paring edges of fistula 621 362 Sutures passed to close fistula . 623 363 American and German methods of paring edges of fistula con- trasted 623 369 Passing of thread with tubular needle 625 370 Knife transfixing edges of a fistula 626 371 Fistula closed with sutures . 626 372, 373 Fork used to prevent sutures from cutting . . . 626, 627 374 Counter - pressure made with blunt hook . . . .627 375-379 Method of twisting sutures 628-629 376 Mode of tying wire sutures . 629 380-381 Bozeman's method of fixing sutures with plates and shot . 629 382, 391 Removal of sutures . 629, 633 383-384 Closure of a four-cornered fistula 630 385 Anterior lip of cervix used to close fistula .... 630 386 Anterior lip divided to close-in vertically a fistula . . . 631 387 Obliteration of cervical canal for vesico-uterine fistula . . 631 388 Operation for atresia urethrae in fistula 632 392-393 Simon's operation for closure of vagina : kolpokleisis 634, 635 396 Division of base of an anal fissure 641 PART I. ANATOMY, PHYSIOLOGY, AND METHODS OF EXAMINATION OF THE FEMALE PELVIC ORGANS. Section I. Anatomy and Physiology of the Female Pelvic Organs. ,, II. Physical Examination of the Female Pelvic Organs. SECTION I. ANATOMY AND PHYSIOLOGY OF THE FEMALE PELVIC ORGANS. TN order to give a comprehensive idea of the Anatomy and Physiology -^ of the Female Pelvic Organs, it will be advisable to consider them in the following manner. CHAPTER I. General Anatomy of External Genitals and Contents of Pelvis. CHAPTER II. The Sectional Anatomy of the Female Pelvis. CHAPTER III. The position of the Uterus and its Annexa, and the relation of the Superjacent Viscera. CHAPTER IV. The Structural Anatomy of the Pelvic Floor ; Pelvic- Floor Projection. CHAPTER V. The Blood-vessels, Lymphatics, and Nerves of the Pelvis. Development of Pelvic Organs. CHAPTER VI. Physics of the Abdomen and Pelvis, with special refer- ence to the Semiprone and Genupectoral Postures. CHAPTER VII. Ovulation and Menstruation. CHAPTER I. GENERAL ANATOMY OF. EXTERNAL GENITALS AND CONTENTS OP PELVIS. LITERATURE. EXTERNAL GEXITALS. BallantyneThe Labia Minora and Hymen : Edin. Med. Jour., Nov. 1888, p. 425. Budin Recherches sur 1'hymen et 1'orifice vaginal : Paris, 1881. Garrard Beitrag zur Anatomie und Pathologie der Kleinen Labien : Ztschrift fiir Geburtshiilfc and Gynakologie, Bd. X., Hft. 1. Matthews Duncan Papers on the Female Perineum : Churchill, London, 1880. F. P. Foster A Contribution to the Topographical Anatomy of the Uterus and its Surroundings : Am. J. of Obst., Vol. XIII., p. 30. Garrigues The Obstetric Treatment of the Perineum : Am. J. of Obst., Vol. XIII., p. 231. Hart, D. Berry "Note on the Naked-eye Anatomy of the Female External Genitals : Ed. Med. Jour., 1882. Atlas of Female Pelvic Anatomy, Edinburgh, 1884. Henle Handbuch der Eingeweidelehre des Menschen : Braunschweig, 1866. Klein The External Genitals of the Male and Female, by E. Klein : Strieker's Manual of Human and Comparative Histology, Vol. II. (Syd. Soc. Tr., 1872). Klein and Smith Atlas of Histology : Smith, Elder, & Co. London, 1880. Sutton On the Nature of the Hymen : Brit. Gyn. Jour., 1888. MUSCLES OF PELVIC FLOOR. Cunningham The Dissector's Guide ; Abdomen : Mac- lachlan & Stewart, Edinburgh, 1880. Doran A Dissection of the Muscles of the Female Pelvis and Perineum : Lond. Obst. Tr., 1886, 274. Henle op. cit. Luschka Die Musculatur am Boden des weiblichen Beckens : Wien, 1861. Savage Female Pelvic Organs, 2d Edition : London, 1870. Turner An Introduction to Human Anatomy : A. & C. Black. UTERUS, AND ANNEXA ; ORGAN OF ROSENMU'LLER AND GARTNER'S CANALS ; VAGINA. Barnes The Diseases of Women ; London, 1878. Breisky Die Krankheiteii der Vagina : Billroth's Handbuch, Stuttgart, 1879. Coe The Anatomy of the Female Pelvic Organs : Amer. Syst. of Gynecology, Vol. I., p. 95. Cruveilhier Traite d'Anatomie Descriptive : Paris, 1871. Engelmann The Mucous Membrane of the Uterus: Am. J. of Obst., Vol. VIII., p. 30. Farre The Uterus and its Append- ages : Todd's Cyclopaedia, Vol. V. Hart Structural Anatomy of Female Pelvic Floor : Maclachlan & Stewart, 1880. Henle op. cit. Hennig Der Katarrh der inneren weiblichen Geschlechtstheile : Leipzig, 1862. Kiistner Das untere Uterinsegment und die Decidua cervicalis : Jena, ]882. Munde Prolapse of the Ovaries : American Gynecological Transactions, Vol. IV., 1879. Rainey On the Structure and Use of the Ligamentum Rotundum Uteri : Lond. Phil. Tr., 1880, p. 515. Rieder Ueber die Gartner'schen (Wolff'schen) Kanale beim menschlichen Weibe : Virch. Archiv. Bd. 96. (This paper gives literature and references to papers by Gartner, Dohrn, Freund, and others.) Ruge and Veil Zur Pathologie der Vaginal Portion : Stuttgart, 1878. Sappey Traite d'Anatomie Descriptive : Paris, 1873. Schroedei Handbuch der Krankheiten der weiblichen Geschlechtsorgane : Leipzig, 1879. Taylor Gastro-Hysterectomy, or the Recent Modification of the Caesar ean Section, by Dr Porro : American Journal of Medical Science, Vol. LXXX., p. 115. Turnei op. cit. BLADDER. H. J. Garrigues Remarks on Gastro-Elytrotomy : Am. Gynecol. Tr., Vol. III., p. 212. Polk, W. M. Landmarks in the Operation of Laparo-Elytrotomy : N. Y. Med. Jour., May 1882. Skene Diseases of the Bladder and Urethra : New York, 1870. The Anatomy and Pathology of Two Important Glands in the Female EXTERNAL GENITALS. 3 Urethra : Am. J. of Obst., Vol. XIII. Winckel Die Krankheiten der weiblichen Harnrohre und Blase : Billroth's Handbuch, Stuttgart, 1877. RECTUM. Braune Topographisch-anatomischer Atlas, Zweite Auflage : Leipzig, Veit and Co. , 1872. ChadivickThe Function of the Anal Sphincters so-called : Am. Gyn. Tr., Vol. II., p. 43. Hart Physics of Rectum and Bladder : Edin. Med. Jour., 1882. Otis Anatomical Researches on the Human Rectum : Leipzig, 1887. Pirogoff Anatome Topographica etc. sectionibus per corpus humanum congelatum : Petropoli, 1859. Ruedingei Topographisch-chirurgische Anatomie des Menschen : IV. Abtheilung. Symington Rectum and Anus : Jour, of Anat. and Phys., XXIII. PERINEAL BODY Hart, Henle, Savage, op. cit. Ranney The Female Perineum : New York Med. Jour., Vol. XXXVI., Nos. 1 and 2. T. G. Thomas The Female Perineum ; its Anatomy, Physiology, and Pathology : Am. J. of Obst., Vol. XIII., p. 312. PERITONEUM AND CELLULAR TISSUE. Bandl Die Krankheiten der Tuben, der Lagamente, und des Beckenperitonaums : Stuttgart, 1879. Barnes St. George's Hospital Re- ports, Vol. VII., p. 57. Freund Anatomische Lehrmittel zur Gynakologie : Beitrage zur Geburtshulfe und Gynakologie. Herausgegeben von der Gesellschaft fur Geburtshiilfe in Berlin, IV. Band, 1 Heft. S. 58. Guerin Sur la Structure des Ligaments Larges : Comptes Rendus, 1879, 1364. Le Bee Contribution a 1'etude des Ligaments Larges (au point de vue de 1'anatomie et de la pathologic) : Gaz. Hebd., 15 Avril 1881. Von Preuschen Ueber Cystenbildung in der Vagina : Virchow Archiv. Bd. 70. De Sinety Gynecologic : Paris, 1880. Spiegelberg Remarks upon Exudations in the neighbourhood of the Female Genital Canals : German Clinical Lectures (New Syd. Soc. Tr.), p. 169. Braune, Cunningham, Hart, Pirogoff, op. cit. EXTERNAL GENITALS AS OBSERVED CLINICALLY. UNDER the term external genitals are comprised the structures known External as Labia Majora, Fourchette, Labia Minora, Clitoris with its prepuce, Genitals - Vestibule, and Fossa Navicularis. For clinical convenience the urethral orifice and hymen also are described with these ; although the urethral orifice belongs to the urinary system, and the hymen separates anatomi- cally the external genitals (vulva) from the vagina. The Labia Majora (fig. 1, a) are two thick folds of hair-clad skin, Labia extending from the symphysis pubis backwards between the thighs, and |ora " meeting each other nearly in the middle line and about 2.7 cm. (1 inch) in front of the anus ; their blunted posterior ends can be seen most distinctly in the foetus. Each labium has an outer and inner surface, and consists of a thick fold of skin enclosing a quantity of fat, blood- vessels, and dartos. Superiorly, where they are best developed, they form by their junction anterior commissure the structure known as the mons veneris (vide Plate IV.) ; while posteriorly they are a mere fold of skin known as the Fourchette or posterior commissure. The fat and connective tissue are almost entirely wanting at the fourchette, which is not a distinct structure but may be the posterior junction of the thinned-out labia minora or labia majora. Both labia majora are, in the adult, covered with crisp hair which is abundant over the mons veneris and outer surface but very much less so on the inner. The Labia Minora (fig. 1, b) are two small oblique folds of skin, one Labia on the inner surface of each labium majus. Posteriorly each blends ora> insensibly with the labium majus at about its middle, while anteriorly 4 ANATOMY OF PELVIS. they converge and each divides into two small branches an upper and a lower. The upper branches meet to form the prepuce of the clitoris (fig. 1, e), while the lower in a similar way form its suspensory ligament. As a rule the labia minora do not, in the adult, project beyond the labia majora. Sebaceous glands are present on both labia. Microscopically FIG. 1. EXTERNAL GENITALS OF VIRGIN, with Diaphragmatic Hymen. The Labia Majora and Minora are drawn apart, and the prepuce drawn back. The cadaver is in the lithotomy posture. (Modified from Sappey.)^ a Labium majus ; & Labium minvis ; c Vestibule just above urethral orifice ; d Glans clitoridis ; f Praeputium clitoridis ; /Mons Veneris. (}) the labia minora have the structure of skin and Carrard has found in them Meissner's corpuscles which are nerve end-organs found only in the papillae of skin. As above stated, the labia minora may be con- tinued into the fourchette. The Clitoris, covered by its prepuce, lies in the middle line and at the apex of the smooth piece of mucous membrane known as the vestibule. Only that part analogous to the glans penis is seen (fig. 1, d). The clitoris proper consists of two crura which arise from the rami of the EXTERNAL GENITALS. 5 ischium and pubes and unite superiorly to form the body of the clitoris, which lies beneath the mucous membrane. The glans clitoridis is not directly continuous with the body, but joins it through the pars inter- media of the bulb (vide post, p. 10). The Vestibule (fig. 1, c) is a triangular smooth mucous surface bounded Vestibule, superiorly by the clitoris, laterally by the labia minora, and inferiorly by the upper margin of the vaginal orifice. In the middle line, at its base, the dimple of the urethral orifice can be distinctly felt 1 inch (2 2.5 cm.) in front of the fourchette. Small depressions and mucous glands open on its surface. The Vaginal Orifice lies in the middle line between the base of the Vaginal . r* *" vestibule and the fossa navicularis. Its orifice is guarded by the hymen, a thin fold of mucous membrane enclosing some connective tissue, blood-vessels, and nerves (?). The hymen may be crescentic in shape, attached to the posterior margin of the vaginal orifice and with a free Orifice. FIG. 2. VERTICAL MESIAL SECTION OF EXTERNAL GENITALS (Henle). a Anus ; 6 Perineal body ; c Vagina ; d Urethra ; e Labium Minus ; / Prepuce of Clitoris ; g Fossa Navicularis, with Hymen in front and Fourchette behind. (}) edge towards the base of the vestibule (figs. 2 and 5) ; or diaphragmatic, attached all round the vaginal orifice but with a small hole (figs. 1 and 4) or vertical slit (fig. 3) in it. Sometimes it is not so perforated, constituting a pathological condition. The point as to whether the Hymen belongs developmentally to the external genitals or vagina is disputed. Budin believes that the hymen is simply the thinned-out inferior margins of the anterior and posterior vaginal walls. One specimen we have examined certainly supports his statement that the vaginal columns run on the inner aspect of the hymen. Matthews Duncan has pointed out the interesting fact that in atresia vagina the hymen may be present, i.e. may be present although the vaginal walls are absent. More recently Pozzi has 'described cases of mal-development of the sexual organs, and brought out some interesting facts. One case was that of a male hypospadiac with external genitals simulating a female type, i.e. with a pseudo-vulva, a distinct hymen, and a fourchette. Pozzi found a ridge passing from the base of the glans penis, encircling the meatus urinarius and becoming continuous with the hymen : this he terms the male 6 ANATOMY OF PELVIS. vestibuLir band. In a female with atresia vaginse he found a similar band passing from the clitoris, surrounding the urethral orifice, and blending with the hymen. He advances the view that the hymen is vulvar in its origin and alleges that in women the ' ' male veatibular band" can be seen on careful examination. In the hypospadiac already described this band was the remnant of the corpus spowjiosum, so that he believes the hymen to be the analogue of the bulb in man. Recent papers by Ballantyne and Button support the view that the hymen is vulvar in its origin. Ballantyne has also confirmed Pozzi's view. Fossa Navicularis. Normally, the inner aspect of the fourchette is in contact with the outer and lower surface of the hymen. When the fourchette is pulled back by the finger, a boat-shaped cavity is made the fossa navicularis. Its posterior boundary is, therefore, the inner aspect of the fourchette ; its anterior is the posterior aspect of the hymen. These two are in contact unless artificially separated (fig. 2). From behind forwards, in the female ano-vulvar region there lie in the middle line the following structures. (1.) Anus. (2.) Skin over base of Perineal Body. (3.) Fourchette. (4.) Fossa Navicularis. (5.) Vaginal orifice, with Hymen or its remains. (6.) Urethral orifice. (7.) Vestibule. (8.) Clitoris with its prepuce. Laterally, we have the labia majora and minora. FIG. 3. FIG. 4. FIG. 5. HYMEN OF VIRGIN, with Vertical Slit. ({) HYMEN with Oval Opening. (}) CRESCENTIC HYMEN. (}) The following points should be carefully noted. In the nude erect female only the mons veneris is seen, and the labia majora and minora lie in a plane nearly parallel to the horizon. The well-developed labia majora have their inner surfaces always in contact, and are only slightly separated by the widest divergence of the knees. The labia minora are PELVIC FLOOR AS A WHOLE. 1 always in contact, and require to be artificially separated in order to see their inner surfaces. The fossa navicularis only exists when artificially opened up. Therefore, to see the external genitals fully, the labia must be separated and the prepuce drawn back. A line running as follows separates mucous membrane from skin. Starting from the base of the inner aspect of the right labiuni minus, it passes doivn beside the base of the outer aspect of the hymen, up along the base of the inner aspect of the left labium minus, in beneath the prepuce of the clitoris, and down to where it first started from. The vulvar slit is sagittal, and lies in the middle line between the labia majora and minora. The vaginal orifice is transverse, only exists when artificially made, Hymen, and is anatomically defined by the hymen which separates the external genitals from the internal genitals. The sharp line between skin and mucous membrane can be distinctly seen on the living subject. The labia minora are skin, thin and fine, and not mucous membrane as often alleged. The following measurements by Foster are useful for reference : Tip of Coccyx Anus to Anus. to Fourchette. Average distance in nulliparae, . . 4 '5 cm. . .2*7 cm. ,, ,, multipart, . . 4 '7 cm. . . 2 '5 cm. Meatus urinarius, 2 2 '5 cm. from fourchette, in nulliparae; 2 3'1 cm., in women who have borne children. The virginal vaginal orifice should have the appearances shown at figs. 1, 3, 4, and 5, and the free edge of the hymen should be intact. In a healthy woman who has experienced complete coitus, the hymen is torn or often only stretched. It admits two fingers without pain. In a woman who has borne full-time children, the vaginal orifice is always torn, although the fourchette and all behind it may be intact. The carunculse myrtiformes are probably the remains of the hymen. In addition, the passage of the child's head may cause tears of the posterior vaginal wall, perineal body, or even anterior wall of anus. THE PELVIC FLOOR AND ORGANS RESTING ON IT CONSIDERED AS A WHOLE. The outlet of the bony female pelvis is filled in by what is generally described as the 'soft parts.' This term, however, should not be employed, as it is misleading, especially in scientific obstetrics. It is better named the pelvic floor or pelvic diaphragm. The pelvic floor is a thick fleshy elastic layer, dovetailed all round Pelvic to the bony pelvic outlet (fig. 6). It may be considered as an irregularly-edged segment of a hollow sphere, with an outer skin aspect and an inner peritoneal one. On the outer skin aspect lie the external genitals already described. On the inner peritoneal surface we have 8 ANATOMY OF PELVIS. the organ known as the uterus, and its appendages the Fallopian tubes and ovaries. The vagina runs, in the erect female, at an angle of about 60 to the horizon from the vaginal orifice upwards to the mouth of the FIG. 6. BONY PELVIC OUTLET, with transverse line showing Rectal and Urethral Triangles (D. J. Cunningham). (\) womb, as a transverse slit in the pelvic diaphragm. In front of the vagina lies the bladder, while behind it the rectum is placed; these structures, along with muscles, connective tissue, blood-vessels, nerves, and lymphatics, making up the pelvic diaphragm. Figure 1 shows, accordingly, the pelvic floor seen from its convex, skin aspect ; fig. 50 gives it and the organs resting on it as viewed from its concave, peritoneal side ; while fig. 32 displays it as seen in sagittal mesial section. THE PELVIS CONSIDERED IN DETAIL. PELVIC FLOOR DISSECTED FROM BELOW. If a female cadaver be placed in the lithotomy posture and a trans- verse line drawn just in front of the ischial tuberosities, the perineal region will be divided into a posterior rectal triangle and an anterior urethral one (fig. 6). The former contains the anus, the latter the external genitals. The fascia of the pelvic floor and its relations demand a few words here. (1.) The superficial fascia. (2.) The deep layer of the superficial fascia. (3. ) The triangular ligament in two layers. (1.) The superficial fascia lies beneath the skin, and is simply the continuation over the pelvic floor of the general superficial fascia of the body. (2.) The deep layer of the superficial fascia has the following attachments : Laterally and above, it is joined to the pubic arch ; while posteriorly it passes round the trans- FERINE AL MUSCLES. verse perineal muscles to join the base of the anterior layer of the triangular ligament. If air be injected beneath this deep layer, its passage is limited by the attachments given, and a sac is made the pudendal sac. Into this sac an inguinal hernia may push its way, and in it the round ligaments of the uterus end. (3.) The triangular ligament consists of two layers of fascia, filling in the pubic arch. They are termed anterior and posterior. The following table may be omitted at present, imtil the whole anatomy is mastered. Between skin and superficial fascia. Between deep layer of superficial fascia and anterior layer of tri- angular ligament. ( Supfl. haemorrhoidal vessels and nerves. ( Supfl. perineal artery and nerve. Transversus perinei. Bulbo-cavernosus. Erector clitoridis. Transverse perineal blood-vessels and nerves. Venous plexuses. Bulbs of vagina. Pudendal sacs. Dorsal artery and vein of clitoris. / Compressor urethrae. Between the layers of the triangular j Vagina in part. ligament. , Urethra-in part. (v. also p. 11.) (Pudic vessels and nerves. By suitable incisions the skin and superficial fascia can be removed Ischiorectal around the anus, and the ischiorectal fossa defined. This is a small 08sa ' FIG. 7. DISSECTION OF PERINEAL REGION (Sarape). a is just above Trans versus Perinei ; 6 Base of Perineal body ; c Bulbo-cavernosus ; d lies on Levator Ani and in Ischiorectal Fossa ; e Erector Clitoridis ; / Bulb of Vagina ; g Bartholinian Gland ; h Vestibule ; j Glans Clitoridis. (\) pyramidal cavity on each side of the rectum, bounded externally by the 10 ANATOMY OF PELVIS. Muscles beneath superficial fascia (deep layer). Bulbi Vaginre. obturator interims muscle, internally by the levator ani. Its apex is formed by the junction of these muscles, while its base is partially closed in by the transversus perinei and the edge of the gluteus maxi- mus muscle (fig. 7). If axial- transverse sections of the fossa be made (PI. II. fig. 2, and PI. III. fig. 2), \ve see that it is merely the passage of the subcutaneous fat between the gluteus maximus, levator ani, and obturator internus muscles. The gluteus maximus forms the posterior and inferior boundary. On transverse sections from before backwards it can be noted that its boundaries vary. At the level of the ischial tuberosity it is bounded as follows : inside, levator ani ; outside, lower half of obturator internus ; while the gluteus floors it in incompletely. About an inch posterior to the tuberosity, we find the boundaries change as follows : inside, we have still the levator ani ; outside, a small portion of the obturator internus ; while the gluteus maximus floors it in completely. At the posterior margin of the fossa, the levator ani is the inner and upper boundary, the gluteus maximus the outer and lower, the fossa here being quite below the level of the obturator internus. If the skin and superficial fascia be now removed from the urethral triangle, the following muscles, etc., will be exposed (fig. 7). Perineal muscles. On each side of the vaginal orifice three muscles lie, viz., the bulbo-cavernosus (fig. 8, b c), erector clitoridis or ischio-cavernosus (fig. 8, e c), and trans- versus perinei (fig. 8, t p). The Bulbo-cavernosi consist of two muscular slips, one on each side of the vaginal orifice, which spring behind from the perineal body and pass round the vaginal orifice, partially covering the bulb and the vagina (fig. 7, c). The anterior end of each slip splits into three portions which end as follows : One passes to the under surface of the corpus cavernosum of the clitoris, a second goes to the posterior surface of the bulb, and a third blends with the mucous membrane between the clitoris and urethral orifice (Henle, v. fig. 9). The Erector Clitwidis arises from the inside of the ischial tuberosity and is inserted into the back and sides of the crus clitoridis (fig. 9, e ). The Transversus Perinei arises from the ramus of the ischium, and passes to the perineal body. It is difficult to define practically in dissection (fig. 7, a). Now that these muscles have been described, we are in a position to localise more important structures. The Bulbi Vaginae, (corpora cavernosa urethrse) are small masses of erectile tissue about the size of a bean, lying one on each side of the vaginal orifice and partly under cover of the bulbo-cavernosus muscle. Each rests on the triangular ligament, and has internally the mucous membrane of the vagina ; while, as already said, they are partly covered by the bulbo-cavernosus muscle. Anteriorly each blends with PERINEAL MUSCLES. 11 its fellow, and this pars intermedia becomes continuous with the clitoris (fig. 7,/>. The Bartholinian Glands lie one on each side of the vaginal orifice Bartho close to the posterior end of the bulb, and in front of the posterior layer Q^^ S of the triangular ligament (figs. 7, g, and 10, e). Each has a long duct opening at the sides of the hymen. Ranney asserts that these glands lie behind the posterior layer of the triangular ligament. Between the lower one-third of the posterior wall of the vagina andP e " neal FIG. 9. Symphysis Pubis, showing muscles in connection with Clitoris and Bulb. The Clitoris, c, c", is cut across near its point, and thrown down with the vestibulary mucous membrane (Henle). e Erector Clitoridis ; / Bulbo-cavernosus with its three insertions ; d Branch to Dorsal Vein of Clitoris. (}) the anterior wall of the rectum, is an angular interspace (fig. 2, &) filled up by the structure known as the perineal body. This will be more fully described afterwards. At the present stage of the dissection only its base is seen, with the following muscles taking origin from or having an insertion into it, sphincter ani, transversus perinei, bulbo-cavernosus, levator ani (fig. 7). Between Between the layers of the triangular ligament lie the urethra, a portion layers of of the vagina, compressor urethrfe, dorsal vein of the clitoris, internal ligament. 12 ANATOMY OF PELVIS. pudic vessels and nerves, the artery to bulb, dorsal nerve of clitoris, and Bartholinian glands (Cunningham). The dissection of the urethral triangle has now been considered until the bladder has been exposed as it lies behind the pubes, from which it is separated by a considerable amount of loose fatty tissue. In order to complete the consideration, we have now to take up the muscles not yet described, viz., levator ani, coccygeus and the obturator internus. FIG. 10. OBLIQUE SECTION, parallel to the Anterior Pelvic Wall and through the External Genitals (Henle). a Vagina ; 6 Urethra ; c Corpns Cavernosum Clitoridis, covered by its Erector ; d Bulbus Vaginae covered by Bulbo-cavernosus Muscle ; e Bartholinian Gland. THE PELVIC FLOOR DISSECTED FROM ABOVE. The pelvic floor must now be looked at from its internal concave or peritoneal aspect. If the peritoneum and connective tissue beneath it, with the nerves and blood-vessels, be removed on one side of the pelvis, say the right, the two muscles known as the coccygeus and levator ani will be exposed. These spring from the middle of the inner side of the true pelvis and, blending partly directly and partly indirectly with one another, form what may be termed the diaphragmatic muscles of the pelvic floor. If looked at through the pelvic brim, they are seen to form on both sides a concave arrangement analogous to the thoracic diaphragm (fig. 11). Ooccygeus. The Coccygeus springs from the spine of the ischium and is inserted into the side of the lower part of the sacrum, and side and front of coccyx. There are two coccygei, one on each side (figs. 11 and 12). Levator The Levator Ani has an extensive origin. It springs in front from *" the back of the body and horizontal ramus of the pubes, from the pelvic fascia (white line) and the spine of the ischium. From this the muscle sweeps downwards and inwards to become attached in the middle line from before backwards as follows, to the vagina, the rectum, its fellow PELVIC MUSCLES. 13 of the opposite side, and finally to the tip of the coccyx (fig. 12). The pubic fibres blend "with the posterior half of the upper border of the sphincter vaginse " (Doran). The levator ani can act on the vagina, elevating it, and is also believed to aid the sphincter ani (v. PI. II. and III.). The Obturator internus has the following Origin : deep surface of obturator membrane except at its lowest part fibrous arch completing canal for obturator vessels and nerves ; and surface of true pelvis bounded above by iliopectineal eminence, posteriorly by great sciatic notch, inferiorly by ischial tuberosity (vide PI. III.). Its relations are well FIG. 11. DISSECTION OF PELVIS from above (Savage), a Sacrum ; 6 Urethra ; c Vagina ; d Rectum ; e Levator Ani ; / Coccygeus ; g Obturator internus. (J) shown in axial-transverse sections (v. Chap. II. and PI. III.). In fig. 2, PI. III., its inferior half bounds the ischiorectal fossa ; its upper half, the bladder and levator ani. It can also be seen that it lies in relation to the broad ligaments, i.e. it bounds them where the peritoneal laminae diverge. 14 ANATOMY OF PELVIS. We have now to take up the consideration of the generative organs. It is difficult to describe these without alluding to structures not fully considered until further on. The student may, therefore, not entirely grasp some of the points until the whole anatomy of the organs has been mastered. Corpus Uteri. FIG. 12. LEVATOB ANI and COCCYGEUS seen from without, after removal of part of hip bone and clearing out of Ischiorectal Fossa (Luschka). a Fibres of Levator Ani on Vagina ; 6 Anus, with Sphincter. (J) THE UTERUS AND ITS ANNEXA. TheUtems. The Uterus is a triangular body, with a truncated apex downwards, placed between the bladder and rectum, and with the appearance seen at figs. 13 A and 14 B. In describing it we take up its external appearance, its nature on section, and its structure and relations. On external examination we find the parts known as the body (fig. 13, A, c), and neck (fig. 13, A, a, b). Keeping in mind its description as a triangle, we see the neck occupying the apex and the uterine orifices of the Fallopian tubes at the other two angles. Between the Fallopian tubes lies the fundus uteri. The anterior surface of the uterus is almost flat ; the posterior is convex at its upper part, as is well seen in fig. 13, B. Where the body passes into the cervix there is a slight depression noticed on the posterior surface. This corresponds to the isthmus. On making a vertical mesial section, we observe that the uterus is a hollow organ possessing a cavity with the anterior and posterior walls in apposition (fig. 13, .5). In order to see the cavity it is advisable to look at the uterus in coronal section, i.e., a section which, passing through the cavity, divides the uterus into an anterior and a posterior half, as shown in fig. 13, C, fig. 14, A. This latter section enables us more fully to understand the division of the uterus into body proper Cavity of Uterus. UTERUS AND ANNEX A. 15 and cervix, and the division of the uterine cavity into cavity of the FIG. 13. A. VIRGIN UTERUS (front view) (Sappey). The Appendages and Vagina are cut away. a Cervix (vaginal portion) ; 6 Isthmus ; c Body ; a 6 Cervix proper. B. The SAME in vertical mesial section. a is anterior surface, and lies just above where peritoneum passes on to bladder. C. The SAME with cavity exposed by coronal section. e Os Extei-num ; d Os Internum ; / Uterine Opening of Fallopian Tube, (jj) body proper and cervical cavity. FIG. 14. A. MuLTirARors UTERUS in coronal saction to show cavity. B. MULTIPABOUS UTERUS from front (Sappey). () 16 ANATOMY OF PELVIS. Cavity of Body. This is a triangular slit in the uterus with the apex downwards, and with anterior and posterior walls. At each angle there is an opening, viz., at the lower angle we have the os internum opening into the cervical canal (fig. 1 3, C, d), and at the upper angle the uterine openings of the Fallopian tubes (fig. 13, C, f). The lining of the cavity is known as its mucous membrane. Cavity of the Cervical Canal. This is spindle-shaped or conical (fig. 13, B, C), and has two openings, viz., os internum above and os externum below. The former opens into the uterine cavity, the latter into the vagina. The Cervix is divided into two portions, the vaginal and the supra- vaginal. The vaginal portion is within the vagina, and appears as a conical mass of the size and shape seen at fig. 13, A, a. The os externum is in virgins a mere dimple, and feels to the examining finger like the tip of the nose. In women who have borne children it is transverse (fig. 14, B\ and in most cases has its lips fissured more or less deeply, and the mucous membrane of the cervical canal partially everted. The supra- vaginal portion is continuous with the body through the isthmus. The length of the whole unimpregnated uterus is, speaking generally, about 3 inches; the length of the cavity of cervix and body about 2^ inches. Measurements with the sound on the living female are a little in excess of those obtained in sections on cadavera, owing probably to the sound's elongating the uterus somewhat. Length of uterus . Width .... Thickness Vertical diameter of cavity Transverse . . , , Virgin. 2'35 in. 1-50 0-85 1-80 0-60 Nulliparse 2 '50 in. 1-55 0-90 Length of entire organ in young women .... Do. body of uterus Do. cervix Do. vaginal portion of cervix .... Capacity of uterus in nulliparse = 2-3 c.cm. ; in multiparse 3-5 c.cm. Mnltiparae. 270 in. 1'70 1-00 Sappey. 2-44 in. 1-24 Richet. 5-6 cm. 3-3-5 2-3 55- '6 Hennig. Sappey. Various authors divide the cervix uteri more minutely as follows. of cervix They consider it as made up of a. a vaginal portion ; b. an intermediate portion ; c. a supravaginal portion. (Fig. 15.) STRUCTURE OF UTERUS. 17 This view is of importance in relation to the seat and extent of the changes in the size of the uterus in prolapsus uteri. The question as to the precise position of the os internum in the Position of unimpregnated uterus is at present much disputed. Kiistner, who n u m n ei has examined the point carefully, places the os internum at the narrow part where the lumen of the cervical canal becomes continuous with that of the uterine cavity proper. This part lies at the level of the isthmus uteri (v. fig. 16) and is also the point where the com- plicated uterine musculature passes into the simpler cervical muscular arrangement. The folds of the arbor vitse sometimes cease at this point but may pass above it or in multiparse may end below it. FIG. 15. DIAGRAM of UTERUS to show divisions of Cervix (Schroeder). a Vaginal portion ; 6 Intermediate portion ; c Supravaginal portion ; Bl Bladder P Peritoneum. The dotted line shows peritoneum. Kiistner also alleges that for i cm. (i in.) below the os internum as defined by him the cervical substance and mucous membrane are like that of the uterine body and that this special part of the cervical canal participated in the menstrual and pregnancy changes ; and he there- fore terms this the " inferior uterine segment," and speaks of a "cervical decidua." The os internum is believed by some to be at the level where the peritoneum passes on to the bladder. While the two great divisions of the uterus are the body and cervix, Lower it is of importance to keep in mind that in pregnancy we distinguish a special part of the body as the Lower Uterine Segment. It has the following characteristics : that the peritoneum is loosely attached over it, the muscular wall thinner there and the muscular bundles more separable ; further, it plays in labour a passive role, and comes to be marked off from the part above by a thickening in the wall known as 18 ANATOMY OF PELVIS. Body Cervix the contraction or retraction ring. We may show the relations of all the divisions in the following scheme : ( Upper Portion. (in pregnancy) j Lower Uterine Segment. I supra-vaginal portion. . -< intermediate ,, ' vaginal ,, Kiistner, as we have seen, speaks of the inferior uterine segment as cervical in origin. Structure Structure of the Uterus. If the uterus be viewed in vertical mesial of Uterus. sect i 011) it will be seen to be made up of three distinct elements, viz., peritoneum, unstriped muscular fibre, and mucous membrane (fig. 13, B.}. The peritoneum covers, partially, its external surface ; the mucous mem- brane lines the cavity of the body and cervix ; while the muscular fibre, by far the largest constituent, forms the tissue lying between these. Peritoneum The Peritoneum of the Uterus clothes its posterior surface (except of Uterus. the vaginal an d middle portions of the cervix), but only dips down Ligaments of Uterus. FIG. 16. CORONAL SECTION of UTERUS (Kustner). a. a. Uterine opening of Fallopian tubes ; o. i. Os internum ; o. e. Os externum. on the front surface as far as the isthmus, at which level it is reflected on to the bladder (fig. 13, JB, a). At the sides of the uterus the peri- toneum on the anterior and posterior surfaces runs out to the wall of the pelvis, thus forming the important structures known as the broad ligaments. The Ligaments of the uterus are Broad ligaments ; Round ligaments ; Utero-sacral and Utero-vesical. STRUCTURE OF UTERUS. 19 The broad ligaments are described under the peritoneum. (See p. 40.) The round ligaments are two in number. According to Rainey, each Round Ligaments. FIG. 17. DIAGRAM of Course of GLANDS of Mucous MEMBRANE OF UTERUS (Engeltnann). (*$) springs by three fasciculi of tendinous fibres the inner from the tendons of the internal oblique and transversalis, the middle from the superior FIG. 18. VERTICAL SECTION, through the Mucous MEMBRANE of the HUMAN UTERUS (Turner). Columnar Epithelium, the cilia are not represented ; gg Utricular Glands ; ct, ct Interglandular Connective Tissue ; vv Blood-vessels ; mm Muscularis Mucosae. (*$-) column of the external abdominal ring near its upper part, and the outer fasciculus from just above Gimbernat's ligament. These unite into a 20 ANATOMY OF PELVIS. rounded cord which crosses in front of the deep epigastric artery and passes between the layers of the broad ligament backwards, downwards, and inwards to the anterior and superior part of the uterus. Striped and unstriped muscle, blood-vessels, etc., are found in each. Utero- The utero-sacral ligaments are peritoneal folds, two in number, enclosing figments connective tissue and unstriped muscular fibre, passing from the lower, ' lateral part of the body of the uterus outwards and backwards towards the second sacral vertebra. They are known as the folds of Douglas, and form part of the upper, lateral boundaries of the pouch of Douglas. They are of the highest importance practically. The peritoneum, as it passes between uterus and bladder, constitutes the utero-vesical ligaments. Muscula- The Musculature of the Unimpregnated Uterus is of little importance in Gynecology, and needs only a passing notice. Three coats are FIG. 19. Mucous MEMBRANE of CERVIX in Microscopical Section (de Sinety). t Ciliated Columnar Epithelium, Cilia not shown ; g Glands ; in Muscular Fibre ; v Blood-vessels ; ct Connective Tissue shown only at one part of figure. (*f) described : a thin subperitoneal coat passing into the round ligaments, broad ligaments, utero-sacral and utero-vesical ligaments ; a middle coat ; and an inner concentric and very abundant layer which surrounds the Fallopian tubes, os externum, and os internum. The student should not forget that the arrangement of the muscular fibres is of the highest importance in practical obstetrics. Mucous The Mucous Membrane of the cavity of the body of the uterus is a of e uterua? tnin reddish-gray layer, about 1 mm. (^ T inch) thick in the unimpreg- nated but fully developed organ. It is set on the inner aspect of the muscular layer of the uterus without the intervention of any sub-mucous layer, is made up of ciliated columnar epithelium on a basis of connective tissue, and has numerous glands the utricular glands. On section and STRUCTURE OF UTERUS. 21 microscopic examination, the glands, lined by the ciliated epithelium, lying on a thin membrana propria, can be seen coursing down obliquely from the free surface and ending at the muscular fibre. Fig. 17 shows them perpendicular, but this is less correct, as Turner's drawing indi- cates (fig. 18). The glands usually bifurcate at their lower ends, and two may have a common mouth. The innermost layer of muscular fibre sends up prolongations between them muscularis mucosae. The connective tissue in which the glands are embedded consists of delicate round and spindle-shaped cells, the former being more abundant near the surface, the latter deeper. Fibrillated bundles of connective tissue lie also between the cells and pass out between the muscular fibre of the uterine wall (fig. 18). According to Leopold, the connective tissue is in the form of a plexus of fine bundles, covered with endothelial plates each with a nucleus. The spaces between these bundles form lymph sinuses. The mucous membrane lining the cervix is different in arrangement Mucous and structure from that lining the cavity of the uterus. It is thrown into numerous folds, presenting to the naked eye the appearance known as the arbor vitse, which consists of a longitudinal mesial ridge on the anterior and posterior walls, from both sides of which secondary ridges branch off obliquely. It is lined throughout with a single layer of epithelium (fig. 19), which is ciliated on the elevated portion of the ridges, but is columnar in the depressed portions (de Sinety}. The upper boundary of the arbor vitse vai'ies. The boundary lies about midway between os externum and fundus. Before puberty, the folds pass up into the cavity of the body. In multiparse, they do not pass up so far as in nulliparse (Kiistner). The glands are of the racemose type, and consist of elongated repeatedly- branching ducts, which extend deeply into the connective tissue, and are somewhat dilated at their extremities (Ruge and Veit}. They are lined by columnar epithelium, resting on a membrana propria, and open on the ridges and furrows of the mucous membrane. There is a sharp line of demarcation between this single layer of epithelium (columnar and ciliated) which lines the cervical canal and the epithelial covering of the external surface of the vaginal portion, and this line of demarcation corresponds in the adult to the os externum. Beyond the os externum, the epithelial covering has all the characters of skin ; it consists of vascular papillae covered with many layers of squamous epithelium. The vascular papillae are not easily recognised without the help of reagents (Ruge and Veit}. The epithelial cells are like those found in the skin, and dovetail into one another by denticulate edges (de Sinety}. It is a disputed question whether glands are present on the vaginal aspect of the normal cervix. De Sinety says he has never met with them 22 ANATOMY OF PELVIS. except in the neighbourhood of the os externum, and their occurrence there he attributes to an eversion of the mucous membrane of the canal. Ruge and Veit also consider the existence of glands as a pathological condition, which is, however, easily induced. The normal histology of the cervix uteri has an important bearing on the pathology of the so-called ulcerations and on laceration of the cervix and ectropium. FALLOPIAN TUBES. Fallopian The Fallopian tubes are two tubes, one on each side of the uterus, Tubes. ru nning sinuously from its upper angles out towards the side of the Isthmus. FIG. 20. VIEW from behind of the LATERAL ANGLE of the UTERUS, with part of the Left Broad Ligament, Fallopian Tube, Ovary, and Parovarium (Henle). a Uterus ; 6 Isthmus of Fallopian Tube ; c Ampulla ; y has Parovarium to the right, and Fimbriated end of Fallopian Tube and Ovarian Firnbria just below it ; d Parovarium ; e Ovary ; /Ovarian Ligament ; I Infundibulo-pelvic Ligament (}). The topographical relations are disturbed here. pelvis (figs. 20 and 50). They lie enclosed in the upper free margin of the broad ligaments, and vary in length from 10 to 16 cm. (4 to 6 inches). They are not of equal length, the right being frequently longer than the left. The Fallopian tube, the uterus lying to the front (anteverted), has been found by His to pass first outwards and then upwards over the ovary the fimbriated end lying on the posterior aspect of the ovary (PI. I. fig. 2). Three parts come up for consideration the isthmus, the ampulla, and the pavilion or fimbriated end. The isthmus is the straight narrow part of the tube (fig. 20, 6), which at its internal end opens into the uterine cavity, and has a lumen barely OVARIES. 23 admitting a bristle. On transverse section the diameter of the whole thickness is about 2 to 3 mm. The ampulla is the curved and thick part of the tube (fig. 20, c), Ampulla, having an average diameter of about 6-8 mm., with a lumen admitting the ordinary uterine sound. The free fimbriated end of the Fallopian tube is expanded and funnel- Fimbrise. shaped (infundibulum) ; and it is provided with primary and secondary fimbriae surrounding the opening of the tube to which they converge. One special fimbria runs to the ovary (fig. 20, g). On section the Fallopian tube is seen to be made up of three layers Structure from without inwards: viz., peritoneum, longitudinal and circular unstriped Jjj, ub g opiau muscular fibres (the latter being inner), and mucous membrane lined with ciliated columnar epithelium. Connective tissue and elastic fibres lie between the peritoneal and muscular layers. No glands exist in the mucous membrane which is much folded in a longitudinal direction, especially in the ampulla. It is remarkable that the ciliated epithelium lining the Fallopian tube and pavilion should be continuous with the squamous epithelium of the peritoneum ; and that, further, there is direct continuity between the vagina, uterus, Fallopian tubes, and peritoneum, so that the peritoneal sac in the female is not closed as in the male. Parovarium or Organ of Rosenmiiller. If the broad ligament be heldPar- between the light and the observer's eye, this rudimentary structure ov will be seen enclosed in its folds in the space between the ovary and ampulla (fig. 20, d). It consists of closed tubules lined with ciliated epithelium, which converge towards the ovary, and are united by a longitudinal one. In the cow and sow the longitudinal tube persists, extending in the latter animal from a point a little above the division of the uterus into its cornua down the side wall of the vagina and opening into the vagina at the sides of the urethral orifice. These are named Gartner's canals after their chief investigator, and they correspond to the vas deferens, etc., in the male. Beigel has shown that these canals may be found in the uterus of the human foetus, a statement verified by Kolliker, Dohrn, and others. According to Rieder, they may persist either as a closed muscular epithelium-lined tube or as a muscular bundle without epithelium. The epithelial lining consists of a single or double layer of cylindrical cells (cells^G^u. ) : this is surrounded by connective tissue and by three coats of unstriped muscular fibre (inner and outer longitudinal and middle circular). It may produce one form of cervical or vaginal cyst as was shown by Von Preuschen (v. chapters on Ovarian Pathology and Vaginal Cysts). OVARIES. The ovaries, two in number, lie one on each side of the uterus, pro- jecting markedly through the posterior layer of the broad ligament. Form, Size, and Relations. The ovary is a small oval-shaped body Ovaries. 24 ANATOMY OF PELVIS. about the size of an almond, the weight of which varies from 60 to 135 grains. According to Farre its measurements are as follow : Greatest Smallest Average Longitudinal Diameter. 2 in. 1 in. Ik in. FIG. 21. SECTION OF CAT'S OVARY (Schrijri). The free border of the ovary is, in the fig., above; the base of attachment li Hum below. The division into Cortical and Medullary Layers is indicated. Note smallest Giaafian Follicles at surface, and larger ones not so superficial. A Corpus Luteum lies to the left of the hilutn. (f). FIG. 22. SECTION through the CORTICAL part of the OVARY (Turner) The ovary has an anterior and posterior border, and an upper and lower surface. The posterior border is convex and free, the anterior OVARIES. 25 flattened and attached to the broad ligament. It should be noted that this anterior border is called the hilum, and that the blood-vessels and nerves enter there. The position of the ovary will be discussed afterwards (p. 57), but at present it is sufficient to consider it as lying behind the broad ligament suspended as it were by the infundibulo-pelvic ligament so that its long axis lies more or less parallel to the axis of the brim of the pelvis. Ligaments of the Ovary. In addition to the attachment which the Ligaments broad ligament gives to the ovary, two important ligaments are described the ovarian ligament and the infundibulo-pelvic ligament. The Ovarian Ligament (fig. 20, /) is about 3 cm. (li inch) long, and Ovarian extends from the inner end of the ovary to the corresponding upper lgam angle of the uterus, just below the uterine origin of the Fallopian tube. It is a longitudinal fold of the peritoneum into which the unstriped muscular fibre of the uterus is prolonged. The Infundibulo-Pelvic Ligament (fig. 20, I) is about 2 cm. long, andlnfun- runs from the outer end of the Fallopian tube to the side wall of thepe^" pelvis. It is simply that part of the upper margin of the broad ligament Ligament, unoccupied by Fallopian tube. The Ovarian Fimbria (fig. 20, g) prevents the separation of the ovary Ovarian and infundibulum tubse. Fimbria, Thus the ovary is kept in position by its attachment to the broad liga- ment, by the ovarian and by the infundibulo-pelvic ligaments. Its own specific gravity has also a share, i.e., the ovary floats at a certain level. Structure of the Ovary. The ovary is covered with epithelium differing Structure from the squamous epithelium of the peritoneum in being made up of Ovarv ' columnar nucleated cells with a dull lustre. It is continuous, however, with the peritoneal epithelium, the line of contact being marked by a whitish and elevated line. The epithelium covering the ovary is known as the germ-epithelium. This distinctive term is of importance in con- nection with the development of the ova, and will be more particularly alluded to afterwards. A tunica albuginea made up of condensed connective tissue has been described as lying below the germ- epithelium. On section and microscopical examination, the ovary is found to consist of connective tissue with the structures known as the Graafian follicles embedded in it, along with blood-vessels, nerves, lymphatics, and some unstriped muscular fibre. These are enclosed in the epithelial covering already described. The connective tissue is divided into a cortical and medullary layer ; the former lying beneath the peritoneum, the latter being at and near the hilum (fig. 21). The medullary layer is very vascular, and has some unstriped muscular fibre round the branches of the ovarian artery (fig. 22). 26 ANATOMY OF PELVIS. The Graafian follicles are scattered through the whole substance of the ovary. The following points should be carefully noted : a. The younger and smaller Graafian follicles lie in the cortical layer. Their diameter is generally about y^ in., and they exist in immense numbers. According to careful estimates, the ovary of a female infant may contain 40,000 to 70,000 such follicles. b. The larger follicles are much fewer in number and lie deeper in the ovary. Diameter ^-th to T J^th in. c. There are also still larger follicles nearer the surface than the latter. These have advanced from the deeper layer (vide under Men- struation). FIG. 23. A SECTION OF WHOLE VAGINA passing through Lateral Fornix ; and B SECTION OF UPPER THIRD passing through the Cervix Uteri (Hart). P. D. Pouch of Douglas ; ut Uterus ; o e Os Externum ; Vg Vagina ; p f P< a f Anterior Fornix ; V.u.p. Vesico-uterine Peritoneum ; Bl. Bl 'osterior Fornix ; Bladder. Structure of a Graafian Follicle. This consists of 1. A Tunica fibrosa and Membrana propria ; 2. The Membrana granulosa, a layer of nucleated columnar epithelial cells forming the discus proligerus at one part ; 3. Fluid the liquor folliculi. VAGINA. 27 The ovum (diameter y^y to j-^ in.) lies in the discus proligerus ; it has the following structure : 1. External envelope zona pellucida, a homogeneous membrane, 2. Yelk protoplasm, 3. Germinal vesicle ( T ^th in. diameter), 4. Germinal spot (^-(nnrth m - diameter). THE VAGINA. The vagina is a mucous slit in the pelvic floor, extending from the Vagina- Position. FIG. 24. ANTERIOR VAGINAL WALL AND MULTIPAROUS CERVIX, looked at from behind (Henle). a TJrethral Orifice ; 6 Anterior Vaginal Cohimn ; c Cervix Uteri. (|) hymen to the cervix uteri, and lying between the urethra and bladder in front and the rectum behind. In the upright posture it makes an angle of about 60 with the horizon, i.e., it is nearly parallel to the pelvic brim. The vagina has two walls, an anterior and posterior, which are con- Vaginal tinuous at their sides. The anterior vaginal wall is triangular in shape, WaUs - the base being above. Its lower limit is marked out by the hymen. 28 ANATOMY OF PELVIS. At its upper end it is reflected down to a small extent on the an- terior lip of the cervix uteri, the anterior fornix being thus formed (fig. 23). It is closely incorporated with the urethra, but between it and the posterior aspect of the bladder there is loose connective tissue. Its length is about 5 cm., i.e., 2-2^ inches. Vaginal The mucous membrane of the wall is arranged in folds roughly trans- Murnbrane verse - At its lower end is a vertical mesial single or double thickening of the mucous membrane, about 2 cm. long, known as the anterior vaginal column (fig. 24, b). This begins near the urethral orifice, or about 1| cm. above it. According to Budin, the columns are prolonged on the hymen. The posterior vaginal wall is triangular in shape, and extends from the vaginal orifice upwards to the cervix uteri, upon which it is reflected, FIG. 25. DIAGRAM OK VERBAL MESIAL SECTION OF FEMALE PELVIS, showing Sigmoid curve of posterior Vaginal Wall (Schultze). (J) thus forming the posterior fornix vaginee, which is deeper than the anterior one. Its length is about 7| cm. (3 inches) i.e., about 2i cm. (nearly an inch) longer than the anterior. It is also transversely rugous, and has a posterior column analogous to the anterior, but smaller. While the direction of the anterior vaginal wall is almost straight, that of the posterior vaginal wall is sigmoid (fig. 25). The curve varies, however, according to the position of the uterus and the fulness or emptiness of the adjacent bladder and rectum. VAGINA. 29 When the bladder and rectum are empty, we find the direction of the vagina parallel to the pelvic brim. When the bladder is distended, the vagina is, chiefly at its upper part, driven nearer the sacrum ; while, if the rectum be distended, the vaginal axis may be almost perpendicular. Stwicture of Vagina. The vaginal wall, on section and microscopical Structure examination, is found to consist of nrncous membrane, made up of epi- thelium (the superficial layer being squamous and nucleated, the deeper layer cylindrical and with elongated nuclei), connective tissue, elastic FIG. 26. HORIZONTAL SECTION OF THE PELVIC: FLOOR AT THE PELVIC OUTLET (Henle). Da Urethra ; Va Vagina ; R Anus ; L Levator Ani. FIG. 27. HORIZONTAL SECTION OP THE POSTERIOR WALL OF BLADDER AND THE ANTERIOR WALL OF THE VAGINA (Henle.) Epithelium of the Bladder ; 6 Mucosa ; c Layer of circular fibre ; d Layer of longitudinal fibres ; e Loose Tissue ; / Layer of circular fibres ; g Layer of longitudinal fibres ; h Mucosa ; i Epithelium of Vagina. (>f-) tissue, and some unstriped muscular fibre. The superficial layer of the connective tissue forms papillae, into which blood-vessels project. The epithelium is therefore ridged. External to this lie two layers of 30 ANATOMY OF PELVIS. unstriped muscular fibre; the inner longitudinal, the outer circular (Henle). Breisky alleges the inner to be circular. Von Preuschen has described glands in the vagina but they are very few in number. He found the ducts lined with squamous epithelium and the deeper part with ciliated epithelium the latter being continuous with the cylindri- cal deep cells of the vagina. Gland-like crypts and lymph follicles also exist (Lowenstein) (fig. 27). The whole is surrounded by loose connec- tive tissue, containing the outer venous plexus of the vagina (fig. 27). As already said, the vagina is a mere slit in the pelvic floor, although it is often erroneously described as a tube or cavity. On vertical section, as fig. 23 shows, it appears as a mere linear slit; while on trans- verse section it is H-shaped, or crescentic (figs. 26 and 44). The vagina is eminently dilatable and its walls separable, as will be more fully consi- dered under the structural anatomy of the pelvic floor ; but this dilata- tion or separation is the result of posture with manipulation, or of partu- rition. Under mere changes of posture the vagina retains its slit-like form. THE BLADDER. Position. The empty female bladder lies behind the pubes and in front of the vagina. We here consider the urethra and bladder. Urethra The urethra is a straight slit (some describe it as sigmoid) about If inches long, with thick walls closely incorporated with the anterior vaginal wall behind. It runs parallel to the plane of the pelvic brim. Its lower opening is known as the meatus urinarius, the position of which has been already considered in the section on the External Geni- tals ; its upper opening is at the neck of the bladder. On section and microscopical examination, its mucous membrane is found covered with squamous epithelium in its lower part ; while higher up it is like that Micro- of the bladder, and is very rich in elastic fibres. There is a double Structure, layer of unstriped muscular fibre, the longitudinal layer being internal and the circular outside ; and, according to Uffelman, a circular (inner) and longitudinal layer of striped muscle, which stretches from the neck of the bladder to within 6 in. (1^ cm.) of the meatus urinarius. Luschka also describes a special sphincter of the vaginal and urethral orifices. It should be further noted that the mucous membrane is folded longi- tudinally, and contains mucous glands lined with cylindrical epithelium, papillae, and lacunae, and also villous tufts near the meatus ; and that there is a submucous layer between the mucous membrane and un- Skene's striped muscle, containing many veins. Recently Skene of New York has described two tubules in the female urethra. They lie on each side (figs. 28 and 29), " near the floor of the female urethra, and extend up from the meatus urinarius for about inch They lie beneath the mucous membrane, and in the muscular walls of the urethra." We have in section of the female urethra : BLADDER, Mucous membrane ; Submucous layer ; Muscular layer, longitudinal and circular, unstriped ; do. do. striped (Uffelman). 31 FIG. 28. TRANSVERSE SECTION of URETHRA much enlarged (Skene). a Urethral Canal ; b b Glands described by Skene ; c Vein ; d Artery. FIG. 29. URETHRA LAID OPEN from above, showing glands with probes passed in (Skene). Bladder- Openings. Structure of Bladder. 3i> ANATOMY OF PELVIS. External to these, there is the anterior vaginal wall behind and loose tissue in front. According to Henle, the closed urethral slit is on section transverse near the bladder, sagittal at the rneatus, and star-shaped between these two points. In the bladder proper we have three openings the internal orifice of the urethra and the orifices of the two ureters. The latter lie one on each side, about 1 inches from the internal orifice. These openings give us the landmarks for the division of the bladder into neck, base, and body. All above the lines joining the ureteric openings and the centre of the symphysis is the body; all below is the base, and that portion between the ureteric openings and the internal orifice is the trigone. Just above the ureters is the bas fond. The wall of the bladder is made up of three layers, viz., a mucous, a muscular, and a peritoneal. The mucous membrane consists of connective tissue lined by several layers of transitional or multiform epithelium (fig. 30). It is arranged Ureters. FIG. 30 EPITHELIAL CELLS from the Mucous MEMBRANE of the BLADDER. Those in the upper row are the superficial squamous cells ; those in the lower row are the peculiar cells of the middle stratum (Turner). in folds, except over the trigone and openings. The folds or rugse are due to the laxity of the submucous coat. The muscular coat of the bladder is of the unstriped variety, and has a complicated arrangement. There are external longitudinal fibres, circular fibres within these, and an internal longitudinal layer on which rests the submucous coat. It is disputed whether there is a sphincter at the neck of the bladder. Probably there is not ; but the puckering of the mucous membrane at the neck is alleged to have a valve-like function. The peritoneal covering of the bladder will be considered subse- quently. The relations of the ureters are of importance with regard to inflammatory exudations, fistula), and excision of the uterus for cancer. SHAPE AND POSITION OF BLADDER. 33 To Freund and Joseph, Luschka, Garrigues, Holl, and Polk, we are indebted for anatomical researches as to the course of the ureter in the FIG. 31. RELATION OF URETER ON THE EIGHT SIDE OF A DISSECTED PELVIS (Holl). V Vagina ; C Cervix ; B Bladder ; Ur, Ur, Ureter. 1 Common iliac artery ; 2 External iliac artery ; 3 Internal iliac artery ; 4 Uterine artery ; 5 Pudic artery ; 6 External iliac vein. pelvis. We give Holl's drawing of the right ureter (fig. 31), and follow in the main his description, Its course may be conveniently described in four portions. (1. ) From the brim of the pelvis to the origin of the uterine from the internal iliac artery. About *6 inches (1J cm.) below the division of the common iliac artery into its external and internal branches, the Ureter passes over the external iliac vessels, and lies in front of the internal iliac artery and then in the space between the internal iliac artery and external iliac vein. So far, the portion described is at or about the level of the pelvic brim. The Ureter next passes down into the true pelvis, and at the origin of the obturator, vesical, and uterine arteries begins to describe a bow-shaped portion 3? inches (9 cm.) long, with the greatest convexity of the bow where the uterine artery crosses it. By this crossing, the bow-shaped portion of the Ureter is divided into an upper and a lower part. (2.) From the origin of the uterine artery to where the Ureter is crossed by it. This is the upper part of what is known as the bow- or spindle-shaped portion. (3.) From v:here the Ureter is crossed by the uterine artery to the bladdei the lower part of the spindle-shaped portion. C 34 ANATOMY OF PELVIS. Shape and Position of Bladder. The uterine artery as it crosses the Ureter is separated from it by a venous plexus. In this way, a distance of about if inch (1 cm.) separates Ureter and uterine artery at this point. At the level of the os uteri externum the uterine artery crosses the Ureter to reach the uterus, and at this point the Ureter is I inch (1J cm.) distant from the cervix. The course of this portion is of great importance. It is 1'6 inch (4 cm.) long, lies in relation to the side of the vagina, and then for the last two centimetres, before it pierces the bladder, lies between the anterior vaginal wall and the posterior wall of the bladder. The Ureter does not pass lower, therefore, than about the middle of the anterior vaginal wall. (4.) The portion piercing the bladder. The Ureter runs through the bladder wall obliquely downwards and inwards for from '6 to "8 inches (1'5 to 2 cm.). Shape of empty Bladder and changes in its position. The empty FIG. 32. VERTICAL MESIAL SECTION of FEMALE PELVIS, showing Y-shape of Bladder (Fa, -*t). a uterus, b bladder, c rectum. (!) SHAPE AND POSITION OF BLADDER. 35 female bladder lies completely behind the pubes, and has its fundus covered by peritoneum. When empty and viewed in mesial section it may present one of two shapes. In the large majority of specimens figured, it forms with the urethra a Y-shape on sagittal mesial section. The oblique legs of the Y may be about equal in size, or the posterior may be shorter (figs. 32, 38). This form is so common that it has been accepted hitherto by all authors as the normal one. In certain cases, however, but not in so many as the former, the empty bladder cavity forms with the urethra a continuous tube on vertical mesial section (fig. 33). In such cases, it is oval in shape, corrugated, and firm to the touch. This latter shape is the one always found in the lower animals, such as the rabbit and dog, and is the only one seen in the human foetus. If, therefore, the pelvic floor be viewed on its FIG. 33. VERTICAL MESIAL SECTION OF FEMALE PELVIC FLOOR, showing contracted bladder in a suicide (Untune). The peritoneum descends in front of the uterus to & and behind it to d ; b a and d c are loose extra-peritoneal tissue. (|) peritoneal aspect, the fundus of the empty bladder will be found to be very often large and concave, while in some cases it is small and convex. In the former case, the inner surface of the upper segment of the bladder, large in area, is in contact with the surface of the lower segment ; in the latter, the anterior and posterior walls, small in area touch one another. It is probable that when the bladder has the Y-shape on section, it is relaxed and empty (fig. 32) ; and when the oval shape (fig. 33), it has been caught in systole. The bladder contracts to expel the urine and then relaxes. Between the acts of urination the bladder is therefore only a flaccid sac. Some additional facts as to the position and disten- 36 ANATOMY OF PELVIS. tion of the bladder are best considered further on, under the structural anatomy of the pelvic floor. We may here state, however, that (1) when empty, in the non-parturient female, it is behind the pubes (fig. 40); (2) it is drawn above the pubes in the parturient female ; (3) it is tilted above the pubes in retroversion of the gravid uterus. RECTUM. The Rectum is not separated by any division from the sigmoid flexure, but may be denned as extending from the left sacro-iliac synchondrosis FIG. 34 a. RECTUM INFLATED (Chadinck). a 6 Sphincter tertius ; c Ampulla of Rectum. FIG. 34 b. CORONAL SECTION THROUGH ANUS (Symington). r rectum ; i internal sphincter ; e s external sphincter ; I a levator ani ; v vagina. to the anus. It curves downwards, backwards, and inwards, to about the third sacral vertebra. This is known as the first part of the rectum ; it is completely covered by peritoneum, which forms the mesorectum. The peritoneum is reflected from the rectum on to the upper part of the vaginal wall, about 3 inches above the vaginal orifice. Thereafter, the rectum lies in relation anteriorly to the posterior vaginal wall to which it is loosely attached until about 1 inches from the anus. The rectum is made up of peritoneal investment ; unstriped muscular fibre in two layers, longitudinal and circular, the former being the outer ; a submucous coat ; and a mucous lining with its muscularis mucosae, RECTUM. 37 columnar epithelium, no villi, but with Lieberkuhnian follicles closely set together. At the upper limit of the anus, the circular fibres are very Micro- well marked, and constitute the sphincter ani internus (fig. 35). Stmcture Certain oblique folds in the rectum consisting of mucous, submucous, Recturn - FIG. 35. PERPENDICULAR SECTION through the end of the RECTAL WALL enlarged (Ruedinger). 1 Mucous Membrane of the Rectum ; 2 boundary between Mucous Membrane and skin of buttock ; 3 Fat ; 4 Levator Ani ; 5 Sphincter Ani externus ; 9 Fibres of Longitudinal Layer separating external Sphincter into parts ; 7 Sphincter Ani internus ; 8 Longitudinal Fibres of muscular coat, which radiate outwards at 9 ; 13 Longitudinal Fibres of Muscularis mucosae which radi- ate outwards at 12 ; 11 Circular Fibres of muscular coat ; 6, 10, and 14 Slips of muscular fibre passing into tissue beyond. and circular unstriped muscular coats are of special interest. One exists li inches from the anus, another is near the sacral promontory, and one is intermediate (Turner). The lowest (the valve of Houston or sphincter ani tertius of Hyrtl) has been described by Chadwick of 38 ANATOMY OF PELVIS. lioston, as being not an entire circular fold, but made up of two semi- circular constrictions, one on the anterior wall, and one on the posterior an inch higher up (fig. 34 ). Anus. The Anus is that part of the rectum at its external orifice. It is about an inch long, and has its long axis directed backwards and cutting the axis of the vagina at about a right angle. The rectum, therefore, when in contact with the posterior vaginal wall closely follows its direction, but at a little above the anus turns sharply backwards. There is thus left between it and the last l^ inch of the posterior vaginal wall, an angular interspace to be filled up by the structure known as the peri- neal body. During life, the anus is closed by its sphincters in such a way that the lateral walls are in contact (Symington). This explains that the apparent gaping of the anus in sagittal mesial sections is approximately right (v. Plate I.), and that the appearance figured at page 67 is wrong. Fig. 35, from Ruedinger, shows the arrangement of voluntary and involuntary muscle in the anus. The division of the external sphincter into two parts, and the separation of the lower division (5) into compart- ments by fibres from the longitudinal unstriped layer (9), are noteworthy. Similarly the internal sphincter (7) is divided into compartments by fibres from the muscularis mucosae (13). Near the anal orifice the mucous membrane has certain perpendicular folds in it known as the Columnae Morgagni, with depressions between these the Sinus Morgagni (fig. 2, a). PERINEAL BODY. Perineal The posterior vaginal wall is in contact with the anterior rectal wall, for about li inches above the apex of the perineal body, there being only loose tissue between. The anus has its long axis directed back- wards, while the vaginal axis runs forwards ; we thus get a pyramidal space filled up by the structure known as the Perineal body (Henle and Savage). The Perineal body is made up of muscular insertions and origins (striped and unstriped), and fibrous and elastic tissue. Its base is covered by the skin lying between the anus and vagina ; its anterior side is in great part below the level of the posterior vaginal wall: its posterior side lies in front of the anterior rectal wall and anus ; while laterally, it is bounded by fat. The voluntary muscles passing into it are the sphincter ani, transversus perinei, bulbo-cavernosus, and levator aui (fig. 7). This Perineal body measures about li inches (4 cm.) vertically, the same transversely, and f in. antero-posteriorly. If a straight line be made to join the tip of the coccyx and the subpubic ligament, it will just clear the apex of this structure. PERITONEUM. 39 Its functions are important, but have been both exaggerated and underrated. It gives a fixed point for many muscles, prevents pouching of the rectum forwards, and strengthens that part of the pelvic floor which has no posterior bony support. Its special significance, however, will be considered further on. At present, the nomenclature in regard to the " Perineal region" is exceedingly vague the term Perineum being xised in this general sense by accoucheurs, especially in regard to the tears caused by parturi- tion. It is better to speak of these as tears of the hymen, fourchette, and perineal body, instead of saying "perineal tears." The surface between the anal and vaginal orifices is, strictly speaking, not the perineum but the "skin over the base of the perineal body" and "the fourchette." . ' PERITONEUM. This is the thin serous covering of the concave surface of the pelvic Pelvic floor and the organs resting on it. A knowledge of its disposition is e ^ of the highest importance to the gynecologist. This is best considered as follows. 1. The Pelvic Peritoneum followed in a Vertical Mesial Section and from before backwards. The Peritoneum of the anterior abdominal wall is reflected, at a point a little above the symphysis pubis, on to the fundus of the empty bladder (figs. 36 and 37). It passes downwards over the posterior surface of the bladder, from which it crosses on to the anterior surface of the xitems at a point about the level of the os inter- num. From this it passes up over the anterior surface of the uterus. Thus there is formed a vesico-uterine pouch, containing no small intestine Vesico- either when the bladder is in systole or in diastole (figs. 36 and 37). When the bladder has the Y- shape in pathological anteflexion, the peritoneum passes directly backwards across the fundus of the bladder and on to the anterior surface of the uterus at or below the level of the os internum (fig. 38). There is thus produced a utero- abdominal pouch (fig. 38). The peritoneum covers the whole of the anterior surface of the uterus above the os internum, passes over the fundus, and down the posterior surface which it covers almost completely. From this it descends still deeper, on to the posterior aspect of the posterior vaginal wall for about one inch (fig. 36). The depth of the peritoneal pouch thus formed behind the uterus is greater on the left side than on the right. The amount of its dip varies. In one section by Pirogoff (fig. 39) the peri- toneum runs down on the posterior vaginal wall till within about an inch from the vaginal orifice. This extent of posterior peritoneal duplicature is abnormal. This variation in depth is quite evident in sections : in some it ends at the level, of the posterior fornix (fig. 37), while in others it is seen passing as deeply as has been already described 40 ANATOMY OF PELVIS. (figs. 36, 39). This descent of the peritoneum behind the uterus is of Pouch of the highest importance practically, and forms the well-known pouch of Douglas. Douglag This pouch is best denned as follows: Its upper lateral boundaries are the utero-sacral ligaments ; its anterior boundary is the uppermost inch of the posterior vaginal wall and posterior aspect of the supra- vaginal portion of cervix ; its posterior boundary is the sacrum and rectum, covered by peritoneum. It is the lowest part of the peritoneal cavity, and from its relation to the posterior vaginal wall can be explored through the posterior vaginal fornix. It is partially filled by intestine when the uterus lies to the front, which becomes displaced when the uterus is retroverted or retroflexed. Broad 2. TJie Disposition of the Pelvic Peritoneum at the sides of the Uterus : Ligaments. -g rQa ^ Ligaments. At the sides of the uterus, the peritoneum clothing its anterior and posterior sxirfaces passes outwards and some- what backwards to the sides of the pelvis in front of the sacro-iliac synchondrosis. In this way we get two laminse of peritoneum nearly in apposition, which become more separated at their junction with the pelvic floor and sides of the pelvis ; the space between the laminse is, at its outermost part, in relation to the obturator internus muscle (v. Chap. II.). These are the broad ligaments of the uterus. Immediately within their upper free margin, the Fallopian tubes are placed. That part of the free margin not occupied by Fallopian tube forms the infundibulo-pelvic ligament of the ovary (figs. 20 and 50). Projecting through the posterior lamina of the broad ligament is the ovary, covered by its germ-epithelium. The ovarian ligament and parovarium have already been described under the ovary and Fallopian tube. Between the layers of the broad ligament lie connective tissue, un- striped muscle, blood-vessels, and lymphatics. According to M. Guerin, the broad ligaments enclose a small space shut off from the rest of the cellular tissue of the pelvis, and he denies that as yet there is proof of any special diagnosable inflammatory affection of the broad ligaments. Guerin alleges that, by inflation, it can be demonstrated that the broad ligaments are thus shut off a fact denied by other observers. The -position of the broad ligaments varies according to that of the uterus. When the uterus is normal in position, i.e., lying to the front, their posterior surfaces look upwards and somewhat backwards, and they run outwards and backwards as already described. Displacement of the uterus backwards causes their coincident displacement, and in pregnancy they are drawn up and lie almost vertically. Pathologically, they cicatrize after inflammatory attacks and cause unilateral deviations of the uterus. Peritoneum 3. The Pelvic Peritoneum on the side ivalls of the Pelvis. The pelvic watts of peritoneum clothes the side walls of the pelvis. It dips down least at Pelvis. the sides of the bladder, and most at the utero-sacral ligaments. FIG. 36. FROZEN SECTION showing Peritoneum (Fiirxt). The dotted line indicates Peritoneum in this and figs. 37-42. a Anus ; b Vagina ; c Bladder ; d Uterus ; e below pouch of Douglas ; / Symphysis Pubis. ({) FIG. 39. PERITONEUM DIPPING ABNORMALLY DEEP between Rectum and Vagina (Pirogoff). - g2 B o 2 <) 2 j a .. B S 2 fe o is o ^ P - ' o S g .. K N 00 O 3 Q > a Z S- 1^' CONNECTIVE TISSUE. 41 Although the pelvic peritoneum has been described in three sections, it must of course be kept in mind that it is a continuous membrane with no breaks in its continuity. Some special facts about the peritoneum should now be noted. 1. As to the Bladder. Over the bladder and anterior abdominal Relation to wall, the peritoneum is easily separable. According to Spiegel- an( j berg, posteriorly it is closely blended with the uterus above the Rectunu os internum, below this quite loosely attached. When the bladder is distended, the peritoneum is stripped off the lower part of the anterior abdominal wall to an extent varying with the distention (fig. 42). During parturition, the peritoneum is drawn off the bladder (fig. 41) (Hart). 2. As to the Rectum. Its upper part is completely invested by peri- toneum ; the second part is only partially covered, i.e., the peritoneum gradually leaves the rectum, quitting first the posterior surface, then the sides, and finally passing from the anterior surface on to the posterior vaginal wall. See also Chapter II. on The Sectional Anatomy of the Female Pelvis, and especially Chapter III., p. 57. Practical Points. Although the vesico-uterine pouch can be reached Peritoneum by a transverse incision through the anterior fornix, it will not be to opera- cut into in operations on the anterior vaginal wall. In the upper tions - third or so of the posterior vaginal wall the peritoneum may be opened into. This has indeed been done by the most skilful operators, but the risks attending it are not so considerable as usually alleged, especially when asepsis is secured. When the fingers are passed into the posterior fornix vaginse, only about ^ inch of tissue intervenes between them 'and the peritoneum. The possibility of there being a deep dip of the peritoneum, as shown at fig. 39, should not be forgotten in opera- tions on the posterior vaginal wall. CONNECTIVE TISSUE OF PELVIS. By this we understand (I.) the Fascia described so elaborately by the human anatomist as the Pelvic Fascia; and (II.) the loose Connective Tissue padding the interstices between the muscles, lying round the cervix uteri, and spreading out beneath the pelvic peritoneum. I. The Pelvic Fascia of the anatomist is carefully described in the Pelvic ordinary systematic and dissecting-room manuals, to which the student Fascia - is therefore referred (v. also p. 8 and Chap. II.). II. The loose connective tissue found lying subperitoneally, surround- Pelvic Con- ing the cervix uteri and spreading out between the layers of the broad Tissue. 42 ANATOMY OF PELVIS. ligament, is of the highest importance pathologically, as in it and in the pelvic peritoneum occur those inflammatory exudations so common in women. Of late years our knowledge of the disposition of this tissue has been rendered much more accurate, and accordingly our discrimination of pelvic inflammatory attacks made much more precise. Methods of The distribution and relations of the pelvic connective tissue may be studying s t u( jj ec i j n various ways. The most valuable information is obtained by considering sections of frozen or spirit-hardened pelves. This gives the precise position of the tissue, its amount, and distribution. Another valuable method of investigation is to inject air beneath the peritoneum, between the layers of the broad ligament, and at other points. By this we learn the varying attachments of the pelvic peritoneum to the sub- jacent tissue, and the lines of cleavage, as it were, of the pelvic con- nective tissue along which pus will burrow. Instead of air we may inject plaster of Paris or water ; plaster of Paris will be found the most useful. We therefore consider a. Kesults obtained by the injection of water, air, plaster of Paris ; I. Results obtained by section. a. Results obtained by injections of water, air, or plaster of Paris. The best summary of these results is given by Bandl, to whom on this point we are indebted for much valuable information. Connective Konig in his researches employed the bodies of women who had died vestigated a short time after labour from non-puerperal diseases, and injected air by injec- or water. The following briefly are his results tions. ,.. x TT7 . . . (1.) Water injected between the layers of the broad ligament, high up in front of the ovary, passed first into the tissue lying at the highest part of the side wall of the true pelvis. It then passed into the tissue of the iliac fossa, lifting up the peritoneum, and followed the course of the psoas, passing only slightly into the hollow of the iliac bone. Lastly, it separated the peritoneum from the anterior abdominal wall for some little distance above Poupart's ligament, and from the true pelvis below it. (2.) On injection beneath the base of the broad ligament to the side and in front of the isthmus, the deep lateral tissue became filled first; then the peritoneum became lifted up from the anterior part of the cervix uteri. The separation passed thence first to the tissue near the bladder, and ultimately the fluid passed along the round ligament to the inguinal ring. There it separated the peritoneum along the line of Poupart's ligament, and passed into the iliac fossa. CONNECTIVE TISSUE. 43 (3.) An injection at the posterior part of the base of the broad liga- ment filled the corresponding tissue round Douglas' pouch, and then passed on as described at (1.). Schlesinger has followed out these results in more elaborate researches. b. Results obtained by section. The Sectional Anatomy of the Pelvis has now become a subject of such importance that it demands consideration in a separate chapter. The student will find at pp. 46, 47, reference made specially to the dis- tribution of the connective tissue. CHAPTER II. THE SECTIONAL ANATOMY OF THE FEMALE PELVIS. LITERATURE. Barbour, A. H. /'.Spinal Deformity in Relation to Obstetrics : \V. & A. K. Johnston, Edinburgh, 1884. The Anatomy of Labour as exhibited in Frozen Sections : W. & A. K. Johnston, Edinburgh, 1889. Braune Topographisch-anatomischer -Atlas, Zweite Auflage : Veit & Co., Leipzig, 1872. Dwight Frozen Sections of a Child : Wood & Co., New York, 1883. Hart, D. Berry Atlas of Female Pelvic Anatomy : W. & A. K. Johnston, Edinburgh, 1884. Supplement to Atlas of Female Pelvic Anatomy : W. & A. K. Johnston, Edinburgh, 1884. Legendre Anatomic Homolographique : Paris, 1868. His Ueber Praparate zum Situs Viscerum, etc. : Arch, fur Anat., 1878. Die Lage der Eierstocke, Arch, fur Anat. 1881. Luschka Die Anatomie des menschlichen Beckens : Tubingen, 1864. Pirogoff Anatome Topographica sec- tionibus per corpus humanum congelatum, etc. : Petropoli, 1859. Rucdingcr Topo- graphisch - hirurgische Anatomic des Menschen : Stuttgart, 1873. Simpson and Hart The Relation of the Abdominal and Pelvic Organs in the Female : "W. & A. K. Johnston, Edinburgh, 1881. Veit Die Anatomie des Beckens : Enke, Stuttgart, 1887. Pirogoff and Braune's Atlases are the great storehouse of Sectional Anatomy. Accounts of the method of freezing are given by Braune, Barbour, and Simpson and Hart. WHILE dissections are valuable in ascertaining the anatomy of any region, it must be remembered that they involve displacement of relations and therefore may lead into error or exaggeration. These may be corrected and additional accuracy obtained by making sections of frozen bodies or parts of them. If a body or a pelvis be covered with mackintosh and embedded in a mixture of salt and finely pounded ice or snow, it will in three or four days become as firm and solid as marble, and may then be sawn in any direction necessary. Tracings of the sawn surface may be made while it is still frozen ; and in this way an accurate and trustworthy drawing may be obtained on which valuable measurements can be made. We have said that the sections may be sawn in any direction, but usually they are made in special and definite lines as follows : (1.) Sagittal Mesial, i.e. parallel to the sagittal suture so that the body or pelvis is divided into right and left halves ; (2.) Sagittal Lateral, i.e. parallel and to one or other side of the sagittal mesial plane; (3.) Transverse or Horizontal, i.e. at right angles to the long axis of the body, and with surfaces upper and lower ; PLATE I. FIG. 2. POSITION OF UTERUS AND OVARIES. FIG. 1. Sagittal Mesial Section of Pelvis (Hart). FlO. 2. Fundus Uteri and Ovaries Seen through the Pelvic Brim (His). SAGITTAL LATERAL SECTION. 45 (4.) Coronal, i.e. parallel to the coronal suture dividing the body or pelvis into anterior and posterior portions with surfaces anterior and posterior ; In sections of the pelvis alone, the axis of the brim is taken instead of the long axis of the body. We have therefore the following : (5.) Axial coronal, i.e. a section cut parallel to the axis of the brim and from side to side, with sawn surfaces anterior and posterior ; (6.) Axial transverse, i.e. at right angles to the axis of the brim and with surfaces therefore upper and lower. We now take up the consideration of certain special sections. 1. Sagittal Mesial Section. Plate I., fig. 1, shows a frozen sagittal mesial section of the pelvis with Sagittal the uterus in position, the bowel and bladder naturally empty and the s c ^, n> small intestine removed from the pouches so as to display the Fallopian tube and ovary. This section brings out the following facts : the uterus is not mesial but displaced somewhat to the left ; the empty bladder is Y-shaped in sagittal mesial section ; the urethra, vagina, and rectum are nearly parallel to one another and to the conjugate of the brim ; the anus cuts these axes at right angles. The intestines have been removed from the Pouch of Douglas and vesico-uterine pouch. The nearness of the anterior abdominal wall to the promontory of the sacrum is well shown. The Perineal body is seen in section, and it should be noted that the greater part of it lies below the Hymen. Those Gynecologists who exaggerate its functions usually draw it as being entirely behind the lower part of the posterior vaginal wall. Plate I. and fig. 23 shows that it does not do this. The student should note the peritoneal relations. Plate I. also shows the relations of the Fallopian tube and ovary. When freshly cut, the intestines filled the peritoneal cavity ; but after the section had been hardened in spirit, these were carefully lifted out so as to expose the ovary and Fallopian tube. The ovary lies with its long axis vertical, as His has pointed out. The preparation bears out his views completely with regard to the position of the ovaries, for on the other side of the body the ovary had its long axis somewhat transverse ; and he has found that when the uterus was laterally displaced the ovary of the side towards which the uterus was displaced lay vertical while the other ovary was somewhat transverse. In this cadaver the uterus lay to the left side and it is the left ovary which has its long axis vertical. The Fallopian tube does not form a loop enclosing the ovary as His found in his specimens (Plate I. fig. 2). 2. Sagittal Lateral Section. Sagittal By this section a specially valuable view is obtained. Fig. 43 shows Section. 46 ANATOMY OF PELVIS. a drawing of a section at the junction of the uterus and broad ligaments ; in it, although the pubes is divided mesially, the pelvic contents are cut to one side of the mesial plane. It should be noted that the amount of Connective retropubic tissue is less than in the sagittal mesial one ; that at the June- Tissue of tion of the broad ligaments with the uterus there is a large amount of Laments, tissue with large blood-vessels ; and specially that the finger placed in the lateral fornix vaginas touches the base of the broad ligament there. FIG. 43. SAGITTAL MESIAL SECTION OF PELVIS cutting at Junction of Broad Ligament and Uterus. y any means. Schultze's "Pathological anteflexion," so commonly caused by utero-sacral cellulitis (v. also chap, on Displacements of the Uterus). w3n of The P^ion of the uterus, with empty bladder and rectum, is such ; lies with its anterior surface touching the posterior aspect of the POSITION OF UTERUS. 55 bladder, no intestine usually intervening ; the os externum uteri looks downwards and backwards : and the uterus is slightly twisted as a whole on its long axis, so that the uterine end of the right Fallopian tube is nearer the symphysis than that of the left. We have expressly said with bladder and rectum empty. According to Schultze, the long axis of the uterus is nearly parallel to the horizon. This is probably exag- gerated, as Schultze's researches were conducted in a way that certainly FIG. 49. SECTION of FEMALE CADAVER (Pirogojf). a Vagina ; 6 Uterus ; c Bladder. Note Bladder in diastole, Uterus parallel to horizon, and shallow dip of Douglas' Pouch. anteverted the uterus unduly (figs. 25 and 47). Many authors figure the uterus nearly vertical to the horizon, for this purpose distending the bladder until the uterus is elevated to what they consider the proper angle (fig. 48). It is needless to say how absurd this is. Kohlrausch's 56 ANATOMY OF PELVIS. diagram, so often quoted in support of this allegation, really shows, if it show anything, the position of the uterus when the bladder is well distended. The student should note this point, as Kohlrausch's section is the favourite diagram of those who treat as pathological what is really a normal uterus. Fig. 49, from Pirogoff, shows a frozen section support- ing Schultze's contention. J. FIG. 50. FEMALE PELVIS and CONTENTS viewed through the Pelvic Brim (Hasse). y. Para vesical Pouch ; u Uterus; o Ovary ; t Fallopian Tube; d Pouch of Douglas; v~?, V?* , Dou 8 las ' l P Infundibulo-pelvic Ligament ; I r Bound Ligament ; p u Powtion of Ureter ; I o Ovarian Ligament ; r Rectum ; c Colon. [t is important to know how results as to the uterine position have been obtained. The chief methods are as follows : a\ 7} * . . ) By frozen, spint-hardened, or chromic-acid sections. Results tained in this way are valuable, if we make allowance for some post- nortem change in the uterine position not yet thoroughly understood. POSITION OF UTERUS. 57 (2.) By the bimanual examination of the pelvic contents. This is pro- bably the best method, although it exaggerates the normal anteversion of the uterus in a way that will be readily understood when the chapter on the Bimanual has been studied. (3). By the use of the sound, or by a more elaborate means described by Schultze. Space does not permit of a full description of the latter, but a good account of it is given in Foster's paper. THE LOCAL DIVISIONS OF THE PELVIC-FLOOR PERITONEUM AS VIEWED THROUGH THE PELVIC BRIM, AND THE POSITION OF THE UTERINE ANNEXA. For valuable papers and sections on this subject, we are indebted to Hasse of Breslau, Ruedinger of Munich, and His of Leipzig (fig. 50 and Plate V.). Hasse froze not quite thoroughly a female cadaver in the upright posture, cut through the abdomen transversely, and then lifted out the softened viscera until the pelvic contents were exposed undis- turbed. The bladder was moderately distended. , the Brim. FIG. 51. POSITION of FUSDCS UTERI and lie of OVAEIES. Bladder distended (Schultze). Fig. 50 shows Hasse's drawing. The fundus of the uterus lying Pelvic on the bladder is well seen. In front of the broad ligament of which ^seen the infundibulo-pelvic ligament is the only portion visible in fig. 50 through we have, on each side, the paravesical pouch of the peritoneum. Behind it, lies the lateral pouch of Douglas; while just behind the uterus and bounded on each side by the utero-sacral ligament is the pouch of Douglas proper. The Fallopian tubes lie in the true pelvis, in the paravesical pouch. Each broad ligament sweeps outwards and backwards to near the sacro-iliac synchondrosis of its own side. The position of the ureter is well indicated. 58 ANATOMY OF PELVIS. l>inrtic.n of OvarieB. According to Hasse the long axis of each ovary runs outwards and forwards, forming with the transverse axis of the uterus an angle open to the front. Part of each ovary (the half) projects above the plane of the pelvic brim. Schultze figures the ovaries as having their long axes almost antero-posterior (fig. 51), and His in his cases found the long axes nearly vertical. In recent sections, the authors found the ovary lying nearly vertical as His describes (v. PI. I.). The long axis of the ovary on the side to which the uterus is displaced is nearly vertical, while the ovary of that side from which the uterus is displaced is more transverse (v. page 22, and PI. I., fig. 2). r> FIG. 52 TTERUH. A with bladder and rectum empty; B, C, D according to distention of bladder (V anile Wark-er). THE PHYSIOLOGICAL CHANGES IN THE POSITION OF THE UTERUS. The mobility of the uterus is one of its most characteristic features. 'ery movement of respiration, in singing, in walking, and in 1'l.ATU IV. SURFACE-VIEW OF ABDOMEN AND THORAX ; THE SECTION IS SEEN AT PLATE V. 1. Right Hyi>ochon(iriac. 4. Right Lumbar. 7. Right Iliac. 2. Epigastric. :.. rmbilicul. 8. Hypogastric. 3. Left Hypochondriac. (5. Left Lumbar. 9. Left Iliae. Hit jin.y Callipers. 9-15 8-27 9-75 Mode of measuring pelvic- poor pro- jection. Schroeder's deduction is that the average projection of the pelvic floor beyond the plane of the pelvic outlet is 4'1 cm. There is no doubt that this is an excessive average. F. P. Foster of New York has written ably on this subject, and made a large series of observations. Fig. 55 shows the callipers he FIG. 55. CALLIPERS for measuring PELVIC-FLOOR PROJECTION (Foster). employed. The ends of the limbs (a and b) are placed on the tip of the coccyx and lower border of the symphysis pubis. respectively. The horizontal bar between these limbs is graduated in cm., and the limb (a) glides along it in a groove. A movable upright (c), also gradu- ated, has its upper point placed against the most projecting part of the pelvic floor. If now the whole apparatus be removed and laid flat on a sheet of paper, the conjugate and amount of projection can be read off at once. Greater accuracy is ensured by noting, before removing the apparatus, the point on the transverse bar at which the upright (c) stands as well as the reading which it gives. Foster's average (2 '5 cm.) of the pelvic-floor projection is less than PELVIC-FLOOR PROJECTION. 67 Schroeder's. He placed the patient semiprone, however ; a position in which the pelvic-floor projection is slightly diminished. Fig. 56 shows Foster's diagram of pelvic-floor projection. The uterus is more ante- verted than in Foster's original drawing. Measurements made on frozen sections must be used with caution. Schroeder has justified his average by such measurements, but has taken no account of the existence of pregnancy in some of the cases. Summary FIG. 56. DIAGRAM of PELVIC- FLOOR PROJECTION and position of uterus, modified from foster. The anterior and posterior walls of the anus are not in apposition, as shown in the diagram. We might tentatively advance the following statements : (1.) The pelvic-floor projection is over-estimated by Schroeder; (2.) Foster's average is nearer the mark ; (3.) The retropubic fat gives a rough index of the position of thejection. pubic segment (figs. 39, 40, 47) ; (4.) The pelvic-floor projection is increased by advanced and even by early pregnancy (Braune's Plates). The whole inquiry needs further investigation in order to settle also other points, among which we may mention the relation of the vagina to the pelvic outlet and the varying amount of pelvic-floor projection in different postures. CHAPTER V. THE BLOOD-VESSELS, LYMPHATICS, AND NERVES OF THE PELVIS: DEVELOPMENT OF PELVIC ORGANS. LITERATURE. BLOOD-VESSELS. Henle Handbuch der Eingeweidelehre des Menschen : Braunschweig, 1866. Hyrtt Die Corrosions-anatomic und ihre Ergebnisse : W. Braumiiller, "\Vieii, 1873. Klein and Smith's Atlas. Luschka Die Musculatur am Boden des weib- lichen Beckens : Wien, 1861. Quain Anatomy, 8th Ed. : London, 1882. Sappey Traite d'Anatomie Descriptive : Paris, 1873. Savage Female Pelvic Organs, 5th Ed. : London, 1882. Tail, Lawson The Pathology and Treatment of Diseases of the Ovary, p. 8. : Birmingham, 1883. J. Williams On the Circulation in the Uterus, with some of its Anatomical and Pathological Bearings : Obstet. Soc. of London, 1885. LYMPHATICS. Bouryery and Jacob Trait6 Complet de 1'Anatomie de 1'Homme : Paris, 1839. Championnttre Lymphatiques Uterines et Lymphangite Uterine : Bull, de la Soc. Med. des Hdpitaux de Paris, Vol. VII. Curnow The Lymphatic System and its Diseases : Lancet, 1879. Klein The Anatomy of the Lymphatic System : London, 1873. Le Bee Contributions ;\ 1'Etude des Ligaments larges, etc. : Gaz. Heb., 15 Avril 1881. G. Leopold Die Lymphgefasse des normalen nicht schwangeren Uterus : Archiv fur Gynak., Bd. VI., S. 1. W. T. Lusk Puerperal Fever : International Congress Tr., Philad., 1877. Sappey, Savage Op. cit. NERVES. T. Snow Beck The Nerves of the Uterus : Phil. Tr., 1846. Flower Diagrams of the Nerves of the Human Body : J. and A. Churchill, London, 1872. Franken- hdusei Die Nerven Der Gebarmutter und ihre Endigung in den glatten Muskel- fasern : Jena, 1867. Jastrebow On the normal and pathological Anatomy of the ganglion cervicale uteri : Lond. Obstet. Trans., 1881. R. Lee The Anatomy of the Nerves of the Uterus : London, Bailli^re, 1841. Tiedemann Tabulze Nervorum Uteri : Heidelberg, 1822. DEVELOPMENT OK THE PELVIC ORGANS. Foulis The Development of the Ova, and the Structure of the Ovary in Man and the other Mammalia : Tr. E. S., Edin., Vol. XXVII. Klein and Smith, Quain, Turner Op. cit. BLOOD-VESSELS. Preliminary Remarks: The blood supply to the pelvic organs and perineum is derived from the ovarian arteries (which are branches of the abdominal aorta), and from the uterine, vaginal, and internal pudic arteries (which are all branches of the anterior division of the internal iliac). We shall first consider the arterial supply of the uterus, ovary, Fal- lopian tubes, vagina, bladder, rectum, and that of the perineal region ; and then the venous distribution. Arterial supply to ARTERIAL SUPPLY. Uterus and ,, , . . . <>..>. (1.) Arterial supply to uterus, ovary, etc. The Ovarian artery of each fl.ATK VI . BLOOD-VESSELS. 69 side (corresponding to the spermatic of the male) is a branch of the abdominal aorta. Its relations when in the abdomen do not concern us here. In the pelvis it passes between the layers of the broad liga- ment, running tortuously towards the upper angle of the uterus. Near this it divides into two branches. The upper supplies the fundus uteri ; the lower anastomoses at the side of the uterus with the uterine artery (Plate VI. c, d). The Ovarian Artery gives off Branches to the ampulla of the Fallopian tube (Plate VI. a' a'), Branches to the isthmus (&'), Numerous branches to the ovary (c' c c'), Branch to the round ligament (6). The Uterine Artery (Plate VI. e) springs from the anterior division of the internal iliac, and passes downwards and inwards towards the cervix uteri. It then passes upwards between the layers of the broad ligament by the side of the uterus, in an exceedingly tortuous manner well shown in Plate VI., to anastomose with the lower branch of the ovarian. The course of the blood-vessels in the uterine wall has been recently studied and described by J. Williams with special reference to some ana- tomical and pathological points. The primary branches after enter- ing the uterine tissue have a somewhat superficial course, being separated from the peritoneum by only a thin layer of muscular fibres. From these, secondary branches run towards the mucous surface in a direction perpendicular to that surface ; these anastomose freely and end in capillary loops in the mucous membrane. All internal to the primary branches -the greater part of the muscular wall .belongs, according to Williams, to the mucous membrane, i.e., is muscularis mucosae. The Vaginal arteries (g g g} usually spring immediately from the anterior division of the internal iliac artery, but sometimes arise from the uterine or middle hsemorrhoidal. A special branch of the uterine artery to the cervix joins with its fellow at the isthmus to form the circular artery, and with those of the vagina to form the azygos artery of the vagina (h Ji). The vaginal arteries of one side anastomose freely with those of the other. Plate VI., from Hyrtl, illustrates beauti- fully the free anastomosis of branches of the aorta with the ovarian, uterine, and vaginal arteries. It should be noted that, in operation for removal of the uterus, ligature of the broad ligament controls all haemorrhage. From the same anterior division of the internal iliac proceeds the blood supply to the bladder and rectum. Arterial supply to the perineal region. This comes from the internal Arterial pudic. The superficial perineal branch supplies the labia the artery to the bulb supplies the bulbus vaginae ; the terminal branches go to the clitoris. 70 ANATOMY OF PELVIS. VENOUS SUPPLY. Veins of Pelvis. The venous supply of the pelvis is very abundant, and exists in the form of numerous plexuses freely communicating with one another. The veins are unprovided with valves ; haemorrhage from a wound is therefore often exceedingly profuse, especially during pregnancy when the whole pelvic vascular system is hypertrophied. II S > tH > I* The following is a summary of the main facts as to the venous supply of the female pelvis. The Vesical plexus lies external to the muscular coat of the bladder. J Oamon^dalpbxtu lies below the mucous membrane of the lower part of the rectum. LYMPHATICS. 71 The veins of the labia correspond in distribution to the arteries, and those from the outermost parts drain into the pudic which opens into the common iliac vein. Large veins from the labia ininora open into the pars intermedia of the bulb. The veins from the glans and corpus clitoridis pass into the dorsal vein of the clitoris, which communicates with the vesical plexus. The veins of the bulb pass into the vaginal plexus. The Vaginal plexuses one outside the muscular coat and one in the submucous tissue are most abundant at the lower part of the vagina, communicate with the hsemorrhoidal and vesical plexuses, and open into the internal iliac vein. The Uterine plexus is very abundant, as is well shown in one of Hyrtl's plates ; it ultimately opens into the ovarian veins (fig. 62), which pass on the right side to the inferior vena cava, on the left to the left renal vein. The right ovarian vein has a vah-e where it pierces the coat of the inferior vena cava (Brinton, quoted by Lawson Tait). The veins are small, lie in the outer muscular coat, and run longi- tudinally ; in the middle layer of that coat they open into large sinuses (surrounded by circular unstriped muscle) with which the capillary vessels communicate. This is an arrangement like that in the corpus spongiosum of the penis (Klein). The Ovarian plexus, otherwise known as the pampiniform plexus, lies between the folds of the broad ligament and communicates with the uterine plexus (fig. 57). Some apply this term to all the veins in the broad ligament. The ovarian plexus opens into the inferior vena cava. Just at the hilum of the ovary lies the collection of veins known as the bulb of the ovary. Beneath the peritoneum and between the layers of the broad ligaments are vast venous plexuses. Knowledge on this point is of the highest importance in relation to pelvic hsematocele. The vesical, hsemorrhoidal, and vaginal plexuses, with the pudic veins, open into the internal iliac vein which joins the inferior vena cava. From the hsemorrhoidal plexus, the superior hsemorrhoidal vein passes into the portal system; and thus we get a communication between the pelvic and portal venous systems. In the vaginal mucous membrane, clitoris and uterus, we have erectile tissue, i.e., veins in connective tissue with unstriped muscular fibre. LYMPHATICS. Under this we take up a. The Lymphatic glands ; b. The Lymphatic Vessels. a. The Lymphatic Glands. These are (1.) the inguinal glands, which o 72 ANATOMY OF PELVIS. lie parallel to and just below Poupart's ligament ; and (2.) the pelvic gland*. These latter consist of the following : (a) A gland at the isthmus uteri (C/tampionniere) ; (b) Hypogastric glands, which lie subperitoneally in the space between the external and internal iliac vessels ; (c) Sacral, on the lateral aspect of the anterior surface of the sacrum and in the mesorectum; and (d) A gland or collection of small glands at the obturator foramen the obturator gland of Guerin. These all pour into the lumbar glands, which lie in front of the lumbar vertebrae and discharge into the thoracic duct. Lymphatic b. The Lymphatic Vessels. (1.) Of External Genitals. Numerous External vessels f rm a network on the internal aspect of the labia majora, over Genitals, the labia minora, and round the vaginal and urethral orifices, vestibule, and clitoris ; all of these open into the inguinal glands. From this arrangement, the enlargement of the inguinal glands in syphilis and vulvar cancer is intelligible. The lymphatics of the lower fourth of the vagina also open into these glands. Of Vagina, (2.) Of Vagina (upper three-fourths) and Cervix Uteri These lym- phatics open into the hypogastric glands. So far we have followed Sappey's description. Le Bee, however, asserts that the lymphatics of the vagina pour into a series of trunks at the level of the isthmus uteri, and that those of the cervix join them ; and that the conjoined lymphatics then pass below the base of the broad ligament to the obturator gland, from which vessels communicate with others from the thigh and even from the epigastrium. The relation between lymphatics and glands is as follows : - (a) Those of the external genitals pass into the inguinal glands ; (6) The lymphatics of the bladder, vagina, and cervix pass to the hypogastric glands (Sappey). According to Le Bee, they pass to the obturator gland. Of Uterus. (3.) Of Uterus. The lymphatics of the body of the uterus pass through the broad ligaments ; and, along with those from the ovary and Fallopian tube, enter the lumbar glands. If Le Bee be right, the lym- phatics from the cervix pass below the broad ligament and those from the uterus along the upper part of the same. Some of the uterine lym- phatics pass along the round ligament to the groin. Leopold, who has investigated the lymphatics in the unimpregnated uterus, considers " the mucous membrane of the uterus as a lymphatic surface which contains no special lymphatic vessels, but consists of lymph sinuses covered with endothelium. The lymph passes from the lymphatic spaces of the mucous membrane, through the mucous membrane hollows, into the lymph NERVES. 73 spaces and vessels of the muscular coat, surrounds here all the bundles up to the serous covering, and flows into the larger vessels which enter the broad ligament in the neighbourhood of the blood-vessels" (loc. cit., S. 31). These are matters not of mere anatomical detail, but of the very highest pathological and practical importance. The richness of blood and lym- phatic supply to the vagina, cervix, and uterus explains the extraordinary rapidity with which septic matter spreads through the body, and the extreme danger which may attend even an insignificant lesion of the internal genital organs, when septic matter is present and is absorbed. We may remark here that septic matter will of course follow the lym- phatic routes already laid down, and that bacteria can penetrate the walls of blood-vessels and pass into the general circulation. It should not be forgotten, however, that the bacteria passing along the lymphatic vessels may penetrate them, pass into the peritoneal cavity, and thence spread through the diaphragm to set up the pleurisy and pericarditis so common in septicsemia (Lusk). Thorough comprehension of lymphatic distribu- tion and knowledge of the evil effects of septic matter are of the first importance to the student. The lymphatics of the Rectum lie in two layers (mucous and muscular), and open into the glands of the mesorectum or into the sacral glands. The stomata of the peritoneum of the pelvis communicate with lymph capillaries lying in the subendothelial tissue. Relation The Inguinal Glands (parallel to Poupart's ligament) receive the^mls" lymphatics of the vulva, lower Jth of vagina, and urethra. and Lym- The Hypogastric or Internal Iliac receive those of the bladder, upper f ths of vagina, and neck of uterus. The Sacral Glands receive those from the rectum. The Lumbar Glands receive the lymphatics from the pelvic glands, body of the uterus, Fallopian tubes, and ovaries. NERVES. These are (a) Spinal ; (b) Sympathetic. (a) Spinal. The pelvic muscles are supplied as follows : Levator and Pelvic Sphincter ani by inferior hsemorrhoidal branch of pudic, 4th and 5th sacral, and coccygeal nerves ; Coccygeiis, by 4th and 5th sacral and coccygeal nerves ; Muscles of Perineum and Clitoris, by the branches of pudic nerve. (I) Sympathetic. The hypogastric plexus lies between the common iliac arteries ; it gives off branches which, reinforced by branches from the lumbar and sacral ganglia and sacral nerves, form the inferior hypo- gastric plexuses one on each side of the vagina. From these, filaments proceed to the vagina, uterus, Fallopian tube, and ovary. Frankenhauser describes a ganglion at the cervix uteri and also a 74 ANATOMY OF PELVIS. vesical one. Jastrebow found the cervical ganglion to be a plexus with a ganglion enclosed in it. The terminations of the nerves in the muscular layers of the uterus have been studied by Frankenhauser, who figures them passing to the nuclei of the unstriped muscle. Those entering the mucous membrane are said to end in ganglia. Numerous end bulbs have been found in the clitoris and vagina. DEVELOPMENT OF PELVIC ORGANS. The following is a very brief summary : Develop- The Wolffian bodies appear in the foetus about the third and fourth week. They fulfil the function of kidneys until the second month, and then wither, leaving traces in the presence of parovarium and Gartner's canal. The Fallopian tubes, uterus, and vagina arise from the ducts of Miiller. These appear on the anterior aspect of the Wolffian bodies; coalesce below to form the uterus and vagina ; while, above, they remain separate, as the Fallopian tubes, and leave traces in the hydatid of Morgagni. The ovary first appears as a thickening on the Wolffian bodies. It is made up of interstitial tissue projecting from them and covered by epithelium the germ epithelium. According to Foulis, the ova are developed from the latter ; the cells of the membrana granulosa are formed from the connective-tissue corpuscles of the interstitial, tissue. Waldeyer believes that the ova and the cells of the membrana granulosa both originate from the germ epithelium ; and in this Balfour agrees with him (vide PI. X., fig. F). The parovarium arises as a small distinct structure at the summit of each Wolffian body. It persists in the female (fig. 20). In the male it forms the epididymis. The clitoris is developed from a small eminence at the foot of the urogenital sinus. Up to the second month of fetal life the genital, urinary, and intestinal ducts open into the cloaca ; this then becomes divided by a transverse partition into a posterior anal, and anterior urogenital sinus. The vesti- bule in the adult female is simply the lower part of the latter sinus. The labia minora result from the non-coalescence of folds analogous to those which, by their coalescence, form in the male the corpus spongiosum urethree. The labia majora are two folds which remain separate in the female but coalesce in the male to form the scrotum. The two bulbi vagina are homologous to the corpus spongiosum urethra. For fuller details, see Turner and Quain. CHAPTER VI. PHYSICS OF THE ABDOMEN AND PELVIS, WITH SPECIAL REFERENCE TO THE SEMIPRONE AND GENUPECTORAL POSTURES. LITERA TURE. W. Braune Die Oberschenkelvene des Menschen in anatomischer und klinischer Bezie- liung : Leipzig, Veit and Co., 1871. J. M. Duncan On the Retentive Power of the Abdomen : Researches in Obstetrics, p. 409. Hart The Structural Anatomy of the Female Pelvic Floor. Schatz Beitrage zur physiologischen Geburtskunde : Archiv fur Gynak., Bd. IV., S. 191. Einfluss der Lehre vom intraabdominaleii Drucke auf die Gynakologie : Archiv fiir Gynak., Bd. V., S. 227. Simpson and Hart The Relations of the Abdominal and Pelvic Organs in the Female. Van de Warkei A Study of the Normal Movements of the Unimpregnated Uterus : N. Y. Med. Jour., Vol. XXI., p. 337. IN this chapter it is proposed to give a brief sketch of a subject of the highest importance but still in its infancy. The resume must be re- stricted, from want of space, to certain practical points of which we consider here the following : 1. The effect of intra-abdominal pressure on the female pelvic floor ; 2. The results brought about by change of posture, especially by the f/enupectoral posture ; 3. The effect on uterine position of digital pressure in the vaginal fornices. THE EFFECT OF INTRA-ABDOMINAL PRESSURE ON THE FEMALE PELVIC FLOOR. We suppose the body to be in the upright posture. For simplicity, Effect of the pelvic floor is considered as being under fluid pressure. Fig. 58^*^^- shows the effect of this on the pelvic-floor segments. Fluid pressure pressure, acts at right angles to the limiting surface, which in this case is the pelvic peritoneum. Thus, if the perpendiculars be counted, starting from the symphysis, it can readily be seen that the first three will press the pubic segment against the symphysis ; that the fourth and fifth will do this also, biit will further have a resultant tending to drive the pubic past the sacral segment ; that the sixth and seventh will, directly, tend to do this last ; and that the others will drive it partly past the sacral seg- ment, and partly against it. From want of rigidity in the pubic segment, this driving-down tendency is partly lost. Thus the effect of ordinary intra-abdominal pressure is to press the pubic against the sacral segment. 76 ANATOMY OF PELVIS. Increased intra-abdominal pressure displaces downwards a definite por- tion of the pelvic floor, viz., all lying in front of the anterior rectal wall. There is in the pelvic floor a definite line of cleavage at which it yields, which line runs between the anterior rectal and posterior vaginal walls (see p. 63). This definite downward displacement causes the lesion known as prolapsus uteri. From this we see that the female pelvic floor is not equally strong FIG. 58. DIAORAX to illustrate effect of intra-abdominal pressure on the segments of the pelvic floor (Hart). a Uterus pathologically anteflexed ; 6 Bladder ; c Eetropubic fat ; d Labium majus ; e Symphysis ; / Perineal body ; g Rectum. throughout It would be, were the sacral segment prolonged and attached to the symphysis pubis. But then parturition would be an impossibility. It has been constructed not only qud intra-abdominal pressure, but also qud parturition and the vesical and rectal functions. Effect of change of THE RESULTS BROUGHT ABOUT BY CHANGE OF POSTURE, ESPECIALLY BY THE GENUPECTORAL POSTURE. The abdominal walls, along with the viscera bounded by them, are often spoken of as the abdominal cavity with its contained viscera. We must, however, keep in mind that this cavity is always perfectly full. There is never any vacuum in it. The viscera are always in apposition, with only a little fluid as a film separating them. The abdominal walls PHYSICS OF ABDOMEN AND PELVIS. 77 are yielding, and any tendency to a vacuum is counteracted by atmo- spheric pressure 011 the walls. In no posture, is there ever a vacuum in the abdominal cavity. Even if the trunk were inverted, the small intes- tines would still touch the uterus as they do in fig. 45 and Plate V. The abdominal walls and viscera enclosed by them behave, therefore, like a plastic viscous fluid like so much thick gum or treacle. In the upright posture, the viscera bulge above the symphysis pubis, more or less, according to the development of the subject. Plate IV. shows this bulging in a well-formed female ; the bulging is excessive if the woman is fat. Just below the sternum, the antero-posterior diameter of the abdomen is lessened. The pelvic floor is convex as FIG. 59. OUTLINE OF FEMALE FIGURE IN GENUPECTORAL POSTURE. The dotted line indicates the contour when the vaginal orifice is unopened ; the continuous line, the change in contour after air is admitted into the vagina (Simpson and Hart). seen from without, i.e., the pelvic-floor projection is well marked. Atmospheric pressure is acting equally all over the abdominal and pelvic surfaces ; but the pelvic-floor, bearing the weight of the viscera probably bulges more than the other boundaries of the abdomen. A fluid contained in a bag suspended from a fixed point is pyriform, with the bulb nearer the earth. This shape is due to the weight of the fluid. If a man be made to assume the posture known as the genupectoral (better genufacial), the bulge is at the sternum. The following points should be noted in regard to this posture (fig. 59) : 1. The antero-posterior diameter of the abdominal cavity is increased at the sternum ; 2. It is diminished above the pubes and in the iliac fossae ; 3. The pelvic-floor projection is diminished ; 4. The pubic and sacral segments are still in contact, and the abdo- minal viscera always in contact with the uterus and one another. 78 A. Y ATOMY OF PELVIS. Upright 1 and Genu- pectoral Postures contrasted. Let us now contrast these postures. Upright posture (Plate IV.). Greatest antero-posterior (a-p} diameter of abdomen in hypo- gastrium . Leagt a _ p diameter a t sternum. its Genupectoral posture (fig. 59). 1. Greatest antero-posterior dia- meter at sternum. 2. Least a-p diameter in hypogas- trium. 3. Pelvic-floor projection dimin- ished. 4. Pelvic-floor sements in contact. 3. Pelvic-floor projection at maximum. 4. Pelvic-floor segments in contact. In the latter posture, on inspection of the genitals, the labia can be seen to be furrowed and the skin over the ischiorectal fossa slightly hollowed. If now the labia majora and minora be separated and the fourchette lifted up, no further change as yet takes place : but when the hymen is opened up, air passes into the vagina (often with a distinct hiss), and the vaginal walls become separated, enclosing a somewhat large cavity. The bulge at the sternum is now slightly increased, while the diameter in the hypogastrium is diminished (see fig. 59). It is only ivhen the anatomical entrance of the vagina (the hymeneal orifice) is opened up, that tJie vagina distends with air. It has been shown by A. R. Simpson and D. Berry Hart, that the segments of the pelvic floor separate from each other when a woman assumes the genupectoral posture and the hymeneal orifice is opened. The pubic segment passes down with the viscera ; the sacral segment remains behind, recoiling slightly upwards. Thus, functionally, the pubic segment is visceral, the sacral one is vertebral. They have shown further that there is a definite displacement of the pubic segment constituents, viz. : a. The empty bladder is partly above the pubes ; 6. The peritoneum passes from abdominal wall to bladder, at a point 1^ inches above the symphysis; c. The retropubic fat is partly above and partly below the top of the symphysis. We may now once more contrast these postures. Result of Upright posture (Plate IV.). li-t.-iitimi of Vagina with Air. 1. Pubic and sacral segments in apposition and vagina a slit. 2. Retropubic fat behind pubes. 3. Empty bladder behind pubes. Genupectoral posture (vagina dis- . . tended with air) (fig. 60). 1. Pubic and sacral segments separated and vaginal walls bounding a cavity. 2. Retropubic fat partly above pubes. 3. Empty bladder partly above pubes. PHYSICS OF ABDOMEN AND PELVIS. 79 5. 4. Peritoneum passes from anterior abdominal wall to fundus of empty bladder, immediately above symphysis. 5. Urethra and bladder meet at a right angle. The reason why the pubic segment passes downwards when the vaginal orifice is opened is, that atmospheric pressure now acts on the vaginal aspect of the pubic segment (with its movable attachment to the pubes) and drives it further down. As the result of this posture, 4. Peritoneum passes from anterior abdominal wall to fundus of empty bladder, 1^ inches above symphysis. Urethra and bladder almost in same line. FIG. 60. PELVIS FROM FROZEN SECTION OF CADAVER IN GEXUPECTORAL POSTURE. A anus ; P perineum ; R rectum ; V vagina ; u urethra ; B bladder ; / retropubic fat ; U retroverted uterus ; pp peri- toneum. Between the small intestine and peritoneum is fatty omentum. (Simpson atid Hart.) changes take place in the length and direction of the vaginal walls and in the position of the uterus. 1. Vagina. (a.) Both walls elongate. (b.) The anterior follows the direction of the posterior 80 ANATOMy OF PELVIS. aspect of the symphysis ; the posterior, the curve of the sacrum. 2. Uterus. (a.) The normally placed uterus passes nearer the sacrum and nearer the thoracic diaphragm. (6.) The retroverted uterus, fixed or unfixed, becomes more retroverted. (c.) The retroverted unfixed uterus does not become replaced so as to lie anteverted. The results given have been obtained as follows : a. By observation on living patients, aided by silhouettes of the out- lines of the nude body in the upright and genupectoral postures ; b. By study of frozen sections of the female pelvis, and especially by study of a frozen section of a cadaver placed in the genupectoral posture. For further details on this subject Simpson and Hart's atlas may be consulted. An important practical result follows from these observations. The vagina dilates, or, more properly, the segments of the pelvic floor separate exposing their free margins the vaginal walls when a patient assumes the genupectoral posture and the hymeneal orifice is opened so as to admit air. If a patient be so placed opposite a good light, and the sacral segment be drawn up, a complete view of the vaginal walls and cervix is obtained. The same results can be got by placing the patient in the posture known as the semiprone. On this last fact is based the use of the vaginal speculum known as Sims' or duckbill speculum (v. Chap. XL). THB EFFECT ON UTERINE POSITION OF DIGITAL PRESSURE IN THE VAGINAL FORNICES. This is a subject of great practical importance. Effect of If, when a patient is lying on her left side, the index finger of the Pressure examiner's right hand is passed into the vagina as far as the posterior fornix, and pressure made there, the following results may be noted : (1.) The posterior vaginal wall is elongated, the cervix drawn back, and the uterus, if anteverted, becomes more so. (2.) If the uterus is retroflexed, the flexion is not remedied. Should the fundus be fixed, the retroflexed is increased as the cervix is drawn back while the fundus remains. Similarly, if pressure be made in the anterior fornix : (1.) The uterus becomes elevated and slightly rotated backwards, because the cervix is pulled forwards. (2.) If the uterus is anteflexed, the flexion is not diminished. PHYSICS OF ABDOMEN AND PELVIS. 81 By pressure in these fornices, therefore, we only act on the cervix, unless the uterus is very much retroverted or anteverted. The body of the uterus is acted on only indirectly, through its union with the cervix. Consequently, no vaginal pessary can undo the flexion of a retroflexed or anteflexed uterus. CHAPTER VII. MENSTRUATION AND OVULATION. LITERATURE. BeiffelDie Krankheiten des weiblichen Geschlechtes : F. Enke, Stuttgart, 1875. Dalton Report on the Corpus Luteum : Am. Gyn. Tr., Vol. II., p. 11. Physiology, 6th edition, J. & A. Churchill, 1876. Engelmann The Mucous Membrane of the Uterus, with especial reference to the Development and Structure of the Decidua : Am. J. of Obst., Vol. VIII., p. 30. Prey's Histology Barker's Tr., 1874. Goodman The Cyclical Theory of Menstruation : Anier. Jour, of Obstet., Oct. 1878. Jacobi -The Question of rest for women during Menstruation : Smith, Elder & Co., London, 1878. Kinkead On the passage of the Ovum from the Ovary into the Fallopian Tubes : Med. Press, September 14, 1881. Kundrat Untersuchungen liber die Uterusschleim- haut : Strieker's Jahrbuch, 1873. (Kundrat and Engelmann were co-workers. ) Leopold Studien iiber die Uterusschleimhaut wahrend Menstruation, Schwangerschaft und Wochenbett: Archiv fur Gynak., Bd. XL, S. 1091. Untersuchungen iiber Men- struation und Ovulation : Archiv f. Gyn., Bd. XXI., S. 347. Loewenhardt Die Berechnung und die Dauer der Schwangerschaft: Archiv fur Gynak., Bd. III., S. 456. Moricke Die Uterusschleimhaut in den verschiedenen Altersperioden und zur Zeit der Menstruation: Ztschr. filr Geburtshiilfe und Gynak., VII. Band, 1 Heft, 1881. Reinl Die "Wellenbewegung der Lcbensprocesse des "Weibes : Volkmann's Sammlung, etc., No. 243. Ritchie, C. G. Contributions to Ovarian Physiology and Pathology : Churchill, London, 1865. Simpson, A. Russell Emmenologia ; Contri- butions to Obstetrics and Gynecology : Edinburgh, A. and C. Black. Stephenson On the Menstrual Wave : Amer. Jour, of Obstet., April 1882. Tait, Lawson Br. Med. Journ., June 4, 1881. Notes on the Relations of Ovulation and Menstruation : Medical Times, London, 1884. UnderhillNote on the Uterine Mucous Membrane of a Woman who died immediately after Menstruation : Ed. Med. J., 1875. Williams On the Structure of the Mucous Membrane of the Uterus, and its periodical changes : London Obst. Jour., Vol. II., p. 681. Wyder Das Verhalten der Mucosa Uteri wahrend der Menstruation : Zeit. f. Geburtshiilfe und Gynak., Bd. IX., Hft. 1. See also Index of Recent Gynecological Literature in Appendix. THE subject of Menstruation is not as yet well known, and on many points eminent and trustworthy observers are at variance. The nature of the process is at present sub lite. The old theories of its being due to plethora or its being a disease are now exploded. The modern view, termed the ovulation theory, asserts that the starting point in menstruation is the bursting of a Graafian follicle. But in cases of .abdominal section performed between the menstrual periods, as has been specially observed by Tait and Leopold, Graafian follicles have been found on the point of bursting, clearly showing that ovulation may in certain cases occur remote from menstruation. The only objection that may be urged to this is that abdominal-section cases are not normal. Ritchie, however, long ago insisted on the same view. MENSTRUATION AND OVULATION. 83 Jaeobi, Stephenson and Reinl (working on Goodman's cyclical theory) have given good proof that a woman in her full sexual vigour seems to pass through a series of cyclical changes, of each of which the menstrual period is the climax. Jaeobi found that, during the few days before the flow, the excretion of urea is increased ; the temperature is slightly raised ; and that, in regard to the pulse, there is a rhythmic wave beginning at a minimum point 1 to 4 days after the cessation of the flow and gradually rising to a maximum 7 or 8 days before menstruation. So far as our present knowledge goes, the follow- ing is a brief resume. PRELIMINARY CONSIDERATIONS^ Definition. A cyclical change with constitutional disturbances whose Prelimi- most marked local phenomena are periodical flow of blood from the uterine na cavity, with shedding of the superficial layers of its mucous membrane, accompanying (according to the hitherto accepted theory) the discharge of an ovum from the ovary, occurring in properly developed women between the ages of 14 and 44, and interrupted by uterogestation and lactation. Period of its Onset. Menstruation begins, in this country, usually at the age of 13 to 15 (puberty). It may be delayed till 16, 17, or 20; but this is unusual. Its onset is earlier in warm countries, later in cold ones ; earlier in delicately nurtured girls. Period of its Cessation. With the interruptions of pregnancy and lactation, it continues in healthy women until the age of 44 to 50. The period of its final cessation is known as the menopause. As a general rule the menopause is early when menstruation has begun early, and vice versa. GENERAL PHENOMENA OF MENSTRUATION. Changes at Puberty. At this period of life, when the girl becomes the General Pheno mena. -woman, we find certain well marked general changes occurring. The^ bust and inons veneris develop and the whole contour of the body becomes more rounded and attractive ; hair appears on the genitals. The romping carriage of the girl becomes subdued, and greater shyness characterises her conduct to the opposite sex. Phenomena premonitory to each menstrual flow. There is usually a feeling of weight in the pelvis and increase of sexual inclination. Many women, however, have very little uneasiness during the whole flow ; while others are always considerably distressed, this distress being istill outside the boundary of actual disease. Periodicity and duration of Discharge. When once established it recurs, in the large majority of cases (about 87 p. c. of the whole), with great regularity : the most common intervals are 28 days (in 71-p. c.) 84 PHYSIOLOGY OF PELVIS. and 30 days (in 14- p. c.); less frequent are 21 days (in 2- p. c.) and 27 days (in 1 + p. c.). We speak therefore of the 21 day type and so on. The discharge lasts for a number of days, varying from 2 to 8 : if below 2 or above 8 it is abnormal ; but of course other points besides mere duration must be taken into account. LOCAL PHENOMENA. Local Three periods are distinguished: 1. Invasion; 2. Persistence; 3. 1. Invasion. Discharge pale. 2. Persistence. Discharge bright red, non-coagulable from its ad- mixture with mucus. It consists microscopically of epithelium from vaginal, cervical, and uterine cavities ; mucous globules ; compound granular corpuscles ; and red and white blood-corpuscles. 3. Decline. Discharge lessens in amount and becomes lighter in colour. The total quantity varies from 2 to 8 ounces. Thus far we have related facts fairly well ascertained and not much disputed. We now enter on more debateable ground, in considering I. Ovulation ; II. The Corpus luteum ; III. Source of discharge, and changes in the uterine mucous membrane. Ovnlation. I. Ovulation. According to the ovulation theory, ovulation forms the starting point of the process of menstruation. We have already con- sidered the structure and development of the ovary, and now describe The changes in the Ovary at each Menstrual Period. A Graafian follicle enlarges and moves nearer the surface. Probably this produces, through a nervous mechanism, a hypersemia of the whole pelvic contents, peri- toneum, connective tissue, uterus, ovaries, Fallopian tubes, and vagina. It is alleged, as yet on insufficient grounds, that the fimbriated end of the Fallopian tube grasps the ovary, and that the ovum from the ruptured Graafian follicle passes into it and along the tube to the uterine cavity. Professor Kiukead of Galway has recently advanced another explanation. He points out that, between the fimbriated end of the Fallopian tube and the ovary, we have the ovarian fimbria (fig. 20) forming a groove which is converted into a tube by the surrounding viscera ; and that we have thus capillary action towards the uterus. This would lead the ovum into the Fallopian tube. However it reaches the Fallopian tube and uterus, its further development depends on its fertilization or non- fertilization. In the latter case it passes off unnoticed in the menstrual discharge ; in the former it developes into the foetus. lun'u," IL The Cor P us tut. After the rupture of the Graafian follicle, we ;s cavity filled up by the structure known as the corpus luteum This is formed by proliferation of the cells of the membrana granulosa MENSTRUATION AND OVULATION. 85 by the sprouting of new capillaries with migratory cells into the hyper- trophied convoluted epithelium. The central portion degenerates into gelatinous tissue, the cortical into fatty tissue (Klein and Smith). The corpus luteum thus consists of a vascular framework, with a yellow pigmentary and cellular substance. It varies according as pregnancy does or does not follow its formation. The difference is well given in Dalton's table, which we subjoin. CORPUS LUTEUM OP MENSTRUATION. COKPUS LUTEUM OP PREGNANCY. End of 3 weeks. 12 by 13 mm. in diameter ; central clot reddish, con- voluted wall pale. One month. Smaller; convoluted wall Larger ; convoluted wall bright bright yellow; clot still yellow ; clot still reddish. reddish. Two months. Insignificant cicatrix. 12 by 22 millimetres in diameter; convoluted wall bright yellow; clot perfectly decolorized. Four months. Absent or unnoticeable. 18 by 22 millimetres in diameter; clot pale and fibrinous ; con- voluted wall dull yellow. Six months. Absent. Still as large as at the end of the second month ; clot fibrinous ; convoluted wall paler. Nine months. Absent. 10 by 13 millimetres in diameter; central clot converted into a radiating cicatrix ; external wall tolerably thick and convoluted, but without any bright yellow colour. III. /Source of Discharge and CJianges in the Uterine Mucous Mem- Source of brane. All observers are agreed that the mucous membrane of the * uterine cavity is the source of the discharge, i.e., that it comes from the area limited by the uterine ends of the Fallopian tube and the os internum. Now begins the divergence. (1.) Williams holds that " uterine contraction drives the blood from "\yilliams' the muscular wall into the mucous membrane ; the vessels of this mem- brane, having undergone fatty degeneration, give way, and extravasation of blood results. This extravasation takes place always near the surface, for in that situation the degenerative change has most advanced. The rush of blood into the vessels of the mucous membrane expels the contents of the glands, together with the greater part of their lining epithelium. When haemorrhage has taken place into the membrane, it undergoes rapid disintegration, and becomes entirely removed." The new mucous membrane " is produced by proliferation of the elements of the muscular wall of the organ : the muscular fibres producing the fusiform cells ; the connective tissue, the round cells ; and the groups 86 PHYSIOLOGY OF PELVIS. of round cells in the meshes formed by the muscular bundles, the glandular epithelium." These "groups of round cells " may be the ter- minations of the uterine glands. In a more recent paper, 1 Williams has modified the statement of his view by affirming that the greater portion of the muscular wall of the uterus represents the muscularis mucosse. According to this, only the glandular portion of the mucous membrane is shed. Entire removal of the mucous membrane down to the muscular fibre, and its regeneration from groups of round cells in the muscular coat, are the essentials of Williams' view. . Kundrat FIG. 61. DIAGRAM of UTERUS just before MENSTRUA- TION. The shaded portion represents the Mucous MEMBRANE (/. Williams). FIG. 62. DIAGRAM of UTERUS when MENSTRUATION has just ceased, showing the cavity of the body deprived of Mucous MEMBRANE (/. Williams). (2.) Kundrat and Engelmann thus describe the changes. Mucous membrane becomes swollen and pulpy, and measures in thick- ness 3-6 mm. The thickness is most marked at the fundus and central portions of the anterior and posterior surfaces. The surface is puffy and injected ; glands are distinctly seen on section as fine spirals. Microscopically, this increase in thickness is seen to be due to a pro- iferation of the round cells of the stroma, an enlargement of all the cell ements in the superficial layers, and an increase of the intercellular stance. This superficial layer has grown far above the original gland ungs, causing the funnel-shaped depressions or small pits seen on 1 On the Circulation of the Uterus, etc. : Lond. Obs. Trans., 1885. MENSTRUATION AND OVULATION. 87 surface view. The glands are increased in thickness and length. The vessels are enlarged and gorged with blood. Fig. 63 shows the mucous membrane of the menstruating uterus magnified 40 times ; it should be compared with the mucous membrane of the non-menstruating uterus at fig. 17, also magnified 40 times. The increase of the thickness of the mucous membrane begins as the time of menstruation approaches, is most marked during the period itself, and gradually decreases after the cessation of the catamenial flow. FIG. 63. Mucous MEMBRANE OF MENSTRUATING UTERUS (Kundrat and Engdmann). (*f) Fatty degeneration takes place in the cells of the interglandular tissue, blood-vessels, and glandular and surface epithelium. They hold that " the haemorrhage is always confined to the surface of the lining membrane, and is due to the fattily degenerated tissue being unable to resist the blood pressure ; " and they therefore maintain, what is most probably the case, that only the superficial layer of the mucous membrane is shed at a menstrual period. 88 PHYSIOLOGY OF PELVIS. Leopold's (3.) Leopold denies the existence of any fatty degeneration of the superficial layers of the mucous membrane. He believes that an extra- vasation of red and white blood corpuscles from the superficial capillaries takes place especially towards the superficial layer, undermining the uppermost layer of cells ; and that, finally, the copious supply of blood reaching these capillaries from the numerous arteries causes rupture and bleeding. The mucous membrane is regenerated by an upward growth of the glandular epithelium. MSricke'a Williams, Kundrat, Engelmann, and Leopold examined uteri from post-mortem cases. Recently Moricke has curetted the uteri of living women at various stages of menstruation, and microscopically examined what he removed. He asserts " that during menstruation the mucous membrane disappears neither partially nor fully." This shows how widely microscopists vary. Williams says all the mucous membrane down to the uterine muscle is removed; Kundrat, Engelmann, and Leopold say only the superficial layers are removed ; and Moricke says none is removed. We have deemed it best to lay these views before the student. The subject is difficult to investigate, and one on which the authors are not qualified to give an opinion. They incline, however, to the views of Kundrat, Engelmann, and Leopold. A dispute still exists as to which ovum is fertilised when pregnancy occurs the ovum of the last menstruation, or that of the first period missed. Many observers believe in Loewenhardt's theory, viz., that the ovum fertilized is that of the first period missed. Lately the dominant influence of the ovary in menstruation has been questioned by some, notably by Lawson Tait. The operation known as Battey's operation, where both ovaries are removed, does not always cause a cessation of menstruation. Tait asserts that menstruation will always cease if the Fallopian tubes also are excised ; and therefore believes that they play an important part in menstruation, hitherto unsuspected. Leopold's monograph is illustrated by many valuable lithographs, and the same may be said in regard to Dalton's work on the Corpus Luteum. SECTION II. PHYSICAL EXAMINATION OF THE FEMALE PELVIC ORGANS. TN this section we have to take up the physical examination of the -*- female pelvic organs that is, exploration by the hands and instru- ments of the gynecologist. This will be considered in the following manner. CHAPTER VIII. Abdominal Examination; Vaginal Examination; the Bimanual Examination, with its various modifications. CHAPTER IX. Examination per Rectum. CHAPTER X. The Volsella. CHAPTER XI. Vaginal Specula. CHAPTER XII. The Uterine Sound. CHAPTER XIII. Tents and other Uterine Dilators. CHAPTER XIV. The Curette. CHAPTER XV. Knives ; Scissors ; Needles ; Sutures ; Douches and Syringes ; Anaesthetics. CHAPTER XVI. Relation of Micro-organisms to Gynecology; Anti- septics. CHAPTER VIII. ABDOMINAL EXAMINATION; VAGINAL EXAMINATION; THE BIMANUAL EXAMINATION, WITH ITS VARIOUS MODIFICATIONS. IN a female patient whose symptoms point to a pelvic cause, it is neces- sary to investigate the case by what is commonly known as a vaginal examination. A mere vaginal examination, however, gives very little information. The proper method is first to make an external abdominal examination and then the vaginal examination, the latter being only a stage of the more complete method of investigation known as the bimanual. Special cautions as to cases unsuitable for pelvic exploration are given under the head of vaginal examination. We consider the examination in the following order : I. External abdominal examination ; II. Inspection of external genitals (only when necessary) ; III. Vaginal examination ; IV. The bimanual (abdomino-vaginal) examination. EXTERNAL ABDOMINAL EXAMINATION. External The patient should lie on the back, with knees drawn xip, and head E^mTiir 1 8U PP orted on a pillow. The bowels and bladder should be empty. The tion. abdominal surface should be exposed from the epigastrium downwards ; no part of the mons veneris should be uncovered. The most delicate method of accomplishing this is as follows. A sheet or blanket is thrown over the recumbent patient ; beneath this she raises up her dress as far as the pit of the stomach ; the examiner then places his one hand on the sheet, a little above the mons veneris, and turns it down over it with his other hand. The abdominal surface is examined in four ways, viz., inspection, palpation, percussion, auscultation. Inspection. A. Inspection. The form, colour, equality or inequality of bulge of the abdominal surface should be noted ; the presence or absence of the linea nigra, linese albicantes (fresh and old), pigmentary deposits, fat streaks, and skin eruptions. The linea nigra has little significance. The linese albicantes indicate that the patient's abdominal cavity is or has been distended beyond the normal. They are not specially characteristic of pregnancy. Fresh linese albicantes are glistening and pearly ; old ones have a dull-white or scarred appearance. ABDOMINAL EXAMINATION. 91 B. Palpation should be performed with both hands. For this purpose Palpation, the hands, well warmed, are laid flat on the abdominal surface ; and the whole ai'ea is manipulated between them. One hand alone is of no use. By this method the abdominal contents may be compressed and moved between the hands. The feeling given normally is that of manipulating a plastic fluid. Tapping with one index finger so as to give a fluctuating impulse to the other hand is of great value. Circumscribed nodules or tumours, fluid collections, thickening of the skin, should be noted and mapped out on the scheme given in the chapter on case-taking. For the more exact localisation of the normal and abnormal abdominal Abdominal contents, anatomists divide the anterior abdominal surface into definite reglons- regions by vertical and transverse lines. The lower transverse line is drawn at the level of the anterior superior iliac spines ; the upper one, between the most prominent parts of the ninth costal cartilages. A vertical line joining the cartilage of the eighth rib with the middle of Poupart's ligament on each side, completes the division into nine areas, which are named in order as follows (vide Plate IV.). 1. Right Hypochondriac. 2. Epigastric. 3. Left Hypochondriac. 4. Lumbar. 5. Umbilical. 6. Lumbar. 7. ,, Iliac. 8. Hypogastric. 9. Iliac. In these regions the following structures are found. Epigastric Region. Right part of stomach ; pancreas; liver. Right HypocJiondriac. Right lobe of liver ; gall bladder ; part of duo- denum ; hepatic flexure of colon ; part of right kidney, and its suprarenal capsule. Left Hypochondriac. Cardiac end of stomach ; spleen and narrow ex- tremity of the pancreas ; the splenic flexure of the colon; the upper part of the left kidney, with the left suprarenal capsule ; sometimes also a part of the left lobe of the liver. Umbilical. Part of the omentum and mesentery ; the transverse part of the colon ; lower part of the duodenum, with some convolutions of the jejunum and ileum. Right Lumbar. The ascending colon ; lower half of the kidney; and part of the duodenum and jejunum. Left Lumbar. The descending colon ; lower part of the left kidney, with part of the jejunum. Hypogastric. The convolutions of the ileum ; the bladder in children, and, if distended, in adults also ; the fundus uteri when the bladder is distended. Right Iliac. The caecum with the appendix vermiformis, and the ter- mination of the ileum; right broad ligament, with its ovary, parovarium, and Fallopian tube. 92 PHYSICAL EXAMINATION OF THE PELVIC ORGANS. Left Iliac. The sigmoid flexure of the colon ; left broad ligament, with its ovary and Fallopian tube. The student will observe that the above table mentions several of the pelvic organs (uterus and its appendages) as lying in the lower regions of the abdomen ; this is done because the obliquity of the brim of the pelvis brings these organs to lie underneath the regions, in which consequently any marked change in them will be recognised. Ruedinger's Plate V. shows a valuable coronal section, published by Ruedinger ; it should be carefully studied. The numbers refer to the following structures. 1. Right lung. 2. Right auricle; to its left is the larger coronary vein. 4. Right branch of pulmonary artery. The shorter left branch is seen at the left. 7. Liver. Note the impression on its under and right side from the right flexure of the colon. 8. Stomach. Note how its long axis is vertical, and that the main bulk of the stomach is to the left of the middle line. 9. Ascending colon. 9*. Opening of small intes- tine. 10. Small piece of junction between stomach and duodenum. 11. Pancreas. 12. Duodenum. 13-13. Small intestine. 14. Fundus uteri. 15. Bladder, with ureteric openings. 16. Connective tissue. 17. Descending colon. 18. Sigmoid flexure. 19. Mesentery. For the relations of the lower regions of the abdomen to the pelvic contents, the student might consult fig. 50, which shows very well the latter as seen through the brim. In palpating the normal abdomen, the sensation given is one of impulse communicated generally through a plastic fluid. When free fluid is in the abdominal cavity, the impulse is more distinct. When the fluid is encysted, the impulse and tense feeling are localised. When any large body is felt in the abdominal cavity, the first point to be determined is whether the body is pelvic or abdominal. This is easily done by attempting to press the hand downwards just above the sym- physis pubis. If the tumour is pelvic, and rising up into the abdomen, the hand cannot be so pressed ; and conversely. The next point is to ascertain with which of the organs the tumour is connected ; and, for this, perfect familiarity with the topography of the viscera is of the highest importance. The student should ask himself what structures are normally present in the region, and then to which of these the tumour is to be referred ; with regard to the iliac regions he should bear in mind the frequency of inflammatory deposits in the peritoneum and cellular tissue, e.g. in the right iliac region, besides large intestine, broad ligament, ovary, parovarium, and Fallopian tube, there are peritoneum and cellular tissue in both of which inflammatory deposits are frequent. In all tumours, the existence or non-existence of intermittent contrac- ABDOMINAL EXAMINATION. 93 tions should be carefully noted. Their presence indicates a uterine tumour pregnancy or soft fibroid. The following general points should be kept in mind. The bladder is only in the hypogastric region when distended or displaced upwards ; if empty, it is behind the pubes and in the true pelvis; a distended bladder may be as large as a six months' pregnancy. Ovarian tumours are more or less lateral ; uterine tumours generally central, although the pregnant uterus has usually a right lateral obliquity. In advanced pregnancy, the parts of the foetus can be distinctly palpated. Finally, it should be kept in mind that in all cases of cystic tumours the catheter should be passed into the bladder, for an obvious reason. CASE. Mrs A. was sent for consultation as to removal of internal tumour. On exami- nation, a cystic tumour was felt mesially in the abdomen and reaching up to umbilicus. Vaginal and bimanual examinations were exceedingly painful. A catheter passed into the bladder evacuated a large amount of urine. The uterus was now found to be retroverted and gravid 3^ months, and the cystic tumour had disappeared. Palpation of the inguinal region is of great importance and should Palpation never be omitted. Glandular and other enlargements in this position may be the following. (1.) Glands enlarged from gonorrhoea. There are usually one or two large, painful, and often suppurating. (2.) Glands enlarged from syphilis. These are multiple, hard, small, painless, and never suppurate in an uncomplicated case. (3.) Glands enlarged from vulvar malignant disease, or malignant disease of vagina (lowest ^) or urethra. (4.) Femoral or inguinal hernia. (5.) Thrombosis of femoral vein. C. Percussion is to be made in the usual way. To perform this Percussion, thoroughly, the patient should be percussed (a) when on her back ; (6) when on the left side ; (c) when on the right side ; (d) when sitting up. Changes in the percussion note on the patient changing her posture should be carefully noted, as they are of great value (vide under Ovarian Tumours and Ascites). D. Auscultation is performed with the ordinary stethoscope. TheAusculta- foetal heart, uterine souffle, and friction may be heard by it. The im- portance of auscultation is evident. Fostal heart-sounds indicate preg- nancy ; the point of greatest intensity of the heart-sounds indicates the lie of the child. Uterine souffle and no heart-sounds (after 4^ months) indicate either pregnancy and child dead, or fibroid tumour. Ovarian cysts have no souffle. Before finishing abdominal examination, the patient should be made to raise her shoulders by grasping the examiner's hands. When there is no encysted abdominal tumour, the recti can be seen to flatten the abdominal contour ; if, however, a solid or cystic tumour be present, the 94 PHYSICAL EXAMINATION OF THE PELVIC ORGANS. contour is unaltered. An exception should be made in the case of thin- walled cysts not tensely filled, where the recti do flatten the contour. INSPECTION OF EXTERNAL GENITALS. Iwpection This should not be made a routine practice. As a general rule, inspec- S2T l tion of the genitals should only be made when there is local tenderness, where syphilis or gonorrhoea is suspected, or where it is said by the patient that something comes down at the vaginal orifice. Soft chancres, hard chancres (almost never seen in females), mucous patches, condy- lomata ; urethral caruncles ; irritable spots causing vaginismus ; labial abscess; parturition tears of perineum and labia; prolapsed pelvic organs; external or internal piles, may be found. VAGINAL EXAMINATION. Vaginal Preliminaries. Vaginal examination should not be made on girls Examina- below or little beyond the age of puberty, unless the symptoms are urgent, e.g. mechanical retention of menstrual fluid from atresia. In the case of unmarried women it should not be performed unless specially necessary. In both classes of patients the value of a rectal examination should be kept in mind. The vaginal examination should be made on married women whose symptoms point to a pelvic cause. Finally, no woman should be examined vaginally when menstruating normally, unless under exceptional circumstances. Special cases require consideration : viz., that of a mistress who requests a medical man to examine her servant, who is suspected of pregnancy ; or of a yoving woman, who, owing to a malicious report, requests examination as to her condition and a certificate that she is not pregnant. In the first case, it is better for the medical man not to examine the patient, as he may be liable to an action for assault. In the second case, the medical man should advise the patient against being examined. This hitter case is quite different from that of an unmarried woman who, having run the risk of impregnation, requests examination to settle whether she is pregnant. In this instance the medical man investigates the case in the usual way. After settling these preliminaries, and having obtained the patient's consent to " examine " (a term which will readily be understood by her as meaning a vaginal examination), the next point is to determine the posture the woman is to occupy while the examination is being made. Position of In this country it is customary to place the patient on her left side for the vaginal examination, and in the dorsal posture for the Bimanual. The patient lies on a convenient couch, with knees well drawn up and clothes loose. The examiner carefully oils or soaps the index and middle finger of his right hand. With his left hand he clears away the clothes from the hips so as to make a passage for the examining fingers, which he passes onwards till he reaches the cleft between the buttocks. He next passes them forwards over the anus, skin over base of perineum and VAGINAL EXAMINATION. 95 fourchette, until the pulp of the finger rests at the vaginal orifice. In multiparous women, the lax vaginal orifice is easily felt. When in doubt, he passes his fingers cautiously on until he touches the vestibule, which is always smooth. Carrying his fingers back, he will then reach the vaginal orifice at the base of the vestibule. The tyro must be careful not to pass his finger into the rectum by mistake. He should remember that the vaginal axis passes backwards, the anal axis forwards ; that no force is required to pass the finger into the vagina where the hymen has been ruptured, whereas some force is necessary to overcome the resistance of the sphincter ani. The clitoris, lying at the apex of the vestibule, should never be touched, on vaginal examination. The two fingers being now at the vaginal orifice, should be carried backwards into the vagina until its upper limits are felt. In doing so, the following points should be noted. 1. State of Vaginal Orifice: patulous or narrow, presence or absence What to of painful spots, presence or absence of spasm. 2. Walls : shape and length ; presence or absence of rugae ; moisture, heat, secretion, tumours attached to them ; fistulse ; foreign bodies, such as pessaries, glycerine plug, oakum plug. 3. Cervix : direction, size, shape, and consistence. Note whether thickened, expanded, and fixed ; drawn to one or other side ; mobile and not fixed ; or whether split and with cicatrices radiating from it to vaginal roof. 4. Os : size, shape, consistence of lips. Thus, it may be a dimple, as in nulliparse ; transverse, as in parous women (figs. 13 and 14); or the cervix may be split on one or both sides, and thus no os externum be present but the cervical canal be more or less exposed (Plate XII.). Bodies projecting through it should be noted : these may be polypi, fragments of abortion, cancerous masses, stem pessaries. 5. Posterior fornix is concave when felt from below. It has normally a feeling like that of the inside of the angle of the mouth. Note if any lump can be felt through it, projecting downwards in Douglas' pouch, rendering the fornix convex. A body or resistance felt through the posterior fornix may be the following : (1.) Faeces or tumours in the rectum ; Bodies felt (2.) Acute or chronic inflammatory deposit in the peritoneum O r tllr ? u h posterior cellular tissue ; fornix. (3.) Retroverted fundus uteri (non-gravid or gravid) ; (4.) Blood effusion ; (5.) Fibroid attached to posterior wall of uterus ; (6.) Ovary inflamed or cystic ; (7.) Ascitic fluid ; (8.) Extra-uterine foetation or hydatid (rare). 96 PHYSICAL EXAMINATION OF THE PELVIC ORGANS. Anterior fornix. Note if there is any body felt through it. If so, it is most probably the fundus uteri, normal or enlarged from pregnancy or fibroid. There may be also inflammatory or blood effusions, or a tender ovary, but these are rare here. 7. Lateral fornices. Note cicatrices, prolapsed or cystic ovary, lateri-. flexed uterus, inflammatory or blood effusion in broad ligament, dilatation of Fallopian tubes, fibroids placed laterally. The vaginal examination has now been completed. The student should keep in mind that he really learns very little from a vaginal examination, just as he can learn very little as to the size and relation of any object by touching it with the fingers on a but limited area. Vaginal examination is thus only the preliminary to the bimanual or abdomino-vaginal. BIMANUAL (ABDOMINO-VAGINAL) EXAMINATION. Bimanual. This method of examination is the all important one in gynecology, and is the one which the student and practitioner will find most valuable, so that its practice should precede all other methods of internal investiga- tion. As the practitioner's experience increases, he will find that he relies more upon this and becomes less dependent on other means of examina- tion. Method of performing Bimanual. Posture of Patient. The patient must now be placed in the dorsal posture. The head and shoulders should be supported and the knees drawn up. FIG. 64. RIGHT HAND IN BIMANUAL EXAMINATION. Arrangement of Examiner's hands. The internal hand (the right) is placed as follows: The fingers (index and middle) are in the vagina, the thumb rests in the fold between a labium majus and the thigh or upon the symphysis, and the other fingers lie in the cleft of the nates (fig. 68), or flexed on the palm (fig. 65). The whole hand is then rotated backwards so as to bring its long axis as nearly as possible into B I MANUAL EXAMINATION. 97 the axis of the brim, and is then pushed up towards the brim of the pelvis. Thus the pubic segment, uterus with annexa, and posterior vaginal wall are lifted up towards the brim. The middle finger is placed over the os and the index one in the anterior fornix, so that the uterus as it is pushed up becomes more anteverted. The right hand while FIG. 65. BIMANUAL EXAMINATION. The upper hand is not shown. (Hart) examining, therefore, has the appearance at fig. 64. The external hand Position of (the left) is placed on the abdominal wall just above the pubes. It i now steadily depressed until the abdominal wall below it is markedly cupped (figs. 65 and 66) and moulded over the uterus and appendages, which have been elevated by the inner hand. In this way the two hands estimate the size and relations of the pelvic contents, just as one would estimate the size of a watch covered with a cloth. The student should note specially that the upper hand should be steadily and not spasmodically depressed ; that he should always keep the ulnar edge of the hand (rather than the palm) towards the abdominal surface, so that he may not retrovert the uterus ; and that he should palpate all the abdominal areas along the pelvic brim so as not to miss anything. His first object in the bimanual examination is to determine where the uterus is, as this greatly simplifies the recognition of abnormal products in the pelvis. He then bimanually explores the fornices, moving the internal fingers appropriately and noting what he feels. At first his diagnosis should be simply physical, e.g., "uterus felt to front and a large firm 98 PHYSICAL EXAMINATION OF THE PELVIC ORGANS. Normal condition on Bi- inanual. lump behind it;" or, "uterus felt retroverted and a small moveable tumour on its left side." It is of importance that the student should know what a " normal bimanual " is. The following is a description of the condition found in a nulliparous married woman, on vaginal and bimanual examination. "Ostium vagina) patulous, and admits two fingers; vaginal walls moist, rugous, with no abnormalities. Vaginal portion of cervix normal in size (fig. 13); os uteri felt like a dimple, looking downwards and backwards. No bodies are felt through the lateral and posterior fornices, which are concave on their vaginal aspects, and have the feeling, on pressure, of the angle of one's mouth. In the anterior fornix a body is nlWfac FIG. 66. ANTERIOR ABDOMINAL SURFACE with upper hand placed for Bimanual (ad naturam <* line than appears in the cut, and are almos * perpendicular to the abdomi- towards * he fingers " tbat the felt, which on bimanual examination is discovered to be the uterus lying to the front and not enlarged. The fundus and cervix meet at a very use angle. Bimanual exploration of the fornices reveals nothing dis- tinctly palpable, i The patient complains of no pain during the whole examination." 1 One practised in the Bimanual can feel the normal ovaries. BIMANUAL EXAMINATION. 99 Cases ivhere the Bimamial is difficult. The student will soon find that Difficult the bimanual can be performed in certain cases with great facility and Bimanua1 ' accuracy, while in others it is exceedingly unsatisfactory. The best case for a Bimanual is in a patient a fortnight or three weeks after delivery. The reasons for this are evident : The ostium vaginse and vaginal walls have been relaxed by the child's head ; the pubic segment has been drawn up and its attachments slackened ; the abdomi- nal walls have had their elasticity diminished by the full-time uterus, and the uterus itself is not involuted to its normal size. In such a case, there are evidently all the requisites for a good bimanual. Difficult bimanual cases are found in stout nulliparous women, and in cases of pelvic inflammation. In such, the rectal examination (with or without the use of the volsella) is indicated. FIG. 67. DISPLACEMENT OF PELVIC-FLOOR SEGMENTS AND ABDOMINAL WALL IN BIMANUAL (Hart). Students at first find the Bimanual unsatisfactory. By perseverance, however, they will obtain by means of it an accuracy in diagnosis which is astonishing. It is not only the best means of investigation, but one from which no possible harm can arise. In no cases is it contra-indicated except those of advanced cancer or of acute inflammation. We have described the simple abdominal- vaginal examination. It will Varieties of be readily understood that we may have others, as follows : (1.) Recto-abdominal (finger in rectum and left hand above); Bimanual. 100 PHYSICAL EXAMINATION OF THE PELVIC ORGANS. (2.) Kecto-vagino-abdominal (middle finger in rectum, index finger in vagina, and left hand above) ; (3.) Vesico-vagino-abdominal (middle finger in vagina, index in bladder, and left hand above) ; Of these the third is very rarely practised. Anatomy Note that in the Bimanual the pubic segment with uterus and its ''" - annexa are elevated, the sacral segment shortened, and the abdominal wall depressed (fig. 67). Before and after the Bimanual or other examination, the examiner should scrupulously cleanse his hands. There are no better substances for this than turpentine and ordinary soap. The odour is by no means disagreeable, and if found objectionable can be easily covered by vinegar, which in itself is a good cleanser. The hands should finally be rinsed (without soap) in corrosive sublimate, 1 in 2000 or 3000. In examining cancerous cases, where the odour is exceedingly penetrating and per- sistent, it is a good plan to dip the fingers in turpentine prior to the examination, (v. Chap. XVI. Antiseptics.) CHAPTER IX. EXAMINATION PER RECTUM. LITERATURE. Hcyar Die operative Gynakologie, zweite Auflage : Stuttgart, 1881. Munde Minor Gynecology : Wood & Co., New York, 1881. See also Index of Recent Gynecological Literature in the Appendix. THE results obtained by a vaginal examination are limited by the fact Rectal that the reflection of the vaginal walls to form the fornices, prevents the^*^ finger being pushed up to a sufficient distance. This defect is compen- sated for by the downward pressure of the upper hand in the Bimanual ; but in cases where the abdominal walls are unyielding or ' the pubic segment stiff, due pelvic exploration by an abdomino-vaginal examina- tion alone is impossible. In such cases, rectal exploration and the abdomino-rectal or abdomino-recto- vaginal examination are invaluable ; they give better information than the more commonly practised abdomino-vaginal. The usual methods are the following : Methods. (1.) Simple rectal, abdomino-rectal, abdomino-recto- vaginal ; (2.) Passage of the ivhole hand into the rectum (Simon's method). SIMPLE RECTAL ; ABDOMINO-RECTAL ; ABDOMINO-RECTO-VAGINAL. Preliminaries. The patient should be told that it is necessary toprelimi- examine the bowel. If the rectum is loaded the examination should be naries - deferred till next day, and the patient instructed to use a purgative at night and an enema in the morning. The following points should be especially noted. The examiner Manner of should thoroughly soap the fingers and nails. A vaginal examination ^j may be made first ; and then, the index finger being kept in the vagina, the middle one is passed into the rectum (fig. 68). If the patient is virginal, and it is wished to avoid a vaginal examination, then the index finger alone is passed into the rectum. When the finger or fingers are withdrawn from the rectum the hands should be at once cleansed ; there can be nothing more hurtful to a patient's feelings than the passing of the uncleansed fingers from the rectum into the vagina. The patient lies first on the left side and then on the back. The finger passed into the rectum goes forwards ; when passed into the Anatomy vagina, the direction is backwards. After overcoming the resistance the strong external sphincter it enters the rectal ampulla (fig. 34), which t ion - What to Note. 102 PHYSICAL EXAMINATION OF THE PELVIC ORGANS. is often expanded by flatus. Passing the finger onwards and to the left side, a confused mass of tissue is felt in which we may detect the open- ing betwixt the segments of the sphincter tertius. As we pass the finger inwards we note piles (internal and external), fissures, polypi, ulcers, stricture (specific and malignant). Diagnosis of Ante- flexion. FIG. 68. ABDOMINO-RECTO-VAOISAL EXAMINATION. Upper hand not shown. Xote prolapsed ovary. We next turn the pulp of the examining finger so that it lies on the anterior rectal wall. Through this can be felt the cervix. Note that the whole cervix is felt, which is much larger than the vaginal portion felt on vaginal examination. Be sure not to mistake it for the body of the uterus. If the uterus lies to the front, its forward direction can be noted ; if to the back, then the body will be felt on passing the finger further up. Pushing the finger well upwards and passing it first to the right and then to the left, we feel the ovaries (more distinctly when enlarged) as small oval tender bodies (fig. 68). Fig. 38 shows a common condition of the uterus which is frequently mistaken for and treated as a retroversion. We allude to the uterus anteflexed and drawn back by cellulitis of the utero-sacral ligaments. As such patients are usually nulliparous and have therefore somewhat unyielding abdominal walls which cause a difficult bimanual, and as a RECTAL EXAMINATION. 103 lump is felt in the posterior fornix, the diagnosis of retroversion is often made. The rectal examination, however, clears up the case ; as the finger feels the knee of the flexion and the fundus going forwards from it. The upper hand is used during the rectal examination just as in the Bimanual, i.e., the examination is abdomino-recto-vaginal or abdomino- rectal. The simple rectal (with the finger in the rectum unaided by the other hand) does not give much information as to the condition of the uterus. Where, from rigidity of the abdominal walls, it is difficult to press down or fix the uterus with the external hand, this may be done with the volsella in the vagina. The use of the volsella enables us to draw the uterus better within reach of the finger in the rectum. This examination per rectum aided by the volsella will be considered in the next chapter. Of all manual examinations of the pelvis, the abdomino-rectal or Value of abdomino-vagino-rectal is the most thorough. In retroversions, pro-5 ecta ! lapsed ovaries, and pathological auteflexion, it is of special value. Ation. patient may object to it and refuse to allow it ; and, of course, the practitioner must keep this in mind. SIMON'S METHOD OF PASSING THE HAND INTO THE RECTUM. This consists in passing the whole hand through the sphincter ani Simon's into the rectum, and even up to the transverse colon. The patient j s Metllod - deeply narcotised ; the hand is passed cautiously through, by inserting first two fingers and the others successively until the entire hand is passed ; incision of the sphincter ani may be necessary. Sometimes an incurable incontinence of faeces has resulted. The unanimous opinion of gynecologists is that this severe method of examination is unnecessary. Careful bimanual examination, aided when necessary by anaesthetics, gives equally good results. For specialists it is of use to know that valuable results in minute precise rectal examination can be got by first injecting air into the rectum. The whole rectum up to the sigmoid flexure can be dilated, the sphincters made out and the bony pelvic wall carefully explored. It is necessary to add, however, that this is an adjunct to the rectal method of examination of use only in certain very rare instances. CHAPTER X. THE VOLSELLA. LITERATURE. GooddlSome Practical Hints for the Treatment and the Prevention of the Diseases of Women : Medical and Surgical Reporter, January, 1874. Hegar Zur gynakolo- gischen Diagnostik : Die combinirte Untersuchung, Volkmann's Sammlung, Xo. 105. Simpson, A. R. The Use of the Volsella in Gynecology : Contributions to Obstetrics and Gynecology, p. 183. The literature is fully given in A. R. Simpson's paper. Volsella. WE have already seen that one of the most striking anatomical features and properties of the uterus is the considerable range of its mobility in almost every direction. It can be pushed upwards from its normal posi- tion 11 or 2 inches, and is displaceable forwards or laterally in a very marked degree. If laid hold of with the instrument known as a volsella, it can be drawn downwards (by a force not exceeding five or six pounds) until the 6s externum lies close to the vaginal orifice. This procedure facilitates, in suitable cases, diagnosis and treatment of gynecology so much that it is well worthy of the allotment of a special chapter to its discussion. We consider the following points : 1. Description of instrument ; 2. Method of use ; 3. Mechanism of the displacement it causes ; 4. Uses ; 5. Centra-indications. Descriji- 1. Description of Volsella. At fig. 69 is seen the useful volsella em- Vo'lselln. ply e( i by A. R. Simpson. As it is generally the anterior lip of the cervix that is laid hold of, and the volsella lies along the straight anterior vaginal wall, the slight pelvic curve given to the blades is unnecessary. Fig. 70 shows Hart's volsella, where this straightness of the blades q-ud the vagina is secured, and the handle and fingers of the gynecologist are kept away from the vaginal orifice by the bend on the handle. Every volsella should have a catch on it. Sometimes it is useful to have an instrument whose blades pass over one another, so as to separate, for instance, the lips of a split cervix : such is Hanks' instrument. Method 2. Method of Use. (a). Without previous passage of Speculum. The patient is placed in the ordinary left lateral posture. Two fingers of the right hand are passed into the vagina, and the anterior lip of the cervix THE VOLSELLA. 105 touched. The volsella, held in the left hand, is gnided along between the index and middle exploring fingers ; the anterior lip of the cervix is seized and drawn down. Rectal examina- tion is now made. (6.) With the Speculum. For this see Chapter XL 3. Mechanism of the displace- Mechanism ment it causes. The uterus is f tne Dis- placement drawn down so as to lie behind caused. the symphysis pubis. If drawn down fully, as it may be in exceptional cases, it has its long- axis in the vagina and the os externum near the vaginal orifice. The vaginal walls are in- verted : i.e., when the os exter- num is at the vaginal orifice, we have a deep pouch behind and in front of the uterus. The relations of the bladder and rectum are given in fig. 71. 4. Uses. (a) In diagnosis. Use in (1.) The cervix, which may seem " ulcerated," as it is com- monly called, is easily demon- strated by the volsella to be singly or doubly lacerated. For this purpose the anterior and posterior lips are laid hold of, and when brought together the ulceration is seen to be due to laceration with eversion. (2.) Abdominal tumours can be shown to be connected with the uterus or not as the case maybe. If the patient be placed in the dorsal posture and the tumour be laid hold of by an assistant, then when the uterus is drawn down, the tumour can be felt to descend, if fixed to it. FIG. 69. A. R. SIMPSON'S VOLSELLA with catch 106 PHYSICAL EXAMINATION OF THE PELVIC ORGANS. (3.) To the examination per rectum the volsella is a valuable addi- tion. If one finger be placed in the rectum and the cervix laid hold of with a volsella and drawn down, the mobility of the uterus can be estimated ; the whole posterior uterine surface may be palpated for small fibroids. The ovaries are made more accessible ; and the uterus, especially if small, can have its length estimated by the rectal finger. This method of examination of the uterus by rectum and volsella, judiciously con- ducted, is of the very greatest value. It is evident that it will also help one as to the diagnosis of displacements of the uterus ; but its value in this respect is somewhat lessened by the displacement its use causes. Thus it makes a retroversion less retroverted ; an anteflexion less ante- flexed ; an anteversion less auteverted. Use in \\ \\ (b) In treatment. In this the volsella Treatment. |\ |\ is Qne of the mogt use f u i instruments the gynecologist possesses. Thus it helps greatly in the examination of the aborting uterus ; in replacement of the gravid or non-gravid retroverted uterus ; in insertion of sponge or tangle tents, or stem pessa- ..*-;.- :? ries. In operations such as Emmet's for repair of the cervix, Sims' division of the ft cervix, amputation of vaginal portion of HART'S VOLSELLA. cervix, excision of the uterus through the vagina for cancer, it is indispensable. Details of its uses in these cases will be given under the special descrip- tions of the operations ; and it will also be shown in the Chapter on Specula, that by using the volsella the speculum may be dispensed with in certain cases. Contra- 5, Contra-indications. It should not be used in acute peritonitic or tions. cellulitic attacks, in distended Fallopian tubes, in hsematocele or in . advanced cancerous disease. No pain should be caused by its use provided that only the vaginal aspect of the cervix is laid hold of. Amount of The amount of traction to be made will vary with the necessities of traction ,, T to be used. tne case - "* many instances only a mere steadying action is requisite ; in others the cervix has to be drawn half-way down "the vagina. In special cases the cervix is drawn down to the vaginal orifice or beyond it, as in amputation of the cervix or excision of the uterus. THE VOLSELLA, 107 For simply steadying the cervix, Sims' tenaculum is of great service (fig. 72). This is a form of sharp hook with a delicately made stem diminishing to the point which is set on the stem almost at a right FIG. 71. MECHANISM OF DISPLACEMENT OF PELVIC-FLOOR SEGMENTS when Volsella is used. angle ; the hook should be only very slightly curved in. In operating FIG. 72. SIMS' TENACULUM. on carcinoma cervicis uteri, the volsella is occasionally unsuitable as the tissue is too friable. A hook may be passed into the cervical canal in such cases so as to draw down the uterus sufficiently. CHAPTER XI. Vaginal Specula. VAGINAL SPECULA. LITERA TURE. Barna Diseases of Women : London, 1878. Goodell Lessons in Gynecology : Phila- delphia, 1880. Hart Structural Anatomy : Edin. , 1880. Munde Minor Gyneco- logy : Wood & Co., New York. Sims, J. Marion Clinical Notes on Uterine Surgery : Hardwicke & Co., London, 1866. Thomas Diseases of Women: Philadelphia, 1881. WE have already seen that the segments of the pelvic floor are separable when a woman assumes certain postures ; that the sacral segment can be hooked up, and that by this 'means we get a view of the vaginal boundaries of these segments and of the os uteri. This is the natural method of opening up the pelvic floor ; or the natural specular method. Gynecologists had used various instruments for enabling them to look into the vagina : but all of these proved \insatisfactory until Marion Sims, noting the natural postural dilatation of the vagina, introduced his famous duckbill speculum. Varieties. We take up the consideration of three types of speculum, viz. : 1. spatular the duckbill or Sims speculum ; 2. tubular the Fergusson speculum ; 3. bivalve the Neugebauer, Cusco and other modifications. We note under each its nature, the method of employing it, and the theory of its action and uses. Sims' 1. The SIMS or DUCKBILL. SPECULUM is shown at figs. 73, 74, and Speculum. plate vm Nature. Its Nature. Each instrument in reality consists of two specula, which are of different size and connected by a handle ; usually, however, we speak of these specula as the blades of the speculum. The real Sims speculum is light, has each blade slightly concave on its anterior aspect, and has the blades at right angles to the intermediate handle. Modifications of Sims' speculum are numerous. Indeed, it seems difficult for gynecologists to resist modifying an instrument, and rare to I ;../ man's, find them improving it. The most widely known modification is Boze- man's ; it is heavier than Sims', has the blades meeting the handle sit an acute angle, and the blades more concave on the anterior aspect. (Fi- s 74 and 75.) One curious fact about almost all specula is, that they are too long. Modifica- tions. VAGINAL SPECULA. 109 Sims' blade is 4 inches long, though the posterior vaginal wall measures only 3~ inches. Thus, as we wish to expose only the anterior vaginal wall and cervix uteri, a 3-inch length of blade is sufficient. FIG. 73. SIMS' SPECULUM. A modification of Sims' speculum, by Battey of Georgia, is worthy Battey's. of note. It has one short blade which meets the handle at a more acute angle. (Fig. 76.) FIG. 74. SIMS' SPECULUM. FIG. 75. SIMS' SPECULUM modified by BOZEMAN. The method of employing Sims' speculum. Under this it is important Method to note : (a) How to place the patient, (b) How to pass the speculum, of Use ' and (c) How to hold it when passed. FIG. 76. BATTEY'S SPECULUM. (a). How to place the patient. The patient must be placed in the Position of Sims or semiprone posture. This is briefly as follows : the patient Patient - lies almost on the breast ; the loiver left arm is over the edge of the couch next the gynecologist ; the hips are close to the edge ; the knees are well drawn up ; and the upper or right knee touches the couch with its inner aspect. The posterior aspect of the sacrum is therefore oblique to the horizon. (Plate VII.) 110 PHYSICAL EXAMINATION OF THE PELVIC ORGANS. As the result of this posture a modified genupectoral one the vaginal walls separate when air is admitted ; the pubic segment passing down with the viscera, the sacral one remaining behind. PuMgeof (6). How to pass the speculum. Choose the blade which is of the Speculum. proper s j ze to p ass the vaginal orifice; warm it, and oil it with the fingers on its convex aspect only. The concave surface must be dry to reflect light, and therefore the speculum should never be oiled by dipping it. Hold it by the other blade in the left hand, as shown at fig. 77. Then pass the index and middle fingers of the right hand into the vagina to separate the labia ; carry in the speculum between them ; push it onwards, following the curve of the posterior vaginal wall, until the beak of the instrument lies in the posterior fornix. Now draw the instru- ment back as a whole, in a direction at right angles to the posterior vaginal wall ; then turn the beak forwards, so as to bring the cervix more into view. Finally, tilt the blade so that the beak lies on a lower level than the proximal end of the blade ; this keeps up the upper labium. FIG. 77. One method of holding the SIMS SPECULUM. How it is held. (c). How to hold the speculum when passed. Plate VIII. shows the speculum passed, and a convenient way of holding it. When passed. the cervix may be drawn down with a volsella (also shown in Plate VIII.). Various attempts have been made to add to the Sims speculum a means of rendering it self-retaining ; the majority of these are by no means successful, and therefore we need not describe what is seldom used. The knowledge of a simple method of effecting this in Battey's speculum is of use. This has a piece of indiarubber, with a hook at the end attached to the handle, which can be fastened in the pillow, sheet, or patient's dress ; the cervix is drawn down with a volsella held in the one hand, leaving the other free for minor manipulation. Action and Theory of action and uses of the Sims speculum. The Sims speculum sj ^ " "' is based on the effects consequent on the genupectoral posture. When Speculum, the patient is semiprone and the vaginal orifice opened, the segments of the pelvic floor separate ; and then the Sims speculum is a simple means of hooking the sacral segment well back. The Sims speculum is, on the whole, by far the most useful speculum. PLATE VIII. VAGINAL SPECULA. Ill It is difficult to manipulate at first, but amply repays practice. Its in- vention has been one of the greatest strides in gynecology. In vaginal and cervical operative surgery, it is the only speculum that can be used. 2. THE FERGUSSON SPECULUM is seen at fig. 85. It is made in three Fergusson suitable sizes ; and may be described as a glass tube, with a proximal pec trumpet and a distal bevelled end. It is made of glass, silvered on the outside and coated with caoutchouc. The bevelling of the distal end makes a shorter anterior side and a longer posterior one. The maker's name is usually placed at the trumpet end, at the foot of the anterior side, and serves to indicate that side when the speculum is in the vagina. FIG. 78. FERGUSSON SPECULUM. Mode of employment of the Fergusson speculum. The patient lies in HOW used, the left lateral position with hips raised. Warm the speculum, and oil it on the outside. Take it by the trumpet end with the right hand and pass it into the vaginal orifice previously opened up by index and middle fingers of the left ; now push it in, short side to the front, until arrested. By looking along it, the practitioner can note if the cervix is in view. It is generally not so, but may be snared by the following manoauvres : carry the trumpet end well back towards the perineum, and then depress the distal end first to the left and then to the right, finally turning it round if these fail. In multipart with lax vagina it is easy to pass the Fergusson ; but it is more difficult in nulliparse. The Fergusson is a favourite speculum with many. It is useless in Uses, vaginal and cervical surgery, but with it applications to the cervix can be made very well and easily. When used for making applications to the endometrium, it is advisable to pull the cervix well down with a 112 PHYSICAL EXAMINATION OF THE PELVIC ORGANS. volaella after the speculum is passed, and to use a straight sound covered with cotton wool. 3. Of bivalve specula there are various forms : the Neugebauer with its modification the Crescent Speculum of Barnes ; the Cusco, which is often called the Bivalve Speculum ; and other varieties. Neuge- The NEUGEBAUER is like a Sims speculum divided transversely at the middle of the handle (fig. 79). It is also made in suitable sizes. FIG. 80. Cross section showing i-elation of blades ; the upper is posterior. FIG. 79. NEUGEBAUER'S SPECULUM when passed. How used. Mode of employment. Warm and oil two blades. Introduce one blade (the broader one) with its convexity touching the posterior vaginal wall. Then introduce the other with its convexity touching the anterior vaginal wall and so that its edges fit within the edges of the posterior vaginal wall blade (fig. 80). The beak of the posterior blade is thus in the posterior fornix ; that of the anterior blade in the anterior fornix. From their contact a leverage is obtained on approximating the handles, by which traction is made on the fornices, and the cervical canal more or less everted. Km ii.->' Fig. 81 shows a useful modification of this by Barnes, known as the SSm. Crescent speculum. The Neugebauer and Crescent specula are useful in making cervical and endometric applications, and are better specula than the Fergusson. The Cusco or BIVALVE SPECULUM is shown at fig. 82. It is composed of two blades jointed on to one another at their bases. The blades are VAGINAL SPECULA. 113 opened to the desired distance by pressure on the thumb-piece, and kept open by a screw. It is introduced with its blades right and left, and then turned so that they lie anterior and posterior, that with the FIG. 81. BAENES' CRESCENT SPECULUM. screw being posterior. It is then pushed onwards, and the blades opened and fixed by the screw. Care should be taken not to catch any of the FIG. 82. Cusco's SPECULUM. hair in the screw ; and, in withdrawing it, not to pinch up the vaginal walls. H 114 PHYSICAL EXAMINATION OF PELVIC ORGANS. The Cusco speculum is self-retaining and useful in cervical and endo metric applications. W. L. Reid of Glasgow has introduced another variety of bivalve speculum which he has found useful. In it the blades are separable and move on parallel bars. If the patient be placed in the genupectoral or semiprone posture, the posterior vaginal wall hooked back with the fingers and the cervix drawn down with a volsella, a useful view can be obtained without the aid of any speculum. USES AND COMPARATIVE VALUE OF THE VARIOUS SPECULA. The Sims is undoubtedly the best and most scientific speculum we possess. When properly used and aided by the volsella or tenaculum, it leaves nothing to be desired. For operative cases its use is imperative ; and it is the only speculum which does not distort the split cervix. It is objected by some on insufficient grounds that it is difficult to mani- pulate, requires a skilled assistant, and exposes the patient unduly. The Fergusson is easily passed, involves only slight exposure, and is good in very minor gynecology. It gives only a limited view of the vaginal walls. The student should note that it brings the flaps of a split cervix together and somewhat conceals the lesion. The Neugebauer, on the other hand, opens up a cervical split, and may do this so effectually as to give the impression that there is none. The Fergusson and Cusco are self -retaining. CHAPTER XII. THE UTERINE SOUND. LITERA TURE. Simpson, A. R. The Uterine Sound : Ed. Med. Journal, 1882. Simpson, Sir J. Y. Memoir on the Uterine Sound, Selected Obst. Works : A. & C. Black, Edinburgh, 1871. See Munde's Minor Gynecology and Thomas as to Huguier & Lair. WE shall consider this important gynecological instrument as follows : Uterine 1. Its nature ; 2. Preliminaries to its use, contra-indications ; 3. Method of use, difficult cases ; 4. Employment for diagnosis and treatment ; 5. Dangers attending its use ; 6. Relation to bimanual and rectal examination. NATURE. The sound of Sir James Simpson is not only the classical instrument, Nature, but, taken all in all, is probably the best. We describe it, therefore, as a type of the instrument, and then consider its modifications. FIG. 83. SIR J. Y. SIMPSON'S SOUND. Simpson's sound is a rod of flexible metal 12 inches long, specially graduated, and provided with a suitable handle (fig. 83). It is made of copper, nickel-plated ; this is sufficiently pliable to be moulded, and yet sufficiently stiff to retain any special shape given to it. Instrument- makers often make this sound too unyielding. It should be always pliable enough to be bent with two fingers. The handle has the shape shown at fig. 83. Note that it is roughened on the same side as that towards which the point of the instrument lies. Consequently, when the sound is in the uterus, we can tell the direction of the point by noting this roughness on the handle. The graduation is important. 2^ inches from the point is a rounded 116 PHYSICAL EXAMINATION OF PELVIC ORGANS. knob : this is the length of the fully-developed unimpregnated uterine cavity. Other markings are 3^ inches, 4^ inches, 5| inches, and so on up to 8i inches. The notch, 11 inches from the point, is of little use and weakens the instrument. The modifications of this instrument are numerous. The changes are chiefly in its flexibility, lightness, and in the use of another material. A. R. Simpson has modified the instrument by making it shorter, abolishing the li inch notch, and squaring the handle (fig. 91) : this gives a very handy and useful instrument. Sims, Emmett, and Thomas have each a special sound. Thomas' is made of hard rubber or whalebone, and he claims that it is specially useful in the case of sub- mucous fibroids. Other modifications are- by Matthews Duncan, Protheroe Smith, Aveling, Jennison and Hanks. FIG. 84. A. R. SIMPSON'S SOUND. PRELIMINARIES TO ITS USE : CONTRA-INDICATIONS. No instrument should have the preliminaries to its use more carefully u" 1 . 63 considered. The rash and careless use of the sound may do immense mischief to the patient Note, then, when not to use it. (1.) The sound is not to be passed during an ordinary menstrual period. (2.) It is not to be passed in an acute inflammatory attack of uterus, ovaries, pelvic peritoneum, or connective tissue. (3.) It is not to be passed in cases of cancer of the cervix or body of the uterus. (4.) It is not to be passed if the patient has missed a menstrual period. This is a safe rule, but admits of limitation, as we shall see afterwards. Before using it, attend to the following points. (1.) Ascertain that the patient has not missed a period. UTERINE SOUND. 117 (2.) Do the bimanual carefully. If in doubt, use the rectal exami- nation aided by the volsella. (3.) Place the patient in the left lateral posture. (4.) Give the sound the curve you find the uterus to have. METHOD OP USE. After the preliminaries mentioned above, take the sound in the hand, Method dip its first 3 inches in an antiseptic solution. Pass the index finger of FIG. 85. FIRST STAGE OF PASSING THE SOUND. the right hand into the vagina and touch the anterior lip of the cervix, i.e., in front of the os. Guide the sound along the vaginal finger and make the point enter the os uteri (fig. 85). Pass it in for an inch or so, to fix it. If the uterus be retroverted then carry the handle towards the symphy- When sis, when the point of the instrument will glide into the uterine cavity t ro verted. until arrested by the fundus (fig. 86). No force is needed. If force seems necessary, the instrument should be withdrawn and a more careful Bimanual performed. 118 PHYSICAL EXAMINATION OF PELVIC ORGANS. Whan Uterus to front. If the uterus lie to the front, the procedure is different. Pass the sound as already described until it has entered the cervix for an inch or so (fig. 85). Note now that the point of the sound looks back, whereas the fundus lies to the front. Clearly, we must make the point look to the front. This is done by turning the handle so that its roughened surface looks to the front. To do this we do not twist round the handle on its long axis, but make it sweep round the arc of a wide semi-circle as in fig. 87. The point, during this manoeuvre, remains fixed or nearly so. FIG. 86. SECOND STAGE OF PASSING THE SOUND when UTERUS is Retroverted. Now carry the handle back to the perineum when the point glides into the cavity (fig. 88). Another way of passing the sound, when the uterus lies to the front, 5 follows. Place the patient well across the bed. Do Bimanual and curve sound appropriately. Take the sound in the right hand. Pass two fingers of the left hand, palmar surface forward, into the vagina, and ich the posterior lip of the cervix. Carry the sound, point looking UTERINE SOUND. 119 forwards, into the vagina ; make it enter the os, and then carry the handle towards the perineum, when the point will glide on This method (a.) FIG. 87. (6.) (a.) Proper method of TURNING THE SOUND, contrasted with improper method (6.). avoids the sweeping round of the handle, and is useful if the uterus is very much ante verted. FIG. SECOND STAGE OF PASSING THE SOUND when UTERUS is to the Front. The sound may be passed after the uterus is drawn down with a volsella, or after the Sims speculum has been introduced. Difficult Cases. These are chiefly found in markedly anteflexed uteri. Difficult The sound passes in so far (fig. 89), but when turned has its point Iook-g und. 120 PHYSICAL EXAMINATION OF PELVIC ORGANS. ing too directly upwards. In such cases first draw the cervix down with a volsella, now pass the sound, and should it still stop at the flexion make pressure with a finger in the anterior fornix to push up the fundus. FIG. 89. SOUND ARRESTED (before Rotation) in a case of Anteflexion. Then get an assistant to carry the handle of the sound towards the perineum. When the uterine cavity is tortuous as in submucous fibroids a gum- elastic bougie No. 10 may be used to ascertain its length. Thomas', Jennison's, or Emmet's sound is specially useful here. UTERINE SOUND. 121 EMPLOYMENT OP THE SOUND FOR DIAGNOSIS AND TREATMENT. (A) DIAGNOSIS. (1.) Length of uterine cavity. This varies in different pathological Use of Sound in conditions. Thus the cavity is Diagnosis. (a) lessened in Superinvolution of uterus, Atrophic uteri ; N.B. The sound easily perforates the thin wall of the super- involuted uterus ; this does no harm. It may also pass along the Fallopian tube. (6) increased in Subinvolution of uterus, Hypertrophy of uterus, Cervical hypertrophy, Endometritis, Submucous fibroids, Interstitial fibroids, Small uterine polypi, Prolapsus uteri. (2.) Direction of uterine axis ; whether retroverted, anteverted, lateri- verted. (3.) Relation of axis of uterine body to that of cervix ; whether we have anteflexion or retroflexion. (4.) Stenosis and atresia at os internum and os externum ; tenderness of fundus, as in endometritis. (5.) Mobility of uterus. This should be ascertained in the following- way. Pass the sound as already described. Make the patient turn on her back, and then place two fingers in the vagina, palmar surface up- wards and touching the posterior lip of the cervix. The sound lies on the palm of the hand, is steadied with the thumb, and can be used to move the uterus gently about as desired. (6.) Rough condition of endometrium ; often associated with bleeding when sound is passed. (7.) Differential diagnosis between uterine polypi projecting into vagina, and inverted uterus, etc. When we have a polypus to deal with, the sound passes in through the cervix for more than the usual distance because the uterine cavity is enlarged. In inversion, it passes for only a short distance into the cervix and is then stopped by its reflexion. Sometimes, however, the neck of the polypus is adherent all round to the cervical canal, thus simulating inversion : and in some very rare cases the mucous membrane of the uterus becomes separated and expelled from the uterine cavity, simulating inversion of the whole uterus owing to the separation stopping at the os internum. It is evident that in these last two cases the Bimanual clears up the diagnosis, the upper hand feeling 122 PHYSICAL EXAMINATION OF PELVIC ORGANS. the body of the uterus in its normal position in both of them. The sound is only confirmatory of the Bimanual. (B) TREATMENT. Use of _ (1.) Rectification of abnormal angular relation between the uterine body Treatment. anc ^ cervix (anteflexion, retroflexion) ; dilatation of uterine canal as a whole, or of stricture at os intemum. (2.) Replacing of retroverted unfixed uterus, (3.) Application of acids to endometrium on the sound covered with cotton wool. FIG. 90. SOUND combined with BIHANCAL Examination (A. R. Simpson). DANGERS ATTENDING ITS USE. Dangersof The great dangers to the patient from the passage of the uterine sound bortion, and abrasion of the mucous membrane with absorption of septic matter and resulting pelvic cellulitis or peritonitis. UTERINE SOUND. 123 The former untoward result must be very carefully guarded against. One valuable caution is never to omit the question as to the menstruation, and to ask if it was the usual amount. Some women have a slight discharge of blood at the first period after they conceive, some even menstruate during the whole period of uterogestation. The best safe- guard is the careful performance of the Bimanual. This soon teaches the practitioner to know whether he has an unimpregnated uterus between his hands, or one at the second or third month of gestation. Special care should be taken when the uterus is retroverted : it may be also gravid ; and the pregnancy may, by causing pressure, have induced the patient to consult a medical man. As the Bimanual is often difficult, an unwary use of the sound may make the diagnosis disagreeably evident. The means to avoid setting up any inflammatory disturbance are to perform the Bimanual carefully, to curve and oil the sound properly, and to pass it gently. SOUND COMBINED WITH BIMANUAL. The importance of this method of examination has been recently use of pointed out by A. R Simpson. For its performance the short sound Sound m with the square handle (fig. 84) is necessary. It is of such a length that, when the middle finger is at the knob, the flat surface of the handle rests on the ball of the little finger, against which it is steadied by the flexed little and ring fingers. The sound is introduced into the uterus in the ordinary way. The fingers are passed into the vagina as for a vaginal examination, and the sound grasped as in fig. 84. Or the sound may be steadied with the middle finger while the index is used to feel the uterus through the anterior fornix (fig. 90). The external hand is placed as in the Bimanual. This method is specially useful (a) when the uterus is flaccid ; the sound stiffens it, and enables the external hand to define it : (b) when, from the presence of small fibroids or pelvic deposits, there is doubt as to what is the fundus uteri ; the sound felt by the external hand in the uterus, indicates the fundus. RELATION OF SOUND TO BIMANUAL AND RECTAL EXAMINATION. Before Sir James Simpson introduced the use of the sound, gyneco- Relation of logical examination was confined to the exploration of the vagina and Sound to Bimanual cervix. and Rectal Simpson gave an immense impulse to Gynecology, by placing in the hands of gynecologists an instrument which explored the uterine cavity above the cervix, and enabling them to obtain a perfection of diagnosis before undreamed of; thus gynecological examination came to consist of a vaginal examination, and then a passage of the sound, due attention 124 PHYSICAL EXAMINATION OF PELVIC ORGANS. being given to the non-existence of pregnancy. He recommended, further, the elevation of the uterus with the sound, and its definition with the upper hand. The next step in Gynecology was the use of the two hands the bimanual and rectal examinations which in the last twenty years has developed immensely. Consequently, the use of the sound has become more limited. The teaching in this chapter has been based on a recog- nition of this fact, inasmuch as the use of the sound is recommended only after the bimanual, rectal, and volsellar examinations have been carefully employed. CHAPTER XIII. TENTS AND OTHER UTERINE DILATORS. LITERATURE. Hegar und Kaltcribach. Die Operative Gynakologie : Stuttgart, 1881. Landau Ueber Erweiterungsmittel der Gebarmutter : Volkmann's Sammlung, No. 187. Lewers On Rapid Dilatation of the Cervix Uteri: Lancet, 1887, II., p. 507. Mundt Minor Gynecology : New York, 1881. Simpson, J. Y. Selected Obst. "Works, Vol. I. : Edinr. 1871. Sims, J. M. Uterine Surgery : London, 1867. See also Index of Recent Gynecological Literature in Appendix. HITHERTO we have considered only the means which have placed the Uterine vagina and cervix within range of digital examination. In this section x a ors ' we take up the methods by which we get digital examination of the uterine cavity methods of the highest practical value, which, like the sound, we owe to the genius of Sir James Simpson. We therefore consider the following methods of dilating the cervical canal : I. Slow dilatation with Sponge Tents, Tangle Tents, Tupelo Tents ; II. Rapid dilatation with graduated hard-rubber Dilators Tait's, Hanks', and Hegar' s ; III. Dilatation by incision and screw Dilators (v. Chap. XXVI.). DILATATION BY SPONGE, TANGLE, AND TUPELO TENTS. 1. Material. The sponge tent is a cone of good, unbroken, thoroughly Sponge- dried sponge, impregnated with some antiseptic, and then firmly com- material, pressed into small transverse bulk, its original length being preserved. When thus prepared and placed under conditions where it can absorb moisture, it swells up ; and in thus expanding dilates any dilatable structure which may grasp it. Good sponge tents of various sizes may be had from all chemists. In order to prevent the antiseptic from volatilizing, the sponge tents are covered with grease. They are provided with a tape at the base to aid their extraction from the cervix after use. Tents are also made from the ordinary sea-tangle (laminaria digitata) (fig. 91), and from tupelo wood (nyssa aquatilis). It is alleged that the tupelo expands more rapidly than either tangle or sponge. Fig. 92 Uses of Tents. 126 PHYSICAL EXAMINATION OF PELVIC ORGANS. shows its power in this respect Tangle tents may be had hollow ; this facilitates the imbibition of moisture but weakens their expanding power. 2 Purposes for which used. (1.) To restrain haemorrhage in cases of abortion, and at the same time dilate the cervix for further interference. (2.) To dilate the cervix and uterine cavity, and enable the prac- Scope of Tents. FIG. 91. Shows on the left a straight and a curved tangle tent, and on the right these tents after expansion. Note how one has been gripped by the os internum (Munde). titioner to ascertain and remove the cause of pathological uterine haemorrhage, whether due to endometritis, sarcomata, polypi, or incom- plete abortion. (3.) To correct pathological flexions of the uterus, or to dilate a stenosed cervix. Their use for this is not only unnecessary but dangerous. Tangle tents have the same scope as sponge tents. They do not, however, expand so well and thoroughly. Their special advantages are due to their smaller size, and the fact that several may be passed at the same time into the cervix. They are specially useful, TENTS. 127 therefore, in cases of narrow cervix and flexions. Tupelo tents are very good ; they are easily passed and, from their rapid expansion, preferable to sponge tents. FIG. 92. DIAGRAM to show relations between size of Tupelo Tent, before and after expansion. The dotted outside line indicates the size of the tent after expansion ( Munde). 3. Preliminaries to and Method of use. Tents should not be passed Prelimi- during an ordinary menstrual period, although they often require to be Mode of used when pathological bleeding is going on. They should always be Use - FIG. 93. EXPANDED TUPELO TENT with constriction at os internum (Munde). passed at the patient's own house ; and she should be kept strictly in bed during their use, and for some time after. Before their use, the vagina should be thoroughly washed out with warm carbolic lotion (1-40), or with corrosive sublimate (1-2000). Schultze, in passing tangle tents 128 PHYSICAL EXAMINATION OF PELVIC ORGANS. for flexions, first ascertains the uterine curve with the sound ; if blood follows its use, he postpones the introduction of the tent for forty-eight hours, in the meantime applying pure carbolic acid to the endometrmm. Before using the sponge tent, it is advisable to remove most of the gre covering it Sponge tents may be used in various ways. How (1 ) The patient is placed in the genufacial, or better, in the semi- pa8Bed< prone posture. Sims' speculum is passed, the anterior lip of the cervix laid hold of with a volsella and drawn down. The sponge or tangle tent, held in forceps, can then be passed into the cervix (fig. 95). (2.) The tent is fixed on the spike of an appropriate instrument, and FIG. 94. SPONGE TENT POLYPUS OF SIR JAMES SIMPSON. (\) Drawing of the uterus which contained a polypus obtained from a patient of Sir James Simpson's, who died from the haemorrhage it caused. It was this preparation which suggested to him the sponge tent. is then passed like the uterine sound; i.e., with the patient placed in the left lateral position, the index and middle fingers carried into the vagina and placed on the anterior lip of the cervix. The tent, fixed on the spike, is passed along these fingers and its point made to enter the cervix. The handle is then rotated and carried to the perineum. (3.) The patient is placed on her left side and athwart the bed. Pass the volsella, draw the anterior lip of the cervix down. The volsella is not always needed. Place the tent between the index and middle fingers of the left hand with the thumb at the base, carry these fingers into the vagina with their dorsum on the posterior vaginal wall, make the point of the tent enter the cervix and push it on with the thumb. TENTS. 129 Another way is to use the volsella as above described, but to fasten it to the bed. Then pass Sims' speculum holding it with the left hand, so that the tent held in the right hand can be passed into the cervix without difficulty. Occasionally, difficulty is experienced in passing a tent, owing to marked anteversion of the uterus. If the cervix be drawn down with a volsella, the difficulty may be overcome ; or it may be necessary to partially retrovert the uterus bimanually prior to passing the tent. FIG. 95. SIMS' DIAGRAM ILLUSTRATING PASSAGE OF TANGLE TENT. Patient is semiprone, Sims' speculum passed, and cervix steadied with tenaculum. The tent is passed with forceps. Tangle and Tupelo Tents. The same instructions as for sponge tents Moulding hold good. Tangle tents, however, when used to correct flexions must^a Tupelo first be moulded as follows : Ascertain the curve of the uterus by Tents - bimanual and sound, select a suitable tent and dip it for a few seconds in boiling water, then mould it to uterine curve and pass it as already explained. Tents require to be left in the cervix for a period varying from 12 to 15 hours, and the vagina should be frequently douched with carbolic lotion during this time. At the end of this period the tent should be removed. During the removal no great force should be used. Some- times the removal is difficult owing to constriction by the os internum or to irregularities in the mucous membrane. The cervix is generally then sufficiently dilated to admit of digital examination of the endometrium. 4. Dangers of Sponge and Tangle Tents and contra-indications. The Dangers practitioner must keep prominently before him that the use of a tent Q on fr a _ may prove by no means a harmless measure. Cases of death from septi- indica- tions. 130 PHYSICAL EXAMINATION OF PELVIC ORGANS. cjemia after the careful and proper use of one tent have occurred. The patient runs a risk proportionate to the number used ; and, therefore, it is not advisable to use more than two consecutively unless under special circumstances. They are not to be used if acute or sub-acute pelvic inflammation, pyosalpinx, ovaritis (acute or chronic), carcinoma cervicis, or pelvic haematocele be present. The reason why sponge tents may prove dangerous is only too ap- parent. The uterine mucous membrane is a lymphatic surface absorbing most rapidly. We cannot insert sponge tents with Listerian precau- tions; and, in addition, we have the expanding pressure of the tent forcing septic matter into the mucous membrane. FIG. 96. TAIT'S DILATORS. To sum up briefly, tents are highly useful in necessary cases no means at the disposal of the gynecologist gives him in proper cases such valuable help ; but he should not forget the risks occasionally arising from their use risks which should make him cautious but not timid. Hard RAPID DILATATION BY GRADUATED HARD-RUBBER DILATORS TAIT'S, HANKS', HEGAR'S. Dilators Taitx The statement already made as to the dangers attending the use of slowly expanding tents would lead one to expect that attempts at rapid dilatation have been made. For this purpose, graduated vulcanite dila- tors have been employed by Tait, Hanks, and Hegar. Taifs dilators consist of graduated vulcanite cones (fig. 96) which can be screwed on to a suitable handle. The proximal end of the handle is perforated for elastic bands which, passing in front and behind, are attached to a suitable belt round the patient's waist. Thus the elas- ticity of the bands causes the cone gradually to pass up into the cervix, dilating it as it goes. By this apparatus, Tait claims to avoid septic infection and to dilate rapidly. The obvious objection is the amount of watching it entails and the absence of the pelvic curve on the handle. In cases of abortion where the cervix is dilatable, Hanks' dilators seem serviceable. They have the oval shape seen at fig. 97, are gradu- ated in size and screw on to the sigmoid handle. They can be used manually to dilate the cervix until the fingers can be passed through. UTERINE DILATORS. 131 Hegar's dilators consist of a series of slightly curved stems 4|^ in. to 5i in. (12-14 cm.) in length, with a short flat handle 2 in. long, numbered from 1 to 30 and with diameters ranging from about T V in. to 1 T V in. (2-30 mm.). There is little doubt that, to prevent sepsis, vulcanite dilators are the best. For dilating the cervical canal quickly in order to explore the FIG. 97. HANKS' DILATOR. (}) uterine cavity with the finger, for the removal of polypi, or for curetting, they are specially indicated and are to be used as follows. In a case, for instance, where the cervical canal is to be dilated in order to gain access for the removal of a polypus, the patient is chloroformed, placed in the 30 FIG. 97A. HEGAR'S DILATOR. The lower figure represents the dilator (No. 15) complete, reduced to one-third scale ; the two upper figures show cross sections of the smallest (No. 1) and the largest (No. 30) sizes. lithotomy posture and the vaginal douche employed. Hegar's dilators, which are lying in a solution of corrosive sublimate 1 in 2000, are then passed, until sufficient dilatation is obtained. The polypus is then removed, and the uterine cavity carefully douched. We recommend therefore the use of the tupelo tents in cases of threatened abortion where the practitioner has not sufficient assistance to enable him to use the vulcanite dilators. Where, however, this assistance can be procured, especially for exploration, curetting, and endometric applications, Hegar's dilators are the safest and best. CHAPTER XIV. THE CURETTE. LITERATURE. Mundi The Dull Wire Curette in Gynecological Practice : Ed. Med. Jour., XXIII., p. 819. Recamier Memoire sur les Productions Fibreuses et les Fongosite's Intra- ute'rines : Univ. Med., 1850. Simon Die Ausloffelung breitbasiger weicher sar- komatoser und carcinomatoser Geschwiilste aus Korperhohlen : Beitrage zur Geburtshulfe von der Gesellschaft in Berlin, 1872. Sims, J. Marion Clinical Notes on Uterine Surgery : London. Thomas Diseases of Women : London, 1882. Curette. THE curette is an instrument, provided with a cutting or a dull edge, which can be introduced into the uterine cavity (previously dilated by tents if necessary) for the purpose of scraping off or removing abnormal endometric granulations, sarcoma of the mucous membrane, carcinoma of the cervix, or the remains of an incomplete abortion. This instrument has had a somewhat chequered career. Originally introduced by Recamier, whose instrument was stiff and sharp, it did good work in some cases ; but fell into disrepute, undoubtedly deserved, after the record of certain instances where its use had caused perforation of the uterus. Marion Sims and Simon recommend a modified instrument FIG. 98. LOOP OF RECAMIER'S CURETTE. (}) which, owing to its stiff unyielding nature, did not at first find much favour with the profession. Thomas then introduced his flexible dull wire curette, but this has now been found too feeble and a return has been made to stronger instruments. There are four varieties of curette (1.) Recamier's (fig. 98); (2.) Simon's (fig. 99); (3.) Thomas' (fig. 100); (4.) Martin's (fig. 101). Of these we recommend Martin's. Ca8e * in which the Curette is *5/W- The curette may be used to remove a piece of intrauterine tissue for aid in diagnosis. It is most frequently employed to remove abnormal tissue, in abortion, sarcoma tous or carcinomatous diffuse growth, and endometritic conditions. THE CURETTE. 133 Method of Use. We take curetting for incomplete abortion as a type of procedure. The instruments necessary are Sims' speculum, volsella, Hegar's dilators, sound or probes armed with cotton wool, and Fritsch's uterine double catheter (fig. 110). The instruments are placed in carbolic lotion (1-20) or in biniodide of mercury (1-2000). The F ' " Simon's SIMON'S SPOON. () Spoon. patient is placed semiprone or, if chloroform is given, in the litho- tomy posture: the speculum is passed and the cervix steadied with FIG. 100. THOMAS' DULL WIRE CURETTE, with knob added by A. R. Simpson. (J) a volsella. Hegar's dilators are now introduced until the cervical canal is patulous enough to admit the index finger. The curette is then employed by being passed systematically over the anterior and _ __ M ,, , ,,, , tfij _ _ ___ ^-sssss^'3 Martin's ^^^~^~ = =^"^ smir F^..^_-;" _~^Tr-"- --=^~?f-*^ Curette. FIG. 101. MARTIN'S CURETTE. posterior surfaces from above downwards. No-force is required, and the finger can make out by the feeling of the curette when the resistant muscle is reached. The cavity of the uterus is then washed out with a mercurial lotion, and pure carbolic acid applied. Cautions and dangers. The same precautions should be used as given Cautions under sponge tents. The dangers have proved in the authors' hands ?? d s slight, a minor attack of pelvic peritonitis being the worst. RELATION OF POSTURE TO EXAMINATION AND TREATMENT. We have already mentioned several postures as being the proper ones for certain manipulations ; and we here sum up briefly what it is of use to know in regard to these. The lateral posture, where the patient lies on her side in the ordinary 134 PHYSICAL EXAMINATION OF PELVIC ORGANS. way, is convenient for vaginal examination; for the use of Fergusson's, Nengebauer's, or disco's speculum, and the passage of the sound and catheter. The dorsal posture is imperative for abdominal examination and the bimanual. The semiprone is the best posture for passage of Sims' speculum or for vesico-vaginal fistula operation. The litJiotomy posture is specially valuable for operations on the perineum, vaginal walls, cervix and uterus. The genupectoral posture is used in replacement of the retroverted uterus. CHAPTER XV. KNIVES ; SCISSORS ; NEEDLES ; SUTURES ; DOUCHES AND SYRINGES; CAUTERY; ANESTHETICS. KNIVES. FOR perineal operations, the surgeon's ordinary straight bistoury is suffi- Knives, cient. For vaginal and cervical surgery, long-handled knives with the blade straight or at an angle to the shaft are required (v. under operation for vesico-vaginal fistula). SCISSORS. These are of the greatest use to the gynecologist and in many Scissors, instances supersede the knife. Straight sharp - pointed scissors are valuable in repair of the perineum. Curved scissors are necessary for fistula cases (fig. 102), Bozeman's being specially good. They are right FIG. 102. SIMPLE CURVED SCISSORS. and left, but no woodcut gives a proper idea of their curves. For cervical operations, stout and sharp scissors are necessary. It is very important to remember that the vaginal portion of the cervix is exceedingly tough, and that the ordinary scissors in. dividing it slip down or even turn obliquely, leaving the tissue uncut. Kuchenmeister's scissors have this tendency obviated by one of the blades being hooked (fig. 103). Even these scissors sometimes prove unsatisfactory, as the finger-and-thumb grip they give is not powerful enough. Fig. 104 shows a pair of cervical scissors devised by Hart, where the handles are like those of bone forceps, and are provided with a ratchet. They can, therefore, be grasped in the 136 PHYSICAL EXAMINATION OF PELVIC ORGANS. of the hand while being used, and cut even the densest cervix with great precision. Scissors are highly useful in perineal, vaginal, and cervical operations. FIG. 103. KUCHENMEISTER'S SCISSORS. FIG. 104. HART'S CERVICAL SCISSORS. HMQw. NEEDLES. We need only note that for cervical and fistula operations strong short needles either curved or perfectly straight are needed. The cervical tissue is so dense that markedly curved needles snap when slight. SYRINGES AND DOUCHES. 137 They are passed with a needle-holder, of which fig. 106 shows a simple ^eedle form. Curved or tubular needles set on handles are also useful. Holders. FIG. 105. FOKMS OF NEEDLE (Emmet). Hagedorn's needles are flattened laterally and full-curved. A special needle-holder is necessary for them. FIG. 106. NEEDLE-HOLDER. SUTURES. These may be silver wire, carbolized silk, catgut, silk-worm gut, or horse-hair. For fistuke, deep stitches, and cervical lacerations, silver wire or silk is used. For perineal operations, for superficial stitching, as also for stitching the ovariotomy incision, silk-worm gut is good. Catgut is valuable in the rectal stitches of complete rupture of the sphincter ani ; and is now largely used instead of silk for operations on the cervix, vagina, and perineum, as it obviates the necessity of removing the stitches afterwards. Carbolized silk (thin and fine) is best for the ovariotomy pedicle. Horse hair is useful for superficial skin stitches. VAGINAL SYRINGES AND DOUCHES : UTERINE DOUCHE. For the purpose of applying antiseptic and astringent lotions to the vagina and split cervix, for hot-water injections, and for merely cleansing FIG. 107. HICGINSON'S SYRINGE. purposes, the vaginal syringe and douche are employed. . Vaginal Syringes. Fig. 107 shows the well-known Higginson syringe. Syringe. Vaginal Douche. 138 PHYSICAL EXAMINATION OF PELVIC ORGANS. Valuable as this is, it is difficult for ordinary patients to manage single- handed. For them we should therefore recommend the Vaginal Doudie. A convenient form of this is shown at fig. 108. It can be hung up after being filled, and a gentle flow is thus obtained by gravitation. The overflow from the vagina is received into any suit- able receptacle on which the patient sits. For patients in bed its use is equally easy. The nurse or attendant should be instructed to make the patient lie on her back, her hips being well raised with a pillow. The pillow itself should be covered with a waterproof or folded blanket. An ordinary basin is then slipped below the hips to receive the overflow. Instead of the douche, a simple tube working by syphon action may be FIG. 108. VAGINAL DOUCHE. FIG. 109. SYPHON DOUCHE. employed. This consists of a "sinker," a long piece of gutta percha tubing with a bent piece of glass tubing inserted so as to render it rigid where it passes over the edge of the vessel containing the fluid, and a terminal vaginal tube. The " sinker " should be large and hollow, so that when inverted it may serve as a cup by which the tube may be filled with water ; once filled, the tube is temporarily compressed while the sinker is being dropped into the jug or pail full of water ready for use. The great advantage of the douche is its simplicity. Half of the women who buy a Higginson do. not know how to use it, and find it troublesome even when they do know. Medicated The material for injection is various. Hot water, as hot as the patient ' can bear it, is invaluable in inflammatory conditions. Hot carbolic lotion (equal parts of boiling water and 120 lotion) is admirable for cleansing purposes in abortion cases. SYRINGES AND DOUCHES. 139 In leucorrhoeal conditions, injections of alum (5j to oj), sulphate of copper (3ss to oj), sulphate of zinc (3ss to oj) are good. The general formula for these is R Aluminis vel Cupri Sulphatis, vel Zinci Sulphatis 5j- Fiat pulv ; mitte tales xij. Sig. To be used as directed. The patient is told to dissolve one powder, or half of one, in a pint of water, to place this in a douche and use as already explained. It is a good plan to make the patient first douche with hot water and then finally, in the dorsal posture, to end with the special lotion. After it is finished the dorsal posture should be maintained for ten minutes, and the last of the injection expelled by sitting up. The Uterine Douche is to be employed only after the cervical canal uterine and uterine cavity have been so far dilated as to admit the index finger. Douche - FIG. 110. FRITSCH'S CATHETER FOB WASHING OUT THE INTERIOR OF THE UTERUS. Aii ordinary vaginal douche or Higginson syringe may be employed ; if the former, a clean catheter is substituted for the vaginal tube ; with the latter, it is best to place the catheter at the one end of a long piece of indiarubber tubing, the other end of the tubing being attached to the syringe. In giving a uterine douche after the removal of abortion or fibroid polypus, the vulva and vagina should first be thoroughly douched. Care must be taken to give the uterine douche gently and slowly, allowing free exit of the fluid, and carefully excluding air from the apparatus. The size of the uterine tube should never be such as to fill the cervical canal. The best uterine tube is Fritsch's (fig. 110), or some of its modifications, as the double canula entirely obviates any retention of fluid. Passage of the fluid through a patent Fallopian tube into the peritoneal cavity is one of the risks but can usually be avoided by giving the injection gently. The uterine douche is used once only, immediately after the operation, unless septic symptoms arise. In the after treatment, the vaginal douche is sufficient. 140 PHYSICAL EXAMINATION OF PELVIC ORGANS. CAUTERY. Cautery- The ordinary cautery may be employed in the treatment of the pedicle Paquehn's. - n ovar i otonl y. Details are postponed till that subject is considered. In the well-known Paq'uelin's cautery, the vapour of benzoline is pumped through a slender, hollow cone of platinum, which has been previously heated in a gas flame or spirit lamp. It speedily becomes red or white hot by the combustion of the vapour, and can then be used. Note as to its use : (1) To be careful with the benzoline as it is exceedingly inflammable ; (2) To heat the platinum cone first (in outer- most zone of the flame) before pumping in the benzoline. If the vapour is pumped in before the platinum is hot enough to ignite it, the cone is cooled by its cold stream. The cautery should be used at a dull heat. When white hot it causes bleeding, because it thoroughly burns the tissues and thus leaves no char to act as a haemostatic. When used to cauterize the cervix, care is necessary that the hot metal rod does not touch the vaginal walls. Various plans have been tried to prevent this accident. Thus the rod may be covered except at its terminal two inches with a wooden case which must not touch the metal. Fig. Ill shows some of the various rods of Paquelin's cautery. ANESTHETICS. LITERATURE. Brunton, T. L. Remarks on One of the Causes of Death during the Extraction of Teeth under Chloroform : Br. Med. J., II., 1875, p. 395. Chiene Chloroform : London Practitioner, January 1877. Hart, D. B. On Death from Insufficient Administration of Chloroform: Ed. Med. J., 1879. Lister Chloroform : Holmes' System of Surgery, Vol. V. Report of Br. Med. Ass. Com- mittee : Br. Med. J., Vol. I., 1879. Murray, B. Milne The Cessation of Respiration under Chloroform and its Restoration by a new method : Edin. Med. J., 1885. See also Index of Recent Gynecological Literature in the Appendix. Ansesthe- THE chief anesthetics are chloroform and ether. Other agents or mix- tures have been tried viz. ethidene ; mixtures of alcohol, ether, and chloroform ; nitrous oxide ; bichloride of methylene : the results have not been satisfactory with these. In the British Medical Report on the action of anesthetics, ethidene is strongly recommended. Chloroform and ether, however, still remain our most trustworthy agents. Action of Action of Chloroform. Chloroform when administered to a patient has form a perfectly definite effect on the nervous system. Sensation is first abolished, and then reflex action. This is all the effect wished for in any case. If, however, the chloroform be pushed further, the respiratory centre becomes paralysed so that breathing ceases ; and finally the heart stops from paralysis of its ganglia. In almost all cases this is the sequence in the susceptibility to chloroform of the parts of the nervous system regulating 'sensation, reflex action, respiration, and the circulation. Rarely have we the heart affected before the respiratory centre. When ANAESTHETICS. 141 first administered, it causes a transient rise in the blood pressure ; and then a gradual irregular fall. The more recent investigators on this point (see the British Medical Report) found that in dogs chloroform reduced the blood pressure more rapidly and to a greater extent than FIG. 111. VARIOUS FORMS OF PAQUELIN'S CONES. A rectangular ; B curved ; C straight. ethidene, and that ether did not cause any appreciable depression. As the blood pressure is the resultant of the force and frequency of the heart's action and the state of dilatation of the small blood-vessels, it is evident that chloroform when administered to dogs slowed the heart and weakened the vasomotor centre more than ethidene or ether. It should 142 PHYSICAL EXAMINATION OF PELVIC ORGANS. be kept in mind, however, that dogs are very susceptible to the action of chloroform and easily killed by it. Death not It is wrong to suppose that in every death under chloroform the fatal to^er-' U result is caused by - an over-dose, or by the action of the drug on dose. a fatty heart. This is a very common view, but an exceeding^ erroneous one. To prevent the patient's feeling, though one of the most gratifying results of anaesthesia, is not by any means the great object in operative cases. One of the most essential aims of its administration is to prevent the reflex transmission of powerful nervous impulses from the part oper- ated on to the heart, or their direct transmission to the respiratory or vaso- motor centres. If chloroform be administered to a limited extent so that sensation alone is abolished, and any large nervous trunk like the Fifth, or large nervous area like the splanchnic, be irritated, then we may have reflex inhibition of the heart or paralysis of the vasornotor and respiratory centres ; in man, death may result. There are reliable clin- ical reports that this reflex inhibition of the heart has caused its stoppage in man. It is sometimes urged against this that no amount of stimu- lation of the lower end of the cut vagus in a rabbit can permanently stop its heart ; in man, however, the conditions are not the same as in the rabbit. Goltz, quoted by Lauder Brunton, gives some most inter- esting facts in this connection. A frog was decapitated, its heart exposed, and the animal hung with its legs downwards. On tapping the intes- tines pretty hard, the heart stopped through reflex inhibition of the vagus but soon resumed again. It contracted vigorously but had no blood in it to propel. The irritation of the splanchnics had not only inhibited the heart but so lowered the tone of the vasomotor centre that the veins of the abdominal cavity were widely dilated ; and thus the blood, when the animal was vertical, did not reach the opening of the inferior vena cava into the right auricle. When the frog was laid on its back, how- ever, the blood flowed at once to the heart. This then gives us the proper view of the administration of chloroform in all cases where cutting operations or operations involving large nervous trunks are being performed : the chloroform must be pushed until sensation and reflex action are abolished, and this state is to be kept up during the operation. Uses. Uses. Chloroform is used in all cutting operations except very slight ones ; where the straining of the patient prevents the manipulation necessary for accurate diagnosis and treatment ; in phantom tumours ; and also, when necessary, in cases where vaginal examination of virgins is indicated. In division of the cervix, curetting of the eudometrium, and applica- tion of caustics to the endometrium, it is unnecessary unless the patient is unusually sensitive. ANAESTHETICS. 143 Method of administration. The patient should have no food for three Method of or four hours prior to the operation. Just before the administration chloroform is begun, half a glass of wine or brandy may be given. The patient lies on the back with all fastenings unloosed, and should not sit up. A towel or napkin folded square is taken and chloro- fjorm poured on it. Fig. 112 shows a convenient and economical drop- cork which can be fitted into any bottle. The amount does not matter. We judge of the amount of chloroform required not by the quantity poured on the cloth but by the effect on the patient. If reflex action be not abolished, even though a quart has been used, the patient has FIG. 112. CHLOROFORM DBOP CORK. not had enough ; while if respiration be affected after a few whiffs, she has had too much. The face of the patient should look to the side, and the chin should be kept well away from the sternum. The administrator keeps the chin forward with his right hand. This has the additional advantage of allowing him to feel the piiff of the breath on the palm. The cloth is to be held not too closely over the face and the patient directed to take long breaths. 144 PHYSICAL EXAMINATION OF PELVIC ORGANS. The administrator has to keep two points before him. He is to watch- the breathing most narrowly, and to ascertain when reflex action is abolished. He can watch the breathing well by feeling the puff of the breath con- stantly on his hand. The abolition of reflex action is generally tested by touching the conjunctiva; when the patient is not fully under, the orbicularis contracts. This is not a perfect test, but the best we have. When reflex action is abolished, no more chloroform is to be given ; should it show signs of returning, fresh chloroform is put on the cloth. DANGERS. These are the following : Dangers. (!) Asphyxia; (2.) Reflex inhibition of heart or respiratory or vasomotor centres. (1.) Asphyxia. This may arise early from fainting, muscular relaxa- tion allowing the tongue to fall back on the pharynx ; or from closure of the glottis, owing to paralysis of its intrinsic muscles. The marked extension of the head already insisted on prevents the former from hap- pening. If it arise, the tongue is to be pulled well forward with a pair of forceps. Foulis recommends that the tongue be pressed forward by a spatula or spoon applied at its root. When asphyxia arises from paralysis of the respiratory centre owing to an overdose of chloroform, the treatment is immediate stoppage of the administration of the chloroform and artificial respiration by Sylvester's or Howard's method for hours if necessary. The head should be kept hanging over the edge of the table, so as to send blood to the respira- tory centre ; or the patient may be inverted (Nelatonized). Recently, Milne Murray in an elaborate research has pointed out the interesting practical fact that artificial respiration must in the first place send more chloroform through the system, inasmuch as the lung is charged with chloroform vapour. He therefore advocates aspiration of the chloroform vapour from the lungs prior to beginning artificial respir- ation. For this purpose he recommends that a gum elastic catheter, provided with a conical collar to fit the glottis, be passed into the trachea and the air be sucked by the administrator from the lungs. When this has been done several times the tube should be partially withdrawn so as to remove the conical collar from the glottis, and pernation employed : i.e., the chloroform vapour is still sucked from the lung, but air now passes in between the tube and trachea, and thus a current is established. When all traces of chloroform vapour have disappeared, ordinary artificial respiration should be practised. Reflex In- (2.) Reflex inhibition of the heart or respiratory or vasomotor centres. This can only happen when there has not been given sufficient chloroform to abolish reflex action. It is by no means an uncommon thing, there- ANAESTHETICS. 145 fore, for the patient to die because sufficient chloroform has not been administered ; sensation alone had been abolished when the operation began. The usual account is that " the patient gave a start when the first incision was made, and died." In some cases this has happened after only a teaspoonful had been poured on the cloth. Yet this is often called "a death from chloroform." Contra-indications. Every patient on whom an operation is to be Contra- performed may have chloroform ; if the operation is indicated, so is tions. chloroform. If the patient has a weak heart, then chloroform is impera- tive for any major operation ; it must be given till reflex action is abol- ished, as reflex inhibition of the heart is specially dangerous here. Occasionally, chloroform causes severe vomiting after the operation. Vomiting. For this reason Keith always uses ether. Vomiting during the operation is dangerous only when any solid matter regurgitates back into the trachea ; tracheotomy may then be necessary. Sickness after the operation is treated by the sucking of ice and the application of a mustard leaf to the pit of the stomach. COCAINE,* introduced by Roller as a local anaesthetic, is coming to be much used in Gynecology, especially in the removal of urethral caruncles, Emmet's operation, ligature of piles, and plastic operations on the perineum. A solution of the hydrochlorate (4 20 p. c.) is the one usually employed. * See T. L. Brunton Pharmacology, Therapeutics and Materia Medica : London, 1885. Many papers on the use of Cocaine in Gynecology will be found under "Anaesthesia" in the Index of Recent Literature in the Appendix. CHAPTER XVI. RELATION OF MICRO-ORGANISMS TO GYNECOLOGY: ANTISEPTICS. LITERATURE. Barbour Puerperal Septicaemia : Edin. Med. Journ., Nov. 1885 ; Discussion, Feb. 188G. Bockhart Beitrag zur jEtiologie und Pathologic des Harnriihrentrippers : Viertel- jahrschrift f. Derm. 1883, Heft 1. Brunton, T. L. Pharmacology, Thera- peutics, etc. : London, 1885. Bumm Beitrag zur Kenntniss der Gonorrhoe der weiblichen Genitalien : Arch. f. Gynak., Bd. XXIII. S. 327. Cheyne, W. W. Antiseptic Surgery : London, 1882. Manual of the Antiseptic Treatment of Wounds : London, 1885. Davaine Rechercb.es relatives k 1 'action des substances antiseptiques sur le virus de la septice'mie : Com. Rend. Soc. de Biolog., Tom. I., 6th Series, p. 25. Dougall On the Prevention of Putrefaction and the Destruc- tion of Contagia : Glasgow Med. Journal, Vol. VII. Klein Micro-organisms and Diseases : Lond. 1884. Koch Article " Ueber Desinfection " in Mittheilungen aus dem kaiserlichen Gesundheitsamte : Berlin, 1881. La Place Saure Sublimat- losung als desinficirendes Mittel und ihre Verwendung in Verbandstoff en : Deutsch. Med. Woch., Leipz., 1887, XIII., 866. Lister, Sir J.On Corrosive Sublimate as a Surgical Dressing : Lancet, 1884, p. 223. Lomer Our present Knowledge of the Relations between Micro-organisms and Puerperal Fever : Am. Journ. of Obstet., Vol. XVII., p. 673. Lusk Nature, Origin, and Prevention of Puerperal Fever : Intern. Congr. Tr., 1876. Also article "Puerperal Fever " in Pepper's Practical Medicine, 1885. Neisser Die Mikrokokken der Gonorrhoe : Deutsch Med. "Woch. 1882, No. 20, S. 279. Petit Sur les substances antifermentescilles : Comptes Rendus de 1'Academie des Sciences, 1872. Russell, J. A. Article "Disinfection : " Quain's Diet, of Medicine, 1883. Stadfeldt Sind als Desinficiens in der Geburt- shiilfe Sublimatlosungen der Karbolsaure vorzuziehen: Centralbl. f. Gyn. 1884, No. 7. Tarnier Contribution to Discussion on Spiegelberg's paper on " Antisepsis in Geburtshiilfe : " Transactions of London Intern. Congress, Vol. IV., 1881, p. 390. Woodhead, O. S. Notes on the use of Mercuric Salts in Solution as Antiseptic Surgical Lotions : Proc. of Roy. Soc. Edinr, 1888. v. also Reports of Laboratory, R.C.P.E., 1888. Woodhead and flare Pathological Mycology: Edinr. 1885. Ziegler Pathologische Anatomic, Bd. II. S. 805. The U.S.A. Catalogue gives full references under Antiseptics and Disinfection. See also Index of Recent Gyneco- logical Literature in the Appendix. RELATION OP MICRO-ORGANISMS TO GYNECOLOQY. of e micro- 8 THE recent advances in regard to the part played by micro-organisms in organisms the etiology of disease have not been shared, to any great extent, by oology"! 6 Gynecology. Steurer, who investigated an epidemic of puerperal fever at ANTISEPTICS. 147 Strassburg, found cases with diphtheritic patches about the vulva ; and from these traced bacteria into the connective-tissue spaces where their presence gave rise to cellulitis ; from the spaces, they entered the lym- phatics causing lymphangitis. Klebs, who terms the bacteria found in a wound "microsporon septicum," traced their extension (with or without the aid of wandering white blood-corpuscles) from serous membranes into the connective tissue and noted their penetration through the eroded wall of a vein. Recklinghausen found the lymphatics of the skin, at the edge of an erysipelatous patch, filled with bacteria. Gynecologists have thus been led to suspect that pelvic peritonitis and cellulitis, as well as septiccemia following operations, are all caused by micro-organisms or their products ; but as yet the definite proof of this, as formulated by Koch, has not been forthcoming. Although many authors have pointed out that various micro-organisms have been found in the tissues after death from such diseases, yet the four criteria demanded by Koch have not been satisfied. These are the following : (1) The micro-organisms must be present in the tissues or blood-vessels of the diseased animal or man, and in that disease only ; (2) a pure culti- vation of these must be obtained ; (3) inoculation with this must give the same disease to an animal capable of receiving it ; (4) in the tissues or blood of this newly affected animal the micro-organisms must be found, and in the same relation to them as in the original disease. Until these are satisfied we shall not reach such demonstration of the relation of micro-organisms to these diseases as we have in the case of splenic fever. It is to be hoped that the application of the processes now known to pathologists will solve this problem. In GonorrJuea, however, by the researches of Neisser, Bockhart, Bumm, and others, special micrococci have been found. Bumm describes these as diplococci (i.e. the micrococci are dual), half cylindrical, and measuring in length 2 '2-2 '5 //,. Not only have the micrococci described by Neisser been isolated so as to give a pure cultivation, but gonorrhoea has been caused by an inoculation with this (Bockhart). Advances have also been made in our knowledge of tubercular diseases, as the bacillus tuberculosis has been found in peritonitis and Fallopian- tube disease. ANTISEPTICS. By an Antiseptic we understand an agent capable of destroying Antiseptics, or inhibiting the growth of the septic or pathogenic micro- organisms. Formerly, the evidence of the antiseptic properties of any substance 148 PHYSICAL EXAMINATION OF PELVIC ORGANS. was considered sufficient if it kept a wound free from foetor and caused no blackening of the protective at the wound. Owing however to increased knowledge as to the nature of micro-organisms arrived at by improved methods of isolation and cultivation on gelatine or peptonised jellies, more exact information has been gained as to the trustworthiness of our many antiseptic agents. Thus Dougall of Glasgow mixed vaccine matter with carbolic lotion (1-20) and left it exposed for twelve days ; he found that it was still cap- able of producing the usual vaccine pustule. The most elaborate and exact researches have, however, been made by Koch, and his results have been found to tally with subsequent clinical trial. Koch's method was as follows : he dipped sterilised threads in culti- vations of bacilli not containing spores, and others in those containing spores ; the former were then immersed in a solution of carbolic acid (1 p. c.) for two minutes, and thereafter placed on some of the materials used for cultivation, and he found they did not grow ; the latter (i.e. those with spore-bearing bacilli) were however unaffected after being steeped even for two days in a 2 p. c. solution of carbolic acid. Immersion in even a 5 p. c. aqueous solution of carbolic acid did not render the spores incapable of development. 5 p. c. solutions in alcohol and in oil were ineffective on the spares even after 70 to 110 days' immersion ; similar solutions destroyed the bacilli after six days' immersion. The most powerful germicide was found to be corrosive sublimate, which in weak solutions (1 in 20,000) killed spore-bearing bacilli almost immediately and inhibited their growth when of a strength of only 1 in 30,000. An evident difference exists between micro-organisms in relation to their resistance to antiseptics : bacilli without spores, and micrococci, are readily killed by a 1-20 aqueous solution of carbolic acid, while spores resist immersion in 1-20 carbolic lotion even for days. Carbolic oil and alcoholic solutions of carbolic acid have proved inefficient as antiseptics and should therefore be discarded in prac- tice. These researches give a guide in determining what antiseptics we should use but require, as we shall see, to be accepted with some modification. Activity The following is taken from a table given by Koch of the activity of . various antiseptics. The double underlining means that after that number of days the spores of the bacillus anthracis were taken out of the fluid and found to be no longer capable of development. When the numeral is not so underlined it means that after immer- sion for the special number of days the spores were still capable of growth. ANTISEPTICS. 149 FLUID. PERIOD (in days) OF THE IMMERSION OF THE SPORES IN THE FLUID. REMARKS. Absolute alcohol 1 3 5 ... 110 JEther 158* 30 incomplete growth. Oil of Turpentine Chlorine water 1* 5_10 1 5 *Isolated but well-mark- ed development. Bromine (2 % in water) 1_ _5_ Iodine water 1 Iron chloride Sublimate (1 % in water) 2* 6 1_ 2 'Delayed but well de- veloped. Thymol (5 % in alcohol) 1 6 10 15 Salicylic acid (5 % in alcohol) 1 6 10 15 In regard to thymol and salicylic acid it should be noted that alco- holic solutions were used, which, like oily solutions of antiseptics, are less effective than aqueous ones : e.g. an alcoholic is less active than an aqueous solution of iodine. We must now consider our chief antiseptics from the clinical stand- point. Carbolic acid is in many respects one of our most trustworthy anti- Carbolic septics. A watery solution of 1 in 20 is thoroughly effective except in the case of spore-bearing bacilli, and can be relied on in operative work. Frorn its not acting on metals and having no injurious action on sponges, it is useful for cleaning these as well as for skin cleansing. A solution of 1 in 20 if prolonged in its use has, however, a disagreeable action on the skin and the odour is pronounced. Corrosive sublimate was recommended in 1874 by Davaine, vised by Tar- Corrosive J J pi__i_i; i_ nier in obstetrics prior to 1880, and was very many years ago the favourite ' antiseptic of the late A. B. Stirling, assistant-curator in the Edinburgh Anatomical Museum, so well known for his freezing-microtome and microscopic work. Since Koch found it the only germicide for the spores of bacillus anthracis, it has come into great prominence. Solutions of 1 in 2000, 1 in 4000, 1 in 8000 are very effective ; it is undoubtedly a valuable addition to antiseptics, as it is rapid in action, very soluble, odourless, and non-irritating to the hands. Its corrosive action on instruments and injury to sponges are the drawbacks to its use. Some important facts as to the action of corrosive sublimate on soaps Sublimate. 150 PHYSICAL EXAMINATION OF PELVIC ORGANS. and blood albumin must be kept in mind. With ordinary soaps, albumin, or blood, we get insoluble and inert compounds formed. Thus if 5 c.c. blood be added to 50 c.c. corrosive sublimate (1-1000), nearly all the mercury is thrown down as albuminate of mercury. This precipitation of the mercury is prevented however by the addition of tartaric acid or common salt, so that p.c. to 1 p.c. salt solution should be used in making 1 to 1000 corrosive sublimate (Woodhead). Messrs Duncan, Flockhart *. SfiL. Pelvic cellulitis, Fibroid on posterior wall of uterus. Ovarian cyst behind uterus, Extra-uterine pregnancy, Retention of blood in horn of a malformed uterus, Retroversion of non-gravid or gravid uterus. Of these we consider at present only pelvic peritonitis and pelvic cellulitis. The others will be treated of each under its respective head. In these two purely inflammatory affections we have the inflammatory symptoms from the first ; without a history of sudden onset, of menor- rhagia, or of the symptoms of internal haemorrhage. Further, the difference in etiology of hsematocele and peritonitis will help us. The history is the most important aid in diagnosis. COURSE AND RESULTS. In many cases (4 according to Voisin) the blood effused becomes Course and entirely absorbed, in a time varying from 2 to 10 months. The tumour, with partially clotted or purulent contents, may burst into the rectum, vagina, or peritoneal cavity ; in the last case, fatal peritonitis follows. When the blood effusion is very large, death may be rapid. PROGNOSIS. As to life. This is, as a rule, settled soon. The most fatal cases are Prognosis, extra-uterine pregnancies, and those in which there are no peritonitic adhesions to limit the blood effusion. After peritonitis is set up, the prognosis is much as in pelvic peritonitis. TREATMENT. (1.) At onset of hcemorrhage. (2.) When suppuration occurs. (1.) At onset of haemorrhage. The treatment here is expectant. The Treatment, patient is to be put at complete rest, with ice-bags to the abdomen. Ergotine should be injected into the buttock. The ice-bag is to be kept on for several days, as this will limit the subsequent peritonitis. If the patient is collapsed, then stimulants and hypodermic injections of sulphuric ether or whisky must be freely used ; a large mustard poultice 186 PERITONEUM AND CONNECTIVE TISSUE. over the abdomen is often serviceable, both as a blood derivative and in allaying vomiting. In most cases, the source of the bleeding is unknown ; the present state of knowledge does not enable us to lay down any rule as to the opening of the abdominal cavity and the attempt to ascertain and secure the bleeding source. In Fallopian-tube pregnancies which have burst, however, the abdomen has been opened and the tube ligatured on either side of the rupture ; Lawson Tait has operated successfully on forty-two cases of rupture of Fallopian-tube gestation, but always at some period after the rupture. Sinclair, Herman, and Berry Hart in this country, and Johnstone in America, have also operated success- fully. Martin has performed laparotomy in four cases successfully. He opens the abdomen, incises the sac, clears out clots, ties vessels, and drains. When possible, the opening of the blood sac should be stitched to the abdominal wound. Imlach of Liverpool has also recorded cases where he opened the abdomen and tied the Fallopian tubes along which blood had regurgitated. Accordingly, we may now look forward to an extension of more active interference by abdominal section. Zweifel has in several cases incised the tumour per vaginam, turned out the clots and drained the cavity. In Haematoma, when absorption is very slow, Gusserow has had good results by incising through the vagina, washing out, and draining. When absorption is going on, the treatment is the same as in pelvic peritonitis. (2.) After suppuration has occurred. The tumour is to be opened and drained, as recommended at p. 171 For suppurating pelvic cellulitis. Recently, Lawson Tait has recommended that some pelvic abscesses be opened by abdominal section, as we often get very tedious cases when they perforate into the bowel. The following was the treatment in one of six cases in which he performed it. "I determined to open it from above. ... I found a large cavity containing about two pints of foetid pus with decomposing blood-clots. This I carefully cleansed out, and after having united the edges of the opening into the cyst carefully to the abdominal wound, I fixed in one of Koeberle's drainage tubes five inches long. . . . The patient went home cured on the thirtieth day." Tait's cases were chiefly suppurating hsematoceles (Tr. of Lond. Roy. Med. and Chir. Soc., vol. 62). NEW GROWTHS. 187 NEW GROWTHS IN THE PELVIC PERITONEUM AND CONNECTIVE TISSUE (BROAD AND ROUND LIGAMENTS). LITERATURE. PERITONEUM AND CONNECTIVE TISSUE : BROAD LIGAMENT. Cobbold, W. A. Parasites : Churchill, 1879. Freund, W. A. Das Bindegewebe im weiblichen Becken und seine pathologischen Veramlerungen mit besonderer Beriicksichtigung der parame- tritis chronica atrophicans und der Echinococcuskrankheit : Gynakologische Klinik, Strassburg, 1885. Freund and Chadunck Four cases of Echinococcus in the Female Pelvis: Am. J. of Obstet., 1874. Hart, D. Berry Sarcoma of pelvic connective tissue in Atlas of Female Pelvic Anatomy : Edinburgh, 1884. Neisser Die Echino- coccuskrankheit : Berlin, 1877. Schatz Die Echinokokken der Genitalien und des kleinen Beckens beim Weibe : Cent. f. Gyn., 44, 1886. Simmons Malignant disease of female Sexual Organs : Edin. Med. Journ. Dec. 1885. Cobbold and Neisser give the literature on Echinococci fully and references to cases by Hewitt, Corrigan, Turner, Wynne, and others. ROUND LIGAMENT. Goodell Lessons in Gynecology : Philadelphia, 1880. Sanger "VVeitere Beitrage zur Lehre von den primaren desmoiden Geschwiilsten der Gebar- mutterbander, besonders der Ligamenta rotunda : Archiv f. Gyn. XXI. 279 and XXIV. 1. Schroedei Krankheiten der weiblichen Geschlechtsorgane : Leipzig, 1878, S. 417. Thomas Diseases of Women : Philadelphia, 1880, p. 136. Wile- Hydrocele in the Female : Am. J. of Obst., July 1881, which see for further literature. Winckel Lehrbuch der Frauenkrankheiten : Stuttgart, 1886. TUMOURS OF THE BROAD LIGAMENT. Hsematoma and inflammatory conditions of the broad ligament have Tumours been already considered. We need only further mention that we may Ljg ament . have cysts, fibroids (rare), phleboliths, cancer, and tuberculosis ; the last two are only parts of the general peritoneal affection. Ovarian cysts may develop into the Broad Ligament, and cysts may develop in the Broad Ligament independently of the Parovarium. Cysts of the Broad Ligament will be considered along with Ovarian Tumours. HYDROCELE OF THE BOUND LIGAMENT. Nature and Pathological Anatomy. This is a rare malady, and may Hydrocele exist as encysted fluid about the round ligament (extra-peritoneal), orj ^^ in the canal of Nuck a process of peritoneum extending from the internal inguinal ring into the labium majus. It may be closed at the internal ring, thus forming a cyst ; or it may communicate with the peritoneal cavity. The fluid is serous in its nature ; it may be olive-green in colour. Physical Signs. (a) Of encysted hydrocele of the cord. An oval trans- lucent swelling exists in the ingiiinal canal. It cannot be returned into the abdominal cavity, has usually existed for some time, is not tender on pressure, and gives rise to no symptoms. It must be differentiated from an ovary in the inguinal canal, and from incar- cerated hernia. 188 PERITONEUM AND CONNECTIVE TISSUE. (b.) Ofhydrocele in the labium ma jus. The labium majus is distended with a fluctuating tumour, dull on percussion and of translucent appearance; usually, the contents cannot be returned into the abdo- minal cavity. Aspiration gives a clear fluid. It is to be diagnosed from hernia in the usual way. Treatment. Aspiration and drainage; or aspiration and injection of a few drops of tincture of iodine. Goodell recommends that when the labial form communicates with the abdominal cavity, the internal ring should first be firmly compressed and the injected fluid then sucked out. TUMOURS OF THE ROUND LIGAMENT. Tumours Fibrous, myomatous, sarcomatous tumours, and their combinations, ligament, have been described in the round ligament by Sanger. They may develop in any part of its course : intra-peritoneally ; within the inguinal canal ; or extra-peritoneally in the abdominal wall, the pelvic cellular tissue or the labia majora. Such tumours are rare, those of the third group (extra-peritoneal) being the most frequent. They may be removed unless dipping down into the pelvis. ECHINOCOCCI IN THE PELVIC ORGANS. Echino- Echinococci or Hydatids are the sexually immature forms of the Pely'lc" Tsenia echinococcus, a small tapeworm found in the intestines of the Organs. dog. When present in the human body, they form elastic tumours and may occur in the female pelvic organs. Freund, in 25 years, met with 19 cases of which 7 were in the pelvic connective tissue : while Schatz met with 6 out of 7000 gynecological and obstetric cases (1 in 1166). Schatz has also collected 66 cases of Echinococcus disease in the female pelvic organs and found the frequency as follows : 14 in uterus, 14 at pelvic brim, 10 in Douglas' pouch, 7 in ovary, 7 in broad ligament, 7 in pelvic connective tissue, 5 between rectum and vagina, 2 between bladder and vagina. They may remain many years without symptoms or may perforate into bowel or bladder. When large, they cause pressure symptoms on bladder and rectum. The physical signs are those of a tense elastic tumour without pain ; at first, usually situated near the rectum ; and ultimately, when increased in size, displacing the pelvic organs as an ovarian tumour would when developing between the layers of the broad ligament, i.e. first forwards and then upwards. The diagnosis is often difficult and tapping may be requisite. When they project sufficiently into the abdomen, the treatment is laparotomy with shelling out of the tumour ; or incision of the sac, with careful cleansing and stitching the edges to the abdominal incision (v. Abdominal Section in Appendix). When pelvic, the sac is opened and drained (v. pp. 171-2). Hydatids are rare in this country, but common in Iceland and Australia (Cobbold). NEW GROWTHS. 189 TUMOURS OF THE PELVIC CONNECTIVE TISSUE. We may have fibromyomata, sarcomata, or dermoid cysts as primary Tumours conditions in the pelvic connective tissue. f Pelvic Fig. 120 shows the pelvis from an interesting case of primary sarcoma Tissue. Avhich began in the connective tissue at the left side of the uterus and spread through the lymphatic glands. This case presented the follow- ing points of interest. A. B., set. twenty-seven, was an undersized, wretchedly thin girl, who had felt unable for her usual occupation of a domestic servant ; but the medical man whom she had con- sulted had been unable at first to find anything tangible to account for her condition. Afterwards, however, the inguinal glands of the left groin (those parallel to Poupart's ligament) began to be enlarged, and the left leg was painful and somewhat swollen. In FIG. 120. SARCOMATOUS TUMOUR OF THE PELVIC CONNECTIVE TISSUE (Hart). A Tumour, B Uterus, Bl Bladder, Ov Ovary, c c Inguinal and c' c' Sacral Lymphatic Glands. the vast majority of cases, enlargement of the inguinal glands parallel to Poupart's liga- ment means some irritation in the external genitals or lower fourth of the vagina, an irritation either syphilitic, gonorrhceal, or cancerous. The external genitals and vagina were in this girl, however, perfectly healthy, and the condition of the parts was, further, virginal. Deep palpation of the left iliac region gave a sense of resistance at the left margin of the true pelvis ; and, on bimanual examination of the pelvic organs, the normal-sized uterus was lying close to the right margin of the true pelvis ; at the left side of the true pelvis could be felt a firm resisting mass, about the size of half a cocoa- nut. It seemed firmly fixed to the pelvic wall, and gave no feeling of fluctuation. Any operation was hopeless, and one could only palliate the pain by large doses of morphia given hypodermically. 190 PERITONEUM AND CONNECTIVE TISSUE. The girl died miserably about six months afterwards. On post- mortem the pelvis was removed, and fig. 1 20 gives a view of the parts as seen through the brim. The displaced uterus (B), subperitoneal malignant mass (A), enlarged inguinal glands on both sides (c c), and the large mass of the sacral glands (c' c') are well seen, On more minute examination, the enlarged obturator glands were found, as well as the sacral ones in front of the sacrum. The primary tumour (A) did not communicate directly with the enlarged left inguinal glands. Micro- scopical examination showed it to be a round-celled sarcoma. This case illustrates not only a rare form of pelvic disease but also lymphatic communication between the obturator glands and those of the inguinal glands parallel to Poupart's ligament. Sarcoma may also arise in the recto-vaginal septum and produce a swelling simulating, from its position and the displacement caused by it, a retro-uterine tumour in the pouch of Douglas. SECTION IT. AFFECTIONS OF THE FALLOPIAN TUBES AND OVARIES. CHAPTER XIX. Affections of Fallopian Tube. and Parovarium. XX. Malformations of Ovary : Ovaritis and Periovaritis : Displacements of Ovary Hernia, Prolapsus. ,, XXI. Operations for Removal of Fallopian Tubes and Ovaries. ,, XXII. Pathology of Ovarian Tumours. ,, XXIII. Diagnosis of Ovarian Tumours. ,, XXIV. Operative Treatment of Ovarian Tumours. CHAPTER XIX. AFFECTIONS OF FALLOPIAN TUBE AND PABOVABIUM. LITERATURE. andl Die Krankheiten der Tuben, etc., Billroth's Handbuch : Stuttgart, 1879. Barnes Diseases of Women : London, 1878, p. 376. Doran Clinical and Pathological Observations on Tumours of the Ovary, Fallopian Tube, and Broad Ligament : London, 1884. v. also Trans. Path. Soc., Lond.,1887; and Trans, of Lond. Obst. Soc., 1887. Duncan Diseases of "Women: Lond., 1882. Foidcr, J. K. Hydro- and Pyo-Salpinx : Med. Times and Gazette, 1884. Freund Ueber die Indika- tionen zur opera tiven Behandlung der erkrankten Tuben : Volk. Sam ml., ZSo. 323. Griffiths Tubo-ovarian Cysts: Trans. Lond. Obst. Soc., 1887. Hcnnig Krank- heiten der Eileiter und die Tubarschwangerschaft : Stuttgart, 1876. Klob Patho- logische Anatomie der weiblichen Sexualorgane : Wien, 1874. Lewers On the Frequency of Pathological Conditions of the Fallopian Tubes : Trans, of Lond. Obst. Soc., 1887. MacDonald, Angus Ten Cases of Laparotomy : Ed. Med. Jouni., June 1885. Martin Ueber Tubenerkrankung : Zts. fur Geb., Bd. XIII., S. 299. Noegyerath The Vesico-vaginal and Vesico-rectal Touch : Am. J. of Obst., VIII.. p. 123. Sdngei Etiology, Pathology, and Classification of Salpingitis : Amer. Jour, of Obst., 1887, p. 317. Simpson, Sir J. Y. Diseases of "\Vomen (Edit. A. R. Simpson), p. 539. Schrocder Handbuch der Krankheiten, etc. : Leipzig, 1878, S. 329. Tait Menstrual Fluid retained in the Left Fallopian Tube simulating Ovarian Tumour: Br. Med. J., 1878, p. 677. The Pathology and Treatment of Diseases of the Ovaries : Birmingham, 1883. Note on Chronic Inflammatory Disease of the Uterine Appendages : Ed. Med. Jour., Sept. 1885. Thomas Diseases of Women : Philadelphia, 1880, p. 760. Wells, Sir T. S. Diseases of Ovarian and Uterine Tumours : London, 1882. Williams Ovarian Tumours : Reynold's System of Medicine, Vol. V. Winckel Die Pathologic der weiblichen Sexual- organe : Leipzig, 1881. Wylie, W. G. Operations for Salpingitis : N. Y. Medical Record, Aug. 29th, 1885. Zemunn Ueber die Aktinomykose des Bauchfells und der Baucheingeweide beim Menschen : Medicin. Jahrbiicher der K. K. Gesellschaft der Aertzte in Wien, 1883, S. 477. For other literature see Bandl and Doran, whose works and that of Hennig we mainly follow : see also the Index of Recent Gyne- cological Literature in the Appendix. FALLOPIAN TUBE. Fallopian Preliminary Considerations. The anatomical relations of the Fallo- Tube. pj an tubes have been already considered (p. 22). Functionally, they act as ducts along which the ovum, fertilised or non-fertilised, is carried to the uterine cavity; and up which some believe the spermatozoids pass to fertilise the ovum. So far as we know this is all their physiological function, unless we hold with Tait that they play some important though as yet undefined part in menstruation. Pathologically, the Fallopian tubes are important from the occurrence ABNORMALITIES OF TUBES. 193 of extra-uterine pregnancy in them and their not infrequent dilatation with pus or blood. From the fact that they open on the one hand into the uterus and on the other hand into the peritoneal cavity, very serious results may follow from fluid accumulations in them ; as also from spreading gonorrhoea, or from injections into the uterus. It is of great interest to note the fact that the majority of inflammatory pelvic affections lie posterior to the broad ligaments, suggesting their etiological relations to Fallopian-tube disease. Can the normal Fallopian tubes be palpated in the Bimanual ? The student will probably have already noted that, in considering the Bimanual (Chap. VIII.), we did not name the Fallopian tubes as structures whose form and limits he was expected to define. In a very favourable case, the conjoined manipulation may recognise them at their uterine origin more especially if the rectal examination be made and the uterus be well drawn down with the volsella. Nceggerath has pointed out that they may be defined in those cases where the finger is passed along the urethra to explore the interior of the bladder, an operative procedure to be described afterwards. Practically, the Fallopian tubes (unless much dilated) are not palpable on ordinary examination. It must not be forgotten that many cases have now been recorded, where abdominal section showed the Fallopian tubes to be dilated with pus to the size of coils of small intestine, although the most careful Bimanual had failed to detect their presence. Catketerisation of the tubes. In certain undoubted cases the uterine Catheteri- sound has been passed along the Fallopian tube, while in others the ^^ supposed sounding of the tube has been really the perforation of the uterine wall. It is impracticable to sound the normal Fallopian tubes to any effect; and the procedure is by no means devoid of danger. We now consider their pathological conditions under the following heads : Abnormalities, Stricture and Occlusion, Patent condition, Inflammatory conditions, Hydrosalpinx, Pyosalpinx and Hsematosalpinx, New Formations, Tubo-ovarian Cysts. ABNORMALITIES. These are of little practical interest. The chief are an accessory Abnor- fimbriated end ; defective development ; displacement ; want of apposi- mallties - tion of fimbrise to ovary (Lawson Tait). N 194 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. Stricture and Occlusion. Patency. STRICTURE AND OCCLUSION OF THE TUBES. The tube may have a congenital stricture ; or may become closed at the uterine or the fimbriated end, or in the middle. When stricture occurs at the uterine end, it is caused by implantation of the placenta there or by endometritis with adhesion. In the middle, small tumours or adhesions may cause strictures in the latter case usually partial. At the fimbriated end, the occlusion is due to a catarrh of the tubes which has spread to the peritoneum and set up adhesive peritonitis. These strictures are of importance in relation to sterility and fluid accumulations (pus, serum, blood) which they favour ; but in themselves cannot be diagnosed during life. PATENT CONDITION OF THE TUBES. By this is meant undue dilatability. It is of great importance in FIG. 121. HYDBOPS TUBJS : a Uterus with Cervix laid open in front ; Ib Fallopian Tubes ; cc hydrops ; d part of an inflammatory adhesion ; ee ovaries (Hennig). relation to uterine injections. Even in careful injection of the uterine cavity, post partum or otherwise, fatal results have followed from the fluid's passing along the tube into the peritoneal cavity. "Forcible uterine injections on the cadaver, with the cervix entirely filled up by the syringe, almost always sent fluid along the tubes into the peritoneal cavity. Less forcible injections under like conditions sent the fluid along a less distance (2-3 mm.), and often sent it into the veins ; while gentle injections with a tube not filling the cervical canal sent fluid neither into the tubes nor veins." Bandl, from whom the above is taken, records a case where death resulted from injection of an aborting uterus with perchloride of iron, although the injection pipe was less in SALPINGITIS. 195 diameter than the cervix. Death may be immediate from shock, or some days after from peritonitis. In uterine injections, 110 more than 1-4 drops should be used. Winckel has recorded a unique case where a round worm (Ascaris Lumbricoides) was found calcified on the posterior surface of the uterus and left broad ligament. It had probably passed from the anus into the vagina and ultimately through the Fallopian tube into the peritoneal cavity. INFLAMMATORY CONDITIONS OF THE TUBES, SALPINGITIS. The Fallopian tube has three layers peritoneal, muscular, and Salpingitis mucous. An inflammatory condition of the peritoneum (perisalpingitis) is simply part of ordinary pelvic peritonitis, is not diagnosable, and is not in itself of any importance. The same may be said of meso- salpingitis (inflammation of the muscular coat). The most important changes occur in the mucous membrane. Pathology. The pathology of these changes is not by any means thoroughly worked out, and our knowledge is specially deficient in regard to the part played by micro-organisms in its production. We here briefly take up the varieties mentioned below, following Sanger's classification. GROUP I. Forms of Salpingitis y^roduced by knoivn specific microbes. 1. Salpingitis gonorrhoica, produced by the gonococcus of Neisser ; 2. Salpingitis tuberculosa, produced by the bacillus tuberculosis of Koch ; 3. Salpingitis actinomycotica, produced by the actinomyces bovis of Bellinger. 1. Salpingitis gonorrhoica. This is held by many to be the most frequent form. It should be kept in mind, however, that the gonococcus is not by any means readily demonstrated in the secretion of the tubes in these cases, probably because the organism is in greater part destroyed by the leucocytes. The history is here at present our great guide to the special diagnosis. 2. Salpingitis tuberculosa is now thoroughly proved, thanks to Koch's discovery, by the presence of the bacillus tuberculosis. To the naked eye, the tubes appear somewhat enlarged and beaded. 3. Salpingitis actinomycotica. This is a pathological curiosity, but has been demonstrated by Zemann. GROUP II. Forms of Salpingitis due to specific microbes identical with, those producing traumatic infection. 4. Salpingitis septica. No special microbes have been demonstrated here, but they are in all probability identical with those found to cause 196 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. acute suppuration, viz., streptococcus pyogenes and staphylococcus pyogeues. This form follows abortion, puerperal fever, and use of tents or stem pessaries. GROUP III. Farms of infectious Salpingitis produced by specific but as yet unknown microbes. 5. Salpingitis syphilitica is the chief one of this group. Another classification is that of Martin into 1. Salpingitis catarrhalis, Endosalpingitis ; 2. Salpingitis interstitialis ; 3. Salpingilis follicularis. In the first, we have small-celled infiltration causing thickening of the mucosa; in the second, the same chiefly affects the muscular coat; while in the third, the spaces in the mucous membrane of the tube caused by the folding of the mucous coat are dilated. Treatment. This will be considered under the Treatment of Pyosalpinx. HYDEOSALPINX OR HYDROPS Hydro- As the result of strictiire of the tube and marked catarrh, B^P 31 *- we get the tube distended with serum (hydrosalpinx) or pus (pyosalpinx). Pathological Anatomy. The whole or only a part of the tube is dil- ated, according to the locality of the stricture (fig. 121). There maybe several strictures and thus several cysts. The tube distends and atrophies, so that the mucous membrane becomes thin and the muscular coat disappears. The fluid is usually serum with cholesterin, and occasionally blood. It is alleged that fluid can accumulate in the tube although the uterine end is open ; the fluid at a certain stage of its accumulation flows into the uterus (profluent dropsy of the tube). Physical Signs. An elongated tortuous tube is found at one side of the uterus and high up in the pelvis. Usually a small piece of the undilated tube can be felt between the sac and the uterus. The Differential Diagnosis must be made from the following : (1.) Inflammatory conditions or blood extravasation in the broad ligament, (2.) Fallopian-tube pregnancy, (3.) Small ovarian cyst, (4.) Parovarian cyst, (5.) Retention of blood in malformed uterus. Treatment. When the dilated tubes are free or but partially adherent, they may be removed by abdominal incision (v. Pyosalpinx). PYOSALPINX. 197 PYOSALPINX. Pyosalpinx arises when the fimbriated end of the tube is closed andPyosal- the secretions thus retained. The usual explanation is that the pus pmx * exuding from the ostium abdominale of the tube sets up a limited pelvic peritonitis and thus closes it. The tube so distended may rupture into the peritoneal cavity with a fatal result. Until recently it was not believed that the Fallopian tubes played an important part in diseases of women. Lawson Tait's abdominal sections, however, reveal the fact that Pyosalpinx is present in a number of cases hitherto unsuspected. Although this was not believed at first, it has been amply proved not only by abdominal sections of other gynecologists, but also by careful post mortem examination. J. K. Fowler found in the post mortem record for 3 years of the Middlesex hospital, 15 cases of pyosalpinx ; in 8 of these, it had been the cause of death. Tait's state- ments have therefore been fully borne out. When acute, the disease may run its course rapidly from general perito- nitis. Indeed in cases of general peritonitis, this lesion should be kept in mind ; and Tait believes we may save such " by boldly opening the abdomen and cleansing its cavity." In chronic cases, there has prob- ably been some attack of ovaritis or peri-ovaritis, with occlusion of the fimbriated end of the tube, and accumulation of inflammatory secretion. Symptoms. -It is not possible at present to give any very accurate Symptoms, symptomatology of this disease. The cases are usually chronic, have been under many gynecologists, and not improved under treatment. Pain, intolerable dysmenorrhoea, recurrent attacks of pelvic peritonitis, probably due to the escape of pus from the ostium abdominale of the tube into the peritoneal cavity, and a chronicity of the symptoms should lead one to suspect pyosalpinx. The history often helps, as in many cases we find that gonorrhoeal infection has started a specific vaginitis which has spread until the Fallopian tubes have become seriously involved. Menstruation is irregular usually increased both in amount and frequency. There have also been described recurrent lateral swellings in the region of the uterus, their disappearance being accompanied sometimes with an escape of pus from the vagina. These are probably cases of pyosalpinx discharging periodically through the uterine cavity. Physical Signs. Bimanually one finds swellings in the site of the tubes, and can make out occasionally that these are sausage-like in form. Pain is felt on examination. Lawson Tait, to whose work on Diseases of the Ovaries we are indebted for the symptomatology and physical signs, narrates several cases of which the two following are examples. "E. C. , aged thirty-two, was married at seventeen years of age, and had her first child when she was eighteen, and her second in the following year. She was quite well until 1876, when she had a smart attack of inflammation of the pelvis, and ever after 198 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. that she had extreme pain at her periods, when she had to remain in bed for several days ; and she described her sufferings as amounting to agony, and resembling labour-pains more than anything she knew of. She was seldom free from pain in the back, and for the last three years she has been utterly unable to endure married life. I found the uterus slightly retroverted, and on each side of it there was a distinct mass in the posi- tion of the ovary, large, fixed, and extremely tender. She bad been under a great variety of treatments, without the slightest benefit. On October 5th, 1880, I made an exploratory incision, and found both ovaries adherent in the cul-de-sac, the infundibula of both tubes occluded, and the tubes themselves distended into cysts. The whole of the organs were matted together, and the operation for their complete removal was extremely difficult. The amount of fluid in each tube was about two ounces. She made an uninterrupted recovery from the operation until the monthly period after, at which time she had a small hsematocele on the right side, coincident with a slight menstrual appear- ance. From this, however, she speedily recovered, and on February 17th last I found the uterus perfectly free and normal in direction, I last saw her on March 26th, and found her in perfect health, absolutely free from pain, and she told me that she had seen no appearance of menstruation since November, and that marital functions had been resumed without the slightest pain. " H. S. , aged thirty-seven, had been married seventeen years, and had only one child, fifteen years ago. She did not recover well from that confinement, and ever since had menstruated too often and too profusely, being rarely a fortnight clear. I found the fundus large and tender, somewhat anteverted, and what I regarded as the ovaries formed two large masses low down, and somewhat behind the uterus. For a long time past, sexual intercourse had been impossible on account of the suffering it caused her. Dr C. H. Phillips of Hanley, who placed her iinder my care, had exercised a large amount of ingenuity in her treatment without any benefit, and from February till August 1880, we conducted further treatment equally in vain. On August 3rd, I opened the abdomen, and found the ovaries large, completely adherent in the cul-de-sac, covered with lymph, and having the infundibula of the tubes occluded. The tubes were distended into large cysts, each containing from four to five ounces of clear serum. The organs had to be very carefully detached, as the adhesions were extremely firm, and the haemorrhage during the operation was tolerably profuse. Her recovery from the operation was rapid and easy, and the only distresses she encountered were the climacteric flushings. In May last, Dr Phillips sent me a most satisfactory account of her condition. " Treatment. Treatment.' 1 The treatment hitherto advised in such cases has been to tap. Lawson Tait has introduced abdominal section with removal of the tubes, and has proved that this is the safest and best method of treatment. He makes a small abdominal incision, frees adhesions by manipulation with the fingers, and taps any cysts with a long curved trocar guided by the fingers. When adhesions are thus broken down, he brings up the tubes to or through the abdominal incision, ligatures with the Staffordshire knot, cuts away the parts above the ligature, drops the pedicle and drains with a glass tube. Where he cannot remove the tube, he stitches the opening in it carefully to the abdominal incision. Some operators, especially in Germany, make a larger incision, a Pply ligatures to adhesions, and do not hesitate to turn out the small intestines (suitably covered with warm towels) to facilitate this. HJEMATOSALPINX. Thi8 is a rare condition in which the blood from the congested mucous membrane of the tube is detained and dilates it. It is often associ- 1 See also the chapter on Abdominal Section in the Appendix. PAROVARIUM. 199 ated with retention of menstrual blood in the uterus (v. Atresia Vaginae, Section VI.). Diagnosis is difficult ; Bandl records one case where he diagnosed the condition as a fibroid ; and Lawson Tait, one simulating a parovarian cyst, in which he did abdominal section and removed six quarts of thick dark brown fluid. NEW FORMATIONS : TUBO-OVARIAN CYSTS. The most important new formations are connective-tissue growths, New For- fibroma, lipoma, primary tuberculosis, carcinoma. In tuberculosis matlons - of the Fallopian tube, Steven has found, sparingly distributed, the bacillus tuberculosis recently discovered by Koch in tubercular phthisis of the lungs (Glas. Med. J., Jan. 1883). In 46 cases of tuberculosis of the female genital organs, the tubes were affected in 34 (Mosler). Tubo-ovarian cysts result from adhesions between the fimbriated end of the Fallopian tube and the ovary, with degeneration of the corpora lutea of the Graafian follicles thus enclosed. The contents may be poured into the uterus along the tube. PAROVARIUM. The diagram shewn at fig. 122, taken from Doran's interesting andParo- varium. F.T. FIG. 122. DIAGRAM OF THE STRUCTURES IN AND ADJACENT TO THE BROAD LIGAMENT (Doran). 1. Framework of the parenchyma of the ovary, seat of a simple or glandular multilocular cyst. 2. Tissue of hilum, with 3, papillomatous cyst. 4. Broad ligament cyst, independent of paro- varium and Fallopian tube. 5. A similar cyst in broad ligament above the tube, but not connected with it. 6. A similar cyst developed close to 7 ovarian fimbria of tube. 8. The hydatid of Morgagni. 9. Cyst developed from horizontal tube of parovarium. Cysts 4, 5, 6, S, and 9 are always lined internally with a simple layer of endothelium. 10. The parovarium ; the dotted lines represent the inner portion, always more or less obsolete in the adult. 11. A small cyst developed from a vertical tube ; cysts that have this origin, or that spring from the obsolete portion, have a lining of cubical or ciliated epithelium, and tend to develop papillo- matous growths, as do cysts in 2 tissue of the hilum. 12. The canal of Gartner, often persistent in the adult as a fibrous cord. 13. Track of that duct in the uterine wall ; unobliterated portions are, according to Coblenz, the origin of papillomatous cysts in the uterus. 200 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. valuable work, shews that the Parovarium, which is the remains of the Wolffian bodies, consists of a horizontal tube and 8 or 10 well-developed vertical tubes with 5 or 6 in addition represented only by fibrous threads. The horizontal tube may be traced (12, Fig. 122) to the side of the uterus forming the canal of Gartner already alluded to (page 23). It is important to observe that the vertical tubes become lost in the hilum of the ovary ; the significance of this will be referred to under ovarian tumours. The tubes are lined with cubical or broken-down epithelium, and may give rise to the tumours known as parovarian (9, 11, Fig. 122). This form of tumour is usually produced by the distension of one or more, usually one, of the tubules ; its mode of production may however be like that of papillomatous ovarian tumours in which true tumour- growth takes place. The diagnosis and treatment of parovarian tumours will be best considered along with those of ovarian (v. Chaps. XXIII. and XXIV.). CHAPTER XX. MALFORMATIONS OP OVARY: OVARITIS: PERI- OVARITIS: DISPLACEMENTS OF OVARY-HERNIA, PROLAPSUS. LITERATURE. Barnes Diseases of Women, p. 297 : Lond. 1878. On Hernia of the Ovary, and Observations on the Physiological Relations of the Ovary : Am. J. of Obst. XVI. p. 1, 1883. Engelmann The dry Treatment in Gynecology : Amer. Jour, of Obst. , June and July 1887. Englisch Oesterr. Med. Jahrbuch, 1871, p. 335 ; or, Sydenham Year Book, 1871-72, p. 293. Freund Die Lage und Entwickelung der Beckenor- gane : Breslau, 1863. Herman Prolapse of the Ovaries : Med. Times and Gazette, 22d October 1881. His Die Lage der Eierstocke in der weiblichen Leiche : Archiv fiir Anatomic und Physiologic, Anat. Abtheilung, 1881. Klob Pathologische Anatomic der weiblichen Sexualorgane : "VVien, 1864. Lebedinsky Ovarien bei Scharlach : Centralb. f. Gyn. I. Munde Prolapse of the Ovaries : Am. Gyn. Tr., 1879, p. 164. Olshausen Die Krankheiten der Ovarien : Billroth's Handbuch, Stuttgart, 1879. Schroeder Die Krankheiten der weiblichen Geschlechtsorgane : Leipzig, 1878, S. 341. Schultze Zur Kenntniss von der Lage der Eingeweide im weiblichen Becken : Arch. f. Gynak, Bd. ix. S. 262. Slavjansky Die Entziindung der Eierstocke : Arch. f. Gyn. Bd. iii. S. 183. Tait, Lawson The Pathology and Treatment of Diseases of the Ovary : Birmingham, 1883. WE first take up some preliminary considerations. Palpation of Normal Ovaries. After the student has had practice in Examina- the Binianual, he will probably meet with some favourable case where he is able to feel the normal-sized ovary. This is best done as Schultze recommends. To map out the right ovary, use the index and middle fingers of the right hand internally and the left hand externally ; for the left ovary, the left hand is used internally and the right externally. The patient should lie on her back, with the knees drawn up and the legs rotated outwards. This rotation of the knees renders the psoas muscles tense, thus making their inner edges (which Schultze gives as a guide to the position of the ovaries) more easily palpable. Normally, they lie at about the level of the pelvic brim, half way between the Fallopian-tube angle of the uterus and the psoas (v. pp. 25, 57, 58). Another method of palpating the ovaries is to draw down the uterus with the volsella, and make the examination with the finger per rectum. MALFORMATIONS OF OVARY. Absence of one or both ovaries or rather their very rudimentary Malforma- development, is generally only part of maldevelopment of the uterus, ovary. 202 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. Ovaritis. Patho- logical Anatomy. Etiology. Occasionally a third ovary is present a fact worth keeping in mind in relation to Battey's operation (Chap. XXI.). OVARITIS. SYNONYM Oophoritis. NATURE An acute or chronic inflammation of the ovary. Simple Hypercemia of the Ovary may also occur. PATHOLOGICAL ANATOMY. Acute ovaritis. Of this we recognise two forms corresponding to the two subdivisions of ovarian tissue the follicular or parenchymatous, and the interstitial. In the follicular form, the ovary is not much enlarged ; but we find on microscopical examination the peripheral follicles increased in size, their contents turbid or purulent, the cells of the membrana granu- losa and the ovum in a state of cloudy swelling. The zona pellucida becomes thickened and folded. Usually the surrounding tissue participates, though to a less marked degree, in the inflammatory changes ; and in marked cases the germ-epithelium becomes cloudy and broken down, with fibrinous deposits on its surface. Lebedinsky has examined the changes in the ovary in scarlet fever. To the naked eye, there was no difference ; but on microscopic examina- tion, the Graafian follicles were found altered with cloudy swelling or destruction of the epithelium. The younger follicles were most markedly affected, but the stroma was unaltered. In this way the follicles become destroyed and cicatrized, and the ovarian function thus greatly impaired. In the interstitial form, the ovary is increased in size and its con- nective-tissue elements are proliferated. Pus may form, and often there are small apoplexies. Slavjansky speaks of the following varieties of the interstitial form : serous, suppurative, hsemorrhagic, and necrotic. Chronic ovaritis. As the result of this, we get destruction of the follicles and a cirrhotic condition of the organ, as was found in a case of Tait's examined by Doran. To the naked eye, the ovaries appeared markedly fissured on the surface. Occasionally the ovary remains distinctly larger. Whether or not we get a super-involution of the uterus as the result of severe and double ovaritis, is not as yet settled. The ovaries may be small and cystic, and according to Tait this form gives rise to severe menorrhagia. ETIOLOGY. The causes of ovaritis are the following : o 1. Chill at menstrual period ; VARITIS. 203 2. Gonorrhoea, latent gonorrhoea in the male ; 3. Instrumental exploration of the uterus ; 4. Childbirth and abortion ; 5. Acute febrile disease ; 6. Pelvic peritonitis. Gonorrhoea. The ovaries maybe inflamed sympathetically, just as the testicles are in gonorrhoea of the male. Instrumental exploration. Sometimes after the passage of the uterine sound, especially in difficult cases, the ovary becomes tender. Childbirth and abortion. This is a common cause of ovaritis. Thus, in 27 cases at Halle, Olshausen found the ovaries affected in 13. Usually both ovaries are implicated. Acute febrile diseases. Cholera, the exanthemata, septicaemia, and phosphorus and arsenic poisoning have ovaritis as one of their results. Pelvic peritonitis. It will readily be understood that ovaritis often occurs as part of general pelvic peritonitis. The follicular 'form usually occurs in febrile diseases and pelvic peritonitis ; the interstitial form is generally puerperal. SYMPTOMS AND PHYSICAL SIGNS. Acute ovaritis. A case of simple acute ovaritis is not common. The Symptoms patient usually complains of pain at the side radiating to the back, and an of pain on pressure in the iliac regions. When the Bimanual is made, the ovary or ovaries are unusually accessible, and are felt as mobile, tender, and somewhat enlarged bodies, often about the size of a walnut; and pressure causes great pain of a sickening character. Owing to adhesions, the mobility may be wanting. Chronic ovaritis. The symptoms and physical signs are as in the acute form, but much less marked and with a chronic history. Men- orrhagia is often present. Sympathetic pain is sometimes felt below the left mamma. In some cases a form of epilepsy is brought on (menstrual epilepsy), menstruation being in abeyance. DIFFERENTIAL DIAGNOSIS. When the ovary is not fixed, there is nothing else with which it can Differ- be confounded. ggj^ PROGRESS AND RESULTS. We may have resolution of the affection, adhesion, suppuration, and Progress abscess. Sterility is a frequent result of double ovaritis ; hysteria is Results, often present. TREATMENT. Treatment Acute ovaritis. A fly blister should be applied over the appropriate Acute. 204 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. iliac region, and the hot vaginal douche frequently used. Bromide of potassium may be given as follows. R. Potassii Bromidi gr. xxx to 3i. Fiat pulv : tales xii. Sig. One powder at night. Treatment Chronic ovaritis The hot douche and occasional blisters are best. Chronic. The glycerine plug is of value. Glycerine A glycerine plug is made as follows: Take a square piece of absorbent cotton wool about the. size of the palm of the hand ; pour on its centre about ss. glycerine ; turn the corners over and squeeze the whole so as to saturate it; lastly, tie a piece of thread about 8 inches long round it. Pass Sims' or Fergusson's speculum, and place the plug in the fornix below the ovary. It should be left in for 18 to 24 hours, and then withdrawn. This plug reduces congestion, owing to the affinity of glycerine for water; has an antiseptic action; and, as we shall afterwards see, forms an admirable pessary. It sets up a watery discharge, so that the patient should be told to wear a diaper. A tampon of non-absorbent cotton wool dipped in bismuth or any mild antiseptic powder may be substituted for the glycerine tampon. It is passed with the aid of a speculum, and should be smeared at its upper part with vaseline. It does not become hard like the glycerine plug, and the elasticity of the non-absorbent wool is of benefit. The following mixture is of use. R. Potassii Bromidi 3ij. Potassii lodidi 3j- Inf. Gentian. Co. gvi. Sig. Tablespoonful thrice daily. In menorrhagia uncontrollable by ordinary means, oophorectomy may be performed (Chap. XXI.). PEBIOVABITIS. Peri- By this we understand an inflammatory affection of the tissues sur- ltl8 - rounding the ovary, which fixes the organ. It is a convenient clinical term for local peritonitic inflammations at the site of one of the ovaries. It is higher up than the usual cellulitic deposit. The treatment is the same as in chronic ovaritis. DISPLACEMENTS OP THE OVARY HERNIA. Herma of The term Hernia is limited to those cases where the ovaries are f - present in the inguinal canals, in the obturator foramen (rare), or as part of an abdominal hernia. Percival Pott's case, where this first con- dition existed and where he excised both of the displaced organs, is the PROLAPSUS OF THE OVARY. 205 classical instance of this displacement. The usual form is where they are present in the inguinal canal. ETIOLOGY. Ovaries in the inguinal canal are usually congenital, having descended Etiology, along the unobliterated process of peritoneum. In 17 cases out of 23 cases, Englisch found it to be congenital ; and in one-third of these, the hernia was double. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. An oval tumour of the size of the ovary, tender on pressure, is found Diagnosis, in the inguinal canal. Its connection with the uterus may be demon- strated by drawing the latter down with a volsella. It requires to be diagnosed from an ordinary hernia, and from hydro- cele of the round ligament. TREATMENT. A protecting shield may be worn ; and where very troublesome, the Treatment, ovaries may be cut down upon and removed. Reduction is usually impossible, owing to adhesions. PROLAPSUS. We have already considered the support of the ovary. Its attach- Prolapse of ments to the broad ligament, to its own special ovarian ligament, and to vary ' the ovarian fimbria of the Fallopian tube, assist, but its chief support is the infundibulo-pelvic ligament of the Fallopian tube; in addition, its own specific gravity has an influence in determining its level. Its position is constantly changing. As the bladder fills, it is displaced backwards, and its lower end rises ; during pregnancy, it is drawn upwards out of its pelvic position and somewhat enlarged. The ovary is thus an organ liable to displacement, of which the most important is the downward one known as prolapse of the ovary. PATHOLOGICAL ANATOMY. The ovary lies lower than usual, in the lateral or in the true pouch Patho- of Douglas; the uterus may be in its normal position, but oftener it retroverted. The ovary is usually enlarged, and often fixed by peritonitic adhesions. Munde considers the varieties of prolapsus as (1.) Retro-lateral, in the lateral pouch of Douglas; (2.) Retro-uterine, in the true pouch of Douglas; (3.) Ante-uterine, in the utero-vesical pouch, very rare ; (4.) In the infundibulum of an inverted uterus. 206 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. ETIOLOGY. Etiology. The conditions present in the puerperium favour displacement of the ovary for two reasons; the normal ascent of the uterus during pregnancy may stretch the ovarian and infundibulo-pelvic ligaments, and the ovary may not return to its normal size after parturition. Simple congestion of the organ may cause it to descend; and it is alleged that sudden jolts may also drive it below its normal site. It is not quite certain whether the congestion is cause or result. Probably it is the cause; but it is also aggravated by the displacement. SYMPTOMS. Symptoms. These are radiating pains, pain on defsecation and coitus, a dragging sensation, reflex nervous symptoms with general irritability. PHYSICAL SIGNS. Physical Bimanually, we feel in the true or in the lateral pouch of Douglas a small body or bodies, exquisitely tender and lying distinct from the uterus. By the rectal examination, the ovary is felt with unusual distinctness. Great care must be taken to be gentle in examination. Cystic small ovaries are often adherent, the adhesion being probably caused by rupture of the cysts which may be done by even gentle mani- pulation and cause aggravation of symptoms and fresh adhesions. TREATMENT. Treatment. Blisters over the iliac region, hot vaginal douche, and bromide of potassium in fifteen-grain doses thrice daily. The bowels are to be opened by means of saline purgatives, such as the Friedrichshall water or Carlsbad salts. The following mixture is good : R. Magnesise Sulphatis 3\-j. Quinina3 Sulphatis gr. xxiv. Acidi Sulph. dil. 3iij. Tinctures Capsici 3j. Aquam ad gvj. Sig. Tablespoonful thrice daily. This relieves the congestion by unloading the bowels. A course of treatment at Kreuznach or other German Spa is often of service. Often the prolapsed and non-fixed organ becomes, after a week of this treatment, distinctly higher in position. The glycerine plug or dry tampon is then of the utmost value. In the chronic stage, when the uterus is retroverted and not fixed, the ring or the Albert Smith pessary is good (v. Eetro version of Uterus). PROLAPSUS OF THE OVARY. 207 The cases where the tender ovaries are fixed low down by adhesions are exceedingly difficult to treat. When the uterus is retroverted and fixed and the ovaries below it, we get one of the most troublesome cases possible. Palliative treatment by blisters and the hot douche is best; if the case is not amenable to this treatment and the patient's general health is suffering, the propriety of Battey's operation should be con- sidered. Prolapse of the ovaries and their fixation are contra-indications to treatment indicated otherwise such as Emmet's operation. CHAPTER XXI. OPERATIONS FOB REMOVAL OP FALLOPIAN TUBES AND OVARIES. IN this chapter we have to consider two operations : " Removal of the uterine appendages," in which both Fallopian tubes and ovaries are taken away ; and " Oophorectomy," in which the ovaries alone are removed. The latter operation was the earlier of the two and will therefore be considered first. History of The real history of these operations dates from August 17th, 1872, when Battey of Rome, Georgia, U.S.A., successfully removed the ovaries of a patient who suffered from intolerable dysmenorrhoea. On July 27th of the same year, Hegar of Freiburg had removed both ovaries in a case of severe ovarian neuralgia : the patient died, and Hegar did not publish an account of the case. Lawson Tait removed the ovaries for pain in October 1871, and for menorrhagia, on August 1st, 1872, both successfully. Bluudell of London (1823), with that rare medical insight and experimental knowledge which led him to advocate if not to practise what recent obstetric science has shown to be a valuable mode of performing the Csesarean Section, had already thrown out the suggestion that the ovaries should be removed in dysmenorrhoea and to arrest haemorrhage in inverted uterus. To Battey, however, is due the honour not only of conceiving the idea, but what was more difficult of successfully carrying it into execu- tion and impressing the profession with its importance and value in special cases. The same honour is due to Tait, with regard to his operation for removing the uterine appendages. OOPHORECTOMY (BATTEY'S OPERATION). LITERATURE. The literature on this operation is too extensive to be given in detail in a student's manual. The best summaries of cases are by Engelmann, Hegar, and Simpson. See also Index of Recent Gynecological Literature in the Appendix. Battey Battey 's Operation : Transactions of International Medical Congress, Lond., 1881. See Am. J. of Obst., October 1881, for discussion. See also Battey' s Operation: American System of Gynecology edited by Mann, Vol. II., p. 837. By ford Removal of the Uterine Appendages, etc., by Vaginal Section : Am. Journ. of Obstet., 1888, pp. 337 and 872. Engelmann The Difficulties and Dangers of Battey's Opera- tion: Am. Med. Asso. Trans., 1878 (date of reprint). Battey's Operation, 3 fatal cases : Am. J. of Obst., July 1878. Hegar Die Castration der Frauen : Volkmann's Sammlung, Nos. 136-138. Simpson, A. .R. History of a Case of Double Oopho- rectomy or Battey's Operation : Br. Med. J., May 24th, 1879. Sims, J. Marion Remarks on Battey's Operation : Br. Med. Journal, 1877. OOPHORECTOMY. 209 NOMENCLATURE. We have adopted the term Oophorectomy as a convenient andNomen- useful one. Other terms, however, have been proposed. Marion a ure ' Sims suggested that it should be called Battey's Operation after its originator, and this name has been widely adopted. " Normal Ovario- tomy " is a misnomer, inasmuch as the ovaries are not normal. " Spaying," a term advocated by Goodell, does not recommend itself by its delicacy. "Die Castration der Frauen," the German name for the operation, is open to a similar objection. NATURE AND AIMS OF OPERATION. Oophorectomy is the removal of diseased ovaries not enlarged by Nature tumour-growth but causing serious symptoms such as menorrhagia, an ms ' epilepsy, severe pain. Battey proposed it for dysmenorrhoea, on the theory that it would bring on the menopause prematurely. This, however, does not occur as an immediate result. More recently, Battey has declared that he operates to arrest ovulation. INDICATIONS FOR OPERATION AND ITS RESULTS. These are not as yet strictly determined; i.e., so far as our present Indica- knowledge goes, the operation is indicated in certain conditions, but as yet we do not know whether in all of them it produces the anticipated effect. They are as follows : (1.) Intolerable Dysmenorrhoea ; (2.) Bleeding from Fibroid Tumours, uncontrollable by other means ; (3.) Hystero-epilepsy, convulsions and threatened insanity, dependent on ovarian irritation or presence of ovaries with absence of uterus ; (4.) Prolapsed and fixed ovaries. (1.) Dysmenorrhoea. In those cases where the patient has intolerable and prolonged pain every month, wearing her down and rendering habitual recourse to opiates necessary, the operation may be performed. It should not be forgotten that the results in such cases are not so bril- liant as was once expected. The menstruation is not at first entirely arrested by the removal of the ovaries ; and, as we have always in such cases pelvic peritonitis adding to the patient's misery and untouched by the operation, it is evident that we must not expect too much from it. Lawson Tait believes that the Fallopian tubes must also be removed in order to arrest menstruation completely. (2.) Bleeding from fibroid tumours, uncontrollable by other means. It is in this condition, for which Battey's operation was first advocated by 210 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. Treiiholm and Hegar, that the most brilliant successes have been won. Not only has hemorrhage been checked, but the tumours themselves have diminished in size and even in some cases disappeared. (3.) In some cases of hystero-epilepsy, convulsions, insanity, and dandn fibrous coat and an inner one composed of true skin. They may contain hair, teeth, bone, striped muscle, nervous matter, cholesterine, and seba- ceous matter. Doran draws attention to the fact that dermoid cysts may contain malignant new growths, notably sarcomata (fig. 131). When teeth are present, their crowns have been found to slope slightly towards the median plane of the body : in this way, the side of the body from which the tumour has arisen can be made out (Hollander: v. Olshausen). Ovarian Fluid. 222 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. The Cystoma malignum is a cystic tumour which has undergone malignant degeneration. It is noteworthy that malignant disease often develops after the removal of an apparently simple tumour, notably after papillomatous tumours. THE NATURE OF OVARIAN FLUID. Ovarian fluid varies much in consistence and colour. It is usually viscid, and may be so thick as to be almost gelatinous. Its colour is yellowish or greenish ; and the specific gravity, when of the more fluid consistence, varies from 1010 to 1020. Chemically, the fluid is complex. The chemical composition has been investigated by Eichwald, whose paper may be consulted. Ovarian fluid does not give a flocculent precipitate as ascitic fluid does. The presence (in ascitic) or absence (in ovarian) of such a precipitate can be most easily determined by suspending, as Foulis has suggested, a soft cotton thread in a bottle containing the doubtful fluid ; the thread FIG. 132. ed blood SOME CELLULAR ELEMENTS of OVAKIAN FLUID. At the upper right hand corner we have red bio corpuscles. Below these lie the granular ovarian cells, and below them free granular matter. At the upper left hand corner is shown an epithelial cell ; below it, a pus cell after addition of acetic acid ; and below this, pus cells before addition of acetic acid. (Drysdale). can then be examined microscopically for the deposit which forms in its interstices. The corpuscular elements of ovarian fluids are various. There may be oil globules, cholesterine crystals, blood fresh or altered, with large granular cells. SBennett Hu ^ hes Bennett of Edinburgh and Drysdale of Philadelphia have and Drys- described a corpuscle, seen at fig. 132, as characteristic of ovarian fluids. According to Drysdale it "is generally round, delicate, transparent, and contains a number of granules but no nucleus ; " its size varies from TTHTTT of an incn to W?nr f an inch in diameter. Acetic acid added to pus makes the cells larger and brings nuclei into view ; while it only increases the transparency of the ovarian cell and makes its granules more evident. Recently, Garrigues has investigated the microscopical PATHOLOGY OF OVARIAN TUMOURS. 223 nature of ovarian fluids in an able research. He believes Drysdale's cell and Bennett's corpuscle to be the nuclei of epithelial cells fattily degener- ated, and that there are no pathognomonic ovarian cells. SOLID OVARIAN TUMOURS ; MALIGNANT TUMOURS AND THE NATURE OF THE ASCITIC FLUID ASSOCIATED WITH THEM. Non-malignant (solid) tumours are rare. Myoma of the ovary (fig. Solid and Malignant Tumours. F. ~ FIG. 133. MYOMA OF THE OVAKY (Doran). 133) has been described by Doran ; and Cullingworth has reported an FIG. 134. CANCER OF THE OVARY (2-inch and J-inch objectives) (Doran). interesting case of fibroma of both ovaries. A tubercular condition of the ovary is found as part of general tuberculosis. 224 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. Malignant disease of the ovary is a comparatively frequent occurrence. It often complicates cystic degeneration, specially the papillary form of ovarian cyst. It arises also independently, and may occur either as primary Carcinoma or Sarcoma. Fig. 134 shows the character of the growth in a case of scirrhus of the ovary in a girl aged fifteen, described by Thornton and Doran. Sarcoma may occur both in the spindle-celled and alveolar forms. The FIG. 135. SPINDLE-CELLED SARCOMA OF THE OVARY, 8howing the superficial and the more central part of the tumour (Doran). spindle-celled (fig. 135) forms a transition from the simple fibro-myo- matous tumour to the alveolar sarcoma (fig. 136). Foulis' An important feature is the rapid development of ascites, without the ' existence of cardiac, hepatic, or renal disease to explain it. Of great importance are the cells in the ascitic fluid associated with malignant FIG. 136. ALVEOLAR SARCOMA OF THE OVARY (Doran). ovarian disease. Foulis has investigated this subject, and has brought out results of very great value. Through his kindness we have been able to reproduce in Plates IX. and X. the cells he has drawn attention to ; and he has kindly furnished us with the following description. "A. Sprouting cell groups found in ascitic fluid surrounding a large cysto-sarcoma of the ovary. For a history of this case see Edin. Med. Jour., 1875, p. 838. In figures 3, 4, 5, 7, great variation in form and size of the cells in each group is seen. The largest cells are generally seen at the margins of the groups. Pig. 9. Several large polynucleated cells, evidently detached from cell groups. Fig. 11. Cells undergoing fatty degeneration. Fig. 12. Blood corpuscles. PLATE X PATHOLOGY OF OVARIAN TUMOURS. 225 " B. Cell groups found in the deposit from ascitic fluid surrounding a large soft malignant tumour of the ovary. In many of the cell-masses, large vacuoles are seen. " C. Cell groups found in the deposit from ascitic fluid surrounding a large flat or pancake-shaped tumour of the omentum. The tumour was thought to be ovarian. In the fluid in the pleural sacs exactly similar cells and cell groups were seen, and the pleural surface of the diaphragm was studded over with can- cerous nodules. " D. Cell groups found in ascitic fluid in the case of a gentleman, aged seventy, suffering from malignant peritonitis. In the centre a very large cell mass, with numerous vacuoles in the substance of the protoplasm, is seen. All the cell groups and cells were drawn by the aid of the camera lucida under a power of 350 diameters, with No. 3 ocular." It is probable that these liberated cells found in ascitic fluid graft themselves on the peritoneum, and pass through the diaphragm into the pleura and pericardium. They behave as we have seen bacteria do (vide p. 147). To illustrate the development of the normal ovary and of the Graafian follicles, we have added the following figures from Foulis' paper on this subject. Plate X. " E, Section through ovary and Wolffian body of a foetal lamb. a stalk of ovary, STR stroma, MD duct of Mtiller, e epithelium of peritoneum, g germ epithelium, y deepest part of the paren- chymatous zone of the ovary. F. Connective tissue sprouting out and surrounding the germ epithelium." PAROVARIAN CYSTS. These tumours are developed from the parovarium, have a separable Parovarian peritoneal covering, are thin-walled, and contain a watery fluid which is ys s< little more than a mere solution of salt. They may contain papillomatous growths, however, owing to their Wolffian origin an argument for their being always removed by abdominal section. Small parovarian tumours are common, but they may also be of very large size. They are seldom lined by ciliated epithelium, but usually by cubical or squamous cells, the flattening being, according to Spiegelberg, due to pressure of contents. It must be remembered of course that all cysts of the broad ligament are not parovarian in their origin. Parovarian cysts are in the site of the parovarium, with the ampullary portion of the tube and the ovarian fimbria stretched and the ovary intact. p 226 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. OTHER BROAD LIO-AMENT CYSTS (PAROVARIAL CYSTS). Parovarial By these we mean cysts developed in the broad ligament but not from the ovary or parovarium. They are however identical in origin with Parovarian cysts, as they arise from Wolffian relics ; further, they may be papillomatous. The direction of development of these tumours is of great practical interest as they may spread within the folds of the ligament towards the side of the pelvis, towards the uterus, or down in the direction of Douglas' pouch. This renders their removal troublesome as they have then to be enucleated, owing to the absence of a pedicle (v. Plate XL). These cysts may rupture and cause infective papillomatous growths of peritoneum and ovary. F. T. B.L.C. FIG. 137. A SIMPLE BROAD LIGAMENT CYST (Damn). Or. Ovary split open ; F. T. Fallopian tube ; B.L.C. Broad ligament cyst. Plate XI. from Coblenz will be helpful to the student in enabling him to understand the genesis of ovarian tumours, and will also show him the value of a knowledge of development in clearing up the origin of disease. Fig. 1 shows diagrammatically the development of the urinary and generative organs in the human foetus female organs (chiefly developed from the ducts of Muller while the Wolffian bodies are rudimentary) shown to the right of the line m, and male organs (chiefly developed from the Wolffian bodies while the ducts of Muller are rudimentary) to the left. The rudimentary organs are coloured blue in the figure. On both sides, we have nn supra-renal capsule, n kidney, u ureter, v bladder, ua urethra ; to the right (female organs) are ovary, po parovarium, PLATE XI. DIAGRAM OF MODE OF ORIGIN AND GROWTH OF MULTILOCULAR AND PAPILLOMATOUS OVARIAN TUMOURS (COBLENZ). PATHOLOGY OF OVARIAN TUMOURS. 227 wb part of Wolffian body not forming parovarium, gc Wolffian duct persisting in Gartner's canal, of fimbriated end of tube, ft Fallopian tube, ut uterus, vg vagina, ur urachus ; to the left (male organs) are T testis, ep epididymis, vd vas deferens, md duct of Miiller rudimentary down to vp vesicula prostatica. Fig. 2 shows the fully-developed generative organs in the female : on the left, the organs found in the normally developed female are given ; while, on the right, the coloured portion shows the rudimentary struc- tures from which there may be pathological development. On the left, the broad ligament is supposed to have been removed ; on the right, the organs are shown in coronal section (^ nat. size) ; ota ostium tubse abdominale, km hydatis Morgagni, fo ovarian fimbria, ovary, lo ovarian ligament, po parovarium, Ir round ligament, vg vagina, wv upper wall of vestibule, cc corpus cavernosum clitoridis, u ureter, I labium minus, Im labium majus; wb Wolffian body in its special separate parts as follows : Segment I. parovarium, II. III. IV. normally obliterated parts of Wolffian body and duct. From II. we may get cysts of broad ligament developing as well as papillomatous ovarian ones. From the duct (III. and IV.), we may get cysts of cervix uteri and vagina. Fig. 3 shows a section (in line ss Fig. 2) of broad ligament, Fal- lopian tube, and ovary. The blue line pp is the peritoneum, u being posterior layer of broad ligament ; the red one, the germ epithelium of ovary ; t tube, ov ovary, Ir round ligament. Fig. 4 shows development of ordinary multilocular tumour : C cystic and o v solid parts of tumour ; a a line of section when tumour is removed ; other letters as before. Fig. 5 shows a tumour which is multilocular and papillomatous, the latter feature caused by Wolffian remains at hilum of ovary. Fig. 6 shows papillomatous tumour of the parovarium developing in broad ligament, the ovary being intact. Fig. 7 shows papillomatous cyst extending within the layers of broad ligament developed from remains of Wolffian body and pushing up posterior layer of broad ligament (cf. Fig. 3u). The student will see by comparing Figs. 3, 4, 5, 6, and 7, how glandular and papillomatous cysts alter the relations of structures in the broad ligament. He will also understand the formation of the pedicle (v. figs. 4, 5, and 6), as well as the necessity for enucleation in such a case as Fig. 7. RELATION OF EVOLUTION TO THE PATHOLOGY OF OVARIAN TUMOURS. As we have seen, the undeveloped Graafian follicles are the most probable source of the multilocular ovarian tumour. From the remains of the Wolffian body known as the Parovarium the parovarian tumour 228 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. develops : while from the less constant remains at the ovarian hilum and near the uterus, the infective papilloma arise. It is remarkable that in the ovary of woman we should have not only so many thousands of unnecessary Graafian follicles formed, but that at an early period of intrauterine existence there should be in the foetus structures from which both ovaries and testes are developed, and that, in the Wolffian relics already mentioned, the adult woman should have traces of what in the other sex developes into the male organs. At present, we know of no explanation of these facts unless on the evolution hypothesis. Whether this explanation will hold good it is impossible to say, but at present it appears that to structures which in her are rudimentary and functionless woman is mainly indebted for the serious risks of ovarian cysts, simple and malignant. CHAPTER XXIII. DIAGNOSIS OF OVARIAN TUMOURS. LITERA TURK Atlee, W. L. The General and Differential Diagnosis of Ovarian Tumours : Lippincott and Co., Philadelphia, 1873. On Sarcoma of the Ovaries : Am. Gyn. Tr., Vol. II. Barnes Diseases of "Women, p. 400 : London, 1878. Brown, J. Baker Surgical Diseases of Women : London, 1866. Duncan, J. Matthews Diseases of Women : London, Churchill, 1886. Hicks, Braxton Further Remarks on the Use of Intermittent Contractions of the Pregnant Uterus as a means of Diagnosis : Lond. Inter. Congress Tr., 1882. Also Tr. of Lond. Obst. Soc., Vol. XIII., and Proc. of Royal Soc. of Lond., 1878. Jastrebow On a point in the Diagnosis of Ovarian Tumours: Lond. Inter. Congress Tr., 1882. Olshausen Die Krankheiten der Ovarien : Billroth's Handbuch, Stuttgart, 1877. Ritchie, C. G. Contributions to Ovarian Physiology and Pathology : Churchhill, London, 1865. Schroedei Hand- buch der Krankheiten der weiblichen Geschlechtsorgane : Leipzig, 1879. Tait, Lawson Diseases of the Ovary ; Cornish, Birmingham, 1883. Wetts, Sir T. Spencer Ovarian and Uterine Tumours: London, 1882. Williams, John Ovarian Turn ours: Reynold's System of Medicine, Vol. V. Lectures on the Diagnosis and Surgical Treatment of Abdominal Tumours : Br. Med. Jour., 1878. FOR convenience we take up the diagnosis and differential diagnosis of ovarian tumours under three heads : A. When small (pelvic in position); B. When large, multilocular, and pediculated (chiefly abdo- minal in position) ; C. When large and extraperitoneal (often papillomatous). A. WHEN SMALL (PELVIC IN POSITION). These may be either (a.) Lateral to uterus, or (b.) Posterior to uterus. (a.) Pelvic ovarian tumours lateral to Uterus. 1. Symptoms. These are chiefly those of pressure and bearing-down, Diagnosis and have no diagnostic value. There is no menorrhagia. Tumours' 11 2. Physical signs. Palpation and percussion give evidence of the when presence of a tumour only when it projects much above the brim. Auscultation gives negative results. On vaginal examination, the cervix Uterus, is found displaced to the side opposite to that where the tumour is. Through the fornix a tense, rounded, fluctuating mass is felt projecting downwards. Bimanually the uterus is felt not enlarged, but is displaced to the one side and is distinct from the tumour, which can be mapped 230 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. out between the hands. Usually the uterus and tumour are not very movable, owing to the limited space of the pelvic cavity. When the tumour is tapped, ovarian fluid is got. 3. Differential diagnosis. When lateral to the uterus, they require to be differentiated from the following : (1.) Pelvic cellulitis ; (2.) Pelvic peritonitis (encysted serous effusions) ; (3.) Parovarian cysts ; (4.) Hydrosalpinx, Pyosalpinx ; (5.) Fallopian- tube gestation ; (6.) Fibroid and fibro-cystic tumours of uterus ; (7.) Blood effusion ; (8.) Solid ovarian tumours. (1.) Pelvic cellulitis. With this we have inflammatory history and probable cause (as abortion or labour) to guide us. When the cellulitis has gone on to suppuration, there will be rigors and other indications of suppuration. Cellulitic deposits, unless when in the broad ligament, are always fixed ; are firm when not purulent, and even when purulent do not give very distinct fluctuation. (2.) Pelvic peritonitis. This will not cause the fornix to bulge downwards, and the history will help us. Tapping gives serum, and not ovarian fluid. When an ovarian tumour is fixed by peritonitic adhesions, it will be almost impossible to diagnose it from encysted pelvic peritonitic effusion except by examination of the fluid. (3.) Parovarian cysts are not so rounded and have very distinct fluctuation ; their secretion is usually simple salt and water. (4.) Hydrosalpinx and pyosalpinx are high in pelvis, tortuous, elon- gated from side to side. (5.) Extra-uterine gestation. The symptoms and signs of pregnancy with a tumour beside the uterus corresponding to the period of amenor- rhoea (sometimes masked however by irregular haemorrhages from the uterus) point to extra-uterine gestation. (6.) Fibroid and Jibro-cystic tumours of uterus (v. Section V.). (7.) Blood effusion in the broad ligaments is more difficult to diagnose during life, but sudden onset with history of fainting and pallor are found (v. Chap. XVI.). (8.) Solid ovarian tumours are rare. When malignant, there are often nodules in the fornices and ascitic fluid which shows the cells shown at Plates IX. and X. Diagnosis Ovarian (k) Pd Ovarian Tumours posterior to Uterus. Tumours -i c- t mi when *' symptoms. ine most noticed ones are associated with urination; posterior 1 ^ ere may be either reten tion or constant desire to micturate. There to Uterus, is no menorrhagia. DIAGNOSIS OF OVARIAN TUMOURS. 231 2. Physical signs. Palpation, auscultation, and percussion give the same result as when the tumour is lateral. On bimanual examination, the uterus is felt markedly displaced to the front but is not enlarged ; and bulging downwards behind the cervix, the round globular cystic ovary can be grasped. Tapping gives ovarian fluid. Differential diagnosis. When posterior to the uterus, they require to be differentiated from the following conditions. (1.) Encysted serous peritonitic effusion, (2.) Retro-uterine hsematocele, (3.) Fibroid and fibro-cystic tumours of the uterus, (4.) Retroverted gravid uterus and extra-uterine fetation, (5.) Parovarian cysts. (1.) Peritonitic effusion has an inflammatory history; it is not so rounded nor so well defined above. The fluid is serous. (2.) Retro-uterine hcematocele has, after the blood has coagulated, a hard feeling and is more expanded transversely. There is a history of sudden onset, menorrhagia, and subsequent inflammatory symptoms. (3.) Fibroid and fibro-cystic tumour of the uterus (v. Section V.). (4.) Retroverted gravid uterus and extra-uterine gestation. In both of these there will be the signs and symptoms of pregnancy; the amenorrhoea in the latter case may be masked by haemorrhages from the uterus. (5.) Parovarian cysts. The character of the fluid is our only certain guide. It should be specially noted that these pelvic ovarian tumours are apt to cause pelvic inflammation, and thus render the exact diagnosis, unless aided by tapping, very difficult. B. DIAGNOSIS OF OVARIAN TUMOURS WHEN LARGE, MULTILOCULAR, AND PEDICULATED (CHIEFLY ABDOMINAL IN POSITION). 1. Symptoms. These are chiefly due to its bulk. The patient's Diagnosis notice is attracted to the fact that she is getting rapidly stout. 2. Physical signs. When the patient lies on her back and the abdominal surface is exposed, the following points can be noted. On inspection the abdomen is seen to be greatly distended. The dis tention may be uniform, but is often more or less markedly lateral. The distance from the anterior superior spinous process to the umbilicus is greater on one side than the other. The superficial abdominal veins may be dilated, and lineae albicantes are sometimes present. On palpation, the distention is felt to be due to an encysted collection of fluid. A mass is felt in the abdominal cavity which is like a sac filled with fluid. Fluctuation is got by placing one hand at a special part and tapping at an opposite point with the fingers of the other hand. How- 232 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES, ever long the tumour be manipulated, there is never felt any muscular contraction of the cyst wall. On percussion when the patient lies dorsal, a dull note is obtained over the tumour (fig. 138) ; but at the flank where the tumour does not bulge, it is clear and tympanitic, since the intestines are there. When the patient turns on her side, with this flank uppermost, the dulness and tympanitic note do not change in position. This sign shows we have to deal with an encysted collection of fluid. Auscultation gives entirely negative results. No sound is heard unless that of friction over a localised peritonitis. On vaginal examination, the uterus is felt displaced to one or other FIG. 138. The shaded portion shows the dull area : left figure, ovarian tumour ; right figure, ascites (Barnes). side, or very much to the front. It is rarely retroverted, and unless impregnated is not enlarged. The tumour does not usually bulge down into the fornices, but may be made out bimanually. In order to ascertain how the pedicle lies, we have to make the examination per rectum. The tumour is drawn upwards in the abdominal cavity by an assistant. We now lay hold of the cervix with a volsella, pass the index finger of the right hand into the rectum, make traction on the cervix till the fundus is brought within reach of the rectal finger. AVe recognise a tense band passing from one angle of the fundus, and the enlarged ovarian artery may be felt pulsating in it. AVe now examine for the ovary of the opposite side, to ascertain if it is normal in size. The possibility of both ovaries being cystic (which would produce a pedicle on each side), should not be forgotten, though DIAGNOSIS OF OVARIAN TUMOURS. 233 this is comparatively rare. The examination with the volsella is made easier by placing the patient in the genupectoral posture ; the weight of the tumour makes it gravitate into the abdomen, and renders the pedicle tense ; it is also easier to make the rectal examination in this position. 3. Differential Diagnosis. Differen- They must be diagnosed from the following conditions : nosis 8 (1.) Pregnancy and Hydramnios, (2.) Fibroma uteri, (3.) Ascitic fluid, (4.) Fibrocystic tumours of the uterus, (5.) Parovarian tumours, (6.) Encysted dropsy, (7.) Thickened omentum enclosing intestines by adhesions, (8.) Omental tumours, (9.) Renal tumours, (10.) Hydatid of liver, (11.) Pseudocyesis, (12.) Distended bladder. In examining a case of abdominal tumour, the practitioner first makes his examination systematically in every case what is called the routine examination, noting what he observes. By this means he may get facts enough to warrant his drawing a positive conclusion as to its nature. This, however, is not always the case, and he has then to use diagnosis by exclusion : it must be one of a certain fixed number of things, and the possibilities are excluded one by one till a definite diagnosis is reached. When examination is unsatisfactory, it should be repeated under chloroform. We have stated above that ovarian tumours require to be diagnosed from twelve conditions. On each of these we make some brief remarks. (1.) Pregnancy. At the period of pregnancy when the uterus is so enlarged as to be above the pelvic brim, certain conditions are present. These are suppression of menstruation for a given period, and size of the uterus corresponding to this ; mammaiy signs ; linese albicantes, and pig- mentation. On palpation, we feel a tumour without distinct fluctuation and having intermittent contractions; the foetus can be palpated out. The foetal heart (after the fourth month) and the uterine souffle are heard. The vagina is dark in colour, the mucous secretion increased, and the cervix soft. We need hardly say that palpation, the foetal heart-sounds, bruit and vaginal changes mark out the pregnancy unmistakably. These points may seem too simple to require mention, but cases have been recorded where the pregnant uterus has been tapped for an ovarian cyst. 234 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. Hydramnios may simulate an ovarian cyst. The amenorrhcea will help, aud especially the occurrence of intermittent contractions as Braxton Hicks has specially pointed out. In one of his recorded cases, the tumour was the size of a seven months' uterus with distinct fluctuation, and there was amenorrhoea for five months. Palpation gave the uterine hardening. Previous to this it had been tapped as a cystic ovarian tumour. (2.) Fibroma uteri (v. Section V.). (3.) Ascitic fluid. When the patient lies on the back, percussion gives a tympanitic note at the umbilicus and a dull one at the flanks (fig. 138) ; when on the left side, the note is dull on that side and clear over the right ; when on the right, it is dull on that side and tympanitic on the left; when she sits up, the upper limit of the dulness is curved with the convexity downwards. The reason of this is evident. The intestines float on the fluid at its highest point, and give the tympanitic note accordingly (fig. 138). (4.) Fibrocystic tumours of the uterus are difficult to diagnose. The following points should be noted. Fluctuation is only partial and the consistence is variable ; the rate of growth is slower ; and the fluid drawn off coagulates spontaneously (Atlee). It is often difficult to distinguish these from ovarian tumours, and the best operators have sometimes failed to do so (v. Section V.). (5.) Parovarian tumours have very well-marked fluctuation, have their characteristic fluid, and when once tapped do not usually refill as they are often retention cysts. (6.), (7.), and (8.). In many cases we can make out that the tumour does not pass down into the pelvis and is not connected with the uterus. Sometimes the case is obscure, and abdominal incision alone clears matters up. (9.) Renal tumours grow downwards and inwards, have all their edges rounded, and do not as a rule project posteriorly. When right-sided, the colon lies between them and the liver. Their fluid contains urea. (10.) The hydatid is connected with the liver and contains hooklets. (11.) In Pseudocyesis, the percussion note is tympanitic and the swelling disappears under chloroform. (12.) The distended bladder is of course emptied by the catheter. WHEN LARGE AND EXTRAPERITONEAL (OFTEN PAPILLOMATOUs). In this class the tumour is not pediculated, and in its extraperitoneal burrowing growth pushes aside uterus, bladder, or large intestines, so that extreme displacement of these may take place (v. fig. 7, PI. XL). It is therefore of importance in the diagnosis of large abdominal cysts to ascertain the position of the uterus, and also the percussion note so as to make out if large intestine is displaced. When these tumours DIAGNOSIS OF OVARIAN TUMOURS. 235 develop laterally, the displacement of the uterus is an aid to diagnosis; when posterior to the uterus, however, their diagnosis is less easy, as they may only slightly displace the uterus. They usually then bulge well down into the pelvis, lying below the peritoneal level. Their existence should therefore be suspected (1.) If uterus or bladder is displaced markedly; (2.) When over a cyst of size sufficient to displace the small intestine, we get a tympanitic note. This indicates dis- placement of large intestine, which can only be done by an extraperitoneal cyst. DIAGNOSIS OF ADHESIONS. When pelvic, the fixation of the tumour they cause can be felt. Diagnosis Adhesions are often the result of tapping; they may also arise from s i ons- mere pressure. Careful inquiry should always be made as to the his- tory of inflammatory attacks. On palpating the tumour, one can often feel friction. On making the patient take a deep breath, it should be noted whether the abdominal walls move over the surface of the tumour. Much less importance is attached nowadays to the existence of ab- dominal adhesions. When pelvic, especially if to the bladder or deep in the pouch of Douglas, they are more serious. CO-EXISTENCE OP PREGNANCY AND OVARIAN TUMOUR. It should be kept in mind that pregnancy may co-exist with anCo-exist- ovarian tumour, giving its own special symptoms and physical signs i addition. CHAPTER XXIV. OPERATIVE TREATMENT OF OVARIAN TUMOURS. LITERA TDRE. AtleeThe General and Differential Diagnosis of Ovarian Tumours : Philadelphia, 1873. Bantock First Series of Twenty-five Cases of Completed Ovariotomy : Brit. Med. Jour., 1879, p. 766. Specimen illustrating the changes in the Pedicle of an Ovarian Cyst when treated by Ligature : Tr. Lond. Obst. Soc., XIV., 1872. Early Operative Treatment of Ovarian Cysts : Lond. 1882. Cheyne, Watson Antiseptic Surgery : Smith, Elder, & Co., London, 1882. Cfiiara Accidental Puncture of Pregnant Uterus: Annali di Ostetricia, etc., 1885, 412 and 453. Goodell, Wm. Article "Ovariotomy : " in Vol. II., American System of Gynecology and Obstetrics (edited by Mann). See also Amer. Jour, of Obst., Jan. 1888. Hegar und Kaltenlach Die operative Gynakologie : Stuttgart, 1881, S. 201. Lee, G. C. Accidental Puncture of the Pregnant Uterus : Amer. Jour. Obstet. , 1885, 190. Lister Address on the Treatment of Wounds : Lancet, Nov. 19 and 26, 1881. M ahomed Lancet, 1879. Miner Ovariotomy by Enucleation : Philad. Intern. Cong. Tr., 1877. Munde, P. F. The Value of Electrolysis in the Treatment of Ovarian Tumours : Am. Gyn. Tr., Vol. II., p. 348. Semeleder Twenty Cases of Ovarian Cysts treated by Electrolysis : Am. Jour, of Obst., XV., 515. Sims, J. M. Thomas Keith and Ovariotomy : Am. Jour, of Obst., April 1880. Tail, Lawson On Axial Rotation of Ovarian Tumours leading to their Strangulation and Gangrene : London Obst. Tr., Vol. .XXII., p. 86. The Antiseptic Theory tested in Ovariotomy : Lond. Roy. Med. and Chir. Tr., Vol. LXIIL, p. 161. Recent Advances in Abdominal Surgery : London Intern. Cong. Tr., 1882. Diseases of the Ovary: Birmingham, 1883. Thornton, J. K. The Silk Ligature as a means of securing the Ovarian Pedicle : Brit. Med. Jour., 1878, p. 125. Also, "Rotation of Ovarian Tumours ; its Etiology, Pathology, Diagnosis, and Treatment : " Inter. Jour, of Med. Sc., Vol. XCVI., p. 357. Wells, Sir T. S. Ovarian and Uterine Tumours : Lond. 1882. Recent Advances in the Surgical Treatment of Intraperitoneal Wounds : London Intern. Cong. Tr., 1882. Additional Cases of Ovariotomy performed during Pregnancy : London Obst. Tr., Vol. XIX., p. 184. See also Index of Recent Gynecological Literature in the Appendix. Treatment REMOVAL of the ovarian tumour, or Ovariotomy, is the treatment now Tumours, practised. Other methods have, however, been employed ; a brief resumd of these will be useful to the student. Exploded These methods have been tapping, tapping and injection of the cyst with iodine, Methods, electrolysis, drainage into the peritoneal cavity or through the vagina. Tapping is not a method of treatment followed by cure, and should be used only when it is absolutely necessary to obtain fluid for diagnosis. It may cure parovarian cysts, but it is best to remove them by abdominal section. Ovarian cysts are not retention cysts but have a proliferating lining membrane, for which reason tapping does not cure them. An additional reason against tapping is that it is a procedure by no means free from danger, even to life. By oozing of the fluid through the puncture, adhesions are set up : OPERATIVE TREATMENT OF OVARIAN TUMOURS. 237 in some cases, septic peritonitis has proved fatal. Tapping, further, is only palliative and must be followed by ovariotomy. Method of Tapping. See that the bladder is empty. With the patient lying on her back make an incision through skin and fat for about an inch, and midway between umbilicus and pubes. Then plunge in the trocar seen at fig. 140. To the side-tube a long piece of tubing is attached, which dips under water. While the fluid is flowing, the patient lies on her side. No bandage is necessary. Care should be taken to prevent regurgitation of air, and a suitable dressing should be applied to the wound (vide under Ovariotomy). Tapping and injection of the cyst with iodine is a procedure not now practised, owing to the risks and uncertainty attending it. Electrolysis was at one time advocated as a means of cure. Its pretensions to this are unfounded, and few now practise it. Its use has been carefully considered by Munde of New York, and Semeleder, city of Mexico, in the articles cited, which may be consulted for details and information. Drainage into the peritoneal cavity, or through the vagina. The former is dangerous, and the latter is practised only where the cyst is immovably fixed by adhesions. One fact must be finally noted. Cases of cure of ovarian cysts by tapping, drainage, or electrolysis, are sometimes recorded. These cysts have probably not been ovarian but cysts of the broad ligament parovarian. Mere tapping often .cures the latter. Electrolysis does the same. Electricity has nothing to do with it, the puncture of the needle is enough. OVARIOTOMY. This used to be performed either by vaginal or abdominal incision. The former is now never employed. VAGINAL METHOD. This was practised when the tumour was pelvic and small. Thomas of New York, Vaginal Goodell of Philadelphia, Gilmore, Hamilton, and others have recorded cases. TheOvari- following was the plan of procedure. otomy. Chloroform or etherize the patient. Place her semiprone or in the lithotomy posture. Pass the Sims speculum. Incise the posterior vaginal wall behind the cervix, in the middle line. Tap the tumour with an aspirator, and then draw it through the incision with the finger or curved forceps. Ligature the pedicle with thin carbolised silk threaded on a handled needle, and divide it on the side next the tumour. Pass a T-shaped drainage tube into the wound which may be stitched round it or left open. Should the temperature rise or the discharge become foetid, irrigate daily with weak carbolic lotion (1-100). ABDOMINAL METHOD. The question used to be discussed as to the best time to operate in a Abdominal case of ovarian tumour whether, if small, one should wait until it i large. The opinion now held is that one should operate whenever the tumour is diagnosed without reference to its size. Let us suppose, then, that the ovariotomist has a patient who is other- wise healthy with an ovarian tumour free from adhesions, and that her period has occurred ten days before. How is the operation performed 1 If the patient has not been in any way confined to bed, it is probably better to delay the operation till another period has passed, in order to accustom her to an invalid's life. A pulse and temperature chart should also be taken for a few days prior to the operation. She is kept on 238 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. light diet, and has no solid food for six hours previous to the adminis- tration of chloroform. On the evening prior to the operation, castor oil should be given and an enema used in the morning. Requisites The following are the requisites for operation : forOpera- Chloroform and ether ; Hypodermic syringe ; Spray (?) 5 Carbolic lotion ; Porcelain trays for instruments ; Sponges (a definite number), some small and fixed on sponge- holders ; Waterproof, with oval opening of which the edges are coated with adhesive plaster ; Ordinary knives ; Probe-pointed curved bistoury ; Scissors, straight and curved ; Spatulse ; Dissecting and dressing forceps ; Pean's or Wells' artery forceps a definite number (12) of pairs ; Tenacula, blunt hooks ; Needles on fixed handles ; Aneurism needle ; Fine catgut for bleeding vessels ; Carbolised silk (Nos. 3 and 4) ; Two pairs ovariotomy forceps (Nelaton's or Keith's) ; Wells' trocar ; Clamp (in reserve) ; Cautery, actual or Paquelin's ; Cautery-clamp ; Long straight needles, threaded two on each suture of silk-worm gut; Needle-holder with small needles on horse-hair sutures ; Drainage tubes (glass or ordinary) ; Reflecting mirror ; lodoform, iodoform gauze, salicylic wool, flannel bandages. Assistants. The assistants necessary are three in number, viz., one for chloroform, one for instruments, one to help the operator. It is good however for the operator alone to handle the instruments, and thus two assist- ants are sufficient. A trained nurse who can pass the catheter and administer purgative or nutritive enemata, is necessary. The patient is placed on an ordinary table, of convenient height and length, and lies on her back. The table is placed so that the patient's feet are towards the window. The legs and chest are to be warmly covered, and hot- water bottles should be laid at her sides and feet. The room should be OPERATIVE TREATMENT OF OVARIAN TUMOURS. 239 comfortably warm. The best position for the operator is to stand on the patient's right side, with his back to her feet and to the window. The question of the use of antiseptics in ovariotomy will be discussed afterwards. The instruments are placed near the operator in shallow porcelain trays, and in 1-40 carbolic solution. The sponges should be soft, fine, and thoroughly clean. Twelve are Sponges, sufficient. Some are small and on sponge holders ; one is large and flat. They should be thoroughly wrung out of warm 1-60 solution. The sponge assistant should know hoio many sponges he has, and should be sure that he has recovered them all before the abdominal wound is dosed. Sponges should never on any account be torn up during an operation. The spray, if used, should be placed eight or ten feet from the wound Spray, and throw out a finely-divided vapour. Preliminaries. The patient, who has had a very light breakfast somePrelimi- hours previously, should be chloroformed or etherized; the skin washed nanes - and shaved ; and the waterproof made to adhere to the skin, so that the incision shall bisect the portion exposed through the oval opening. This waterproof keeps the patient dry and comfortable. The following are the steps of an ordinary operation : 1. The abdominal incision ; 2. Evacuation of the cyst contents ; 3. Drawing out of the cyst from the abdomen ; 4. Securing of the pedicle ; 5. Treatment of adhesions, and bleeding from them ; 6. The peritoneal toilette ; 7. Closure of the abdominal wound ; 8. Drainage when necessary ; 9. Dressing of the wound ; 1 0. After-treatment complications. 1. The abdominal incision. This is usually four inches long, is made Incision, in the middle line, and has its lower limit about an inch above the symphysis. It passes through skin, fat, linea alba, extraperitoneal fat, peritoneum. Sometimes the linea alba is missed, and the rectus muscle cut into. By passing a probe in towards the middle line, the operator gets the right track and thus avoids bleeding. The extraperitoneal fat is a good landmark. All bleeding points are carefully attended to before the peri- toneum is opened. They may be seized with Pean's forceps which are left on for a time, or they may be ligatured with catgut. When the 240 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. extraperitoneal fat is reached, it is picked up with two Pean's forceps so as to get a short transverse fold ; this is cut, and the manoeuvre repeated until the peritoneal cavity is opened. The cyst is then exposed. x Methods of 2. Evacuation of the cyst contents. This may be accomplished in vari- Evacua- ous ^ & ^ & Wells' trocar (fig. 139), with its point projected, is plunged FIG. 139. WELLS' TROCAR (J). o, sharp point, protected by tube 6, which is projected by pushing out thumb-piece d ; c toothed catch to grasp cyst wall ; gutta-percha tubing is fitted on to e, in, and the fluid passes along the thick tube to a suitable pail below the table. As soon as the trocar enters the cyst, the shield is pushed out to guard the point. The trocar has teeth for catching up the cyst wall. Keith uses a large aspirator, so as to empty speedily. Schroeder used no trocar, but simply cuts in with his knife and squeezes the fluid out. The kneed trocar may be used (fig. 140), but a simple large trocar without toothed catch is best. When the fluid is very thick it may not flow, and have to be squeezed or scooped out. Secondary cysts, if large, are also per- forated. While the fluid is being evacuated an assistant keeps up steady pres- sure on the abdominal walls, in order to prevent fluid from passing in or the intestines from passing out. Cyst drawn 3. Drawing out of the cyst from the abdomen. This is accomplished by seizing the collapsed walls of the tumour with Nelaton's (fig. 141) or Keith's forceps, and steadily pulling it out. The assistant still keeps out. FIG. 140. TROCAR FOR TAPPING. Tubing is fitted to side-piece. up pressure. By this means the operator now has the pedicle at the Cyst abdominal incision, and the cyst outside. The assistant by means of sponges keeps back the intestines should they attempt to protrude. 1 Sometimes the cyst develops between the layers of the broad ligament (v. PI. XL, fig. 7), lifts up the anterior lamina, and strips the peritoneum off the anterior abdominal wall. When the operator has cut through the abdominal muscles he is puzzled by finding no peritoneum. Puncture and dragging out the collapsed cyst will, however, clear up matters. OPERATIVE TREATMENT OF OVARIAN TUMOURS. 241 Securing of the pedicle. This is one of the most important steps of the Securing of operation. There are three methods which may be used, viz. The clamp, The cautery, The ligature. Of these, the clamp is now seldom used. Keith and others advocate the cautery ; but the ligature and dropping back of the pedicle is the favourite and probably the best method. The clamp may be necessary if the pedicle is thick. FIG. 141. N^LATON'S FORCEPS. The clamp was introduced by Jonathan Hutchinson, but, as already said, By Clamp, is now yielding to the ligature. The varieties of clamp are numerous. Fig. 142 shows Wells'; it consists of two short arms jointed together and provided with a screw and removable handles. It is used as follows. The clamp is held by its handles and made to grasp the pedicle between the cyst and the uterus ; the bars of the clamp proper are then approxi- mated, and the screw tightly screwed up. The pedicle is examined to see FIG. 142. WELLS' CLAMP (J), with removable handles. The serrated part with the screw is the clamp proper. that it is grasped and equally compressed ; if one part is thin, Spencer Wells recommends that the pedicle be first secured with a ligature. The pedicle is treated extra-peritoneally with the clamp, which rests on the skin. The great advantage of the clamp is its security against haemorr- hage. Its evident disadvantages are the following : It does not suit all cases, as it cannot be used when the pedicle is too large or too short ; it may cause ventral hernia ; it exercises undue traction on the uterus ; but, 242 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. above all, it may cause a slough deeper down than the skin, and the discharges, passing into the peritoneal cavity, may do great mischief. Thus the mortality was high (25 p.c.) in cases where the clamp was used. By Cautery. The cautery was introduced, as a means of treating the pedicle, by Baker Brown of London. In order to use the cautery, we need a special cautery-clamp and either cautery irons or Paquelin's cautery. Keith uses ordinary cautery irons heated in a little charcoal brazier. The cautery-clamp has two hinged bars provided with handles ; each bar has one surface which is made of ivory a non-conductor and is placed next the skin ; the other surface is made of metal ; one of the bars has on its metal surface a metal upright running the whole length of the bar. The pedicle is seized with the clamp (ivory side next to the skin), and the screw turned to fix it. Then the cyst is cut off, so as to leave about an inch of the pedicle on the metal side. The dull cautery iron, which is hatchet- shaped, is then passed firmly over the surface, in the angle between the horizontal bar and the upright, until the pedicle is seared flush with the clamp. The pedicle is now caught at the under surface of the clamp with two pairs of forceps, and the clamp removed. If all is right, the pedicle is dropped into the abdomen after the peritoneal toilette is finished. By Liga- The ligature should be thin carbolised Chinese silk No. 3 or 4. It is used in the following way. A double silk ligature is threaded on a Hunt needle. The pedicle is transfixed with this, and the ligature cut. Thus we have two ligatures through the pedicle ; one is passed round the one half of the pedicle, the other round the other half. They may be made to interlace first so as to make a figure of eight. Each is tied firmly in a reef knot. The pedicle is then seized with Pean's forceps, one on each side below the ligature; the cyst is clipped off about half an inch on the cyst side of the ligature ; while the pedicle is still held up by the forceps it can be carefully examined to see if any bleeding occurs. It should be noted whether the ligature splits the pedicle vertically so as to cause bleeding; if so, the ends of the thread can be made to surround the whole pedicle below this. If there is no bleeding, the ligature is cut short and the pedicle dropped into the pelvis. The raw end of the pedicle may be stitched with catgut to the broad ligament, so as to prevent its adhering to and constricting intestine (Thornton). When the pedicle is thick and fleshy it may require to be tied in three portions as follows : Pass a double thread so that its shorter half will embrace only one-third of the pedicle; withdraw the needle, but keep it still running on the thread, and use it to carry the longer half of the OPERATIVE TREATMENT OF OVARIAN TUMOURS. 243 thread through a second point so as to embrace the middle third of the pedicle; one portion of the longer half thus forms a loop round the middle third, while the other portion embraces the other third of the pedicle. Tait's knot may also be used (v. p. 211). After the pedicle has been secured by one of these methods, the other ovary should be examined and if cystic removed also. The distal portion of the pedicle does not slough. According to Thornton, we may Changes in have the five following results. Pedicle. (1.) Adhesion of the peritoneal surfaces on opposite sides of the ligature, and absorption of ligature. (2.) Lymph effused over ligature and end of stump, formation of new vessels. (3.) Adhesion of pedicle raw surface to some neighbouring peritoneal surface and passage of blood-vessels between. (4. ) Haemorrhage from pampinif orm plexus at outer edge. (5.) No change or sloughing if patient dies soon. 5. Treatment of adhesions and bleeding. Adhesions in certain cases may Treatment give a great deal of trouble. They may be at any point of the periphery j^,^ nd of the tumour. When close to important viscera (especially the bladder, Bleeding, intestine, or liver) they are serious. Their treatment is best considered as follows : (a.) when short, (b.) when long. (a.) When easily separable, these may be detached by sponging. If the cyst is connected with the anterior abdominal w r all, it is sometimes cut into. The operator then separates the cyst from the wall by pass- ing his finger in between them where the adhesion ceases ; or he may evert the abdominal wall, and strip the cyst off it with dissecting forceps. Spencer Wells recommends in bad cases to evacuate the cyst, and then, by seizing the posterior wall of the cyst with a hand passed into the interior, to evert it and afterwards separate the adhesions. Pressure with sponges or ligatures will arrest any bleeding, or the cautery may be applied. If the bleeding is intractable, a good plan is to pinch up the abdominal walls at the bleeding part and pass a long straight needle through this fold, so as to keep the bleeding peritoneal surfaces in apposition. Adhesions in the region of the sacro-iliac sychondrosis are dangerous owing to the risk of tearing into the large veins or ureter. The possi- bility of an adhesion to the tip of the vermiform appendix must be kept in mind. (&.) When the adhesions are long, they may be ligatured at two points close to the cyst and divided between these. When adhesions to the bladder are present great care must be taken, as, in separating them, the bladder may be torn into. If this happens, the tear should be stitched with fine silk or catgut, and a catheter kept in for some days. ( Vide under Vesico-vaginal Fistula.) When adhesions are inseparable, the adherent portion of the cyst may be ligatured all round 244 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. Peritoneal Toilette. Closure of Wound. with silk, and then cut beyond the ligatures ; or it may be simply cut all round the adherent portion, and the edges then cauterized. For reflecting light into the pelvis or other deep parts, an ophthal- inoscopic mirror is invaluable. 6. The peritoneal toilette. This term is a convenient one used by German operators to indicate the cleansing of the peritoneum. It must be laid down as a cardinal principle in abdominal section that no serum or blood is to be left in the abdomen. The peritoneum should be thoroughly dry, and no oozing points are to be left. The importance of the toilette cannot be too strongly insisted on. Thomas Keith, whose success in ovariotomy is unrivalled, takes the greatest care in this matter, and attributes his success to it. Sims indeed savs, " But I think now that it matters very little what we / * do with the pedicle, whether we use the clamp, the cautery, or the ligature, provided we take every care against the exudation of bloody serum into the peritoneal cavity after the closure of the abdominal wound." 7. Closure of the abdominal wound. This is done as described under Abdominal Section in the Appendix. Drainage. 8. Drainage. As to drainage, the rule is that none is needed in simple cases. This rule may seem to the student to clash with the invaluable principle that every wound from which there will be discharge ought to be drained. In ovariotomy, however, the peritoneum is an absorbent sac, and the discharge, after a simple operation, is absorbed before it has time to putrefy (Lister). In complicated cases, as where there have been many adhesions, this drainage by absorption is insufficient ; it becomes also dangerous from the amount of serum thrown out, and the risk of its putrefying. External drainage is, in such cases, imperative. A per- forated glass drainage-tube is passed in at the lower angle of the wound and down into the pelvis. To keep the patient dry, there is laid over the abdomen a piece of thin rubber sheeting with a slit in it through which the tube passes. Over the end of the tube, a sponge or some other absorbent is placed and removed when soaked (Keith). Several pints of serum may thus come away. 9. Dressing of the wound. Where there is no drainage, it is sufficient to dust with iodoform and lay on a pad of iodoform gauze or other antiseptic material. Where a drainage-tube is used we dust the wound as before, lay over it a piece of protective silk and then pack round the tube some antiseptic absorbent wool. The dressing is kept in place by strips of plaster or a loose flannel bandage. If the pulse and tempera- ture do not rise and there is no uneasiness, the dressing is left untouched in simple cases for eight or nine days. If there is drainage, the dressing should be changed occasionally according to the amount of discharge. Dressing. OPERATIVE TREATMENT OF OVARIAN TUMOURS. 245 10. After-treatment: treatment of complications. Morphia may be After- given hypodermically, but only when necessary (vide p. 164). Little an( j Q om . food is allowed for the first thirty-six hours; hot water should be given plications. ad libitum, as it helps flatus. At the end of this time, milk and beef-tea are added. An enema may be administered on the third or fourth day. When flatus is troublesome, a tube may be passed into the rectum. Sickness is often great, and should be treated with mustard poultices over the epigastrium and enemata of beef-tea and brandy. If it persists to the third or fourth day, two or three grains of calomel may be given. Tait recommends thirty or forty grains of Epsom salts each hour until the bowels move. Complications may be Secondary haemorrhage ; High temperature ; Septicaemia. Secondary haemorrhage, if from the pedicle or adhesions, must be treated by the reopening of the wound and application of ligatures. For high temperatures the ice-cap is good. The Americans recommend the more wholesale method of reduction of temperature by Kibbee's ice- cot. Krohne and Seseman of London supply very convenient ice-caps made of block-tin pipe. Quinine in fifteen grain doses should be tried. It is probable that some high temperatures, recorded by ovariotomists, have been due to the absorption by the peritoneum of carbolic acid used in Listerism. In cases of septicaemia with peritonitis where drainage has been employed, the peritoneal cavity should be washed with very weak carbolic lotion whenever there seems to be any tension or accumulation of putrid fluid ; the abdominal incision may require to be reopened for this purpose. The condition should be further treated by iron and stimulants as needed. (Vide Treatment of Pelvic Peritonitis.) Paralysis of the bowel, with great distention and death, has also been noted ; as also death from heart clot (Tait). Tetanus has also occurred. The patient should after convalescence wear an abdominal belt to prevent hernia at the abdominal scar. ABDOMINAL METHOD WHEN THE TUMOUR IS PAPILLOMATOUS AND EXTRAPERITONEAL. In such cases (v. fig. 7, Plate XL), -a different procedure has to be adopted, viz. Enucleation. The tumour is tapped, drawn on as much as possible, and its peritoneal covering incised so as to include an elliptical portion. The finger is then used to separate the tumour from its capsule, steady traction facilitating this. Bleeding is arrested with forceps or ligature. Goodell, who has given by far the most graphic description of this method, advises that the uterus and bladder be carefully defined, and the separation begun at the uterine side of the tumour 246 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. where the large blood-vessels enter. The difficulty in the operation is the separation in the pelvis, since the large veins there (as well as the ureter) are apt to be torn. Injury to the ureter is especially dangerous : it is often not recognised, and, unless a fistula form, is fatal. When enuclea- tion is finished, a large oozing extraperitoneal surface is left. Its edges should be stitched to the abdominal incision so as to close it off from the peritoneal cavity, and a glass drainage-tube passed in. Some, however, close this opening and drain per vaginam. Cases like these are the really difficult and dangerous ones. The chance of return or peritoneal infection is very great. The idea of this method of enucleation is due to Miner of Buffalo, although the pathology of this form was not clearly understood then : indeed, Miner's original paper, inasmuch as it seemed to apply to the ordinary ovarian cyst, was not very intelligible. THE RELATION OP LISTERISM TO OVARIOTOMY. Listerism The Listerian method of treating wounds is based on the now generally otomy*' accepted theory that the germ-laden air coming in contact with a wound leads to putrefactive changes which may end in septicaemia. Lister found carbolic acid destructive to the activity of these germs; and, consequently, Listerism requires that the air in contact with the wound, and all else that touches it, must be purified either with the spray or lotion. Lister- ism is in no sense a treatment of wounds, but is a treatment of wound- surroundings. The application of carbolic lotion to a wound is a necessary evil, as carbolic acid is an irritant and may be absorbed. In the cases treated by the surgeon, Listerism is of the greatest value ; and, with drainage, has worked the most mighty revolution in surgery. In per- itoneal operations, however, its good is marred by the fact that the peritoneum absorbs the carbolic lotion, and thus its surface is irritated and often toxic effects ensue. Keith, Tait, and Bantock have therefore abandoned Listerism in abdominal surgery ; but Wells and Thornton still carry it strictly out. Listerism has been modified, but only in this, that less importance is now attached to air-contamination of raw surfaces during an operation. Unclean "touch" is the real danger. Practically most ovariotomists at present trust to modified Listerism, and to drainage when necessary. All Listerian precautions should be used except the spray. OVARIOTOMY WHEN PREGNANCY IS PRESENT. Pregnancy Although pregnancy co-exists with a large ovarian tumour, ovariotomy otomy. should be performed. In the paper of Spencer Wells quoted he gives a table of nine cases where the pregnancy varied from the third to the seventh month, with the following results. Only one mother died : the OPERATIVE TREATMENT OF OVARIAN TUMOURS. 247 pregnancy went on to full time in five of the cases ; in three the child was expelled prematurely, and in one the child was removed at the opera- tion. Puncture of the gravid uterus during the progress of the operation must be guarded against. This may happen if the pregnancy has not been diagnosed and the pregnant uterus mistaken for a secondary cyst ; or it may be as in Lee's case that owing to a change of the position of the patient from the dorsal to the lateral posture, the ovarian cyst recedes from the abdominal incision and the uterus lies below it without the changes being noted. When this accident occurs, the treatment depends on the depth of the wound. Should the uterine cavity not be opened, then bleeding is arrested by pressure, the wound stitched with continuous silk suture. If the amniotic cavity is opened into, the same treatment may be adopted (v. Chiara's case) ; or the incision may be suitably enlarged, and the foetus, placenta, and membranes extracted. The treatment after this may be removal of the uterus by Porro's opera- tion, simple suture of the walls with silver wire, or the Ceesarean section with the modification introduced by Sanger. The question of the treat- ment of a labour complicated with an ovarian tumour concerns the obstetrician rather than the gynecologist. CONTRA-INDICATIONS TO OVARIOTOMY. These are universal adhesions and malignant disease. Ordinary Contra- ascites, kidney disease, or heart disease, is not a contra-indication unless 111 ' far advanced. Prognosis should be careful in these cases. In some fatal cases it has been found on post mortem that the kidneys were small and granular from interstitial inflammation. This may be present while there is no albumen in the urine. There is usually a pulse of high tension and cardiac hypertrophy (v. Mahomed's articles). COURSE AND RESULTS OP OVARIAN TUMOURS WHEN LEFT ALONE. In some rare cases the operator is unable to remove the cyst after he Natural has begun his operation. He may then stitch the cyst edges to theovafrian abdominal walls carefully closing it off from the peritoneum. The best Cysts, results by this method are got in dermoid and parovarian cysts : they are not good in ordinary ovarian cystomata. Adhesions may be set up as the result of chronic peritonitis arising from pressure or tapping. Occasionally the cyst bursts, and in the case of the ordinary ovarian tumour we may get rapid death or the condition termed Pseudomyxoma peritonei by Werth (v. p. 221). When par- ovarian tumours burst, the fluid is usually non-irritating and is absorbed by the peritoneum, the patient thus becoming cured. Matthews Duncan and others have recorded cases of burst ovarian tumour rapidly becoming fatal. Waxy disease of the liver, kidneys, etc., may result in those 248 AFFECTIONS OF FALLOPIAN TUBES AND OVARIES. cases where the tumour suppurates and discharges into the bowel or through the skin. Torsion of the pedicle to a slight extent is often noticed in ovarian tumours. When the torsion is so great as to cut off the blood supply from the cyst, we get gangrene of the tumour, and in some cases very serious symptoms, viz., peritonitis, vomiting, and severe abdominal pains. Wiltshire of London was the first to operate for this condition, and recently Lawson Tait has operated successfully in three cases. His paper should be consulted for details. It is interesting to note that the tumours so rotated are usually right-sided, and not necessarily ovarian. The usual explanation of the rotation is that it is caused gradually by the fsecal contents passing down the rectum. Tait's book and Thornton's paper may be consulted for fuller details. If peritonitis occur before the tumour is removed, ovariotomy should be at once performed. Keith was the first to do this successfully. The course and results of ovarian tumours when left alone can fortu- nately not now be studied. The picture of ovarian disease running its course unchecked, so eloquently described by West, is happily now almost unknown. " We have symptoms of the same kind as we see towards the close of every lingering disease, betokening the gradual failure, first of one power, then of another ; the flickering of the taper, which, as all can see, must soon go out. The appetite becomes more and more capricious, and at last no ingenuity of culinary skill can tempt it, while digestion fails even more rapidly, and the wasting body tells but too plainly how the little food nourishes still less and less. The pulse grows feebler, and the strength diminishes every day, and one by one each customary exertion is abandoned. At first the efforts made for the sake of the change which the sick so crave for are given up ; then those for cleanliness ; and lastly, those for comfort till at length one position is maintained all day long in spite of the cracking of the tender skin, it sufficing for the patient that respiration can go on quietly, and she can suffer undisturbed. Weariness drives away sleep, or sleep brings no refreshing. The mind alone, amid the general decay, remains undisturbed ; but it is not cheered by those illusory hopes which gild, though with a false bright- ness, the decline of the consumptive ; for step by step death is felt to be advancing ; the patient watches his approach as keenly as we, often with acuter perception of his nearness. We come to the sick chamber day by day to be idle spectators of a sad ceremony, and leave it humbled by the consciousness of the narrow limits which circumscribe the resources of our art." (Quoted by Spencer Wells.) The question of the mortality after ovariotomy is a complex one, owing to differences in cases and also because the use of the clamp in early operations unduly raised the death-rate. Of late years the mor- OPERATIVE TREATMENT OF OVARIAN TUMOURS. 249 tality has fallen considerably, chiefly owing to the use of the intraperi- toneal treatment of the pedicle (ligature or cautery) and greater care as to sponges and surroundings. Keith has had 32 cases with one death : and also 76 consecutive cases without a death. Lawson Tait records a series of 101 cases with 3 deaths. Sir Spencer Wells' Statistics in 1000 cases are given in his well- known work. Thornton gives his mortality, with strict Listerian pre- cautions, as 2 p.c. SECTION Y. AFFECTIONS OF THE UTERUS. rriHERE are three periods during which morbid conditions of the -*- uterus arise. 1. The period of evolution or development from the ovum up to puberty. During this stage they appear as anomalies in development before birth or during childhood. They produce no marked symptoms, but a recognition of their existence is important as regards the future history of the patient. 2. The period of physiological activity from puberty to the meno- pause. During this stage there occur in the uterus the morbid processes of acute and chronic inflammation, and of new-formation or tumour- growth ; on account of its mobility, the uterus is also liable to various forms of displacement. These pathological processes give rise to symp- toms of themselves, and also from their effect on the normal functions of the uterus menstruation, conception, and pregnancy. During parturi- tion the cervix uteri is frequently lacerated, and this may be the starting-point of important pathological conditions. 3. The period of senile involution or retrogressive development from the menopause to death. The term involution is generally used in the restricted sense of the process which occurs after childbirth, but it is the only one which conveniently expresses the retrogressive changes after physiological activity has ceased. During this stage, the most important pathological process is that of malignant new-formation. Accordingly the following subjects have to be considered in this Section : CHAPTER XXV. Malformations of the Uterus. XXVI. Atresia and Stenosis of the Cervix Uteri. XXVII. Atrophy of the Cervix and Uterus : Superinvolu- tion. XXVIII. Hypertrophy of the Cervix ; Amputation. ,, XXIX. Laceration of the Cervix and its Consequences. XXX. Chronic Cervical Catarrh. 252 LIST OF CHAPTERS. CHAPTER XXXI. Endometritis. XXXII. Metritis, Acute and Chronic ; Subinvolution. XXXIII. Displacements of the Uterus : Anteflexion ; Ante- version ; Retroversion ; Retroflexion. XXXIV. Inversion of the Uterus. XXXV. Tumours of the Uterus. Fibroid Tumour : Path- ology and Etiology. XXXVI. Fibroid Tumour of the Uterus : Symptoms and Diagnosis. ,, XXXVII. Fibroid Tumour of the Uterus : Treatment. XXXVIII. Fibrocystic Tumour of the Uterus, XXXIX. Polypi of the Uterus. XL. Carcinoma Uteri (of Cervix) : Pathology and Etiology. XLI. Carcinoma Uteri (of Cervix) : Symptoms and Diagnosis. XLII. Carcinoma Uteri (of Cervix) : Treatment. XLIII. Carcinoma Uteri (of Body). XLIV. Sarcoma Uteri. CHAPTER XXV. MALFORMATIONS OF THE UTERUS. LITERA TURE. Barnes Diseases of Women : London, 1878, p. 462. Dirner Ein Fall von Uterus didelphys, etc. : Archiv f. Gyn., XXII., S. 463. Dos Santos, Las Casas Missbil- dungen des Uterus : Zeit. f. Geb. u. Gyn., XIV. S. 140. Kussmaul Von dem Mangel, der Verkiimmerung und Verdoppelung der Gebarmutter, etc. : "VVurzburg, 1859. Macdonald, Angus Case of Pregnancy in the Left Horn of a Bifurcated Uterus, etc. : Ed. Med. Jour., April 1885. Mayerhofer Die Entwickelungsfehler der Gebarmutter : Billroth's Handbuch fur Frauenkrankheiten, Stuttgart, 1878. Schroeder Krankheiten der weiblichen Geschlechtsorgane : Leipzig, 1878, S. 33. Sechcyron Du Cloisonnement Pelvien Ante'ro-Posterieur : Annal. de Gyn., XXI. 441 and XXIII. 247 et seq. Simpson, A. E. Case of Double Uterus : Ed. Med. Jour., 1864, p. 957. Turner Malformations of the Organs of Generation: Edin. Med. Jour., June 1865 and May 1866. The standard work is that of Kussmaul. The literature is given by Mayerhofer and Dos Santos. See also Index of Recent Gynecological Literature in Appendix for isolated cases. WHAT is usually described as " a malformation " is really a nonformation Relation of of one part, involving a relative disproportion. Of this we have illustration in the uterus. The one-horned uterus is not a malforma- Develop- tion," if by this term we mean that the part which is present is maldeveloped ; the condition is a result of the wowformation of the other horn and intervening fundus. It is misleading also to speak of a " double uterus ;" the structure thus described is really one uterus, in which the halves have not united into a whole. The word as used, therefore, means an incomplete result, not a defective process. Mal- development is a contradiction in terms, there can only be arrested development. Malformations must be studied in connection with the normal development of the organ. In this way, they become at once intel- ligible. There are two processes in the progression of an organ to its mature form development and growth. There are therefore two causes which together operate in producing malformations arrested develop- ment and arrested growth. The period of development of the uterus, by which we mean formation of parts, extends up to the twentieth week ; the period of growth is much longer, and extends to the twentieth year. The student should not pass over this section of the subject as of little importance. To the practical man, malformations seem of little 254 AFFECTIONS OF UTERUS. Uterus absent or rudi- mentary. value because he has no power of modifying the result. To the scientific man they are, however, of the greatest interest as furnishing him with permanent impressions of the transitional states of develop- ment ; they are development caught in the act and fixed permanently for after-investigation. In this chapter we recommend the student to read Etiology before Pathology. PATHOLOGY. Complete absence of the uterus is an extremely rare occurrence, and cannot be demonstrated except on post-mortem examination. It has been described only in cases of foetal monstrosities. A rudimentary condition sometimes occurs ; in this the uterus is represented by a band of muscular fibre and connective tissue on the posterior wall of the bladder (fig. 143), and the peritoneum forms a single pouch between the bladder and the rectum (fig. 144). FIG. 143. RUDIMENTARY UTERUS (Veil). So. Sacrum ; U Solid Rudiment of Uterus ; h Rudimentary Horn ; Bladder ; Ovary ; T Fallopian Tube ; r Round Ligament. In the uterus bipartitus (fig. 145), rudimentary horns are present and are solid or hollow. The cervix is represented by a fibrous band which connects the horns with one another and with a rudimentary vagina. The ovaries are sometimes well developed, so that ovulation takes place. The breasts and external genitals may be fully formed. The uterus unicornis (fig. 147) may exist with or without a rudi- mentary second horn. The vaginal portion of the cervix is small ; the palmse plicatae within the cervical canal are most marked towards the non-developed side. The body of the uterus is of disproportionate length and curves towards one side. The fundus, by which we under- stand the fully-developed horn, is small and tapering ; it has only one Fallopian tube and ovary connected with it. On the convex side of the somewhat curved body is the representative of the other horn which is either solid or hollow ; it is connected with the developed one by fibrous tissue which may or may not form a pervious canal. Connected MALFORMA TIONS. 255 with this rudimentary horn are the Fallopian tube and ovary of the same side, which are sometimes perfectly developed. In examining preparations of this and other uterine malformations, it is sometimes difficult to determine what is rudimentary horn and what is Fallopian tube. Here development furnishes us with a guide. The insertion of the round ligament indicates the point up to which the ducts of Miiller are to be formed first into uterine horn and then into fundus FIG. 144. The same in its relation to the Pelvic Organs. U Rudiment of Uterus on the posterior wall of Bladder. The Peritoneum forms one pouch between Bladder and Rectum. (Schroeder) uteri. Accordingly, on examining such preparations we determine the Round point of attachment of the round ligament ; all below this is uterine horn, j^^es all above it is Fallopian tube. Associated with this malformation weJ unc tin sometimes find absence or rudimentary condition of the kidney of the Horn 16 and Tube. FIG. 145. UTERUS BIPARTITUS (Rokitansky). V Vagina ; U Uterus ; h Rudimentary Horn ; Ovary ; T Tube ; r Round Ligament ; & Broad Ligament. same side, since the development of the renal is closely connected with that of the generative system. In the uterus didelphys the two halves of the uterus remain separate uterus throughout their course ; the vagina may be absent, single, or double. Didelphys. It is a rare condition in the living adult female ; Dirner gives only seven reported cases of this condition in the adult with no other maldevelop- 56 AFFECTIONS OF UTERUS. inent and having normal sexual functions, and Dos Santos gives refer- ences to three others in addition to four seen at the Berlin University Clinique. Fig. 146 shows a uterus described by Paterson and Coats from a patient who died a fortnight after the delivery of a seven months' child. FIG. 146. UTERUS DIDELPHYS (Coats). There are apparently two uteri, which are separate, but open into a common vagina ; they are of nearly equal size the right which con- tained the foetus measuring 5 in. and the left 4f in. in length, and being respectively 2| and If in. in breadth. K FIG. 147. UTERUS UNICORNIS (Schroeder). R Right Side ; L Left Side. The left horn (h) is well developed and communicates with the Uterine Cavity. The right horn is in the form of an elongated band ; its point of connection with the Fallopian tube is indicated by the insertion of the round ligament which is hypertrophied. Other letters as in preceding diagrams. Uterus By uterus tiicornis we understand that the separation into two horns is distinctly visible externally. Of this there are various degrees, from a mere depression at the middle of the fundus to a well-marked bifurcation, MALFORMATIONS. 257 which rarely extends lower than the os internum ; the further down the separation extends, the more obtuse is the angle between the divergent horns. There is occasionally a fold of peritoneum, containing muscular fibre and blood-vessels, running from the bladder to the rectum in the hollow between the horns. In addition to this external division, the separation is usually carried further down by an internal septum which may extend to the os externum. FIG. 148. UTERUS BICORNIS UNICOLLIS (Sclroeder). r Bound Ligament. In the uterus septus (fig. 149) there is no external indication of the Uterus internal division. The uterus is divided by a septum beginning at the ep us ' UTERUS SEPTUS IN VERTICAL TRANSVERSE SECTION (Kussmaul). U (Uterus) placed on septum which divides Cavity into two lateral portions ; T Fallopian Tubes ; V Vagina divided into lateral cavities by prolongation of septum downwards. fundus uteri and extending downwards for various distances, sometimes as far as the os externum. It is otherwise normal. R 258 AFFECTIONS OF UTERUS. Infantile The infantile uterus (fig. 150) is characterised by shortness of body and Uterus. disproportionate length of cervix ; in fact the relative lengths of body and cervix remain the same as at birth, from which the name " infantile " is derived. The cervix (1 \ inches long) is two or even three times the length of the body (J in. to f in.). The whole uterus is smaller than FIG. 150. INFANTILE UTERUS (Schroeder). normal. The walls (specially those of the body) are thin and the cavity is small. Congenital The term congenital atrophy is applied to cases in which the propor- Uterus. tions of body and cervix are of the normal virgin type, while the organ FIG. 151. PRIMARY ATROPHY oy THE UTERUS ( Virchow). as a whole is atrophied (fig. 151). An excess of connective tissue is present in the walls, which makes their consistence firmer. This mal- formation occurs in scrofulous and chlorotic patients and with cretinism, and is often associated with hysteria and epilepsy. MALFORMATIONS. 259 ETIOLOGY AND CLASSIFICATION. Malformations differ according to the period at which development and Five growth are arrested, and the extent to which they are interfered with. J^""]^!,. 111 There are five periods in development and growth (Furst], which can bementof easily remembered when we bear in mind the division of the period of . intra-uterine life into ten lunar months. In the first period, which extends over the first and second lunar months (from fertilization to the eighth week), the septum between the adjacent ducts of Miiller is as yet unbroken. By the end of the second period, which corresponds to the third month (i.e. eighth to twelfth week), the septum has entirely dis- appeared ; but the upper portions of the ducts remain distinctly separate, forming the horns of the uterus and the Fallopian tubes. During the third period, fourth and fifth months, the angle between the uterine horns disappears so that the base of the uterus becomes flat. In the fourth period, last five months, the flattened end of the uterus, between the Fallopian tubes, becomes arched through the development of the fundus. The fifth period extends from birth to puberty. During this period no important change takes place till, at puberty, the uterus passes from the infantile to the virgin form. It does not, however, cease to grow till the twentieth year. We are not yet in a position to refer each malformation in detail to Classifica- its proper period ; but the more perfectly we are able to do this the more satisfactory will our classification be. At present we separate the first tions. four periods from the fifth, and speak of the period of foetal life in con- tradistinction to the period of childhood. This forms the basis of our classification. 1. MALFORMATIONS ARISING DURING FCETAL LIFE. Of these there are the following : complete absence or rudimentary condition of the uterus ; the uterus bipartitus, produced by a development of only the upper parts of the ducts of Miiller into rudimentary horns of the uterus and Fallopian tubes ; the uterus unicornis, due to the development of only one duct ; the uterus didelpkys, due to the development of the ducts separately, without coalescence ; the uterus bicornis, in which the ducts coalesce below, and the horns remain un-united by a fundus above ; the uterus septus, in which the coalescence of the ducts and development of the fundus takes place so that the uterus appears normal externally while internally the septum has persisted. These last three are sometimes spoken of as varieties of the double uterus or uterus duplex. The associa- tion of an antero-posterior reduplicature of the peritoneum with some cases of uterus bicornis is of interest from an etiological point of view, pointing back to some mechanical cause which kept the ducts of Miiller from blending. It is interesting that a rudimentary condition of the uterus has been observed in more than one member of the same family. 260 AFFECTIONS OF UTERUS. 2. MALFORMATIONS ARISING DURING CHILDHOOD. Of these there are the following : the uterus infantilis, in which the uterus does not undergo the development which should take place at puberty, but remains of the same type as it was at birth ; congenital atrophy of the uterus, in which it assumes the virgin type but the organ as a whole is atrophied. SYMPTOMS. The symptoms of malformation consist in an impairment of function, and hence do not appear until puberty. In the external appearance of the patient there is not necessarily any- thing to attract attention. The figure, features, temperament, and voice are of the feminine type, even though the uterus is not developed. The mammae may be fully formed. The external genitals may be found well- formed, as their development is independent of the internal organs. It is rare, on the other hand, to find a normal vagina present when the uterus is rudimentary. 1 Sometimes Complete absence and rudimentary condition of the uterus may give symptoms r ' se ^ no l ca l symptoms, except the non-appearance of menstruation, absent. If the ovaries are developed, ovulation with associated monthly disturb- ance is present and the accumulation of menstrual blood in a rudimentary horn may call for operative measures to form a channel for its escape. Even on entering married life the condition need not necessarily attract attention ; if the vagina be not well developed, the urethra becomes dilated so as to take its place. Cause of In the uterus unicornis, menstruation, conception and pregnancy may symptoms on undisturbed in the developed horn. It is the imperfectly developed horn which gives rise to symptoms the result of the retention of men- strual blood and of the products of conception. If the mucous membrane of this horn discharge blood periodically and there be no communication with the uterus to allow of escape, the blood collects and produces a dis- tended sac a very rare occurrence. It is of great interest to note that we may have a fertilized ovum growing in the isolated horn ; we have not space here to discuss how this interesting condition is produced (fig. 152). Pregnancy has also occurred in the one-half of a uterus didelphys, and the empty half formed an obstruction to labour at term. 2 Uterus bicornis and uterus sept us produce no symptoms, unless one half of the partitioned uterus does not open into the cervical canal in which case hsematometra occurs at puberty (v. Chap. XLV.). The statement that the patient menstruates regularly throws the practi- tioner off his guard. He should remember that the menstrual blood may flow undisturbed from one half of the uterus while it is accumulating 1 As in cases by Kalm-Bensinger'a Centralb. f. Gyn., 1887, S. 377 ; Grechen, ib 8. 493 Munde ib. 8. 670 ; Steinschneider, ib. 1888, S. 49 ; Zweifel, ib. S. 474. * Dos Santos, op. cit. See also case by Litechkus, Zeits.f. Geb. u. Gyn., XIV. a 369. MALFORMATION'S. 261 in the other. In both of these forms we have two possible seats for a growing ovum (fig. 153); and this accounts for super-foetation, and those curious cases in which an ovum has been expelled in the course of a pregnancy which went on to full-time. 1 When the uterus is double, abortion and premature labour are more frequent ; the septum also causes difficulty in delivery, and involution progresses more slowly. It has been noted that a decidua forms in the empty half of the uterus, as it does in extra-uterine gestation, and may be expelled in the puerperium. The anomaly of menstruation during pregnancy has also been thus explained ; Henderson found a double uterus in a patient who men- struated regularly during two of her pregnancies the flow coming probably from the empty cavity. 2 The uterus iiifantilis and the congenitally atrophic uterus are char- acterised by the absence or scantiness of the menstrual flow and the constitutional nervous disturbance which is usually associated with them. DIAGNOSIS. Complete absence of the uterus cannot be diagnosed with certainty in Diagnosis the living subject. A rudimentary condition may be present, and yet f u^ruT not be detected on the most careful examination. To examine cases in which this condition is suspected, we first pass a sound into the bladder and then with one or two fingers of the right hand in the rectum palpate the tissues which lie between the sound and the fingers. It is evident that in such a condition as is represented in fig. 144 the rudiment of the uterus may escape observation, or be considered as a thickening of the posterior wall of the bladder. We now remove the sound from the bladder, as it only reaches to a limited height in the pelvis, and with the left hand on the abdomen make a careful recto-abdominal examination which, under chloroform, gives much more definite information. If we feel two bodies laterally without any distinct body between, it is impossible to say whether these are rudimentary horns or ovaries. The diagnosis of the one-horned uterus is not easy. The points to Diagnosis rely on are the following : the fundus turns to one side of the pelvis, isunkornis tapering, and has only one ovary connected with it. The rudimentary horn and the other ovary lie removed from it. The uterus didelphys is rare. A groove on the external surface of Of Uterus the uterus separating it into lateral halves, so that sounds can be passed J e p ys ' into the separate cavities without coming in contact, indicates this condition. The uterus bicornis is a comparatively frequent condition, and if Of Uterus well marked is easily recognised. Unusual breadth of the fundus, 1 As in Gray's case (Glas. Med. Journ., XXXI., p. 182) where an abortion took place in the sixth week of a normal pregnancy, and Ross's (Edln. Med. Journ., 1885, p. 131) where there was a twin abortion in the sixth month and a full-time labour three months later. z Glas. Med. Journ. XIX. p. 276. 262 AFFECTIONS OF UTERUS. Diagnosis of Uterus Septus. with a slight depression in the centre, points to a minor degree of this deformity. The uterus septus is easily diagnosed if the septum extend as far as the os externum, so as to be within reach of the examining finger. If the septum does not extend so far, the condition may not be detected as there is no change in the external form to direct attention to the internal malformation. The sound may pass with equal ease into either cavity, or always into the same, and thus furnish no indication. In a case that MALFORMA TIONS. 263 came under our own observation the patient was examined frequently during life, bimanually and with the sound, and the uterus pronounced normal. At the post-mortem, the external appearance of the uterus was normal ; it was only on cutting into it that it was observed that the cavity was divided into two portions by a septum which extended to the os internum. The uterus infantilis and the congenitally atrophic uterus are re- Of Infantile cognised by their smallness. This is most distinctly made out the finger in the rectum, the uterus being at the same time drawn Atrophic down and fixed with the volsella. The well-developed vaginal portion FIG. 153. UTERUS SEPTUS (posterior view) FROM A WOMAN WHO DIED IN THE PUERPERIUM (fruveilhier). The Uterine Cavity is divided by a septum which extends to the os externum. The left half (1) is strongly developed and contained the foetus. The right half (2) was empty. and the unusual length of the cervix, as felt per^ rectum, enable us to diagnose the infantile from the congenitally atrophic uterus. With regard to differential diagnosis, gestation in a detached horn Differential becomes a condition of great importance to the gynecologist when i simulates a fibroid tumour. The occurrence of irregular haemorrhages from the empty uterine cavity, the absence of the foetal heart and uterine souffle when the foetus is dead, and the difficulty that there may be in palpating foetal parts, mask the existence of pregnancy. In the cases 264 AFFECTIONS OF UTERUS. recorded by Angus Macdonald and Werth, the nature of the case was clear only on abdominal section ; Macdonald draws attention to such cases as explaining the phenomena of " missed labour," the occurrence of which might sometimes give a clue. PROGNOSIS. Prognosis In prognosis we must keep in view the possibility of ovulation with ations. ' m menstrual molimina, the secretion of menstrual blood and its accumula- tion in a closed cavity, the probability of conception and of gestation in an isolated horn. The most difficult cases are those in which the practi- tioner has to decide whether marriage is justifiable or not. TREATMENT. Treatment. Malformations of the uterus lie beyond the range of treatment, except when they give rise to retention of menstrual blood or of the products of conception. The treatment of the former condition will be considered under Atresia of the Vagina (see Section VI.), and reference will be made to the latter in the chapter on Abdominal Section. Extirpation of the ovaries 1 has been performed, and even of the uterus 2 or its detached horn, 3 for dysmenorrhcea in cases of rudimentary uterus. Cases of con- genital atrophy, associated with chlorosis, are amenable to treatment by feeding-up and iron. 1 By Kleinwiichter, Langenbeck, Peaslee, Savage, Taufer ; 2 by Leopold ; 3 by Schroeder : Las Casas dos Santos (op. cit.). CHAPTER XXVI. SMALL OS EXTEBNUM; RIGIDITY, STENOSIS, AND ATBESIA OF CERVIX. LITERA TURE. Barnes Diseases of "Women : London, 1878, p. 245. Burton So-called Obstructive Dysmenorrhcea : Brit. Med. Jour., 1884, II. 607- Chrolak Die Uiitersuchung der weiblicheii Genitalien : Billroth's Handbuch, Bd. I. S. 106. Duke On the Rapid Dilatation of the Cervix Uteri (with discussion at Brit. Med. Ass.) : Brit. Med. Journ., 1888, II., p. 873. Duncan, Matthews On Sterility: Brit. Med. Jour., 1883, I. 702. Goodell Rapid Dilatation of the Uterine Canal : Amer. Jour. Obstet., 1884, p. 1179. Greenhalgh Intra-uterine Pessary : British Med. Jour., June 1878. v. Grunewaldt Ueber die Sterilitat geschlechtskranker Frauen : Archiv f. Gyn. VIII. 415. Mackintosh Practice of Physic : London, 1836, p. 481. Marckwald Ueber die kegelmantelformige Excision der Vaginalportion und ihre Anwendung : Archiv f. Gyn., Bd. VIII., S. 48. Miillcr'Die Sterilitat der Ehe : Billroth's Hand- buch, Bd. I. S. 385. Schroedei Krankheiten der weiblichen Geschlechtsorgane : Leipzig, 1878, S. 64. Schultze Ueber Indication und Methode der Dilatation des Uterus : Wiener med. Blatter, 1879, Nos. 42, 43, 44, 45. Simpson, Sir J. Y. Diseases of Women : Edinburgh, 1872, p. 245. Sims, Marion On the Surgical Treatment of Stenosis of the Cervix Uteri, and Discussion : Am. Gyn. Trans., 1878, p. 54. Thomas Diseases of Women : London, 1880, p. 613. Vedeler Ueber Dysmenorrhoe : Archiv fiir Gyn., XXI. 211. See Index of Recent Gynecological Literature in Appendix. ETIOLOGY AND PATHOLOGY. THE various conditions treated of in this chapter have been described Etiology mainly from clinical observation and in relation to the symptoms FIG. 154. A NORMAL AND A PIN-HOLE Os, as seen in the SPECULUM (Schroedcr). dysmenorrhoca and sterility. Owing to the absence of exact data, there has been room for great difference of opinion as to the pathology and frequency of these conditions. Small Os Externum. In a certain number of cases, 6-9 p.c. (Vedeler), the os externum is congenitally smaller than the normal size ; it may 266 AFFECTIONS OF UTERUS. be so narrow as to admit only a fine probe (pin-hole os). The contrast between this and the normal os is shown in fig. 154. The cervix is conical in form (fig. 155) and of unusually firm consistence; sometimes it is hypertrophied, the vaginal portion measuring as much as two inches. The cervical mucous membrane is frequently in a condition of catarrhal inflammation ; according to Von Griinewaldt, the conical shape of the cervix is often the result of the accumulation of mucus. Rigidity of Cervix. The changes in ' the cervix resulting from an increase of its connective tissue have been fully described by Scanzoni. A peculiarly rigid condition of the cervical tissue, apart altogether from any contraction of the canal, is observed on passing bougies in cases of dysmenorrhcea (Matthews Duncan). A similar condition has been noted as specially frequent in cases of sterility (Olshausen, Martin, and Chrobak). Stenosis (contraction) of the cervical canal is congenital or acquired. As a congenital condition affecting the cervical canal throughout its whole extent, it is a comparatively rare occurrence. It is always associated with smallness of cervix and body, pointing to generally defective development of the uterus (which is further indicated by the TIG. 155. CONICAL VAGINAL PORTION (Barnes). scantiness of menstruation). The commonest cause of the acquired form is cicatrisation after labour, after amputation of the cervix, or after the repeated application of strong caustics ; the last is perhaps the most frequent. Inflammation of the mucous membrane, resulting in adhesions, also produces it. Atresia of Cervix (d-rp^o-ts, non-perforation), or occlusion of the canal, is rare as a congenital condition, and is due to the presence of a cap of tissue covering the os uteri. The canal is seldom, if ever, imperforate throughout its course. An incomplete transverse septum has .been described in a few cases. 1 It is more frequently acquired, and results from the following causes : - sloughing and cicatrisation after labour ; cicatrisation after the applica- 1 Budin Progres M'edical, 1887. STENOSIS OF THE CERVIX. 267 tion of caustics, and after amputation of the cervix ; adhesion of granu- lations in cervical catarrh (after menopause), and round the base of tumours. The practical point for the practitioner to remember is that atresia may follow the repeated application of caustics and amputation of the cervix. It occurs also as part of the physiological changes which take place after the menopause. Twenty-eight per cent, of women above fifty years of age have atresia of the cervix (Hennig). SYMPTOMS AND DIAGNOSIS. The symptoms found most frequently associated with these conditions Symptoms, are Dysmenorrhoea, Sterility. We say 'associated,' because the relation of the symptoms to the pathological condition is as yet not known. There is no subject in Gynecology round which more discussion has raged, and concerning which there are at present more abrupt differences of opinion. Dysmenorrhcea. Mackintosh, from a doubtful analogy between the menstruating uterus and the bladder, introduced dilatation with bougies as a treatment of dysmenorrhoea. The theory was that a stricture pre- vented the discharge of blood in the former case, just as it prevents a discharge of urine in the latter and that the pain was due to uterine efforts to overcome obstruction. Sir James Simpson showed that stenosis could not be the only factor, since obstructive dysmenorrhoea might be equally present with a patulous cervix ; it depended also on the amount of the menstrual discharge and the danger of its clotting while in the uterus, and may be absent where though the os is small the flow is scanty. Marion Sims took up the position that painful menstruation was almost wholly due to mechanical causes, and was the great exponent of what is known as 'the mechanical theory.' Thomas, Barnes, Schroeder and De Sinety all accept this theory, more or less, in their handbooks of Gynecology. On the other hand, Matthews Duncan, in his recent lectures on Sterility, says he has never seen a pin-hole os in cases of dysmenorrhoea ; and attributes the pain to irregular contractions of the uterus which have nothing to do with expulsion of its contents. Vedeler's recent investigations have shown that a small os externum is as common in patients without as in those with dysmenorrhoea. Emmet, at the discussion on Sims' Operation before the American Gynecological Society, characterised the mechanical theory of dysmenorrhoea as a myth ; in his Gynecology, he says that, unless the flow is scanty, painful menstruation is accompanied by clots but that their formation does not depend upon obstruction. Hitherto, conclusions have been drawn almost entirely from the con- 268 AFFECTIONS OF UTERUS. dition of the uterus and cervix between the menstrual periods ; and it will be evident from the foregoing how wide is the difference of opinion on the subject. It seems to us that valid conclusions can only be drawn from the condition of the cervix during menstruation, and that the diversity of opinion will remain until we have accurate knowledge on this point. We have called the condition "Small Os Externum" instead of "Stenosis" advisedly; as the latter word implies that there is resistance to the outflow of blood, while the as yet scanty evidence rather seems to show that the canal becomes more patulous during menstruation than at any other time. Relation of Sterility. When we come to treat of sterility, we shall find that it is Sterility. frequently associated with dysmenorrhoea. According to the statistics given by Matthews Duncan, as well as those by Marion Sims and Emmet, about one-half of cases of sterility suffer from severe dysmenorrhcea ; and two-thirds of Vedeler's cases of dysmenorrhoea in married women were sterile. A narrow os externum, according to the mechanical theory, hinders the upward passage of the spermatozoa just as it retards the downward flow of the menstrual blood. This explanation is evidently open to the criticism that the spermatozoa are microscopic ; and that, as Fritsch puts it, a drop of water will fall as easily through a ring of 2 cm. diameter as through a hoop of 100. It is, however, quite possible that a narrow os externum while not absolutely preventing conception may retard it : Miiller, in enforcing the very important distinction between absolute and relative sterility, thinks that a contracted os may render conception more difficult, especially where the spermatozoa are scanty in the spermatic fluid. Thus, a counter-illustration to Fritsch's would be that where the drops are few there is more chance of catching them in a bowl than in a thimble. Although there is a general reaction against stenosis per se as a cause of sterility, yet the associated cervical catarrh is considered by the majority to play an important role through stagnation of the mucous secretion. It has not, however, been proved that a plug of mucus can be an effectual bar to the progress of spermatozoa, and catarrh is a very frequent condition in parous women. A rigid condition of the cervix has, as already said, been frequently noted as present in cases of sterility. Matthews Duncan suggests that it operates through checking spontaneous dilatation of the cervix during coition. In studying the complex question of sterility (v. Section IX.), the at first too obvious mechanical causes sink into insignificance as soon as we come in sight of the less obtrusive and more subtle physiological and vital considerations ; and, after a careful survey of the literature, we come to the conclusion that any discussion of sterility in which STENOSIS OF THE CERVIX. 269 mechanical considerations have a prominent place must be inadequate and will always be bootless. DIAGNOSIS. A history of dysrnenorrhcea and sterility will lead us to suspect that Diagnosis one of [these conditions of the cervix may be present. On vaginal f Stenosis examination, the finger recognises the conical shape and firm consistence Cervix, of the cervix. In cases of small os externum, the first impression is that it is altogether absent ; but more careful examination detects a slight depression. The speculum shows the appearance represented in figs. 1 54 and 155. The sound is passed with difficulty : but we must remember that difficulty in passing the sound is quite unreliable as a test of the canal's being relatively narrower at a given point ; a sharp flexion, a projecting tumour or even a fold of mucous membrane may arrest the sound. Burton by passing the sound in six cases of dysmenorrhoea during the height of the pain made the interesting observation that the canal was more patent then than at any other period. PROGNOSIS. This must always be guarded, as the etiological relationship between Prognosis, the conditions of the cervix described and these symptoms is still sub lite, and the results of our empirical treatment correspondingly uncertain. TREATMENT. The methods of treatment are A. Dilatation, B. Division. Dilatation for stenosis is carried out by passing graduated bougies, by sponge or laminaria tents, by forcible dilatation with instruments. Division is effected by the metrotome or by scissors. We here consider only dilatation for stenosis ; its use for intra-uterine medication will be dealt with under the treatment of Endometritis. A. Dilatation. Sponge and laminaria tents were formerly used, but are now abandoned Treatment because of the dangers of septicaemia; at a recent discussion in the y 8 British Medical Association (1888) the consensus of opinion was entirely tion. in favour of rapid dilatation, or division, as against the use of tents. Dilatation by means of graduated bougies was brought into prominent notice by Mackintosh, who employed straight metallic bougies of different degrees of thickness. He passed first a small one not thicker than a probe, and then larger ones till the os was rendered quite patulous. This mode of treatment is specially recommended by Matthews Duncan. 270 AFFECTIONS OF UTERUS. A No. 9 bougie is the largest size which will pass through a virgin cervix. We have, therefore, to begin with one of smaller calibre, say 6 or 7, and go up to a No. 11 or 12, as the cervix must be over-distended to effect a cure. The successive numbers are passed at various sittings and not on the same day ; so that the whole treatment requires about a week. Hegar's dilators (seep. 131) are also used in stenosis. Various dilators with expanding blades have been devised. Fig. 156 shows the form used by Schultze. He dilates the cervical canal before- hand with laminaria ; he then washes it out with a 2 per cent, solution FIG. 156. SCHULTZE'S DILATOR. of carbolic acid, as he attributes many of the serious consequences of forcible dilatation and incision to the absorption of the secretions. The dilator is now introduced, and the blades (which open antero-posteriorly) are forcibly separated. Ellinger has made a dilator so constructed that the blades remain parallel to one another while being separated ; Goodell has had very good results from forcible dilation with this instrument both with regard to Dysmenorrhcea and Sterility. The dilator em- FIG. 157. MAKION SIMS' DILATOR (Sims). ployed by Marion Sims is seen at fig. 157. Other forms have been recently introduced by Reid, Duke, and More Madden. 1 B. Division. Treatment Division of the cervix with the knife was introduced by Sir James Y. by DM S1S Sim P son - The instrument which he devised for this purpose was the sion. metrotome represented at fig. 158. 1 See under " Instruments ' in Index of Recent Gynecological Literature in Appendix. STENOSIS OF THE CERVIX. 271 It is a bistoury cache, with a single blade sharp on the outer edge Sir James which is unsheathed on compressing the handle. The screw on the Metro- handle regulates the extent to which the blade is to be protruded. tome - FIG. 158. Sir JAMES SIMPSON'S METROTOME (Sir J. Y. Simpson), a shows position of blade when protruded. The instrument was passed in till the point almost -reached the os internum ; it was turned with the blade to one side, and then withdrawn, the handle being at the same time more and more compressed. The result was a lateral incision in the cervix, super- ficial at its upper extremity but becoming deeper as it passed downwards till at its base it completely divided the vaginal portion. The instrument was re-introduced and a FIG. 159. NULLIPAROUS Os UTERI (Sir J. Y. Simpson). similar incision made on the opposite side. The result of this operation was that the narrow circular os became an orifice with gaping lips. As Sir J. Y. Simpson points out, the nulliparous os is thus made to resemble in form the os of a uterus which has been pregnant ; that is instead of being circular and small, it is made transverse and gaping (cf. figs. 159 and 160). That a patulous condition of the os and cervical canal greatly favours fertilisation is proved by the readiness with which conception follows abortion. FIG. 160. PAROUS Os UTERI (Sir J. Y. Simpson) Other forms of nietrotome have been introduced by Coghill, Greenhalgh, Savage, and Routh. Those of Greenhalgh and Savage are double-bladed, while that of Routh has the blades curved. 272 AFFECTIONS OF UTERUS. We are indebted to Marion Sims for substituting the scissors for the metrotome. The objections to the latter instrument are that we do not know how deep the incision is being made, nor whether both incisions are being made equally. The practitioner will find the scissors easier to handle than the knife. A pair of ordinary strong scissors will do, provided they are sharp and the cervix be firmly held with the volsella. FIG. 161. SHOWING THE BILATERAL DIVISION OF THE CERVIX, with Kuchenmeister's Scissors (Barnes). The scissors of Kuchenmeister (fig. 103) and Hart (fig. 104) have this advantage, that the hook on the external blade prevents the cervix from slipping out as the section is being made. Operation The operation is performed as follows. The patient is placed semiprone. ral Divi- 6 ^ ne Sims speculum is passed, and held by an assistant. This operation, sion of as indeed all operations on the cervix or vagina, should be performed under continual irrigation from a vaginal douche. If the irrigation be not employed, the vagina should be thoroughly syringed beforehand with 1 to 40 carbolic acid solution. The anterior lip of the cervix is laid hold of with the volsella ; the scissors are introduced, the straight blade being passed within the cervical canal ; the point or hook of the external blade is carried to about one-third up the vaginal portion of the cervix (see fig. 161) and the section made. In many cases, all that is necessary is to divide the ring round the os extern um ; when this is FIG. 162. GLASS PLUG TO KEEP THE CERVIX PATULOUS AFTER DIVISION (Thomas). divided the cervical canal is sometimes found to be dilated above it. Should haemorrhage occur, some perchloride of iron is swabbed on the cut surface and a vaginal tampon of lint soaked in an antiseptic is applied. One result of Emmet's work on laceration of the cervix has been to draw the attention of gynecologists to the fact that ectropion of the mucous membrane and secondary cervical catarrh may follow artificial STENOSIS OF THE CERVIX. 273 division of the vaginal portion of the cervix. When this operation is necessary, we recommend, therefore, that it be done by three or four shallow notches round the margins of the os externum. As will be evident from what has been said under Symptoms, the scope of this operation is very limited imless we have recourse to it as a stage in treating cervical catarrh in a nullipara. We have described it min- utely as the practitioner is more apt to be careless in minor operations. More important than the incision is the after-treatment. The patient Treatment must be seen on the following day, and every second day for a fortnight, and the finger passed in on each occasion to prevent union of the cut Division of surfaces and dilate the cervical canal. To keep the canal open, Thomas recommends the use of a glass cervical plug (fig. 162) kept in position by a solid plate of the form of an Albert Smith pessary. Duke uses a spiral wire stem to keep the canal patulous after dilatation. FIG. 163. CONICAL EXCISION OF CERVIX. The figure to the left (a) shows the flaps and position of sutures ; that to the right (6), the appearance of the os after the sutures are tied. Excision of a portion of the cervix is also done with a view to convert the stenosed into a gaping os like that of a multipara (v. fig. 160). It is a favourite operation in Germany, was introduced by Simon and elaborated by Marckwald, and is known as the " kegelmantelformige " (" cone- mantle-like," from the shape of the piece cut out) excision. The cervix is split into an anterior and a posterior lip, and a wedge-shaped piece cut out of each so that the cervix seen from the front has the appearance of fig. 163 a, while from the side it looks like fig. 168. The lips are then stitched separately cervical mucous membrane being united to vaginal (fig. 1636). We shall have to refer to this operation again in Chap. XXVIII. Atresia of the cervix is chiefly of importance in regard to the accumula- Treatment tion of menstrual blood or mucus above the obstruction. It is this of Atresia - which produces the Symptoms and calls for Treatment. It will be better to defer the consideration of these till we treat of Atresia Vaginae (Section VI.). CHAPTER XXVII. ATROPHY OP THE CERVIX AND UTERUS: SUPERINVOLUTION. Conditions \y E meet with an atrophic condition of the cervix and uterus under which four different conditions : Atrophy of Uterus 1. As a congenital condition ; 2. Associated with certain constitutional affections, as phthisis, scrofula, chlorosis ; 3. In the puerperal uterus, as the result of superinvolution ; 4. After the menopause. Should the student find on vaginal examination that the cervix is small and projecting only slightly into the vagina, and on bimanual examination that the body of the uterus is found with difficulty and is smaller than it should be, he must next ascertain which of the above- mentioned causes has produced the atrophy. The history will enable him to form his diagnosis. With the congenital condition there is a history of amenorrhoea or scanty menstruation since puberty, of sterility if the patient has entered married life, and of hysteria and other disturbances of the nervous system which usually accompany imperfect development of the uterus. The constitutional condition, and especially the state of the blood and of the lungs, in other cases enables him to account for the condition of the uterus. Probably the small uterus found in chlorotic patients is a congenital condition, and not secondary to the constitutional state. If the atrophic condition be the result of superinvolution, there is a history of childbirth or abortion with non-appearance of menstruation after it. With regard to the meno- pause, the age of the patient is the chief guide ; we must remember the possibility of an early menopause, as early as at the age of thirty-five. The only atrophic condition which we shall consider here is that occurring in the puerperal uterus as the result of superinvolution. To Sir James Simpson's description of this condition we are chiefly indebted. SUPERINVOLUTION OF THE UTERUS. 275 STJPERINVOLUTION OP THE UTERUS. LITERATURE. Frommel Ueber puerperale Atrophie des Uterus : Zeits. f. Geburts. und Gynak., Bd. vii., H. ii., S. 305. Jaquet Ueber Atrophia Uteri : Berl. Beitrage zur Geburts. und Gynak., Bd. ii., S. 3. Johnson, T. J. Superinvolution of the Uterus Am. Gyn. Trans., 1883, p. 1064. Klob Patholog. Anatom. der weib. Sexualorgane : "VVien, 1864, S. 205. Simpson, A. R. Superinvolution of the Uterus : Edin. Med. Jour. , May 1883 (in which the literature is given to date). Simpson, Sir J. Y. Morbid Deficiency and Excess in the Uterus after delivery : Selected Obstetrical and Gyne- cological Works, 1871, p. 595. On Superinvolution of the Uterus and Amenorrhosa : Diseases of Women, Edin., 1872, p. 597. PATHOLOGY. The uterus is small. Its external length may be reduced from the normal 3 to If inches. The walls are thin and flaccid, sometimes of a dense and fibrous consistence. The vaginal portion projects only slightly into the vagina, and may be almost flush with the vaginal roof. The os may be relatively patulous, or contracted so as only to admit a probe. The uterine cavity is reduced to 2i, 2, or even Ii inches in length. The ovaries are atrophied, and sometimes show an increase of fibrous tissue in their structure. The accompanying specimen (fig. 164), described by Sir James Simpson, illustrates these points. ETIOLOGY. As to the frequency of this condition, A. R. Simpson found it present in 22 out of 1300 cases, that is in about 1-7 per cent. ; Frommel estimates its frequency at 1 per cent. The reason why, in certain cases, the pro- cess of involution during the puerperium goes on till the uterine cavity is reduced to less than 2i inches in length is not known. A condition of transitory Superinvolution in which the superinvoluted uterus returns to the normal length again has been observed. Protracted Lactation seems the most important cause (Frommel). We have seen this in two cases, and Chiari has also drawn attention to it. In some instances there is a history of great loss of blood at the confinement ; A. R. Simpson found this in 10 out of his 22 cases, and in a case of this, reported by Whitehead, * the atrophic changes had progressed so far that no trace of a uterus was found on the most careful examination. In other instances pelvic peritonitis has occurred during the puerperium : this can produce, we know, atrophy of the ovary through binding it down with adhesions ; and atrophy of the ovaries may lead to atrophy of the uterus. It is also associated with the tubercular diathesis (Klob). The term Superinvolution has also been applied to atrophy of the uterus following hypertrophy from causes other than pregnancy, e.g. sub- mucous fibroids, and that following operations on the cervix, 2 but it is best to limit it to cases of atrophy after parturition. 1 British Med. Jour., Oct. 1872. 2 Harden describes it as following Emmet's operation : AM. Joum. of Obslet., 1888, p. 1018. SUPERINVOLUTIOX OF THE UTERUS. Ill SYMPTOMS. Continued amenorrhoea is the symptom which leads the patient to seek advice. After she has ceased nursing, she expects the flow to return. It does not do so, however, even after months have passed. Pain in the back, weakness, and hysterical symptoms are sometimes present. DIAGNOSIS. The small cervix at once suggests what the condition is. We some- times have difficulty in making out the uterus bimanually ; here the examination per rectum, combined with the volsella, is useful. The best idea of the size of the uterus is gained by pressing the ball of the finger in the rectum against the isthmus of the uterus, and then moving the uterus upwards and downwards upon the finger which can thus estimate accurately its size ; having done this, we make more traction on the uterus to bring it as far down as possible, and examine the ovaries. The sound must be used with care, as it easily perforates the thin walls of the uterus. It does not pass into the uterus as far as the 2^ in. knob. Differential diagnosis must be made from Congenital malformation ; Congenital atrophy ; Senile atrophy. PROGNOSIS. This should always be guarded. The curability of the case depends, as Fordyce Barker has pointed out, 011 the condition of the Ovaries a point, however, exceedingly difficult to determine. When the patient has the menstrual molimina and the menstruation though scanty still persists, we may hope for improvement even though the uterus is small. TREATMENT. From the unsatisfactoriness of treatment, such cases may, as a rule, be left alone. Iron and other constitutional remedies may be tried. When local treatment is called for, this consists in stimulating the uterus to hypertrophy by placing a foreign body in its cavity. The galvanic intra-uterine stem pessary of Sir James Simpson was devised for this Mode of purpose. The stem is made in its upper half of zinc, in its lower half of copper ; the bulb Introduc- is also of copper. The stem should always be shorter than the uterine cavity by a | of ln S Intra- an inch ; otherwise it may perforate the fundus. It is introduced as follows. The cervix is laid hold of with the volsella to draw it towards the vaginal orifice and to steady it. The stem is held with the bulb between the finger and thumb, and passed into the 278 AFFECTIONS OF UTERUS. cervix for about an inch. If the vaginal orifice be too narrow to allow of this manipula- tion, the bulb is fixed on the end of a staff and thus carried in. A glycerine plug is passed to keep the stem in position at first. The patient should keep at rest for one day after the stem has been introduced, and should be instructed to send at once if pain is felt in the pelvis ; we have seen pelvic inflammation follow the introduction of a stem pessary. Galvanism has also been used. CHAPTER XXVIII. HYPERTROPHY OF THE CERVIX: AMPUTATION. LITERATURE. Byrne Amputation and Excision of the Cervix Uteri : Trans. Americ. Gyn. Soc., Boston, II. pp. 57 and 110. Galabin Lond. Obst. Journ., Sept. 1878. Goodell Clinical Notes on the Elongations of the Cervix Uteri : Am. Gyn. Trans., 1880, p. 268. Hegar und Ealteribach Operative Gynakologie : Stuttgart, 1881, S. 445. Huguier Meraoires sur les Allongements Hypertrophiques du Col de 1'Uterus : Paris, 1860. Leblond Operative Gynecologic : Paris, 1878. Marckicald Ueber die kegelmantel- formige Excision der Vaginal portion, etc. : Archiv f. Gyn. Bd. viii.' S. 48. Milller Die Amputatio Colli Uteri : Zeitschrift fiir Geburt. und Gyn. Bd. ix. S. 178. Schroeder Charite-Annalen, 1878. Zur Technik d. plast. op. am cervix uteri : Zeitschrift fiir Geburt. u. Gyn., Bd. iii. S. 419 ; Bd. ,vi. Hft. 2, S. 218. Simon Monatsch. f. Geburtskunde, xiii. S. 418. Sims, Marion Uterine Surgery, 1866. Stratz Ueber einseitige Hypertrophie des untern Cervicalabschnitts : Zeits. fiir Geb. und Gyn., Bd. XII., S. 229. See also Index of Recent Gynecological Literature in the Appendix. HYPERTROPHY of the whole uterus occurs in two forms : 1. Hypertrophy of the muscular tissue in pregnancy ; 2. Hypertrophy of the connective tissue in subinvolution and chronic metritis, both of which will be considered under Chronic Metritis (Chap. XXXII.). Hypertrophy of the cervix alone calls for special notice here. HYPERTROPHY OF THE CERVIX. Under this head we consider two conditions : A. Hypertrophy limited to the vaginal portion, which is a distinct primary lesion ; B. Hypertrophy of the supra-vaginal portion, which is usually associated with hypertrophy of the body of the uterus; this occurs in prolapsus uteri and is probably secondary to that condition. A. HYPERTROPHY OF THE VAGINAL PORTION. Pathology. The characteristic of this condition of the cervix is a great Hyper- increase in length affecting it equally all round 1 (fig. 166). The mucous Vaginal membrane and the subjacent tissue are not thickened, so that the Portion. * Only one case of unilateral hypertrophy in a nullipara could be found by Stratz in the literature a case recorded by Huguier. Partial hypertrophies are less rare in multipart and will be referred to under Laceration of the Cervix. 280 AFFECTIONS OF UTERUS. diameter of the cervix is not much increased. As the result of the increase in length, the conical apex of the cervix comes to lie immediately behind the hymen and may protrude through the vaginal orifice (fig. 165). The os externum is often small. Etiology. This condition is a true hypertrophic growth ; it is not very common and the cause of it is unknown. As it occurs in the virgin, it is probably congenital. Sometimes it does not attract atten- tion till the patient enters married life, when it produces as a rule sterility because the form of the cervix interferes with conception. The cervix is frequently thickened as the result of chronic inflamma- tion consequent on its laceration in childbirth ; this is not a true FIG. 165. HYPERTROPHIED VAGINAL PORTION c PROTRUDING THROUGH THE VULVA. The Sound has passed very far into the small os o (Schroeder). hypertrophic growth, and will be considered under Laceration of the Cervix (Chap. XXIX.). Symptoms. The symptoms are due to the presence of the hypertro- phied cervix in the vagina. There is bearing-down as in prolapsus uteri, irritation of the mucous membrane of the vagina and consequent leucorrhoea, discomfort on walking about and on rising suddenly. If the cervix protrude beyond the vulva, ulceratiou of its mucous membrane and excoriation are produced. Diagnosis. This presents no difficulty. The fornices are found in AMPUTATION OF THE CERVIX. 281 their normal position on vaginal examination (see fig. 166), the fundus uteri at its normal height in the pelvis on bimanual examination. These two clinical facts indicate that the law position of the apex of the cervix is not due to a descent of the fundus but to a hypertrophy of the cervix, and that the hypertrophy of the cervix is limited to the portion which projects into the vagina (cf. fig. 166 with fig. 174 and fig. 175). The sound may pass five inches or more into the cervical canal ; as the patient is usually a nullipara and the abdominal walls therefore firm, it facilitates the Bimanual to do it with the sound in the uterus. The combined recto-vaginal examination shows that the uterus, above the vagina, is of normal length. FIG. 100. HYPERTROPHY OF VAGINAL PORTION OF CERVIX. Neither fornix is obliterated (Schroeder). Section of Pelvis seen in fig. 165. Treatment. This consists in amputation of the cervix which is the only course open to us, because the hypertrophy will not diminish but rather increase. Amputation is performed by three methods : 1. Scissors or knife, 2. Ecraseur, 3. Galvano-caustic wire. The successive improvements in the method of amputation with the knife may be thus tabulated ; by Marion Sims was made the advance of covering the stump with mucous membrane. (1.) Old method. Circular amputation; raw r surface touched with caustic or cautery ; healing by granulation. (2.) Sims' method. Circular amputation ; vaginal mucous mem- brane stitched to vaginal mucous membrane ; healing partly by first intention (fig. 167). 282 AFFECTIONS OF UTERUS. (3.) Hegar's method. Circular amputation ; vaginal mucous mem- brane stitched to mucous membrane lining cervix (figs. 170 and 172) ; healing by first intention. (4.) Simon and Marckwald. Flap amputation by wedge-shaped excision of lips separately (figs. 163 and 168); vaginal mucous membrane stitched to that lining cervix on each lip (fig. 170) ; healing by first intention. The supra-vaginal amputation will be considered under operations for cancer of the cervix. The best method of performing the amputation is to split the cervix by a transverse incision into an interior and posterior lip ; then ampu- tate each lip separately making the line of amputation wedge-shaped ; finally bring together the projecting flaps of vaginal and cervical mucous membrane with wire sutures. FIG. 107. SIMS' METHOD OP PASSING THE SUTURES. Vaginal mucous membrane stitched to vaginal (Sims). Amputa- The operation. The instruments required are the following : tion of the Cervix for Antiseptic douche, Bistouries, Sims' speculum, Dissecting forceps, Spatulse, Blunt hook, Volsellse, Scissors, Straight needles fixed on Artery forceps, handles, Small curved needles and needle Silver wire, holder. Simple Hy- pertrophy. A. R. Simpson operates as follows. The patient is placed in the lithotomy posture. Continued irrigation with a 2 p.c. solution of carbolic is employed. The cervix is drawn down with volsella. An india-rubber ring may be passed over the volsella on to the cervix and placed so as to constrict the cervix just below the fornices (fig. 169) to control haemorrhage. The cervix is pierced in the middle line from below with a straight needle on a fixed handle. A straight needle passes more AMPUTATION OF THE CERVIX. 283 easily through the dense tissue of the cervix ; if the cervix does not pro- ject sufficiently through the vulva to allow of the straight one being used, a curved one is required. When the point of the needle projects as far as the eye, this is threaded with a long wire suture and then drawn back (fig. 169, MN). A similar thread is carried through on either side of the middle line so that the cervical canal is pierced with three long sutures, one in the middle of it, and one at each side of it. The cervix is now split horizontally with the knife or scissors so as to divide it into an anterior and posterior lip ; this horizontal section is carried as far as the sutures, so that they are exposed at the bottom of the incision. We now hook them up in turn and drag the loop of each down through the wound (fig. 169, mn). Each loop is then divided ; the three sutures are thus converted into six three through the base of each lip. A portion FIG. 168. MARCKWALD'S METHOD OF SPLITTING THE CERVIX into an anterior and a posterior lip and then uniting cervical to vaginal mucous membrane (Schroeder). of the anterior lip is excised along the line 1, 2, 3. The sutures are now vised to bring together the margins of this amputation. The pos- terior lip is next treated in the same way. Additional sutures are put in on each side to close the side walls of the cervix (fig. 170, * and y}. When the cervix is not unusually thick, these lateral sutures are passed as in fig. 170; but when the cervical walls are thick, it makes a neater stump to bring these sutures also out through the cervical canal and unite vaginal to cervical mucous membrane all round (see fig. 172). The peculiarity of this method of operating is, that the sutures are introduced before the knife is used. The advantages of this are the following : it is easier to pass the needle through the dense tissue when the cervix is fixed with the volsella ; the sutures serve as a means of traction when the portion grasped by the volsella has been cut away ; 284 AFFECTIONS OF UTERUS. and we can ligature the flaps immediately after the lip has been ampu- tated and thus check haemorrhage. M FIG. 169. DIAGRAM OF AMPUTATION OF CERVIX. To the right is seen the cervix with the ring constricting it, a suture MN in position, the cervix split, and the line of amputation marked 1 to 6 ; a,/, anterior and p.f. posterior fornix. To the left is seen the cervix, in cross-section ; two threads are passed and the needle carried through but not yet threaded with the wire jr. The appearance of the stump after the sutures have been twisted is seen at fig. 171. The ends are left long enough to protrude clear of the J n FIG. 170. THE SUTURE MN has been divided and the halves brought down the canal as Mm, Nn ; the lateral ones also, x x and y y are additional side Sutures. FIG. 171. APPEARANCE OF STUMP of fig. 170 when Sutures are twisted up. vulva ; the free ends of the same suture are twisted together to keep them separate from the others ; finally, all the ends are wrapped in a AMPUTATION OF THE CERVIX. 285 piece of lint to prevent their fretting the labia. Catgut is being used now instead of wire in operations on the cervix to obviate the necessity of removal, which is always a disagreeable and sometimes a painful oper- ation ; it must be strong, as some force is required in tying it tight to secure coaptation of surfaces. Removal of Silver-unre Sutures The sutures are removed in a week's Mode of removing Sutures. FIG. 172. HEGAR'S METHOD OF STITOHIXG THE CERVIX after the circular amputation (Hegar u. Kaltenbach). time. The patient is put in the Sims position and the Sims speculum passed. Slight traction is made on a suture, and if the twisted knot is visible, we clip the wire with the wire scissors. Generally we find the knot is embedded in tissue; in which case the rake (fig. 173) is used to hook up the loop. In snipping the loop we place one blade of the scissors under it, and then press the tissue back from the wire so as to divide the loop as far away from the knot as possible. Amputation with the Ecraseur or with the Galvano-caustic wire is not Amputa- such a neat method of operating as with the knife. Further, there isj; craseur liability to closure of the cervical canal through cicatrisation; this may orGalvan - caustic I FIG. 173. POINT OF RAKE ; although finely made, it should be blunt. (}). be prevented by introducing a stem pessary after amputation. The galvano-caustic wire is recommended by Barnes, Thomas, and others ; its use has been followed with remarkably good results in the hands of Byrne of Brooklyn, whose valuable paper on this subject should be consulted. The method of using the ecraseur and galvano-cautery will be described under amputation of the cervix for carcinoma (see Chap. XLIL). 286 AFFECTIONS OF UTERUS. Diagnosis of Hyper- trophy limited to supra- vaginal portion of Cervix. With the galvano-caustic wire we must see that the wire does not dip doumwards, and thus " scalp " instead of amputating the cervix. The fact that the galvano-cautery diminishes haemorrhage is of no advantage in amputating the hypertrophied cervix. The use of the india-rubber ring makes this a bloodless operation ; and the introduction of the sutures in the way described minimizes the danger of haemorrhage where the ring is not employed. B. HYPERTROPHY OF THE SUPRA-VAGINAL PORTION. The existence of hypertrophy limited to the supra-vaginal portion of FIG. 174. HYPERTROPHY OF INTERMEDIATE PORTION OF CERVIX. The anterior fornix is obliterated (Schroedcr). the cervix and not affecting the body of the uterus cannot be determined by clinical examination alone. The obvious reason is that we have no means of ascertaining in a case of hypertrophy where the precise upper limit of the cervix lies. The position of the os internum cannot be learned from the sound, and the distance to which the utero-vesical pouch of peritoneum descends can only be ascertained on post-mortem examination. We cannot affirm, therefore, that the hypertrophy is limited to the supra-vaginal portion of the cervix and that it does not affect the body of the uterus as well. In the present state of our knowledge it is impossible to say whether this hypertrophy is primary or secondary. We believe that in the great proportion of cases it is secondary to prolapsus uteri. It has also been described as an exceptional occurrence in the early months of pregnancy. 1 By French and by many German gynecologists, however, hypertrophy 1 By Martin Berliner Gesellschaft f. Geb. u. Gyn. 1880. AMPUTATION OF THE CERVIX. 287 of the supra- vaginal portion of the cervix is considered a distinct primary lesion. Huguier first drew attention to the increase in the length of the uterine canal in cases described as prolapsus uteri ; he affirmed that the fundus uteri always remained in its normal position, and that the os externum came to lie outside the vulva because the cervix had increased in length ; this hypertrophied condition of the cervix was occasioned by a prolapse of the vaginal walls which made traction on the cervix, and thereby stimulated it to increased growth. By these gynecologists, three forms of cervical hypertrophy are de- Three scribed according to the portion of the cervix which is hypertrophied. Cervical The division of the cervix into three portions a vaginal, an intermediate, Hyper- trophy. FIG. 175. HYPERTROPHY OF SUPRA-VAGINAL PORTION OF CERVIX. Both fornices are obliterated (Schroeder). and a supra-vaginal portion has been already described (see page 16). The vaginal portion is limited superiorly by the insertion of the anterior fornix ; the intermediate by that of the posterior fornix ; the supra- vaginal by the os internum. Hypertrophy of the vaginal portion is characterised by the persistence of both fornices in their normal position ; it has been already described (see fig. 166). In hypertrophy of the in- termediate portion the posterior fornix remains, while the anterior is obliterated (see fig. 174). In hypertrophy of the supra- vaginal portion both anterior and posterior fornices are obliterated (see fig. 175). In the accompanying preparation (fig. 176), described by Barnes, the elongation affects both uterus and cervix if we take the utero-vesical pouch of peritoneum as indicating the position of the os internum. Similar specimens are figured and described by Winckel (Die Pathologic der weiblichen Sexual-Organe, Tafel XlXa), and by Gallard (Annales de Gyn. XXIV., p. 219). 288 AFFECTIONS OF UTERUS. Conoid Amputa- tion of Hyper- trophiecl Cervix. Treatment While hypertrophy limited to the vaginal portion of the cervix is very rare, that affecting the whole cervix and usually associated with prolapsus uteri is a common condition, and it was for it that the various modes of amputating a portion of the cervix described at p. 281 were introduced. Huguier, who first exactly described supra-vaginal hypertrophy, introduced the conoid amputation. One incision is made from the posterior foniix obliquely upwards and forwards as far as the cervical FIG. 176. PROLAPSUS UTERI WITH CERVICAL ELONGATION (Barnes) ; p, p, peritoneum. canal; a second is made from the anterior fornix upwards and back- wards to meet the latter ; by this means a wedge-shaped or conical piece of the supra-vaginal portion of the cervix is removed. Flap The flap operation already described, however, gives the best stump. Operation. j n am p u tating for supra-vaginal hypertrophy, the relations of bladder and peritoneum of the pouch of Douglas require to be considered. The bladder invariably descends for a varying distance in relation to the AMPUTATION OF THE CERVIX. 289 front of the hypertrophied cervix. The peritoneum of the pouch of Douglas, inasmuch as it lines the upper part of the posterior vaginal wall, will, when that wall is everted, dip down alongside of the hyper- trophied cervix. If the posterior fornix is not obliterated, the peri- toneum will not descend alongside of the protruding cervix. The relations of the bladder and peritoneum are represented diagram- matically in fig. 177. The line of reflection of the posterior vaginal wall on to the cervix indicates how much is vaginal portion, and by passing the needle below that line we keep clear of the pouch of FIG. 177. AMPUTATION OF HYPERTROPHIED CERVIX IN PROLAPSUS UTERL B sound in bladder ; p peritoneum of pouch of Douglas. The sutures are passed as M N, and the cervix split laterally, so as to form an anterior lip, which is amputated along lines 1, 2, 3, and a posterior lip amputated along 4, 5, 6. peritoneum. The sound passed into the bladder will show us how far down that organ comes, and the needle is brought out an inch below that point. The steps of the operation are the same as in the former case. The peritoneum of the pouch of Douglas has been frequently cut into without bad results following, so that many operators regard this as an accident of little importance. CHAPTER XXIX. LACERATION OF THE CERVIX AND ITS CONSEQUENCES. LITERA TURE. Boer Analysis of Twenty-seven Operations for the Restoration of the Lacerated Cervix Uteri, with special reference to the effect on sterility and labour : Amer. Jour. Obstet., 1883, pp. 295, 852. Breisky Wiener med. Wochenschrift, 1876, Nos. 49-51. Also, Prager med. Wochenschrift, 1876, No. 18 and 1877, No. 28. Czempin Risse des Cervix Uteri ihre folgen und operative Behandlung : Zeit. fiir Geb. undGyn., Bd. XII., S. 287. Desvernine These de Paris, 1879. Dudley New York Med. Jour., Jan. 1878. Emmet Surgery of the Cervix: Am. Jour, of Obst., Feb. 1869; ibid., Nov. 1874. American Practitioner : Indianapolis, Jan. 1877. Principles and Practice of Gynaecology, p. 440 : Philadelphia, 1884. Eustache La Trachelorrhaphie ou opera- tion d 'Emmet : Archiv. de Tocolog., 1884, p. 684. Goodcll Notes of one hundred and thirteen cases of operation for laceration of the cervix : Am. Journ. of Obst., Jan. 1882. Hegar Operative Gynakologie, S. 538 : Stuttgart, 1881. Hewitt, Orally Clinical Lecture on Laceration of the Os and Cervix Uteri, etc. : Brit. Med. Journ., 1886, I. p. 1. Houzel Note sur 1'Operation d'Emmet ou Trachelorraphie : Annal. de Gyn., XXX., 241 and 351. Howitz Gynakologiske og. Obstetriciske Meddelelser, Bd. I., Heft 3. Johnson Trachelorrhaphy : Amer. Jour. Obstet., 1884, p. 539. Kaltenbach Ueber tiefe Scheiden-u. Cervicalrisse bei der Geburt : Zeitschrift f. Geb. u. Gyn., Bd. II., S. 274. Klein Prager med. Wochenschrift, 1878, No. 24. Lee The Proper Limitations of Emmet's Operation : New York Med. Jour. Sept. 1881. Macdonald, Angus The Caiises, Results, and Treatment of Laceration of the Cervix : Ed. Med. Jour., July 1882. Munde Am. Jour, of Obst., Jan. 1879; Death after Trachelorraphy, New York Med. Jour., 1883, p. 332. Murphy Observations on the effects of Trachelorrhaphy on Fertility and Parturition : Amer. Journ. of Obstet., Jan. 1883. Nieberding Ueber Ectropium und Risse : Wiirzburg, 1879. Noeyr/erath Cervixrisse und Erkrankungen der Gebar- mutter : Berl. klin. Wochenschr., 1887, No. 41 ; and (for Discussion) Archiv f. Gyn., Bd. XXXI., S. 469. Olshausen Zur Pathologic der Cervicalrisse : Centralbl. f. Gyn., 1877. Nr. 13. Fallen St. Louis Med. and Surg. Jour., May 1868; Richmond and Louisville Med. Jour., 1874 : British Med. Jour., May 1881. Park Trachelorr- haphy : Edin. Med. Jour., XXXIII., II., p. 1130. Play fair Trachelo-raph6 : Lond. Obstet. Trans., 1883, and Medical Times and Gazette, 1885, I. 340. Roser Das Ectropium am Muttermund : Arch. f. Heilk. II. Jalirg., 2 H., 1861. Huge u. Veit Zur Pathologic der Vaginalportion ; Stuttgart, 1878. Sanger Ueber die klinische Bedeutung der Cervixrisse : Centralb. f. Gyn., Bd. XII., S. 441. Simpson, Sir J. Y. Edin. Jour, of Med. Science, 1851, p. 152. Spiegelberg Weber Cervicalrisse, ihre Folgen u. ihre operative Beseitigung: Breslauer artz Zeitschrift, 1879, No. 1. Van de Warker Etiology of Lacerations : Am. Journ. of Obst., Jan. 1882. Thirty- one operations for Repair of Laceration of the Cervix Uteri: ibid., July 1883. Vuttiet Douze cas d'operation de Trachelorrhaphie: Archiv. de Tocolog., 1884, p. 1000. Wells, B. H. Possible Dangers of Trachelorrhaphy : Amer. Jour. Obstet., 1884, p. 561. Also, The Etiological Relation of Cervical Laceration to Uterine Disease : Amer. Jour. Obs., 1888, p. 257. Zinke Emmet's Operation : Phil. Med. Reporter, Aug. 1885. See Index of Gynecological Literature in the Appendix for recent cases of the Operation. LACERATION OF THE CERVIX. 291 THE student will not have gone far in the clinical study of Gynecology Introduc- without being surprised at the large number of patients who refer the ory> commencement of their illness to a confinement or miscarriage. They come complaining of various ailments a weak back, pain in the side, white discharge, losing too much at the monthly time, or general unfitness for work. On physical examination, he finds a variety of conditions a fissured and thickened velvety cervix, thickenings in the lateral fornices or behind the uterus often displacing it by traction, and the uterus itself enlarged. We do not mean that all of these are present in one case, but that one or more of them may be ; nor is any one symptom invariably connected with one lesion. He asks himself why labour is so often the starting-point of female complaints ; and one important reason, though by no means the only one, is that the tear of the cervix in labour literally opens the door to a variety of lesions. Cervical catarrh is favoured, if not started (as Emmet says), by the split condition of the cervix ; the raw surface has admitted septic matter which leads to chronic inflammation of the parametrium with all the changes in the train of parametritis; and sub-involution is kept up (if not directly by the tear, as Emmet holds) indirectly by the consequent parametritis which Freund has shown to affect the venous and lymphatic circulation in the uterus. It is impossible to consider laceration of the cervix separate from the results which in the great majority of cases follow, and hence this chapter deals with " Laceration of the Cervix and its Consequences." Many of these latter being distinct lesions in themselves, will be treated of separately in the following chapters and only referred to here in their relation to laceration as an antecedent. For the recognition of laceration of the cervix as a distinct and Historical, important lesion we are indebted to the genius of Emmet of New York, who was the first to insist on its clinical significance and elaborate an operation for its treatment. J. H. Bennet of London had previously described the changes produced in the cervix by its laceration in labour, unfortunately attribut- ing them to a process of ulceration. Roser of Marburg had described the pathology of the condition; but its importance as a factor in uterine disease was brought into notice by Emmet's first paper which was published in 1869, seven years after he had introduced his operation. Emmet's views as to the importance of lacerations of the cervix have given rise to a great deal of discussion ; and their significance is a qucestio vexata in Gynecology, which has been revived in the last two years through a paper by Noeggerath in 1887. 1 From a comparison of fifty gynecological cases in which laceration was present with another fifty in which it was absent, he concludes that it has no effect on fertility, on 1 Read in the Gynecological Section of the Versammlung deutscher Xaturforscher und Aerzte in Wiesbaden. His paper and the others referred to in the text are given in the Literature. 292 AFFECTIONS OF UTERUS. the length or position of the uterus, cervical catarrh or ectropion, or disease of the uterus generally. His paper has given rise to considerable discussion in Germany, America, and this country ; and it has been shown 1 that Noeggerath's method of inquiry is in several respects fallacious, and that the clinical evidence proves that his extreme position is indefensible. PATHOLOGY. Seat, form, The commonest seat of the laceration is to the front and left 2 side of of lacera"* the cervix, probably because the long diameter of the child's head is most tion - commonly in the right oblique diameter of the pelvis, and the thicker end of the wedge is to the front. The next in frequency is a double laceration to the front and left, and to the back and right sides. Less FIG. 178. SINGLE LACERATION. The flaps are held apart with a double tenaculum (Emmet). frequently is the laceration at either end of the left oblique diameter. We have found lacerations to the front and right side in cases where the head presented right occipito-anterior. The form of the laceration is various single (see fig. 178), double (see Plate XII., fig. 2), or multiple (see fig. 179). The extent of the laceration varies, from a mere indenta- tion of the ring of the os externum to a gaping fissure separating the lips of the cervix up to the vaginal fornices. Occasionally it extends into the roof of the vagina, 3 and is marked by a cicatricial band drawing 1 See the papers by Siinger, Park, and Wells given in the Literature. 2 According to Emmet and Spiegelberg ; Klein and Czempin found right-sided laceration more frequent. 3 Czempin, in an extremely interesting paper on cases of laceration of the cervix observed in Martin's Clinique at Berlin, draws especial attention to these tears extending into the fornix which he describes as " Cervix-Laquearrisse." They are not infrequent (having been present in sixty -eight out of his two hundred and eighty-seven cases), usually unilateral, and more frequent with single than with double tears of the cervix itself. Their symptoms are more marked, due to the changes in the parametrium. LACERATION OF THE CERVIX. 293 the cervix to one side ; we have noticed this in forceps cases, specially when the forceps had been applied before the os was dilated. Among the pathological conditions which are the consequences of lacera- Results. tion are the following. One result is that the mucous membrane of the cervical canal is exposed, and the occurrence of cervical catarrh favoured (v. Cervical Catarrh). The submucous tissue is also thickened and the whole cervix thus hypertrophied. * With these inflammatory change^ there is eversion of the lips of the cervix, although this is sometimes counteracted by the formation of cicatricial tissue in the cleft. Another consequence is cellulitis ; frequently we find, on the same side as the laceration, a localised cellulitis in the shape of a distinct deposit, or a tense condition of the utero-sacral or broad ligament, accompanied with tenderness on pressure through the fornix. This tenderness, as FIG. 179. MULTIPLE OR STELLATE LACERATION (Emmet). well as the constant pain complained of in the side, is probably due to changes in the sympathetic plexus in the connective tissue already referred to under Parametritis. Subinvolution of the uterus is also frequently present ; there is a formation of cicatricial tissue, which compresses the veins and lymphatics and leads to passive congestion and hypertrophy. The compression of the vessels seems sometimes to have an opposite result, leading to atrophy through stoppage of nutrition. ETIOLOGY. A laceration of the cervix will be found, according to Emmet's Frequency statistics, in 32*8 per cent, of parous women ; according to Wells, takes the average of all the various authorities, in 32 per cent. Though 1 Partial hypertrophies of such a size as almost to form a tumour sometimes, but very rarely, occur. Stratz describes three cases, in one of which the tumour weighed 2 Ibs. (Zcitscli. fur Geb. und Gyn., Bd. xii., S. 229. * 294 AFFECTIONS OF UTERUS. it is obvious that lacerations may be produced and heal again so that all trace of them escapes notice, we cannot affirm that the cervix is lace- rated with every first full-time labour ; but when present, a laceration of the cervix (if we exclude the possibility of the cervix having been divided artificially) is the most reliable diagnostic of a former parturition. It must, however, be remembered that a divided condition of the cervix with ectropium of the cervical mucous membrane has been described as a congenital condition by Fischel and Kiistner ; in such cases, the everted mucous membrane does not become much altered and retains the arbor vitae. We should have expected that lacerations would be more readily produced in a rapid labour, in which the os had not time to dilate ; Emmet and Fallen, however, have found that they are more commonly the result of tedious labours. Spiegelberg blames early rupture of the membranes done to hasten labour; while Klein finds them most frequent where there is a short interval between rupture of the membranes and delivery of the child, as also where the child is heavy. Barker and Munde both draw attention to the fact that they are less common among the wealthy than among the poor. This is probably explained by the better care and longer rest in the puerperium which the former enjoy. Produced Even during pregnancy, according to Nieberding, fissuring of the pregnancy. cerv ix with ectropium is produced. He examined the cases admitted to the lying-in hospital at Wurzburg at three periods during pregnancy, as shortly as possible after delivery, and on dismissal. Only in 26 per cent of the primiparse examined (thirty-eight cases) was the appearance of the cervix normal during pregnancy ; in all the others more or less ectropium was present. In 50 per cent, there were in addition small fissures, which made the os stellate or irregular in form. SYMPTOMS. Symptoms It is very important to know what symptoms are referable to a lace- tion. rated cervix. Those who revel in operative treatment ascribe every pathological condition in the uterus to lacerations, while others alto- gether deny that they have any pathological significance. We advance the following considerations in regard to the symptoms. 1. Lacerations of the cervix in themselves produce no symptoms. Haemorrhage may arise at the time of production, but is not a symptom of the persistence of the laceration. 2. Other pathological conditions arise secondarily as the result of the laceration, of which the most important are cervical catarrh and cellulitis ; cicatricial tissue in the cleft produces reflex nervous symptoms. We sometimes find a well-marked laceration by chance, as it LACERATION OF THE CERVIX. 295 were, the patient having had no symptoms referable to a pelvic cause. Frequently she complains of leucorrhcea and symptoms common to pelvic or uterine inflammation. Menstruation is often irregular, in- creased in 50 per cent, according to Emmet's statistics ; this is in many cases due to subinvolution. Sterility, when present, is probably due to the accompanying catarrh ; and the tendency to abortion^ to the secondary changes in the uterus or parametrium. Neuralgia is sometimes present, which may show itself locally in excessive tenderness to touch at the seat of laceration and has been compared to the sensitiveness present in toothache. In other cases it has taken the form of neuralgic pain in the pelvis generally, often in the groin and extending down the leg, or sympathetic neuralgia elsewhere. Emmet and others record cases in which persistent neuralgia disappeared on excision of the cicatricial plug in a lacerated cervix. Other reflex disturbances (such as cataleptic con- vulsions, persistent salivation, profuse sweating, hysterical anuria) have disappeared after Emmet's operation. General weakness and inability to work are present here as in other chronic conditions. The relation of laceration to malignant disease, of which it seems sometimes to be the starting-point, will be considered under Cancer of the Uterus. DIAGNOSIS. This presents, in many cases, no difficulty. The finger feels the indentation or fissuring of the vaginal portion. Occasional Sometimes the cervical canal is patulous, and admits the distal phalanx i u recogni- of the finger easily. Difficulty in diagnosis arises when there is much tlon - eversion of the mucous membrane of the cervical canal with thickening of the cervical tissue ; the fissure is thus obliterated, because the circle of the os is not formed of the os externum but of a higher unfissured portion of the canal. This thickening and the velvety feeling of the everted mucous membrane lead us to suspect the condition. The speculum shows the cleft in the cervix with, in the great majority of cases, round it appearances which will be more fully described under Cervical Catarrh. We see a bright red irregular patch on one side of or surrounding the os ; from its granular appearance, its vascularity, and the fact that it bleeds easily, it resembles an ulcerated surface. For this reason it is often described as " ulceration " of the cervix, but it is no more an ulceration than is the inflamed mucous membrane of the conjunctiva. By ulceration we understand a destruction and loss of tissue. The epithelium and subepithelial tissue may be destroyed as an immediate result of injury during labour; but the raw-looking sur- face, appearing secondary to and also independent of lacerations (see 1 To the importance of which Graily Hewitt has called attention in a recent paper (toe. cit.). 296 AFFECTIONS OF UTERUS. Catarrh in Nulliparae), is not an ulcerated surface and should therefore not be treated as such. As already mentioned (p. 114), Sims' speculum must be used; the other forms only mask the laceration. For the appearance presented by the various forms of laceration when seen in the speculum, the student should compare fig. 178 and fig. 179. The difference between the colour of the everted cervical mucous mem- brane and that of the vagina is represented in Plate XII., figs. 1 and 2. A beautiful series of chromo-lithographs is appended to Munde's article (Am. Jour, of Obstet., Jan. 1879), which illustrates the various degrees of laceration. The most complete series is in Nieberding's pamphlet which gives representations of the cervix uteri before and after parturi- tion, both in primiparse and multiparse ; the colouring, however, is unnatural. The microscopic changes which produce the appearance simulating ulceration will be described under Cervical Catarrh. The tenacula are a valuable adjunct in examination with the specu- lum. If we place one in the anterior and one in the posterior lip, and roll these in on one another, the raw-looking surface will in many cases disappear. This easily demonstrated fact had not been recognised till Emmet drew attention to it, and based on it the operation which will be always associated with his name. By thus rolling the lips inwards, we restore the laceration and see the extent of it so as to judge of the possibility of approximating the lips with sutures. TREATMENT. From what has been said in the introductory paragraph, and also under " Pathology," it is evident that the treatment of laceration of the cervix means much more "than the closure of the split. Emmet in his operative procedure not only closes the laceration but excises the cicatricial tissue ; he also makes his patients undergo a long preparatory treatment directed to the cervical catarrh. The cases calling for his operation are much fewer than might at first sight be supposed, * because no laceration however well marked calls for treatment unless it is pro- ducing* symptoms ; and there are other operations (Schroeder's and Martin's) for removing the consequences of laceration which are as efficient as Emmet's. operation ^he stitching up of a laceration immediately after parturition was for lacera- tion. * Principles and Practice of Gynaecology : 1884, p. 483. The conservation as to this operation which exists in this country is almost justified by what Emmet says in his letter given in the interesting tabulated record of opinions of the leading operators which Zinke has collected as to when and when not the operation is to be performed; the italics are ours. "The Operation has long since passed out of my hands, and so fully endorsed that I have no fear for its future. The great point is to check the abuse, which is fearful. Every one feels competent to perform it ; it is done without the proper preparatory treatment, and with no special purpose. I believe in nine ca*e out often, where it is done, or attempted, the execution of the operation is defective and with- out any benefit to the patient." LACERATION OF THE CERVIX. 297 first performed by Fallen of New York. Having failed to check by the tampon post partum haemorrhage from a lacerated cervix, he passed Sims' speculum and sewed up the laceration with silver-wire sutures ; this checked the haemorrhage. We have never had occasion to perform the " immediate " operation ; injections of very hot water have always sufficed to check haemorrhage. Considering the liability to septic inflammation in the puerperal condition, we would be very chary about operating unless the haemorrhage were considerable and not diminished by hot injections. The paring of the edges of an old laceration and uniting of them Emmet's with sutures is known as "Emmet's operation," which is a simpler and Operation ' more suggestive name than "Trachelorrhaphy." Preliminaries to Emmet's Operation. The patient should use hot- water Prelimi- injections for some weeks previous to the operation, and apply a blister nanes - if there be any indication of cellulitis. Emmet lays great stress on this preparatory treatment, and says that we should not operate so long as there is any tenderness on pressure in the fornices. He further recom- mends, in cases where the cervix is thickened and the mucous follicles enlarged, scarification of the cervix and painting with iodine or tannin and glycerine. The Operation. The following instruments 1 are required : Emmet's Vaginal douche, Dissecting forceps, Sims' speculum, Short needles (fig. 105) straight ated Volsellae, and curved, Tenacula, Needle holder, Rubber ring, Medium silver wire, or catgut. Bistoury and scissors, The patient is placed under chloroform in the lithotomy posture (in the semiprone posture by Emmet, but this does not give the operator so much room) ; the sacral segment is drawn back with the speculum by an assistant, and the cervix is laid hold of with the volsella and drawn down. The uterus may be curetted at this stage. Draw the edges of the laceration together with the tenacula to see how much tissue must be pared from the edges of the cleft to allow it to be sewed iip, and then proceed to operate. Slip the rubber ring over the volsella on to the cervix and place it so as to constrict the base ; this prevents bleeding and thus allows the operator to see that the edges are completely pared, which is essential to union of the raw surfaces. Wash out the vagina with carbolised water. When possible, continual irrigation is kept up during the operation ; with this, the india-rubber ring is not required as the stream of water keeps the denuded surface always clean. Now 1 It is of great advantage, as Martin has pointed out, to curette the uterus before operating on the cervix ; this can be done at the one operation, in which case we need the curette and sounds dressed with cotton-wool dipped in iodine or carbolic acid in addition to the instruments mentioned. 298 AFFECTIONS OF UTERUS. pare the edges of the laceration with the scissors or knife (fig. 1 80) ; J! FIG. 180. OPERATION FOB LACERATED CERVIX ; a 6 extent of denuded surface. scissors are preferable, because they cut with greater ease and rapidity. FIG. 181. EXTENT OF DENUDED SURFACE AND COURSE OF SUTURES ACCORDING TO EMMET (Emmet). The sutun-s are passed in order 1234; the course of suture 4 alone is indicated by letters abed. With long-bladed scissors we can remove the tissue from one edge of the LACERATION OF THE CERVIX. 299 laceration with a steady clean cut right into the angle ; Emmet lays great stress on the removal of the cicatricial tissue in the angle but uses the bistoury to do this. When the laceration is bilateral this must be done on both sides. Fig. 181 shows the extent of surface denuded by Emmet in a case of bilateral laceration. Great care must be taken to leave a broad strip (broader than represented in fig. 181) undenuded in the middle line to form the walls of the cervical canal. Now introduce the sutures ; these if of wire are about eight inches long so that both ends protrude from the vagina, and are well adapted to the eye of the needle so as not to obstruct its passage. Emmet recommends the round needle as it makes a smaller hole and is therefore followed by less haemorrhage ; when the tissues are dense, the lance-shaped point perforates more easily. Catgut x has the great advantage over silver wire, that the stitches do not require to be removed afterwards; FIG. 182. MODE OF PASSING SUTURES ; a 6 denuded surface as in fig. 181. The sutures are passed in order as numbered. strong sutures are necessary, as some force is needed to tie them tight. Pass the sutures as in fig. 182, beginning at the upper part of the wound : each is drawn half through but is not twisted up till its fellows are in position, as it is sometimes necessary (when the tissues are thick) to pass the needle first through one lip and then through the other ; they are then twisted up ; the ends are brought out at the vaginal orifice, tied together, and wrapped round with a piece of wadding (fig. 183). Emmet cuts the sutures short, but the long ends facilitate their removal. No special regimen is required afterwards, the diet need not 1 Meinert recommends passing the catgut right through the cervix and fixing the ends with shot on plates : Eine sichere Catgutnahtfur die Emmet'sche Operation : Archiv f. Gyn. XXXIII., S. 310. 300 AFFECTIONS OF UTERUS. be restricted. Secondary haemorrhage has sometimes followed the operation : it is best checked by passing a suture through the cervix higher up and tying it tightly on the side from which the haemorrhage comes so as to constrict the vessels in the cervix. Removal of wire sutures. The stitches are removed on the seventh or eighth day. To do this we require speculum, wire-scissors, rake, and forceps. The rake is" almost indispensable in removing sutures from the cervix or vagina; it is represented and described at fig. 173. The sutures are removed from above downwards ; if we reverse the order, we may tear the lower portion apart in removing the upper sutures ; if the surfaces have not entirely united, the lower sutures should be left in for a few days longer. The effect of the operation on sterility has given rise to a great deal FIG. 183. APPEARANCE OF CERVIX WITH SUTURES TWISTED UP. They are left long so as to extend to vaginal orifice and are removed in order as numbered. of discussion. Wells gives in his paper an interesting table of statistics as to subsequent conceptions, and affirms that the operation increases fertility; the proportion (one-fourth) of cases fertile after Emmet's operation is, however, the same as Emmet gives for cases of laceration generally, i.e. whether operated on or not. The cicatrix does not cause difficulty in subsequent parturition. The cervical catarrh may persist after the operation. Sometimes metritis, cellulitis, or peritonitis has unfortunately followed it. Six fatal cases have been collected by Wells. LACERATION OF THE CERVIX. 301 Other operations to meet the consequences of laceration. Emmet's opera- tion is directed not only against the split but also its conse- quences, the cicatrisation and the cervical catarrh. Simply to close an old split would be as meaningless as shutting the stable door in the proverb. For the treatment of the catarrh, we have also Schroeder's excision of the mucous membrane of the cervix and Martin's amputation and excision, both of which will be described in the next chapter. For extensive tear into the fornix 1 which has resulted in cicatri- sation in the parametrium with lateral displacement of the uterus, Martin has introduced as a special operation 2 the separation of this cicatricial tissue from the cervix. Under chloroform, in the lithotomy posture, the cervix is drawn over with forceps from the affected side and a semilunar incision made in the cicatrix in the fornix, following the contour of the cervix. This may be sufficient; or it may be necessary in addition to cut out a portion of the cicatrised tissue. The antero-posterior incision is then stitched so as to bring front and back together and thus make the line of junction transverse. 1 See footnote 3, p. 292. 2 Czempin (loc. cit.) gives three cases in which marked symptoms disappeared after this operation, and also a tabular report of nine more recent cases in Martin's clinique with similar good results. CHAPTER XXX. CHRONIC CERVICAL CATARRH. LITERA TDRE. Barnes Diseases of "Women : London, 1878, p. 530. Bennett, G. H. Practical Treatise on Inflammation, Ulceration, and Induration of the Neck of the Uterus : London, 1845. Candia L'amputazione della porzione dell' utero come cura radicale delle erosioni e della metrite parenchimale cronica : Annali di Ostet., 1888, 463. Duncan, Matthews Diseases of Women : Lond., 1886. Fischel Bin Beitrag zur Histologie der Erosionen der Portio vaginalis uteri: Archiv f. Gyn., Bd. XV., S. 76. Fritsch Erosionen, Ectropium und Cervicalcatarrh : Billroth u. Luecke's Handbuch der Frauenkrankheiten, Stuttgart, 1885. Hennig Der Katarrh der inneren weiblichen Geschlechtstheile : Leipzig, 1862. Hildebrandt Ueber den Katarrh der weiblichen Geschlechtsorgane : Volkmann's Sammlung klin. Vortrage, Leipzig, 1872, No. 32. Hofmeier Folgezustande des chronischen Cervixkatarrhs und ihre Behandlung : Zeitsch. f. Geb. u. Gyn., Bd. IV., S. 331. Klotz Gynako- logische Studien iiber die pathologischen Veranderungen der Portio vaginalis Uteri : Wien, 1879. Kustnet Beitrage zur Lehre von der Endometritis, Erosion und Ectropium: Jena, 1883. Mundi The treatment and curability of chronic uterine catarrh : Amer. Journ. of Obstet., 1883, p. 857. Buge and Veit Zur Pathologic der Vaginalportion : Zeitschrift f. Geb. u. Gyn., Bd. II., S. 415. Schroedei Krankheiten der weiblichen Geschlechtsorgane : Leipzig, 1879, S. 122. Smith, Heywood So-called Ulceration of the Womb : Obst. Journ. of Great Britain, 1876, p. 604. Steavenson Note on the use of Electrolysis in Gynecological Practice, and Discussion : Trans. Lond. Obs. Soc., June and July 1888. Thomas Diseases of Women : London, 1880, pp. 275 and 336. Vulliet De la dilatation permanente de 1'ut^rus : Arch, de Toe., 1886, p. 933. ACUTE catarrh of the cervix is known to us only as part of a general catarrh affecting both body and cervix, and will be described under Acute Endometritis. Chronic catarrh occurs localised in the cervical mucous membrane ; it is a very common condition and one of the most troublesome which the practitioner has to treat. DEFINITION. A chronic inflammatory process affecting the mucous, membrane lining the cervical canal. SYNONYMS. Cervical endometritis, Endo-cervicitis. PATHOLOGY. The mucous membrane of the cervical canal is inflamed. When the os externum has been lacerated, the lips gape and the mucous membrane is thus everted ; on bringing the margins of the laceration together, this eversion will disappear. Further, there are granular patches with irregular outline which extend beyond the limits of the os externum ; PLATE m. EROSION AND LACERATION OF CERVIX (RuoE AKD VEIT). CHRONIC CERVICAL CATARRH. 303 these have a red appearance resembling the cervical mucous membrane, and are therefore sharply denned from the paler mucous membrane which covers the vaginal portion of the cervix. This last condition was till late years generally held to be an "ulcera- Pathology tion" and is still described, even in recent English works, under name. The term should, however, be discarded as based on an erroneous pathology and suggesting most pernicious treatment. The cause of the error is easily explained : a raw-looking granular surface was seen with the speculum; the raw appearance was ascribed to the loss of the epithelium, and this supposition was supported by the microscopic examination of specimens taken from the dead body, in which the epithelium had been macerated and removed ; the granular points were supposed to be the subjacent papillae which had become hypertrophied. Both of these suppositions have been shown to be erroneous by the Ruge and careful investigations of Huge and Veit, who examined specimens of the inv'estiga- tions. FIG. 184. PAPILLARY FORM OF EEOSION (Schroeder). so-called ulcerations cut fresh from the living subject ; they demonstrated (1) that the apparently raw surface is covered with epithelium, (2) that the granular points are new formations and have no connection with the papillae of the mucous membrane. The microscopic appearance of the mucous membrane described by them is as follows. The surface is covered with a single layer of epi- thelium ; the cells are smaller than those which line the normal cervical canal, and being narrow and long have a palisade-like arrangement ; the thin layer of cells allows the subjacent vascular tissue to shine through, hence the redness of colour. The surface is further thrown into numerous folds producing glandular recesses and processes ; these processes cause the granular appearance of the surface. The condition is well seen in Plate XII., and constitutes the simple erosion : fig. 1 shows such an erosion as seen in the speculum : fig. 3 shows a microscopic section of the 304 AFFECTIONS OF UTERUS. same, stained with carmine ; the left half of the section corresponds to the deep red portion of fig. 1, the right half to the paler portion outside of this. If the recesses be long and narrow, the surface is split up into distinct papillae ; this constitutes the papillary erosion (see fig. 184). If the ducts of the glandular recesses become obliterated, the section will distend the gland below and produce retention-cysts ; these will increase in size, and may come to the surface and burst. Thus there is formed the follicular erosion (see fig. 185). The raw-looking surface is therefore a newly-formed glandular secreting surface, resembling in structure the cervical mucous membrane. This addition to the extent of secreting surface increases the leucorrhceal discharge which is the leading symptom. These observations of Huge and Veit have been confirmed in their essential points by Fischel and other observers ; Fischel considers the secreting processes, while being new formations, to have the structure of papillae and not to be mere foldings of the mucous membrane. While there is, therefore, no disagreement as to the microscopical so-called "ulcerations," the origin of this new epithelial Origin E *th 1' 1 a PP earance new forma- tion. FIG. 185. FOLLICULAR FORM OF EROSION (Schroeder). structure is disputed. Ruge and Veit hold that this single layer of small cylindrical cells is produced by proliferation of the cells of the deepest layer of the rete Malpighi, while those of the superficial layer are shelled off; the appearance seen in fig. 185 favours this view. It will be observed also that they regard the simple follicular and papillary "ulcera- tions" as the results of one and the same process, viz., proliferation of epithelial cells. On the other hand, those red patches are generally con- tinuous with the mucous membrane of the cervical canal and resemble it in their microscopic structure ; it is therefore much more probable that they are occasioned by proliferation of the epithelium which lines the cervical glands, leading to an extension of the glandular surface beyond the os externum. Fischel holds that there is not only the proliferation CHRONIC CERVICAL CATARRH. 305 of epithelial cells, but of connective tissue ; and that according to the preponderance of the one over the other, the follicular or papillary forms are produced. He also thinks erosions are due to the persistence of the cylindrical epithelium (found outside the os externum in the foetus) into adult life, and the desquamation of the squamous epithelium which had come to cover it. The question as to the origin of the cylindrical epithelium found in erosions is rendered more difficult by the fact that the boundary-line between the squamous epithelium outside of and the cylindrical within the cervical canal varies at different periods of development and in different individuals. In the foetus, according to Ruge's investigations, the cylin- drical epithelium extends down the vagina also ; and we have a hint of the persistence of this foetal condition in the congenital ectropium described by Fischel. Klotz describes two types of cervix characterised by the distribution of the squamous epithelium : one, cavernous in texture, and having the squamous epithelium extending some distance FIG. 186. TRUE ULCERATION OF THE CERVIX. At the sides of diagram is seen the normal epithelium, which is prolonged in processes, e. p. between the connective tissue papillae ; e is superficial layer of squamous epithelium reduced to a thin layer at e' ; c t, tissue of mucosa infiltrated with small cells ; b v, blood-vessels surrounded by small-celled infiltration (Fischel). into the cervix ; the other, glandular in its substance, and having the squamous epithelium stopping at the usual seat of the os externum. The foregoing description of the microscopic changes makes it evident Nomen- that the process is not one of " ulceration ; " and this term should, there- fore, be abandoned. The German term Erosion is open to a similar changes in criticism. "Ectropium" or "Eversion of the mucous membrane" de- Catarrh. scribes the condition in its relation to laceration, but does not describe the extension of the secreting surface beyond the os externum ; the term is preferable to " ulceration," as it is at least not misleading. Thomas describes these conditions under the name of "Granular and Cystic Degeneration of the Cervix Uteri." This term is based on the naked eye appearance of the cervix, and conveys no idea as to the pathological change which takes place. Under granular degeneration, he describes the pap- 306 AFFECTIONS OF UTERUS. Catarrhal Patches. True Ulcera- tions. Ovula Nabothii. Cysts in the Cervix. Normal and Patho logical conditions of Cervix contrasted. illary form ; under cystic degeneration, the follicular. As we are not in a position to introduce a term based on pathology, it is preferable to designate it according to its symptom as Cervical Catarrh. The red patches which lie outside the os externum, we shall speak of as " catarrhal patches" Sometimes a true ulcerated process destruction of epithelium with inflammation of connective tissue does occur ; such a condition is represented in fig. 186. Along with those changes in the mucous membrane, chronic inflam- matory changes occur in the other tissues of the cervix. There is increased formation of connective tissue, which produces antero-posterior thickening and sometimes elongation. The secretion in the obstructed glands becomes inspissated, and hence the retention cysts are felt as firm pea-like bodies ovula Nabothii in the substance of the cervix or projecting from it ; or their contents may suppurate and form small abscesses. As there are no racemose glands on the vaginal portion beyond the limits of the os externum (see Histology of Normal Cervix, p. 21), these ovula Nabothii must be produced from the glands of the mucous membrane of the cervical canal or from the newly-formed glandular tissue. Fritsch draws attention to the fact that the glands of the cervix are enormously hypertrophied during pregnancy, so that the cervix becomes almost a glandular organ ; the persistence of this con- dition after the puerperium, may explain the increased glandular formation which is described above as the chief pathological element in cervical catarrh. Sometimes we find a single large cyst in the cervix, due to obstruction of the mucous glands. When it is in the substance of the wall, the soft bulging into the cervical canal and the accompanying menorrhagia may lead one to suspect commencing sarcomatous infiltration. Puncturing with a trocar removes a clear or straw-coloured fluid, rich in mucous corpuscles. The microscopic pathology of the cervix has only of recent years been carefully investigated, and there are many points on which definite information has not as yet been obtained. The following is a brief summary of the pathological changes described, which are best under- stood by comparison with the microscopic structure of the normal vaginal portion. NORMAL CONDITION. The vaginal portion is covered on its vaginal surface with many layers of squamous epithelium, resting on papillae of connective tissue ; there are no mucous follicles. The cervical canal is lined with a single layer of cubical epithelium (ciliated only on the ridges), folded so as to form shallow recesses which do not branch ; there are racemose mucous glands, which have branching ducts. The substance of the cervix is made up of connective tissue. CHRONIC CERVICAL CATARRH. 307 PATHOLOGICAL CHANGES. These, according to the extent and dura- tion of the process, affect the three elements epithelium, glands, connective tissue. The epithelium of the cervical canal may be simply exposed (ectropium after laceration), or it may be inflamed. When inflamed, the folding of the mucous membrane is greatly increased so that the surface has a papillary or granular appearance. Further, this inflamed mucous surface may be found extending beyond its normal limit (the os externum) in the form of red patches (catarrhal patches) which are smooth or granular. The glands hypertrophy and new glands form as the result of the proliferation of epithelium described above. The openings of the glands are at first restricted to the area covered, with a single layer of cubical epithelium, but their branching ends extend below the limiting surface of stratified squamous epithelium. Their ducts become obstructed, and retention cysts form not only on the red patches but also underneath the adjacent apparently normal vaginal mucous membrane. They may remain as little nodules in the mucous membrane, or may come to the surface and burst ; in the latter case, the cubical epithelium and papillae on the inner wall of the cystic gland are exposed and, being now on a free surface, proliferate. When the glands are the special seat of the pathological changes, the whole substance of the cervix is converted into a cystic mass. The connective tissue always increases in amount, specially when the process is chronic. This increase constitutes the "areolar hyperplasia" of Thomas. ETIOLOGY. The most important cause is, undoubtedly, the injury of the cervix Frequenc produced in parturition ; hence cervical catarrh is common in parous ?* j?/ 1 *,^ women. How this injury produces the inflammatory condition is a parse, disputed point. Emmet refers it to the persistence of the split in the cervix, and holds that the exposure of the mucous membrane to friction against the vaginal walls leads to irritation and inflammation ; but we frequently see cases of well-marked lacerations without consequent cervical catarrh. It is admitted by all that the existence of lacerations greatly favours the development of catarrh. Other less important causes are the spread of inflammation from the vagina upwards (vaginitis, which may be simple or gonorrhoeal), and from the endometrium downwards. The latter is favoured by the fact that the discharges from the endometrium necessarily flow over the cervix and irritate it. Cervical catarrh is the most frequent complication of retroflexion of the uterus. The flexion favours gaping of the lacerated cervix and produces passive congestion of the cervical tissues. 308 AFFECTIONS OF UTERUS. SYMPTOMS. These are Leucorrhcea ; Pain in back and loins, increased on exercise ; Irregular menstruation ; Sterility. Leucorrhcea is the prominent symptom. Under normal conditions the secretion from the mucous membrane of the uterus and cervix is not sufficient to attract attention; when it is excessive, it is termed leucorrhoea (\ewc6s white, p 364 AFFECTIONS OF UTERUS. cases of well-marked retroflexion. The ureters are often compressed or bent, which leads to dilatation ; frequently they are found dilated to the thickness of the finger. Fritsch observed in one case the left ureter obliterated by a mass of cicatricial tissue, and the corresponding kidney changed into a sac full of white atheromatous debris. The rectum may have the retroflexed fundus pressing against its anterior wall. The peritoneum is altered in its normal relations as follows. The broad ligaments have their surfaces reversed, that is to say, the anterior, which was formerly inferior, is now superior ; from their attachments, they offer no obstacle to retroflexion. The utero-vesical pouch neces- sarily disappears. The pouch of Douglas must, on the other hand, be FIG. 211. CONGENITAL RETROFLEXION (Ruffe). Note the thinning of the anterior wall of the uterus. distended by the fundus uteri ; this implies stretching of the utero-sacral ligaments associated with the alteration in position of the cervix. The pelvic nerves are occasionally affected, as shown by weakness in the lower limbs. This loss of power must be produced reflexly ; from the anatomical relations, the retroflexed fundus cannot compress the motor nerves of the sacral plexus as is sometimes affirmed. ETIOLOGY. Retroflexion is, according to Frankel's recent statistics, more common than retroversion, l As a congenital condition, it is not nearly so 1 In 1882-85 he treated 930 retrodeviationa of uterus of which 645 were retroflexions and 291 retroversions. RETROFLEXION. 365 frequent as auteflexion. It is more common in multipart than in nulliparse, because the etiology is specially related to the puerperal condition. In this condition the uterus is enlarged and heavy and its walls are soft. The ligaments are lax, and the tissues of the pelvic floor have been recently stretched and have not recovered their tone. Through the distention of the bladder, the uterus is often thrown into a retroverted position. We sometimes find on examining a patient shortly after her confine- ment that the uterus is lying back in the pelvis even though the bladder be not distended ; we may thus suppose that the intra-abdominal pressure (which, when the uterus is in its normal position, is directed upon its posterior surface) comes now to act on the anterior surface and drives the fundus backwards and downwards. If the uterine tissue is soft enough to allow the fundus to be fixed on the cervix, such a flexion will gradually take place when the patient makes straining efforts. Apart from this, the dorsal posture and the common practice of tight bandaging after confinement will favour backward displacement of the fundus. If the patient rise too soon while the uterus is still large and heavy and the uterine supports correspondingly lax and weak, the tendency to displace- ment is increased. The cause of retroflexion in nulliparse is obscure. SYMPTOMS. The following are the more important local symptoms : Local Weakness in the back, Symptoms .... < Dysmen- Symptoms of chronic pelvic peritonitis, orrhcea. Painful defalcation ; Leucorrhoea, Dysmenorrhoea, Menorrhagia ; Sterility, Abortion. In long-standing cases, there may follow the train of general constitu tional symptoms consequent on chronic uterine disease. The symptoms are arranged in three groups : the first, including those which are more or less continuous ; the second, those which are within the menstrual period, variable or periodic ; the third, those connected with the function of reproduction. The connection between the symptoms present in cases of retroflexion and the displacement itself has given rise to much discussion and difference of opinion ; and here we must emphasize what was said on page 346 that the symptoms are not due to the lesion immediately but 366 AFFECTIONS OF UTERUS. to other pathological changes consequent on or associated with it. Herman 1 would refer the symptoms in displacements entirely " to weakness and over-stretching of the muscular and ligamentous tissues which support the uterus," but we cannot thus ignore chronic metritis and endometritis and the disturbances of menstruation and repro- duction. On the other hand, in judging of the symptoms of retro- flexion we must keep before us Vedeler's 2 statistics, who found in 40 p.c. of cases of retroflexion no symptoms, and concludes that every degree of retroflexion may exist either with or without symptoms. Weakness in the back is the most common complaint. It may amount to actual pain, which is aggravated on muscular exertion and generally at the menstrual periods. The symptoms of chronic pelvic peritonitis are usually present ; the feeling of weight and discomfort in the pelvis is sometimes due to the stretching of old adhesions. The importance of pelvic inflammation, fixing the uterus in its abnormal position and pre- venting its replacement, we shall consider under treatment. Painful defalcation with tenesmus is explained by the relation of the loaded rectum to the retroflexed uterus ; irritation from pressure of the fundus against the wall of the rectum may produce straining efforts, but this is very rare. The leucorrhcea is due to chronic inflammation of the mucous mem- brane. As the result of the displacement, there is passive congestion of all the tissues of the uterus ; this leads in the first instance to a simple hypersecretion of mucus, which gradually passes into chronic inflamma- tion. The mucous secretion is more marked immediately after the increased congestion of the menstrual period ; but, gradually, it spreads itself over the intermeustrual period. Dysmenorrhcea is not so frequent a symptom here as in anteflexion ; the explanation is, on the mechanical theory, that retroflexion usually occurs in multipart where the cervical canal is patulous. Menorrhagia forms one of the more prominent symptoms ; it is due partly to the chronic inflammation of the mucous membrane, partly to obstruction to the return of the blood from the uterus. The reproductive function is variously and seriously affected. This is brought under our notice when retroflexion occurs in one who has already been pregnant, and presents an obstacle to conception or at least to the growth of a fertilised ovum in the uterus. Sometimes a patient tells us that she had a child several years ago ; that she has suffered from pain in the back, leucorrhoaa, and irregular menstruation since that time and has never conceived again. With this history, we may find retroflexion of the uterus although often it is the tubes that are at fault. The sterility may, of course, be due to a variety of causes the altered ' The Pathological Relationship of Uterine Displacements : Brit. Med. Jour., 1S8S. I., p. 1213. 2 Retroflexio Uteri : Archiv f. Gyn., Bd. XXVIII., S. 228. RETROFLEXION, 367 position of the cervix, the increased mucous secretion, obstruction of the Fallopian tubes, malposition of the ovaries. We cannot therefore be sure of curing the sterility by replacing the uterus, although we fre- quently find that the patient does conceive shortly after this treatment. After conception has taken place, there is the further risk of abortion; Abortion with a history of repeated abortion, we sometimes find retroflexion. Con-j? ^etro- ception probably often takes place in a retroflexed uterus, which after- wards may right itself so that pregnancy goes on to the full time. Abor- tion is due to the inability of the uterus thus to right itself, or to the pathological condition of the mucous membrane which prevents the ovum from becoming securely attached. When abortion does not occur and the pregnant uterus does not straighten itself so as to grow upwards into the abdomen, it enlarges without the undoing of the flexion ; in this case it will expand more and more into the hollow of the sacrum and become wedged below the promontory. This constitutes Retroflexion of the Gravid Uterus. DIAGNOSIS. On vaginal examination the cervix is felt low down in the pelvis, the cause of which has been explained under Pathology. The os looks directly downwards. A firm round body is felt in the posterior fomix, continuous with the cervix uteri but separated from it by a groove more or less distinctly marked according to the amount of flexion. Place the forefinger on the cervix, and the middle finger on this body ; on moving the former, the latter moves with it. But a fibroid tumour of the posterior wall would produce similar con- ditions; therefore make the bimanual examination. First place the vaginal fingers in the anterior fornix and make pressure with the external hand until the fingers of both hands meet ; there is nothing between them except the abdominal and vaginal walls, the fundus is therefore . not to the front. Now put the vaginal fingers into the groove behind the cervix, or, better still, lay hold of the cervix with the index finger in front of it and the middle finger in the groove behind (see fig. 212), and lift up the uterus as high in the pelvis as possible ; make pressure with the external hand until the cervix lies fairly between the hands ; the upper surface of the uterus is felt to curve backwards. In a favour- able case (with lax abdominal walls) we can do the bimanual examination on a still deeper plane, and get both, hands to meet behind or at least fairly embrace the retroflexed fundus. Having ascertained that the fundus uteri is retroflexed, we ask ourselves whether it be fixed or mov- able whether it can be replaced or not. In making our diagnosis we at the same time take a step towards treatment. To ascertain the mobility of the fundus, make steady pressure on it upwards ; observe whether it gives way before the finger, and whether, on its yielding, the flexion 368 AFFECTIONS OF UTERUS. Rectal examina- tion in Retro - flexion. Uterine Sound in Retro- flexion. becomes undone or the uterus simply rotates as a whole ; note also whether this manipulation causes pain. The rectal examination has this advantage, that the finger passes upwards over the free surface of the fundus without displacing it. It is indispensable in cases where the rigidity of the abdominal walls pre- vents our getting the uterus between the hands in the Bimanual. The drawing down of the uterus with the volsella is an additional help in such cases, as it enables the finger in the rectum to reach the fundus. The sound confirms the diagnosis in doubtful cases, and tells us further whether the retroflexed uterus is' enlarged. Before using the sound, we must palpate the uterus carefully to ascertain that it is not becoming enlarged with a growing ovum and inquire as to the patient's FIG. 212. DIAGNOSIS OF RETKOFLEXION BY BIMANUAL EXAMINATION. menstruation. We curve the sound to correspond with the degree of flexion ascertained on bimanual examination. If introduced with the concavity directed backwards, it passes into the uterine cavity without our having to make the rotation (v. fig. 86) ; through the posterior fornix, we feel the end of it in the retroflexed fundus ; it usually passes in beyond the two and a half inches. We can also learn from the sound whether the uterus can be replaced or not ; but it is better to get the information from the bimanual examination. The sound is of most use in differential diagnosis. RETROFLEXION. 369 Differential diagnosis. The following are the conditions arranged in Differential the order of frequency, which might be mistaken for retroflexion : of ifT^ 8 flexion, Fteces in the rectum ; ( Peritonitis, Pelvic deposit in the pouch of Douglas -^ Hsematocele, ( Carcinoma ; Cellulitis behind the cervix ; Myoma of the posterior wall ; Prolapsed ovary or small ovarian tumour. Fcecal matter in the rectum gives rise to difficulty only on superficial from load- examination. We should always decline to give an opinion as to the 6 ilectum> condition of the pelvic organs when the rectum is loaded. If this be attended to, no mistake in diagnosis will be made under this head. Pelvic deposit in the pouch of Douglas gives rise to more difficulty, from because it may closely simulate the condition found in retroflexion ' a body felt through the posterior fornix and moving along with the cervix.' Such a deposit will be proved not to be the fundus uteri by our finding the latter in another position. If inflammation is present, it is difficult to make the examination necessary to ascertain this ; we may not be justified in using the sound just where it would give us the desired information : such cases present great difficulty in diagnosis, and the true condition can only be ascertained on repeated examination or after the inflammation has subsided. Cellulitis behind the cervix is rarely present in such a form as to give from rise to a mistake in diagnosis, unless the inflammation renders the neces- ltls ' sary examination difficult. A myoma projecting posteriorly from the lower segment of the uterus from resembles, in form and firmness, the retroflexed fundus. On bimanual Myoma ' examination, however, we find that we have between the hands a larger body than the uterus alone. The fundus may also be felt to the front, and distinct from the tumour. To ascertain its position, it is best to make the bimanual examination with the sound in the cavity of the uterus. Fig. 204 shows the information given by the sound, if we suppose that the structure to the left of the figure is the rectum. A fibroid tumour accompanied by inflammation presents great difficulty. If the ovary be prolapsed, enlarged through inflammation, and adherent from to the posterior aspect of the uterus, it simulates (on vaginal examination) la p g " e ^ the retroflexed fundus. So also does a small ovarian tumour lying inO vai 7- the pouch of Douglas, though it is softer and more elastic than the uterus. The bimanual examination, supplemented if necessary by the 2 A 370 AFFECTIONS OF UTERUS. Possibility of cure of Retro - flexion. use of the sound and the drawing down of the uterus with the volsella, enables us to ascertain the exact position of the fundus and its relation to the tumour. PROGNOSIS. The prognosis depends upon the mobility of the uterus, and the possi- bility of replacing it. It is always less favourable where inflammation is present ; though we have seen considerable exudations become after a time absorbed, and the uterus again movable so that it could be replaced. As regards the probability of future conception, our statements should be guarded ; though the probabilities are increased if we can replace the uterus. Whether a permanent cure of the displacement (so that the uterus FIG. 213. REPOSITION CJF THE RETEOFLEXED UTERUS BY THE FINGER IN THE RECTUM. will keep its normal position after the instrument is removed) is often effected, we have not much definite information. A priori, we should not expect that the stretched utero-sacral ligaments would readily become shortened again unless a pregnancy supervene. The curability of the retroflexion depends, according to Munde, on the recency of the displacement ; " recent displacements of any variety are the only cases which offer a fair chance of complete recovery by any of the mechanical means at our disposal." The length of time during which a pessary must be worn so as to effect a cure of recent puerperal retroflexion is, according to Munde", six months to a year. RET HO FLEXION. 371 TREATMENT. This consists of two parts : 1. Replacement of the retroflexed uterus; 2. Retention of it in its normal position by suitable means. The first question which suggests itself on discovering a retroflexion is, whether we can replace the uterus ; this has been ascertained at the same time as we made the diagnosis. The two obstacles to treatment are the presence of existing inflamma- tion and the fixation of the uterus in its abnormal position. The former must be treated by blistering, hot- water injections, and the use of the glycerine plug ; these may have to be continued for a month or more, and then we may attempt the reposition. This last may be impossible through the firmness of the flexure or the presence of old adhesions. It must be left to the operator to determine how much force he is justified in employing. Sometimes it is necessary to put the patient under chloroform. In cases where we cannot replace the uterus, benefit may be derived from simply supporting it with a pessary. Schultze recommends the breaking of adhesions by recto-abdominal manipulation under an anaesthetic not aiming at forcible reposition, but purely at the loosening of the adhesions through careful bimanual stretching. Method. Bladder and rectum are empty ; dorsal posture, thighs flexed and abducted. Irrigate the rectum with warm water. "With the index and middle fingers in rectum and the external hand grasping the fundus, lift the uterus carefully up. Slight adhesions yield to pressure of fingers ; broader ones are stretched by the ends of the fingers, although repeated attempts may be necessary. A pessary introduced after reposition. He also attempts to replace adherent prolapsed ovaries in same way. Let us suppose that we are treating a case suitable for reposition, after inflammation has subsided. 1. Methods of Replacing the Retroflexed Uterus. These are the three following : (1.) By bimanual vagino-rectal manipulation; (2.) With the sound; (3.) By genupectoral posture, combined with traction on the uterus with the volsella and (if necessary) pressure on the fundus with the finger in the rectum. (1.) The bimanual manipulation is the safest method, and can be at Reposition once proceeded with as soon as we have diagnosed the pathological f ^ etr - condition ; owing however to its causing more discomfort to the patient Uterus by it is not so much used. The replacement is best effected with the index Bimanual - 372 AFFECTIONS OF UTERUS. finger in the vagina and the middle finger in the rectum. If with both fingers in the vagina we make pressure through the fornices, we simply push the uterus, as a whole, upwards. With the finger in the rectum, however, we get behind the uterus and push it forwards. Place the patient in the dorsal position; pass the fingers into the vagina and rectum, as in the accompanying diagram (fig. 213). Make steady gradual pressure on the posterior surface of the fundus with the middle FIG. 214. REPLACEMENT or THE UTERUS WITH THE SOUND. 1, 2, 3, the successive positions of the SOUND and of the UTERUS. finger. Direct the pressure to one side of the middle line, so as to keep the fundus clear of the promontory of the sacrum. With the index finger placed in front of the cervix, push it backwards and thus rotate the fundus forwards. Having by this manoeuvre brought the fundus uteri to the front (into the position indicated by the dotted line in the diagram), make with the external hand steady downward pressure so as. RETROFLEXION. 373 to get between it and the hollow of the sacrum and thus depress the fundus still more to the front. A glycerine plug is now placed in the vagina to keep the uterus in position. The plugging should be chiefly in the anterior fornix, so as to exert upward pressure on the cervix and thus favour the tilting of the fundus forwards. On the following day, if there be no indication of inflammation, a pessary may be introduced. (2.) Replacement Avith the sound has the advantage that it causes Replace- less discomfort to the patient; it is therefore the method generally thT employed. We may have the sound already in the uterus to make sure of our diagnosis, and (without withdrawing it) we can proceed at once to effect the reposition. In the employment of force we require to be more careful than in the bimanual manipulation, because the sound gives us greater leverage, pressure is being made on the mucous membrane of the uterus, and there is not the same delicate sense of resistance as when the finger is immediately in contact with the uterus. The end of the sound should not be too much curved. If the flexion be pretty acute, so that the sound requires to be well curved to pass easily into the body of the uterus, we should first reduce the acuteness of the flexion by repeatedly passing in the sound more and more straightened. Having by this means partially converted the retroflexion into a retroversion, we proceed to reposition as follows. The sound lies as in position 1 in the figure (fig. 214) : the direction of the handle is backwards, and the roughened face looks to the back; the intra-uterine portion (1) also has the curve backwards. Now lay hold of the handle loosely, rather allow- ing it to lie between the fingers than grasping it. Carry the handle upwards towards the patient's right buttock (as she is on her left side) forwards with a wide sweep and downwards again towards the couch, the shaft describing half of a cone. The sound thus comes to lie in position 2 in the figure : the direction of the handle is forwards, and the roughened face is now to the front ; the intra-uterine portion of the sound has also rotated, so that the curve is now forwards, but the uterus as a whole is still to the back (fig. 214, 2, 2). Now carry the handle of the sound gently and slowly backwards, in a straight line towards the perineum. The sound now lies in position 3 : the roughened surface is to the front, and the handle is now directed backwards ; the fundus uteri is consequently in its normal position (fig. 214, 3). The reason for this manipulation is evident. If we rotated the handle of the sound forcibly round its long axis (bringing it at once from position 1 to 3), the intra-uterine portion would describe a wide curve within the uterine body and probably produce laceration of the mucous membrane. Before withdrawing the sound we make sure by external palpation that the fundus uteri is to the front, as the latter is more easily felt when stiffened by the sound. After withdrawal of the sound, the uterus must 374 AFFECTIONS OF UTERUS. be kept in position by the glycerine plug or pessary. Frequently we find that the uterus falls back into its abnormal position as soon as the sound is withdrawn ; in such cases, the pessary should be slipped in over the handle of the sound and put in position before the latter is with- drawn. Various forms of uterine repositors have been devised by Sims and others. They might be compared to a sound having the intra-uterine portion jointed to the stem, on which it can be rotated antero-posteriorly by a suitable mechanism. They are not of such practical value as to FIG. 215. REPLACEMENT or THE UTERUS WITH THE VOLSELLA AND THE FINGER IN THE RECTUM ; the patient is in the genupectoral position. require further description here. No mechanism can equal the fingers in nicety of action. (3.) The importance of the genu-pectoral posture in replacing the retroflexed uterus has been brought forward by H. F. Campbell. On placing the patient in this posture, the abdominal contents gravitate downwards and forwards; this displacement withdraws the internal pressure from the pelvic floor, so as to subject it to the atmospheric RETROFLEXION. 375 pressure from without. If the vaginal orifice be now opened, the vaginal cavity becomes distended with air ; if the walls are lax, the cavity may be so large that the finger reaches the cervix with difficulty. The posi- tion of the uterus changes j 1 but the retroflexed uterus does not become The Retro- replaced, as Campbell supposed. It moves as a whole near the sacrum ; ? xe< * and, if already retroverted, it becomes still more so. To effect replace- in Genu- ment, we must either push the fundus forwards or draw the cervix j^^ backwards. It is best to combine these actions ; having laid hold of the cervix with the volsella per vaginam, we draw it downwards while with the index finger of the right hand, per rectum, we press the fundus towards the bladder (see fig. 215). This method of reposition is only used in cases of retroflexion of the gravid uterus. Having replaced the uterus by one of those methods, we have to retain it in its normal position. FIG. 216. HODGE PESSARY. FIG. 217. ALBERT SMITH PESSARY. FIG. 218. SIDE VIEW OF ALBERT SMITH PESSARY. The Hodge is similar, but has the lower curve less marked. 2. Methods of Retaining the Replaced Uterus. The retention of the uterus in its normal position is effected by vaginal pessaries. Of these the best forms are the Hodge or, its modification, the Albert Smith. The material of which they are made is vulcanite, which is light and Material of smooth and not affected by vaginal discharges. To bend the vulcanite, Pe the pessary should be placed in hot, almost boiling, water. It is thus made pliable and can be moulded to the desired form, but becomes firm again on placing it in cold water ; this is also effected by oiling the pessary and heating it in a spirit lamp. Pessaries are also made o 1 For full account of changes produced by the genu-pectoral posture, the student should consult the Atlas of the " Relations of the Abdominal and Pelvic Organs in the Female : Simpson and Hart, 1881. 376 AFFECTIONS OF UTERUS. gutta-percha, which has the advantage of being easily moulded ; these cannot, however, be worn for a long time, as the gutta-percha is absorbent and, retaining the secretions, sets up irritation. The patient can wear one for a few weeks till we see that it fits comfortably and is effective, and then we can substitute one of a similar form made of vulcanite. Celluloid pessaries are now sometimes used instead of vulcanite ones. The Hodge The form of the Hodge is an elongated horse-shoe, with a straight transverse bar joining the free ends. Seen from the front (fig. 216), it has a curved upper end which is adapted to the posterior fornix ; the lower end consists of a straight bar which serves to keep the sides apart, FIG. 219. INTRODUCTION OF PESSARY, FIRST STAGE. and lies under cover of the symphysis pubis ; the external angles of this end are rounded to prevent their cutting the vagina; the sides run almost parallel. Seen from the side (fig. 218), it is a mould of the vaginal slit; there is an upper sacral curve, which is long and well- marked ; there is a lower pubic one, which is not necessarily present or The Albert is only slightly marked. The pessary lies so that the concavity of the sacral curve looks forward, that is to say, the upper end of the pessary RETROFLEXION. 377 (like the posterior fornix vagiuse) curves forwards. The Albert Smith (fig. 217) contracts in its lower half to a more or less beak-shaped end ; seen from the side, it has the pubic curve more marked (fig. 218). Scientifically it is the more correct form, because the posterior wall of the vagina is narrower below than it is above. The lower end should not be too much contracted, otherwise it is apt to interfere with married life ; also when the vaginal orifice is wide, it favours the expulsion of the instrument. A second modification of the Hodge is recommended by Thomas, in which the upper bar is thicker, the sacral curve more pronounced, and the whole instrument longer. The choice of an instrument suitable to the case must be made. The Choice of Hodge Pessary. FIG. 220. SECOND STAGE : PESSARY CARRIED ON BY FINGER. pessary should be narrower and shorter than the posterior vaginal wall, so that it produces no tension when it is in position. The upper bar should be of such a size that it can be passed in easily; the lower should be narrower than the uppei-, but not too narrow for the reasons given above. The proof of a good fitting instrument is that the patient does not feel its presence, nor should it interfere with married life. The mode of introduction of the pessary demands special attention. It is important that this apparently simple manoeuvre be effected without ^on of causing pain to the patient. From the fact that the vulvar orifice isp e ssary. 378 AFFECTIONS OF UTERUS. antero-posterior while the cavity of the vagina is transverse, the instru- ment must be introduced with its plane surface horizontal (the patient is supposed to be on the side) and afterwards rotated so that this comes to be vertical. From the position of the cervix, the instrument is very liable to run into the anterior fornix. When in position the upper end must curve forwards. Having oiled the instrument, grasp it with the lower end (the square end in the case of the Hodge, the narrower end in the case of the Albert Smith) between the finger and thumb of the right hand. Separate the labia with the first and second fingers of the left hand ; when the vaginal orifice is narrow, hook back the fourchette with one finger or get the posterior corner of the end which is being intro- duced within the vaginal orifice ; and press back the perineum with it so FIG. 221. PESSARY in situ IN THE VAGINA, ad naturam. a perineum, bb pessary, c anterior and d posterior vaginal wall, e anterior and /posterior lip of cervix. that the anterior corner is not pushed against the clitoris or vestibule. Now push the pessary backwards in the axis of the vagina till it is half within the cavity (see fig. 219), and rotate it so that the concavity of the sacral curve looks forwards. Pass the index finger behind the instru- ment into the vagina, and place the tip of it against the upper bar ; carry the pessary onwards, keeping the upper bar well against the posterior vaginal wall to prevent its slipping up in front of the cervix (fig. 220). Hodge 6 The position and action of the pessary when in situ are as follows. Pessary It lies exactly adapted to the vaginal walls (see fig. 221); the upper in situ. end being in the posterior fornix behind the cervix, the lower just within RETROFLEXION. 379 the vaginal orifice. It is kept in position through its resting on the oblique anterior face of the sacral segment of the pelvic floor, against which it is compressed by the posterior face of the pubic segment. The student will readily understand and remember the position of the pessary in the following way. Hold the hand inclined as in fig. 222, with the palm slightly inflexed. It resembles the posterior vaginal in the following points : (1) It is broader above than below ; (2) it curves forwards above ; (3) from its obliquity, it allows the pessary to sit on it. Now place the pessary on it. It will only lie adapted to the hand when the broad end is above and the upper curve is directed forwards. The Hodge pessary does not act as a lever; that is to say, the intra- Action of abdominal pressure does not act specially on the lower bar and depress ^ FIG. 222. HAND HOLDING ALBERT SMITH PESSARY. it, causing the superior one to rise. The intra-abdominal pressure acts nearly equally on both bars, of which fact the student may satisfy him- self clinically. Its action is that the upper bar gives a point d'appui to the posterior fornix. The posterior vaginal wall runs round the upper bar as on a pulley, and, as it is inserted into the cervix, the latter is thereby drawn upwards and the fundus thrown forwards (fig. 223). The pessary, therefore, has the same action as the utero-sacral ligaments, if we suppose that these keep the cervix backwards. This is only the action in the case of a retroverted uterus which has been replaced. A vaginal pessary, however, gives relief even though we may not be able to replace the uterus. In this case we may suppose that it acts by 380 AFFECTIONS OF UTERUS. supporting the uterus as a whole, thus diminishing tension on the liga- ments and passive congestion. 1 Another way of showing how the Hodge pessary acts is as follows. With the patient lying on her left side, pass the index finger into the posterior fornix vaginae and push it up in a direction parallel to the posterior vaginal wall. This necessarily pulls the cervix back, and thus the fundus is kept forward. In other words, if the cervix be thus kept back by the tension of the finger in the posterior fornix, the uterus cannot become retroverted although the fundus may become retroflexed. FIG. 223. POSITION AND ACTION OF PESSARY. Now if a Hodge pessary be passed into position and held by the hand, it will act just as the finger does. It does not require to be held, how- ever, as it rests on the oblique sacral segment and is pressed against it by the pubic segment and abdominal viscera. Note that the pressure 1 See Granville Bantock on The Use ami Abuse of Pessaries, London, 1884 ; Hart on The Structural Anatomy of the Female Pelric Floor. RETROFLEXION. 381 on the Hodge is at right angles to the posterior vaginal wall ; there is no side to side pressure on the instrument, and thus it does not require to extend from side to side of the vaginal walls. The after-watching of the case is important. The patient should be instructed to return in two days to see that the instrument is in place, and to return at once if it causes pain. After this she should report herself occasionally, say at intervals of a month, when examination is made to ascertain that the uterus keeps its place. If she uses hot-water injections occasionally, it is not necessary to remove the instrument to clean it more frequently than this. After the pessary has been worn for some months, it may be removed to see if the uterus remains in position without it. Sometimes we find that the uterus falls back again into its abnormal position as soon as the instrument is withdrawn ; in such a case, it must be introduced again and may have to be worn for years. FIG. 224. FIG. 225. SCHULTZE'S PESSARY. MEADOW'S COMPOUND STEM PESSARY. Should conception occur, the pessary may be worn till the fourth month, after which the uterus rises above the brim and there is no longer reason to fear displacement. In Germany, Schultze's pessary (fig. 224) is the one in general use. ItSchultze's has the form of a figure of eight, the upper ring embracing the cervix. Pessar y < It is interesting to note that it also goes on the principle that the pessary acts on the cervix, not the body of the uterus. In some cases the uterine tissue is flaccid at the angle of flexion, and the body falls to the back or front as if it were jointed to the cervix. Here the Hodge, which acts on the body through the cervix, does no good ; the intra-uterine stem, along with a Hodge which has transverse bars, is suitable for some of these cases. Wynn Williams, Meadows(fig. 225) and Routh have devised good forms of pessary on this principle. 382 AFFECTIONS OF UTERUS. Their use has recently been again advocated by Routh, l but the general opinion of gynecologists in this country is against intra-uterine stem pessaries. Hodge's From what has been said on the action of the Hodge pessary, it is KooTonlv ev ident that in the treatment of Retroversion + Retroflexion the version in Retro- alone is affected by the pessary. Whether the flexion is remedied will depend on the state of the uterine walls and the effect of intra-abdominal pressure upon them. For illustrative examples showing the value of pessaries in suitable cases, the student may consult Bantock's monograph, or Macan's trans- lation of Schultze. Operations for Retaining the Uterus in position. In many cases pessaries fail to keep the uterus in position, and ingenuity has of late been exercised in devising operative measures for this. These must be held as sub judice, for two reasons : We cannot a priori affirm that the symptoms were due to the displacement ; and the cases have not been followed for a sufficient number of years to judge from their results alone that such operations are called for. Three methods of acting on the uterus have been tried : (a) Through the vagina, by causing cicatrisation to pull on the cervix ; (6) through the round liga- ments, by shortening them and then pulling the uterus forwards ; (c) through peritoneal adhesions, by tacking the fundus to the anterior abdominal until it becomes fixed there. Under the first of these methods, we have to notice an operation by von Rabenau. In cases where a pessary cannot be borne or where it will not keep the uterus to the front, he amputates the anterior lip high up, and says that the resulting contraction causes the uterus gradually to become anteflexed. Six cases treated thus are reported on, " but they were not observed over a long enough period to pronounce on the ultimate result. The second method is known in this country as the Alexander-Adams operation. It will be described under Prolapsus Uteri, as it is used for the treatment of prolapse as well as retro version. The third method has been tried by various operators Koeberle (1877), Olshausen (1879), Lawson Tait and Heywood Smith (1880), and Kelly (1885). After Olshausen 1 called attention specially to the operation by reporting on two cases, we find Klotz 4 recording seventeen, Sanger 5 seven, Lee 6 six, and Leopold 7 nine. Different methods of attaching the uterus to the abdominal wall have been tried : fixing one or both pedicles (after removal of the uterine appendages) into the abdominal incision ; stitching the round ligaments to the abdominal wall ; or Leopold's method (probably the best) of carrying three of the sutures, used to close the abdominal incision, also through the upper anterior aspect of the fundus (the surface of the fundus to be apposed to the wall was scraped so as to ensure better adhesion, but Leopold is not sure that this is necessary). The cases in 1 On the various modes of treatment of the worst cases of uterine flexions : Brit. Gyn. Trans. 1SSS, p. 229. 2 Ueber eine neue operative Behandlung der Retroflexio Uteri : Centralb. f. Gyn. 1886, p. 429. 3 Ueber ventrale Operation bei Prolapsus and Retroversio Uteri : Centralb. f. Gyn. 1886, p. 698. Centralb. f. Gyn. 1888, S. 11. 6 Ueber operative Behandlung der Retroversio-flexio Uteri :. Centralb. f. Gyn. 1888, S. 17. 8 The value of Hysterectomy in the Treatment of Retroflexions of the Womb : Americ. Journ Obttet. 1888, p. 1249. 7 Saminlung klinitcher Vortriige, No. 333. RETROFLEXION. 383 which this operation has been done are (1) when the appendages are being removed at any rate, and the uterus is found retroflexed ; (2) when ovarian or fibroid tumours which have produced permanent retroflexion are being removed ; (3) when there is retroflexion alone, causing serious symptoms and incurable otherwise through adhesions. The greatest difficulty is in the separation of adhesions especially when they are tough and numerous and implicate the bladder and ureters or rectum. The results in Leopold's cases as to rel : .ef of symptoms were satisfactory, but it is evident that the scope for such an opera- tion must be very restricted. Apart from stitching the uterus to the wall, some have tried, after they have done laparatomy for releasing the retroflexed uterus from adhesions, to keep it to the front by means of the glass drainage tube passed into the pouch of Douglas and the consequent adhesions set up along the tract of the tube. Polk records four cases in which he did this ; and Klotz used the tube in addition to fixing the pedicles of the uterine appendages in the abdominal incision. Another method of producing adhesions anterior to the uterus has been tried by Schiicking, 2 who passes a curved guarded needle into the uterine cavity like a sound ; the point is then extruded so as to go through the anterior wall, the utero-vesical peritoneum and the anterior fornix of the vagina. The thread carried through is knotted and left for ten to fourteen days, and by its irritation sets up adhesions in the utero-vesicle pouch. In eleven out of twelve cases of retroflexion treated thus, a permanent anteflexion was produced. 1 Laparotomy for Adherent Retroflexed or Ketroverted Uterus : Americ. Journ. Obstet. 1887, p. 630. - Die vaginale Ligature des Uterus und ihre Anwendung bei Retroflexio und Prolapsus uteri : Centralb.f. Gyn. 18S8, S. 682. CHAPTER XXXIV. INVERSION OF UTERUS. LITERATURE. Atthill Inversion of uterus due to fibroid tumour : Dublin Medical Journal, Feb. 1879. Aveling On Inversion of the Uterus : Brit. Med. Journ. 1886, I., p. 475. Barnes Diseases of Women : London 1878, p. 721. Med. Chir. Trans, 1869. CrosseAn Essay, literary and practical, on Inversio Uteri : Trans. Provincial Med. and Sur. Assoc., London 1845. Duncan, Matthews On the Production of inverted Uterus : Edin. Med. Jour., May 1867. Emmet Principles and Practice of Gynaecology : Churchill, London, 1884, p. 406. f'ritsch Die Lageveranderungen der Gebar- mutter : Billroth's Handbuch fiir Frauenkrankheiten : Stuttgart 1881. M'Clin- tock Diseases of Women : Dublin 1863, p. 76. Macdonald Two cases of chronic inversion of the uterus : Edin. Obst. Trans. Vol. VI., p. 170. Spiegelberg Zu den Inversionen der Gebarmutter : Archiv f. Gyn., B. IV. S. 350, and B. V. S. 118. Thomas Diseases of Women, p. 453, Philadelphia 1880. Werth Ueber partielle Inversion des Uterus durch Geschwiilste : Archiv f. Gyn., Bd. XXII. S. 65. See also Index of Recent Gynecological Literature in the Appendix. The essay by Crosse gives the fullest anatomical description of inversion, and contains a series of lithographic plates of specimens. PATHOLOGY. IN inversion the uterus is turned inside out, so as to form a polypoidal projection into the vagina ; its peritoneal surface is converted into a cup-shaped hollow ; its mucous membrane becomes everted so as to lie exposed on all sides in the cervix and vagina. The mechanism by which this condition is brought about is the following. 1. A portion of the muscular wall of the uterus Jiaving lost its tone, becomes depressed towards the uterine cavity. In the puerperal condi- tion this is usually that portion of the wall to which the placenta has been attached, and the condition has been described by Rokitansky as " paralysis of the placental seat;" this partial inversion will be frequently found on abdominal palpation in cases of post-partum haemorrhage (Fritsch). In cases of tumour-growth, fatty degeneration (Scanzoni) or malignant infiltration (A. R. Simpson) weakens the wall of the uterus round the base of the polypoidal growth, and thus produces an analogous condition. 2. Muscular contractions of the non-depressed portion of the uterus, combined with intra-abdominal pressure, carry the depressed portion further into the uterine cavity, until the fund us reaches the os INVERSION. 385 internum (fig. 234). In the puerperal condition, muscular contrac- tions occur spontaneously, or are produced by the presence of the placenta ; in the case of a polypoidal tumour, they are due to the pre- sence of the foreign body. Traction from beloio, such as the pulling away of the placenta or the tension of the pedicle of a polypus which is being extruded, also produces inversion. 3. The fundus of the uterus, by continuation of the same process, dilates the cervical canal and is "born" into the vagina (fig. 231). In some cases inversion seems to take place from below upwards with a mechanism similar to that of prolapsus uteri, the lower part of the body of the uterus becomes inverted into the cervical canal (Taylor). Matthews Duncan, whose paper was a valuable contribution towards Varieties establishing the correct theory of inversion, distinguishes between active g ion nver ' and passive inversion. The active is that described above ; the passive is produced by inertia of the whole uterus, in which the organ is driven FIG. 226. INVERSION OF UTERUS (half-size, Barnes from Crosse's essay). The fundus lies in the vagina ; the cervix is not inverted ; the lips are flattened out to a swelling seen below the angle of inversion. The ovaries (seen from behind) are not in the peritoneal cup. down entirely by intra-abdominal pressure or by traction from below and not by uterine contractions. It is evident that the process may become arrested at any of these stages and persist as a permanent condition. When it has persisted for a few weeks, it constitutes "chronic inversion;" this is found in the following forms. (1.) Inversion of one horn only is a rare occurrence. Slight inversion of the uterine wall, at the base of a polypoidal fibroid, has been more frequently observed. (2.) Partial inversion, when the fundus has descended as far as the os internum, is also found as a chronic condition. (3.) Complete inversion is the condition most frequently met with. An exact knowledge of the relation of parts in complete inversion is Anatomy necessary for diagnosis and treatment. This can only be gained byi on nv( 2s 386 AFFECTIONS OF UTERUS. studying the inverted uterus as seen in section (fig. 226). We must study the position of The body of the uterus, The cervix uteri, The Fallopian tubes and ovaries, The peritoneum, The bladder. V SmF.. u FIG. 227. INVERSION OF UTERUS+INVERSION OF VAGINA, occasioned by a small sub-mucous fibroid (Af l Clintock). Sm F, sub-mucous fibroid ; U uterus, V vagina, B bladder. The body of the uterus. The inversion extends, in simple uncompli- cated cases, as far as the os internum but no further. The uterus lies partly in the vagina, partly in the cervical canal. Its neck is embraced by the os externum, which may lie loosely on it (favouring haemorrhage) or constrict it firmly (favouring gangrene). After involu- tion takes place, it becomes small, rounded and of [firm consistence, INVERSION. 387 closely resembling a pediculated fibroid tumour ; and it has been amputated by mistake for such. It has a rounded form, is of a softer consistence and deeper red colour than a pediculated fibroid, and has a smooth and slippery surface which bleeds freely when handled. The softness may be so marked that the uterus moulds itself to the vaginal cavity and, becoming flattened against the posterior vaginal wall, takes on a mushroom-like form (FreuncE). The mucous membrane of the uterus may undergo all the changes of any tumour with a constricted base and exposed surface. It is usually congested and bleeds easily ; it may become ulcerated and even gan- grenous, or may be hypertrophied with polypoidal formations ; it may lose its single layer of cubical epithelium and develop a stratified squamous epithelium. The occurrence of these changes has an impor- tant bearing on the necessity of replacing the organ. The cervix uteri. This is rarely 1 displaced in simple uncomplicated inversion ; it forms a broad ring embracing the neck of the tumour. Sometimes the inversion is complicated with prolapsus, or, more pro- perly, the vagina also becomes inverted and the inverted uterus caps the inverted vagina (fig. 227). When this occurs, the cervix uteri is also more or less inverted ; a part remains just above the os externum, as a depressed ring which also disappears on making traction on the uterus (Fritscli). The Fallopian tubes and ovaries, with some coils of small intestine, may (at first) lie within the inverted cup, which is lined with peri- toneum; afterwards, they retract out of it. In long-standing cases, the rim of the peritoneal cup is contracted by the muscular fibre of the cervix so as scarcely to admit a finger (fig. 228). In a case of six months' standing, in which A. R. Simpson performed Thomas' operation before having recourse to amputation, the contracted ring just admitted the finger ; an ovary was caught within it. Adhesions rarely form between the peritoneal mrfaces ; this is an interesting fact and is of importance in regard to replacement. We might have expected detachment of the peritoneal lining or tearing of it by the sudden dislocation; the previous stretching of it during pregnancy is perhaps the reason why this has not been noticed. Fritsch says that the lifting up of the fornices by the tumour in the vagina, diminishes the strain on the peritoneum. The bladder, from its relation to the cervix (v. Chap. IV.), is not altered in position unless there is prolapsus. When the latter occurs, there is cystocele (v. fig. 227). We may therefore contrast the two types of inversion as follows. Inversion of uterus cervix and bladder normal in position. 1 Crosse figures one preparation in which the cervix as well as the body of the uterus was inverted although there was no prolapsus. 388 AFFECTIONS OF UTERUS. Inversion of uterus + prolapsus (i.e., inversion of vagina) cervix inverted and cystocele. ETIOLOGY AND FREQUENCY. Inversion arises under two different conditions : 1. In the puerperium puerperal inversion ; 2. Secondary to intra-uterine tumours growing from the fundus. Inversion has also occurred independent of the puerperal condition and of tumour growth ; this is quite exceptional. Etiology of l. Puerperal inversion. This is by fat the most frequent form ; out Inversion, of 400 cases, 350 occurred in the puerperal uterus (Crosse). FIG. 228. INVERSION OF UTERUS (Crosse). The inverted uterus (U) lying in the vagina (V) is cut open to show the peritoneal sac which does not contain the ovaries (0) ; bristles are passed into uterine orifices of tubes, b Broad and r round ligaments ; T tube. Its former frequency was due to improper management of the third stage of labour. When the uterus was flabby and not contracting and the placenta not coming away, the removal of the latter by traction on the cord drew down the part of the wall to which it was attached and thus inverted the uterus. This accident was favoured by the situation of the placenta over the fundus (He/twig). Since the removal of the placenta by compression (which is best done by the Crede method with the thumbs of both hands well down behind the fundus so that the INVERSION. 389 uterus may be firmly compressed antero-posteriorly) has been adopted, this accident has become rarer. A dilated condition of the uterus (distention by blood clots) or a flaccid condition of the walls favours inversion. 2. Inversion secondary to uterine tumours is much rarer. Of 400 cases, Etiology of only forty (ten per cent.) arose in this way (Crosse). It has been d g 6 ^ 1011 observed with pediculated fibromata (fig. 227), 1 and will be referred to Tumours - again when we treat of them (v. Chap. XXXVIIL). Brewis 2 has recorded a case of its occurring spontaneously in a uterus from which a polypus had been previously discharged. It is frequent in sarcoma (v. Chap. XLIIL), but very rare in carcinoma uteri. Tait 3 found it with villous epithelioma, and Barnes describes a specimen in which both conditions were present, but does not say which was the primary lesion. SYMPTOMS. The symptoms produced by inversion at the time of its occurrence, concern the obstetrician rather than the gynecologist. There is the feeling of something giving way in the pelvis, accompanied with pain, haemorrhage, and sometimes collapse. With complete inversion, there is retention of urine ; it often occurs, or at least becomes so marked as to attract the patient's notice, when she has made a straining effort. The cases where the patient says that it first came down several days after labour, are to be explained by supposing that partial inversion occurred after labour but only the final stage attracted attention. If the uterus be not replaced at the time, the case becomes one of chronic inversion. The symptoms of chronic inversion are Haemorrhage, Pain in the pelvis of a bearing-down character, Anaemia and weakness. Hcemorrhage is the most dangerous symptom. The menstruation is always profuse, as may be easily understood from the fact that the mucous membrane is extended in its area and lies exposed in the cervical canal and vagina. There are also inter-menstrual haemorrhage, which comes on unprovoked or on straining. The bearing-down pain in the pelvis resembles that felt in prolapsus uteri. It varies indefinitely in intensity ; sometimes it is very acute, rarely is it so slight that the patient becomes reconciled to her dis- comfort and is able for work. The ancemia and weakness may be so marked as to cause suspicion of malignant disease. 1 Lee records two cases of its occurrence with fibroid tumours Amer. Journ. Obstet. 1888, p. 616. 2 Edin. Mai. Journ. July, 1887. 3 Brit. Med. Journ. 188", I. p. 66. 390 AFFECTIONS OF UTERUS. DIAGNOSIS. Diagnosis The diagnosis of recent inversion is easy. If the placenta has not yet Inversion, been born, the hands laid on the fundus to expel it by the Crede method find that the rounded fundus is replaced by a cup-shaped hollow. The cervix is sometimes lifted up by the inverted uterus, so as to be " high above the pubes, even near the umbilicus " (Crosse). On passing the hand into the vagina to remove the placenta, care is required to recognise what is placenta and what is inverted uterus, and not to increase the inversion in detaching the placenta. If the placenta is already expelled, the hand on the abdomen recognises the same condi- FIG. 229. INVERTED UTERUS DRAWN DOWN BY TAPE-NOOSE ; c 6 line of incision in cervix in Barnes' operation (Barnes). tion ; while a large soft body, varying in size according to the extent of the inversion, fills the vagina. Diagnosis Chronic Inversion. Before the Sound and the Bimanual came to the Aversion. gynecologist's aid in diagnosis, it was impossible to diagnose this condi- tion with certainty. Mistakes were committed by the most eminent surgeons, just because they had not the means of examination which we now possess. Even nowadays mistakes occur through the hasty making of a diagnosis before all the means of examination have been employed. We therefore describe fully the routine examination. INVERSION. 391 1. Pass the fingers into the vagina; a rounded and firm or flattened and soft tumour, which bleeds easily, is felt in the vaginal cavity. Sweep the fingers round it, and recognise that it is free on all sides except at its iipper extremity. Round this extremity is felt the cervix, the lips and fornices being recognised ; or the cervix is thinned out to a ring and the fornices obliterated. If the cervical canal be obliterated by adhesions, the finger will not pass farther up ; if it be patulous, it will pass for one-and-a-half to two inches and find that the cervical mucous membrane is reflected equally all round on to the neck of the tumour. 2. With one finger in front of the tumour and the other behind it, lift it up towards the abdominal wall which is depressed with the external hand till the fingers in the vagina are in contact with it. The FIG. 230. UTERINE POLYPUS (after Thomas). The uterus in its normal position. Sound passes into uterine cavity. FIG. 231. INVERSION OF UTERUS (after Thomas). A cup-shaped de- pression is in the place of the uterus. Sound arrested at angle of flexion. FIG. 232. UTERINE POLYPUS. Adhesions round pedicle obliterate cervical canal. external hand feels, in the place of the fundus uteri, a truncated body with a depression in the centre (see fig. 231). 3. Now pass one finger into the rectum, which first comes on the body in the vagina : drag this body downwards with the noose repre- sented at fig. 229, as the volsella causes haemorrhage ; the finger in the rectum, reaching the upper border of the body, can thus feel that it ends abruptly and can pass into the cup-shaped end. Now depress the abdominal walls till they reach the finger in the rectum, or pass a sound into the bladder and direct the point of it backwards till it can be touched by the rectal finger. 4. The sound may be used to probe round the neck of the body where 392 AFFECTIONS OF UTERUS. there is not space for the finger to pass upwards. It is most useful, however, in differential diagnosis. Differential DIFFERENTIAL DIAGNOSIS. Inversion must be differentiated from the Diagnosis ,, . .. . following conditions : 1. Polypus in the vagina, simple or with adherent pedicle; 2. Intra-uterine polypus ; 3. Uterine polypus with partial inversion ; 4. Prolapsus uteri ; 5. Inversion and prolapsus. 1. In a uterine polypus which lies in the vagina, the fundus will be found to lie somewhere else than in the vagina ; it may be retroverted and thus escape recognition in the Bimanual ; the rectal examination will then discover it. Having found what we suppose to be the fundus, pass the sound along the side of the pedicle ; if it is in the uterus, the FIG. 233. POLYPUS STILL INTRA-UTERINE (after Thomas'). FIG. 234. PARTIAL INVERSION OF UTERUS (after Thomas). sound passes more than 1\ inches ; if it passes 2~ inches or less, suspect that partial inversion complicates the polypus. When there are adhesions round the pedicle obliterating the cervical canal, a careful Bimanual will reveal the fundus in its normal position and justify us in breaking down the adhesions with the sound so as to effect a passage into the uterine canal (fig. 232). 2. In a uterine polypus which is still intra-uterine the differential diagnosis is more difficult. A case has been recorded in which inversion of one horn of the uterus was diagnosed and amputated as a polypus. A careful examination per rectum under chloroform might detect the cup-shaped depression found in partial inversion ; the uterine cavity is always enlarged when a polypus is present (fig. 233 and fig. 234). 3. Having satisfied ourselves that there is a polypus, the possibility of there being partial inversion of the uterus at its attachment must be INVERSION. 393 kept in view (fig. 235). A careful rectal examination might reveal a depression on the peritoneal aspect of the uterus. The greater sensitive- ness of the uterine mucous membrane also helps us ; thus if we apply the ecraseur without chloroform which is not necessary to remove the polypus and the patient has great pain on our tightening up the wire, we may suspect that the loop has embraced the wall of the uterus. * 4. Uncomplicated prolapsus uteri would only on a very superficial examination be mistaken for inversion. The obliteration of the fornices, the presence of the os externum at the end of the protruded tumour, and that of the uterus within it as demonstrated by the sound and examination per rectum show that it is a case of prolapsus. If, how- ever, the prolapsus be due to a fibroid tumour of the cervix and the os externum be closed by adhesions or distorted, diagnosis is more difficult (v. Uterine Polypi). FIG. 235. UTERINE POLYPUS + PARTIAL INVERSION. 5. Prolapsus + inversion is a rare condition. The specimen repre- sented at fig. 227 is quite unique ; the apex of the tumour protruding through the vulva consists of a submucous fibroid, the inverted uterus constitutes the next portion, while the base is formed by the inverted vagina. COURSE AND RESULTS OF CHRONIC INVERSION. Spontaneous reinversion and cure has been observed, according to Spontane- Thomas, in twelve cases. 2 From the rarity of its occurrence, it is to be version" 1 1 Faucon noted this in one case even though the patient was under an anaesthetic ; the inversion was partial and only of one horn, and could not be recognised before the operation Sur une form particuliere d'Inversion polypeuse de 1'uterus, etc. Archiv. de Toe., 1887, p. 1042. = A recent case is recorded by Kemarski-Cen?-aZ6./. Gyn., 1889, S. 287. 394 AFFECTIONS OF UTERUS. regarded as a gynecological curiosity rather than a natural termination ; the mechanism of its production is not yet known. Toleration of the condition is also rare, though cases are reported in which the uterus has become reconciled to its new position and sur- roundings and the patient has recovered perfect health. The greater proportion of unrelieved cases end fatally through anaemia, haemorrhage, septicaemia, or peritonitis. PROGNOSIS. As to the hope of reduction of sixty-six cases collected by Mac- donald, forty-four were successful. TREATMENT. Historical. The reposition of the inverted uterus is one of the gynecological triumphs of the last five and twenty years. Up to 1856 when Tyler Smith effected reposition by gradual compression with an air pessary, the only hope of cure was by amputation with the many risks attendant on that operation. About the same time White of Buffalo (1858) independently succeeded in replacing an inversion by pressure with the hand. After these a number of successful cases are recorded, among which the most noteworthy is one of Noeggerath who replaced an inver- sion of thirteen years' duration. Various methods of reduction have been recommended by Tyler Smith, White, Emmet, Courty, Noeggerath, Thomas, Matthews Duncan, Barnes, Braxton Hicks, and Tate. It would take too much space to describe each method in detail ; the references will enable the student to consult the original articles. The treatment of inversion is best considered as follows : A. Reposition (a) with the hand alone or aided by instruments, (V) by continuous slight elastic pressure ; B. Amputation. A. Reposition. The obstacle to reposition is the resistance of the tissue of the lower segment of the uterus ; the principle of treatment is to overcome this by steady pressure. Suppose that we have a case of inversion, how are we to proceed ? The patient is kept perfectly at rest for a few days ; injections of very warm water are employed twice or thrice daily ; nutritious diet is given, and iron is usually required for anaemia. Ergot is required if there is menorrhagia ; should it not be the menstrual period, the best thing to check haemorrhage is injection of very hot water. Having thus prepared the patient we proceed to reposition. Are we to employ the more rapid manual method or the slower one with an INVERSION. 395 instrument ? If the patient does not object to an operation under chloro- form and if we can have assistants to take turns with us in keeping up manual pressure, the former method should certainly be tried first. (a.) deposition ivith the hand alone or aided by instruments. For a Reposition few days previously, the largest size Barnes bag which the patient can bear is placed in the vagina and distended ; this makes space for the operator's hand, and may itself effect the reposition. 1 The patient, under chloroform, is placed in the lithotomy position ; pass the right hand into the vagina, and grasp the uterus with the fingers as far into the angle of reflexion as possible (fig. 236). Now press the uterus steadily upwards FIG. 236. REPOSITION OF THE INVERTED UTERUS WITH THE HAND ALONE (after Emmet). against the left hand on the abdomen. The fingers maybe separated as far as possible so as to open out the cervix. 2 Sometimes the process of re-inversion is started by dimpling inwards Noegger- one horn of the uterus, and then forcing the depressed horn onwards as ra a wedge to open up the ring of the cervix. 3 As the hand cannot keep White, up steady pressure for any length of time, a cup is set on a curved iron rod with a spiral spring 4 to make the pressure equal. A curved wooden Atthill. 1 Kroner has collected six cases of inversion (longest of eleven years standing) replaced by this means ; the pressure was applied for periods varying from one to eleven days. Archiv f. Gyn., B. xiv., S. 270. 2 Emmet Op. cit. p. 418. It is very doubtful whether the constricting cervix has anything to do with preventing reposition, though upward and outward pressure round the neck favours it. 3 Noeggerath Am. Med. Times, 18(52, vol. iv. pp. 230, 235. 1 White Intern. Med. Cong. Trans., Philadelphia, 1876. Byrne New York Med. Journ., Oct. 187S. 396 AFFECTIONS OF UTERUS. rod, with a large cup at one end and a small one at the other, has also been used to keep up pressure. x The end of the instrument is pressed against the operator's chest, and the cup is steadied with the hand in the vagina. It is evident that these instruments require a roomier vagina than when the hand alone is used ; and if the cup slips unexpectedly it may rupture the fornix. Counter-pressure is made over the abdomen with the hand, or if the abdominal walls are thin and there is a distinct Thomas, cup on the peritoneal aspect, with a cone of wood, 2 which is used to dis- Schroeder. tend the ring of the cervix ; the traction can be taken off the vaginal walls by fixing the cervix with volsellse. 3 Counter-pressure may be made Courty. per rectum in the following way : Pass index and middle fingers of right hand into rectum, draw down the uterus with the left hand or the noose Tate. FIG. 237. WHITE'S REPOSITOR, WITH ELASTIC SPRING PLACED AGAINST THE OPERATOR'S CHEST. While the right steadies cup and uterus, counter-pressure is made with the left hand or better by an assistant (Thomas). (fig. 229) until these fingers get fairly above the cervix so as to press on the margins of the peritoneal depression ; grasp uterus now with left hand, turning it so that the fundus is towards the symphysis and the cervix towards the sacrum ; finally, make pressure with the index and thumb in the angle of reflexion against the two fingers in the rectum. 4 The urethra has also been dilated so as to allow one finger to press on the anterior rim of the depression, while the rectal finger presses on the posterior. 5 To weaken the resistance of the cervix, lateral incisions have been made into its substance (Barnes, see fig. 229). 1 Atthill Loc. cit. Braxton Hicks Brit. Med. Journ., Aug. 1872. 2 Thomas Op. cit. p. 408. 3 Schroeder Op. cit., S. 203. Atthill Inc. cit. * Courty Maladies de I'uterus, 1866. 6 Tate Cincinnati Lancet and Observer, March 1871. INVERSION. 397 This manual pressure is, with the help of assistants, to be kept up .FIG. 238. TATE'S METHOD OF MAKING COUNTER-PRESSURE WITH FINGERS IN BLADDER AND RECTUM (Mundi) FIG. 239. EMMET'S METHOD OF RETAINING THE PARTIALLY RE-INVERTKD FUNDUS BY CLOSING THE os EXTERNUM WITH SUTURES ; the traction, produced in the direction of the arrows, favours re-inversion (Emriiet). from half-aii-hour to two hours according to the condition of the patient. 398 AFFECTIONS OF UTERUS. If not successful in this time, the patient is kept in bed and under the influence of opium while a Barnes bag is placed in the vagina to main- tain the uterus as far as it has been replaced. When the uterus has Emmet, been so far reinverted that the fundus is above the level of the os externum, the lips of the latter may be drawn together with wire sutures (fig. 239). 1 Abdominal Abdominal section, so as to allow the operator to get at the con- fOT^nver- Dieting rim of the cup from its peritoneal side and dilate it with ex- sion. panding forceps, has been proposed by Thomas. It was successful in the first case ; a second proved fatal from peritonitis. It has been tried un- successfully by A. R. Simpson, while Malins, " and more recently Munde, 3 succeeded so far in dilating the ring, but failed in pulling up the uterus by the ingenious method of passing a thread through the fundus ; Schmalfuss 4 has recently recorded a successful case. Brown 5 suc- ceeded in dilating the ring by getting at it per vaginam through an incision in the inverted fundus ; a dilator was introduced and the rim expanded : the incision in the uterus was stitched before the inverted fundus was pushed up. Reposition (&) Reposition by continuous slight elastic pressure. If manual repo- by Elastic gj^jon has failed, we try the more gradual method ; in some cases we employ it from the first. Gradual pressure may be produced by an india-rubber bag placed in the vagina and distended Avith water from a douche-can so that hydrostatic pressure is brought to bear. fi Thiry 7 has devised an ingenious bag consisting of a double-walled india-rubber cap- sule, which is slipped over the uterus ; when distended with air, it com- presses and pushes up the inverted fundus. Pressure by an inflated bag is not so efficient as that produced by a wooden cup set on a stem 8 with a vaginal (or, better still, a vaginal and permeal) 9 curve so that the pressure is made in the axis of the brim. Pressure may also be made by the four elastic bands which pass, two in front and two behind, to a broad abdominal bandage ; by the tightening of the front or the back bands, the direction of pressure is altered. In this method there are two points which require careful attention. (1.) The elastic pressure must always act in the line of the axis of the inverted uterus, and likewise of the axis of the pelvic brim ; the cup is apt to slip off the uterus, and the handle of the instrument to alter its direction. Pressure in a wrong direction is injurious, and may produce sloughing. To prevent these accidents we pad, with wadding soaked in Emmet Op. cit., p. 430. * Lancet, 1885, II., 401. Amer. Journ. Obstet. 1888, p. 1279. * Centralb. f. Gyn. 1886, p. 745. New York Med. Journ., Nov. 24, 1883. Range Lancet, 1887, I., p. 1293. Jaggard records an interesting case of inversion of twenty-one months' standing reduced after thirty- three days' use of the colpeurynter Amer. Journ. OMet. 18 7, p. 130. Archiv. de Tocolog., 1885, p. 925. 8 Lawson Tait Obst. Journ. vol. iv., p. 555. Aveling Loc. cit., records ten cases of successful reposition with his cup and stem which has a sigmoid curve. INVERSION. 399 carbolised oil, all round the neck of the inverted uterus and round the cup of the repositor when in situ ; we watch the position of the instru- ment, and remove and re-apply it every day so as to see how it is press- ing and whether there is sloughing. (2.) There must be effective counter-pressure, so as to take the strain off the vaginal walls. This is effected by means of a broad flannel bandage, firmly secured round the loins, under which cotton wool is padded in such a way as to press exactly upon the fundus. The elastic pressure is kept up from one to three weeks. Cases of reposition at this period, or even after it, are recorded. 1 FIG. 240. CUP WITH STEM AND ELASTIC BANDS which are fixed to an abdominal belt, for gradual reduction of inversion (Thomas). In cases of inversion due to tumour growth, the tumour if simple must be removed in the first instance ; we then wait to see if the uterus will replace itself, and if it does not we proceed to replace it. If the tumour be malignant, the propriety of amputating the uterus with the tumour must be considered. . Amputation. Amputation of the inverted uterus is justifiable (except in cases of malignant disease) only after all means of reposition have been fairly 1 As by Neugebauer, after three weeks Centralb.f. Gyn. 1887, p. 63. 400 AFFECTIONS OF UTERUS. Amputa- tion of Inverted Uterus with the knife. tried and failed, or when the uterus is extensively ulcerated and gan- grenous. The length of duration of the inversion is no argument for amputation ; Noeggerath replaced one of thirteen years' standing. The morality in amputation is high, 1 in 3 (Crosse). The dangers of the operation are Haemorrhage, Septicaemia, Peritonitis, Retraction of the stump into the peritoneal cavity. We describe the operation as we have seen A. R. Simpson perform it with success. The following are the instruments required : Vaginal douche, Bistouries, Elastic ligature, Scissors, Sims' speculum, Long straight fixed needles, Spatulae, Smaller curved needles and holder, Volsellse, Silver wire two thicknesses, Dissecting and artery forceps, Carbolised silk and catgut. Place the patient in the lithotomy posture, under chloroform. Keep up irrigation with the douche during the whole operation. Hook back the labia with spatulas, to be held by the assistants who steady the legs ; draw down the perineum with Sims' speculum, to be held by another assistant. Ascertain before making any traction on the uterus where the natural neck of the inverted portion lies, and pass round it an elastic ligature knotted so as to control haemorrhage. The natural neck is our guide as to the line of amputation ; if we drag more of the uterus down into the constricting loop, the stump is liable to spring back after the amputation has been performed. Pass three or four wire sutures through the uterus in an antero- posterior direction, about an inch below the constricting ring, as described under the operation for amputation of the cervix (v. p. 284) ; the same figures will show how the sutures are passed in this operation, if we suppose the inner circle (which represents the mucous membrane of the cervical canal in fig. 169) to represent the cross section of the peri- toneal pouch. The advantages of passing these sutures before amputat- ing are the following : they are ready in situ to control haemorrhage ; they give us a purchase on the stump when the portion in the bite of the forceps is cut away ; they are more easily passed at this stage. The uterus is now amputated about half an inch below these sutures. Bleeding points of any size are ligatured with catgut on the end of the stump. The lips are then brought together with the deep sutures already passed. Kaltenbach ties the lateral sutures over the sides in- INVERSION. 401 stead of the end of the stump ; this constricts the uterine arteries more efficiently. More superficial ones are placed between these to bring the mucous membrane together. To prevent re-inversion of the cervix, it has been proposed to stitch the stump to the adjoining cervical mucous membrane. The india-rubber constrictor is now notched so as to diminish its pressure, and finally cut through. The ligatures are left long enough to be brought out at the vaginal orifice, and a drainage tube is placed in the cervical canal. The elastic ligature is preferred by a great many operators ; when used, we should cut away as much of the tissue below the ligature as possible to minimise the risk of septicaemia from the necrosed tissue. To keep it from slipping, Spencer Wells transfixed the uterus with needles ; Courty x makes a furrow with the cautery to hold the ligature. Instead of putting the elastic ligature directly on the neck of the tumour, a silk noose may be applied on a stem like that for a wire ecraseur and the ends tied to an elastic cord so as to give elastic traction. 2 Re-inversion of the stump is a serious accident, as the raw surface now Re-inver- lies in the peritoneal cavity and may be a source of septicaemia ; further, it is beyond our control should haemorrhage occur. In two cases of amputation with the galvano - caustic wire, performed by Spiegel- berg, 3 this accident occurred : in these no bad effect followed, because the discharge escaped by the cervical canal ; he attributes this happy result to the fact that the stump-surface of the galvano-caustic wire, being a convex cone, became, on re-inversion, a concave cone opening into the cervical canal. 1 Archiv. de Tocolog., 1885, p. 922. * Poncet : Areliiv. de Toe., 1886, p. 351. 3 Archiv f. Gyn., Bd. IV., S. 358. 2c CHAPTER XXXV. TUMOURS OF THE UTERUS. FIBROID TUMOURS : PATHOLOGY AND ETIOLOGY. LITERA TORE. Barnes Diseases of "Women, p. 746 : London, 1878. Doran On Myoma and Fibro- myoma of the Uterus and allied Tumours of the Ovary : Trans, of Lond. Obs. Soc., 1888, p. 410. Duncan, Matthews Haemorrhage from Fibrous Tumours of the Uterus : Edin. Med. Jour., Jan. and Feb. 1867. Gusserow Die Neubildungen des Uterus : Deutsche Chirurgie, Stuttgart, 1885. Johnston A Review of some collected Cases of Fibromata of the Cervix Uteri : Am. Journ. of Obstet., Nov. and Dec. 1885. Kleinwachter Zur Entwickelung der Myome des Uterus : Zeitsch. f. Geb. und Gyn., Bd. IX. S. 68. Klob Pathologische Anatomic der weiblichen Sexualorgane, S. 149 : Wien, 1864. Lee Tumours of the Uterus : London, 1847. M'Clintock Diseases of Women : Dublin, 1863. Beamy Case of Fibroid Polypus of the Uterus, with remarks on some points in Etiology (with Discussion) : Amer. Jour. Gyn., 1886, pp. 813 and 859. Routh Fibrous Tumours of the Womb : London, 1864. Schorler Ueber Fibromyome des Uterus : Zeitsch. f. Geb. und Gyn., Bd. XI. S. 139. Schroeder Krankheiten der weiblichen Geschlechtsorgane, S. 218 : Leipzig, 1886. Simpson, Sir J. Y. Diseases of Women, p. 659: Edin. 1872. Thomas Diseases of Women, p. 519 : Philadelphia, 1880. Winckcl Ueber Myome des Uterus, etc. : Volkmann's Sammlung klin. Vortrage, No. 98, 1876. Wyder Die Mucosa uteri bei Myomen : Arch. f. Gyn., Bd. XXIX. S. 1. See also Index of Recent Gynecological Literature in the Appendix. Intro- OP tumours of the uterus, the most important are Fibroids and Cancer, tory> less important Adenoma, Sarcoma, and Papilloma ; and in the chapters that follow we shall have to consider Fibroids and Cancer at some length, the others briefly. The term "polypus" is so convenient clini- cally that we retain it, but we must remember that it involves cross- classification, including one variety of fibroid tumour the fibrous polypus while the mucous polypus is a pediculated adenoma. Adenoma of the uterine mucous membrane has only of recent years been receiving attention ; we shall refer to it under carcinoma, as its chief importance is in connection with the early stages of that affection. Fibroid tumour is considered first, as in frequency it comes before cancer, although in seriousness the latter is by far the more important. It presents a remarkable contrast with cancer in every respect : it shows itself early in life, while cancer is late; it occurs among the well-to-do, while cancer makes its ravages among the poor and badly fed; it is the tumour of the sterile, while cancer is that of the parous; it very rarely affects life, while the fate of the cancer-patient is almost sealed. FIBROID TUMOURS: PATHOLOGY. 403 Synonyms. Myoma or Fibro-myoma Uteri ; Fibrous Tumour; Tutneur fibreuse; Hysterome. As this tumour is composed of both the connective tissue andNomen- muscular elements of the wall of the uterus, it is at once a fibroma and clature> a myoma ; the most correct term is therefore fibro-myoma. In the majority of cases, however, the fibrous tissue preponderates, so that the tumour resembles a fibroma ; the English term fibroid (a term derived from the root of fibroma and eldos = like a fibrous tumour) is therefore not inappropriate, and is also more convenient. PATHOLOGY. Under this head we shall describe their Situation ; Structure naked eye and microscopic ; Mode of growth, varieties ; Changes in uterus ; Degenerative changes. SITUATION. They occur much more frequently in the body of the uterus than in the cervix ; of seventy-four cases of fibroid tumours recorded by Lee, only four were in the cervix. In the body of the uterus the most common seat is the posterior wall; they occur less frequently in the anterior wall, and very rarely at the sides of the uterus. The soft, truly muscular form is most commonly situated at the fundus. STRUCTURE. They are composed of the same elements as the muscular wall of the Naked-eye uterus, viz., of non-striped muscular fibre and fibrous tissue. These are O f a Fibroid both present in every case, as the name for these tumours (fibro-myoma) Tumour - implies. The proportion of these constituents, however, varies; in some rare cases the muscular tissue preponderates, producing a true myoma which is not circumscribed and grows rapidly; more usually there is excess of fibrous tissue producing a fibro-myoma, which is dis- tinctly marked off from the wall of the uterus and grows slowly. The naked-eye characters of the myoma are those of a pale, flesh-coloured tumour having a soft consistence, passing gradually into the surround- ing uterine wall, and usually single. The fibro-myoma, by far the most frequent form, x is of firm consistence which makes it feel like a foreign body in the softer muscular wall; it is of a pale colour, resembling fibrous tissue ; it cuts like cartilage, the cut surface having a glistening satin-like appearance and being often uneven through the firmer fibrous 1 Doran (loc. cit.) thinks the frequency of fibro-myoma as compared with myoma is over-estimated. Young fibroids are "pure myomata with or without connective tissue." 404 AFFECTIONS OF UTERUS. tissue forcing out the softer parts between ; the bundles of fibrous tissue have a concentric arrangement round one or more centres (fig. 241). Capsule of The tumour is surrounded by loose fibrous tissue, which with the immediately adjoining muscular layer constitutes the so-called capsule ; it has a broad connection at one point with the muscular tissues of the wall, or becoming entirely detached from it lies free in its capsule. This looseness of the tissue round the tumour is important in relation to its removal by the process described as enucleation. Few blood-vessels penetrate into the substance of the tumour, although the tissue im- mediately round it is very vascular and often contains enlarged veins which resemble the venous sinuses of the pregnant uterus (fig. 251) ; Micro- tion. FIG. 241. SECTION OK A LARGE FIBROID TUMOUR, with the Fibres arranged round several centres (Sir /. Y. Simpson). nutrition is apparently effected by transudation from the capsule. In some rare cases, however, these tumours possess a cavernous structure consisting of dilated blood-vessels. Virchow has described this form as "Myoma teleangiectodes seu cavernosurn ; " cases are recorded by Leopold and Schroeder. On microscopic examination, the myomatous form has the appearance ^ mu scular fibre of the uterus the muscle-cells being, according to Doran, 1 larger than those of the uterus in which it grows. The 1 Loc. cit. He figures a section of a myoma from a pregnant uterus which shows this well, the muscle-cells being still larger than the hypertrophied ones of the uterus. FIBROID TUMOURS: PATHOLOGY. 405 fibroniatous form (common fibroid tumour) has the appearance shown at fig. 242, in which the wavy bundles of fibrous tissue are well seen. Sometimes the bundles of fibrous tissue are separated by spaces (fig. 243), which Klebs considers to be lymphatic spaces. Nerves have Lymphatic been traced into the substance of these tumours by Lorey ; but, as an - Bundles - interesting case recorded by Freund shows, they are not sensitive : a submucous fibroid was extruded beyond the vulva; the lower third, which protruded beyond its capsule of mucous membrane, was not FIG. 242. SECTION OF FIBROID TUMOUR, showing wavy bundles of fibrous tissue } (Gusserotc). sensitive to the prick of a needle ; the upper two-thirds, from their being still covered by mucous membrane, were very sensitive. The mucous membrane covering them is ciliated, 1 like that of the uterus generally ; though when it has been exposed for some time (e.g. when a fibrous polypus comes to be in the vagina) it becomes squamous. 2 FIG. 243. SECTION OK FIBROID TUMOUR, showing spaces between bundles of fibrous tissue \ (Giuserow'). MODE OF GROWTH, VARIETIES. Fibroid tumours grow slowly ; the more they consist of fibrous tissue, Rate of the slower the growth. During pregnancy, they increase more rapidly in size ; in the puerperium, they may become smaller again and even cease to be recognisable. It is difficult to determine the rapidity of growth. It is unsatisfactory to estimate it from the appearance of symptoms and compare the time elapsed with the present size of the 1 Gervis Brit. Med. Journ., 1886, II., p. S71. 2 Reamy Loc. cit., p. 817. 406 AFFECTIONS OF UTERUS. Mode of Varieties tumour ; the only reliable data are got from the examination of the tumour from time to time. Schorler has reported on 18 cases observed by Schroeder and comes to this conclusion : A tumour will not grow to be for the first time recognisable in less than three months' time and in a year may not be much larger ; in five years it may grow to the size of a man's fist, and in thirteen to the size of the head. It is evident that these statements only give a general idea of the rapidity of growth, to which there are great exceptions. After the menopause, their growth is, as a rule, arrested ; the meno- pause is generally late in cases of Fibroids. All fibroid tumours are, in the beginning, interstitial or intra-mural. As they increase in size they expand in the substance of the wall or towards one of the free surfaces (peritoneal or mucous), thus becoming subperitoneal or submucous. Hence three varieties are recognised interstitial, subperitoneal, and submucous. It is evident that these terms are revive, as & i 8 difficult to say when an interstitial fibroid becomes FIG. 244. PEDICULATED SUBPERITONEAL FIBROID TUMOUR (Sir J. Y. Simpson). submucous. Gusserow limits the term "submucous" to pediculated submucous, and " subperitoneal " to pediculated subperitoneal fibroids. A submucous tumour, however, often gives rise to the clinical signs diagnostic of the submucous variety long before it becomes pediculated. Each variety requires short description. For the sake of convenience, we describe first the fibroid tumours found in the body of the uterus ; the comparatively rare fibroid tumours of the cervix are best noticed separately (p. 412). A. The Subperitoneal grow outwards into the peritoneal cavity. The thickness of the pedicle varies (compare fig. 244 with fig. 245) ; its length determines the mobility of the tumour. When the tumour attains a certain size, one of two things happens. (1.) It may grow up men.* ^ n * * ne a bdomen and expanding there draw the uterus forcibly upwards, producing by this traction elongation of the cavity (fig. 245) with thin- Subperi- Fibroids, Growth FIBROID TUMOURS: PATHOLOGY. 407 ning of the walls. An interesting case is recorded by Times 1 in which the cavity of the body of the uterus was elongated to six inches; the cervical canal, extending only one inch inwards from the os externum, ended blindly at a point two inches distant from the beginning of the cavity of the body ; the intervening portion was obliterated so as to form a solid muscular cord. Virchow says that the body may even be torn from the cervix by forcible traction. (2.) The tumour, growing Incarcera- from the first within the pelvis, may through pressure produce t FIG. 245. UTERUS WITH ELONGATED CAVITY DUE TO THE PRESENCE OF SEVERAL FIBROID TUMOURS (Sir /. Y. Simpson). symptoms of incarceration ; or, having a long pedicle, may fall down from the abdomen into the pelvis and produce similar symptoms. The point of origin of the tumour and the length of the pedicle determine whether these symptoms can be relieved by pushing the tumour out of the pelvis. Twisting of the pedicle occurs less frequently in fibroid than 1 Land. Obit. Tranit., vol. ii., p. 34. 408 AFFECTIONS OF UTERUS. in ovarian tumours; when it occurs, it leads to oedema or gangrene. schroeder 1 mentions a case where, on operating, he found the tumour distended with blood from partial twisting of the pedicle. Gangrene of the tumour, leading to a fatal peritonitis, was observed by Cappie ; 2 the pedicle was twisted round its axis one and a half times. Adhesions form with other organs, as occurs with all abdominal tumours ; these may become new sources of nutrition. Sometimes they lead to detach- ment of the tumour from the uterus : the tumour is anchored, as it were, to the abdominal walls ; and, when the uterus from pregnancy or other causes becomes displaced, the pedicle gives way. Turner 3 reports a case in which a small calcareous fibroid was found free in the pouch of Douglas ; a second was attached to the posterior wall of the bladder and FIG. 246. INTERSTITIAL FIBROID TUMOUR (Sir J. Y. Simpson). to the pelvis ; a third was bound down to the bladder and the pelvic wall by adhesions, but still retained its connection with the uterus by a thin pedicle. Adhesions to the intestines have produced symptoms of intestinal obstruction. 4 Hernial protrusion of the abdominal walls has been described by Dull : 5 he reports two cases of this very rare occurrence ; in one case, the skin covering the hernial sac became gangrenous, so that the tumour lay exposed. 1 Op. cit., 8. 230. 2 OMet. Journ, ii., p. 303. x Sdin. Med. Journ., 1861, p. 69S. 4 Bade Lancet, Dec. 21, 1872. 8 Cited by Schroeder, op. cit., S. 233. Lawson Tait mentions the same condition Brit. Med. Journ., 1888, I., p. 861. FIBROID TUMOURS: PATHOLOGY. 409 E. The Interstitial remain in the substance of the uterine wall, and Interstitial do not become pediculated. The appearance of such a tumour is well * seen at fig. 246. Usually there are many such tumours present (fig. 245) ; Schultze counted as many as fifty in one uterus, and Thomas describes the uterus of a negress containing thirty-five. C. The Submucous are the most important clinically. They lie im- Submucous mediately underneath the uterine mucous membrane, and project into the cavity of the uterus (fig. 247). They are attached along a broad base, or by a pedicle ; when they hang free, they are known as fibrous polypi the most frequent form of uterine polypi (v. Chap. XXXIX.). When a fibroid tumour projects into the uterine cavity, it acts as a foreign body and produces uterine contractions. These lead, in some instances, to pedunculation of the tumour and even to its extrusion from the uterine Fibroids. FIG. 247. SCBMUCOUS FIBROID TUMOUR PROJECTING INTO UTERINE CAVITY (Sir J. Y. Simpson). cavity ; in such a case, it hangs as a polypus in the vagina. In other rare cases, the capsule ruptures and the liberated tumour is expelled in shreds spontaneous enucleation. The muscular ivall hypertrophies, more especially when the tumour Changes in is submucous or interstitial. A small fibroid lying in the lower segment of the uterus has caused the whole organ to hypertrophy to the size of a child's head. x In submucous fibroids, the mucous membrane is also hyper- trophied. According to Wyder, 2 the increase in thickness is limited to the portion over the tumour and is due to a hypertrophy affecting in Uterus. 1 Tillaux Gaz. des Hop., 1867, Xo. 144. - Archiv f. Gyn., Bd. xiii. S. 35. 410 AFFECTIONS OF UTERUS. some cases the glands and in others the connective tissue. The mucous membrane may ulcerate leading to enucleation of the tumour. In a more recent paper 1 he gives a very full account of the changes in the mucous membrane which he has examined carefully in twenty cases of uteri removed in Gusserow's Clinique in Berlin. His object was to study it specially with a view to the cause of menorrhagia FIG. 248. PEDICULATED SCBMUCOUS FIBROID IN PROCESS OF EXTRUSION (Sir/. Y. Simpson). which is the important symptom of fibroids. From a comparison of the mucous membrane in subperitoneal as compared with interstitial he comes to the conclusion that the thicker the muscular capsule is the less likely is the tumour to affect the circulation in the mucous membrane. The 1 Loc. eit. S. 34, 38. FIBROID TUMOURS: PATHOLOGY. 411 uterine glands in this case are hypertrophied, but the interglandular tissue little or not at all affected ; while the nearer the tumour comes to the uterine cavity, the more does the interglandular connective tissue become affected, and this sometimes at the expense of the glands which atrophy. The bearing of this on bleeding is that it is the affection of the inter- glandular tissue, causing compression of the veins, which leads to con- gestion and bleeding. Changes in the position of the uterus have been already referred to ; when subperitoneal fibroids rise up into the abdomen, it is sometimes drawn forcibly upwards by them and may be twisted on itself. 1 At other times the weight of a subperitoneal or interstitial tumour leads to prolapsus iiteri. Inversion of the uterus is also occasioned by submucous fibroids when these are situated near the fundus and when their pedicle does not admit of their extrusion as polypi. 2 DEGENERATIVE CHANGES. These are the following : Softening, Induration, Calcification, Sup- puration. The softening may be due to oedema, to fatty degeneration, or to Softening, myxomatous degeneration. The occurrence of oedema is unquestioned, and many cases of sudden increase in the size of fibroid tumours may be thus explained. From analogy with the changes affecting muscular fibre in the puerperal uterus, we should expect fatty degene- ration to occur ; there is, however, only a small quantity of muscular tissue present in these tumours. There are only two cases 3 recorded in which the existence of fatty degeneration has been demonstrated by microscopic examination, although many cases are reported in which this is supposed to have occurred. Myxomatous degeneration, resulting in the formation of spaces containing mucus between the layers of the tumour, sometimes occurs. Induration, with atrophy or shrinking of the tumour, occurs in someindura- cases after the menopause ; the muscular tissue fattily degenerates and tlon> disappears, the fibrous tissue contracts.* An infarction has also been found. 5 When calcification occurs, lime salts (chiefly phosphates) are deposited Calcifica- in the fibrous tissue and produce the so-called womb-stones. 6 This tlon< deposit usually commences in the centre of the tumour and extends out- wards, more rarely in the external layers so as to form a shell round the 1 As in the case reported by Ktister Beitrage zurGeb. u. Gyn. 1872, i., 8. 7 ; the uterus was twisted two and a half times, so that the broad ligaments formed a spiral. Skutsch records another case operated on by Schultze in which the uterus was twisted half round Centralb.f. Gyn. 1887, S. p. 52. 2 Kotschau records a case of partial inversion, with what he calls " eversion of the uterine mucous membrane," i.e. its being pushed downwards without the tumours becoming pediculated Centralb. /. Gyn. 1S87, S. 757. 3 Gusserow Zoc. cit., S. 32. The cases are reported by Freund and Martin. 4 Sir J. Y. Simpson Obst. Mem., p. 115. 5 ^ y v -_Ott. The patient had felt pain over it, ascribed to a local peritonitis Centralb. f. Gyn. XII. S. 2(4. 6 See a recent case by Bach Amer. Journ. Obstet. 1886, p. 293. 412 AFFECTIONS OF UTERUS. tumour. Sometimes it is so extensive that the tumour can be cut with the saw, and the cut surface polished ; more usually it is incomplete, and forms a coral-like skeleton. Calcification of portions of the tumour is often accompanied with suppuration in others, probably from interference with nutrition. Suppura- Suppuration occurs frequently in submucous fibroids, as the result of injury from operative interference or from constriction of the pedicle during the process of expulsion. It has also been observed as a rare occurrence in subperitoneal fibroids, accompanying calcification or from torsion of the pedicle. In such a case, the tumour either finds its way through the abdominal walls or fatal peritonitis follows. Carcino- Whether cardnomatous degeneration specially affects fibroid ti\mours, Degenera- is a disputed point. We occasionally find carcinomatous degeneration tion. j n a u terus where a fibroid tumour is also present (fig. 280) or from which a polypus has on a former occasion been removed. Whether this is merely a coincidence, or whether there is a liability that the non- malignant tumour may become the seat of malignant disease, is not settled. The practical importance of this question is evident. As to the frequency of these various changes, Martin 1 gives us the following interesting statistics of his own cases. Of 205 fibroids he found slight retrogressive changes in 70, fatty degeneration in 3, suppuration in 10, cedematous swelling in 11, cystic degeneration in 8, blood-cavities in 3, sarcomatous degeneration in 6, but never carcinoma. FIBROID TUMOURS OF THE CERVIX. The occurrence of fibroid tumours in the cervix is rare ; but, when they are present, they often give rise to difficulty in diagnosis on account of the distortion which they produce. They spring from either wall, and grow outwards towards the peritoneal cavity or downwards into the cellular tissue beside the vagina. When subserous, they easily produce symptoms of incarceration, as, from their low position, they are liable to become wedged in the pelvis. When submucous, they produce elon- gation of one lip and may form a polypoidal tumour in the vagina (fig. 249) ; the accompanying distortion of the os externum leads to difficulty in diagnosis. Cases in which a large tumour bulges through the ostium vaginae have been mistaken for inversion and prolapsus. Sometimes prolapsus is due to the weight of the tumour and disappears after its removal. 2 The interstitial form is easily mistaken for inver- sion when the os is converted into a transverse cleft which escapes observation and the unaffected lip is thinned out to a mere band. Johnston reports on ninety-six cases of fibroid tumour of the cervix, dealing especially with their effect on pregnancy and labour. He finds 1 Ueber Myome : Archivf. Gyn. Bd. XXXII. S. 470. 2 Barnes Obst. Tram., III., p. 211. FIBROID TUMOURS: ETIOLOGY. 413 that abortion is more frequent with fibroid tumours in the body, pre- mature labour with those in the cervix ; he affirms that during preg- nancy or labour one-third of the mothers and more than one-half of the children die so that, where the tumour cannot be removed, celibacy is to be recommended. ETIOLOGY. Gusserow, to whose exhaustive article Die Neubildungen des Uterus in Billroth's Handbuch we are greatly indebted in this Chapter, says in regard to etiology, " Ueber die Ursachen der Uterusmyome wissen wir so wenig, wie iiber die Ursachen der meisten pathologischen Neubild- ungen, namlich Nichts" (of the causes of fibroid tumours we know as little as of the causes of most pathological new-formations, that is nothing). Virchow and Winckel have both made elaborate attempts to FIG. 249. CERVICAL FIBROUS POLYPUS springing by a pedicle from the region of the os internum, and pushing itself under the whole mucous membrane of the cervical canal ; so that its insertion is partly continuous with the tissue of the uterus, partly truly submucous. Between these a cavity has formed through tearing of the mucous membrane, so that the tumour has apparently two pedicles (Schroeder). assign a cause to the development of fibroid tumours. The number and variety of causes adduced by these observers only show how far we are from the knowledge of the real cause ; with such a variety of causes, the difficulty would not be to explain why they are present in some but why they are not present in every case. The development of the true myoma has been recently studied by Kleinwachter. He examined uteri with very small myomata and found that there was a small isthmus of muscular fibre uniting the myomatous mass, lying in its connective tissue capsule, with the muscular tissue around. This isthmus some- o EH O to o o 02 P O P EH M O w ^ H- 1 P O OP PH O E=N <1 O a o a 02 o i i Q Q M ^ S -2 I s s s o 8 \ 10 o m o s s s s HH V (S C W lll " " -I FIBROID TUMOURS: ETIOLOGY. 415 times bifurcates and resembles in form an obliterated blood-vessel (capillary). He also saw some capillaries surrounded with round cells and forms transitional to muscular fibres. Hence he concludes that the true myoma is due to a degeneration of a blood-vessel with its branches. From finding micrococci in them, Galippe and Landouzy 1 have suggested that they are due to the irritation of a parasite. Olshausen 2 has found pain (sensitiveness to pressure and dysmenor- rhoea) and menorrhagia complained of before any tumour could be detected by palpation, and thinks this points to congestion of the uterus as being an early clinical symptom in some cases of myoma. Fibroids are without doubt the most frequent new-formation in the uterus. Klob says that they are present in 50 p.c of women who die over fifty years of age ; and Bayle, in 20 p.c. of those who die over thirty- five years ; both of these estimates are probably beyond the mark. Their appearing is in some way related to the development of theDevelop- sexual apparatus. Thus, there are no well-authenticated cases of their p-t nt -^ arising before puberty 3 or after the menopause. The majority of patients according are between the ages of thirty and forty when they first seek medical age ' advice, as it is evident from the accompanying table based on statistics collected by Gusserow (fig. 250). Schroeder says that of 196 patients, who during three years of his private practice consulted him for fibroid tumours, 104 were between forty and fifty, and 62 between thirty and forty. Sexual activity predisposes to their development, as they are more frequent in married than in unmarried women. Of 1876 cases from various authorities collected by Reamy, 4 we find that 1422 or 75 o / of persons with fibroid tumours seeking advice were married ; the larger number of married compared with unmarried persons must be borne in mind in judging of such figures. It is important to note this as it was formerly supposed that single life favoured their development. As the presence of a fibroid tumour interferes with conception, we often find sterility present. 1 Brit. Med. Journ. 1887, I. p. 799. 2 Notizen ueber das klinische Anfangsstadium der Myome : Archivf. Gyncik. XXVIII. S. 494. 3 Tillaux reports a case of a fibroid tumour of the cervix in a girl of nineteen which had caused symptoms for six years. Annales de Gyn. XXVI., p. 241. * JLoc. cit. p. 818. CHAPTER XXXVI. FIBROID TUMOURS OF THE UTERUS: SYMPTOMS; DIAGNOSIS; PROGNOSIS. LITERATURE. See Literature of Chaps. XXXV. and XXXVII. LIKE other pathological conditions of the uterus, fibroid tumours some- times produce no symptoms and their presence is discovered accidentally or on post-mortem examination. This absence of symptoms is more likely to occur should the tumour be small, or should there be no sexual activity as in unmarried women. In the latter case, although symptoms appear only when the patient enters married life, the tumour may have been already a long time present. Subperitoneal tumours, even when large, may only produce discomfort from undue abdominal distention. The symptoms usually present may be tabulated as follows : 1. Menorrhagia, irregular haemorrhages ; 2. Painful menstruation ; 3. Pelvic sensations due to size and weight of tumour, peritonitic pain; 4. Symptoms of pressure on bladder and rectum, blood-vessels and nerves, ureters ; 5. Sterility and abortion. Hsemor- 1. Haemorrhage is the most characteristic symptom in submucous Fb ge 'd Q fibroids, and appears first as a gradual increase of the normal menstrual flow ; it never begins with a sudden flooding as in carcinoma uteri. In menorrhagia, the haemorrhage comes from the hypertrophied mucous membrane of the uterine cavity generally ; it does not come from the mucous membrane covering the surface of the tumour which is frequently thinned and atrophied, nor from the substance of the tumour itself which as we have seen is sparingly vascular. When, however, the sub- mucous fibroid projects as a polypus, passive congestion and haemorrhage from the mucous membrane covering it may be occasioned by the con- striction of its pedicle. Irregular haemorrhages arise from ulceration of the mucous membrane covering the tumour, or rupture of the dilated SYMPTOMS OF FIBROID TUMOURS. 417 veins in its capsule. Fig. 251 shows a case 1 in which, through the rupture of a uterine sinus in the lower part of the tumour, a sudden and fatal haemorrhage occurred. In subperitoneal fibroids menstruation is not increased, and in certain rare cases is diminished. 2. Pain accompanies menstruation. In the submucous variety there Pain in is often characteristic uterine dysmenorrhoea, in which the pain resembles Fibroids - FIG. 251. UTERUS CONTAINING FIBROID TUMOUR, from a case which terminated fatally through haemorrhage. Note the large venous sinuses in the capsule, one of which ruptured at the point a {Matthews Dv/iicati). labour pains. The congestion causes the polypus to swell and this pro- duces uterine contractions (v. Uterine Polypi). In interstitial and even in subserous fibroids, there is often pain at the menstrual period which 1 Reported by Matthews Duncan Edin. Med. Jour., 1867, p. 634. He also refers to a case of Cruveilhier's in which death was occasioned in the same way. 2D 418 AFFECTIONS OF UTERUS. cannot be thus explained. In subserous fibroids with a pedicle con- taining large vessels, as well as in interstitial, Gusserow ascribes the pain to the distention of the tumour with blood. This pain is of a stretching or dragging nature, and is quite different from the pain of uterine contractions. Weight 3. Increased weight of the uterus occasions sensations of discomfort, in Fibroids, which are described as "fulness or weight in the pelvis," " a sensation of dragging," "bearing-down pain." When the tumour is so large that it fills the pelvis and becomes wedged in it, intense pain is produced ; this is either always present, or recurs only at the menstrual periods when the tumour is distended by blood. As in carcinoma uteri, peritonitic pains indicated by local tenderness and reflex contraction of abdominal muscles may arise at any time from secondaiy chronic peritonitis. Neuralgic pain is sometimes present locally (see below), but may be also through the whole body. Pressure 4. Frequency of micturition, due to pressure on the bladder, is the inFibroids. m st common pressure symptom. Pressure on the urethra produces difficulty of micturition and even retention ; with some patients, this recurs regularly at the menstrual period. Even very small fibroids, when they are situated in the anterior uterine wall, may press on the neck of the bladder and produce symptoms of cystitis. Pressure on the rectum by fibroids in the posterior wall occasions constipation or, more rarely, mucous diarrhoea. Incarcerated fibroids have produced complete obstruc- tion, and led to a fatal result 1 or furnished an indication for colotomy. Intestinal obstruction has also resulted from adhesions between the tumour and the small intestine. 2 Pressure on the veins produces haemor- rhoids and varicose veins in the legs. Interesting cases of neuralgia due to pressure on pelvic nerves have been recorded. In these cases the neuralgia entirely disappeared as soon as the tumour was lifted up and supported by a pessary. 3 Compression of the ureters, with consequent dilatation and hydronephrosis, occurs less frequently in fibroid tumours than in carcinoma. The reason for this is evident ; in carcinoma the compression is due to infiltration of the tissue round the ureter, which from the anatomical relation of the ureters to the cervix easily occurs ; fibroid tumours in their growth simply press against the ureters, and may push them aside. Several cases of single and double hydrone- phrosis and of death from uraemia 4 have been recorded. Bright's disease has developed secondarily. 5 In fibroid tumours where pressure symptoms are present, we should always examine the urine. Sterility 5. Sterility is frequent. Of 149 cases of married women collected by 8 ' Schroeder, 33 per cent, were sterile and the average number of children 1 Holdhouse Land. Path. Soc. Trans., III. 371. 2 Bade Lancet, Dec. 21, 1872. Kidd Dub. Quart. Journ., 1872. Jude Hue Annales de Gyn., IV., p. 239. 4 Gusserow quotes cases from Jude Hue, Murphy, Hanot Neubildunyen, etc., S. 52. * Hubert Bui. de la Soc. Anatom., 1873, p. 870. SYMPTOMS OF FIBROID TUMOURS. 419 to each mother was about three. When conception occurs, fibroid tumour may lead to abortion or complicate labour. PROGRESS AND RESULTS. A relative cure usually takes place at the menopause, when the tumour ceases to grow. In the case of subserous tumours, this may happen even before that time. Spontaneous disappearance of the tumour has been observed in certain Spontane- cases, although nothing definite is known as to the means by which it is ous c ^ s " appearance effected. After sifting the reported cases, Gusserow's conclusion is that of Fibroids. there are thirty cases in which this undoubtedly occurred. x Out of these thirty, thirteen were associated with the puerperium and the rest chiefly with the menopause. We might account for their disappearance during the puerperium by a process analogous to invohition. Of the reason of the disappearance at the menopause we know nothing. Complete cure also results from spontaneous expulsion. This occurs in Spontane- three ways:- -^f^ (1.) By pediculation and extrusion of the tumour as a polypus Fibroids. (v. under Uterine Polypi) ; (2.) By enucleation, in which the tumour is shelled en masse out of its bed ; (3.) By the breaking-do wii of its substance and consequent ex- pulsion in fragments. Enucleation occurs in submucous and also in interstitial tumours. The Spontane- mucous membrane of the capsule ulcerates, and the tumour is thus "j^" f cle " exposed; partly through suppuration, partly thro ugh uterine contractions, Fibroids, it becomes detached all along the line of its capsule and, being thus liberated, is expelled. This process is comparatively safe for the patient, though there is always the risk of haemorrhage from the large veins in the capsule (fig. 251). In spontaneous enucleation, suppuration does not occur in the tumour itself but only in its capsule. The breaking-doivn of the substance of the tumour is a much more Breaking- dangerous process for the patient. As it is a slow one, there is a risk of pj absorption of septic matter. The commencement of this change is indicated by increase in the size of the tumour, which becomes tense and painful to the touch. There is a purulent foetid discharge from the vagina, and sometimes haemorrhage. The constitutional symptoms of loss of appetite and hectic fever afterwards develop, and most of such cases end fatally. Expulsion of the tumour generally takes place per vaginam. As in other tumours we have inflammatory adhesions forming with neighbour- ing organs, followed by suppuration and perforation by the tumour. Thus calcified fibroids have perforated into the bladder, and have been 1 He does not refer to a case observed by A. R. Simpson, and possibly others have been overlooked. 420 AFFECTIONS OF UTERUS. Causes of Death in Fibroids. Diagnosis of Small Fibroid Tumours. mistaken for vesical calculi. 1 A fibroid has perforated into the rectum, and has been discharged per anum. In some cases adhesions with the abdominal wall have formed, and the tumour has been thus discharged. Considering the frequency of fibroid tumours, it is rare that death follows immediately from their presence. A fatal result, however, may follow from (1) suppuration in the tumour producing death from septi- caemia, or a septic peritonitis ; (2) uraemia, due to compression of the ureters ; (3) direct haemorrhage ; (4) acute simple peritonitis. PHYSICAL SIGNS: DIFFERENTIAL DIAGNOSIS. The physical signs of fibroid tumours are usually so well marked that diagnosis is easy. In certain cases, however, diagnosis is very difficult ; and when inflammation is superadded, certainty is impossible. Physical diagnosis is best considered under two heads : a. of small fibroid tumours, up to the size of a walnut or egg ; 6. of larger ones, which rise up as distinct tumours into the abdomen. a. OF SMALL FIBROID TUMOURS. 1. Pediculated mbmucous fibroids should be easily recognised. When they are small and not projecting through the os, we have to dilate the cervix to ascertain their presence and attachment ; when larger and projecting into the vagina, they may readily be mistaken for inversion of the uterus. On sweeping the finger round the base, we recognise the commencement of the cervical canal unless the polypus be adherent at its neck leading to obliteration of the canal (v. fig. 232). Further, the bimanual or rectal examination shows the fundus uteri to be in its normal position. 2. Small interstitial fibroids when situated low doivn and causing bulging of one lip of the cervix, give rise to difficulty ; owing to the great enlargement of one lip, the os is displaced to the other side and its form altered to that of a mere slit which easily escapes observation. Such cases have been occasionally mistaken, even by the most experi- enced for inversion. This mistake is prevented by examination per rectum. Further, the sides and base of the tumour must be carefully scrutinised to discover the os ; when this is found, the sound will show the position of the uterine cavity. 3. Interstitial fibroids placed high up in the uterus, or small subserous ones with a broad base of attachment, often escape detection. To ascer- tain their presence we proceed as follows. Pass the sound ; this defines the course of the uterine canal and position of the fundus. Now make the bimanual examination with the sound, as represented in fig. 90 ; the finger in the anterior fornix detects the th^kening of the anterior wall, produced by a small fibroid. Now steady the sound with the left 1 M'Clintock J>ub. Quart. Jour., Feb. 1868. DIFFERENTIAL DIAGNOSIS OF FIBROID TUMOURS. 421 hand, and pass the forefinger of the right hand into the rectum so as to feel the sound lying in the uterus. Should there be a fibroid in the posterior wall, the finger recognises an unusual thickness of tissue between it and the sound. Carry the sound, firmly grasped by the left hand, towards the symphysis, so as to bring the fundus better within reach of the rectal finger ; and, by moving it from side to side, ascertain whether the tumour is intimately connected with the uterus so that it moves along with it. From their being largely composed of fibrous FIG. 252. CASE OF TWO-AXD-A-HALF MONTHS' PREGNANCY ASSOCIATED WITH TWO LARGE FIBROID TUMOURS one in the anterior, the other in the posterior wall. The uterus and tumours were removed by Laparotomy (Barnes). tissue, these tumours are firmer than the uterine wall ; the localised hardness, therefore, helps us in recognising them. Differential Small fibroid tumours, when submucous or interstitial, require to be^g^jj 18 diagnosed from chronic metritis, Fibroid Tumours, early pregnancy, ante- and retro-flexion. When subperitoneal and pediculated they must be differentiated 422 AFFECTIONS OF UTERUS. from enlarged Fallopian tube or ovary, tumour or inflammatory collection in the broad ligament. In chronic metritis the uterus is not globular but flat, and the enlargement is equable ; the uterine canal is patulous ; the os is everted, and shows catarrhal patches. We must remember that chronic metritis is occasionally present along with a fibroid tumour. In early pregnancy, the uterus is soft and elastic : the cervix is generally softened, while in fibroids it remains hard. Pregnancy, how- ever, may occur in a uterus which is already the seat of a fibroid tumour (fig. 252) ; and in such a case the diagnosis becomes certain only after the uterus is considerably enlarged. The possibility of pregnancy must specially be kept in mind here, as we involuntarily think of using the sound to aid in detecting fibroids. Anteflexion is closely simulated by a fibroid in the anterior wall; a body is felt in the anterior fornix, continuous with it, but separated by a groove. Similarly, a fibroid in the posterior wall has all the characters of the retroflexed fundus. Examination by the sound (v. fig. 204), and especially by the sound plus the Bimanual, clears up the case. Enlarged Fallopian tube 1 or ovary may closely resemble a pedicu- lated subserous fibroid ; they are not so firm and sharply defined, nor do they move so rigidly with the uterus. In the former also there are the history and symptoms of tubal disease. Inflammatory collections in the broad ligament are recognised by their history, the fixation of the uterus, and the changes they undergo ; but solid tumours there cannot be diagnosed from pediculated fibroids except by exploratory incision. 6. OF LARGE TUMOURS. When the tumour extends into the abdomen, we proceed with the systematic examination as described at page 90. Diagnosis Palpation. The tumour has a well-defined outline, and a firm solid Fb^iP cons i s tence. It is intimately connected with the uterus; this is best Tumours, ascertained by laying hold of the cervix with the volsella, when the cervix will be found to move along with the abdominal tumour. Sub- serous fibroids have a certain range of free movement depending on the length of the pedicle. In soft fibroids, there may be intermittent contractions. Percussion. The note is absolutely dull, unless intestines come between the tumour and the abdominal wall. Auscultation. The uterine souffle is heard most distinctly at the sides, sometimes all over the tumour. As the uterine souffle simply means enlarged uterine arteries, there is no souffle when these are not enlarged ; hence it is absent in subserous fibroids with a small pedicle. Vaginal examina- 1 Horrocks discusses this point in differential diagnosis in the Brit. Met. Journ., 1888, I. pp. 441, 586, 821. DIFFERENTIAL DIAGNOSIS OF FIBROID TUMOURS. 423 tion. Should the tumour be large and lifting the uterus into the abdomen, the cervix will be high up ; or it may be displaced in various ways, according to the position of the tumour ; it has a firm consistence. Bimanual. With pediculated subserous fibroids, the uterus is felt distinct from the tumour; with interstitial and submucous, we simply feel a large mass continuous with the cervix. The Sound. This should not be used till all possibility of pregnancy has been excluded. In doubtful cases, we wait three or four months till the positive signs indi- cative of pregnancy should have had time to develop. From the use of the sound we learn (1) the length, (2) the direction of the uterine cavity. The length of the cavity is always increased in submucous, and generally in interstitial, but not in subserous tumours ; it may measure six or eight inches. The direction of the canal is often tortuous in sub- FIG. 253. SOUXD USED TO DETECT PEDICULATED SUBMUCOUS FlBROID (Leblond). mucous tumours ; hence the passage of the sound is difficult, sometimes impossible. We feel that the sound goes so far and then catches on a hard projection. In such cases, a soft (No. 8) bougie is very useful, as its flexibility allows it to pass the obstruction. Usually, the sound passes to only one side of the tumour ; sometimes we can sweep it more or less round the tumour, showing that it projects free into the uterine cavity (fig. 253). Large fibroid tumours require to be diagnosed from Differential , Diagnosis Advanced pregnancy, of Large Ovarian tumours, Fibroid Tumours. Extra-uterine gestation, Haematocele and inflammatory deposits. 424 AFFECTIONS OF UTERUS. In advanced pregnancy the uterus is of softer consistence, and shows ballottement the indication of a solid within a fluid ; further, we can feel the parts of the foetus. It becomes occasionally harder under the hand, specially if we make the patient change her position ; this varia- tion in consistence is a most valuable diagnostic, as it is rarely present in fibroid tumours. We hear the uterine souffle and, unless the child be dead, we hear in addition the foetal heart; the possibility of the child's being dead should always be kept in mind. On vaginal examination, there is discoloration of the vaginal walls with free secretion ; the cervix is softened. There is usually amenorrhosa corresponding in duration to the size of the uterus. The diagnosis is not so easy as it appears on paper ; witness a case 1 in which abdo- minal section was about to be done in a case of four months' pregnancy, which was not recognised, on the most careful examination, until the patient was under the anaesthetic. Such a case shows the necessity, in doubtful cases, of anaesthesia even for examination. Ovarian tumours are soft and elastic ; small ones may be firm. There is no uterine souffle. They only give rise to difficulty in diagnosis when they have become adherent to the uterus, and move along with it. It is sometimes impossible to diagnose between them and cystic fibroid tumours (v. Fibro-cystic Tumours). Extra-uterine gestation presents great difficulty in diagnosis, especially when the gestation is in an undeveloped horn of the uterus. This con- dition may so closely simulate a fibroid that it may not be diagnosed till Abdominal Section has been made (v. p. 263). But we delay its consideration till the chapter on that subject. In hcematocele and inflammatory deposits we have the history of the attack to guide us. It may be impossible to form a diagnosis on first examination ; but after watching the case for a few weeks and noting any change in the deposit in addition to ascertaining its precise situa- tion, we can form a diagnosis. Pelvic peritonitis frequently occurs round a subperitoneal fibroid, or any fibroid producing pressure ; and in such a case it is impossible to diagnose between the tumour and the effusion round it. Many cases reported of gradual absorption of a fibroid tumour under treatment were probably cases of mistaken inflammatory exudation. PROGNOSIS. In forming our prognosis we must take into account (1) the site of the tumour in the uterus, most favourable when subserous; (2) its position in the pelvis, whether low down and likely to become wedged within it ; (3) the symptoms already present, of which haemorrhage is the most important ; (4) rapidity of growth, which by itself rarely forms a reason for interference. Though (as already said) they are rarely dangerous to life, they may cause the patient many years of suffering from which she only finds relief at the menopause. 1 Brit. Med. Journ. 1886, II. p. 474. CHAPTER XXXVII. FIBROID TUMOURS OF THE UTERUS : TREATMENT. LITERATURE. Atlec The treatment of the fibroid tumours of the uterus : Internat. Med. Cong. Trans., Sept. 1876. Bantock British Medical Journal, 1881, p. 426. Bigdow Gastrotomy for Myofibroma of the Uterus : Amer. Jour. Obstet. , Nov. and Dec. 1883, Jan. to March 1884. Duncan, Matthews Diseases of "Women : London, 1883, p. 289. Fritsch Bechzig Falle von Laparomyomotomie mit epikritischen Bemerk- ungen iiber die Methoden dieser Operation : Volk. Samml., No. 339. Greenhalgh On the use of the actual cautery in the enucleation of fibroid tumours of the uterus : London Med. Chirurg. Trans., Vol. LIX. Hegar u. Kaltenbach Die operative Gynakologie : Stuttgart, 1881, S. 416. Hofmeiei Die Myomotomie : Stuttgart, F. Enke, 1884. Keith Surgical treatment of tumours of the abdomen : Edinburgh, 1885. On Supra-vaginal Hysterectomy, with remarks on the principle of the Extra- peritoneal method of treating the pedicle : Brit. Med. Journ., Dec. 8, 1883. Thirteen cases of Hysterectomy, with remarks on Carbolic Acid Spray in Abdominal Surgery : Brit. Med. Jour. , Jany. 31, 1885. Lcblond Traite elementaire de Chirurgie gyne - cologique : Paris, ] 878. Martin Pathologic und Therapie der Frauenkrankheiten : "Wien und Leipzig, Urban und Schwartzenberg, 1887. Palmei Laparotomy and Laparo-Hysterotomy, their indications for fibroid tumours of the uterus : Americ. Gyn. Trans., 1880, p. 361. Schroedei Handbuch der Krankheiten der weiblichen Geschlectsorgane : Leipzig, F. C. "W. Vogel, 1886. Simpson, A. JR. The treatment of fibroid tumours of the uterus : Contributions to Obstetrics and Gynecology, Edinburgh, 1880. Sims, Marion On intra-uterme fibroids : New York Medical Journal, April 1874. Thornton Cases of Hysterectomy, with remarks on the value of the Carbolic Acid Spray in the operation : Brit. Med. Journ., May 23, 1885. Wells, Spencei On Ovarian and Uterine Tumours, etc. : London, 1882. See also references in the text, and Index of Recent Gynecological Literature in the Appendix. THIS is best considered under the heads of medical treatment, including that by electricity, and surgical treatment. MEDICAL TREATMENT. Under this head we include the administration of such medicines as ergot and hydrastis canadensis, and the use of electricity. There is no medicine which acts immediately upon fibroid tumours so Ergot in as to cause disintegration and absorption. We have, however, a very lbroids - important remedy in ergot of rye ; the beneficial effects of this have been brought forward by Hildebrandt, * and by A. R. Simpson, whose paper on the treatment of fibroids may be consulted for illustrative cases. 2 It acts beneficially in two ways by checking their nutrition through 1 Berl. L-lln. Wochetuchrift, 1872, Ko. 25. 1 Dobronrawow gives two cases in which size of tumour distinctly diminished Centralb. /. Gyn. 1886, S. 16. 426 AFFECTIONS OF UTERUS. Adminis- tration of Ergotin Subcu- taneously. Bromide of Potas- sium in Fibroids. diminishing the amount of blood circulating to them, and by favouring their pedunculation and expulsion ; these are both due to its action on the unstriped muscular fibre of the walls of the uterus and coats of the blood-vessels. 1 Success in its use depends, according to Simpson, on securing that the preparation of ergot used be active, that it be properly administered, and that the case be a suitable one. The formula for the preparation which he recommends is R Ergotinse 3"- Aquae 3 y i- Chloral-hydratis 3ss. M. Three grains of ergotin are contained in twelve minims of the fluid, which is a good medium dose. Chloral is added to make the solution keep ; but even with this it becomes after some weeks unfit for use, and should therefore be made up repeatedly and in small quantities. It is administered with the ordinary hypodermic needle. Care must be taken that the syringe contains no air ; this is best secured by holding it with the needle upwards and squirting out some of the liquid. The injection is made in the gluteal region, which is readily done when the patient is lying on her side ; and on the right and left sides alter- nately, so as to dimmish the frequency of punctures in the same region. Enter the needle vertically and plunge it rapidly deep into the muscle, the point entering to the depth of from an inch to an inch and a half ; now empty the syringe, and quickly withdraw the needle. After use, remember to cleanse the needle with water and to replace the wire in it. The patient soon becomes accustomed to the prick of the needle and, if it be entered deeply into the muscle, there is little fear of local suppuration ; after three years' experience we have seen this in but one case, and this was probably due to a bad preparation of the solution. For the first few weeks the injections may be made twice a week, afterwards only once a week. The treatment is continued for several months until its effect is seen in diminution of the size of the tumour or, at least, of the haemorrhage from it. The suitable cases are those in which the tumour is intra-mural or submucous ; " it must be surrounded by layers of muscular fibre, sufficiently developed to be capable of being excited to contraction. " When the patient cannot be seen frequently by a physician, a friend or a nurse should be instructed how to apply the needle. Ergotin can also be administered in the form of pill, suppository (4 grs. in each) or liquid extract (30 drops thrice daily). When given by the mouth, however, it does not act so quickly or surely as when given hypodermically. Hydrastis Canadensis, 2 fifteen minims to one drachm of the tincture or up to four drachms of the liquid extract, is now being used instead of ergot ; it does not disturb the digestive system by causing constipation as ergot sometimes does. Bromide of potassium was recommended by Sir J. Y. Simpson, who believed that it had a marked influence in checking the growth and even in reducing the size of fibroid tumours. Being a nervine sedative, it is useful in cases where the only symptoms are discomfort from the 1 Ringer Srit. Med. Journ., Jan. 19, 1884. 1 Rutherford gives five cases treated by it it controlled haemorrhage, but had no effect on size of tumour Brit. Med. Journ., 1888, II. p. 123. MEDICAL TREATMENT OF FIBROID TUMOURS. 427 presence of the tumour or neuralgic pain. As a prolonged use of the bromide is generally necessary, small doses (ten grains, three times a day) should be administered. When the patient can afford it, benefit is undoubtedly derived from a course of treatment of mineral waters (such as those of Kreuznach) as recommended for chronic metritis. In the case of growing tumours, keeping the patient on a low non- stimulating diet is beneficial ; the full diet and free use of stimulants, to which a patient inclines to make up for the loss of blood, rather favour the growth of the tumour. 1 The symptoms due to the weight of the tumour may be relieved by artificial support. Thus patients with a small fibroid often derive great benefit from wearing a Hodge pessary ; the discomfort of a large abdo- minal tumour is materially lessened by wearing a broad flannel bandage. When the tumour nearly fills the pelvis and is beginning to press injuriously upon the bladder and rectum, we should, when possible, push it up out of the pelvis into the abdomen ; this is done before the occurrence of pelvic peritonitis, which may hopelessly bind it within the pelvis. The most favourable case for this manipulation is a subserous fibroid with a distinct pedicle. TREATMENT OF FIBROIDS BY ELECTRICITY. More than twenty years ago, Tripier of Paris treated uterine fibro- mata with Faradisation, and as far back as 1867 Althaus wrote in the British Medical Journal on the electrolytic treatment of tumours ; 2 while in America in 1870, Cutter 3 began to use galvanism for the treatment of fibroid tumours. It is, however, to Apostoli that the credit is due of elaborating the electrical treatment of fibroids and bringing it prominently forward before the profession. 4 The technique will be more fully described in the chapter on Electri- city in the Appendix. Here we need only say that the internal electrode consists of a platinum rod the thickness of a uterine sound, sheathed in a vulcanite tube except over the portion within the uterus. The external electrode consists of a pad of clay laid on the abdomen, having a copper or leaden plate connected with the battery wire. The internal electrode is usually negative unless haemorrhage is the chief symptom, in which case it is made positive on account of the haemostatic action of that pole. The current strength used varies from 70 to 100 milliamperes for the first application, increased afterwards to 200 or even 250 milliamperes. 1 See J. Knowsley Thornton on the Treatment of Uterine Fibro-myoma Lancet, 1886, II., p. 811. 2 See letter by Althaus in the British Medical Journal, 18S7, I., p. 1364. 3 Amer. Journ. Obs., 1888, p. 384. 4 In his paper read at the Dublin meeting of the British Medical Association in 1887, "On the Treatment of Fibroid Tumours of the Uterus by Electricity with Observations and Complete Statistics of all the Cases so treated from July 1882 to July 1887. Brit. Mecl. Jour., 1887, II., 699. 428 AFFECTIONS OF UTERUS. Electricity in the treatment of fibroids is still on its trial. It is only two or three years old, and as yet we have not data for coming to any definite conclusion as to its value ; and there is a remarkable divergence of opinion on this subject. On the one hand, we have Keith, who has had great success in the removal of fibroid tumours by abdominal section, in one of his most recent utterances, x saying " Apostoli's treatment puts a woman with a fibrous tumour who suffers much into the position of a woman with a fibrous tumour who does not suffer or may be even unaware of its presence. It does not bring about the disappearance of the tumour, or it does so very rarely, but size is lessened more or less one-half, one-third, two-thirds "What I now plead for is, that for a time all bloody operations for the treatment of uterine fibroids should cease, and that Dr Apostoli's treatment as practised by him should have a fair trial. " On the other hand, we have Steavenson, who has charge of the Electrical Department of St. Bartholomew's Hospital, writing recently as follows 2 "In my paper referred to [St Bartholomew's Hospital Reports], I have said that 'compared with other methods it is probably the best short of actual operation.' I have admitted that the results are not so brilliant as we could have wished, or as we were led to hope they would be. All the palliative modes of treatment of uterine fibroids are eminently unsatisfactory, and the profession would have hailed with delight any mode of treatment that would have promised a cure. This certainly electricity does not accomplish, at any rate with tumours of any size ; but there is no doubt that in the majority of cases the symptoms are relieved, and one of the most troublesome that yields to electrical treatment is that of haemorrhage. Improvement will also take place under the administration of ergot and by the imbibition of the iodo-bromine waters of Kreuznach and Woodhall Spa. ... It certainly is a question whether in their case [i.e. hospital patients] the advantage obtained by the electrical treatment is sufficiently great over other modes of treatment as to call for the expenditure of the time and trouble necessary for carrying it out." From the foregoing it will be seen that the application of electricity to fibroids is in great measure a treatment of symptoms. It finds its place alongside of ergotin, being perhaps more certain, but, on the other hand, exacting more time and trouble in its use. Looking over the literature, and selecting only the reports of more than ten cases treated by this method, we find the following results : Apostoli 3 mentions 278 cases of "fibromata or hypertrophy of the uterus," treated by "4246 applications of the continued current of electricity" the positive pole being applied to the uterus or tumour 2518 times, and the negative 1726. As to results, he says, " I can affirm that when there has been no negligence and my advice has been fully acted upon, 95 times out of 100 permanent benefit has been acknowledged. " Cutter* records details of 50 cases, with the following results : 11 cured, 3 relieved, 25 arrested, 4 fatal, 7 non-arrest. Deletang 6 mentions its use in 97 cases, with the result that haemorrhage stopped, pain and functional disturbances were relieved, the fibromata shrunk, but this last result was not invariable. 1 Brit. Med. Jour., June 8, 18S9. 2 Lancet, April 6, 1889. 3 Brit. Med. Jour., 1887, II., p. 699. * Aimer. Jour. Obs., 1887, p. 113. 6 Brit. Med. Jour., 1888, II., p. 1412. SURGICAL TREATMENT OF FIBROID TUMOURS. 429 Skene Keith 1 mentions 13 cases, in all of which the tumour was reduced and symptoms relieved. In a later article, Thomas Keith 2 speaks of its having been used in considerably over 100 cases, the majority being uterine fibroids ; in every case, the tumour was reduced in size, haemorrhage and pain gone, and general health restored. J. H. Martin" mentions 14 cases, in which 4 were benefitted, 5 symptomatically cured, 5 completely cured. SURGICAL TREATMENT. This consists in the removal of the tumour through the vagina, or through the abdominal walls. Removal of the uterine appendages is also done with a view to check haemorrhage and the growth of the fibroid. a. REMOVAL THROUGH THE VAGINA. We have seen that this process takes place spontaneously, either by Removal pedimculation and extrusion as a polypus or by enucleation. In oper- of Polypl ' ating, we simply favour these natural processes. The former will be described under " Treatment of Polypi " (see Chapter XXXIX.). We favour enucleation of the tumour (1) by dilating or dividing theEnuclea- cervix uteri ; (2) by incision of the mucous membrane covering the s face of the fibroid ; (3) by stimulating the uterus to contract and expel it spontaneously from its bed, or by laying hold of and forcibly detaching it. These might be considered either as different consecutive operations, or as successive steps in the same operation. 4 The dilatation of the cervix is affected in any of the ways already described. Some- times this is all that is required. After dilatation or division of the cervix, the haemorrhage (which is usually the indication for the operation) ceases ; if the tumour is in the process of expulsion, this takes place more readily through the dilated cervix. Should this operation be insiifficient, we proceed next to incision of the mucous membrane covering the tumour. The purpose is twofold. (1.) It checks haemorrhage. We have referred to the existence of venous sinuses in the capsule of the tumour, from which profuse haemorrhage sometimes occurs (v. fig. 251) ; when these are cut through, they retract and are closed by thrombi. After this operation the haemorrhages are, for a long period at least, checked. (2.) It favours spontaneous enucleation of the tumour, which comes to protrude through the incised mucous membrane. The mucous membrane is incised either with the bistoury or with the thermo-cautery as follows. Carry a probe-pointed bistoury, which has the lower half of the blade sheathed, into the uterus through the previously dilated cervix ; make one or more incisions, about an inch long and from a quarter to half-an-inch deep, upon the surface of the tumour. The great danger of the operation is the introduction of septic matter ; to diminish this risk, Greenhalgh employs the actual cautery with an olive-shaped bulb to incise the mucous membrane and at the same time to destroy the heart of the tumour ; he also uses it to burn away, from time to time, portions of the tumour as they protrude through the capsule. It is evident that the cautery can be used only when we have an interstitial fibroid which has forced itself into one lip of the cervix and projects markedly into the roof of the vagina (v. fig. 249) ; or when a submucous fibroid 1 Edin. Med. Jour., xxxiii., I., p. 470, and xxxiii., II., pp. 670 and - Brit. Med. Jour. 1887, II., p. 1258. 3 Amer. Jour. Obi., 1888, p. (543. 4 Matthews Duncan Edin. Med. Jour., Feb. 1867. 430 AFFECTIONS OF UTERUS. has dilated the os sufficiently to become accessible to the cautery. The cautery, of which the Paquelin is the most convenient form, reduces the dangers of haemorrhage and septic infection to a minimum. The separation of the tumour should be le t to the natural efforts, and may extend over a period of months ; during this time, to promote uterine contractions, the patient is kept fully under the influence of ergot. Greenhalgh remarks that "spontaneous expulsive efforts shortly followed the use of the cautery." Should sloughing of the tumour occur during the process of natural enucleation, we interfere to remove the tumour rapidly. Even although there is no sloughing it is sometimes necessary to shell the tumour out of its bed. The detachment of the tumour from its capsule may be effected by A. R. Simpson's nail curette (fig. 254). It is intended, as its name implies, as a substitute for the finger nail which would be the best instru- ment were it only strong enough to scrape through the tissues. Thomas lias devised a similar instrument which has the form of an elongated spoon with a serrated edge ; it is worked with a pendulum-like movement of the hand. The advantages claimed for it are that it limits haemorrhage and, from its concave form, " hugs the tumour " so as not to cut deeply into the uterine wall. Before operating, he measures with a whalebone probe the extent of attachment of the tumour to the wall of the uterus. He has ' ' operated more than twenty times with this spoon-saw, and its efficiency becomes more and more apparent with increasing experience. " Dangers of With regard to enucleation and removal per vaginam, from the risks tion? ' f the operation, it is now done only when the symptoms justify a critical operation 1 or when nature has begun but is unable to complete FIG. 254. A. R. SIMPSON'S NAIL CURETTE The serre-noeud, The elastic ligature. 1 ArcUvf. Qyn. XXXII. S. 473. He has treated the last 9 of 23 cases thus and with the lest results. 1 Amer. Jour. Obstet., 1888, p. 004. SURGICAL TREATMENT OF FIBROID TUMOURS. 435 The extra-peritoneal method was, we believe, first attempted by Spencer Wells. Comparing the two methods, he says, " When it has Clamp, been possible to secure the pedicle and fix it outside the wound in the abdominal wall, the result has been much more satisfactory." Of 28 cases, in which the method is specified, 15 were extra- and 13 intra- peritoneal. In 6 of the 15 cases, the pedicle was retained in the wound by means of a clamp ; in the rest by means of the ligature, aided in some cases by use of a pin. The searing of the stump with the actual cautery without any Clamp and ligatures, is the modification of the extra-peritoneal method adopted Cautery * by Thomas. He uses a damp to arrest haemorrhage during the amputa- tion of the uterus and while the pedicle is being seared. It is in two separate portions ; the one half is placed below the neck of the tumour or uterus, and the other then adapted to it and screwed FIG. 258. PLAN'S CURVED NEEDLE FOR CARRYING THE WIRES THROUGH THE STUMP OF THE CERVIX (Leblond). down. To prevent retraction of the pedicle, it is before cauterisation transfixed above the clamp with long wire needles. After cauterisation the clamp is loosened, but left in situ for fourteen days so as to be screwed up should haemorrhage occur. The extra-peritoneal method has met with great success in the hands Serre- of Pean of Paris, who has the merit of having elaborated it as a distinct nceud - method. He operates as follows. The tumour having, if necessary, been reduced by "morcellement," it is drawn out of the abdomen and held perpendicularly by an assistant. The operator, having ascertained with a sound the relations of the bladder (which only in rare cases requires to be dissected off), transfixes the cervix with two strong wires at right angles to each other. Below these wires, the curved needle represented at fig. 258 is carried through the cervix and drags back 436 AFFECTIONS OF UTERUS. Keith's Method. fixed by up, but a double wire. This wire is divided, and each half is fitted into a serre-rweud of Cintrat (fig. 259) by means of which it is both tightened and twisted. The tumour and uterus are amputated above the wires. The pedicle is placed in the abdominal wound, and is kept from retracting into the abdomen by means of the wire and the serre-noeud ; these are left in position so that they may be tightened in case of haemorrhage. In Koeberle's serre-nceud (the one generally used in this country) the wire is not twisting the in- strument and wire are left on the stump so that the loop can be further tightened up at any time. Polk 1 advises stripping down the perito- neum round the stump so as to place the wire be- FIG. 259. tween the former and the muscular tissue, thus treat- ing the stump like an enucleated par- ovarian cyst. Keith, who has had the best re- sults of any operator, says with regard to the treat- ment of the pedicle, 2 "I have no one way in dealing with the attachments of uterine tumour. At present each case must be a law unto itself, and of this part of the operation there is much to be learned. A few of the simpler cases may be treated entirely extra- peritoneally. Generally the broad ligaments must be left inside ; and sometimes the whole attach- ment, when there is much enucleation, must be so treated. Sometimes the treatment may be entirely intra-peritoneal by means of Koeberle's serre-noeud, or it may be half intra- and half extra- peritoneal. These cases require much care in the after-dressing, though the convalescence is much shorter than when the whole is left outside. CINTRAT'S SERRE-NCF.UD (Hegar). The wire after having been placed round the neck of the uterus or tumour is tied on the two knobs which travel on the thread of the screw. On turning the handle when the middle piece is held firm at the larger loops, we tighten the noose ; when the head piece is held at the smaller loops, we twist the wire. The result is seen to the right hand side (Leblond). Artier. Jour. Obitet., 1889, p. 629. z Brit. Med. Jour., Jan. 31, 1885. SURGICAL TREATMENT OF FIBROID TUMOURS. 437 I am hopeful that the cautery will yet be the best and safest of all the methods of dealing with some of these tumours." In his monograph on " Surgical Treatment of Tumours of the Abdomen," he says, " At first I used Koeberle's instrument, which is still the best for this purpose ; but for long I have given it up in favour of a very large thin clamp, and I think that this is a safer way. I have not found sloughing take place to the extent that it does when a single wire merely embraces the pedicle. . . . Before applying the clamp, it is better to draw all the parts gently together by a thick silk ligature or by a soft wire. This prevents a too great spreading out of the parts between the blades, which would render the closing of the wound around the clamp somewhat trouble- some. As soon as the tumour has been cut away, he scoops out and disinfects the cervical canal in the stump. A satu- rated solution of perchloride of iron is then freely applied to the stump, the superfluous solution dried off, iodoform dusted over, and salicylic wool used as dressing. His clamp is shown at fig. 260. The elastic ligature was introduced by Kleeberg. Its method of employment has been devised and carried out by Hegar of Freiberg, in whose hands (as already said) it has produced good re- sults. Hegar's method consists in " con- striction of the uterine stump with elastic ligatures, exact closure of the abdominal cavity by stitching the peri- toneum round the stump, and antiseptic treatment of the latter with the cautery and chloride of zinc." Elastic Ligature. FIG. 260. KEITH'S CLAMP FOB SECURING THE PEDICLE EXTKA-PERITONEALLY. The abdominal incision is always made long enough to allow the tumour to be pro- jected through it without artificial diminution. Temporary sutures are placed along its margins to keep the peritoneum in relation to the skin. Vascular adhesions are ligatured in two places and divided between. The tumour is laid hold of with a dry towel by one assistant and raised out of the abdomen, while another presses the edges of the abdo- minal wound behind the advancing tumour ; the greatest care is required to hold the tumour steadily and vertically, as the stretched broad ligaments readily tear leading to hemorrhage. The relations of the bladder and the ovaries having been exactly ascer- 438 AFFECTIONS OF UTERUS. turned, the elastic ligature is placed round the cervix below the seat of amputation. This consists of a double ply of india-rubber ligature 5 millimetres thick. While kept at FIG. 261. NEEDLE FOR CARRYING THROUGH ELASTIC LIGATURE. It consists of a sharp curved point, and a canula split halfway up the side. A loop of the elastic ligature, stretched till it is thin, is drawn with a thread into the canula, which is then screwed into the steel point (Hegar und Kaltenbach). full stretch it is brought round the uterus and firmly knotted. Should this constriction of the whole stump be judged insufficient, it is further ligatured in two portions with the FIG. 262. TREATMENT OF FIBROID TUMOURS BY ELASTIC LIGATURE (Hegar und KalUnbach). a, Abdominal incision with the stump in its lower angle ; only the peritoneum is brought together with the lower sutures, while the upper sutures take in the whole abdominal wall. 6, Same in section, to show the trough floored by the peritoneum round the stump and the position of the elastic ligatures. elastic ligature. The needle represented at fig. 261 is used to carry through the stump a double ligature, which is then divided and tied round each half. The tumour and uterus SURGICAL TREATMENT OF FIBROID TUMOURS. 439 are amputated above these ligatures. The peritoneum is now carefully adapted round the neck of the stump beneath the elastic ligature ; the silk suture, which brings only the edges of the peritoneum together in the bottom of the wound just below the pedicle, is looped into the side of the latter (fig. 262 a) underneath the ligature (fig. 262 b) : the margins of the peritoneum above the pedicle are united in a similar way ; the next two sutures of the wound bring together only the peritoneum, while those further up bring together all the coats of the abdominal wall. Thus there is produced a space which surrounds the pedicle and is floored by the peritoneum ; to keep this space thoroughly dry and aseptic, is the aim of the after-treatment. The projecting end of the stump is thoroughly cauterised; the raw surfaces round it are painted with solution (3-10 per cent. ) of chloride of zinc ; and cotton wadding, which has been soaked in a 2 per cent, solution of the chloride and then thoroughly dried, is packed round the stump. Finally, the end of the stump alone is touched with 100 per cent, solution. The whole is covered with protective silk and carbolised wool, and the antiseptic dressing laid on so that it can be easily lifted. The space round the stump is kept thoroughly dry by repeated dressing (three or four times daily, according to amount of discharge) with the chloride of zinc wool ; the pedicle is pared away gradually with scissors to diminish its size, to allow the chloride to act more thoroughly, and to prevent pus from burrowing. The elastic ligature is clipped away about the tenth day. The abdominal wall is closed in three parts the peritoneum FIG. 263. MODE OF SEWING-U.P STUMP IN EXTRA-PERITONEAL TREATMENT OF PEDICLE (Fritsck). a vaginal wall, aa os externum, 6 cervical canal, d c d funnel-shaped raw surface left after excising mucous membrane, e peritoneum, / suture. with catgut, the aponeurosis and muscle with silk, and the skin with superficial sutures ; the lower angle of the wound (especially when the walls are fatty) is drained, the tube not passing into the peritoneal cavity. Another method of extra-peritoneal treatment of the pedicle, intro- duced by Fritsch, 1 does away with clamp or permanent elastic ligature and uses stitching only to control the vessels as in the intra-peritoneal method. After the tumour has been brought out through the incision, the upper portion of the latter is closed. The broad ligaments are ligatured in two places and divided between the ligatures, and the elastic ligature applied. After the tumour is cut away the end of the stump is stitched as in fig. 263. The elastic ligature is then removed ; and new stitches put in if there is bleeding, the uterine arteries being tied separately when visible. The broad-ligament pedicles are drawn up and stitched to the uterine stump, round which the parietal peritoneum is adapted (fig. 264 a). The sutures to close the abdominal wound are then passed, those next the uterine stump being passed through it (fig. 264 b). 1 Lot. clt. 440 AFFECTIONS OF UTERUS. He has had noteworthy success, having performed 19 cases after this method without any deaths. A similar procedure has been described by Kelly, x with the addition that he passes a ligature horizontally through each side of the cervix so as to constrict the uterine arteries. The pedicle has also been stitched in the abdominal incision so as to be kept extra-peritoneal while the abdominal wall was closed in over it so that it lay buried in the muscle. 2 In the last edition of this Manual we gave the i*esults of operations for the removal of fibroids generally for nineteen of the leading operators, which showed out of a total of 590 operations a mortality of 32*3 p.c. Such statistics which do not discriminate between the different opera- tions for fibro-myoma (v. p. 429) are now felt to be unsatisfactory ; to put the removal of a pediculated subserous fibroid alongside of extirpation FIG. 264 a. FIG. 264 b. MODE OK SUTURING WALLS AND PERITONEUM ROUND STUMP (FritucK). a vagina, 6 cervical canal, c apposed raw faces of o abdominal wound, 6 stump wound, stump, rf suture uniting parietal peritoneum e to c ends of broad ligaments, e lower stump, / suture closing raw surface of stump, g and / upper skin-suture, which suture tyingup broad ligament, h end of sutures d, keeps stump in position, g skin- i surface of abdomen, k abdominal wound, I stump sutures, h sutures uniting peri- of broad ligaments, m their upper margin. toneum to stump. of the greater portion of the uterus manifestly vitiates statistics. We have made the distinction wherever the material for doing so was furnished in the reports, but in very many cases this could not be done, as will be seen in the following references to the literature of the last three years which deal with those who have recorded ten operations and upwards. Albert of Vienna has done 12 supra-vaginal amputations with extra-peritoneal treat- ment of the pedicle, and 8 myomotomies, with only 1 death in the 20 cases. Bantock in a recently reported series of 100 cases of abdominal section* has 15 hysterec- 1 Amer. Jour. Obttet. 1889, p. 375. 1 By von Hacker and Rummel. F. N. Schmidt (Archivf. Gyn. Bd. XXXIII., S. 325) records a case treated successfully after this method. 3 Centralb.f. Gyn. Bd. XII., 8. 045. Lancet, 1887, I., p. 518. SURGICAL TREATMENT OF FIBROID TUMOURS. 441 tomies with 3 deaths, or a mortality of 20 p.c. ; but adding the 9 myomotomies in the series, the mortality is reduced to 12 '5 p.c. Braun' of Vienna reports on 38 cases of operation for fibroid, with 6 deaths, and is strongly in favour of extra- peritoneal treatment of the stump as both of the cases treated intra-peritoneally died. Fehling 2 of Stuttgart has done 10 supra-vaginal amputations, with 3 deaths. Taking with these his 4 myomotomies, we have out of the 14 cases, 11 extra-peritoneal with 1 death, and 3 intra-peritoneal with 2 deaths. Fritsch 3 of Breslau (if we deduct from his sixty -one operations those where the uterine cavity was not cut into) has had twenty intra-peritoneal with 9 deaths, and twenty-seven extra-peritoneal with 3 deaths. T. Keith, * now of London, records 26 operations (one being not for fibroid but for sarcoma), with 4 deaths. Taking along with these his previous series, he has a total of 04 cases with a mortality in hospital (38 cases) of 15 '7 p.c. and in private (26 cases) of 3'8 p.c. Krassowski 5 records 19 cases of operation for fibroids with 8 deaths, viz. 12 extra-peri- toneal cases with 6 deaths, and 7 intra-peritoneal with 2 deaths. Rein 6 of Kiew reports 10 cases of hysterectomy (9 treated intra-peritoneally) with 2 deaths. Tait 7 of Birmingham, in his second series of 1000 abdominal sections, mentions 88 hysterectomies (including myomotomies) with a mortality of 11 '3 p.c. the last 31 cases being without a death. Tauffer of Buda-Pesth" records 16 cases of hysterectomy for fibroid 8 extra-peritoneal with 2 deaths, and 8 intra-peritoneal with 4 deaths. Thornton 9 of London says he has operated 88 times for fibro-myoma with 14 deaths, 11 being in the first half and only 3 in the second half of his cases. Of cases by operators who report no fewer than 10 cases (mostly isolated cases) we have a total of 68 operations with 15 deaths. Of these, 33 were extra-peritoneal with 7 deaths, and 22 intra-peritoneal with 4 deaths ; in 13 cases with 4 deaths, it was not specified whether the treatment was extra- or intra-peritoneal. These last particulars are of little value from a statistical view, because the probability is that isolated unfavourable cases are often not recorded. These results show that the mortality of operations for fibroids is being, under improved methods, distinctly reduced. That it will ever be as low as in ovariotomy is doubtful, because these tumours, though frequent, only exceptionally endanger life and call for operation. A fibroid of the cervix may push its way into the cellular tissue and displace the peritoneum. Such an extra-peritoneal tumour may also be removed by laparotomy . * ganger ' ' reports on two cases of abdominal section for fibroid tumour of the cervix : in one, the pedicle was treated by the elastic ligature and dropped back ; in the other, the uterus was amputated and the stump stitched by Zweifel's method (see p. 434) and dropped back. Kelly * 2 also cut down on two fibroid tumours of the cervix and removed them with ecraseur ; no pedicle was tied, but the peritoneal cavity was drained and washed out for some days afterward. By ford 13 has removed a subserous fibroid of the cervix per vaginam. 1 Brit. Med. Journ., 1888, I., p. 211. 2 Centralb.f. Gyn., Bd. XI., S. 276. Loc. cit. * Brit. Med. Jour., 1887, II., p. 1257. 8 Centralb.f. Gyn., Bd. XII., S. 199. " Centralb.f. Gyn., Bd. XII., S. 852. ' Brit. Med. Join: 188S, II., p. 1096. He attributes the diminution in his mortality (which was 35 - 7 p.c. in his former series of 1000 oases) to tying the broad ligaments so as to strip them off the uterus before its amputation. Centralb. f. Gyn. Bd. XII., S. 123. 9 Lancet, 1S86, II., p. 212. 10 As in Thelen's'case : Centralb. f.Gyn., 18S5, No. 3. " Centralb. f. Gyn., Bd. XIII., S. 207. 12 Amer. Jour. Obstet., 1886, p. 45. 13 Amer. Jour. Obttet., 1888, 1205. 442 AFFECTIONS OF UTERUS. C. REMOVAL OP OVARIES OR OF UTERINE APPENDAGES. The removal of these, as we have seen (v. p. 209), usually stops men- struation and induces the menopause. Hence in the case of fibroid tumours this operation does good in two ways by checking bleeding and stopping the growth of the tumour. The mortality is also low (under 3 p.c.), so that this operation, were it always practicable, would have a wide field in the treatment of myoma. Unfortunately, it is frequently impossible to get at both ovaries in cases of large myoma ; while one is to the front and easily accessible, the other is to the back and sometimes low down towards the pouch of Douglas. The technique is the same as that described in Chapter XXL, with the excep- tion that a long abdominal incision is often necessary to allow the operator to pass the whole hand into the abdomen so as to get at the appendages. As to the mortality, the largest series recently published is by Lawson Tait, who had in 148 cases only 3 deaths. The other cases (37) which we have collected from the literature show a mortality of 5'4 p.c. SUMMARY AS TO OPERATIVE TREATMENT OP FIBROID TUMOURS. We may sum up the question of the treatment of fibroids, so far as it is known at present, as follows : (1.) When polypoid, or submucous and being expelled, treat as recom- mended in Chap. XXXIX. (2.) When subperitoneal, if causing no inconvenience, though large, leave them alone. (3.) When growing rapidly or threatening life from haemorrhage, and where the patient is not near the menopause, we may operate. (a.) We may remove the uterine appendages if they are accessible. It should be kept in mind that it is sometimes very difficult, or even impossible, to do so. (6.) Abdominal section and extra-peritoneal treatment of the pedicle by clamp or serre-nceud or stitching gives the best results. CHAPTER XXXVIII. FIBRO-CYSTIC TUMOUR OF THE UTERUS. LITERATURE. Alice Ovarian Tumours : Philadelphia, 1873. Beates Cystic leiomyoma of Uterus : Am. Journ. of Ohstet., 1884, p. 753. De Sindty Manuel de Gynecologic, Paris, 1879, p. 413. Diesterweg Ein Fall von cysto-fibroma verum : Zts. f . Geb. und Gyn. IX., S. 191. GrasskopffZur Kentniss der Cystomyome des Uterus : Munich, 1884. Gusserow Neubildungen, etc. : Stuttgart, 1885, S. 117. Heer Ueber Fibrocysten des Uterus : Zurich, 1874. Leopold and Fehling Ein Beitrag zur Lehre von den kystischen Myomen des Uterus (Myosarcoma lymphangiektodes uteri) : Archiv fur Gyn. , Bd. VII. , S. 531 . Peaslee Ovarian Tumours : London, 1873. Rein Beitrag zur Lehre von den lymphangiectatischen Fibromyomen des Uterus in pathologisch- anatomischer und klinischer Beziehung : Archiv f. Gyn., IX., S. 414. Schroeder Die Krankheiten der weiblichen Geschlechtsorgane, S. 213 : Leipzig, 1878. Sir Spencer Welh Ovarian and Uterine Tumours : London, 1883. Spiegelberg Die Diagnose der cystischen Myome des Uterus und ihre intraperitoneale Ausschalung, eine neue Operationsmethode derselben : Archiv f. Gyn., VI., S. 341. Thomas Diseases of Women, p. 551 : London, 1882. SYNONYM Cysto-fibroma. Attention has been directed only of recent years to this, the rarest form of uterine tumour. Its pathology is now being worked out, and at present we group under this head tumours which may afterwards be shown to be anatomically separable. Since ovariotomy has come to be extensively practised, they have derived clinical importance from their close resemblance to ovarian tumours. PATHOLOGY. The majority of fibro-cystic tumours are simply fibroid tumours which have become softened. The spaces between the bundles of fibrous tissue open out and contain serum ; the trabeculse between adjoining spaces give way, which allows these to run together to form larger cavities. Fig. 265 shows this in a subserous fibroid, which form most frequently undergoes this change. The term "cystic," is, it is evident, misleading as applied to this form of tumour. The cavities are not "cysts," that is, they do not possess a special wall. Kceberle was the first to suggest that some forms of fibro-cystic tumour Lymphatic might be due to dilated lymphatics. Leopold and Fehling have care- ongin - 444 AFFECTIONS OF UTERUS. fully described a case in which the cavities were lined with endothelium. The fluid from these cavities was of a clear yellow colour, and coagulated as soon as it was exposed to the air ; fibrin was present in it. To this form the name of Fibromyoma lymphangiektod.es has been given. Mtiller 1 has also described recently a preparation in which he found the epithelial lining present in the smaller cysts. Atlee says this coagula- tion of the fluid formation of colourless blood-clot is diagnostic of the fluid from all fibro-cystic tumours, and may be relied on to FIG. 265. LARGE THREE-LOBED FIBROID SPRINGING FROM THE FUNDUS BY A SOMEWHAT THIN PEDICLE, of which CF is cystic, while SsF and the dark shaded mass behind the uterus are subserous. This along with two smaller fibroids growing from the posterior surface of the uterus was removed by Laparotomy (Schroeder). distinguish them from ovarian. Spiegelberg records a case in which this spontaneous coagulation of the fluid was observed, but the most careful microscopic examination could detect no epithelial lining of 1 Beitrag zur kenntniss der cystoiden Uterustumoren : Archivf. Gyn., Bd. XXX., S. 249. FIB RO-CY STIC TUMOURS. 445 the cavities. A transition case has been described by Rein, in which the cavities were not themselves lined with endothelium but communi- cated directly with the lymphatic spaces. Mucoid degeneration of a fibroid tumour has been described byMucoid Virchow as Myxomyoma. In this case the interstitial tissue contained J? egenera " fluid rich in mucin and with numerous nucleated round cells. Sarcomatous degeneration of a fibroid 1 apparently also produces a cystic condition of a fibroid tumour although this is not a true fibro- cystic tumour. Cysts with an epithelial lining have been described by Babesin and Diesterweg. The latter removed on two occasions (with two years' interval) a submucous polypus with cysts ; the cavities were lined with ciliated epithelium and contained thin brownish blood. Baer on cutting through a similar polypus with the ecraseur was afraid that he had cut through the peritoneal cup of an inverted uterus, as the appearance of the section of the cyst resembled it. SYMPTOMS. These are the same as those of fibroid tumours, except that their increase in size is rapid. As they are usually subserous, menorrhagia is not often present. DIAGNOSIS; DIFFERENTIAL DIAGNOSIS. Their diagnosis is often difficult, as the difference in consistence between the more solid and the fluid parts may escape detection. The most important point to make out is the relation to the uterus, and the displacement of the latter which is produced. To ascertain its connec- tion with the uterus, we make the examination per rectum : to do this thoroughly, it may be necessary to anaesthetise the patient and to intro- duce two fingers ; the uterus is at the same time drawn down with the volsella. As to the displacement of the uterus, it is elevated towards the abdomen ; with an ovarian tumour, it is depressed to the front or to the back. The sound is now passed ; if the uterine cavity is increased in size, and more especially if the movement of the tumour by an assistant is immediately communicated to the sound, the tumour is probably uterine. Differential Diagnosis. Their diagnosis from ovarian tumours is the most important and, at the same time, the most difficult. As in the majority of cases they are merely altered fibroid tumours, their differ- entiation from a simple fibroid is merely a matter of degree of softness. In a case described by Beates as one of Cystic Leio-myoma of the uterus, the patient had been tapped twice ; and as the fluid gave the ovarian 1 As in Fenger's case (Awr. Jour. Obstet., 1888, p. 1200), and probably also Erich's (ibid. 1886, p. 517). 446 AFFECTIONS OF UTERUS. cell described by Drysdale (v. p. 222), the case was set down as undoubtedly one of ovarian tumours. The differential diagnosis from ovarian tumour is often not made till the abdomen is opened. TREATMENT. The treatment consists in removal through the abdominal walls, according to the method described for fibroid tumours (v. p. 430). References to recent cases of Laparotomy for Fibro-cystic tumours by Boldt, Byford, Dawson, Harsha, Marta, Morris, Miiller, Negri, O'Hara, Plimmor, Swiecicki, Lawson Tait, Walter, Wilson, and Wylie, will be found in the Index of Recent Gynecological Literature. Morris' 1 case has this special interest that it was a second case of operation, a fibro-cystic tumour having been removed from the same uterus eight years previously. 1 Lancet, 1888, 1., 973. CHAPTER XXXIX. POLYPI OF THE UTERUS. LITERA TDRS. Barnes Diseases of Women, p. 195 : London, 1878. De Sinety Manuel pratique de Gynecologic, p. 419 : Paris, 1879. Gusserow Die Neubildungen des Uterus, Bill- roth's Handbuch, S. 179 : Stuttgart, 1885. Hegar und Kalteribach Die operative Gynakologie, S. 473 : Stuttgart, 1881. Hicks, Braxton Three cases of very large polypi of the uterus, etc. : Obstet. Journ. of Great Brit., Jan. 1879. Kustner Notiz zur Metamorphose des Utemsepithels : Centralblatt f. Gyn. 1884, p. 321. Matthews Duncan Edin. Med. Journ. July 1871 ; and Obstet. Journ. 1873, p. 497. Simpson, Sir J. Y. Diseases of Women, p. 704 : Edin. 1872. Thomas Diseases of Women : London, 1880, p. 558. Underhill On the Structure of three cervical Polypi, and the Structure of a true mucous Polypus of the Cervix : Edin. Obst. Soc. Trans., Vol. IV., pp. 231 and 241. BY the term " Polypus " is understood a pediculated tumour attached to the mucous membrane of the uterus. It includes the following tumours, which are anatomically distinct : 1. Submucous fibroids, which have become pediculated and are in process of extrusion ; 2. Mucous polypi and adenoma ; 3. Pediculated cystic follicles ; 4. Placental polypi ; 5. Papilloma of the cervix. For clinical reasons, it is convenient to use the term polypus in its general sense as implying an external form alone ; the symptoms pro- duced by these tumours resemble one another, and their exact nature is sometimes not made out till they are removed. Pathologically, the term should be limited to mucous polypi. It is confusing to speak of a fibroid tumour which has a broad base of attachment as a submucous fibroid, and of one which has a pedicle as a fibrous polypus. The poly- poidal projections formed by pediculated ovula Nabothii are only pedi- culated retention cysts. Placental polypi are not true new-formations. 1. Pediculated submucous fibroid tumours form the so-called " fibrous Pedicu- polypi." They spring from the muscular wall of the uterus, usually late( * Sul) " from the body which, as we have seen, is more commonly the seat of Fibroids, fibroid tumours than the cervix. They are oifirm consistence, of a size varying from a goose's egg and upwards, and are of a rounded or pyriform shape (fig. 266), sometimes elongated and constricted through the pressure 448 AFFECTIONS OF UTERUS. of the uterine walls (fig. 248) ; the surface is smooth or marked with furrows corresponding to the fasciculi of fibrous tissue. Sometimes they are of such a size * that, although lying in the vagina, they fill the pelvis and press on the bladder and rectum ; the uterus is then raised above the pelvic brim (just as it is elevated when the vagina is distended with fluid), and is felt as a smaller body riding on the top of the tumour. Adhesions may form between the surface of the fibroid and the vagina, producing the impression that the tumour springs from the vaginal mucous membrane. 2 FIG. 266. FIBROUS POLYPUS LAID OPEN TO SHOW ITS IDENTITY IN STRUCTURE WITH A FIBROID TUMOUR (Sir J. Y. Simpson). The pedicle consists of a narrowing of the calibre of the tumour towards its base of attachment, or of a distinct stalk which may be long enough to allow the fibroid to lie at the vulva. As fibroid tumours are sparingly vascular, the pedicle does not as a rule contain large vessels. When a pediculated submucous fibroid lies in the cavity of the uterus, it sets up uterine contractions which lead to its expulsion ; there is a 1 Koeberle removed one weighing over 1J Ibs. (Centralb.f. Gyn. 1889, S. 263). 1 Braxton Hicks Loc. cit. POLYPI. 449 stage at which it lies partly within the uterus (fig. 267), partly in the vagina (the portion constricted by the cervix has been mistaken for a pedicle, and only the lower lobe of the hour-glass tumour removed) ; finally, the whole tumour lies in the vagina but still maintains its con- nection with the uterus through its pedicle (fig. 268). The congestion of the fibroid excites uterine contractions, specially at the menstrual period, FIG. 267. INTRA-UTERIXE SUBMUCOUS FIBROID WHICH is BECOMING VAGINAL (Sir J. T. Simpson). and thus favours its expulsion. At those times only, we may have the cervical canal temporarily dilated and the polypus projecting through it; after the period, the contractions pass off and the polypus is retracted into the uterine cavity. This condition is fully described by French writers under the name of "polypes a apparations intermittentes." Its practical importance is that we should examine sometimes at the men- 2P 450 AFFECTIONS OF UTERUS. Mucous Polypi. strual period, when a polypus (not recognisable at other times) may be felt through a dilated cervix. They have the microscopic structure described at p. 404 (v. fig. 266). 2. Mucous polypi are developed from the mucous membrane of the uterus, most frequently from that of the cervix. They are of soft pulpy consistence, of about the size of an almond rarely larger and have a flattened form; usually, there are more than one present (fig. 269). They are extremely vascular and have the microscopic structure of the mucous membrane from which they are developed. The typical cervical polypus has the structure seen at fig. 270 ; the student should compare this with the section of the normal mucous membrane given at p. 20. From the fact that the gland-ducts appear as FIG. 268. SUBMUCOUS FIBROID WHICH HAS COME TO LIE WHOLLY IN THE VAGINA (Sir J. Y. Simpson) channels on the surface, it was described by Oldham as the " channelled polypus." Sometimes the polypus shows also the stratified epithelium of the vaginal aspect of the cervix, as in a specimen described by Underbill ; he supposes that in this case it sprang from the margin of the os exter- num : he describes also a polypus which sprang from the vaginal aspect and showed only the stratified epithelium. Kustner has shown that stratified epithelium may be found on mucous polypi which have grown high up in the cervical canal ; this is another example of how the single- layered uterine epithelium may become changed into stratified epithelium (cf. Zeller's Observations, p. 318). These polypi sometimes form the POLYPI. 451 starting-point of malignant disease ; Underbill traced the commencement of sarcomatous formation in one case. FIG. 269. GROUP OF Mucous POLYPI GROWING IN THE CERVIX UTERI (Sir J. Y. Simpson). De Sinety divides them into two groups according as they spring (1) from the cervix, (2) from the body of the uterus. Each has the FIG. 270. SECTION OF A Mucous POLYPUS OF THE CERVIX *f-. g dilated glands, e epithelium, mf muscular fibre, v blood- vessel, ct connective tissue (De Sinety). characteristic epithelium (see p. 19) lining the ducts and cysts; the 452 AFFECTIONS OF UTERUS. former have the columnar non-ciliated epithelium of the cervix, the latter the ciliated cylindrical epithelium of the body. A localised hypertrophy of the glands of the uterus has been described by Schroeder as adenoma polyposum; the changes resemble those of glandular endometritis (v. p. 316). Williams, in his recent monograph, 1 describes four cases of adenoma of the cervix, two being simple villous growths and two being malignant. 3. Pediculated Nabothian follicles have been already described under cervical catarrh (p. 306). Placental 4. Placenta! or fibrinous polypi. These are produced as the result of Polypi. incomplete detachment of the placenta; in some cases we can trace placental villi in their structure. On the surface of this irregularity of the mucous membrane, blood coagulates; and thus the fragment of FIG. 271. NON-MALIGNANT PAPILLOMA OR FIBROMA PAPILLARK or CEKVIX (Actermtmri)* placenta grows larger through being coated with fibrin. This increase in size may go on until the polypus is the size of an egg. This form of polypus is not a new formation and only finds a place here on account of its polypoidal form. When it sets up a foetid discharge and the patient becomes cachectic, it may simulate malignant disease of the uterus. 2 After an abortion, 3 they may form in the same way : a piece of decidua left in the uterus maintains its structure and vitality and nutritive connection with the tissues below. 5. Papilloma of the cervix. Simple papilloma of the cervix is a very rare form of tumour ; the great proportion of papillary tumours found 1 Cancer of the Uterus : London, 1888, pp. 40-44. a As in the case reported by Baer : Am. Journ. of Obstet. 1885, 192. * Kiistner Beitrage zur Lehre Ton der Endometritis : Jena, 1883. POLYPI. 453 here are malignant (carcinomatous or sarcomatous). Fig. 271 shows such a tumour, described by Ackermann, 1 which sprang from the anterior lip of the cervix. It consisted of a branching stem of connec- tive tissue, with papillae covered mostly with squamous but in some places with a single layer of cylindrical epithelium. There was no recurrence after removal. The term "cauliflower" excrescence, intro- duced by Clarke, describes very well the appearance of these tumours. Virchow has shown that in many of these papillomata we find proliferation of the epithelium, and that they form the first stage of epithelial cancer of the cervix (v. p. 464) ; we must therefore regard the cauliflower excrescence as, in the great proportion of cases, a malignant tumour. SYMPTOMS. These are Haemorrhage, Leucorrhoea, Dysmenorrhoeal pains, Sterility, Irritation and discomfort. The haemorrhage shows itself first as an increase of the ordinary men-Hsemor- strual flow ; afterwards, it comes at irregular intervals. In the case of a submucous fibroid, it comes from the uterine mucous membrane which is hypertrophied. In the mucous polypus, it comes from the tumour itself which is vascular and bleeds easily ; when the polypus protrudes through the cervix, there' may be haemorrhage 2 (v. the preparation represented at fig. 94). In other cases the drain of blood, though not directly fatal, may produce profound anaemia ; hence the importance of ascertaining and removing the cause of the haemorrhage. The cachectic appearance of the patient, thus induced, may be such as to lead us to form a strong prepossession in favour of the existence of malignant disease before we proceed to physical examination. The leucorrhosa is due to the endometritis which is always present. Leucor- The polypoidal retention cysts are the result of a chronic catarrh of the r cervix or uterus. It is disputed whether mucous polypi are the cause or the result of the inflammatory changes ; De Sinety inclines to the latter view. When the polypus comes to lie in the vagina, it produces an irritating vaginal leucorrhrea. The dysmenorrhoeal pains are due to the muscular efforts of the uterus Dysmen- to expel the polypus, and are most marked when the polypus hasp a i ns descended to the os internum or lies in the cervical canal. In rare cases the presence of the foreign body in the uterus has produced the sympathetic phenomena of pregnancy pigmentation of the breasts and abdomen and morning sickness. 1 Virclww'sArchiv: Bd. XLI1I. S. 88. 2 Barnes records the case of a woman of twenty-six years of age in which a polypus the size of a walnut produced a fatal haemorrhage. 454 AFFECTIONS OF UTERUS. Sterility. Sterility is occasioned by the mechanical obstruction of the polypus, either in the cervical canal or at the entrance to the Fallopian tubes. The obstruction in one case was not sufficient to prevent the spermatozoa from passing upwards, but hindered the entrance of the fertilised ovum into the uterine cavity and thus produced Fallopian-tube gestation. A pediculated fibroid may form a serious complication to labour, in preventing the progress of the child's head ; such a polypus has been laid hold of with the forceps under the impression that it was the presenting head. They may also give rise to haemorrhage in the puerperium. x FIG. 272. PEDICULATED SUBMUCOUS FIBROID, springing from the fundus, which has not dilated the cervical canal (Sir J. Y. Simpson). DIAGNOSIS. 1. When the polypus has dilated the os externum, it will be recognised by the finger per vaginam. If it be larger than a walnut and of firm consistence, and if the uterine cavity be increased in length, it is a 1 See paper by Halliday Crooni on Fibrous Polypi complicating the puerperiiim : Edin. Med. Journ. XXXII. I., p. 289. POLYPI. 455 pediculated fibroid tumour. If it be small and of a pulpy consistence, it is a true mucous polypus ; mucous polypi do not, as a rule, produce hypertrophy of the uterus. Having learned that there is a pediculated body in the vagina or cervical canal, carry the finger upwards to ascertain its point of attach- ment ; if this be high up in the uterine cavity the tumour is a pedicu- lated fibroid; if it springs from the cervical mucous membrane, it is probably a mucous polypus. On bimauual examination, the uterus is found to be enlarged in the case of pediculated fibroids; it is not enlarged with mucous polypi, unless from associated chronic metritis. The speculum shows that the surface of the true mucous polypus has a bright cherry-red colour, which contrasts with the darker red of the cervical mucous membrane embracing it. The appearance of the fibroid tumour depends on the condition of the investing mucous membrane which is often ulcerated or sloughing ; when the capsule has given way, the fibrous substance of the tumour is seen to be of a paler colour. 2. When the uterus is enlarged but the os externum not dilated, the diagnosis is more difficult (fig. 272). If the uterus be markedly enlarged and of firm consistence and (the possibility of pregnancy being excluded) the sound pass for 4 or 5 inches, there is probably a submucous fibroid tumour. It is difficult to determine whether it is pediculated or not. We endeavour first to pass the sound round the tumour or upwards on different sides of it. Fig. 253 shows how the sound passes in a case of a pediculated tumour attached to the fundus. The sound must be used with care as its use is not unattended with risk ; laceration of the mucous membrane, with the introduction of septic matter, has resulted from too free and repeated exploration in this way. Dilatation of the cervix and exploration with the finger are sometimes necessary to ascertain whether the fibroid be pediculated and to what part of the uterus it is attached. 3. When the uterus is not much enlarged, the diagnosis is very difficult. The possibility of a fibroid tumour is excluded. A small mucous polypus, however, may exist in the uterine cavity and escape detection with the sound. In such a case, it is recognised only on dilating the cervix and exploring the uterine cavity with the finger. The curette is a valuable aid to diagnosis when the actual exploration of the uterine cavity with the finger is not desirable. By its use we diagnose and treat the case at the same time. Thus irregularity of the uterine surface (which is easily detected by the curette) and the character of the scrapings removed, may show that we have to do with pediculated retention cysts or placental polypi. 456 AFFECTIONS OF UTERUS. DIFFERENTIAL DIAGNOSIS. The characters which distinguish a pediculated fibroid from a mucous polypus are its larger size, firmer consistence, and its springing from the body of the uterus. The uterine cavity is increased in size. We probably find, also, other fibroid tumours interstitial or subserous. A pediculated fibroid hanging down into the vagina, may readily be mistaken for the inverted fundus uteri ; this is most likely to happen FIG. 273. o, Uterus with a portion of the anterior wall cut out ; 6, pediculated fibroid attached to back wall immediately above os internum. The front of the bony pelvis has been removed ; cc, halves of divided bladder (A. R. Simpson). when there is much haemorrhage from the former, and when concomi- tant pelvic inflammation makes examination difficult. A true diagnosis here is all-important, as removal of the fibroid may save the patient's life ; while amputation of the uterus, under the supposition that it was a fibroid, might lead to disastrous consequences. The preparation shown at fig. 273 is interesting in this connection. The case had been sent into hospital as one of inverted uterus. It is evident how the form of POLYPI. 457 the tumour in the vagina and the fact that it bled freely, would in the absence of further examination lead to this mistake. Given a tumour the size of a pear hanging down through the cervical canal into the vagina, we wish to make sure that it is not the inverted body. First, sweep the finger carefully round the neck and note whether the mucous membrane of the cervical canal is reflected on to the neck of the tumour ; sometimes inflammatory adhesions round the neck produce a condition simulating inversion. Now make the Bimanual ; if the body in the vagina be a fibroid, the uterus will be in its normal place. The abdomino-vaginal examination is often difficult on account of the body in the vagina ; therefore pass the finger into the rectum, through the anterior wall of which we can distinctly feel whether the cervix has a truncated end above (inversion) or passes up into the body of the uterus (fibroid) ; the abdomino-rectal makes this more evident. When examination is difficult and the diagnosis doubtful, we should not hesitate to give chloroform and make a thorough examination; it is well to be prepared to operate at the same time, if necessary. Finally use the sound, which is an important test. Sweep the finger carefully round the neck of the tumour and feel for a depression cor- responding to the os, into which endeavour to introduce the sound. If it passes for two and a half inches or more and is then arrested, it is probably in the uterine cavity ; make sure of this by pressure with the hand on the abdomimal wall, or per rectum. When the tumour in the vagina fills the pelvis or rides above the brim, so that the finger cannot reach the pedicle or feel whether the os is present, the diagnosis is very difficult. We rely on careful abdominal palpation to ascertain whether the uterus can be felt resting on the top of the tumour. We must not forget that we may have both conditions present, i.e., pediculated fibroid + a certain amount of inversion. PROGNOSIS. The prognosis as to danger to life will depend on the haemorrhage. Wherever a polypus is present, we should advise its removal. As to the operation, the removal of mucous polypi and smaller fibroids is safe and easy. The fear of haemorrhage from the pedicle of a fibroid tumour, which led to the treatment by ligature, has been found by experience to have been exaggerated. Where there is a rigid cervix to be dilated before we can remove the tumour, where the tumour is large so that it must be removed in portions, where there is a thick pedicle and consequently a larger raw surface, the operation will be a more serious one and the prognosis given more guardedly. Should there be pregnancy, the polypus may be removed without 458 AFFECTIONS OF UTERUS. interrupting its course. If it be of such a size as to interfere with labour, it should be removed as soon as discovered. TREATMENT. Whenever it is necessary to dilate the cervix for diagnosis, we should have instruments ready to remove the tumour at the same time. The dilata- tion is effected by laminaria tents, or by Tait's graduated dilators. A good method is to place a laminaria tent in the cervix to start the dilatation ; after six or eight hours chloroform the patient, fix the cervix with volsellse, and introduce the graduated dilators in succession till the cervical canal is wide enough to admit the index finger; remove the polypus by the means to be described ; wash out the uterine cavity with 1 to 60 carbolic solution. Small polypoidal projections are re- moved with the curette, as described under Endometritis, followed by the application of carbolic acid. Mucous polypi are twisted off with the forceps, shown at fig. 274. It is advantageous to use forceps with a catch, as this keeps a steady hold of the tumour and leaves the operator's fingers free to twist the forceps round. In removing fibroids, we first ascer- tain the seat of insertion and size of the pedicle. When the tumour is small, we can learn this by the fingers ; when so large that we cannot get the fingers past the tumour to the pedicle, we probe round its base with the sound or, laying hold of the tumour with forceps, en- deavour to rotate it and thus test the thickness of the pedicle. The pedicle will yield to torsion with the forceps. This is the simplest method and should always be tried in the first instance ; the forceps shown at fig. 257, or a pair of Nekton's forceps (fig. 141), are most suitable. If this fail, divide the pedicle with curved scissors. Make traction FIG. 274. FORCEPS WITH CATCH FOR REMOVING Mucous POLYPI. POLYPI. 459 with the forceps to render the pedicle tense ; too forcible traction might produce inversion. Guarding the uterine wall with the fingers, carry in the curved scissors. In cutting, make the scissors hug the surface of the tumour and tlms keep clear of the uterine wall. Strangulation by ligature, formerly widely practised, is now entirely abandoned ; the sloughing stump was a fruitful source of septicaemia. When the pedicle is of considerable thickness, it may be divided with the ecraseur or with the gal vano- caustic wire. The wire ecraseur is preferable to the chain ecraseur, as it is more easily applied. For the nature and method of use of the ecraseur, the student is referred to Treatment of Carcinoma of the Cervix. When the size of the tumour makes the pedicle inaccessible, it must be diminished. This is best effected by Hegar's method : traction is made on the tumour, which is at the same time incised in a spiral manner with scissors ; the tumour is thus (as it were) unwound, till finally the pedicle is reached and divided. Chloroform is not necessary for the removal of smaller polypi. The section of the pedicle is painless ; if pain be present on tightening the ecraseur round the neck of a polypus, the operator should examine care- fully again to make sure that the wire is not constricting the inverted funclus. Where the polypus is large and the operation tedious, it is better to have the patient anaesthetised as the operator has then more freedom. CHAPTER XL. CARCINOMA UTERI (OF CERVIX): PATHOLOGY AND ETIOLOGY. LITERATURE. Harbour Cases of Carcinoma of the Female Pelvic Organs: Edin. Med. Jour., July 1880. Barnes Diseases of "Women, p. 821 : London, 1878. Gusserow Die Neubildungen des Uterus, S. 199 : Stuttgart, 1885. Ueber Carcinoma uteri, Volk- mann's Samml. klin. Vor., N. 18. Huge and Veit Zur Pathologie der Vaginal- portion : Stuttgart, 1878. Der Krebs der Gebarmutter : Stuttgart, 1881. Schrocder Die Krankheiten der weiblichen Geschlechtsorgane, S. 264 : Leipzig, 1878. Simp- son, Sir J. Y. Diseases of Women : Edinburgh, 1872, p. 140. Tanner On Cancer of Female Sexual Organs : London, 1863. Virchow Ueber Cancroide und Papillargeschwiilste, 1850. Williams Cancer of the Uterus : London, 1888. The student will find the fullest references to literature in Gusserow's and Ruge's. THUS far we have considered only the simple or benign tumours in the uterus. We pass now to the malignant ; and these present themselves in three forms Malignant Adenoma, Carcinoma, and Sarcoma. The first two differ from the third in that, while they are of an epithelial, it is of a connective-tissue type. And the first two differ between them- selves in that the one builds itself on the plan of the uterine glands, the new-formed tissue being a reproduction of the branching cervical glands or the tubular glands of the body of the uterus, while the other produces epithelium in an irregular manner in clusters and strings embedded in a proliferating connective tissue. The former type of growth is rare in malignant tumours of the xiterus, and our knowledge of it as yet scanty ; so that, although we shall have occasion to refer to malignant adenoma, we do not describe it as a separate variety of tumour. The cervix, as we have seen, differs anatomically from the body of the uterus ; it also differs pathologically, i.e. is distinctly marked off from the body of the uterus as regards some of the morbid processes to which it is liable. We have seen that while the body of the uterus is the common seat of fibroid tumours, the cervix is rarely so ; in cancer the opposite condition obtains, for the body is rarely, while the cervix is very often, attacked by it* When cancer of the uterus is spoken of, it is in fact almost always cancer of the cervix that is meant ; and it is the latter that we have chiefly to consider here, for only about 2 p.c. of cases of cancer are in the body, the remaining 98 p.c. being in the cervix. CARCINOMA UTERI: PATHOLOGY. 461 PATHOLOGY. On no subject in pathology has more been written and a greater variety of opinion expressed than on carcinoma. We have endeavoured to arrange, in the table on the following page, the facts most important for the student to know. CLASSIFICATION. There are three varieties of carcinoma usually given in the English text-books. These are medullary (encephaloid) and scirrhous cancer, and epithelioma. Now the distinction between the first two is merely a question of degree ; in the former the cellular element, in the latter the fibrous stroma is in excess. When we say that medullary cancer is frequent but scirrhous rare, we only mean that carcinoma runs a rapid course when it occurs in the uterus. The distinction between these two and epithelioma is more marked and is therefore given in the table, but it is very doubtful whether it rests on a pathological basis. From the above it is evident that we are not yet in a position to make a scientific classification. The division according to clinical features into true carcinoma and cancroid (xapKlvos and elSos, like cancer) is con- venient : it expresses nothing more than that in some cases progress is more rapid than in others ; and that the disease in the one case pro- duces metastatic deposits, in the other remains local. ORIGIN. As regards the origin, there are two distinct views. That the disease Virchow's arises from connective-tissue cells alone, is the view maintained by Virchow iew ' and his followers ; while Thiersch and Waldeyer hold that in all cases it View of originates in epithelial cells. In the cervix, as possible sources, there ar e an( j ers two varieties of epithelium; the squamous on the vaginal aspect, the Waldeyer. cubical lining the canal. In the flat cancroid of the cervical canal, it arises from the cubical epithelium which lines the latter ; in the papil- lary form, it originates in the cells of the rete Malpighi on its outer aspect (Klebs). It will be seen that Waldeyer holds the view that, in all cases, it arises from the latter only. More recent investigations into the origin of carcinoma are by Euge Huge and and Veit. According to them carcinoma arises, in the majority ofi nvest ; ga _ cases, from a transformation of the connective-tissue cells ; even the tions. papillary form which produces the so-called cauliflower excrescence, although it apparently springs from the epithelium, is developed from the connective - tissue cells. The connective - tissue stroma becomes vascular and almost like granulation tissue. The young cells, which are apparently produced from the connective-tissue corpuscles, take on an epithelial character. These observers never saw plugs of epithelium extending downwards into the connective tissue. aiq^qsmSui^sip .reSuoi ou 8J suuoj asai^ 'paonp -oad uaaq OABIJ OAVOp r IS l-i ^ a ^ bS S III! 6 H fc. o D ^ ' . D 1 . o - CARCINOMA UTERI: PATHOLOGY. 463 Williams, on the other hand, in figuring a specimen like one by Ruge and Veit, says that the hypertrophied connective-tissue papilla pushing FIG. 275. CANCER or THE VAGINAL PORTION (/. Williams). a. Normal squamous epithelium in the vaginal aspect of the cervix ; I. processes of cancerous cells which have developed from it. their way through the proliferating cancerous epithelium (the super- ficial living layers of which are shed in places) produce only an appear- ance of their being the starting-point of the disease. FIG. 275.* CANCER OF THE CERVIX PROPER (/. Williams). a. Normal columnar epithelium lining a gland within the cervical canal ; 6. cancerous cells derived immediately from it. According to the place in the cervix in which it begins, we distinguish Cancer of the Vaginal Portion from Cancer of the Cervix proper an 464 AFFECTIONS OF UTERUS. important distinction which we owe to Ruge and Veit. It is difficult to draw an imaginary line which would divide the cervix into these two parts ; but if we hold to an exclusively epithelial origin for cancer, we can define the former as cancer beginning in the squamous epithelium on the vaginal aspect, the latter as cancer beginning in the columnar epithelium lining the canal. Figs. 275 and 275* illustrate the origin of cancer-cells from these two sources. Cancer of the vaginal portion is the rarer of the two forms. z POSITION. Three There are apparently three places in the cervix where carcinoma may in* Cervix, develop. (!) It ma y begin as hard nodules in the substance of the cervix underneath the mucous membrane ; these increase in size, come to the surface of the mucous membrane (fig. 276), and produce ulceration. (2.) More rarely does it commence in the interior of the cervical canal and spread along its mucous membrane so as to excavate the canal. (3.) FIG. 276. CARCINOMATOUS NODULE GROWING IK ONE LIP OF THE CERVIX AND PUSHING THE Mucous MEMBRANE OUTWARDS. The figure to the right is a section of the cervix made through the line x (Sckroeder). It may appear on the vaginal aspect of the cervix as an ulcerating surface (fig. 278) or as an irregular papillary tumour, which, extending down- wards into the vagina, attains considerable size. Form of It is important to remember that there is a form of slow ulceration Ulceration on *^ e sur f ace of the vaginal portion which is not malignant. John not malig- Williams 2 described this as " corroding ulcer of the os uteri : " it begins at the os and extends symmetrically downwards into the vagina, without hard or thickened edges, extending by simple ulceration or the formation of reddish raised tubercles which ulcerate ; in one case, there was calcification of the internal iliac arteries ; of three cases observed, the duration was in one for two years and in two for ten years. According to Matthews Duncan, this is a form of lupus which we shall have to notice specially as an affection of the vulva. 1 Seven undoubted cases of it, and fifteen of cancer of the cervix proper, are described in Williams' monograph. 1 Brit. Med. Jour., April 5, 1884. CARCINOMA UTERI: PATHOLOGY. 465 There is also a form of adenoma which, though it is not malignant (v. p. 452), tends to become so. Fiirst 1 has recorded a very interesting case of this in which the amputated cervix showed only the appearance of a cysto-adenoma, while 18 months afterwards the patient died of true cancer of the cervix. PROGRESS. During the first stage we may distinguish the three forms, but after ulceration has occurred they pass into one another and are no longer distinguishable. As regards the further progress, there are three modes of the spread- ing of the disease ; first, upwards into the body of the uterus ; second, downwards into the vagina; and, third, into the connective tissue of FIG. 277. MICROSCOPIC SECTION OF A PORTION or THE CERVIX UTERI SEEN IN FIG. 276. e squamous epithelium in several layers ; c carcinomatous nodule ; between these is seen a portion of inflamed mucous membrane covered with a single layer of epithelium (Schroeder). the pelvis. This last is the most important. It takes place either by a continuous infiltration of the adjacent connective tissue, or as a chain of nodules running in the direction of the utero-sacral ligaments ; these nodules, probably, correspond to lymphatic glands. Cancer of the vaginal portion, according to Ruge and Veit, rarely spreads into the cervix but extends laterally into the fornices and adjacent connective tissue ; cancer of the cervix spreads upwards into the uterus and also to the connective tissue. We shall see the impor- tance of this, when we consider the extirpation of the uterus (v. p. 494). In cancer of the cervix, Abel and Landau 2 have found changes in the 1 Ueber snspectes iind malignes Cervix-Adenom : Zeits. f. Gel. u. Gyn., XIV., S. 352. - Ueber das Verhalten der Schleimhaut des Uteruskorpers bei Carcinom der Portio vaginalis : Archie f. Gyn. XXXII., S. 271, and XXXV., S. 214. 2 G 466 AFFECTIONS OF UTERUS. mucous membrane of the body also not only those of chronic inflamma- tion, but also of carcinomatous degeneration ; they further found micro- scopic changes exactly similar to sarcoma, but which might be the first stage of carcinoma of the body. Eckart, 1 on the other hand, found only hyperplasia of the glands with papillary proliferation into their lumen, i.e. endometritis glandu- laris. Saurenhaus, from the examination of a still larger amount of material, 2 has shown that the changes, though extensive, are of a benign charac- ter, whether we characterise them as a hyperplastic endometritis or a simple adenoma. FIG. 278. SECTION OF A FLAT CANCROID (EPITHELIOMA) OF THE CERVIX. squamous epithelium, cc carcino- matous cells ; between these is seen some granulation tissue (Schroeder). EXTENSION TO NEIGHBOURING ORGANS. In its further progress, the carcinomatous growth invades the sur- rounding organs. Pushing its way forwards in the cellular tissue between the bladder and the uterus, it involves the mucous membrane of the former ; it first produces vesical catarrh, then sloughing of the walls, and finally vesico-vaginal fistula. The bladder is affected in a considerable proportion of cases ; of 311 cases of cai-cinoma this occurred in 41 per cent., fistula resulting in 18 per cent. (Gusseroio). From the position of the ureters, they are frequently involved. The carcinoma- tous growth may press upon the ureters near their point of entrance into the bladder ; or it infiltrates their walls, and the consequent thickening 1 From the examination of ten uteri extirpated by Kaltenbach for cancer of the cervix : Centmlb. f. Oyn., 1888, S. 426. 2 Fifty uteri extirpated for cancer : Centralb.f. Oyn., 1888, S. 755. CARCINOMA UTERI: PATHOLOGY. 467 produces constriction at the part affected. Dilation of the ureter above thus results, which produces hydronephrosis and finally atrophy of the FIG. 279. CARCINOMA beginning in the CERVIX UTERI, and ending in the production of recto-vesico-vagical fistula (Farre). kidney. The frequency of this condition will be apparent from the fact that Blau found it present in 57 out of 93 post-mortem examinations. FIG. 280. VERTICAL MESIAL SECTION OF PELVIS, FROM CASE OF CARCINOMA UTERI, a, Perineal body ; b, Symphysis pubis ; c, Kectum ; d, Body of Uterus ; e, Small fibroid ; /, Urethro- vaginal septum ; g, Bladder. A small tube passes between bladder and excavated cervix through a fistula (Barbw.r). Artaud describes two degrees of kidney affection : with moderate 468 AFFECTIONS OF UTERUS. pressure, the kidney is slightly enlarged and shows hypertrophy of the glomeruli and dilatation of the convoluted tubules with small-celled infiltration round both of these and the arteries ; (2) with greater pressure, dilatation of the ureters and atrophy of the kidney. More rarely does the carcinomatous infiltration extend backwards into the rectum and produce recto-vaginal fistula ; of 282 cases the rectum was affected in 18 per cent., fistula resulting in 8*5 per cent. (Gwserow). 1 When both bladder and rectum have been opened into, a common cloaca is produced as in fig. 279. Perforation into the peritoneal cavity is rare. The peritoneum is not simply pushed forward, but is taken up into the carcinomatous growth. As this process goes on, adhesions are constantly being formed between the walls of the peritoneum in front of the growth so that it does not FIG. 281. VERTICAL MESIAL SECTION OF PELVIS, FROM CASE OF CARCINOMA VAGINAE ET UTERI. /, points to vagina eroded by disease ; e is a malignant growth attached to uterus. Other letters as in fig. 280 (Barbour). project free into the cavity beyond. These adhesions further prevent the peritoneal cavity from being opened into when the carcinomatous mass breaks down. The accompanying sections (figs. 280, 281), made from post-mortem preparations, will serve to illustrate some of the points noted above. Points to be noted in fig. 280. Descrip- 1. Seat of disease in the cervix ; Pelvis with 2. Complete destruction of the cervix and lower segment of the uterus ; Cancer of Cervix. 1 Fere and Carron (Statistics of Complications of Carcinoma Uteri in 51 post-mortems at the Salpetriere 1881-83) found extension to the bladder with fistula in IS, to the rectum in 7, and to the peritoneum in 9 cases. CARCINOMA UTERI: ETIOLOGY. 469 3. Production of an irregular cavity from the extension of the disease in three directions through the cellular tissue (a.) Behind the uterus, (&.) Between the uterus and the bladder, (c.) Between the vagina and the bladder ; 4. The pouch of Douglas entirely obliterated and partially replaced by the carcinomatous excavation, the vesico-uterine pouch shortened by adhesions, perforation into the peritoneal cavity at one point ; 5. Bladder small and contracted, carcinomatous fistula ; 6. Rectum intact. Points to be noted in fig. 281. 1 . Vagina (as well as cervix) affected, the nymphae had a cartila- Descrip- girious consistence, inguinal glands enlarged although not shown figure ; Cancer of Cervix 2. Extension of the disease along the mucous membrane of the uterus, excavating it though not destroying the walls to the same extent as in fig. 280 ; 3. Partial obliteration of the pouch of Douglas ; 4. Bladder dilated through pressure on the urethra, its walls appar- ently not involved ; 5. Rectum intact. ETIOLOGY. The female sex is more liable to carcinoma than the male. According to Sir J. Y. Simpson's statistics, the proportion is 2i to 1. These statistics are drawn from the Annual Reports of the Registrar-General for England during the years 1847-1861. During that time there were 87,348 fatal cases of carcinoma, of which 61,715 were among women and 25,633 among men. For the year 1860, the deaths from carcinoma among men were '97 per cent, of the total male mortality, among women 2 -2 per cent. The cause of this greater relative frequency is connected with the development of the sexual organs in the female. Up to puberty, the mortality (from carcinoma) of the sexes is the same ; after- wards, the relative proportion of female to male deaths gradually rises till it attains its maximum about the age of 50, after which it falls away again (fig. 282). The diagram on page 470 is based on the statistics of 91,058 deaths in Great Britain. It brings out three facts : the total number of deaths in each sex increases with age to a certain point ; the increase among women is relatively the greater ; it reaches its maximum at an earlier age with the female sex. The most frequent seat is the uterus, where fully one-third of the total cases occur ; the next in frequency is the mamma. < s w H i o P3 3 COMPAR. tf o H M CARCINOMA UTERI.- ETIOLOGY. 471 Although the immediate etiology of carcinoma is unknown, there tire certain causes general and local which favour its development. 1. The general predisposing causes are the following : Heredity ; Age; Depreciation of the vital powers. The influence of race is brought out in Chisholm's statistics, which Race and show that carcinoma is more than twice as frequent among the white population as among the black. As regards heredity in families, much less stress is now laid upon this than formerly. According to Gusserow's statistics, in 1028 cases heredity was proven in only 79, that is in about 7 '6 per cent. Schroeder, placing the statistics of Sibley and of Barker together, shows that heredity has been proven in only 8 '2 per cent. ; Picot places it at 13 per cent. These figures show that we cannot lay much stress on heredity as a predisposing cause. On the other hand, we must remember that these statistics are drawn principally from hospital reports, from a class of people who know little about the former history of their families. Age has undoubtedly a considerable influence upon the frequency of Age. this disease. This is evident from the table given on page 472. Gusserow collected statistics of 2270 cases reported by various autho- rities. The mortality per cent, for various ages is represented by the curve in the diagram on page 472. From the table it is evident that car- cinoma does not occur before puberty. The proportion of cases below 20 years (2 in 2270) is so small that it need not be taken into account. The first glance at the diagram would lead one to believe that the increasing frequency of the disease is due to the development of the functional activity of the sexual organs, but a more careful considera- tion shows that the increase continues and reaches its maximum after the latter has ceased. This table should be compared with that for Fibroid Tumours on page 414. Whatever tends to depreciate the vital powers favours the occurrence Deprecia- of this disease. We meet with it more frequently among the poorer y?^ classes, where there is insufficiency of food with privation and hardship. Powers. Schroeder contrasts, in this respect, the development of carcinoma with that of myoma. In his polyclinic among the poorer classes, the pro- portion of carcinoma to myoma was as 100 to 61 ; in his private practice among the wealthier, it was as 100 to 332. 2. The local predisposing causes are the following : Erosion of the cervix and protracted catarrh ; Repeated parturition. The relation of erosion and laceration of the cervix to the development Influence of carcinoma has been recently pointed out by Huge and Veit and also by Breisky. We draw attention to this point specially, because the most important differential diagnosis is that between long-standing EH" o 2 i i 1 ' o / r CO O O I ! / x 1 1 T-H EH O i i 1 - / tf J -5 5 C - - J 5 c^ 1ft 02 g ^ "^ S tn r - i I : 1 S g | 9 1 1 1 Q Q fe S G W ** S3 i 1 "8 i 4 S J ) o -r 8 s tH V O ? N s I_- T-l I-- g o 1 g CARCINOMA UTERI: ETIOLOGY. 473 inflammation and commencing malignant disease ; and the possibility that the former may pass into the latter should always be kept in view. 1 Repeated parturition has an important influence. Carcinoma is much Influence more frequent in multiparse. Gusserow finds an average of 5'1 children p f a j^ te to every case of carcinoma, which is a high average productivity, tion. Whether this is due to the greater functional activity of the uterus or to the production of fissures with their resulting chronic inflammatory changes, is a more difficult question. 1 Williams, however, in his cases never found the disease starting in a tear, and thinks that there is no evidence that laceration plays any part in the etiology of cancer. CHAPTER XLI. CARCINOMA UTERI (OF CERVIX): SYMPTOMS AND DIAGNOSIS. LITERA TURE. See Literature of Chapters XL. and XLII. SYMPTOMS. The local symptoms of carcinoma uteri are three Haemorrhage, Offensive discharge, Pain. There are in addition a considerable number of general symptoms, which arise secondarily. As a rule, however, no symptoms are present in the first stage, that is until ulceration sets in. In exceptional cases, when infiltration of the connective tissue or of the walls of the uterus has taken place at an early period, pain may be an early symptom ; there is no pain so long as the disease is limited to the cervix. This entire absence of symptoms until the disease has already made considerable progress, is the reason of the great difficulty in ascertaining the period of its probable com- mencement. From the same cause, the patient does not seek relief till the possibility of eradicating the disease is much diminished. LOCAL SYMPTOMS. Haemor- Haemorrhage is usually the first symptom noticed by the patient. rhage. g^ e o k serves that menstruation is more profuse than formerly. This, when the disease occurs late in life, she attributes to approach of the menopause. In other cases, profuse haemorrhage occurs irregularly between and independent of the menstrual periods. Sometimes the haemorrhage is noticed only after exertion (as straining at stool) or after coitus. Sometimes the patient states that " the menstrual flow never entirely ceases;" which means that the vaginal discharge is always tinged with blood. The explanation of haemorrhage in these earlier stages is to be found in the vascularity of the stroma of the new forma- tion. It is rich in delicate vessels which readily rupture. In the later stages, haemorrhage is not a prominent symptom unless a large vessel be accidentally eaten into. Death from haemorrhage is rare. Discharge. The discharge characteristic of carcinoma is not present until ulcera- CARCINOMA UTERI: SYMPTOMS. 475 tion has occurred. In the papillary form of epithelioma 1 (cauliflower excrescence), there is a free dischai'ge before the growth has begun to break down ; this is of a watery character, has no odour, and is due simply to the transudation of serum. As soon, however, as ulceration occurs in any of the forms, there is a discharge containing the molecular debris of the breaking down tissue which gives it a characteristic and peculiarly offensive odour. In the rapidly growing forms (medullary) of carcinoma, there is an almost equally rapid molecular death of the newly formed tissue due to fatty degeneration of the epithelial cells. In epithe- lioma this discharge is less marked, because there is less necrosis of tissue ; but in true carcinoma, especially in advanced stages, it is quite characteristic. In fact, a diagnosis may be sometimes made merely from the odour which hangs about the person. At first the discharge is yellowish-white in colour, but afterwards from the decomposition of the fatty cells it becomes of a reddish-brown ; if there is haemorrhage, it will be tinged with blood. Pain is not such a constant symptom as is usually supposed. Some Pain, cases run their whole course without the patient's complaining specially of pain. It is not present so long as the disease is limited to the cervix ; hence it is of no use as a diagnostic of carcinoma of the cervix in its early stage, unless the cellular tissue has been at the same time involved. But as soon as the new growth has extended upwards to the body of the uterus or to the cellular tissue of the pelvis, pain is produced through pressure on or actual lesion of the terminations of the nerves. The character of the pain varies. It is " a dull gnawing pain localised in the pelvis or back," or "a sharp pain shooting through to the back or down the thighs to the knees ; " this last is caused by simple pressure on the crural and sciatic nerves or, in the later stages, from affection of the cellular tissue of the nerve sheaths. Occasionally it is felt in the mammse or other seats of uterine sympathetic pain. The intensity of the pain varies also in different cases ; it is marked where there is more formation of new tissue and less ulceration, that is when there is more pressure on the nerve endings. Thus, if there has beep much deposit between the uterus and the bladder accompanied with an increase of pain, we find that the pain diminishes when the mass breaks down and a vesico-vaginal fistula is formed. We may distinguish between pain due to the development of carcinoma, and that produced by the chronic peritonitis which accompanies it when the peritoneum becomes affected; the latter produces great sensitiveness of the abdominal walls to pressure, and a board-like rigidity from reflex spasm of the muscles. 1 Though, as we have said, we have not at present a truly pathological classification of the different forms of carcinoma, it is convenient, clinically, to use the terms Epithelioma and true Carcinoma. By them we do not imply anything as to the origin of the disease. By epithelioma we understand those forms which begin more superficially, spread more slowly, and do not tend to involve the connective tissue. 476 AFFECTIONS OF UTERUS. Debility. Vaginal Examina- tion. GENERAL SYMPTOMS. In addition to these local symptoms which are immediately due to the carcinomatous infiltration and degeneration, there are more general symptoms which arise secondarily. First we mention loss of flesh and general debility. The patient may continue healthy and well-looking in the early stages ; sometimes, one is surprised to find that the disease is already well advanced in a patient who to outward appearance is in perfect health. But, sooner or later, the drain on the system produces great emaciation. The patient also has a careworn expression, partly from this loss of flesh and partly from the constant pain ; from this expression alone, known as the " cancerous facies," the diagnosis may sometimes be made. The wasting (marasmus) is occasioned not only by the drain of the new growth, but also by disturbances of the digestive system which arise in the course of the disease. Loss of appetite may amount to disinclina- tion for food, and digestion is interfered with. This is produced at first sympathetically, as in other uterine disorders ; but latterly it is due to gastric catarrh, constipation, the condition of the blood (ansemia and ursemia), and the unhealthiness of the atmosphere resulting from the offensive discharges. There is, further, painful micturition and defcecation according to the extent to which the bladder and rectum are involved. The latter is always present, as the rectum, whenever it is distended, presses upon the carcinomatous growth. When fistulse are produced, the urine and fseces pass per vaginam. Pruritus vulvce frequently results from the acrid and irritating dis- charge, and from the dribbling of the urine from a fistula. The skin acquires in the later stages a dingy straw tint, which when very marked is suggestive of jaundice. That disease may actually be present when there is secondary carcinoma of the liver, but this is rare. The colour is due to the ansemia, or (according to Barnes) to the absorption of decomposed faecal matter (coprseinia). DIAGNOSIS. As the patient does not seek advice till the carcinoma has begun to ulcerate, the physical signs have by that time become well marked and the diagnosis is usually easy. On making a vaginal examination, the finger feels the enlarged, thickened, irregular, everted lips of the cervix spreading like a mush- room in the vagina (described by Malgaigne as " champignons can- cereux "). Sometimes a distinct tumour is present, the form of which is sufficiently indicated by the term cauliflower excrescence (see fig. 284). In other cases the finger feels an irregular ulcerated siirface in the CARCINOMA UTERI: SYMPTOMS. 477 position of the cervix, soft and friable with hard and unyielding margins. The examining finger is stained with blood, and the odour of the dis- charge cannot fail to be recognised. If there is any doubt as to diagnosis, a fragment should be removed and examined microscopically. The appearance of a fibrous stroma with alveoli which contain irregular cells of an epithelial type with one or more large nuclei, will confirm the diagnosis of carcinoma. The speculum need not be vised for the recognition of carcinoma, except Speculum, in its early stage or to ascertain more exactly the seat and extent of the growth. If the disease be far advanced and the diagnosis certain, the introduction of it causes unnecessary pain and haemorrhage. The rectal examination is valuable, and in these cases should always Rectal be carefully carried out. It gives us important information in two dis- 5 xamina ' uQflU FIG. 284. CAULIFLOWER EXCRESCENCE GROWING FROM THE CERVIX UTERI (Sir J. Y. Simpson). tinct classes of cases. First, in early carcinoma or in cases where there is a suspicion of commencing carcinoma, the cellular tissue of the pelvis should be carefully examined to ascertain whether any localised deposit or enlarged glands can be felt ; this can be done most easily by the rectal examination. If it is desirable to introduce two fingers into the rectum or if the examination causes much pain, the patient should be narcotised. Second, in cases of advanced carcinoma where the vaginal examination is difficult on account of the haemorrhage and pain which it occasions, a more thorough examination can be made per rectum. The finger can reach higher up than per vaginam, and thus we can ascertain the extent of the carcinomatous deposit and the size and 478 AFFECTIONS OF UTERUS. mobility of the uterus. The condition of the rectal mucous membrane itself is observed at the same time, to ascertain whether it is already involved in the disease. In some cases the rectal examination is the only one possible, as in the case of carcinoma vaginae represented at fig. 281 where the deposit round the ostium vaginae made the introduc- tion of the finger impossible. DIFFERENTIAL DIAGNOSIS. The following are the most important lesions from which carcinoma is to be differentiated : Hypertrophy of the cervix, with induration and occluded follicles ; Papillary erosion or ectropium, with cicatricial tissue ; Syphilitic ulceration, condylomata on the cervix ; Small fibroid in the cervix, sloughing polypi ; Retained portions of placenta or membranes ; Diphtheritic inflammation of the mucous membrane ; Sarcoma of the cervix. As regards the first two of these, it is evident that carcinoma resembles them only at an early stage. But it is precisely at this stage that a correct diagnosis is all important for treatment. We should also remember (as Huge and Veit have pointed out) that these conditions may be at once the result of chronic inflammation and the starting-point of malignant disease. The statement of the patient that the symptoms Importance have existed for a long time, should not throw us off our guard. In all Examina- cases in which a patient over forty years of age seeks advice with symptoms referable to the pelvis, a careful examination should be made. We may thus accidentally discover carcinoma in an early stage, while still within the possibility of radical treatment. If the carcinomatous infiltration be general it cannot be distinguished, except by microscopical examination, from chronic induration. When localised, the diseased part is distinctly marked off from the adjoining tissue, shows a difference in its level, and is of a slightly yellow colour with granular yellowish-white inequalities. 1 Where there is only suspicion of carcinoma, there is no harm in excising a portion of the suspected part and submitting it to microscopic investi- gation. A careful examination per rectum of the pelvic cellular tissue should always be made as mentioned above. A superficial ulcerating epithelioma might be mistaken for a simple erosion, but has thickened infiltrated edges. The latter may, however, pass into the former. Condylomata on the cervix simulate epithelioma, but they disappear under appropriate treatment. Syphilitic ulceration produces sometimes. 1 Stratz Zur Diagnose des beginnenden Carcinoma an der Portio : Zeits. f. Gcb. u. Gyn., Bd. XIII., S. 89. CARCINOMA UTERI: SYMPTOMS. 479 deep excavation, even a rectal fistula. This at the first glance might be taken for carcinoma, but more cai'eful examination and inquiry into the history of the case will remove all doubt. Small myomata are more sharply defined than a carcinomatous nodule of the same size, because the surrounding tissue is not infiltrated. When a small submucous fibroid or a cervical polypus has ulcerated, it presents appearances similar to an ulcerating carcinomatous nodule. The former however is firmer and fragments cannot be broken off by the finger-nail, while the latter is friable and breaks down easily. The possibility that carcinoma may be first noticed during the puer- Carcinoma perium should always be remembered. There should be no difficulty inj? u *^f diagnosing between carcinoma of the cervix and a retained portion ofperium. placenta. If the finger be passed in, it will discover whether the suspected fungus-like mass be simply lying in the cervical canal or be FIG. 285. SCRAPING FEOM CARCINOMA OF THE CERVIX, STAINED WITH LOGWOOD, ; drawn by S. DeWpine. springing from its walls. We have seen several cases of carcinoma in patients who were supposed to be having an abortion. In the case of carcinoma of the fundus, differential diagnosis is more difficult and will be discussed under that head. Diphtheritic inflammation of the mucous membrane may easily be con- founded with ulcerating carcinoma (Schroeder). The irregular swelling of the mucous membrane and the offensive discharge tinged with blood, which are present in diphtheritic inflammation, may be suggestive of carcinoma at the time; but this superficial resemblance soon disappears. Sarcoma of the cervix is a very rare condition. Sarcomatous tumours are softer and grow more rapidly than carcinomatous. A positive diagnosis can only be made after microscopical examination of scrapings taken from the tumour (fig. 285). 480 AFFECTIONS OF UTERUS. PROGNOSIS. The prognosis in carcinoma is always very grave. The possibility of spontaneous cure is a disputed point. There is one apparently well- authenticated case recorded by Habit. 1 Another is mentioned by Barnes, 2 in which there is some doubt as to the correctness of diagnosis. The prognosis as to the probable duration of life will depend on the extent to which the disease has already advanced and the possibility of checking its progress or even extirpating it altogether by operative interference. With regard to the results of operative interference, see under Treatment. As regards the duration of disease if not interfered with, there is a slight difference of opinion. This may be explained by the variable period in the course of the disease at which the symptoms appear. Sir J. Y. Simpson gives the probable duration of life after the detection of the disease as from 2 to 2|- years ; Gusserow and Schroeder give it as from 1 to 1^; while, according to Fordyce Barker, it is as long as 3 years and 8 months. The statistics of H. Arnott, drawn from 57 care- fully observed cases, give the duration, after the first symptom (usually a flooding), of true cancer as 53'8 weeks; of epithelioma, 827 weeks. We may say therefore to the patient's friends that the disease will run a course of from one to two years. It is better not to tell the patient herself what her trouble is, though its serious nature should not be disguised. CAUSES OF DEATH. The causes of death, arranged in the order of importance, are the following : Exhaustion, Uraemia, Peritonitis, Septicaemia, Haemorrhage. Venous thrombosis. Exhaus- Exhaustion, under which we include marasmus, is the result partly of lon ' the drain on the system and partly of the inability to take food. Uraemia. The importance of urcemia as a frequent cause of death has only recently been pointed out. According to Seyfert, 3 in the majority of cases death results from it. It is due to compression of the ureters, as already described under Pathology. It may be acute, accompanied by coma and convulsions ; more generally it is chronic, and shows itself in the dulness of the patient, occasional headache, and decreasing sensibility to pain which diminishes suffering as the disease approaches its termination. 1 Sydenham. Society's Year Book, 1864, page 401. 2 Barnes, Diseases of Women : London, 1878. 3 Saxinger, Pragermed. Viertdjahrsschrift, Bel. I., S. 103. CARCINOMA UTERI: PROGNOSIS. 481 Peritonitis is sometimes the cause of death, but not so frequently Peritonitis, as one would suppose ; the disease is prevented from extending to the peritoneum generally by the adhesions which are formed. When peri- tonitis occurs, it is localised and chronic; in some cases, however, a general peritonitis is set up which proves fatal. Perforation may takePerfora- place from the sudden giving way of adhesions ; the escape of the car- tion- cinomatous debris into the peritoneal cavity produces death from shock or septic peritonitis. The preparation shown at fig. 286 was taken from a patient in whom the cause of death was rupture of FIG. 286. CARCINOMA OF THE CERVIX LEADING TO OCCLUSION or os UTERI, dilatation of uterus and perforation (A. H. Simpson). Uterus and vagina laid open ; a quill is passed through the perforation. the uterus. The case is reported and the preparation described by A. E. Simpson (op. cit., p. 276). There was carcinoma of the cervix which had contracted the lumen of the canal ; the cavity of the uterus was expanded, the walls being thinned out ; at the fundus " was a small perforation about the size of a pea, with thin edges," through which fluid had escaped and set up peritonitis which rapidly proved fatal. Septicaemia suggests itself as a likely cause of death. We are familiarsepti- with it as produced in the puerperal condition : it is explained by the cae 482 AFFECTIONS OF UTERUS. fact that, at that time, there is abundant means for absorption in the numerous lymphatics and large veins which have been recently lacerated ; hence, whenever septic matter is present, there is great risk of septicaemia. Similar conditions exist in carcinoma, during the pro- gress of which the blood vessels are eroded and their extremities bathed in putrid matter. Barnes has drawn special attention to this as a source of blood-poisoning ; according to Eppinger's 1 observations its occurrence is rare, and this he ascribes to the diminution of the absorp- tive power of the eroded vessels. Hsemor- Haemorrhage is in very rare instances immediately fatal. As already pointed out, though it is important as an early symptom, it occurs less frequently and is less abundant as the disease advances. If a large vessel be suddenly opened into, a fatal haemorrhage may follow. Throm- Venous thrombosis, due to mechanical compression of the veins, some- times occurs ; and a clot may be detached producing embolism in the lungs. Fatty degeneration of the heart is, sometimes, also present. Patients with cancer have also died of tetanus, ' 2 which has been ascribed to the action of micro-organisms from secretion retained through plugging of the vagina, 1 Prager med. Wochenschrij't, 1876, S. 210. 2 See case by Hofmeier: CentraHi. f. Gyn. Bd. XI., S. 171. CHAPTER XLII. CARCINOMA UTERI (OF CERVIX): TREATMENT. LITERATURE. Barnes Diseases of Women, p. 856 : London, 1879. Currier, And. F. Removal of the Uterus for Cancer: N. Y. Med. Jour., vol. xxxiv., p. 494. Duncan, W. A. On Extirpation of the entire Uterus : London Obstet. Trans., 1885, p. 8. Freund Samm. klin. Vortrage, Nr. 133 ; and Centralbl. f. Gyn., N. 12, 1878. Gusserow Die Neubildungeu, etc. : Stuttgart, 1885, S. 199. Hegar und Ealtenbach Die Opera- tive Gyniikologie, S. 391. Hofmcier Zur Statistik des Gebarmutterkrebses und seiner opera tiven Behandlung : Zeitsch. f. Geb. und Gyn., Bd. X., S. 269. Lewers On the supra-vaginal amputation of the cervix uteri for malignant disease, etc. : Lancet, 1888, I., p. 464. Pawlik Zur Frage der Behandlung der Uteruscarcin. : Wiener Klinik, 1882, Hft. XII., S. 425. Ueber die endgtiltige Heilung des Carcin. cervic. uteri durch die operation Zeits. f. Geb. u. Gyn., Bd. XIII., S. 360. Sanger Zur vaginalen Totalexstirpation des carcinomatosen Uterus : Archiv f . Gyn. , Bd. XXL, Hft. I. Schroeder Charite Annalen : V. Jahrgang, S. 343, Zeitschrifi fiir Geburtshulfe und Gynakologie : B. III., S. 419; B. VI., Heft II., S. 218. Simpson, A. R. Carcinoma Uteri ; Contributions to Obstetrics and Gynecology, p. 261 : Edinburgh, A. & C. Black. Case of Extirpation of the Cancerous Uterus through the Vagina : Edin. Obst. Trans., vol. vii., p. 136. Simpson, Sir J. Y. Diseases of Women, p. 170 : Edinburgh, 1872. Sims, Marion The Treatment of Epithelioma of the cervix uteri : American Journ. of Obst., July 1879. Thomas Diseases of Women, p. 591 : 1882. Van de Warker A new method of partial Extirpation of the cancerous Uterus : Am. Journ. of Obstet., March 1884. See also Index of Recent Gynecological Literature under Uterus : Cancer of, and Extirpa- tion of (for cancer). THE treatment of carcinoma ought to be regarded in two aspects : first, as treatment of the symptoms; second, as treatment of the disease. Again, the treatment of the disease may be either palliative or radical. We need not discuss here the vexed question whether carcinoma is a constitutional or a local disease. It cannot be too strongly impressed on the practitioner that, as far as our present experience goes, in attacking the disease itself he must rely upon surgical and not on medical treat- ment. Our aim ought to be the removal of the disease and not merely the alleviation of the symptoms. To remove it completely we must recognise it early. Up to the present time successful treatment has been a rare occurrence, because we have failed to recognise carcinoma in its commencing stages. The possibility of treating it successfully in the future will depend on the possibility of our recognising it in its com- mencement. Not less important than early recognition is complete removal and that without delay. In the uterus, more readily than in 484 AFFECTIONS OF UTERUS. the mamma, does the carcinoma get beyond the reach of the operator. In carcinoma mammae, we can excise not only the breast but also the axillary glands if these should be already implicated. But, in carcinoma uteri, as soon as the pelvic glands are involved the case is hopeless as regards a radical cure. We shall consider, first, the treatment of the symptoms ; because, in the majority of cases, when the patient comes under our notice, the disease itself has already got beyond our remedies. TREATMENT OP SYMPTOMS. These are haemorrhage, offensive discharge, pain. HAEMORRHAGE. In the treatment of haemorrhage, there are two points to be con- sidered : first, the instructions to be given to the patient ; and, second, the means which we can ourselves employ. Use of (1.) The patient is instructed to take the liquid extract of ergot in large doses whenever there is much haemorrhage either during the men- strual period or independent of it. If she is subject to floodings, a friend might be taught how to give the ergotin solution hypodermically. Ice applied to the vagina and injections of cold water check haemorrhage; a small piece of sponge or tampon of wadding, soaked in perchloride of iron, might be passed into the vagina if cold is not sufficient. The patient is recommended to avoid sexual intercoiirse, as this favours active congestion and in some cases is the cause of haemorrhage. The (2.) The means at our own command are the following : Tampon. Simple pressure, effected by complete and thorough plugging of the vagina ; The use of styptics, caustics, or the actual cautery ; The removal of diseased tissue by the curette or other means. The plugging of the vagina should be done whenever we are called in on account of profuse haemorrhage. The packing is carefully done with pledgets of lint or cotton wadding (with string attached) soaked in car- bolic oil ; the speculum is introduced carefully and not carried high up. Of styptics, the best are the perchloride and the pernitrate of iron. Sir. J. Y. Simpson recommended a saturated solution of the perchloride in glycerine. A pledget soaked in either of these is introduced, and placed so as to be in contact with the bleeding surface ; and the rest of the vagina is packed, as above described, with the pledgets steeped in carbolic oil. The perchloride should be used with great caution in cases of advanced ulceration, as we have seen it corrode into the tissue so as to reach the peritoneum and produce peritonitis. The use of caustics,, cautery, and curette, will be considered under Operative Treatment. CARCINOMA UTERI: TREATMENT OF SYMPTOMS. 485 OFFENSIVE DISCHARGE. This is best treated by astringent and antiseptic injections. These should be used frequently, as it is important to keep down the unpleasant odour and make the patient's surroundings as comfort- able as possible. If the discharge be plentiful and not very offensive, as in the cauliflower excrescence, the indication is more for the use of astringents like sulphate of alumina and iron (4 grains to the oz.). Tannin or sulphate of zinc can also be used, and it is well to change the astringent occasionally. If there is much necrosis of tissue with very offensive discharge, carbolised water (1 to 50) is required. Acetate of lead (51 to 20) is recommended by Barnes. Solution of bromine (1 of the B.P. solution to 3 of water) is a good disinfectant, but its odour is disagreeable. Condy's fluid is largely used, but it is only deodorant not disinfectant. The skin round the external genitals should in all cases be protected from the acrid discharges, as the irrita- tion is a source of discomfort. A lotion of equal parts of olive oil and glycerine or of olive oil and lime water, applied after each vaginal injec- tion, serves this purpose well. PAIN. This can be effectually relieved only by some preparation of opium ; Use of it is well to delay the habitual use of this remedy as long as possible, as plum * it interferes with digestion and nutrition. It may be given as a morphina suppository ( of a grain in each) per rectum, or as the liquor morphina) hydrochloratis by the mouth. We obtain its action most surely and quickly and with the least disturbance of the digestive system by giving it hypodermically. It is desirable to change the narcotic, as even opium gradually loses its effect ; the hydrate of chloral, in 20 grain doses, may be used as a substitute. Various local anodynes have been suggested, but are of little use. Attention to the general condition of the patient is very important. General The three main points are to give a sufficient quantity of nutritious an easily digestible food, to keep the bowels regular, and to have the atmosphere healthy and the surroundings cheerful. Food should be given in small quantities and frequently; milk, eggs and beef-tea should be substituted for more solid food as soon as digestion fails. In the later stages, the bowels should be evacuated by enemata rather than by purgative medicines. The room shoitld be well venti- lated by day and night, and the vaginal injections repeated fre- qiiently. Gusserow recommends that during the night a piece of waterproof sheeting be tied round the patient's waist to keep down the disagreeable odour. 486 AFFECTIONS OF UTERUS. TREATMENT OF THE DISEASE. As before stated, our aim here is extirpation. If complete removal be possible, carcinoma will be no longer the inciirable disease which haunts the mind of the patient and baffles the skill of the practitioner. The principles of treatment can be best understood by considering the Diagram progress of the disease as consisting of three stages: (1) when the of Cancer, disease is present as a germ infiltrating healthy tissue ; (2) when the germ has developed into a tissue having the typical carcinomatous structure ; (3) when this newly-formed tissue breaks down. The accom- panying diagram (fig. 287) illustrates this progress. The three stages are represented by three zones. The extent of zone 1 is not well defined, for we have no means, unless with the microscope, of ascertaining how far the surrounding tissue is infiltrated. The area of zone 2 is more definite ; the line a b c is well marked, for the carcinomatous tissue when fully formed has charac- teristics by which it can be recognised from the surrounding healthy FIG. 287. DIAGRAM TO ILLUSTRATE THE SPREADING OK CARCINOMA. 1, Healthy tissue infiltrated with germs of Carcinoma ; 2, Carcinomatous tissue fully developed ; 3, Carcinomatous tissue breaking down. tissue by touch or sight. Zone 3 represents the third stage, in which the immediate danger to the patient lies. It is not the formation of the carcinomatous tissue which is dangerous, but its ulceration with accom- panying haemorrhage and exhausting discharge. From these facts we deduce the following principles of treatment. First, to effect radical cure we must remove zone 1, as well as zones 2 and 3 ; i.e., we must remove not only the tissue which is evidently carcinomatous, but also all the surrounding tissue which may contain germs of the disease. Sometimes by a chance the operator has done this through keeping well clear of the evidently diseased part, and thus we can explain the few recorded cases of cure. Second, we may anticipate the natural process of breaking down, with its accompanying exhaust- ing results and risks of a fatal haemorrhage, by destroying the newly formed carcinomatous tissue as far as it is recognisable. We shall thus save the patient from the effects of the disease until zone 1 has passed CARCINOMA UTERI: TREATMENT OF DISEASE, 487 into the condition of zone 2 and is beginning to break down. Thus we explain the temporary benefit (for a period measurable by months) derived from the partial excision of the new growth. Third, the appli- cation of caustics alone may effect the destruction of area 2 ; but we are not so sure that we are removing the lohole up to line a b c, as we are when using the knife or other cutting instrument. The latter means is preferable because we can make certain that we have reached this line in all cases where it is attainable by operation. Fourth, the use of the knife and the application of caustic to the raw surface will, where the disease has spread far, be more effectual than the use of the knife alone ; the caustic will now without doubt operate on the area of zone 1 and destroy so far the germs of the disease : There are four methods of operative treatment : 1. Application of caustics, 2. Scraping out of diseased tissues, 3. Amputation of the cervix, 4. Excision of the uterus. APPLICATION OF CAUSTICS. This should scarcely come under the head of treatment of the dis- Caustics ease. All that we can hope for in the application of caustics is merely J? a superficial destruction of the growth and consequent temporary alleviation of the distressing symptoms. The caustics which we may use are the following. Strong nitric acid is applied with a dossil of lint, the diseased surface having first of all been washed and carefully dried in order to prevent the acid from running ; it is again washed to remove superfluoiis acid. An alcoholic solution of Bromine (1 to 5) has been recommended by Routh - 1 and Wynn Williams ; 2 cotton wadding soaked in it is applied to the diseased part to produce a sloiigh, and the rest of the vagina protected by wadding wet with bicarbonate of soda. Numerous other caustics have been tried. The results of this method are only temporary. The superficial layers of the growth are destroyed while the haemorrhage and discharge cease for a time. Cicatricial contraction takes place on the surface, but the hard infiltration can be felt extending beyond. According to Campbell de Morgan, 3 the superficial application of caustics acts as an irritant]produeing increased growth of the new formation ; so that when they are used they must be applied thoroughly. SCRAPING OUT OF DISEASED TISSUE. We have recourse to this means of treatment (1) in cases in which the disease is not of a form suitable for amputation when it does not form a pediculated mass but is spreading along the mucous membrane 1 British Medical Journal, February and March 1880. 2 London Obstetrical Transactions, vol. xii., p. 249. x "The origin of Cancer considered with reference to the treatment of the disease, " 1872. 488 AFFECTIONS OF UTERUS. of the vagina, (2) in cases which are too far advanced for amputation of the cervix. This method is good and safe in principle, because the carcinomatons tissue is soft and friable compared with the surrounding connective tissue and can be therefore easily scraped away. Curette in The means which we employ are the curette or the sharp spoon. Sir Carcinoma. J- Y. Simpson used to scrape out the diseased tissue with the finger-nail or the curette. The sharp spoon introduced by Simon x is the most efficient instrument : it should be used with short firm strokes, and the raw surface examined from time to time with the finger to feel whether all the hard nodules have been removed. After the scraping has been thoroughly carried out, the surface is burned by the actual cautery and the vagina tamponed to prevent haemorrhage. The results of this method are more satisfactory than those which follow the application of caustic alone ; they depend entirely on the thoroughness with which the scraping has been done. AMPUTATION OF THE CERVIX. This operation is called for by two sets of circumstances : (a) when the disease is as yet limited to the cervix and there is a distinct line of Ecraseur and Galvano- Cautery compared. FIG. 288. SIMON'S SHARP SPOON. demarcation above, so that in operating we can cut through healthy tissues ; (6) when it has spread so far that although we cannot operate upon healthy tissue, we are yet justified in removing as far as possible the projecting mass. The means of amputation are the following : Ecraseur, or galvano-cautery ; Knife and scissors, followed by ligature or caustics. I. ECRASEUR, OR GALVANO-CAUTERY. Relative advantages. Both of these possess the advantages that they are easy of application and cause less haemorrhage than the knife, although with the latter we can follow more certainly the line of demar- cation. The ecraseur has the advantage that it is easily portable, requires no preparation, and is always ready when wanted. On the other hand, there is danger that the peritoneum of the pouch of Douglas or of the bladder may be lacerated by the chain. The galvano-cautery is inconvenient to carry about and is not always ready when wanted, 1 Berlin, Beitrcig. zur Geburt. u. Gyn., 1872, 13d. I. CARCINOMA UTERI: TREATMENT OF DISEASE. 489 but has the advantage that we do not need to draw down the uterus to apply it ; in all cases of operation upon the cervix for carcinoma, the less traction that is made upon the uterus the safer for the patient. As the ordinary ecraseur (fig. 289) has the chain in a line with the handle, the cervix must be drawn down to the vulva for the working of the instrument. This difficulty is obviated in the curved form of instrument, and in the wire ecraseur devised by Sir J. Y. Simpson. The galvano-cautery not only amputates but, at the same time, cauterises the stump ; this is a questionable advan- tage as, though it may diminish the probability of haemorrhage, it pre- vents us from examining whether all the diseased tissue has been removed. Mode of employment. Put the patient under chloroform. If the curved ecraseur or the galvano- caustic wire be used, place the patient semi - prone ; only one as- sistant is necessary to hold the Sims speculum. If the straight ecraseur is used or it is desirable to have the parts well exposed, the lithotomy posture is better ; the two assistants who hold the legs can at the same time draw aside the labia with retractors, while a third draws back the posterior vaginal wall and perineum with the Sims speculum. Now lay hold of the cervix or tumour with volsellee, and if neces- sary draw it down to the vulvar orifice. Place the wire or chain round the cervix or the pedicle of the CarcinomatOUS maSS (fig. 290), as far above the limits of the dis- ease as possible, so as to cut through healthy tissue, but not above the line of reflexion of the mucous membrane of the posterior fornix FIG. 289. ORDINARY CHAIN ECRASECR. n in by a pumping motion of the large Mode of using Ecraseur. 490 AFFECTIONS OF UTERUS. Method of using Galvano- Cautery. upon the vaginal portion lest it should cut into the pouch of Douglas. After the ecrasexir has begun to crush the tissues, work it slowly shortening the loop at the rate of one notch in every twenty to thirty seconds. In using the galvano-caustic wire place it in position cold, tighten it up so as to constrict the cervix, and then make the current. To pre- vent the slipping of the wire, Thomas has devised forceps with shoulders, which he uses in place of volsellse. Byrne of Brooklyn, who has had a FIG. 290. STRAIGHT ECRASEUR IN POSITION. A cervix drawn to vulva with Museux's forceps ; C D chain ; E stem of ecraseur (Chassaignac). large experience with the galvano-cautery, has pointed out that if gradual traction be made on the cervix during the action of the wire the result will be a funnel-shaped excavation ; by this means more of the cervix will be removed. Tighten the wire gradually, so as to burn through not cut the tissue. After amputation, examine the surface of the stump. If there is much haemorrhage, apply a styptic to the stump directly or on a pledget of cotton wadding, and pack the vagina CARCINOMA UTERI: TREATMENT OF DISEASE. 491 with carbolised lint or wadding ; this packing should not be discarded for a week or ten days, as the great after-danger is haemorrhage. Several cases of cure have certainly been observed, but only where the whole disease has been removed. Sir J. Y. Simpson records three cases. In the first the patient was well eighteen years after the operation and had, in the meantime, given birth to five children. Another patient died, four years after removal of the disease, of cancer of the peritoneum, there having been no local return. The third died after four years, of dysentery. Ziemssen, Barnes, Byrne, A. K. Simpson, Thomas and others also record several successful cases. The most interesting statistics of amputation of the carcinomatous cervix with the galvano-cautery are those given by Pawlik. He has gone into the after history of the one hundred and thirty-six cases operated on by C. Braun in the Vienna Clinic since 1861. The mortality from the operation was 7 3 per cent. ; 26 of the cases were still without a recurrence two years after the operation, the longest period being 19i years. None of the patients gave birth to a viable child after the operation, abortion always occurring. II. KNIFE AND SCISSORS. The advantage claimed for this method of operating is that it allows the operator to follow the line of demarcation between the diseased and the healthy tissues ; if in the coiirse of the amputation he finds the carcinomatous new formation extending higher up than he anticipated, he can remove as much more of the suspected part as may be necessary. There are disadvantages in stitching up the Avound so as to produce union by first intention. We must save enough mucoiis membrane to close in the wound, which would be cut away were we to leave the wound to granulate ; and in this, diseased tissue may be left. Further, in the wound itself, germs of the disease may be present which would be destroyed by the subsequent application of caustic. As examples of amputation by the knife and closure of the wound by sutures, we shall describe the method adopted by Schroeder of Berlin. According to the extent of tissue to be removed, he performs either (a) amputation of the vaginal portion, or (6) supra-vaginal excision of the whole cervix. A. Amputation of tlie vaginal portion. The cervix is divided on both sides with the scissors so that distinct anterior and posterior lips are produced. A wedge-shaped portion is excised out of each of these (fig. 168) and the flaps stitched together. The lateral incisions in the cervix are then closed by sutures. B. Supravaginal incision of the whole cervix. 1. The cervix having Schroeder's been drawn down with the volsella, or with a hook if the tissue is friable, j^p^t. the knife is carried through the vaginal mucous membrane of the anterior ing Cervix. fornix round the base of the anterior lip into the cellular tissues below (and beyond the diseased tissue). The bladder is easily separated from the cervix almost as far as the utero-vesical pouch of peritoneum, and retracts upwards carrying the ureters with it ; a sound must be passed into it, to define its position. 492 AFFECTIONS OF UTERUS. 2. The cervix is now carried forwards ; and the mucous membrane of the posterior fornix, which is thus exposed, is incised in a similar way, the ends of this incision being made continuous with those of that made in the anterior fornix. The peritoneum of the pouch of Douglas is liable to injury, but this accident is not of importance. In cases where the posterior lip must be divided high up, it is better to cut into the pouch and remove the peritoneal covering along with the portion amputated. 3. The clearing of the cervix from the cellular tissue above the lateral fornices is more difficult, on account of the firmness of the connective tissue and the presence of large branches of the uterine artery which enter at the sides. To prevent haemorrhage, the tissues are transfixed with an aneurism needle and ligatured before cutting through between the ligature and cervix ; or the tissue may be clamped in Wells' forceps and the forceps left on for forty-eight hours (Lewers). FIG. 291. LINE OF INCISION AND POSITION' OF SUTURES IN THF, SUPRA-VAGINAL AMPUTATION OF THE CERVIX (Schroeder). 4. The cervix being thus made free all round, the knife is carried through its anterior wall at the desired height, till the cervical canal is opened into. The anterior vaginal wall is stitched to the anterior wall of the cervix (fig. 291). This prevents retraction of the cervix while the posterior wall is cut through and the amputation thus completed. The posterior vaginal wall is now stitched to the posterior lip of the cervix. The ends of the wound in the lateral fornices are closed with sutures which, if placed deeply, also control haemorrhage. As the ureters retract, they are not in danger of being caught in the ligatures. As regards the operation itself, Hofmeier reporting on 105 cases done in Schroeder's Clinic gives a mortality of 12-37 per cent.; as regards CARCINOMA UTERI: TREATMENT OF DISEASE. 493 the cure of the disease, out of forty-seven cases, fifteen were -without recurrence two years after the operation and ten had not been heard of; after three years twelve were well and after four years five. All the others were lost sight of or had a return of the disease. Lewers reports on ten cases he has done, all of which recovered from the opera- tion: three had no recurrence till a year afterwards; and, in one of these, removal of the new growth in the stump with the cautery had given at least another year's immunity. Amputation followed by caustics was the method advocated by Marion Sims. FIG. 292. EXCISION OF EPITHELIOMA OF THE CERVIX (Marion Sims). For letters see text. 1. The epitheliomatous mass is broken down and removed with the curette, or cut away with the scissors if it is of a sufficiently firm consistence. It is not merely removed as far as its base (dotted line a, fig. 292), but the bed of the tumour is exsected with the knife and scissors or scraped out with the curette as far as diseased tissue is present (dotted line I, fig. 292). 2. The cavity thus produced is cleaned out with sponges, and examined with the finger to ascertain that all indurated structure has been removed. 3. The edges of the cavernous opening are trimmed. The parts are sponged quite dry, and the cavity plugged with cotton wool squeezed almost dry out of either of the following styptic solutions ; liquor ferri subsulphatis (1 part to 2 of water), or solution of carbolic (1 to 40) saturated with pulverised alum (1 to 12). The upper third of the vagina is packed with the same material, and the rest with cotton wool soaked in carbolic solution. 494 AFFECTIONS OF UTERUS. 4. After an interval of five days, this plug is removed and the caustic introduced. Pledgets of cotton wadding soaked in a strong solution of chloride of zinc (3v to gi) and wrung dry, are packed into the scraped-out cavity ; the upper part of the vagina is tam- poned with wadding soaked in a solution of bicarbonate of soda. Morphia is given hypo- dermically to relieve the intense pain produced by the action of the chloride. 5. After another interval of five days, the cotton wool containing the caustic is removed. A cup-shaped greyish slough will be found under it and is easily taken away. The granu- lating surface beneath will cicatrize in a fortnight. The results of this operation are said by Marion Sims to be more satisfactory than those which follow from the use of the knife with healing by the first intention. He mentions one case in which he removed an epithelioma of the anterior lip (represented in fig. 292) the size of a Sicily orange. A year afterwards the operation had to be repeated to remove a similar tumour from the posterior lip. Five years after this the patient was still in good health, though smaller growths had been removed in the interval. Van de Warker has recorded three interesting cases treated by this method. He uses a stronger solution (equal parts by weight) of the chloride of zinc and a 30 per cent, solu- tion of the bicarbonate with an ointment (1 part bicarbonate to three parts vaseline) to protect the genitals. Frankel 1 has tried this method in six cases which were considered inoperable, with the result that all were free for a longer or shorter period one being without recurrence after seven years. After scraping and applying the actual cautery, he packs with iodo- form gauze until the slough has separated ; and then applies the chloride-of-zinc solution but leaves it on for only twelve to twenty-four hours at a time. The greyish leathery slough comes away in eight to ten days, and then dry iodoform -gauze packing is used again until the surface has healed. Schramm 2 injects occasionally a solution of corrosive sublimate into the cancer-mass with the result that the discharge is lessened and the degenerative process is retarded. Scharlaus 3 used chromic acid to destroy recurrent growths after amputation ; and the patient was well four years afterwards, having had a child in the interval. EXCISION OF THE WHOLE UTERUS. Freund's To Freund of Strassburg is due the credit of having first thought Operation. Qu an( j carr j e( j j n ^ o execution a method by which the whole uterus can be removed. This method has increased the possibility of a radical cure of malignant disease of the uterus, though the number of cases suitable for extirpation is more limited than we should have supposed. The uterus alone can be removed by it, not the glands or connective tissue in the pelvis to which the disease in the majority of cases soon spreads. But when the disease has originated in the body of the uterus, or beginning at the cervix has extended upwards into the uterus rather than into the vagina or the connective tissue, the extirpation of the uterus holds out the prospect of a radical cure. This may be done A. By abdominal incision, B. Through the vagina. 4 Freund's A. BY ABDOMINAL INCISION (Freund's method). As the high mor- Method. tality from this method (72 per cent.) has made most operators abandon 1 Centralb.f. Gyn., Bd. XII., S. 593. 2 Centralb.f. Gyn. Bd. XII., S. 213. 3 Beitrage zur Geburts. Berlin., Bd. II., S. 23. 4 A third method, which is a combination of these, has been so seldom used that it requires no notice here. CARCINOMA UTERI: TREATMENT OF DISEASE. 495 it for the vaginal method, we shall merely indicate in what the operation consists. The abdominal cavity having been opened, the uterus is laid hold of and each broad ligament ligatured in three parts, the lowest ligature passing through the lateral fornix of the vagina. The Uterus is now cut away from the broad ligaments ; and the knife carried through the peritoneum of the utero-vesical pouch and pouch of Douglas into the anterior and posterior fornices so that the whole organ is thus excised. The ends of the ligatures in the broad ligaments are brought through the hole in the roof of the vagina, in which a drainage tube is also placed. The results of this method of extirpation are according to Gusserow 148 cases with a mortality of 71 '6 per cent., according to Duncan 137 cases with a mortality of 72 per cent. l B. EXTIRPATION THROUGH THE VAGINA. Different operators have introduced various modifications, but these are only in detail. We describe the operation as performed by Martin. FIG. 293. VAGINAL EXTIRPATION of THE UTERUS (Martin). The cervix has been drawn downwards with forceps, the pouch of Douglas opened transversely, and row of sutures passed through vaginal fornix and peritoneum. 1. Place patient in lithotomy posture, empty bladder and thoroughly disinfect genital tract. Let assistants hold anterior and posterior vaginal specula and lateral retractors in position, draw down cervix with volsella and direct it forwards towards pubes. Make a transverse incision through the junction of vaginal mucous membrane with posterior surface of cervix. The pouch of Douglas is thus opened. Then sew the peritoneum and vaginal mucous membrane together by three or four sutures parallel to line of incision and slightly behind it (fig. 293). 2. Pass left index finger into pouch of Douglas and press left broad 1 Several cases of total extirpation of the pregnant cancerous uterus are on record. Sir Spencer Wells in 1881 and Zweifel in 1888 removed one at sixth month, patients recovering in both cases. Schroeder operated at full-time in two cases, and Bischoff in one. All three died. 496 AFFECTIONS OF UTERUS. ligament down against vaginal roof. With a large curved needle pass a suture through anterior part of left lateral fornix, through broad ligament above uterine artery, and out again through the vaginal roof close to the outermost suture of the posterior row (fig. 294). Pass a ligature in the same manner, also, on the right side. Then with scissors cut through the bases of the broad ligaments as high as ligatures reach, keeping close to uterus. 3. Draw cervix backwards, and at the line of junction of vaginal mucous membrane with its anterior surface, make a transverse incision down to muscular substance of uterus. Carefully separate bladder from uterus and open into utero-vesical pouch of peritoneum. Bring vaginal mucous membrane and peritoneum into close apposition by a transverse row of sutures applied as was done posteriorly. FIG. 294. VAGINAL EXTIRPATION OF UTERUS (Martin). Application of first ligature in lateral fornix to control vessels in base of broad ligament. 4. With volsella pull down fundus through pouch of Douglas as far as possible. The broad ligaments, and generally the tubes and ovaries, are thus brought into vagina. 5. Now ligature broad ligaments above the level of the uterine arteries. This is done by two or three sutures passed exactly as in the case of that first applied in the lateral fornix, only at successively higher levels in the vaginal roof. The uterus is then cut away, the tubes and ovaries being also removed when possible. Thus the sutures are all tied on the vaginal surface, and they approxi- mate the serous surfaces of broad ligaments and pelvic floor to one another as well as to the vaginal mucous membrane. If a wide opening remains, it can be made smaller by a suture on CARCINOMA UTERI: TREATMENT OF DISEASE. 497 each side. A rubber drainage-tube may be used or not. Dust wound with iodoform and place an iodoform-gauze tampon in vagina. Czerny brings down fundus through opened-up utero-vesical pouch. Olshausen, Leopold and others do not draw fundus clown, but gradually cut away uterus from broad ligaments after suturing the latter in successive stages from below upwards. Fritsch operates in the same way, but ligatures the uterine arteries and cuts through base of broad ligaments before opening into peritoneum. Richelot, Pean, and others do not ligature the broad ligaments but apply a clamp to each one, which is removed in about forty-eight hours. The mortality from the operation of total extirpation (including cases other than cancer) is given by Martin as 16 '6 / o in 134 cases, by Hofmeier and Schroeder as 16*2 / o in 74 cases, by Fritsch as 10 / o in 60 cases, by Leopold as 6'2 / o in 48 cases, by Staude as 4*54 / m 22 cases, and by Sanger as 8 '3 / o . COMPARISON OP THE RESULTS OF AMPUTATION OF THE CERVIX WITH THOSE OF EXTIRPATION OF THE UTERUS. In judging of the relative merits of these operations, we must take into account (1) the immediate result with regard to recovery from the operation, and (2) the ultimate result with regard to the non-recurrence of the disease. (1.) The immediate result. The mortality for amputation of the cervix with the Galvano-cautery is 7^ / (Pawlik's statistics, v. p. 491) ; with the knife, in 33 cases of Gusserow's 9'09 / o , and in 136 cases of Schroeder and Hofmeier's 7'4 / . We have seen, however, that although Schroeder's mortality in total extirpation was greater than in partial amputation, later operators have gradually reduced the death-rate in the major operation to as low a figure as 5 or 6 / o . (2.) The ultimate result. (a.) In amputation of the cervix. BRAUN (PAWLIK). (Galvano- Caustic) SCHROEDER (HOFMEIER). (High Amputation) 136 Cases. 115 Cases. Died after operation Known to be free 1 year afterwards 10 33 18 50 2 26 40 3 28 4 21 5 11 6 . 5 12 2 19 1 Of the cases not accounted for by this table, some had a return, while others were not followed up. 2 i 498 AFFECTIONS OF UTERUS. (b.) In total extirpation. Post l of New York has collected over 700 cases performed before the end of 1887, in which the total death-rate was 24 / o . The results of the leading operators are as follows : Martin Fritsch Leopold Schroeder-Hofmeier (1887). (1886). (1887). (1886). Of 44 cases in years Of 53 cases in years Of 37 cases in years Of 46 cases in years 1880-85, disease had 1883-86, disease had 1883-87, disease had 1878-85, 33 were returned in 13 (297 not returned in 20 retiirned in 8 (21 7=) watched for 1 year, V.) by 1887. (37-7%), 10 months within 1 year. Of and of these 13 afterwards. Two the rest only 18 were (36-4 "/.) had return cases had been free heard from ; and of of disease ; 23 were for 3 years, seven these 12 had had no watched for 3 years, for 2-3 years, and return for 1-2 years, of whom 17 (74 L) eight for 1-2 years. and 6 for 2-3^ years. had return ; and 10 The others had not for 4 years, all of been followed. whom had return. The other cases were not followed. Terrier of Paris reports 11 cases operated on in 1885. Of these, 4 were well after 2 years. The others had had a return within 16 months. Taking the total and partial operations together, we find that Schroeder and Hofmeier have given immunity for at least four years to one-third of their patients. The results as regards recurrence are not nearly so good with total extirpation as with partial amputation, yet it must not be concluded that the former operation favours a return. In all cases in which the cancer was removed by partial amputation, total extir- pation also would certainly have removed it and with (as is now estab- lished) as small a death-rate. The above-mentioned cases of partial operation must have been particularly favourable ones i.e., in which the disease was distinctly localised and in an early stage of growth. In all such cases, the minor operation will be preferred. The great majority of cases, unfortunately, are operated upon when the disease has existed for some time and when there is uncertainty as to whether it has spread beyond the uterus even though that be not demonstrable by manual examination. It is evident, therefore, that in these cases, until we are able to diagnose more correctly, we shall operate in many cases where a return is certain. Although women themselves often put off consulting a medical man owing to the slight disturbance caused by cancer in its early stage, there are many cases in which through ignorance or carelessness the practitioner allows the disease to advance until its exact limits can no longer be denned. The character of the cancer must be taken into account in the prog- nosis as to the ultimate results ; an extensive papillary cancroid of the vaginal portion giving the worst prognosis ; cancer of the cervix a relatively better, and cancer of the vaginal portion the best. 1 Am. Jotirn. Obst., Nov. 1SS7. CARCINOMA UTERI: TREATMENT OF DISEASE. 499 Comparison Letiveen Cancer of the Uterus and the disease elsewhere, as regards operative treatment. Fritsch finds that recurrence after removal by total extirpation is less frequent than after similar removal from any other part of the body. He gives Von Volkrnann's statistics of Cancer of the breast as follows : Out of 131 cases, return of the disease was observed In 1 month in 7 cases, 2-6 ,,23 7-12 12 1 L>J J) )) *~ v> 13-18 ,, 5 ,, 19-24 6 25-36 1 CHAPTER XLIII. CARCINOMA OF THE BODY OF THE UTERUS. LITERA TURS. Brcisky and Eppinger Prager med. Wochenschrift, S. 78, 1877. Gusserow Neubil- dungen des Uterus, S. 254 : Stuttgart, 1885. SchrocdcrDie Krankheiten der weib- lichen Geschlechtsorgane, S. 295. Simpson, Sir J. Y. Selected Obstetrical and Gynecological Memoirs, edited by Watt Black, p. 769. Veit Zeitschrift. fur Geburts. und Gyn., Bd. I., S. 467. Zur Kenntniss des Carcinoma corporis uteri: Centralb. f. Gyn., Bd. X., S. 173. PATHOLOGY AND ETIOLOGY. CARCINOMA affects the body of the uterus much more rarely than the cervix; in only 13 out of 686 cases of uterine cancer, that is in rather FIG. 295. UTEKUS EXTIRPATED FOR CANCER ; no recurrence five years after operation (Hofmeier). less than 2 per cent, was the disease situated in the body of the uterus (Schroeder). Its rarity is apparent from the fact that Gusserow, after a careful survey of the whole literature, has collected but 80 cases. As in the cervix, the disease originates either in the substance of the CARCINOMA OF THE BODY OF THE UTERUS. 501 walls of the uterus or in the mucous membrane. In the former case, it begins as localised nodules which grow rapidly and produce bulging of the mucous membrane or of the peritoneal coat but do not tend to ulcerate. When in the mucous membrane, it causes a uniform swelling (fig. 295) or, more usually, projects in polypoidal masses (fig. 296). Fig. 295 from Hofmeier, shows a uterus extirpated for cancer; the disease had not recurred within five years after the operation. By Eppinger and Huge the disease has been directly traced to the epithelium of the uterine glands ; these first hypertrophy, and then their proliferating epithelium passes into carcinomatous epithelial cells. The new- formation ulcerates, so that the wall of the uterus becomes con- verted into an excavated surface with a hard base. Adhesions rapidly FIG. 296. CARCINOMA OF THE BODY OF THE UTERUS. The uterine cavity is increased in size but the cervix is undilated (Sir J. Y. Simpson). form with neighbouring organs, while secondary deposits may develop in the peritoneal cavity. As to Etiology, what has been said of carcinoma of the cervix applies here with two additional facts. (1) It occurs rather later in life than cancer of the cervix; and (2) is more frequent in nulliparse. 1 SYMPTOMS AND DIAGNOSIS. Again, as in carcinoma of the cervix, the symptoms are pain, haemor- rhage, and foetid discharge. 1. Pain, in contrast with carcinoma of the Pain, cervix, is always an early symptom. Sir J. Y. Simpson drew attention 1 Taking Veit's two series of cases together, we have out of 80 cases, 31 between 50 and 60 and 21 above 60 years of age (cf. table in fig. 283) ; and of 72 cases, 38 were childless. 502 AFFECTIONS OF UTERUS. to periodic attacks of severe pain as characteristic of cancer of the body. This is not always present and is probably due to \iterine contractions Haemor- se t U p by accumulation of secretion (Veit}. 2. HcemorrJiage is also present at an early stage ; it takes the form of profuse menorrhagia, because the mucous membrane from which the menstrual flow takes Discharge. pl ac e is diseased. 3. The discharge is usually profuse and becomes after a time foetid. Sometimes it is watery and not offensive ; rarely is it altogether absent. On vaginal examination, the cervix is found to be either normal (fig. 296) or dilated. The uterus is enlarged, and may be freely movable or may be fixed by adhesions. The sound shows the cavity to be enlarged and may reveal irregularity of the mucous membrane; its introduction is followed by haemorrhage. The condition of the mucous membrane is more precisely ascertained by examination with the finger after dilatation of the cervix with a tent. In the majority of cases, certainty of diagnosis is possible only through microscopic examination of fragments removed by the curette. Should these show merely hypertrophied glands, we must remember that this is sometimes a transition stage to malignant disease. Typical carcinomatous cells are seen at fig. 285. The Differential Diagnosis must be made from Portions of retained placenta, Sloughing submucous fibroid, Haemorrhagic endometritis. These conditions have been already described. As to the first of these we note that carcinoma sometimes develops during the puerperium. In three cases observed by Chiari, the development of carcinoma was directly connected with the puerperium and ran a rapid course to a fatal termination within six months after the birth of the child. During the period of sexual activity, differential diagnosis is often extremely difficult ; rapid growth and development of peritonitis fixing the uterus, point to malignant disease. After the menopause, the recurrence of haemorrhage is an important diagnostic. The microscope is, when available, the most reliable guide. TREATMENT. As to the treatment of the symptoms, this is the same as in Carcinoma of the Cervix (v. Chap. XLIL). As to the treatment of the disease, the scraping away of the polypoidal masses with the curette or sharp spoon gives temporary relief from the haemorrhage and discharge. The only hope of cure lies in extirpation of the uterus (v. p. 494). * 1 Of 7 cases (1 by Schroeder) done by Veit, 1 died after operation ; and of 4 cases followed, 1 had recurrence in first year, 2 in second, and 1 not after three years. CHAPTER XLIV. SARCOMA UTERI. 'LITERATURE. Chroback Beitrag zur Kenntniss des Uterussarkoms : Arhiv f. Gyn., Bd. IV., S. 549. Clay, J. On diffuse Sarcoma of the Uterus : Lancet, Jan. 1887. Galabin Lond. Obst. Trans., Vol. XX. Gusscrow Die Neubildungen des Uterus, S. 158: Stutt- gart, 1885. Jacubash Vier Falle von Uterussarcom : Zeitschrift f. Geburts. u. Gyn., Bd. VII., Hft. I. Kunert Ueber Sarcoma Uteri : Arch. f. Gyn., Bd. VI., S. 29. Rogivue Du Sarcome de 1'uterus : Inaug. dissert., Zurich 1876. Schroeder Die Krankheiten der weiblichen Geschlechtsorgane, S. 320 : Leipsic, 1886. Simpson, A. R. Contributions to Obstetrics and Gynecology, p. 240 : Edin., 1880. Spiegel- berg Sarcoma Colli Uteri hydropicum papillare : Archiv f. Gyn., Bd. XIV., S. 178. Bin weiterer Fall : Ibid., Bd. XV., S. 437. Thomas Diseases of "Women, p. 566, Lond. 1880 ; and Sarcoma of the Uterus, Lond. Obst. Jourii., Vol. II., 1875, p. 437. Virchow Die Krankhaften Geschwulste : Bd. II., S. 350. Winkler Ein weiterer Fall von Sarcoma papillare hydropicum cervicis et vaginae : Archiv f. Gyn., Bd. XXI., S. 309. For a full resume of the earlier literature, see Gusserow and A. R. Simpson ; and, for recent literature, the Index in the Appendix. BY sarcoma we understand a connective-tissue tumour of an embryonic Nature of type. As we trace back carcinoma to the epithelium and true myoma coma " to the muscular fibre, so we trace back sarcoma to the connective tissue. For the recognition of sarcomata as of connective-tissue origin and the limitation of the term to malignant tumours of this type, we are indebted to Virchow. Formerly they were known in English literature as " recurrent fibroids ; " the existence of this form of tumour in the uterus was recognised and fully described by Hutchinson (1857). PATHOLOGY. Unlike carcinoma, sarcoma rarely occurs in the cervix ; in the larger proportion of cases it is in the body of the uterus. It occurs in two forms : 1. Diffuse sarcoma of the mucous membrane ; 2. Circumscribed fibrous sarcoma, The diffuse sarcoma of the mucous membrane arises from the sub- Diffuse epithelial connective tissiie. It appears as a general swelling of the mucous membrane which becomes soft and crumbly, or as irregular foldings or knobby projections into the uterine cavity ; sometimes these 504 AFFECTIONS OF UTERUS. projections have a polypoidal and apparently circumscribed character (fig. 297) so that this form passes insensibly into the fibrous. The masses have a greyish-white brain-like appearance, and soft pulpy con- sistence. The mucous membrane may be broken down but is not deeply excavated as in carcinoma. On microscopic examination the mucous membrane is seen to be infiltrated with masses of closely-set FIG. 297. SARCOMA UTERI WITH TUMOURS IN THE VAGINA from a specimen in the Pathological Institute at Strassburg (Gusseroie). round cells, more rarely spindle-cells. Epithelial-cell proliferation often complicates this form of sarcoma and brings it into close relation to carcinoma. Klebs has proposed to call such forms carcino- sarcomata. Sarcoma. The circumscribed ftbro-sarcoma arises in the muscular coat ; like the SARCOMA UTERI. 505 fibroid it may be submucous, interstitial, or sub-peritoneal, and is found usually in the body, rarely in the cervix. The tumours are of a firm consistence, and feel like knots in the muscular wall of the uterus or project as polypi into its cavity ; they thus resemble small fibroids, but MICROSCOPIC SECTION OF THE Mucous MEMBRANE OF THE UTERUS IN A CASE OF SARCOMA (Schroedir). S Sarcomatous tissue ; c small-celled infiltration ; g uterine glands. have no capsule. Microscopically they consist of a localised sarcomatous generally round-celled infiltration (fig. 298). In some cases it has been alleged that sarcoma is a degeneration of a fibroid tumour^ as in the following specimen described by A. R. Simpson. " On section it presented a uniformly smooth surface of pale-pinkish FIG. 299. SARCOMA UTERI, seen on section, showing fibroid nodules (A. R. Simpson). colour, with some islands in it presenting the familiar cotton-ball struc- ture and clear white glistening aspect seen on section of an ordinary fibroid tumour of the uterus, and separated from the softer surrounding- tissue by a connective-tissue capsule (fig. 299). The larger part of the tumour was composed of fusiform nucleated cells, with an intercellular 506 AFFECTIONS OF UTERUS. matrix having a fibrillated appearance, and running for the most part in small sections in parallel directions." A portion of the tumour, probably then a fibro-myoma, had been removed five years previous to this ; a third portion of the tumour, removed four years subsequent to this, showed only sarcomatous tissue. A similar case is reported by Ballan- tyne, with microscopic sections. * Chroback and Miiller " also have traced the development of sarcoma in tumours which were originally undoubted fibroids. There is therefore no doubt that this is one mode of origin of fibro-sarcoma ; whether (as Schroeder and Kunert have suggested) this is always the origin, is as yet undecided. Secondary nodules may form in the vagina (fig. 297) and peritoneal cavity. Sometimes the peritoneum is affected by continuous spreading of the new growth outwards towards the peritoneal covering ; here it Co-exist- ence of Inversion of Uterus. FIG. 300. SARCOMA UTERI INVADING THE FALLOPIAN TUBES and projecting from their fimbriated ends (A. R. Simpson). causes adhesions, through which the sarcomatous infiltration may extend to other organs (Gusserow). A. R. Simpson records a unique case in which the infiltration spread along the mucous membrane of the Fallopian tubes (fig. 300), so that from their fimbriated ends there pro- jected " rounded masses, having the appearance of the thrombus project- ing from a small vein into a larger trunk." The uterus was of the size of a four-months' pregnancy. A. R. Simpson draws attention to the frequency of inversion of the uterus as the result of sarcoma. We referred to it as a rare complica- 1 Edin. Med. Jour., Nov. 1884. 2 Zur operativen Behandlung der Uterusmyome : Archiv /. Gyn., Bd. VI., S. 125. SARCOMA UTERI. 507 tion of pediculated subucmous fibroid tumours. In sarcoma, it appears to occur more frequently in 4 out of 48 cases. He attributes this to the paralysis of the muscxilar Avail of the uterus through sarcomatous infiltration and to the peculiar dilatability of the cervix observed in some cases. Sarcoma of the cervix is rare ; in Winkler's paper, eight cases are referred Sarcoma of to besides his own. Two of these were spindle-celled, the rest round- celled sarcoma. A special form has been described as Sarcoma papillare hydropicum cervicis. It grows as a papillary tximour which fills the vagina and may project outside the vulva. The cells are embedded in an abundant intercellular substance which stains faintly, is granular and traversed by delicate thi-eads. It has been erroneously described as a myxo-sarcoma ; in Spiegelberg's cases, it was shown that this inter- cellular substance was not mucin but coagulated lymph. Large vascular spaces may form in their substance as occurs in fibroid tumours ; in a case recorded by Jacubash, the bursting of such a vascular tumour into the peritoneal cavity proved suddenly fatal. Metastatic deposits, though rare, are found more frequently in fibro- Metastatic sarcoma than in diffuse spreading sarcoma. They have been found in eposl s ' the lymphatic glands, lungs, liver and vertebrae. ETIOLOGY AND FREQUENCY. Of the reason why a source of irritation should lead the connective tissue to produce a sarcomatous new-formation, we know as little as why the same cause produces a carcinomatous new-formation from the epithelium. As to its frequency, a sufficient number of cases has not yet been Frequency, collected to form any generalisation. It is, however, so rare that every carefully observed case which has been authenticated by microscopic examination should be placed on record. Gusserow has collected only 73 cases. Age has the same predisposing influence as in fibroma and carcinoma. Influence Adding to Gusserow's cases, 8 which we have collected from the litera- ture of the last three years we find that 4 were under 20, 5 between 20 and 30, 17 30 40, 31 40 50, 19 50 60, 4 60 70, 1 was above 70. The number of sterile patients among those affected with sarcoma (25 Sterility out of 63) is noteworthy ; in this respect it contrasts with carcinoma 1 (Gusserou'). 1 In 74 cases of sarcoma, 25 were sterile, and 16 had less than 3 children. 508 AFFECTIONS OF UTERUS. SYMPTOMS. The following conditions characterise the early stage, in which the patient seeks advice : 1. Haemorrhage, 2. Absence of pain, 3. Watery non-offensive discharge, 4. Cachexia. Haemor- Haemorrhage appears first as increase of the menstrual flow, or as r iage- irregular haemorrhages after the menopause. As the new-formation does not ulcerate rapidly like carcinoma, the increased menstruation is due to hypersemia of the mucous membrane (Clay}. Pain. The absence of pain in the early stage is remarked on by Clay and A. R. Simpson; in this respect it differs from intra-uterine cancer. According to Gusserow, on the other hand, pain is frequently present and that of an intense and rending character. This apparent discre- pancy of opinion may be explained by the varying progress of the infiltration. In the spreading of carcinoma, we noted that pain was most severe when the disease was extending upwards and compressing the nerve endings in the uterus and connective tissue. Discharge. The free rice-watery discharge has a slight odour but is not nearly so offensive as in carcinoma ; this is due to the fact that there is not the same rapid ulceration and necrosis of tissue. When the disease has progressed further, the discharge becomes equally foetid. The presence in the discharge of greyish-ivhite shreds, like particles of brain matter, is diagnostic ; under the microscope these are seen to consist of small portions of sarcomatous tissue. Cachexia. Cachexia is of importance as it helps us to distinguish developing sarcoma from a non-malignant polypus ; the drain from the latter may make the patient gradually anaemic ; but there are not the loss of flesh, the loss of appetite and the rapid failure of strength, which point to malignant disease. DIAGNOSIS. If the tumour projects through the os, the diagnosis is not difficult. The age of the patient with the symptoms given above and the existence of a soft friable pediculated tumour which springs from the body of the uterus, will point to the diagnosis ; a portion, detached with the nail, shows the characteristic microscopical structure. When nothing projects through the cervical canal, we try to dilate it with the finger, or, if this fails, with a sponge tent or the rapid method described at p. 458. The finger recognises a soft friable condition of the mucous membrane, or a distinct polypoidal tumour, or a localised thickening in the walls. SARCOMA UTERI. 509 The uterus is in some cases distinctly enlarged and may reach half- way to the umbilicus or lie retroverted ; in the early stages it is movable, but it soon becomes fixed. The sound shows the cavity to be enlarged ; its use causes haemor- rhage. The differential diagnosis is here often very difficult, as these Differen- conditions are also present in tial Diag- nosis. Chronic endometritis (hsemorrhagic type), Small fibroid tumours (interstitial or polypoidal), Carcinoma. Curetting the surface, with microscopic examination of the scrapings, will help us in the first case. FIG. 301. CRAPINGS FROM A FlBROID TUMOUR to show the size and form of the muscular fibre, their rod- shaped nuclei stained, 2f u ; drawn by S. Delepine. FIG. 302. SCRAPINGS FROM A SPINDLE-CELLED SARCOMA to show the larger size of the spindle cells and their oval nuclei stained, 2 p ; drawn by S. Delepine. The removal of the polypoidal mass, with the finger nail or nail- curette, will enable us to examine its nature ; the possibility of both conditions being present, polypoidal fibroid + commencing sarcomatous degeneration, must be remembered. With an interstitial thickening, we can only watch the progress of the case. In carcinoma of the fundus, there is generally excavation of the uterine wall and the base of the ragged surface is harder than in sarcoma. The examination of scrapings is not always decisive, as the cells found in sarcoma sometimes closely resemble epithelial cells. In all cases of doubt we must watch for a few months, when the rapid growth of the tumour or the development of cachexia will clear up the case. 510 AFFECTIONS OF UTERUS. PROGNOSIS. The prognosis is grave. Compared with carcinoma, its development is not so rapid nor are the symptoms of pain and offensive discharge so aggravated in the early stage. In two of the cases recorded by A. R. Simpson the patient survived for four years after the diagnosis of sarcoma was made out, and Gusserow mentions a case where the course was prolonged for ten years. The temporary relief procured by removal is longer of duration than in carcinoma. No case of radical cure is, as far as we know, recorded ; after removal it reappears at periods varying from two to fourteen months (Clay). When it returns, the development of the new tumour is more rapid than that of the first growth. As to the communication of the prognosis to the patient and friends, see under Carcinoma. TREATMENT. The tumour should be removed as soon as we suspect malignancy. Even when there is doubt, its removal will clear up the case. The cervix should be well dilated so as to allow the finger to pass freely into the uterus. Gradual dilatation is preferable ; injury of healthy mucous membrane in dilating or curetting should be avoided, as sarcomatous cells have become engrafted on a fresh wound surface. When circumscribed and polypoidal, remove it with the finger nail or nail curette. After its removal apply carbolic acid thoroughly to its base. When diffuse, curette the uterus. Continue the scraping till all the loose tissue and irregularities of the mucous membrane are removed. After curetting the surface of the uterus, examine with the finger to ensure that all is removed and apply carbolic acid freely. When the os is widely dilated and the seat of the growth low down, cauterisation with Paquelin's cautery would be even more effectual Clay injected perchloride of iron after curetting, and without any bad result ; the application of the caustic on a rod is safer. Extirpation of the uterus offers the only hope of radical cure (v. p. 494). Dawson 1 has recorded a case of extirpation for sarcoma of the cervix. 1 Anier.Jou.rn. ObsM. 1SS5, p. 1184. SECTION" VI. AFFECTIONS OF THE VAGINA. THESE we shall consider in the following order : CHAPTER XLV. Atresia Vaginae. ,, XLVI. Vaginitis : Vaginismus : Tumours. CHAPTER XLV. ATRESIA VAGINAE. LITERATURE. Barnes Diseases of Women, p. 219 : London, 1881. Hreisky Die Krankheiten der Vagina : Stuttgart, 1879. Delaunay Etude sur le cloisonnement transversal du Vagin, etc. : Paris, 1877. Dohrn Angeborne Atresia vaginalis : Archiv fiir Gynak., Bd. X., S. 3. Duncan, J. Matthews Case of so-called Imperf orate Hymen : Lond. Obst. Tr., Vol. XXIV. Emmet Principles and Practice of Gynecology, p. 188 : Philadelphia, 1884. Congenital Absence and Accidental Atresia of the Vagina, etc. : Trans. Am. Gyn. Soc., II., p. 437. Fasola Contribute allo studio dell'origine dell'imene, a proposito di un caso di ematocolpo per mancanza della parte inferiore della vagina e dell'imene : Annal di Ostet., 1885, p. 146. Fuld Salpingotomie wegen Hamatosalpinx bei Gynatresie : Archiv f. Gyn., Bd. XXXIV., S. 191. Leopold Blutansammlung im Verschlossenen Uterovaginalkanale und die Sal- pingotomie : Archiv f. Gyn., B. XXXIV., S. 371. Puech, A. Des Atresies com- plexes des voies g^nitales de la Femme : Ann. de Gynecologie : Paris, 1875. Sirup- son, Sir J. Y. Diseases of Women, p. 256 : Edin. 1872. Simpson, A. R. Con- tributions to Obstetrics and Gynecology, p. 195 : Edin. 1880. Thomas Diseases of Women : London, 1882, p. 220. See Index of Recent Gynecological Literature in the Appendix. Definition. ATRESIA (a-rprjffis, non-perforation) has been already defined as occlusion of the genital tract where the obstruction is complete and leads to accumulation of menstrual blood or mucous secretion. This occurs at three places the hymen, the vagina, and the cervix uteri. Atresia of the cervix has been already described (v. Chap. XXVI.). Accumulation of blood in one-half of a septate uterus or vagina will be considered by itself at the end of this Chapter. PATHOLOGY. 1. ATRESIA HYMENALIS. The structure of the normal hymen has been already described (page 6). In atresia hymenalis it forms a con- tinuous membrane, is thicker and of an almost cartilaginous toughness ; this explains the rarity of spontaneous cure by rupture of the membrane. This condition is produced by the occurrence of inflammatory adhesion of the folds after their formation, that is after the nineteenth week of foetal life. When the vagina is distended with menstrual blood, the hymen bulges forwards. 1 As the menstrual blood accumulates, the vagina distends so as to form a tense membranous-walled sac nearly 1 Blood extravasation occurred into the labia in Davy's case. Lancet, 1880, II., p. 1171. AT21ESIA VAGINAE. 513 filling the pelvis, and with a smaller firmer body (the undiluted uterus) rising from its upper surface (v. fig. 305). If the tension be not relieved, the cervix next becomes dilated and may rupture. Finally the uterus itself becomes opened out, though this does not occur till late. During this period, accumulations of blood may take place in the Fallopian tubes in the form of diverticula, usually situated towards the fimbriated end (figs. 303 and 304). These are not produced, as we should suppose, by a simple reflux of the blood from the distended uterus into the tubes but by hemorrhage from the mucous membrane of the tubes themselves (Schroeder) ; the uterine end of the Fallopian FIG. 303. ATRESIA VAGINAE, SEEN FROM BEHIND. Thickness of obstruction (through which a probe is passed) 8-4 mm. ; of vaginal wall below atresia 2-3 mm., abort it (at x) 6mm. Dilatation of the body of the uterus is small compared with the common cavity formed by cervix and upper portion of vagina. Left Fallopian tube markedly dilated, with no distinct flexion on it, and changed at its free end into a thin-icalled blood sac which had burst. Right tube undiluted. (Breiiky) tube is sometimes undilated or even entirely closed. Blood may escape gradually from the fimbriated end of the tube, and set up a localised peritonitis matting down the tube and uterus ; a hsematocele is some- times thus produced. 2. ATRESIA VAGINALIS. The thickness of the obstruction varies in different cases, according to the extent of the original obliteration and the thinning produced by the pressure from above. The dilatation of the 2K 5H AFFECTIONS OF VAGINA. Seat of Obstruc- tion. vagina above the obstruction is remarkable ; it may form a tumour filling the pelvis, pressing on the bladder and rectum, and raising the uterus above the brim ; the walls become hypertrophied as is well seen in the preparation represented in fig. 303, taken from a patient who died on the same day as the operation for atresia was performed. The seat of the obstruction is most frequently in the lower third of the vagina. This condition may be mistaken for imperforate hymen ; as the wall of the sac, bulging through the hymeneal orifice, becomes adherent to the hymen which appears as a mere fringe on the bulging membrane. There is not, however, the same distension of the vulvar FI;J. 304. CASE or DOUBLE ATRESIA. The lower affects the hymen and was acquired; above this was a cavity one inch long which contained purulent debris : the upper obstruction was one inch thick and was congenital; above it is the dilated uterus and cervix. The Fallopian tubes contain blood- sacs with small.rents in their walls (Breiiky, case reported by Steiner). orifice and perineum as in atresia hymenalis. Atresia of the whole vagina is visually associated with imperfect development of the uterus (Breislcy). Atresia may exist at more than one point in the vagina. The speci- men represented in fig. 304 illustrates this. It has this further interest that the lower atresia at the vaginal orifice was acquired, the result ATRESIA VAGINAE. 515 of a fall on a block of wood when the patient was two years old ; the upper atresia was congenital The accumulation of menstrual blood in the upper sac called for operative interference when the patient was seventeen years of age. The lower sac contained purulent matter. On the fifteenth day after the operation, death occurred from septic peritonitis. The character of the retained menstrual blood is peculiar. It is of a character brownish chocolate-red colour, of a thick treacle-like consistence, and of retained contains no coagula. Microscopically, it shows shrivelled red blood- corpuscles, flat epithelial cells, mucous corpuscles, extravasated blood- pigment, and granular debris. The mucus prevents coagulation ; part of the fluid portion is probably reabsorbed, since the quantity removed is less than the sum of what we should expect from the successive periods passed. 1 ETIOLOGY". 1. Atresia may be congenital, due to non-development of a part of Congenital the canal or its subsequent closure during foetal life. Atresia. Atresia hymenalis implies that the hymeneal folds were developed (at the nineteenth week) but afterwards became blended into a con- tinuous membrane. Atresia of the vagina behind the hymen is, according to Dohrn, due to the fact that (at the eighteenth week of foetal life) the walls of the genital canal become closely approximated behind the site of the hymen, so that closure of the vagina is especially favoured in that part. Atresia of the middle or upper third implies the development of the ducts and their coalescence into a vagina, with a subsequent occlusion due perhaps to inflammation (Breisky). Complete absence of the vagina or its representation by a fibrous cord is due to the non-development of the ducts of Miiller ; absence of the lower third is occasioned by the non-extension of the ducts downwards so as to open into the cloaca. 2. Atresia is also acquired; that is, it arises daring life. The mostAcquired important causes which produce this condition are the following : Sloughing and subsequent cicatrisation after labour ; 2 Sloughing from impaired vitality in typhus, scarlet-fever, small- pox, and cholera ; Cicatrisation after injuries received in childhood ; Superficial inflammation of the mucous membrane, leading to adhesion of apposed surfaces. 3 1 Oliver gives Bedson's chemical analysis of the retained blood in a recently reported case : "It gave the spectrum of reduced hajmatin, and contained '6 p.c. of urea ; 100 c.c. contained total so 7-65 grms., organic compounds 6'93 grms., mineral compounds -72 grms. In the solids were f salts, for example, chlorides, sulphates and phosphates, and such bases as iron, calcium, magnesium and sodium : Brit. Mcd. Jottrn., 1888, II., p. 1160. 2 As in the cases recorded by Holdsworth (Lan-:et, 1883, I., p. 949) and Cross (Amer. /ourn. ObsM., 1883, p. 809, and 1SS6, p. 802). .... . . . . tt a As in the case recorded by More Madden (Dublin Med. Journ., LXXV., p. 158), m which developed in a multipara after a miscarriage. 516 AFFECTIONS OF VAGINA. The commonest form of congenital atresia is due to imperforate hymen ; of acquired, is due to cicatrisation of the upper part of the vagina and cervix after labour. SYMPTOMS. As congenital atresia is productive of bad results only in so far as it impedes the menstrual flow, symptoms do not arise till puberty. Should menstruation not take place at puberty, the condition may not attract attention till the patient enters married life. 1 Cases are however on record in which the accumulation of mucus has called for operative interference even in childhood. Symptoms At puberty the patient experiences menstrual molimina without the Puberty appearance of a discharge. As the vaginal sac distends, pain is felt in the pelvis at first only at the periods and then more continuously. With this there is also constitutional disturbance. The periods of suffering become more protracted, the intervals of relief shorter. When the dilated vagina presses on the bladder and rectum, it causes difficulty in micturition and defsecation. The abdomen swells and this, with the amenorrhcea, causes suspicion of pregnancy which is sometimes the occasion for seeking advice. If the case is left to itself it terminates fatally through rupture of the uterus or cervix (usually the latter) or of a blood sac in the Fallopian tube, or through a simple or septic peri- tonitis independently of rupture. In some cases, the obstructing mem- brane has given way by rupturing (in acquired atresia) or sloughing (in the congenital form). But even this is not a favourable termination, as the risks consequent on operative interference are still more likely to ensue when the hymen ruptures of itself. DIAGNOSIS. The importance of physical diagnosis will be evident from the follow- ing case. "A. B., set. 16, unmarried, has for twelve months suffered from pain in the pelvis and back, with occasional acute exacerbations accompanied by nausea and vomiting. She has been treated for inflam- mation ; and mercurial ointment had been applied to a swelling which had appeared in the left groin, on the supposition that it was an enlarged gland." Examination per rectum showed a condition similar to that seen at fig. 306 ; the swelling in the left groin was the elevated uterus. The practitioner will often ask himself whether a vaginal examination is necessary. On the patient's returning several times and there being nothing in the constitutional state (phthisis, chlorosis) to explain the amenorrhoea, tell the friends that there is no apparent cause for the 1 Zinnstag records a curious case in which an apparently imperforate hymen was not observed until labour set in ; there must have been a perforation (to account for conception) at one time, but it had closed subsequently : Centratb.f. Gyn., XII., S. 219. Doleris reports a similar case : Archiv. de Toe. 1886, p. 135. AT RE SI A VAGINAE. 517 non-appearance of menstruation except on the supposition of a mechani- cal obstruction to its outflow. If there be pain in the pelvis and marked constitutional disturbance, the reasons for demanding an immediate examination will be evident. The conditions found in the various forms of atresia will be easily understood by studying figs. 305 to 308. The external genitals are first examined ; a wide urethral orifice may be mistaken at first glance for the vagina, as in atresia hymenalis the urethral orifice is more patulous than it is normally (Oldkam) ; the hymen is seen biilging forwards at the ostium vaginae. The finger is passed into the rectum and feels that the anterior Avail is made to bulge by a tense elastic sac. On bimanual (recto-abdominal) examination, this sac is felt to be equally distended and to fill the pelvis ; it may extend into the abdomen as far as the umbilicus. The feeling of the sac is quite characteristic and is like that of a tense FIG. 305. ATRESIA HYMENALIS (Sclroider). FIG. 306. ATRESIA V AGIN* lower third (Sckrotdtr). india-rubber ball ; on its upper surface, the uterus is felt as a small firmer tumour. In atresia vaginae the condition is the same, except that the hymen does not bulge and that the sac does not extend so low down. Atresia of the cervix (figs. 307, 308) might be mistaken for earl pregnancy; as the amenorrhcea and the distended uterus are present nancy> in both cases. But the condition of the cervix, the form of the uterus, and specially the characteristic tense feeling of the tumour, enable us to distinguish it from a pregnant uterus. Malignant tumours (sarco-From Sa mata) have a similar elastic consistence, but with them we should not have amenorrhcea. It is not in all cases easy to say whether the atresia be congemfe 518 AFFECTIONS OF VAGINA. acquired. The existence of other malformations would favour the former view, of cicatrices beside the obstruction the latter. There will also be a greater thickness of tissue felt between the urethra and rectum in the acquired form, corresponding to the obliterated vaginal canal. E f s m t ati ? n I n atresia vaginae it is important to estimate the distance to which of Atresia. atresia extends, so that we may know how much tissue we must cut through to reach the sac or the cervix uteri. This is best done by passing the index finger into the rectum till the tip is on the place where the bulging of the sac begins or where the projection of the cervix is felt ; the thumb is at the same time passed into the ostium vaginae till it reaches the obstructing membrane ; the thickness of the latter can thus be estimated. FIG. 307. ATRESIA OF CERVIX AT Os EXTEKNUM (Schroeder). FIG. 308. ATRESIA OF THE CERVIX AT Os INTERXUM {Schroeder). PROGNOSIS. If menstrual blood be accumulating, the prognosis is always grave. In atresia of the hymen the prospect of cure by operative treatment is more hopeful than in congenital atresia of the vagina. In acquired atresia of the vagina, if the obstruction be removable, the prognosis is favourable. The unfavourable cases are those in which the vagina is partially or not at all developed ; the prognosis as to curability by operation depends on the thickness of the tissue between the urethra and the rectum, which determines the possibility of opening up a vagina. When menstrual blood has accumulated, while explaining to the patient's friends the necessity of immediate operative treatment, we AT RE SI A VAGINAE. 519 should inform them also of the dangers attendant on the operation the immediate danger of rupture of a blood sac in the Fallopian tube, the more remote one of simple or septic peritonitis. The seriousness of the complication of hsematosalpinx is seen in Fuld's statistics : l of sixty-five which he has collected, more than two- thirds (forty-eight) died ; while seventeen were saved by operation. TREATMENT. The treatment consists in the formation of a channel to allow the menstrual blood to escape ; in the case of imperforate hymen this is easily done by incising the membrane, but in atresia vaginae we have to construct a new vaginal canal. Two dangers associated with this Dangers of operation must be kept in view. First, too rapid collapse of the sac may lead to rupture of the Fallopian tubes or of vascular adhesions round the uterus. This rupture may be brought about in the following way, as has been shown by post-mortem examination. The Fallopian tube has been previously bound down to the side wall of the pelvis by adhesions ; when the sac is opened into, the uterus necessarily follows its retreating wall and, if this retreat takes place rapidly, the tube is exposed suddenly to a strain which ruptures it ; death results from haemorrhage or peritonitis. To prevent this accident, the operator should allow the contents of the sac to escape slowly and should on no account apply pressure from above to hasten the process. Second, the operation is frequently followed by septicaemia. To prevent this, anti- septics should be used. Listerism cannot be carried out here ; but by washing out the sac carefully with carbolised water, preventing the entrance of air, and allowing free drainage when fluid collects, we greatly diminish this risk. The danger of rupture of hsematosalpinx has only recently been recognised. Puncturing of the dilated tube is now abandoned for abdominal section ; and salpingotomy (Tait's opera- tion) should be performed in addition to the evacuation of the distended vagina when a dilated tube is present. 2 Another danger, which follows some time after the operation, is the contraction of the new canal which, unless specially guarded against, may lead to its obliteration. Emmet expresses this well when he says " the surface of the canal is essentially a cicatricial one, and will con- sequently contract to a greater or less extent." To diminish the liability to contraction, he recommends that the tissues be torn with the finger nail or broken up with the scissors rather than divided with the knife ; * Op. cit. These cases were collected from all sources, and before the operation for hwmatosalpinx was a recognised one. palpation called for in both cases. 520 AFFECTIONS OF VAGINA. the raw surface is made to heal upon a glass plug. 1 Crede ~ prevented cicatrisation by taking a flap from the labium majus and turning it into the vagina so that it could be stitched to the cervix and to the raw surface produced by dividing the old cicatricial tissue in the vagina. We shall describe shortly the operations for (1) imperforate hymen, (2) atresia of the vagina, (3) atresia of the cervix. Operation 1. Imperforate Hymen. This operation, though apparently simple, f orate should never be performed in the consulting room but always at the Hymen, patient's house or in hospital. The time chosen should be between two menstrual periods which are indicated by menstrual molimina. The hymen is punctured with a small trocar which has been rendered thoroughly clean and aseptic beforehand. The fluid is allowed to escape slowly. After it has ceased to flow, the opening in the hymen is enlarged with a knife. This incision is made in the form of a cross, or the membrane is pinched up with forceps and an elliptical portion cut out. A. R. Simpson recommends that the opening in the hymen be made with the cautery, which prevents septic absorption by the wound. We can dispense with the trocar if we take care to make at first only a small opening, which can afterwards be enlarged. A stream of warm antiseptic water is now made to flow gently into the cavity ; the open- ing should be large enough to permit the fluid to flow outwards at the same time, so that the sac may be washed out without being subjected to any pressure. A plug of lint soaked in antiseptic oil is placed in the hymeneal orifice, and a larger pad over the vulva. The patient keeps her bed for ten days after the operation. If there be a rise of tempera- ture or other indication of septic inflammation, the vagina should be again washed out. Operation 2. Atresia of the, Vagina. The patient is placed in the lithotomy pos- Vaginse. ture, and the labia are retracted by the fingers of the assistants who hold the thighs. The sound is passed into the previously emptied bladder ; it is then held by an assistant in such a way that the urethra and bladder are drawn well upwards towards the pubes. The index finger (with, if necessary, the second) of the left hand is introduced into the rectum ; and the thickness of tissue between the finger and the sound, as well as the position of the distended sac above, carefully ascertained : the finger is kept in the rectum during the operation, both to hook that structure backwards so as to prevent its being cut into and to guide in tearing up the septum. Should the operator wish to have both his hands free to use instruments, an assistant can pass the finger into the rectum. The operator now makes with a knife a transverse incision over the hymen, or through the skin between the anus and the urethra. When the sac 1 In the Americ. Journ. Obst. (1887, p. 1180) he refers to his attending in her second confinement a patient on whom he had operated ten years previously to make an artificial vagina when she was fifteen years old. 1 Archivj: Gyn., Bd. XXII., S. 229. AT BE SI A VAGINAE. 521 is reached, it is punctured and washed out with the same precautions as in the operation for imperforate hymen ; it is then carefully and gently packed with strips of lint soaked in antiseptic oil. These are taken out en the following day, but a tightly fitting plug is left in the newly formed portion of the vagina to prevent its contraction ; after three or four days, a perforated glass plug (fig. 309) is passed in to keep the new canal dilated. The plugs are made of various thicknesses, and have a rim at the external end to prevent their being pushed in too far. The plug must not be so long as to press on the roof of the vagina, and should be of such a thickness that, while it can be easily slipped out and in by the wearer, it stretches the new canal ; it is kept in position by tapes which are fastened to the rim and, before and behind, to an abdominal band. A pessary can be employed subsequently ; some instrument may have to be worn constantly for a year or more and where there is continued tendency to contraction, for a short period daily during many years. In a case operated on by Page, there was an accumulation of fluid in PK FIG. 309. RFORATFD GLASS PLUG TO BE USED AFTER OPERATION FOR AlRESIA VACIN/E. figure shows the external end of the tube with the tapes attached. The left hand the vagina, and a second in the uterus itself which did not discharge till the cervix was incised. 1 This operation has been performed even when there has been no accumulation of menstrual blood. The indications for operating are thus given by Thomas : " It should be resorted to (a) if menstrual blood be imprisoned ; (b) if a uterus can be distinctly discovered and the patient be suffering from absence of menstruation ; (c) if the necessity for sexual intercourse be imperative." Cases have been recorded in which the formation of a vaginal canal has led to the establishment of menstrua- tion when it was formerly absent, to the development of the uterus and ovaries where these were rudimentary (?), or to an improvement in tl general health of the patient although there was no indication of furth development in the rudimentary uterus and ovaries. More difficulty is experienced in operating where there is no accumu- lation of menstrual blood and the vagina is entirely absent or represents i lancet 1884, I., p. 706. 522 AFFECTIONS OF VAGINA. by a fibrous cord. In such a case, there is not the same necessity for surgical interference unless it be to satisfy the claims of married life. If the uterus and ovaries be well developed and the patient be anxious to have her condition remedied, the operation is justifiable. Here we have not the distended sac as a guide to the point on which we are to cut down. The cervix, of which the position should be ascertained by a combined recto-abdominal examination, should be fixed as far as possible by an assistant's making firm pressure from above upon the uterus ; there is no danger in such pressure if there be no accumulation of menstrual blood. The mode of procedure is the same as that just described. Operation 3. Atresia of the cervix. Usually the obstruction is so slight that the Cervicis. forcible passage of the sound overcomes it. Should the obstruction resist all efforts to pass the sound we require to use the knife to open the canal. If the uterus be much distended with menstrual blood, it is safer to empty it first with the aspirator-needle passed through one of the fomices ; the emptying should be effected slowly and, if the disten- FIG. 310. BREISKY'S FORCEPS, TUBE AND NOZZLE, FOR OPERATING IN ATRESIA OF THE CERVIX (Breisky). sion be considerable, at more than one sitting ; rapid emptying is apt to set up uterine contractions which may produce rupture of a dilated Fallopian tube. To open up the cervical canal, the following method is adopted by Thomas. The cervix is steadied with a tenaculum. A long exploring needle is passed along the line of the cervical canal into the uterine cavity, the sense of resistance overcome and the escape of a drop of blood indicating that the needle has reached it. A delicate tenotome is placed in the gutter of the needle and pushed upwards for the required distance. This process is repeated so as to divide the cervix on four sides in a radiate manner. The cavity of the uterus is washed out with a syringe, and a glass tube passed into the cervical canal to keep it open. Breisky has devised the instruments represented in fig. 310, to facili- tate the washing out of the uterine sac in cases of extensive atresia of the vaginal canal and cervix with haBmatometra. The septum which separates the urethra and bladder from the rectum is split up so as to form a new vagina, and the cervix is thus exposed. To form the new AT RES I A VAGINAE. 523 cervical canal, Breisky employs a knife-edged trocar running in a canula. The canula is pressed firmly against the cervix, and the knife is run out piercing through the cervix into the dilated uterus above ; the canula is then run on the knife into the cavity, and the knife withdrawn. The contents of the sac escape through the canula. The forceps represented at fig. 310 are now passed in with one blade on each side of the canula. They are forcibly opened so as to distend the new canal still further, and serve to keep it patulous while the canula is withdrawn and the tube represented at fig. 310 inserted in its place. This tube has two channels ; into one of these a nozzle (fig. 310) fits and is employed to pass the stream of water into the sac, while the outflow takes place by the other. Atresia of one half of a Septate Uterus and Vagina. This form of atresia has certain characteristics which distinguish it from the other forms described above. FIG. 311. SEPT WE UTERUS ; the right half is pervious, the left half has been distended with retained menstrual blood (Schroeder). The chief peculiarity is that it presents the phenomena of free menstruation + those of retained menstruation. The pathological condition is apparent from fig. 311. Spontaneous rupture of the septum with escape of the retained fluid (in this case through the patulous uterus or vagina) occurs more frequently in t than in other forms of atresia; rupture of the Fallopian tube, with its fatal consequences, is also a more frequent occurrence (Punch). spontaneous rupture of the septum does not usually occur at its lowes point ; hence there is liability to accumulation of purulent matter pouch below the point of perforation, which is a source of septicaemia The symptoms are the same as in the other forms of atresia, but 1 524 AFFECTIONS OF VAGINA. are masked by the presence of a menstrual flow. This visible menstrua- tion is often irregular, and profuse leucorrhoca (from the patuloxis cavity) is frequently present. Physical examination shows a fluctuating tumour lying beside the uterus and alongside of the patulous vaginal canal. Sometimes it winds in a spiral manner round the latter. The diagnosis is not difficult if the blind sac extend to the ostium vaginas and be felt running alongside of the vaginal canal or winding round it. If, however, it be limited to the side of the uterus or only extend partially on to the vagina, it may easily be mistaken for other para-uterine tumours most frequently for hsematocele. To clear up the diagnosis and also as a step towards treatment, we puncture the sac with the aspiratory -needle. 1 The character of the discharged blood will indicate the diagnosis. The treatment consists in slowly but thoroughly evacuating the sac, washing out and establishing a permanent opening from it. A septate vagina is sometimes found with a septate uterus (v. fig. 149), both halves being pervious so that there are no symptoms. 2 In rare cases, the one vagina is imperforate. Kleimvachter 3 records an interest- ing case of a bulging tumour of the anterior vaginal wall resembling in position a cystocele ; it ruptured and pus escaped. On laying open the fistulous tract, its walls had the naked eye and microscopic characters of vaginal mucous membrane in a state of inflammation. Traces of a septate condition may persist as bands. 1 Kiderlen mentions a case from Martin's Clinic in which about 21 pints of fluid were evacuated from the dilated right half of the vagina and uterus : Zeits.f. Geb. v. Gyn., B. XV., S. 1. 2 Cullingworth has recorded recently two cases of a transverse septum in the lower part of the vagina : Lancet, 1889, I., p. 726. a Zeits.f. Geb. u. Gyn., B. XL, S. 254. CHAPTER XLVI. VAGINITIS: VAGINISMUS: TUMOURS. LITERATURE OF VAGISITIS. Barnes Diseases of AVomen, p. 865 : London, 1878. HennigT>er Katarrh der weib- lichen Geschlechtsorgane. Hildcbrandt Monat. f. Geb., Btl. XXXII., S. 128. Macdonald, Angus Edin. Med. Journ., June 1873. Miller, A. G. Four and a Half Years' Experience in the Lock Hospital, Edinburgh : Edin. Med. Journ., 1883. Nceggerath Latent Gonorrhoea in the Female Sex : Am. Gyn. Trans., Vol. I., p. 268. Buge Ueber die Anatomic der Scheidenentziindung : Zeitschrift, f. Geb. u. Gyn., Bd. IV., S. 133. Schroeder Die Krankheiten der weiblichen Geschlechtsorgane, S. 460 : Leipzig, 1879. Thomas Diseases of Women, p. 211 : London, 1882. Winckel Colpohyperplasia cystica, etc. : Arch. f. Gyn., Bd. II., S. 400. See also Index of Recent Gynecological Literature hi Appendix. VAGINITIS. SYXOXYMS. Colpitis (Gr. K6X7ros, a fold) : Elythritis (Gr. tKvrpov, a sheath). NATURE AND VARIETIES. Vaginitis is an inflammation of the mucous membrane of the vagina. The structure of this mucous membrane has been already described (v. p. 27). From its consisting of connective-tissue papillae covered with several layers of squamous epithelium, it resembles the structure of the skin rather than that of a mucous membrane ; exceedingly few mucous glands are present. Consequently, the inflammatory changes are more allied to those of the skin than to those of a mucous membrane (Schroeder). According to etiology, vaginitis is either simple or gonorrJioeal. Apart from the history, we cannot for certain distinguish between these (v. Etiology). The clinical distinction between acute and chronic vaginitis is merely a question of degree. Diphtheritic vaginitis will be referred to by itself. Senile vaginitis is one of the physiological retrogressive processes occurring after the menopause. PATHOLOGY. Yaginitis occurs most frequently in the form of slight elevations the mucous membrane, which produce a granular surface. These granu- lations, according to Huge, consist of groups of papillae infiltrated with 526 AFFECTIONS OF VAGINA. small cells ; these swell up and push before them the stratified squamous epithelium, the superficial layers of which are shed (fig. 312). When FIG. 312. GRANULAR VAGINITIS acute form (Schrocder). the condition has existed some time, the surface becomes more equal through the thinning of the epithelial covering (fig. 313). FIG. 313. GRANULAR VAOINITIS chronic form (Schroecler). Emphyse- Associated with vaginitis in pregnancy, there is sometimes an emphy- matpus sematous condition of the vaginal mucous membrane. Winckel has Vaginitis. FIG. 314. COLPITIS EMPHYSEMATOSA (Sclirotdir). described cysts containing gas and fluid ; according to Huge, the air is present in spaces among the cellular tissue (fig. 314), while Zweifel VAGINITIS. 527 thinks they arise from vaginal glands the ducts of which have been closed by inflammation. This form of inflammation cannot be separated from vaginal cysts, to be noticed on p. 533. In gonorrhoeal vaginitis, a gonococcus is present which was first Conor- described by Neisser; the individual is like a coffee-bean in shape, and Vagiuitis. they are aggregated in round clusters. Burnm 1 finds its presence to be diagnostic, and notes this interesting fact, that the seat of its propagation is the urethral and cervical mucous membrane; it cannot burrow through the many-layered squamous epithelium of the vagina. The cicatricial contraction of the vagina observed after the meno- pause is due to a senile vaginitis. The epithelium is shed in patches, and the raw surfaces thus produced adhere together (Hildebrandt). This process is similar to that which produces occlusion of the cervical canal after the menopause. Diphtheritic vaginitis occurs either as localised patches or as anDiphther- affection of the whole vagina. In the latter case, the mucous membrane vaginitis. may be so swollen that the finger scarcely reaches the cervix, which also is found to be thickened and covered with the diphtheritic membrane. ETIOLOGY. The following are the most important causes : Gonorrhceal infection ; Irritating discharges from the uterus ; Injurious vaginal injections, badly fitting pessaries, or other causes which injure the vaginal mucous membrane ; Exanthemata. Gonorrhoeal infection produces the most intractable form of vaginitis, Gonor- which may extend over months or years. The poison may spread alon" the mucous membrane of the uterus and Fallopian tubes causing endometritis (p. 321), pyosalpinx (p. 197), and pelvic per tonitis (p. 158). Irritating discharges from the uterus, as in endometritis, produce aEndome- secondary vaginitis which can only be treated by curing the utenne affection. In carcinoma and vesico-vaginal fistula, vaginitis ans< secondarily. Among the causes which irritate or injure the v^nal mucous inwbr aw, K we mention injections of too hot or too cold water and of substances produce abortion, badly-fitting pessaries, tampons or pieces of spoi which have been allowed to lie some days in the vagina, Vaginitis may also develop on a patient's entering married life, simply from awkward ness in sexual intercourse; on being consulted about such cases, we i Beitrag 2 ur Kenntnis* der Gonorrhea der weiblichen Genitalien : Ar**.f. **, * * 528 AFFECTIONS OF VAGINA. Exanthe- mata as a cause. must remember that a simple vayinitis may produce most of the symptoms of one due to gonorrhoea. Diphtheritic inflammation occurs \isually in the puerperal condition and that through bad hygiene. It has been observed in typhus, small- pox, and cholera, and also in some cases of gonorrhoea. Localised diph- theritic patches are seen in fistulae, in carcinoma, and round badly- fitting pessaries. SYMPTOMS. These are the following : A burning heat in the vagina ; Pain in the floor of the pelvis ; Frequent desire for micturition, with a scalding sensation while water is passing ; Free muco-purulent leucorrhoea. These symptoms are present both in simple vaginitis and that due to FIG. 315. HENDERSON'S VAGINAL SPATUL^E (A. G. Miller). gonorrhoeal discharge. In the latter case, the urinary symptoms are more pronounced ; there is a distinct period from- which all the symptoms commenced, their duration is longer, and they resist treatment; they are often complicated with those of enlarged inguinal glands, endome- tritis, cystitis, or pelvic peritonitis. DIAGNOSIS. On vaginal examination, the finger recognises the discharge which escapes on separating the labia, and, in many cases, the rough condition of the mucous membrane. The speculum shows that the mucous membrane is inflamed and covered with muco-purulent discharge ; the redness is usually in the form of patches but may be diffuse. The appearance of the cervix must be noted to ascertain that the leucorrhceal discharge does not come from it ; the differentiation of dis- charge from the uterus and that from the vagina, is made as described on page 309. VAGINITIS. 529 Fig. 315 shows two spatulse used by Henderson of Shanghai in examining gonorrhoeal and specific cases. They are exceedingly" useful in separating the labia ; one blade can be employed -as a Sims speculum, and pressure can be made along the anterior vaginal wall over the course of the urethra to ascertain if there is any urethritis. The differential diagnosis between simple and gonorrhoeal vaginitis is often very difficult. The history of a distinct source of infection is the only certain guide, and the ascertaining of this is a very delicate ques- tion. Apart from this, the following conditions point to a gonorrhceal origin : sudden development of vaginitis with urinary symptoms, in a patient who has had previously no marked leucorrhoeal discharge ; absence of any other cause to explain these ; protracted duration of symptoms and resistance to treatment. However convinced the practi- tioner may be in his own mind that the vaginitis is of a specific nature, the social unhappiness caused by his expressing a decided opinion should deter him from giving it in cases where a cause is not admitted. Pelvic abscesses discharging through the roof of the vagina have been mistaken for vaginitis (Thomas). Such a mistake will not arise when the Bimanual and other methods of examination are employed. We must not be satisfied with finding vaginitis ; the whole routine examina- tion of the pelvic organs must be made after the pressing symptoms have been relieved. TREATMENT. Iii acute cases, rest in bed is necessary. Hot water injections are given three or four times daily : the douche is much more convenient than the syringe ; it leaves the hands free, requires less exposure of the patient, and keeps up a steady stream (v. p. 138). The stream should run for a quarter of an hour. A piece of gutta-percha tubing, weighted at one end and with a clip at the other, makes a handy douche ; the weighted end is placed in a ewer of water above the level of the bed, the tube is coiled up in the water so as to be filled, the clamp is put on at the other end and the tube withdrawn ; the syphon-action is started by the column of water in the tube and continues till the ewer is empty. The bowels are freely moved, and then a morphina sup- pository is given. Complete rest from sexual activity is absolutely necessary. In chronic cases or after the acute stage has passed off, astringents are added to the injections. The vaginal walls having been first thoroughly dried, a solution of nitrate of silver (3j to j of water) is applied and a tampon of antiseptic cotton soaked in glycerine and bismuth introduced to keep the walls apart. Chloride of zinc (2 grs. to is recommended by Fritsch. 2L 530 AFFECTIONS OF VAGINA. Medicated Applications to the vagina are usually made by means of medicated pessaries. The following are those most frequently used 1 : Atropine Belladonna . Sedative do. 1-20 grain. 2 do. Alo. Ext, Morphina Bismuth Oxide Borax . do. i Cicatrising & Emollient 15 do. do. 15 do. do. do. Zinc Oxide do. do. 15 do. Tannin . Alum Astringent do. 10 15 do, do. Acetate of Lead and Opium Gallic Acid do. do. 5 10 do, 2 grs. Opium do. Persulphate of Iron Sulphate of Zinc (dried) Iodide of Lead Haemostatic Caustic Alterative & 5 10 Resolvent 5 do, do. do. Mercurial Carbolic Acid. do. Deodorant do. 30 5 do, ( Ung. Hydrarg. do. Tampons. Lawton's absorbent cotton 2 is the best material for vaginal tampons which are to be soaked in glycerine or other medicaments. Nature. VAG-INISMUS. LITERATURE. Duncan, Matthews Diseases of Women, p. 142 : Lond. 1883, Hcnrich- sen Strictur des Scheidengewolbes, bewirkt durch Krampf des Musculus levator ani ; Archiv f. Gyn., Bd. XXIII., S. 59. Hildebrandt Ueber Krampf des Levator ani beim Coitus; Archiv f. Gyn., Bd. III., S. 221. Scanzoni Lehrbuch der Krank- heiten der weiblichen Geschlechtsorgane, S. 704 : "Wien, 1875. Simpson, Sir J. Y. Edin. Med. Journ., Dec. 1861. And Diseases of Women, p. 284 : Edin., 1872, Sims Cases of Vaginismus : Americ. Med. Times, 1862, Nos. 22 to 25. Thomas Diseases of Women, p. 203 : Lond. 1882. Tilt The Lancet, Aug. 1874. By vaginismus, we understand a painful reflex contraction of the muscular fibres surrounding the vaginal orifice just as laryngismus is applied to the same condition in the larynx. Marion Sims first drew attention to this condition. ETIOLOGY. It is found in some patients of a nervous and sensitive temperament without there being any local source of irritation, but this is excep^ tional. 1 As made up and supplied by Messrs Duncan, Flockhart & Co. 2 Sold in packets (2 oz J lb.). VAGINISMUS. 531 Usually one of the following conditions is present : An irritable spot in the fossa navicularis ; An inflamed hymen which has not been ruptured, or irritable carunculse myrtiformes ; Fissures in the fourchette or round the vaginal orifice ; Small ulcers within the hymen ; Fissure of the aims ; Urethral caruncle. SYMPTOMS AND DIAGNOSIS. Dyspareunia and sterility are the leading symptoms. By dyspareunia (a term introduced by Barnes), we understand painful Dyspar or difficult sexual intercourse ; hence the conditions which produce euma " vaginismus arise on the patient's entering married life. The suffering may be so great that medical advice is at once sought ; often a sense of delicacy prevents this till the condition has existed some time. In some cases there is a care-worn and anxious expression of counten- ance, in others a hysterical manner. As the ordinary vaginal examina- tion is painful the patient involuntarily drawing away as soon as the painful spot is touched it is best to make inspection of the genitals first. Here we may see any of the conditions mentioned under Path- ology. Sometimes no local cause is evident ; but on carrying the finger into the vagina the reflex contraction of the muscle is felt. Hildebrandt has shown that this muscular contraction is sometimes noticed in the upper part of the vagina, and is then due to spasm of the levator ani. Henrichsen found well-marked contraction of the levator ani in one case ; he refers it to the anterior portion of the muscle which springs from the pubes and passes to the vagina near the vulva. The possibility that the dyspareunia may be due to some local pathological condition at the roof of the vagina (prolapsed ovary or cellulitis) and not at the ostium, should be kept in mind. The prognosis as to cure is good. From the distressing nature of the symptoms, and the relief obtained by the means to be described, they prove very satisfactory cases for treatment. TREATMENT. First remove any cause of local irritation, as urethral caruncle or irritable carunculse myrtiformes ; in some cases it is necessary to clip away carefully the whole hymen. Divide the base of irritable fissures of the anus with the knife, or touch them with the actual cautery, lodoform in powder or made into an ointment, is the best local applica- tion to allay irritation or favour healing. Its penetrating and disagree- able odour makes many patients object to it. This is diminished by 532 AFFECTIONS OF VAGINA keeping Tonquin beans in the powder, and by adding oil of eucalyptus or citronelle (10 m. to i) to the ointment or pessary. R lodoform. gr. x. Olei eucalypti M. i. Fiat pessarium. Mitte tales xii. Sig. As directed. Cocaine, 5-20 p.c. solution or ointment, is also useful. After the cause has been removed, the ostium vaginae must be dilated. This is best effected by making the patient wear a vaginal dilator night and morning, for an hour at a time ; it may be made of wood or of glass, and should have a bulbous end about 1^ in. long. The conical form is not good. The pain caused by the introduction passes off after a time. Dilators of gradually increasing size should be used. If the dilator cannot be worn, we must have recourse to Sims' opera- tion. In some cases, when the vaginismus is evidently due to the narrowness of the ostium and specially when a reflex contraction of the muscle is noted, this operation is done without previous use of the dilators. Sims' operation for vaginismus. We have already seen (p. 10) that the Sims ' . bulbo-cavernosi muscles embrace the ostium vaginae and form a kind of operation. sphincter for it ; their position is seen in fig. 7. To divide the super- ficial fibres of this muscle is the aim of the operation. The patient being under chloroform, two fingers of the left hand are passed into the vagina so as to stretch the ostium. With an ordinary scalpel, an incision is made on each side of the fourchette ; the incision is about 2 inches long, and extends from ^ an inch above the ostium to the raphe of the perineum. The ostium is now thoroughly and firmly plugged with lint which is kept in place with a T-bandage ; thorough plugging is essential as there is often smart haemorrhage from the incisions. Next day the lint is removed and a glass dilator introduced, which must be worn for one or two hours night and morning during a period of several weeks. Instead of dividing the sphincter with the knife, it may be forcibly stretched with the fingers till the muscular fibre is ruptured. This is done by passing the thumbs (Tilt) or several fingers (Heyar) of each hand into the ostium, and then forcibly separating them till we feel the muscular fibre yield under the traction. The advantage of this method is that it is bloodless and there is no granulating wound left to heal. With these local measures, we should always combine constitutional treatment. Exercise, fresh air and change of scene are beneficial. It is self-evident that complete rest to the sexual system must be strictly enjoined during any course of local treatment this should be main- TUMOURS. 533 tained for some time afterwards, which may be secured by recommend- ing a few weeks' residence from home. Tonics (such as quinine, iron and arsenic) are given as the case requires. TUMOURS OP THE VAGINA. Under tumours of the vagina we briefly describe the following : Cysts, Fibroid tumours, Carcinoma, Sarcoma, Tuberculosis. Syphilitic ulceration does not call for special description. Lipoma has also been described. 1 CYSTS OF THE VAGINA. LITERATURE. Breisky Die Krankheiten der Vagina, S. 130 : Stuttgart, 1879. DeSintty Manuel pratique cle Gynecologic, p. 164 : Paris, 1879. Fischel Casuistischer Beitrag zur Lehre von den Scheidencysten : Archiv f. Gyn., XXXIII., S. 121. Grafe Zehn Fiille von Vaginalcysten : Zts. f. Geb. u. Gyn., Bd. VIII., S. 460. Johnston A Contribution to the Study of Cysts of the Vagina : Americ. Jour, of Obstet., 1887, pp. 1121, 1241. Lebedeff Beitrag zur Lehre uber Vaginalcysten: Zts. f. Geb. u. Gyn., Bd. VIII., S. 324. Mundt Case of Cyst of the Vagina : Americ. Jour, of Obstet., vol. X., p. 673. Veil Ueber einen Fall von sehr grosser Scheidencysten: Zts. f. Geb. u. Gyn., Bd. VIII., S. 471. Von Preuschen Ueber Cystenbildung in der Vagina: Virchow's Archiv, Bd. LXX., S. 3. Johnston's paper discusses fully the literature of the subject. See also Index of Literature in Appendix. Pathology. They are situated most frequently in the anterior vaginal wall, and usually in the lower third but within the ostium. They are generally single, rarely have two or more been found together. They are lined with a single layer of cylindrical epithelium which contrasts with the many layers of squamous epithelium of the vaginal mucous membrane from which they lie separate (fig. 316). We have seen them of the size of a hen's egg. Their contents vary from a clear thin fluid to a gelatinous chocolate-coloured inspissated mucus. Fischel and others have also found cysts lined with an endothelium, and the former has demonstrated their connection with the lymphatics ; these cysts, which must be regarded as dilated lymphatics, are much rarer than those lined with cylindrical or pavement epithelium. Cheron 2 found a calculus in a cyst of the anterior wall, which communicated with the urethra ; he refers to observations by Priestley, Simon and others, of vaginal cysts associated with urethrocele, and would account for this condition by the coalescence of a cyst with the urethra, Etiology. As there are hardly any mucous glands present in the Conrad Cent.f. Gyn., XII., S. 214. " Archiveide Toe., 1887, p. 539. 534 AFFECTIONS OF VAGINA. vaginal mucous membrane, the mode of origin of these cysts is disputed. In some cases they can be traced to crypt-like depressions of the mucous membrane which become shut off (Von Preuscheri). It has been sug- gested by Veit that they are due to persistence of the canals of Gartner, rudimentary structures which run alongside of the uterus and vagina (cf. PI. XI., and p. 227). They may also be developed from one duct of Miiller, a condition similar to Septate Vagina (v. p. 523) ; they have then the same structure as the vagina. A case of suppurating hydatid of the vagina has been recorded by Porak. 1 Thorn 2 accounts for some cysts by traumatic blood and lymph extravasations. Symptoms. These are often nil ; and such cysts readily escape obser- vation, so that they may be more frequent than is supposed. When of large size, they produce bearing down pain with leucorrhoea and in some cases dyspareunia. Diagnosis. Small cysts readily escape detection. When large, their FIG. 310. SECTION OF VAGINAL CYST (Schroeder). The cyst wall which is lined with a single layer of epi- thelium is separated by some tissue from the mucous membrane which is covered with many layers of squamous epithelium not detailed in the section. smooth elastic surface and fluctuation make them easily recognised. They must not be confounded with cysts due to obstructed Bartholinian glands, which are situated on the labia minora or at the ostium. Care- ful examination will easily distinguish them from a pouching of the bladder or rectum. Treatment. This consists in laying the cyst open and destroying its lining wall, which is best done by the cautery. Schi'oeder cuts out a portion of the cyst wall, and stitches the margins of the rest to the adjoining vaginal mucous membrane so that the cyst is taken up into the vagina ; this does away with the granulating surface and subsequent 1 Archiv. de Tocoloy., 18S4, p. 163. Centralb.f. Gyn., 1889, S. 658. TUMOURS. 535 cicatrisation which accompany cauterisation. If the patient is past the menopause and the cyst gives no trouble, there is no occasion to interfere. FIBROID TUMOURS OF THE VAGINA. LITERATURE. Breisky Die Krankheiten der Vagina : Stuttgart, 1879, S. 139. A. R. Simpson Fibroma Vaginae, Contributions to Obstetrics and Gynecology, p. 201 : Edinburgh, 1880. Pathology. Fibroid tumours rarely originate in the vagina ; Breisky has collected only 37 cases out of the literature. Michie x has recently recorded a case but gives no microscopic examination of the tumour. Like fibroid tumours of the uterus, they consist chiefly of fibrous tissue with some unstriped muscular fibre ; they are usually situated in the anterior wall, in 17 out of 27 cases (A. R. Simpson) ; they are pedicu- lated (forming so-called fibrous polypi) or sessile. Symptoms. These are produced only when the tumour is large. In the case described by A. R. Simpson, in which the tumour was the size of two fists, it interfered with micturition and the escape of the uterine discharges. Diagnosis. This is easy, except in the case of large tumours when the pedicle is difficult to reach. The relation of the bladder should always be carefully ascertained by passage of the sound. Treatment consists in division of the capsule and enucleation of the tumour when it is sessile, or ligature and division of the pedicle when it is pediculated. CARCINOMA OF THE VAGINA. LITERATURE. Breisky-Die Krankheiten der Vagina, Billroth's Handbuch : Stuttgart, 1879 S 15]. Bruckner Der primare Scheidenkrebs und seine Behandlung : Zeit schri'ft'fiir Geburtshiilfe und Gynak., B. VI., Hft. 1, S. 110. GWe-Boston Gyn Jour., vol. VI., p. 383. Kiistncr Ueber den primaren Scheidenkrel Arcliiv f. Gynak., Bd. IX., S. 279. Parry-Primary Cancer of Vagina: Amer. Jour, of Obstet., vol. V., p. 163: and Philad. Med. Jour., Feb 1873 Simpson, A. . Contributions to Obstetrics and Gynecology, p. 205 : Edinburgh, 1880. , also Index of Recent Gynecological Literature in the Appendix. Pathology. Primary carcinoma occurs very rarely in the vagina in 14 out of 8287 cases (Beigel] ; in the paper cited above, Kiistner has collected but 28 cases out of the whole literature. This is the more surprising when we remember how very frequently it affects the cervix. It occurs in two forms, either as a localised broad-based papillary swell- ing seated most frequently in the posterior wall or as a diffuse infiltra- tion which often constricts the canal in a ring-like manner, incminal glands are generally enlarged by carcinomatous mfiltrati Symptom, and Diagnosis. As in carcinoma of the cervix, the* hemorrhage and foetid discharge : the pain is slight in the early stage. i Brit. Med. Journ., 1S84, I., 1154. 536 AFFECTIONS OF VAGINA. The diagnosis that there is primary carcinoma of the vagina is often doubtful, because it is difficult to ascertain the condition of the cervix and uterus ; in the specimen represented at fig. 281 it was supposed to be primary until the post-mortem showed that it was secondary to carcinoma of the cervix. The examination per rectum is useful in these cases. Treatment. This consists in the removal of as much as possible of the diseased tissue with the cautery, spoon, or knife. Bruckner recom- mends that, where possible, the wound produced by extirpation of the carcinomatous mass be closed by deeply placed sutures. Riiter * records a case of non-recurrence for three years after removal. SARCOMA VAGINA LlTEKATUEE. Breisky Die Krankheiten der Vagina : Billroth's Handbuch, S. 150. Mann Sarcoma of the Vagina : Amer. Jour, of Obst., vol. VIII., p. 541. Simpson, A. R. Contributions to Obstetrics and Gynecology, p. 204 : Edin. 1880. Smith Amer. Jour, of Obst., vol. III., p. 671. Spiegelberg Zu den Sarkomen des Uterus und der Scheide : Arch. f. Gyn., Bd. IV., S. 344. See also Index of Recent Gyne- cological Literature in the Appendix. Sarcoma of the vagina has only recently been described, and is still rarer than sarcoma uteri. It may arise very early in life, being some- times apparently congenital. 2 As in the uterus, it is either diffuse or in circumscribed nodules (v. fig. 297). The symptoms are the same as in sarcoma uteri ; and the treatment consists in removal (more easily effected in the circumscribed form), which in a case reported by Spiegelberg effected a permanent cure. A case came under our notice in which the patient died from bleeding within fifteen weeks after the tumour, the size of a walnut, first attracted attention. It was situated on the posterior wall, and the free bleeding was probably due to the venoiis plexuses being eaten into. The case is reported by Simmons, 3 and Plate XIII., fig. 3, taken from his paper, shows a section of the tumour. Schuckhardt 4 has recorded three cases of operation for its removal in children under eight years of age, with the result that one was still without return after two years ; a second died from recurrence, while the third was operated on again for recur- rence. TUBERCULOSIS VAGINA. LITERATURE. Slob Patholog. Anat. d. weibl. Sexualorgane, S. 432: Wien, 1864. Descharnps Etudes sur quelques ulcerations rares et non veneViennes de la vulve et du vagin : Archiv. de Tocolog., 1885, p. 19. Hegai Die Enstehung, Diagnose, und chirurgische Behandlung der Genitaltuberculose des Weibes : Stuttgart, 1886. It is only of importance as part of a general affection, to be treated constitutionally. Hegar divides it into primary and secondary : the 1 Bin Fall von Carcinom der Scheide : Central!), f. Gyn., XI., S. 606. 2 As in a case of Graenicher's where a tumour was first noticed shortly after birth, removed at 15 months, and recurred at 4th year. Ccntralb.f. Gyn., XIII., S. 591. 3 Rare cases of malignant disease of the Female Sexual Organs : Edin. Med. Journ., Dec. 1885. Ueber Sarkom der Scheide: Archiv f. Gyn., XXXII., S. 400. Hsemorrhages ^ >v~ SHb > ' Fig. 2. Section of Epithelioma of Labia stained picrocarmine ( X 50) Extravasated blood Connective tissue J. Tatham Thompson (del. ad. not.) Fig. 3. Section of Ham>ina of Vagina : stained picrocarmine (x PLATE XIV. Cell- nests in section K Connective tissue Venous sinus pig. 1. Section of Epithelioma of Clitoria-fltained picrocarmine ( X 40) TUMOURS. 537 former is specially liable to arise after labour when the tissues are soft through direct infection from instruments, examining fingers or coitus ; the latter takes place through the blood, or from the outside, e.g., by germs from the stools. Barbier J says that the bacilli may be either in the seminal fluid itself or in the discharge from a tubercular epididy- mitis. Zweigbaum, " in reporting a case of primary tuberculosis of the cervix and vagina with secondary of the lung and intestines, has collected twenty-nine cases of tuberculosis of vagina and cervix. 1 fffu. Meil., 1SSS, Xo. 39. 2 Brit. Mid. /own., 1889, 1., p. 93. SECTION VII. AFFECTIONS OF THE VULVA AND PELVIC FLOOR. CHAPTER XL VII. The Vulva : Malformations j Inflammation ; Tumours. XLVIII. Rupture of the Perineum and its Operative Treatment. XLIX. Displacements of the Pelvic Floor : Prolapsus Uteri ; Enterocele. CHAPTER XLVII. THE VULVA: MALFORMATIONS; INFLAMMATION; TUMOURS. LITERATURE. MALFORMATIONS. Hildebrandt Die Krankheiten der ausseren weiblichen Genitalien : Stuttgart, 1877, S. 2. Meyer Virchow's Archiv., XI., p. 420. Schroeder Die Krankheiten der weiblichen Geschlechtsorgane, S. 497 ; Leipzig, 1879. Simpson, Sir J. Y. Hermaphroditism : Collected "Works, vol. II., p. 407. Tail, Lawson Am. Gyn. Trans., vol. I., p. 318. INFLAMMATION. Hildebrandt Op. cit., S. 17 and 64. Simpson, Sir J. Y. Diseases of "Women, p. 286. Thomas Diseases of Women, p. 122 : London, 1880. TUMOURS. Breisky Ueber Kraurosis vulvse, cine wenig beachtete Form von Haut- atrophie am Pudendum muliebre : Zeitsch. fur Heilkunde, vi. 69. Also Centralb. f . Gynak., 1885, 359. Deschamps Epithelioma primitif de la vulve; Esthiomene : Archiv. de Tocologie, 1885, pp. 120, 221. Duncan, J. Matthews On the Hyper- trophy of Lupus of the Female Generative Organs : Lond. Obst. Tr., 1885, p. 230. See also Ed. Med. Jour., July 1884, and Clinical Lectures, 1886. Duncan, J. M. and Thin On the Inflammation of Lupus of the Pudendum : London Obst. Tr., 1885, p. 310. Hildebrandt Op. cit. Chap. VII., where the student will find the literature of the various forms of tumour fully given. Huguier Memoire sur 1'Esthiomene : Memoires de 1'academie de Medecine, t. XIV., p. 508. Kustner Zur Pathologie und Therapie des Vulvacarcinoms : Zeitsch. f. Geb. \\. Gyn., 1882, 70. Lomei Zur Casuistik des Carcinoms der Vulva : Ztschrift. f. Geb. u. Gyn., 1882, 167. MacDonald, Angus Lupus of the Vulvo-anal region, with cases : Ed. Obst. Tr., IX., 49. Peckham A Contribution to the Study of Ulcer Lesions of the Vulva : Am. Journ. Obst., 1887, p. 785. Simmons Rare cases of Malignant Disease of the Female Sexual Organs : Ed. Obst. Tr., X., 202. Tait, Laicson Climacteric Diabetes in Women : Practitioner, June 1886. Taylor, J. E. Lupus or Esthio- mene of the Vulvo-anal region : Am. Gyn. Tr., VI., 199. Zweifel Die Krankheiten der ausseren weiblichen Genitalien und die Dammrisse : Handbuch der Frauen- Krankheiten, Billroth and Luecke, Bel. III., Stuttgart, 1886. See also Index of Recent Gynecological Literature in the Appendix for all of these subjects. MALFORMATION S. Develop- THESE are easily understood when we remember the normal develop- ment of the external organs of generation. 1. At the sixth week of foetal life, the genital eminence appears externally ; at this period the rectum, allantois and ducts of Miiller communicate with one another but not with the exterior (fig. 317). 2. At the tenth week a depres- sion of the skin (known as the genital cleft} occurs ; this extends inwards till it meets the conjoined allantois and rectum, and thus the cloaca is formed (fig. 318). 3. The tissue between the rectum and the allantois grows downwards, and divides the cloaca into an anterior part (the uro- MALFORMATIONS OF VULVA. 541 genital sinus, into which the ducts of Miiller open) and a posterior part (the anus) : thus the perineum is formed (figs. 319 and 320). 4. The uro-genital sinus contracts in its upper portion to form the urethra, while the lower part persists as the vestibule (fig. 321) ; the ducts of Miiller coalesce to form the vagina (y. p. 73). OJ FIG. 317. R rectum continuous with All allantois (bladder) and M duct of Miiller (vagina), x Depres- sion of skin below genital prominence which grows inwards and forms vulva (Schroeder). FIG. 318. The depression has extended inwards and becoming continuous with the rectum and allantois, formed the cloaca el (Schroeder). The parts round the vulva develop, therefore, as follows ; the clitoris from the genital eminence, the labia minora from the margins of the genital cleft, the vestibule from the uro-genital sinus. The following malformations have been described. 1. Complete Malforma- tions. FIG. 319. FIG- 320. The cloaca is becoming divided into uro-genital The perineum is completely formed sinus Su and anus by the downward growth (Schroeder). of the perineal septum. The ducts of Miiller have united into the vagina V (Schroeder). atresia of the vulva through the non-formation of the depression of the skin (fig. 317); the allantois and rectum either communicate as in fig. 317 or have become separated. This condition has only been found in fretal monstrosities. 2. Persistence of a cloaca so that the rectum, FIG. 321. The upper part of the uro-genital sinus has contracted into the urethra; the lower portion pewisto as the vestibule Sit (Schroeder). vagina and urethra have a common orifice (fig. 318); such cases are sometimes spoken of as atresia of the anus but are really due to non- formation of the recto-vaginal septum. 3. Persistence of the uro-genital 542 AFFECTIONS OF VULVA AND PELVIC FLOOR. sinus into which the bladder opens directly as the urethra has not formed (fig. 320); in such cases the vulvar orifice is contracted and opens into a long narrow vestibule which, at its farther end, communi- cates with the bladder and vagina. This condition is sometimes described as hypospadias. HERMAPHRODITISM. For a detailed description of this condition with illustrative cases, the student should consult Sir J. Y. Simpson's exhaustive article on Herma- phroditism (Collected Works, Vol. II., p. 407). References to recent cases will be found in the Index in the Appendix. FIG. 322. FIG. 323. SPURIOUS HERMAPHRODITISM (Sir J. T. Simpson). Pelvis of a female infant in which the external organs simulated those of a male, c Uterus and appendages, 6 hypertrophied clitoris with a sulcus at its extremity a, which ended blindly, and did not communicate with the urethra. Case of hypospadias in the male, making the external organs simulate those of the female. CM Lobes of scrotum ; 6 iniperf o- rate penis, It inches long ; e perineal fissures 1J inches deep, lined with mucous membrane, at bottom of which the ureth- ral orifice d is seen ; c the split urethra, with openings / of glands beside it sup- posed to be orifices of prostatic ducts, of Cowper's glands, and of seminal canals. Of hermaphroditism ( Ep/^s and ' A^poSir??) there are two varieties, true and spurious. True jjy f rue hermaphroditism, we understand that from the Wolffian phroditism. bodies both ovary and testicles have developed so that both forms of MALFORMATIONS OF VULVA. 543 gland co-exist in the same individual. This is an extremely rare occurrence ; when it has occurred, there is a tendency towards the better development of one form of organ (determining the sex) while the other is rudimentary. According to Hildebrandt (loc. cit., S. 6), only two authentic cases of bilateral hermaphroditism (ovary and testicle present on each side) have been recorded ; of unilateral hermaphroditism (ovary and testicle present on one side), the other side having only one form of gland, a case has been recorded by Bannon ; lateral hermaphroditism (ovary on one side and testicle on the other) has been more frequently met with and cases, confirmed by microscopic examination, have been recorded by Berthold, Barkow, and Meyer. By false or pseudo-hermaphroditism, is understood a malformation of False the external organs so that they simulate those of the opposite sex. phroditism. This occurs in two forms. 1. The external organs in the female may simulate those of the male. This is due to a hypertrophy of the clitoris and its prepuce, with approximation of the labia majora (simulating a scrotum) and contraction or occlusion of the ostium vaginae ; in very rare cases is the clitoris perforated by the urethral canal. This condi- tion is seen at fig. 322, which represents the pelvis and external organs of an infant christened as a boy ; a post-mortem dissection showed that the sex was female. 1 2. The external organs in the male may simulate those of the female ; the non-closure of the lower surface of the urethra and perineum, which constitutes hypospadias, produces an appearance resembling the external organs in the female. Numerous cases are on record in which the sex of males has been mistaken, even by medical experts, and the persons have entered married life as belonging to the female sex. The penis may be small and imperforate, the urethra opening at its base ; the perineal fissure, lined by mucous membrane, may closely resemble the vagina ; and the halves of the scrotum may appear like labia. This condition is seen at fig. 323 : the case is reported by Otto ; 2 the person lived in a state of wedlock with three husbands before the true sex was ascer- tained by medical examination. Cases of epispadias, in which the urethra (through defect of the upper EpispadiAs portion of the penis) is exposed along with a portion of the bladder, r Herma . would only on hasty examination be mistaken for the external female phrodit organs. The exposed vesical mucous membrane with its skin margins resembles the vagina with the labia, but it is situated above the pubis ; further, below the penis we find the normal scrotum and testicles. Diagnosis. In examining a case, proceed as follows. 1. Palpate the supposed labia carefully to ascertain whether testicles are present in them ; the possibility of hernia of the ovaries into the labia and non-descent of the testicle into the scrotum, must be kept m view. i Ramsbotham-3/ecfecU Gazette, XIII., p. 184. * Sir J. Y. Simpson-^;, cit. p. 427. 544 AFFECTIONS OF VULVA AND PELVIC FLOOR. 2. Examine per rectum for traces of uterus or ovaries. 3. After puberty watch for the menstrual molimina or haemorrhage in the female, and for development of sexual powers in the male. 4. Note secondary sexual characters : development of breasts, appearance of face, tone of voice, and inclination towards one or other sex. Hermaphroditism, like malformations in general, lies beyond treat- ment. INFLAMMATION OP THE VTJLVA (VULVITIS). Varieties. We may have Acute vulvitis, Chronic vulvitis, Follicular vulvitis, Erysipelas or gangrene, Progressive gangrene or progressive suppuration. Pathology. In the acute stage, the mucous membrane round the ostium vaginae and urethra is red, swollen and painful. Sometimes the Abscess of mucous glands are obstructed, and a form of acne develops ; the Bartho- linian linian glands may inflame and suppurate, producing an abscess about gland. t ne s j ze o f a pigeon's egg; the sebaceous glands at the roots of the hair on the labia majora are sometimes specially affected, producing the " Folliculite vulvaire " of Huguier, an excessively rare affection. In the chronic stage, there is abundant secretion of creamy purulent matter ; when due to gonorrhoea, papillomata form round the vaginal orifice. Erysipelas or gangrene usually occurs after labour, or in infants after fevers (J. M. Duncan). Progressive gangrene with destruction of parts may occur ; and in old or young women we may get recurring boils, for which Duncan recommends rubbing with mercurial ointment. Etiology. It is often secondary to vaginitis, and accompanies urinary fistula and carcinoma. Want of cleanliness and protracted exercise, specially in hot weather, produce it and that most readily in patients with much adipose tissue. It is sometimes occasioned by awkward coitus and by masturbation. In children, it is not uncommon ; it is important to remember this, as the inflamed appearance of the vulva and the profuse discharge make the parents suspect that the child has been violated and has contracted specific disease. It is caused by irritation of urine, want of cleanliness, and the strumous diathesis ; sometimes it takes an epidemic form in the children of a family or district. These last are probably due to speading of gonorrhoea 1 through want of cleanliness. The Symptoms and Physical Signs will be apparent from what has been said under Pathology. 1 Pott Archivf. Gyn., XXXII., S. 493. PRURITUS VULVAS. 545 Treatment. Strict attention to cleanliness must be enjoined ; frequent bathing with warm water and the application of hot linseed poultices will ease pain. In children, the pain in micturition is relieved by its being done while in a warm bath. Sedative lotions such as acetate of lead and opium may be required : R Tinct. opii. = S s. Plumbi acetat. 3i. Aquam ad vi. M. In chronic cases, frequent washing with 2 per cent. sol. of carbolic or with astringent lotion is necessary. In abscess of the glands, the pus is evacuated through the gland ducts on pressure, or by free incision. Occasionally a gonorrhoea of the duct of the Bartholinian gland persists so that the duct requires to be laid open. PRURITUS VULV.S. Definition. An irritable condition of the external genitals producing excessive itchiness. Pathology. The irritable region is at the upper convergent angle of the labia majora at the mons veneris ; it may extend from that over the vestibule and the vaginal orifice, and sometimes over the mons veneris on to the abdomen. The pathological changes in the skin which produce this irritability are not known, because the cases are not seen in an early stage. By the time that the irritation has become so unbearable that advice is sought, the skin is inflamed and excoriated by continued scratching which masks its original condition. Etiology. Any irritating discharges from the vagina as in carcinoma, and even simple leucorrhcea as from senile vaginitis, may produce it. It occurs in diabetes due to irritation from the sugar in the urine (Friedreich] and in affections of the kidney and bladder, just as similar conditions produce irritation of the penis in man. In children, it accompanies vulvitis and has been traced to the passing of the Oxyuris Vermiculams from the anus to the vulva. It is also caused by whatever produces congestion of the labia hence its occurrence at the men- strual period and in early pregnancy; by irritable skin affections as herpes, eczema, and the parasitic eczema marginatum ; and by pediculi. Symptoms. The irritation is not continuous but recurs periodically. In some cases, it appears only after taking a long walk or after getting warm in bed ; sometimes it is most marked before the menstrual period. The irritability is slight at first but becomes aggravated by scratch- ing. To obtain this temporary relief, the patient gradually avoids company and this, along with the constant irritation, has led in some cases to nervous depression and melancholia ; sometimes the practice of 2 M 546 AFFECTIONS OF VULVA AND PELVIC FLOOR. masturbation is learned at the same time, and the consequent nervous symptoms gravely complicate the case. Diagnosis. As the most hopeful cases for treatment are those in which a distinct removable cause is found, a thorough examination is necessary : (1) Carefully inspect the external genitals for irritating skin eruptions, and examine scrapings of the affected parts microscopically for parasites ; (2) expose the vagina and cervix thoroughly with the speculum to ascertain whether there is irritating leucorrhcea, the plugging of the vagina with cotton wadding to check discharge from the vagina or cervix will help us to exclude this (Thomas) (3) test the urine for albumen and sugar ; (4) examine per rectum for any source of irritation there. Treatment. We must first remove the cause. When parasites are Treatment present, the mercurial or sulphur ointment is required ; with vaginal or of Pruritus. r cervical catarrh, a tampon of wadding and glycerine (with acetate of lead 3ii to i) in the vagina will check the irritating discharge. Atten- tion to diet (which should consist largely of vegetables) and to the regular action of the bowels is necessary ; when the gouty diathesis (with which pruritus is often associated in old patients) is pi-esent, lithia water is useful. It is a safe rule to forbid all stimulants. Frequent vaginal injections or sponging with warm water, followed by the applica- tion of boracic ointment or bismuth, will relieve mild cases ; in more severe, the patient should have, several times a day, a warm sitz-bath combined with the douche ; after this, iodoform is dusted over the vestibule or, if the patient is recumbent, lint soaked in acetate of lead and opium lotion is laid between the separated labia. In some cases, chloroform and almond oil have given relief (Scanzoni). R Chloroformi 3"- Olei amygdalae 5ii. M. Sig. Apply externally as directed. Preparations of mercury give benefit in other cases. R Hydrargyri perchloridi 3ss. Aqua? 5vi. M. Sig. Apply externally as directed. Schroeder has seen very good results from the application of carbolic acid of varying strength 1 to 40 up to 1 to 10. Solid menthol is also used. Where milder measures have failed, solid nitrate of silver well rubbed into the irritated parts and followed by cold water dressing has given relief. In parasitic cases a lotion of equal parts of sulphurous acid and glycerine may be used. To procure rest at night, morphina and chloral may be necessary ; Hildebrandt has found tinct. cannabis Indices (m. 10-20) even more effective than these. A 4 per cent. TUMOURS OF VULVA. 547 solution of cocaine may be tried. Application of galvanic current ha< been used with success. 1 ERUPTIONS ON THE VULVA. The skin round the vulvar orifice may be affected with any of the eruptions found on other parts of the body. Of these the most important are erysipelas, eczema, prurigo, herpes, acne. These erup- tions have the same character as when they occur in other situations, and their treatment is the same. Condylomata may be found on the skin, and mucous patches over mucous surfaces. Eczema is frequently caused by diabetes, according to Lecorche. 2 Hebra's plates of Skin Diseases illustrate these conditions very well ; see also a paper in the Annales de Dermatologie et Syphilographie for April 1882, by Gougen- heim and Soyer. TUMOURS OF THE VULVA. Under these we shall notice briefly Cysts of the Bartholinian glands, Elephantiasis, Neuroma, Fibroma, Lipoma, Carcinoma, Sarcoma, Lupus, Kraurosis. This is also the most convenient place to refer to Pudendal hernia, Varix, hsematoma and haemorrhage. Cysts of the Bartholinian glands. The Bartholinian or vulvo-vaginal Cysts and glands, which are the analogue of Cowper's glands in the male, are^t^ situated at each side of the ostium vaginae (see fig. 7); their ducts (about linian 2 cm. long and wide enough to admit a fine probe) run upwards to g nt ' about the middle of the ostium vaginae, where their mouths may be seen in front of the hymen. A cyst may form by dilatation of the ducts or of the glands them- selves. When due to distension of the duct, it has at first an elongated oval form ; when the gland itself is affected, there may be multiple cysts or a lobulated swelling. They generally occur on the left side. 3 The 1 Blackwood, Polyclinic, 1885, No. 9 ; and v. Campe, Central./. Gyn., Bd. XL, 8. 521. 2 Du diabete dans ses rapports avec la vie uterine, etc. : Annalei de Gyn., Oct. 1885. 3 Bonnet Gaz. des Hopitauj:, 1888, No. 69. 548 AFFECTIONS OF VULVA AND PELVIC FLOOR. contents are thick mucus, which is clear or of a brownish tinge. Sup- puration may occur and abscess form (v. fig. 324). The symptoms are due to the discomfort of the swelling, which is most felt on walking. The diagnosis is easy, from the position of the swelling and its fluctuating character ; when it has developed during the puerperium, we must differentiate it from hsematoma (which after a time becomes firm from coagulation) and inflammation after injury. The treatment consists in complete evacuation of the cyst and destruction of its walls. It is not sufficient to open it and allow the fluid to escape ; we must cut out a portion of the wall and then plug the cyst with antiseptic lint. By far the best instrument is the thermo- cautery : we first puncture the cyst with it ; when the fluid has escaped, we pick up the outer cyst wall with forceps and lay it fairly open with FIG. 324. ABSCESS OF THE BARTHOLINIAN GLAND (Huguier). the cautery ; we then cauterise the inner wall also. A piece of anti- septic lint is laid over the wound. Cysts also occur in the labia minora ; * they are very rare and their pathology is not known. Elephant!- Elephantiasis. This is a common condition in tropical countries, but is comparatively rare in Europe and America although a minor degree of it is occasionally met with. The pathological changes consist in a dilatation of the lymphatic spaces and ducts, with secondary formation of connective tissue and thickening of the layers of the cutis vera ; sometimes the papillae are specially enlarged, producing swellings which resemble condylomata in form. The labia majora are most frequently affected, next in frequency the clitoris ; more rarely are the labia minora hypertrophied (Mayer). 1 Smith removed two such cysts : Brit. Med. Journ., 1888, I., 250. TUMOURS OF VULVA. 549 It develops, according to Mayer, most frequently at ages of from 20 to 30 years that is in the period of sexual activity. It has been traced to direct injury, but the most fruitful cause of minor degrees of hyper- trophy is syphilis. The symptoms are due to the weight and discomfort of the tumour which may reach to the knees. For drawings of the various forms, Esmarck and Kulenkampff's monograph Die Elephantiaschenformen (Hamburg 1885) may be consulted. The treatment of the larger growths is removal with the thermo-cautery. Neuroma, an exquisitely sensitive red papule which resembles a Neuroma, urethral caruncle, has been described by Sir J. Y. Simpson (see fig. 353); its occurrence, except at the urethral orifice, is extremely rare. Fibroma. This springs from the labia majora, resembles in structure Fibroma, fibroid tumours of the uterus, and, like them, is embedded in cellular tissue or hangs down by a pedicle. Taylor has reported a case of fibroid of the vestibule. 1 Lipoma may arise from the fatty tissue of the mons veneris or labia Lipoma. majora. Emmet 2 describes a case in which the tumour hung down to the patient's knees and was supported in a bag round the waist; Stiegele 3 removed one which weighed 10 Ibs. Carcinoma of the vulva is rare in comparison with its frequency in Carcinoma, the uterus. In 16,637 cases of tumours of the female sexual organs, Gwilt found that 7479 were cancerous ; and of these, 72 (or 1 per cent.) were vulvar. The most frequent form is the cancroid ( West}. It begins, usually on the inner surface of the labia majora, as small round nodules which elevate the skin ; they may remain for a long time unnoticed, as their growth is at first slow and painless. After ulceration they spread more rapidly, and extend forwards and backwards but rarely into the vagina. The section of such a nodule is shown in Plate XIII. fig. 2. It is important to diagnose it from lupus, which may so closely resemble it that certainty is only got by microscopic examination. The inguinal glands are early involved. Complete removal before the glands are affected, is the only treat- ment. As the growth is accessible, there seems a prospect of cure ; during the last few years cases are reported by Schroeder and others of extirpation without recurrence, but the time elapsed is too short to justify definite conclusions. Kustner has advocated removal of the inguinal glands of the affected side if these are larger than those on the healthy side. Plate XIII. fig. 1 shows a section of an interesting case of epithelioma of the clitoris reported by Simmons. In the position of the clitoris, there was an irregular nodular mass with a soft friable centre and indu- > Amerit. Journ. Obxtet., 1888, p. 434. * Op. eit., p. 601. > Zeits.f. Chir. u. Geb., Bd. IX., S. 243. 550 AFFECTIONS OF VULVA AND PELVIC FLOOR. rated prominent uneven margins. The growth was removed by A. R. Simpson ; wire sutures were passed underneath the tumour which was then cut away, bleeding points tied with catgut and the margins of the wound drawn together with the sutures. Primary epithelioma of the clitoris is a rare condition ; only five other cases are given in Simmons' paper. Sarcoma of the vulva is very rare. Geith and Terrillon 1 have recorded cases of melanotic sarcoma. Haeckel has collected 10 cases of melan- otic tumours, 2 mostly sarcomatous. Lupus Lupus vulvce is a condition drawn attention to by Huguier, West, vse> Taylor, Matthews Duncan, Macdonald, and Peckham. Duncan has recently considered it very fully, and an able histological examination of his specimens has been made by George Thin. It may be defined as a slow chronic hypertrophic condition of the pudenda, prone to ulcerate and erode, causing little pain, lasting long, and not infecting neigh- bouring glands or causing ill-health. Pathology. As to its pathology, it is a hypertrophic condition with tendency to ulcerate and cause stricture of urethra, vagina, or rectum. Pus is secreted by the ulcerated surface, and occasionally considerable destruc- tion of parts is caused. The hypertrophy may be small (lupus mini- mus), large (lupus hypertrophicus), or forming irregular masses extending to the hip. Other terms have been used, viz., lupus prominens, lupus serpiginosus ; it was termed by Huguier, "Herpes 1'Esthiomene." Micro- On microscopic examination, Thin found growth of fibrous tissue Examina- (ordinary white fibrous tissue) and absence of any neoplastic structure ; tion. exudation cells were also present. Blood-vessels were unusually nume- rous. The appearances thus differ from lupus vulgaris, cancer, or syphilis ; they are somewhat analogous to elephantiasis, but differ from that condition in the non - implication of the lymphatics and the presence of inflammatory action. Symptoms The symptoms may be slight and not attract the patient's attention andPhysi- / J . \ . , . cal Signs, unless haemorrhage or inflammation occurs. I he physical signs are those of hypertrophy, ulceration, erosion, lasting for years, not impli- cating glands, and not markedly affecting the patient's health. Large hypertrophies usually affect the clitoris and labia majora ; small ones, the urethral orifice and hymen (Duncan). The vagina and uterus may become affected. Diagnosis. The condition is rare, but good drawings are given by Duncan. It must be diagnosed from epithelioma and syphilis. Epithelioma is harder, implicates glands soon, and has shallow ulcerations. In syphilis, the history is the great test. Jonathan Hutchinson alleges, however, that this lupus is really due to tertiary syphilis. There is good reason to believe that pudenda! lupus is not lupus vulgaris, cancer, syphilis, 1 Ann. de Gyn., XXVI., p. 1. - Archil- f. Gyn., XXXII., p. 400. TUMOURS OF VULVA. 551 nor elephantiasis, but is an affection sui generis whose etiology is unknown. The term " lupus " is thus a clinical one. The prognosis is fairly good. Many can be relieved and some cured. Prognosis. In treatment, hypertrophied or ulcerated portions are removed or cauterised with Paquelin's cautery, and the patient put on arsenic and iron. Kraurosis Vulvce or Atrophy of the Genitals. In old women, theKraurosis pudenda shrink; the labia minora become very small; the vestibule Vulvae - atrophies and shrinks, making the urethral orifice patulous and causing painful ulceration (v. fig. 353). Microscopically, Breisky found the sebaceous glands of the labia few, a cicatricial condition of the papillae and thinness of the rete Malpighii. The sweat glands were also diminished in number. Pudendal hernia. This corresponds with scrotal hernia in the male. Pudendal The round ligaments are the analogues of the spermatic cord, and after Hernia ' emerging from the inguinal canal pass into the substance of the labia majora which correspond to the scrotum ; if the process of peritoneum surrounding the round ligaments known as the canal of Nuck does not become obliterated at birth, it forms a track for the hernia. Though it be very rare, the possibility of a hernia must be kept in mind on examining a tumour of the labia ; the crackling feeling, the impulse communicated on coughing, and disappearance on taxis, indicate hernia. The serious consequences of cutting into such a hernia by mis- take for an abscess, are self-evident. Varix. The plexus of veins which forms the erectile tissue of theVarix. bulbi vaginae has been already referred to (v. p. 10 and fig. 7). A varicose condition of the veins sometimes occurs in pregnancy and with pelvic tumours. In a case described by Holden, 1 they formed, when the patient was erect, a tumour of the size of a child's head. When these vessels rupture and the blood is effused into the cellular tissue, a hsema- toma is formed. Hcematoma. This condition is also called " Thrombus " and " Haema-mema- tocele " of the vulva ; the former term should be limited to a coagulum within a vein, and the latter to blood effusion into the peritoneal cavity. It arises most frequently during labour, from injury produced by the child's head ; the effusion may appear rapidly, as a tumour from the size of a walnut to an orange or larger, or may take place gradually. It has also been known to occur independent of labour or pregnancy, as the result of a blow or violent muscular effort. The treatment consists in the application of ice to the vulva, and regular evacuation of the bladder and rectum without the patient's being allowed to strain. With this treatment, the mass may be absorbed. Should inflammation occur, poultices are applied and pus is evacuated i " Immense Vulvar and Vaginal Varix :" N.Y. Med. Record, July 1868. 552 AFFECTIONS OF VULVA AND PELVIC FLOOR. with the knife ; if this occurs in the puerperal condition, special care is- required to keep the wound aseptic by repeated washing with carbolic solution and dressing with carbolised lint. External External haemorrhage from ruptured veins sometimes occurs. The rhage. rupture may be caused by muscular straining, or by a blow or wound of the vulva. The dilated state of the veins makes such an injury serious during pregnancy, and several cases of a fatal result from a blow or kick have been the subject of a criminal prosecution (Sir J. Y. Simpson). The vascular tissues are forcibly driven against the pubic arch and cut on it. In a case recorded by Hyde, 1 haemorrhage from a vein ruptured by a fall proved fatal in forty minutes. Those who suffer from varicose veins should lie down for some hours during each day ; should a vein rupture, the patient must lie down at once and apply pressure to the bleeding point. 1 Land. Obst. T,-ans., Vol. XI. CHAPTER XLVIII. RUPTURE OF THE PERINEUM AND ITS OPERATIVE TREATMENT. LITERATURE. Bantock, G.On the treatment of Kupture of the Female Perineum, Immediate and Remote: London, 1878. Collis Dub. J. Med. Sc., May 1861. Duncan, John Concerning the Closure of Abnormal Anus: Lancet, 1873, Vol. II., p. 9. Duncan, Matthews Papers on the Female Perineum : Churchill, London, 1879. Emmet Principles and Practice of Gynecology : Third Edition : Philadelphia, 1884. Fritsch Ueber Perineoplastik : Centr. fur Gynak., 1887, No. 30. Goodell Lessons in Gynecology : Philadelphia, 1880. Hart, D. B. The Structural Anatomy of the Female Pelvic Floor : Edin., 1880. HeibergOm. Perinaoraphi, saerligt med. Hensyn til Lawson Tait's Methode : Gynakalog. og obst. Meddel., Bd. vi., Hft. 3, 1887. Hildclrandt Die Krankheiten der ausseren weiblichen Genitalien : Stuttgart, 1877. Malthe Norsk Magazin for Laejevid. enskaben, II. Reihe, 24 Bd. (describes Voss' Method). Sdngcr Ueber Perineorraphie durch Spaltung des Septum rectovaginale und Lapeenbildung : Volkmann's Sammlung, No 301. Schroeder Die Krankheiten der weiblichen Geschlechtsorgane, S. 542 : Leipzig, 1887. Simpson, Sir J. Y. Diseases of Women, p. 644. Tait, Lawson A New Method of Operation for Repair of the Female Perineum: Tr. Lend. Obst. Soc., 1880. Diseases of Women and abdominal Surgery, Vol. I., pp. 68-71. Thomas Diseases of Women, p. 165 : Phila- delphia, 1880. See Duncan and Hildebrandt for literature; also Index in Appendix. Preliminaries and Nomenclature. The question as to the significance Prelimi- of rupture of the perineum is still debated, some authors believing it na to be of no importance unless involving the anus and leading to incon- tinence of faeces, others holding that it is an important lesion even when not so extensive as to involve the bowel. The relation of rupture of perineum to prolapsus uteri is discussed in the next chapter: at present we consider rupture apart from this. The 'views advanced in Chapters II. and IV. must be kept in mind. The student should glance over these and look at the figures in Plates I. III. Complete rupture into the anus is serious as it entails incontinence of faeces, as well as rectocele and some sinking of the pelvic floor from the partial loss of the bracing-up action of the levatores ani (v. p. 38). Another point to be kept in mind is the anatomy of the triangular ligament. This is a piece of sheet fascia filling up the pubic arch and perforated by the vagina and urethra. It strengthens the vaginal walls by its grip and, according to Emmet, prevents their eversion. He believes that the bearing down complained of by some women and associated with a lax condition of the vaginal walls or the existence of rectocele is due to undue distention of this fascia and separation of its lateral attachments : and he bases on this a special operation to be described shortly. It will be most convenient to retain the nomenclature already used 554 AFFECTIONS OF VULVA AND PELVIC FLOOR. in the Section on Anatomy. The pelvic floor is made up of pubic and sacral segments, as already denned ; in labour, each of these behaves characteristically the pubic segment is drawn up, the sacral one driven down (Chap. IV. and fig. 53). In this chapter \ve are specially concerned with the sacral segment. During parturition it is driven downwards and backwards by the advancing foetus and is more or less torn at its inferior angle. The term perineum is often vaguely applied ; in this Chapter, however, the perineum is defined as the inferior angle of the sacral segment (v. p. 60). Fig. 325 shows the perineum. At its lower end, this part of the pelvic floor is made up of the following : 1 . Posterior vaginal wall in front of upper part of perineal body. 2. Hymen, 3. Fossa Navicularis, 4. Fourchette, 5. Perineal body and skin over its base. These are mesial structures ; laterally, we have the labia majora and minora. The perineal body lies in greater part below the level of the vaginal entrance and has as its functions (1.) The union of the following muscles levator ani, bulbo- cavernosus, transversus perinei, sphincter ani ; (2.) The directing backwards of the anus ; (3.) The strengthening of a part much stretched during parturi- tion. PATHOLOGY AND VARIETIES. Pathology It should be kept in mind that the vaginal orifice is transverse, the Varieties, vulvar orifice antero-posterior. When the foetal head is passing through the vaginal orifice, it dis- tends it all round ; while, when passing through the vulvar orifice, it distends the lower half of this only, i.e., it does not stretch so much those parts of the vulva lying above the level of the meatus urinarius. As the result of normal and abnormal child-birth, we get certain tears of the inferior end of the perineum. In all prirniparse there is laceration of at least the hymeneal orifice, usually mesial and poste- rior the " inevitable laceration " of Matthews Duncan. There may be also laceration of the following structures : (a) the vaginal orifice, radiating; (6) vestibule; (c) fourchette; (d) labia minora; (e) perineal body to a varying depth, the most extensive involving the sphincter ani. Further, there is sometimes central rupture of the perineum. In this lesion, the skin over the base of the perineal bod] alone may be involved or only the vagina may be torn. Rarely is it a lesion of vaginal wall, connective tissue, and skin, with an unrupturec RUPTURE OF PERINEUM. 555 band of tissue between it and the fourchette (fig. 326); this, therefore, is a perforation through the inferior angle of the thinned-out sacral segment. ETIOLOGY. The following causes produce rupture in parturition : Etiology. (1) Passage of a large head or of an occipito-posterior rotated into sacrum ; passage of the shoulders ; (2) Narrowness of pubic arch; (3) Straightness of sacrum, as in flat or rickety pelvis; FIG. 325. THE SACRAL OR SUPPORTING SEGMENT OF THE PELVIC FLOOR (Hart), e Symphysis pubis ; / perineum or inferior angle of sacral segment ; g anus. (4) Syphilitic ulceration ; (5) Rigidity of parts in elderly primiparse ; (6) Careless use of forceps ; (7) Too early passage of hand into vagina to bring down arms in turning. Comment on these would lead us too much into Obstetrics. SIGNIFICANCE OF RUPTURE OF PERINEUM. Rupture of the perineum involving the sphincter ani and leading to complete or partial incontinence of fseces is an important imperatively demands operation. Rupture of the perineum alone and not involving the sphmcte 556 AFFECTIONS OF VULVA AND PELVIC FLOOR. may give rise to no symptoms unless associated -with other conditions causing prolapsus uteri. According to Emmet, the real accident in some cases of ruptured perineum is tear of the triangular ligament -where FIG. 320. CENTRAL RUPTURE OF THE PERINEUM, the child was born not through the Vulva but through the Ruptured Opening (Sir J. Y. Siinpson). it is perforated by the vagina, but probably tear of muscle there is of greater importance. TREATMENT. Treatment. We take this up under the following heads : a. Prophylactic ; b. Operative, immediate and deferred. OPERATIVE TREATMENT. 557 a. Prophylactic. This properly belongs to midwifery. The obstetri-Prophy- cian is too apt to think of the perineum as something that delays the 1 * * 10 ' exit of the foetal head, and to forget the gynecological aspect that it is part of the supporting segment of the pelvic floor. Extensive tear of this during labour means not only a larger raw surface for septic absorption, but is also one factor predisposing to prolapsus uteri. The question, therefore, of guarding the head during its passage over the perineum is of importance but belongs to obstetrics. We may note however that the foetal head, in passing through the outlet, drives the sacral segment back and glides forward in a direction parallel to the driven-back posterior vaginal wall. The normal curve of the sacrum favours this latter motion. The perineum may tear (1) from over-distension of the orifice, or (2) from the too forcible driving of the foetal head against it, i.e., at right angles to the perineum ; (3) from descent of the sinciput owing to fixation of the occiput and thus substitution of the larger diameters of the head for the sub-occipito bregmatic. b. Operative treatment, (1) immediate and (2) deferred. No practi- Operative, tioner should leave a labour case until he is satisfied, by actual inspec- tion or digital examination, as to the amount of perineal tear. When the sphincter ani is involved, the operation is on no account to be deferred but must be performed at the conclusion of the third stage. The practitioner should never run the risk of his patient's having incontinence of fseces. (1.) Immediate operation. This belongs to obstetrics. (2.) Deferred operation. This may be to operate for a rupture through Deferred the sphincter or to repair the perineal body. At present we consider Oper( only the former. Preliminary remarks. In complete tear through the anus, the external sphincter, internal sphincter, and levator ani are torn. Fig. 327 shows this clearly, and also explains what has to be done. What is wanted is not skin union, but some operative measure by which the torn muscu- lar ends can be vivified and united. Diagnosis of long-standing rupture of perineum into anus. The patient complains of inability to control the passage of flatus or of faecal matter when a call to stool happens ; she is especially troubled when diarrhoea is present. Sometimes there is a certain amount of control, when some of the fibres of the upper margin of the internal sphincter are intact. Patients in the lower classes occasionally treat this unpleasant condition as of little moment ; to a woman of any refinement, the condi- tion is a most distressing one. On inspection, the practitioner notes that the skin surface between the vaginal and anal apertures is gone, so that these apertures are blended. The finger passed into the rectum feels no muscular con- 558 AFFECTIONS OF VULVA AND PELVIC FLOOR. striction, and notes that the anterior and posterior rectal walls are in contact. The perineal body appears to be gone, and a V-shaped projec- tion of cicatrised mucous membrane (apex above) is all that remains of it. Operation for restoration of function of sphincter ani. The patient's bowels are first freely cleared out by castor-oil and enemata so as to ensure that no scybala remain. Requisites. The instruments requisite are the following : Angled scissors, Two pairs of artery forceps, Plan's forceps, Catgut ligatures, Methods. FIG. 327. FIG. 328. LINES OF INCISION IN OPERATION FOB REPAIK OF PASSING OF SUTURES IN SAME OPERATION. For RUPTURE OF PERINEUM THROUGH SPHINCTER letters see p. 559. The deep sutures are to ANI. For letters see p. 559. be passed nearer the skin edge. Silkworm gut or silver wire, Operating douche, Fully curved needles, large and small, Needle holder. The patient is chloroformed and placed opposite a good light in the lithotomy posture. The knees are held by assistants as follows. Each stands facing the light, and places a knee of the patient under the arm-pit next to it ; with the hand of the same arm, he exercises ten- sion on the nates as the operator wishes. With his other hand, the assistant controls the patient's foot. The stages of the operation are (1) Forming flaps with scissors, (2) Applying the stitches. OPERATIVE TREATMENT. 559 The flaps, as made by A. R. Simpson, are shown in fig. 327. The A. R. point of the lower blade of the angled scissors is entered at b, pushed Simpson's up to a, and then a clip made so as to expose tissue in line 6 a. The point is next entered at 1 on the left side, and pushed between the vaginal and rectal mucous surfaces, i.e., along the loose connective tissue between these until the point emerges at 1 on the right side. A clip is then made so as to expose tissue in the line 1 S 1. Lastly, the point of the scissors is entered at b (right side), and a b clipped as already given on the left side. In this way an H-shaped figure is cut out (fig. 3306). These clipped-out lines map out four flaps which are now to be raised so as to expose for union the muscular tissue lying beneath. The flaps are best raised as follows : Lay hold of flap S 1 a (left) at angle 1, with P can's forceps, and raise it by clipping : do the FIG. 329. RESULT OF SAME OPERATION. Instead of being fixed with button-plates, the deep sutures can be simply tied like the superficial ones. same with flap S 1 a on right side. While the flap is being raised, the index or middle finger of the left hand is kept on its vaginal aspect so as to regulate its thickness. The rectal flaps 2 S 6 are then treated in the same way, the angle 2 of each being seized with the forceps. In this way a quadrilateral surface is now laid bare, with the muscu ends of the external and internal sphincters as well as the interlacing* of the various muscles of the perineal body. Fig. 330rf will make this 016*11* The sutures are now to be passed as follows :-The point of the needle aed with silkworm gut is entered inside the skin, carried across, either 560 AFFECTIONS OF VULVA AND PELVIC FLOOR. completely below the tissue or only above the surface at the apex of FIG. 330a. EXTERNAL GENITALS IN A MULTIPARA, WITH TEAR OF PERINEUM SHOWING LINE OP OPERATION (a c b) FOR LAWSON TAIT'S OPERATION. FIG. 3306. DIAGRAM SHOWING RUPTURE INTO ANUS AND LINE OF OPERATION (/ e g d c). Anterior vaginal wall (6) ; anus (a) ; g is on posterior vaginal wall. the wound, and made to emerge on the other side within the skin sur- o, FIG. 330c. SHAPE OF RAWED SURFACE AFTER FLAPS HAVE BEEN DISSECTED UP AND DOWN ; e and /show relation of stitches to skin edge. FIG. 330d. CORONAL SECTION THROUGH ANUS (Symington), v rectum ; i & internal sphincter ; e s external sphincter I a levator ani ; -a vagina. OPERATIVE TREATMENT. 561 face (fig. 330c). The lowest stitches should pick up and unite the edges of the external and internal sphincter (v. fig. G). The sutures when tied do not include the skin, and cause no pain to the patient. The vaginal flaps are left alone. The mucous membrane of the rectal flaps may be sutured with catgut, but it is unnecessary. Bleeding, which can be checked by a stream of very hot water (110-120 F.) or by Pean's forceps, should have ceased before we tie these sutures (fig. 329). They should be left in for a fortnight and then removed. This is a little troublesome, as they are apt to become buried. The best way to remove them is to have the patient in the lithotomy posture, to lay hold of both ends of the suture and pull it to the one side, with the rake picking up the loop (fig. 391). The advantages of this method of operating are very great. It can be done very rapidly, ensures muscular union, does not allow skin or mucous membrane to interfere with the union of muscle, and is a great improvement on the old methods. In these the union often seemed sound, but the patient had no additional control from want of muscular union. This method is not, strictly speaking, that of one operator, but has been evolved as follows : In 1872 John Duncan closed an artificial anus following gangrenous femoral hernia by dissecting up the mucous membrane round the orifice for more than half an inch, invaginating this dissected portion and bringing the raw surfaces together with interrupted catgut sutures : the margins of the skin were then pared and brought together by wire. Collis, of Dublin, in 1861, in a case of vesico - vaginal fistula split the edges of the fistula instead of paring them. A. Russell Simpson applied the separation of the mucous membrane introduced by Duncan, to tear of the perineum involving the anus, splitting the septum between anus and vagina and sewing similar mucous membranes to each other as well as bringing the deep raw surfaces into union. This procedure really forms vaginal and rectal flaps. Lawson Tait improved on this by the use of angled scissors, and also introduced the method of passing the sutures inside of the skin instead of through it as formerly done. The use of scissors to form flaps is also applicable in perineum opera- tions where the anus is not torn. According to Sanger, Stein, a Danish surgeon, and Voss, a Norwegian, have employed somewhat similar methods in complete rupture. The continuous spiral catgut suture is now much used in Germany in such cases and has many advantages. It is very quickly passed, brings the surfaces well into apposition and does not require to be removed. The catgut used must be specially prepared with oil of juniper and corrosive sublimate so as to be aseptic and last 8 or 9 days. 2 N 562 AFFECTIONS OF VULVA AND PELVIC FLOOR. In this operation it is to be used as follows. With a curved rounded needle begin at the apex of the rectal surfaces and knot the first stitch securely. Then pass the suture continuously to the lower end of the rectal stitches, up the intermediate portions, and finally unite the vaginal flaps and any skin portion un-untied. The last stitch is securely knotted of course. After-treatment. The patient's food must be liquid and not too abun- dant. The bowels are to be confined for 3 days and then moved by a small dose of castor-oil every second day. Prior to the motion, the nurse must inject a large amount of oil and see that scybala if present are broken down. Unless the nurse is skilled, the operator or his assistant must attend to this. The stitches are removed on the 14th to 21st day. FIG. 331. EMMET'S OPERATION FOR RUPTURED PERINEUM (Dudley). 1 Operation for Rupture of the Perineum, the Sphincter ani not being involved. This is described in chapter on Prolapsus uteri. Emmet has devised an operation with the view of restoring the grip of the fascia, forming the triangular ligament, upon the vaginal wall. A double triangular raw surface is made on the posterior vaginal walls. One of these is seen at a b c (fig. 331) stretched by three tenacula. The sutures are now passed along the upper margin in loops so as to fold this edge a b on itself at its central point d, which is hooked up in a fourth tenaculum. The third figure shows this done on both sides and these sutures tied. Finally, additional sutures are passed through the edge b c so as to unite it with the corresponding part of the other triangular raw surface. 1 Pepper's System of Medicine, Vol. IV., pp. 164, 165. London : Sampson Low, Marston, Searle, and Rivington, 1886. CHAPTER XLIX. DISPLACEMENTS OP PELVIC FLOOR: PROLAPSUS UTERI; VAGINAL ENTEROCELE. LITERATURE. Alexander The Treatment of Backward Displacements of the Uterus and of Pro- lapsus Uteri by the New Method of Shortening the Round Ligaments: London, Churchill, 1884. Duncan, Matthews Papers on the Female Perineum : Churchill, London, 1879. Emmet Principles and Practice of Gynecology, p. 367 : Lond. 1879. Freund, W. A. Ueber die Figur des normalen Lumen vaginse und tiber Dammplastik mit Demonstrationen : Arch. f. Gyn., Bd. VI., p. 317. Fritsch Die Lageveriinderungen der Gebarmutter, Billroth's Handbuch : Stuttgart, 1879. Qoodell Lessons in Gynecology, Lesson VII. : Philadelphia, 1879. Hart The Structural Anatomy of the Female Pelvic Floor : Edinburgh, 1880. Hegar und Kalteribach Operative Gynakologie, 1881. Huguier Memoir sur les Allongements Hypertrophiques du Col de 1'Uterus : Paris, 1860. Legendre De la chute de 1'Uterus. Martin Ueber den Scheiden und Gebarmuttervorfall : Volk. Samml., Nos. 183, 184. Schatz Ueber die Zerreissungen des Muskulosen Beckenbodens bei der Geburt: Archiv f. Gyn., XXII., S. 298. Scfiroeder Die Krankheiten der weiblichen Geschlechtsorgane : Leipzig, 1879. Schultze Die Pathologic und Therapie der Lageveranderungen der Gebarmutter : Berlin, 1881. Schiitz Median- schnitt (lurch das Becken einer Frau mit Scheiden und Uterus Vorfall : Arch. f. Gyn., Bd. XIII., S. 262. Sims, Marion Uterine Surgery : London, 1865. Skenc Injuries to the Pelvic Floor from Partxirition and Other Causes : N. Y. Med. Jour., Vol. XLL, 1885. Spiegelbcrg Ein anderer Medianschnitt durch ein Becken mit Scheiden Gebarmutter-Vorfall : Archiv f. Gyn., Bd. XIII., S. 271. Thomas Diseases of Women, p. 168 : Philadelphia, 1880. Veit Klinische Untersuchungen iiber den Vorfall der Scheide und der Gebarmutter: Zeits. f. Geb. u. Gyn., Bd. I. Winckel Die Pathologic der weiblicheu Sexualorgane : Leipzig, 1880. See also Index of Recent Gynecological Literature in the Appendix. Preliminary Considerations. The subject of this chapter can only Prelimi- be understood in the light of an accurate knowledge of the normal na structural anatomy of the pelvic floor, and a consideration of the changes it undergoes during parturition, and in the displacements to be considered. Our information on the last point leaves, however, much to be desired. The student should read over Chap. IV. We note here that the pelvic floor is to be considered as made up of the two portions termed the " entire displaceable " and " entire fixed." Fig. 325 shows a sagittal mesial section of the pelvis with the "entire displaceable portion" removed and the entire fixed portion left: PI. II., fig. 2, shows the two portions in axial coronal section. These two portions are separated by loose connective tissue. During 564 AFFECTIONS OF VULVA AND PELVIC FLOOR. parturition the child is driven through the vagina, i.e., through the pelvic floor, which becomes canalized or opened up through this process. If we regard this process only in sagittal mesial section as shown in Braune's plate, we see that the pubic segment is drawn up and the sacral one driven down and back and the vagina in addition greatly distended. If considered in axial coronal section we should see the " entire displaceable portion " in part drawn up, the foetus driven through it and thus the levatores ani and glutei muscles in the " entire fixed portion " driven out and back and the former perhaps torn (Schatz) or at any rate elongated, and their slope diminished. The slit in the triangular ligament through which the vagina passes is also dilated, and may be unduly so. The upward traction exercised on the " entire dis- placeable portion " necessarily elongates or slackens the loose connective tissue joining the two portions and is one factor in bringing about prolapsus uteri. As the result therefore of the structure of the pelvic floor, of lesions caused by parturition, and intra-abdominal pressure, we may get certain conditions, viz., I. Undue yielding or bulge of the pelvic floor ; II. Prolapse of the " entire displaceable portion " with the uterus and abdominal viscera, in part, past the " entire fixed portion "- so-called prolapsus uteri : III. Vaginal enterocele, anterior and posterior. 1. Undue yielding or bulge of the whole pelvic floor. This is a con- dition to which attention has been drawn by Herman and Skene. Our knowledge on this lesion is however very defective and calls for investi- gation. In Chap. IV. attention has been called to the normal pelvic- floor projection. In undue bulging of the pelvic floor this is increased. Herman measures with a tape the length of the arc described by the curved skin aspect of the pelvic floor between tip of coccyx and lower margin of symphysis pubis. This average, about four inches, may be increased by straining, in virgin cases, to four and a half inches ; but in cases of undue bulge, to about six or more. Causation. This lesion is due to parturition ; we are not yet in a position to give precise details, owing to the complete want of sectional and dissectional work on the pelves of women with such a prolapsed con- dition. Schatz and Skene have described certain conditions of lacera- tion of the levator ani muscles, atrophy and permanent paralysis, but all has been based on clinical investigation uncorrected by anatomical examination. The subject however is important, the researches so far suggestive, and further accurate work called for. The symptoms of undue yielding are bearing down pain with draggings in loins and hips. The treatment is the use of an abdominal belt with a perineal band. PROLAPSUS UTERI. 565 II. PROLAPSUS UTERI. DEFINITION. A downward displacement of entire displaceable portion of pelvic floor, uterus and appendages, past entire fixed portion ; with coincident descent of small intestine. PRELIMINARIES. The subject of Prolapsus Uteri is a complex one, and has been in part made so by erroneous terminology. Thus the well-known term Prolapsus Uteri has biassed many observers as to the nature of this lesion, inasmuch as they have considered some change in the uterus as initiating the prolapsus. This is a natural error, and is perpetuated in most of our text-books by the writers of these considering prolapsus uteri under affections of the uterus. Prolapsus uteri is, however, considered here under Displacements of the Pelvic Floor, as it is really a hernial displacement of part of the pelvic floor in which the entire displaceable segment of the pelvic floor, uterus, and appendages are driven down by intra-abdominal pressure. There is no doubt that change takes place in the length of the uterus as the result of the downward displacement. This change is, however, a secondary one, as will presently be explained, and does not initiate the lesion. The student must therefore use the term prolapsus uteri not in its literal sense, but as equivalent to " sacro-pubic hernia." Prolapsus uteri is sometimes applied to hypertrophy of the vaginal portion of the cervix. This is wrong, as this hypertrophy is a growth phenomenon. ETIOLOGY. The factors producing prolapsus uteri are three in number: (1) Deficient support by entire fixed portion ; (2) Deficient tone of entire dis- placeable segment of pelvic floor, and slackening of loose tissue round it ; (3) Intra-abdominal pressure. Deficient support by entire fixed portion. By this is meant that through parturition the sacral segment has become straightened out or deficient at its lower margin the perineum and that the slope of the levatores ani has been lessened or that they have been torn (Schatz). It is wrong to imagine that tear of the perineum is everything in prolapsus uteri ; the perineum may be considerably torn and yet, if the sacral segment is still sufficiently curved and the intra-abdominal pressure not too great, there will be no prolapsus. Tear of the perineum diminishes the sacral support, and deficient sacral and levator-ani support makes the task of intra-abdominal pressure easier. 566 AFFECTIONS OF VULVA AND PELVIC FLOOR. The bearing of the second and third factors is sufficiently evident. Of all the three, increased intra-abdominal pressure is the most important and is sufficient to cause prolapsus in virgins. The first and second are adjuvant. NATURE. The uterus has nothing to do with prolapsus. It is a classical term, but a misleading one. Prolapsus uteri is really a hernia ; and is analo- gous in every point to what we term a surgical hernia (such as inguinal hernia). Thus it has (1) a sac, the peritoneum ; (2) a definite road to travel FIG. 332. To SHOW THE HERNIAL NATURE OF PROLAPSUS UTERI ; o. peritoneum ; b bladder ; c uterus ; d anterior vaginal wall ; e anterior rectal wall ; / perineum ; y posterior vaginal wall. The dark portions are the coverings of the Hernia (after Schiitz). along, whose boundaries are a. in front, the symphysis pubis, b. behind, the portion of the sacral segment of the pelvic floor from anterior wall of rectum back to sacrum, c. side walls, viz., obturator internus and levator ani muscles ; (3) definite coverings, viz., a. pubic segment of pelvic floor, b. the uterus, c. posterior vaginal wall. Like all hernise, its sac contains small intestine, (fig. 332) Huguier alleged, wrongly we believe, that, by a hypertrophic elongation of the supra-vaginal portion of the cervix, the bladder and posterior PROLAPSUS UTERI. 567 vaginal wall were displaced downwards ; and that many cases of alleged prolapsus uteri are really due to this. Such cases differed from prolapsus uteri in the fact that the fundus uteri and fundus of bladder are in position. Many gynecologists hold this view of Huguier, most of them modifying it somewhat. Schroeder's Handbook, Goodell's Gynecology, and Hart's Structural Anatomy may be consulted on this moot point. SYMPTOMS AND PHYSICAL SIGNS. The discomfort caused by the protrusion and the excoriation of the parts is the prominent symptom. The patient complains of " something coming down in front." Further, there is difficulty in micturition. The physical signs are distinct. If the prolapsus be incomplete, a portion of the anterior vaginal wall has passed out at the vaginal orifice, the os uteri is equally displaced downwards, and the posterior fornix is apparently deeper from the descent of the cervix. The uterus, in addition to being low down, is usually enlarged ; it lies with its axis coinciding with that part of the pelvic curve in which it is. If the prolapsus be complete, we find the whole anterior vaginal wall outside the vulva, the cervix extruded, and the posterior vaginal wall everted (fig. 176). The student must specially note that this description is based on clinical observation. From the study of frozen sections, we further learn that the posterior vaginal and anterior rectal walls are separated by peritoneum driven in between them, and that the uterus with other parts has become hypertrophied through long-standing congestion, and the cervix elongated. MECHANISM OF PROLAPSUS. The displaced organs can be replaced posterior vaginal wall first, then uterus, and lastly pubic segment ; on the patient's straining, the mechanism of the displacement is repeated, is seen to be perfectly definite and to occur as follows. We have first the appearance of the anterior vaginal wall, below upwards, at the orifice. Pari passu with its descent, the uterus q bserv a- and posterior vaginal wall have come down; the cervix tracing out thetions. pelvic curve, while the uterus becomes more and more inclined back- wards until at the vaginal orifice it lies in the vaginal axis ; the posterior vaginal wall forms a pouch, the depth of half its own length, behind it. Finally the uterus is driven outside ; the cervix sweeps upwards forwards, and the posterior vaginal wall is now completely everte its lowest part appearing last. Appear- On vertical section, we now find these conditions : (1) Ala st prolftp8?g complete extrusion of the anterior or pubic part of the floor, the upper on S< 568 AFFECTIONS OF VULVA AND PELVIC FLOOR. and anterior part of the bladder still behind the symphysis ; (2) Com- plete extrusion of the uterus, which sometimes lies with the fundus below the level of the anus ; (3) Rectum in position and only posterior vaginal wall down ; the latter has peeled from the rectum downwards as far as the lowest inch-and-a-half (of close connection) which is elongated (fig. 332). The explanation of this mechanism is as follows. The displacement in prolapsus uteri is caused by intra-abdominal pressure, pushing down that part of the pelvic floor which lies in front of the anterior rectal wall, and inside the obturator internus and upper portion of the levator ani muscles. This part consists of entire displaceable portion of pelvic floor, with uterus and appendages. If we now look at a section of the pelvis such as is seen in PI. I. (vertical mesial section) we find the posterior angle of the pubic segment is attached to the cervix uteri, and the cervix uteri to the top of the posterior vaginal wall. Thus, if intra-abdominal pressure is excessive, this part when driven down must have the following sequence of protrusion at the vaginal orifice : (a) Anterior vaginal wall from below up ; (6) Cervix uteri ; (c) Posterior vaginal wall from above downwards. Our knowledge of the side relations in prolapsus is not yet known, but from the structure of the normal pelvis, we believe that separation takes place inside the obturator internus and upper portion of the levator ani muscles (v. Chap. IV.). The iiterus, while it is being forced down, has the direction of its long axis continually altering. This is often expressed by saying that the uterus becomes more and more retroverted, as it is forced down. The real fact is, that, as the pubic segment is forced down, it is stretched chiefly on its peritoneal aspect. In this way tension is made on the cervix uteri, with the effect of throwing the fundus back and making it rest on the retrojacent structures. As these have (roughly speaking) the pelvic curve, we get the uterus in this way constantly altering the lie of its axis. The enlargement is not purely cervical ; but affects the whole uterus, the pubic segment, and the posterior vaginal wall. This enlargement is a consequence of prolapsus uteri, and not a factor in its production. If we view a prolapsed uterus (with the os at the ostium vaginse) through the pelvic brim, it can be seen that it lies, as it were, at the bottom of a valley the sides of the valley being the broad ligaments, the bed of the valley the uterus. The parts of the uterus do not lie on the same horizontal plane, the cervix lies low. It is thus probable that the venous supply of the uterus, having a mechanical disadvantage to its return, may have a tendency to stasis. This may lead to areolar hyperplasia at first, and, so far as our present knowledge goes, partly accounts for the increased size of the uterus in prolapsus. There is PROLAPSUS UTERI. 569 further probably a tensile elongation of the cervix produced which increases the uterine length. SUMMARY OP DISPLACEMENT IN PROLAPSUS. I. On clinical observation while a complete prolapsus is being repro- duced, we note (a) The anterior vaginal wall from below upwards passing down and out at the vaginal orifice ; (6) The cervix uteri appearing at the vaginal orifice ; (c) The posterior vaginal wall, from above down, coming last. II. If a frozen section of a cadaver with prolapsus uteri be examined (fig. 332), we note that the pubic segment, uterus and posterior vaginal wall are displaced down and out. Fig. 332 is based on Schutz's draw- ing of such a frozen section. Axial coronal sections have not as yet been published, but the ureters are displaced down along with the bladder, and by being pressed on by the pubic arch may give rise to uraemia, as in a case recorded by A. E. Barker of University College, London. III. The combined study of I. and II. shows that The bladder and uterus are displaced down, the vagina everted or turned inside out, the small intestine coin- cidently lowered in the pelvis, the displaced parts con- gested and hypertrophied, and the cervix uteri elongated secondarily. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. The diagnosis is made by noticing the relation of the parts ex- truded and by passing the sound if necessary into the bladder and uterus. The differential diagnosis must be made from the following condi- tions : (1.) Hypertrophy of the vaginal portion of the cervix; (2.) Hypertrophy of the supra-vaginal portion of cervix. For both of these conditions the student is referred back to page 279 (see figs. 166, 174, 175). (3.) Cystocele. Uterus is in position, and displacement is found to be due to bulging back of posterior wall of bladder. (4.) Rectocele. The finger, passed through the anus, can be pushed into the pouched rectum. (5.) Inversion and polypus (v. p. 392). 570 AFFECTIONS OF VULVA AND PELVIC FLOOR. TREATMENT. A. Treatment by pessaries, B. Treatment by operation. A. Treatment by pessaries. In slight cases, where the anterior vaginal wall protrudes only a little, we may use an Albert Smith or Hodge pessary, with or without transverse bars at the lower part. If this fails, FIG. 333. GREENHALGH'S PESSARY, with transverse bars. FIG. 334. RING PESSARY, with diaphragm. a ring pessary with spring inside should be tried ; this instrument is useful here, inasmuch as it is shorter vertically than the Albert Smith and therefore does not project over the lower end of the shortened pos- terior vaginal wall. The instrument may be made of vulcanite, block tin, or india-rubber. The india-rubber forms are best, and may be provided with a perforated diaphragm, but this tends to retain dis- charge. The pessary is taken in the right hand, and compressed between the FIG. 335. SIMPLE ELASTIC RINO PESSARY, compressed between the fingers for introduction (De Sinety). finger and thumb as in fig. 335 while it is being passed through the vaginal orifice ; the labia are separated with the fingers of the left hand. If the ring instrument fail, then others may be tried. Fig. 337 shows Zwanck's pessary, a bad form. A thin india-rubber bag distended with air and provided with a stop-cock is good. In very bad cases and in old women where an operation is out of the question, the patient or her PROLAPSUS UTERI. 571 friends should be instructed how to pack the vagina with marine lint ; FIG. 336. RING PESSARY tit situ (Hart). the packing, if thorough, may remain in situ for a week. Some recom- FIG. 337. ZWANCK'S PESSARY FOR PROLAPSUS. mend pessaries which are attached externally to an abdominal belt 572 AFFECTIONS OF VULVA AND PELVIC FLOOR. When there is much congestion and excoriation, rest in bed with the use of alum injections (3i to Oi) and application of boracic or zinc oint- ments to the raw surfaces, are indicated. If the patient has good abdominal development, an abdominal belt will be of use ; when applied, it should be fairly tight at the lower edge and slack at the upper one. B. Treatment by operation. We must first consider the status quo in FIG. 338. LINES OF INCISION IN OPERATION TOR REPAIR OF RUPTURED PERINEUM. For letters see text. FIG. 339. SUTURES PASSED IN SAME OPERATION. an advanced prolapsus. lesions : There are the following primary and secondary Condition of Parts in Prolapsus Uteri. Primary (1) Perineal body usually torn and perineal union of levatores ani, transversi perinei, and bulbo-caver- nosi, torn to a greater or less extent ; (2) Increase of intra-abdominal pressure ; '(3) Congestion with areolar hyperplasia of uterus, pubic segment, and posterior vaginal wall ; laxity of everted vagina ; (4) Separation of anterior rectal and posterior vaginal walls and of vagina and bladder from their lateral relations, with peritoneum clothing the separated surfaces. These secondary lesions, especially the last, are serious and incurable. Secondary PROLAPSUS UTERI. 573 In order to restore the pelvic floor to its pristine state we should require (1) to repair the perineal body and narrow the vagina ; (2) to restrain increased abdominal pressure ; these are possible : (3) to do away with congestion and areolar hyperplasia is probably beyond our powers, while (4) to bring about adhesion of the anterior rectal and posterior vaginal walls and to restore the lateral supports is impossible. Prolapsus uteri is therefore a condition with serious and irremediable secondary results. OPERATIVE TREATMENT OF PROLAPSUS UTERI. For operative purposes we consider prolapsus uteri as a downward FIG. 340. NEEDLE CARRYING IN STITCHES FOR REPAIR OK THE PERINEUM (Sir J. T. Simpton). and outward displacement of the entire displaceable portion of the pelvic floor past the entire fixed portion, with eversion of the vaginal walls. The various operations may be classified as follows : 1 Those that aim at giving a support to the prolapsed portions by repairing the lower edges of the sacral segment (Perineorraphy) and the lower uniting edges of the labia majora (Episioperineorraphy) ; 2. Those that aim at causing a narrowing of the vagina wal bringing about their partial union so that they are less e (Elytrorraphy) ; 574 AFFECTIONS OF VULVA AND PELVIC FLOOR. 3. Those that combine 1 and 2 ; 4. The special operation which draws up the entire displaceable portion by shortening the round ligaments of the uterus (Alexander- Adams Operation). Preliminary Considerations as to Operative Technique. It should be noted here that the method of rawing the surfaces has recently under- gone a change. Formerly it was done with knife and forceps and the tissue removed : now scissors are often employed so as to raise flaps thus exposing a raw surface for union without loss of tissue. 1. Those that aim at giving a support to the prolapsed portions by Operations re p a { r i n y t/ ie lower edges of the sacral segment and uniting the loiver lapsus. portions of the labia majora. FIG. 341. EESULT OF SAMK OPERATION. (1) Perineorraphy. This operation aims at restoring the perineal body, i.e., it freshens and unites the torn surfaces. Perineorraphy alone is only of use as an operation in slight cases, inasmuch as the part restored lies mainly beyond the vaginal walls and therefore in no way hinders their eversion, although it may make the vulvar opening through which they pass somewhat narrower. We describe this operation briefly as it is always combined with union of the lower portions of the labia majora (Episioperineorraphy) or some operation causing cicatrization of the posterior vaginal walls (Elytroperineorraphy). In the operation we chloroform patient, use douche and have knees held as described at page 559 ; make incision b c and a b ans in fig. 338; PROLAPSUS UTERI. 575 dissect up flaps and pass stitches as in figs. 339, 340 341 After treat ment and removal of stitches as at page 561. As already said this operation by itself is not of the remotest use unless it gets union of torn muscles, but it allows a pessary to be retained. (2) Episioperineorraphy. In this operation the lower portions of the labia majora, as well as the cicatrized surfaces of perineal body arc vivified and the opposing raw surfaces united with silkworm gut sutures. Lawson Tait operates with angled scissors as follows. He first notches the cicatrized surface mesially at the anterior portion of the perineum, the scissors being held parallel to the long axis of the FIG. 342. TO SHOW VARIOUS FORMS OF RAW SURFACE MADE ON POSTERIOR VAGINAL WALL IN OPERATION FOR PROLAPSUS UTERI: 1111, Hegar's; 2222, BischoflTs ; 3333, Simon's; 444oA Winckel's. (Winektl) patient's body. One blade is entered at right angles to this and pushed up in one labium majus to the base of the labium minus or beyond. The same is done on the opposite side. Thus a U-shaped incision is made. Silkworm catgut stitches are passed to unite each side as follows. A handled needle is used and the point entered inside the skin, say on the left side and out inside the mucous mem- brane of the same side. The needle is then withdrawn, and passed at a corresponding part on the right side, entering inside the skin and pass- ing outside the mucous membrane, when the thread passed on the left 576 AFFECTIONS OF VULVA AND PELVIC FLOOR. side is threaded into it and now drawn into the right side. This everts the raw surface on the one side and brings it into apposition with the correspondingly everted raw surface on the other side. Three or four sutures are thus passed and tied. The operation is quickly done but union may not be thorough or broad enough. (3) Elytroperineorraphy. This is a favourite operation with many, and helps at least by enabling the patient to wear a ring pessary. The patient is chloroformed, placed in the lithotomy position and the vaginal douche used. The first thing to be done is to get a raw surface over the site of the perineal body and lower portion of posterior vaginal wall. The shape of this surface varies very much as may be seen at figs. 342 and 343. Whichever is selected should be mapped out by a shallow incision then the raw surface formed by dissection with the knife, by passing a double cutting knife below the mucous membrane, or with scissors. All FIG. 343. RAW SURFACE AS MADE BY MARTIN. 1234, raw surfaces on posterior vaginal wall; II, raw surface round introitus. The surfaces 1-4 are united, A to A and B to B. The edge 4 |3 is turned in, with the corresponding one of opposite side, along the line a. The surface I II, is united by sutures, so that the English and Greek letters are in apposition respectively. that is wanted is a raw surface which should not be excavated, but as shallow as possible. Bleeding can be stopped by the hot douche, pressure forceps or catgut ligatures, if necessary. The passage of sutures is important. Silkworm gut is very good and may be used both for deep and superficial interrupted stitches. The deeper sutures are passed first and may go beyond the depth of the wound : then the superficial ones, beginning internally. All are passed before being tied. The continuous spiral catgut suture is strongly recommended by many and is well worthy of trial (v. page 560). 2. Those that aim at causing a narrowing of the vaginal walls or bring- ing about their partial union (Elytrorraphy). PROLAPSUS UTERI. 577 We may operate on the anterior vaginal wall only by Sims' method (fig. 344) : or remove two strips on each wall and unite the opposing strips (Lefort, Neugebauer). This latter method may be used in complete prolapsus cases. The strips may be rawed by pinching up the necessary length with long-bladed forceps and cutting away what projects beyond the grip. Of course this is done with the parts extruded and then the opposing strips are united from above down with catgut and replaced as the thread is tightened. Neugebauer removes a mesial portion from the vaginal walls, each part being about 4 cm. long by 1^-2 cm. broad. These surfaces are then united to one another. The long axis of the raw surfaces may be vertical or transverse. FIG. 344. To SHOW RAW SURFACE AS MADE BY SIMS (Marion Simt). Each strip in Lefort's operation is 6 cm. by 2 cm. 3. It is evident that we may combine I and 2. 4. The special operation which aims at drawing -up the entire displaceable segment and uterus by shortening the round ligaments (Aran, Freund, Rivington, Alexander- Adams Operation). This operation, first performed in this country by Rivmgton < London and brought into prominence by Alexander of Liverpool a Adams of Glasgow, aims at shortening the round ligaments and fixin them in the inguinal canal so as to draw up and fix somewhat 1 placed parts. 2o 578 AFFECTIONS OF VULVA AND PELVIC FLOOR. The bowels and bladder are emptied, the patient chloroformed and the pubes shaved. All antiseptic precautions are to be employed (Listerism). The pubic spine is felt for and an incision made up and out from it, two inches in length and in the line of the inguinal canal. The incision passes through skin and into the external abdominal ring, known by oblique fibres crossing it and protrusion of fat at its lower end. The tissue now bulging out from the ring (the end of the liga- ment) before entering the mons veneris, is lifted by an aneurism needle, grasped with the finger and pulled out gently, any bands preventing this being cut with the knife. The other side is treated in the same way, both ligaments therefore being pulled out as far as possible. The wound is then stitched, the sutures (catgut, silkworm gut or silver) being passed from side to side of incision, i.e., through skin, pillar of abdominal ring, round ligament, pillar of ring, skin. The after treatment is based on general principles already laid down. Care is to be taken at first when the patient moves about, and a ring or other suitable pessary used if necessary. Sufficient is not yet known about the results of this operation, 1 and from what is known it is falling into disfavour. Deaths have been recorded from it. One evident objection is the risk of inguinal hernia. We may finally note that in advanced prolapsus uteri the uterus has been excised ; and Miiller of Bern has performed abdominal section, drawn"up the iiterus, clamped it at the isthmus, removed the body of the uterus and treated the pedicle extra-peritoneally. Neither of these proceedings is at all to be recommended. We recommend in treatment (1) Use of a ring in slight cases ; (2) Episioperineorraphy or Elytrorraphy anterior and posterior, and a pessary in medium cases ; (3) Lefort's or Neugebauer's method in advanced cases. The use of massage in prolapsus uteri will be described in the Appendix. VAGINAL ENTEROCELE. Of this there are two forms, anterior and posterior. Excessive intra- abdominal pressure usually displaces all of the pelvic floor that lies in front of the anterior rectal wall. Occasionally, but very rarely, intes- tine is forced down between the posterior aspect of the bladder and upper part of anterior vaginal wall, or between the anterior rectal and posterior vaginal walls (fig. 345). We thus get a mass bulging into the vagina, but affecting only one wall ; the uterus and cervix remain in position. This distinguishes it from prolapsus uteri and cervical elong- ation ; by rectal examination, the posterior form of enterocele can be easily distinguished from rectocele. 1 For recorded cases, see Index of Gynecological Literature under " Miscellaneous." VAGINAL ENTEROCELE. 579 The causation is not well known. In the posterior form, a deep dip of the peritoneum behind the posterior vaginal wall may have existed but of this there is no evidence. Treatment. If any ordinary Albert Smith or anteversion pessary fail, an operation may be tried. In the posterior vaginal enterocele, for example, the protrusion should be replaced ; a raw surface is then made FIG. 345. POSTERIOR VAGINAL EXTEROCELE (Brewky). on the posterior lip of the cervix and a portion of the posterior vaginal wall about its middle ; these surfaces are then stitched. Prolapsus uteri and both forms of vaginal enterocele are therefore essentially the same in nature, viz., hernial. Intra-abdominal pressure usually displaces all in front of the anterior rectal wall ; but may also force intestine in front of the anterior vaginal wall, or behind the posterior one. SECTION VIII. DISTURBANCES OF THE MENSTRUAL FUNCTION. CHAPTER L. Amenorrhcea : Menorrhagia : Dysmenorrhoea. SECTION IX. DISTURBANCE OF THE REPRODUCTIVE FUNCTION. CHAPTER LI. Sterility. CHAPTER L. AMBNORBHCEA: MENOBBHAGIA: DYSMENOBBHCEA. THE three subjects to which this section is devoted are not diseases, but are symptoms of a large number of the more or less well-ascertained pathological conditions already considered. Theoretically, therefore, they should not come up for special consideration ; practically, however, it is of use to the practitioner to summarize the conditions causing these symptoms, and to give some special hints as to their treatment. AMENOBBHCEA. (For recent Literature, see Index.} This means cessation of menstruation during the period between puberty and the menopause. It is normal to have Amenorrhoea during pregnancy and lactation. Amenorrhoea may be caiised by the following Local conditions : Causes. /Absence or incomplete development of uterus J and annexa, atresia of the genital canal * ' | (with or without accumulation of the men- ! strual blood), state of cretinism ; (Superinvolution, simple atrophy of uterus, Acquired ....-< cystic ovarian disease, extensive inflamma- ( tory conditions of uterus and ovaries. Constitutional conditions such as phthisis, chlorosis, prematurity of menopause also cause amenorrhcea. The local conditions have already been fully described under the various heads ; we give here only a few hints as to the investigation of the causes of this symptom. When the patient complains of never having menstruated and there is no constitutional cause for the amenorrhoea, the question of examination should always be entertained; abdominal palpation and rectal examination are employed to ascertain that there is no retention from atresia. To ascertain the condition of the uterus, a vaginal examination may be necessary. Sudden cessation of the menstruation in a women neither phthisical nor chlorotic is usually due to pregnancy ; early sickness, mammary and other signs should be looked for. Nothing is a sure sign of pregnancy except the characteristic AMENORRHCEA. 583 increase in the size of the uterus, agreeing with the number of periods In cases where amenorrhoea is due to chlorosis, Blaud's pills are Treatment, indicated. These contain sulphate of iron and carbonate of potash made up as undernoted ; as the result of the combination, the carbonate of iron is formed. R Ferri sulphatis. Potassii 1 carbonatis aa gr. iiss. Mucilaginis tragacanth.se q.s. Fiat pilula : mitte tales 96. Sig. Three, thrice daily. Nine pills must be taken per diem continuously for six to eight weeks, by which time a complete cure usually results. Before the pills are given, the state of the tongue and bowels should be looked to. If the tongue is foul and the bowels constipated, we may give the following : R Magnesii sulphatis 31. Quininae 1 sulphatis gr. xxiv. Acidi sulphurici dil. 3 n j. Aquam ad 5vi. Sig. Tablespoonful twice or thrice daily. This is taken for a week. The Carlsbad salts or Friedrichshall water may be substituted. This hint as to the preliminary purgation is a good one, and is given by Milner Fothergill ; if not attended to, the result will be disappointing as the iron will not be so readily absorbed by the intestinal mucous membranes. Note. The original composition of Blaud's pills is as follows -.Sulphate of iron, carbonate of potash, of each half-an-ounce ; marshmallow root thirty grains ; gum tragacanth q.s. to make 120 pills. The following are the proportions in the pill as made by Messrs Duncan, Flock art, & Co. of this city : Ferri sulph. siccat. 15, Potass, carb. siccat. 15, Pulv. gum. acacias 3, Syrup, simp. 9 ; Divide in 5-gr. pil. Blaud's pill gives a ferrous carbonate and a potash salt, the decomposition taking pla< after the pill is swallowed. In Vallet's pill, which is popular on the continent, the decomposition is effe and the carbonate of iron thus freshly formed is used to make the pill. The quantiti taken to make Vallet's pill are as follows : Protosulphate of iron (in crystals) 10, Carbonate of soda (in crystals) 12, White honey 3, Sugar of milk 3 ; Divide in 5-gr. pil. Ringer recommends permanganate of potash. The following is a good formula : R Potassii Permanganatis. Kaolin aa gr- ij- Vaselini q.s. Fiat pilula : mitte tales xxiv. Sig. One thrice daily. ' According to the terminology of the new pharmacopoeia. 584 DISTURBANCES OF MENSTRUAL FUNCTION. These pills should not be made with any excipient containing glycerine or with an oxidizable substance as their union would cause combustion. Oxide of manganese (manganesii oxidum praeparatum) in two grain doses thrice daily is also excellent. MENORRHAGIA. Menorrhagia is the term applied to excessive haemorrhage at the menstrual periods ; when the haemorrhage is intermenstrual, it is termed metrorrhagia. Causes. The causes of menorrhagia are the following : Constitutional . Haemorrhagic diathesis, scorbutic conditions, alcoholism ; ,0vai'itis, small cystic ovaries, endometritis, I metritis, subinvolution, retroversion of uterus, Local . . . j inversion of uterus, submucous and interstitial (fibroids, polypi, carcinoma uteri, sarcoma uteri, incomplete abortion. It should not be forgotten that we may have menorrhagia in cardiac disease, and also in hepatic congestion (Matthews Duncan, Warner). Women who are drunkards very often suffer from menorrhagia owing to the liver congestion. This may give the practitioner a hint as to the patient's habits, especially as those women who drink always conceal the failing, and often most successfully. When called to such, there is usually found great epigastric pain on pressure, tremulous tongue, and depression of spirits, for which their excuse is quite inade- quate. Treatment. The treatment of menorrhagia is the treatment of the condition producing it. In cardiac disease we give digitalis; and in hepatic disease we may try chloride of ammonium, euonymium or iridin. R Ammonii chloridi 5iij. Aquae gvj. Sig. Tablespoonful thrice daily. R Euonymii vel Iridin gr. ii. Pil. aloes et ferri q.s. Fiat pilula : mitte tales xij. Sig. One at night. In cases where there is menorrhagia due to a simple congested DYSMENORRHCEA. 585 condition or to a flabby state of the uterine muscle, we may give the following at the menstrual periods : R Ergotinee j. j v Argenti oxidi Micae panis Fiat pilula : mitte tales xij. Sig. One thrice daily as directed. Note that it is well not to write "at the menstrual period" on the prescription, but to put "as directed." When the practitioner is con- sulted as to menorrhagia in unmarried women or young girls, he should first try the ergotin and oxide of silver pill. If this fail and the case be urgent, he should request a local examination. If this be declined, the responsibility rests with the patient. R Extracti ergotse liquidi gij. Sig. Thirty drops as directed or R Ergotini gr. iv. Fiat suppositorium : mitte tales xij. Sig, As directed. Inform the patient that two suppositories are to be passed into the rectum each morning after the bowels move. In some cases the hypodermic injection is required (v. p. 426). DYSMENORRHCEA. LITERATURE. Duncan, Matthews Clinical Lectures : London, 1886, p. 141. Goodell Lessons in Gynecology : Philadelphia, 1879. Q-usserow Menstruation and Dysmen- orrhoea: Germ. Clin. Lect., New Syd. Soc. Tr., 1877. Herman, G. E.On the Relation between Backward Displacements of the Uterus and Painful Menstrua- tion : Lond. Obst. Trans., 1882. Solmvieff Decidua menstrualis : Archiv f. Gyn., Bd. II., S. 66. Schroedci Die Krankheiten der weiblichen Geschlechtsorgane : Leipzig, 1887. Simpson, Sir J. Y. Diseases of Women, p. 225 : Edin., 1872. Williams, John Pathology and Treatment of Membranous Dysmenorrhcea : Lond. Obst. Tr., 1877. See also Index of Recent Literature in the Appendix. Dysmenorrhoea may be defined as the occurrence of pain before, during, or after the menstrual period. The pain of dysmenorrhcea varies greatly in intensity. It may be so severe as to render the sufferer a miserable invalid, it may interfere with her work more or less, or it may cause only marked uneasiness. It is always advisable in cases of dysmeuorrhoea to ascertain how much the pain interferes with the patient's occupation or whether it confines her to bed. Note also when the pain occurs prior to, during, or after the blood-flow ; in the purely spasmodic form, it is during the flow. In order to treat dysmenorrhoea intelligently, we must endeavour to 586 DISTURBANCES OF MENSTRUAL FUNCTION. Forms usually given. Practical Varieties. ascertain its cause and try to make ont how this condition brings about the pain. We know nothing at all as to the real cause of dysmenorrhcea. We know that in many instances it is associated with certain pathologi- cal conditions, but how these actually cause the pain is as yet disputed. Some facts as to menstruation help us in understanding dysmenor- rhoea. The uterus is an erectile organ (p. 71), and as the decidua men- strualis is five or six times thicker than the uterine mucous membrane, it is evident that metritis or pathological anteflexion when present will hinder the erection and expansion of the flterus, and cause intense pain analogous to the chordee of the penis in gonorrhoea. In normal menstruation, a fluid made up of blood and epithelial debris escapes from the uterus. Probably, it does not drain away by mere capillary action but is expelled by uterine contractions. There is no absolute proof of this, but it is a fair deduction from anatomical facts If a patient be examined while menstruating, we may feel an arching o slight tension of the fornices indicative probably of uterine action. Dysmenorrhoea is usually divided into certain forms. It is to b regretted that this has been done, because there have not been collectec pathological facts sufficient to warrant a classification. The form usually given are the following : 1. Dysmenorrhoea associated with certain diatheses, such as th gouty and rheumatic ; 2. Spasmodic dysmenorrhoea ; 3. Membranous dysmenorrhoea ; 4. Dysmenorrhoea associated with inflammatory conditions of the uterus, ovary, peritoneum or cellular tissue ; 5. Ovarian dysmenorrhoea. The last term is applied to certain cases which were supposed to be specially connected with the ovaries and which could not be classifiec under the preceding heads. The term is a most unfortunate one. I assumes a cause for dysmenorrhoea which is not, as yet, demonstrated and, instead of pathological facts or a confession of our ignorance o them, gives us what we have too much of already erroneous termin ology. So far as our present knowledge goes we can speak of foui varieties : 1. Spasmodic dysmenorrhoea ; 2. Congestive dysmenorrhoea ; 3. Membranous dysmenorrhoea ; 4. Dysmenorrhoea associated with mal-development of the sexua organs, pyosalpinx, fibroma uteri, rheumatic diathesis and some other unknown causes. DYSMENORRH(EA. 587 1 and 2. Spasmodic and Congestive dysmenorrhoea. Of these the most The Erec- frequent cause is pathological anteflexion, i.e., anteflexion of the uterus Expansion produced by inflammation in the utero-sacral ligaments with cicatrisa-* the tion. The pathology, diagnosis and treatment of this affection is given hindered, at pp. 347-356. We only remark here that it is a very serious lesion owing to its inflammatory etiology. From the flexion produced, we get spasmodic uterine contraction accompanied with very great pain and expulsion of clots. Two theories of dysmenorrhoea have been already explained (p. 351). Those who hold the purely mechanical theory seem to forget that fluid blood passes easily through a capillary. Does any FIG. 346. SKETCH OF A DYSMENORRH(F.AL MEMBRANE AS SEEN UNDER WATER (Sir /. Y. Simpson). one believe that the lumen at the flexion is less than that of a capil- lary? Spasmodic contraction of the os internum and constriction of the cervical canal are also advanced as causes. 3. Membranous dysmenorrhoea. In this condition, the superficial layer Membran- of the mucous membrane is cast oft" as a triangular sac or in shreds of Dysmenor . a more or less firm consistence (figs. 346, 347). This may result fromrh the occurrence of haemorrhage in the deeper layers of the mucous mem- brane ; and then we can understand that, according to the depth, we have present no part of the glands or only their coecal extremiti (Solowieff and Gusserow). Microscopically, there is excess of round , and fibrillated tissue in the membrane. 588 DISTURBANCES OF MENSTRUAL FUNCTION. J. Williams, who has written ably on this subject, believes that, owing to an excess of fibrous tissue in the walls of the uterus, the mucous membrane is expelled in coherent shreds. This excess of fibrous tissue is due to defective evolution, sub-involution, or metritis. The membrane is, further, never a plastic exudation. It is of the greatest importance to remember that it is not a product of conception and should not be mistaken for an early abortion. 4. Dysmenorrhoea from other causes, as defective development of uterus, pyosalpinx, etc. Many of these conditions are now being elucidated by abdominal section undertaken for Battey's and for Tait's operation. TREATMENT. Cautions At the outset we are met with a difficulty. As we are usually con- as to Treatment. FIG. 347. A DYSMENORRHCEAL MEMBRANE LAID OPEN (Coste). suited for Dysmenorrhoea in unmarried women, the question of the pro- priety of a pelvic examination comes up. As Duncan has said " No rules that I can give you will make up for want of good sense and good feeling on your own part, but I shall give you some hints. The first is that you should, as a rule, not resort to this treatment (by bougies) in an unmarried young woman without the concurrence of three parties firstly, your own approval ; secondly, that of the mother or guardian of the patient; and, thirdly, that of the patient herself. All of these should be quite aware of the circumstances, and of what it is proposed to do." DYSMENORRH(EA, 589 Nothing can be more reprehensible than the vaginal examination of unmarried women for trifling ailments. When the Dysmenorrhoea is slight, make no examination but order some such mixture as the follow- ing. R Spiritus chloroformi, Spiritus ammonie aromatici, aa 533. Liquoris ammonise acetatis i. Sig. Teaspoonful in a wine-glassful of hot water occa- sionally. Order a hot hip bath, or the feet to be put in mustard and water. On no account whatsoever allow alcohol in any form to be given. If the mother has been giving whisky and water or gin and water, at once point out the risk the patient is running. Do not give morphina, or other opiate, unless driven to it ; always give it yourself and hypoder- mically, never by the mouth or rectum, and give no prescription for it. When the Dysmenorrhcea is urgent, then an examination should be advised ; the index finger well oiled can usually pass in without much pain. If pathological anteflexion is found, note the amount of inflammatory disturbance, the degree of flexion, and the implication or non-implication of the tubes arid ovaries. Begin by ordering blisters to the iliac regions, bromide of potassium, the glycerine plug, and the hot vaginal douche. See that the bowels are regulated, and soft motions secured by the use of liquorice powder (Pulv. glycyrrhizse co.) and occasional enemata, and that no tight lacing is allowed. Chlorotic patients should be put on Blaud's pills and digitalis, and change of air, when requisite, ordered. Note the effect of this for some periods ; and then, if unrelieved, pass the sound or graduated bougies or use uterine dilator. This course benefits the Dysmenorrhcea, and it is safer than the use of stem pessaries ; the dilatation by bougies seems to act like the stretching of the sphincter ani in fissure of the anus and often gives brilliant results. Patients with neurasthenia often suffer severely at the menstrual periods. Local treatment is contra-indicated, as the dysmenorrhoaa often passes off while the general condition is improving. If the Dysmenorrhcea is membranous, treatment is of little service. The following prescriptions may be tried. R Liquoris arsenicalis 3ij- Sig. Three drops in water thrice daily after food. R Liquoris arsenii et hydrargyri iodidi (Donovan's solution) 3ij- Sig. Five drops in water thrice daily after food. The action may be analogous to that of arsenic in psoriasis. 590 DISTURBANCES OF MENSTRUAL FUNCTION. Treat any endocervicitis or stenosis of cervix present. The prognosis is unfavourable as to cure. The patients are not necessarily sterile. In the third class of cases, Battey's operation has not given the results anticipated. We have not as yet, however, facts warranting any dogmatic utterance. Where the ovaries are developed but not the uterus, with serious menstrual molimina resulting in consequence, Battey's operation is undoubtedly indicated. In cases of pyosalpinx, removal of tubes and ovaries by abdominal section gives good results (v. p. 212). Where any diathesis (rheumatic or gouty) is supposed to influence the Dysmenorrhrea, guaiac, colchicum and such specific drugs may be given. CHAPTER LI. STERILITY. LITERATURE. Duncan, J. Matthews Fecundity, Fertility, Sterility and allied topics: Edinburgh, A. & C. Black, 1866. On Sterility in Women : J. & A. Churchill, 1884. v. Griine- iculdt Ueber die Sterilitat geschlechtskranker Fraueu : Archiv f. Gyn., Bd. VIII., S. 414. Kchrcr Zur Sterilitatslehre : Beitrage zur klinischen und experiment- ellen Geburtskunde und Gynakologie, Bd. II., S. 76. MailerDie Sterilitat der Ehe : Billroth u. Luecke's Handbuch der Frauenkrankheiten : Stuttgart, 1885, S. 297. Sims, Marion Uterine Surgery : London, 1865. Simpson, SirJ. F. Obstet- rics : Edin., A. & C. Black, 1871, p. 830. WhiteheadOn the causes and treatment of abortion and sterility : London, 1847. See also Index of Recent Literature in the Appendix. THE reproductive function is the most complex and subtle of all the functions of life. If we know little about the simpler function of men- struation so that there is room for great difference of opinion with regard to it, we know still less of the function of reproduction. Of its physiology, we know only that it requires the presence of ova and spermato- zoa; of the constitutional influences affecting the vitality of these two and the conditions favourable for their conjugation, even of the place where this occurs, nothing is known. Nor have we yet data for studying the general laws of fertility for the human female. Much has been done by Darwin and others to elucidate these for plants ; little is known of them for animals, and almost nothing for the human species. Of the disturbances of the reproductive function, sterility belongs to Gynecology ; abortion, retroflexion of the gravid uterus and extra- uterine gestation belong more properly to Obstetrics. No simple and yet complete definition of sterility can be given. The Distinction word has a quite different meaning as we use it relatively or absolutely. A e ^^ As the opposite of fertility, it includes cases in which a child is not born and Rela- till many years after marriage or the number of children is comparatively sterility, few ; further, inasmuch as the reproductive function covers gestation as well as the birth of a viable child, sterility includes all cases of intra- uterine disease and death of the embryo or foetus, resulting in abortion, premature labour, or the birth of a non-viable child. None of these cases are absolutely sterile, the sterility is relative. The term also necessarily covers all cases in which under circumstances favourable to conception, this either has not occurred at all or the product has not 592 DISTURBANCES OF REPRODUCTIVE FUNCTION. Relative Sterility. Absolute Sterility. gone the length of even an early abortion. Here the sterility is absolute. This raises the question as to when sterility is relative, and when absolute. What is the standard of fertility by which we decide that a woman is relatively sterile and measure the degree of that sterility? When can we say that a patient is absolutely sterile 1 Relative Sterility. At first sight, we should be inclined to regard the period of child-bearing as co-extensive with the period of menstruation. But it is not so. The period of fertility is not co-terminous with the period of menstrual activity : it begins later and ends earlier, its total duration being about fifteen years, during which time births take place about every eighteen or twenty months. Its commencement is deter- mined by the year of marriage, in this country on an average the twenty- fifth year, the first child being born in most cases twenty months after marriage. It ceases usually about thirty-eight, some years before the menopause. Thus, as Whitehead puts it, there is a period of quiescence in the function of reproduction both at the commencement and at the termination of menstruation. (Matthews Duncan) Taking the foregoing considerations as giving us a standard of fertility, we learn that relative sterility may show itself in such various ways as these, not having the first child within twenty months after marriage, having children at intervals of longer than twenty months, ceasing to have children within fifteen years after marriage. In applying these considerations to an individual case, however, we must of course take into account the age of the patient. There seems also to be great varia- tion in the productive power of different individuals. One patient has many children without injury to health, while in another the birth of one child exhausts the reproductive function. Sir James Simpson found that among British peers unproductive marriages are relatively more common (1 in 6, instead of 1 in 10). As the result of relative sterility we find that the number of children to a marriage in Britain is 5*2 or one-half of what it would be if all the conditions favourable to reproduction were fulfilled. Absolute Sterility. The interval between marriage and the birth of the first child averages twenty months, and any protraction of this interval means a degree of sterility ; but we cannot speak of absolute sterility until several years of married life have passed without even an abortion. Matthews Duncan found in his statistics of the births in Edinburgh and Glasgow for the year 1855, an average interval of 17 months to the first child two-thirds being born before the end of the second year, and only one-twenty-fourth after the fourth year. Hence, he concludes that there is no ground for the assumption of per- sistent sterility until the fourth year of married life has been entered upon. Of the number of absolutely sterile marriages in Britain we have no STERILITY. 593 data. The statistics of Sir J. Y. Simpson, based on the reports of the population of Grangemouth and Bathgate which give the number of sterile marriages as 1 in 10, include abortions and all other cases in which a child would not be registered, so that they cannot be relied upon for data regarding absolute sterility. The Etiology of Sterility is too wide a subject to be exhaustively dis- Etiology of cussed here. We can only indicate what the causes are and point out sterility - the necessity of taking a broad view of this question. Amongst general influences, we note first of all the effect of temperature and climate, and of marriage between near relatives. Under want of sexual agreement have been placed many cases which have not been ex- plained otherwise (such as the classical one of Napoleon and Josephine). Age has an undoubted influence ; the period of nubility is from the age of twenty to twenty-five, and marriages before or after this period are less fertile. The influence of disturbed nutrition is seen in the associa- tion of sterility with obesity ; it seems that the taking-on of fat is at the expense of the reproductive function, perhaps through interference with ovulation. Chlorotic patients are also sometimes sterile. The association of Dysmenorrhoea with sterility has been already referred to (pp. 267 and 352) and is a matter of everyday observation. Matthews Duncan found spasmodic dysmenorrhoea in 47'9 (159 out of 332) of his cases of sterility; while Marion Sims found it in 51 '6 p.c. (129 out of 250) of his. Further, these conditions disappear together under treat- ment, and spasmodic dysmenorrhoea is a rare condition in fertile women. As to local causes, we note that sterility is found associated with the following conditions already described : vaginismus, p. 530 ; hypertro- phied cervix, p. 280 ; conical cervix with pin-hole os, p. 265 ; cervical catarrh, p. 308 ; anteflexion, p. 350 ; retroflexion (more rarely), p. 366 ; endometritis, p. 323 ; ovaritis, p. 203 ; pelvic peritonitis, p. 162. The last three are probably the most important. Taking the function of reproduction instead of the various organs as the standpoint from which to regard sterility, we find that this function may be divided into three processes Insemination, Impregnation of the ovum or Conception, and Gestation. A certain number of cases of sterility are due to defect in Insemination (e.g. all cases of Dyspareunia) ; but the most important group of cases coming under this head are those of absence or deficient vitality of the Spermatozoa. As we are dealing here only with sterility in the female, this last cause of sterility is beyond our subject ; but it is important to remember that Gross's investigations into male sterility show that it is probably the cause in every sixth case which comes before us. As to the relative importance of Conception and Gestation, the investigations of v. Griinewaldt show that interference with the latter is a much more important factor in sterility than is generally supposed. Investigating 500 cases of sterility from the standpoint of the influence 2 P 594 DISTURBANCES OF REPRODUCTIVE FUNCTION. that the condition of the uterine tissue has on gestation, he comes to the following conclusion : Conception forms only one link in the chain of processes involved in the fertility of marriage, and is of slight import- ance compared with the great number of vital processes implied in ges- tation ; the point of greatest importance in the fertility of woman is her capability of carrying a fertilised ovum, which depends to a great extent on the integrity of the uterine tissue. Kleinwachter l met with one-child sterility in 8'32 p.c. of his cases. The age at which the women married seemed to have nothing to do with it. He finds that the causes are the same as in the case of absolute sterility (apart from congenital malforma- tions), viz. : Inflammation after puerperium, . . . . 17 '77 p.c. not . . . . 12-22 Endometritis, . . . . . . . 17 '77 Uterine displacements, . . . . . 12 '22 ,, neoplasms, . . . . . . 8 '88 Constitutional conditions, . . . . . 7 '77 Male impotence, . . . . . . 7 '77 Uterine atrophy, . . . . . . 5 '55 Ovarian neoplasms, . . . . . . 3 '33 Unknown causes, . . . . . . 6 '66 Treatment. In the treatment of sterility, we must take a broad view of the etiology and not allow local conditions to influence us unduly. Attention to the general health, and patient waiting until at least three years of married life have passed is all that is required in the large proportion of cases. Entire cessation of intercourse for several months should be recommended, and can be secured by change of air to some watering-place at home or abroad, according to the patient's means. Where coitus is impossible or painful (as in cases of atresia and vaginismus) operative interference is called for immediately, and such cases offer the most satisfactory results in treatment (see p. 520). In estimating the importance of operations on the cervix (p. 269), we must keep in view the rarity of this indication for treatment and the uncertainty that an operation by dilatation or division will be beneficial. Whether the sterility be due to the rigid condition of the cervix or the smallness of the os externum, such cases form only 4 p.c. (Mutter) or 8 p.c. (Kehrer) of the total number of women who seek advice for sterility. In other words, taking Miiller's statistics the chances are 24 to 1 that the cause of sterility must be sought elsewhere than in the cervix. 1 Centralb.f. Gyn., XII., 287. SECTION X. AFFECTIONS OF BLADDER AND RECTUM. CHAPTER LIT. The Bladder : Anatomy, Physiology, and Methods of Examination. LIII. Affections of the Urethra and Bladder. LIV. Vesico- Vaginal Fistula. ,, LV. The Rectum : Coccygodynia. APPENDIX. Abdominal Section. Electricity in Gynecology. Systematic Treatment of Nerve Prostration. Hysteria and Hystero-Epilepsy. Massage. Relation of Gonorrhoea to Gynecology. Case-Taking. Sources of Gynecological Literature. INDEX OF RECENT GYNECOLOGICAL LITERATURE. CHAPTER LIL THE BLADDER : ANATOMY, PHYSIOLOGY AND METHODS OF EXAMINATION. L1TERA TURE. Burckhardt Endoskopie und endoskopische Therapie : Tubingen, Laupp'schen Buch- handlung. Chiene Bladder Drainage: Ed. Med. Jour., 1880. Groom, J. H. On Retention of Urine in the Female : Ed. Med. Jour., April and May 1878. Femoick, E. H. The Electric Illumination of the Bladder and Urethra : London, Churchill, 1888. Foulis An Antiseptic Catheter for washing out the Bladder : Brit. Med. Jour., Jany. 30, 1886. Hart Physics of Rectum and Bladder : Ed. Obst. Trans., 1882. Nitze Lehrbuch der Kystoskopie : Wiesbaden, 1889. Noegyerath The Vesico-vaginal and Vesico-rectal Touch : Am. J. of Obstet. , viii. , 135. Ogston Ed. Med. Jour., 1878. Pawlik Ueber die Harnleitersondirung beim Weibe : Archiv f. klinische Chirurgie, Bd. XXXVI., Hft. 2. Power Physiology of Mic- turition : The Practitioner, 1875. Stinger Ueber Tastung der Harnleiter beim Weibe: Archiv f. Gyn., Bd. XXVIII., S. 54. Skene Diseases of the Bladder and Urethra in Women : W. Wood & Co., New York, 1878. Winckel Die Krankheiten der weiblichen Harnrohre und Blase : Billroth's Handbuch, Stuttgart, 1886. DISEASES of the bladder are of the greatest importance as they are not only very painful, but, for a reason to be given shortly, very intractable. In a Manual of the present scope, a full consideration of vesical disease is impossible ; we therefore give a mere sketch, and refer the practitioner for details to Skene's or to Winckel's Manual. ANATOMY AND PHYSIOLOGY. Physiology For the anatomy, the student is referred to pp. 30 to 35. We should j o urina ~ here only point out that the female bladder, owing to its greater breadth transversely at the base (v. fig. 359), is relatively more capacious than that of the male. Urination. The mechanism of the storage and expulsion of urine from the bladder is full of interest, both from a theoretical and a practical point of view. The urine trickles along the ureters, a result partly due to blood pressure and partly to the peristaltic action of the ureters them- selves. It thus reaches the bladder, at this stage an empty flaccid sac with its upper half fitting into the lower calyx-like portion. Gradually the bladder distends, until at last the activity of the motor centre (whose constant action keeps the urethral muscles contracted) is reflexly inhibited, and the urine is expelled by the muscular contraction of the bladder and intra-abdominal pressure. The bladder is now contracted ANATOMY AND PHYSIOLOGY OF BLADDER. 597 and, on section, has the shape seen at fig. 348 its shape in systole. The bladder then relaxes, i.e., becomes flaccid its diastole, and once more the urine trickles into it (fig. 25). The bladder therefore has, like the heart, its systole and diastole. A knowledge of this is important practically. It explains the intract- ability of inflammatory conditions of the bladder, since the bladder when inflamed does not get what every inflamed organ requires rest. FIG. 348. BLADDER is SYSTOLE (Brav.nt). The average amounts of the several urinary constituents passed inComposi- twenty-four hours, as given by Parkes, are the following : Urine> Water Total solids Urea . Uric acid . Hippuric acid Kreatinin . Pigment, etc. Sulphuric acid . Phosphoric acid . Chlorine Ammonia . Potassium . Sodium Calcium Magnesium . 1500-000 Grms. 72-000 33-180 555 400 910 10-000 2-012 3-164 7-000 700 2-500 11-090 260 207 598 AFFECTIONS OF BLADDER AND RECTUM. Urine also contains various epithelial scales, a little mucus, nitrogen and carbonic-acid gases. The reaction is acid, and the specific gravity is 1020. METHODS OF EXPLORING THE URETHRA. The urethra is explored by sound, finger, and speculum in the same way as the bladder. We need not therefore go into detail in these, but refer the student to methods of exploring the bladder. We may remark, however, that the exploration by finger, sound, or speculum is not very satisfactory in the case of the urethra, as polypi become flattened against the urethral wall by finger or speculum and are thus overlooked. In such cases the button-hole operation of Emmet is useful and is performed as follows. The patient is put in the lithotomy posture and a sound of calibre sufficient to stretch the urethra, passed. The object of the operation FIG. 349. EMMET'S BUTTON-HOLE OPERATION ON THE URETHRA : the patient is supposed to be on her side and Sims' Speculum passed (Emmet). is to incise the urethra vertically and mesially but not to touch the meatus urinarius or neck of the bladder. The urethra is If inches long, and therefore an incision of the vaginal tissues over the urethra f- of an inch in length will avoid the urethral orifice and neck of bladder. The vaginal tissue is caught up with a tenaculum and divided down to its canal. The scissors are now used to extend this up towards the neck of the bladder and down towards the urethral orifice. The incision in the vaginal mucous membrane should be one-third longer than that into the urethral canal, and the extra length should be at the bladder end. No incontinence of urine is produced if the neck of the bladder be uninjured. Through this incision polypi can be detected and removed, prolapse EXPLORATION OF URETHRA AND BLADDER. 599 of the urethra! mucous membrane can be excised, and medicaments applied. Should the incision be made merely for temporary purposes it can be closed by silver stitches including the mucous membrane of the urethra. When the operator wishes to make a urethro-vaginal fistula for purposes of treatment, he unites the edges of the mucous membrane of the vagina to the corresponding edge of the urethral mucous membrane by means of catgut or silk (Button-hole operation fig. 349). This fistula can be closed when necessary in the ordinary way. For dilatation by Simon's specula, see page 600. METHODS OF EXPLORING THE BLABBER. A. By Catheter and Sound. The catheter is passed for the purpose of drawing off the urine, while the sound is usually employed for diagnostic purposes ascertaining the state of the mucous membrane, the presence of stone or other patho- logical conditions. Method of passing the catheter. The instrument to be employed for this purpose is a male gum-elastic catheter, No. 8 or 10. In some special cases, a silver instrument is required. Battey recommends a long rubber catheter as a very useful instrument. The catheter must first be thoroughly washed with carbolic lotion (1-20), or corrosive sub- limate (1-2000), and then its end dipped in glycerine and corrosive sublimate (1-2000). Cleanliness in the use of catheter is of the very highest importance, as cystitis and even pyaemia may be caused in old people by urine rendered putrid by the catheter. The patient lies on the left side square across the couch, with the hips at the edge and the knees drawn up. The pulp of the index finger of the left hand is passed over the base of the perineal body and onwards until it touches the vestibule. It should then be carried a little backwards until we feel the meatus at the base of the smooth vestibule and in the middle line. The catheter is passed with the right hand ; the index of the left hand feels, through the anterior vaginal wall, that it passes into the urethra. After the last drop of urine has been expelled, the catheter is withdrawn and the finger held over its proximal end so as to retain the fluid remaining in the catheter until it can be poured into a receptacle. The catheter may also be passed with the patient lying on the back ; the index of the right hand is carried under the drawn-up right thigh to feel the meatus, and the catheter is passed between the thighs with the left. Battey's catheter is very convenient, as from its length it reaches the floor and can be withdrawn without any precaution as to spilling. 600 AFFECTIONS OF BLADDER AND RECTUM. Further, it is easily cleaned ; to do this it is coiled up in a bowl of 1-20 carbolic lotion, and then when one end is brought over the edge it empties by syphon action. The indications for the catheter are the various causes of retention of urine (v. p. 614); at present we only remark that it should never be passed unless necessary, and that the greatest care should be taken not to introduce septic matter. Recently Foulis has recommended a special apparatus for washing out the bladder which may be used for drawing off the urine also. B. Digital and Specular Exploration of the Bladder. Owing to the large amount of muscular and elastic tissue in the urethra, it can be stretched to an extent that permits of digital and specular examination of the urethal and vesical lining membrane. Digital examination. With the patient lying in the lithotomy posture d under chloroform, the tip of the little finger is placed against the finger, meatus and by a rotary motion passed through it in the direction of the urethral axis. The meatus is the most resistant portion of the urethra ; therefore, to aid in its dilatation, some recommend to notch it with radiating nicks. This is unnecessary (A. R. Simpson). By steady pres- sure, the little finger is first pushed in and then the index one substi- tuted. Hegar's dilators for the cervix are of great use here also. For exploratory purposes, this is sufficient ; to complete the examination, how- ever, the Bimanual should be performed as shown at fig. 67. This is aided by the middle finger in the vagina, and is therefore termed the vesico- vaginal Bimanual. Instead of chloroform, cocaine may be injected locally. The presence of stone or of tumours, the state of the mucous membrane of the bladder, the nature of obscure bodies in front of the uterus can all be thoroughly ascertained ; vesico-vaginal fistulse can be examined if the vagina has been obliterated ; intestino-vesical fistulae can be detected ; calculi, impacted in the vesical portion of the ureters, can be removed ; fissures of the neck of the bladder can be stretched ; Winckel adds to these that we can open a hsematometra through the bladder, when its evacuation between the bladder and rectum is impossible a very rare indication. The Fallopian tubes can be felt with the finger in the bladder (Noeggerath] ; and, in one special instance, Groom proved by this method that the sound had perforated the walls of the thin superinvoluted uterus and had not passed along the Fallopian tube. with Simon's methods of specular dilatation of urethra. Simon of Heidel- Specula. ber g drew g p ec j a i attention to the dilatation of the urethra by his specula as a means of treatment. The object is to dilate the urethra sufficiently to allow of the passage of calculi, crushed or uucrushed. By it we also destroy temporarily the sphincteric action of the urethra and thus cause incontinence of urine : this allows to the inflamed EXPLORATION OF URETHRA AND BLADDER. 601 mucous membrane, now undisturbed by the frequent muscular contrac- tions which before were necessary to expel the urine, the rest it needs. The difficulty of Simon's method is the risk of causing, by over-stretching, permanent incontinence of urine a condition as yet uncurable. FIG. 349.* SIMON'S URKTHKAL SPECULA (Winckd). Simon's specula are shown at fig. 349* and the various sizes at ng.Sun.ns 350 The specula are provided with bulbous plugs, to be used whi they are being introduced and afterwards withdrawn. Simon oooOOO FIG. 350. .riv vw THE VARIOUS SIZES OF SIMON'S SPECULA (Wincket). the limit of safe disability for the female urethra follows --Adults, 6-6-25 cm. (2 T V^ T V in.) i" cm. (f in.) in diameter; young women (of -3 . 602 AFFECTIONS OF BLADDER AND RECTUM. in circumference, or 1-8-2 cm. (f in.) in diameter; girls (of 11-15 years), 4 -7-5-6 cm. (1|~2^ in.) in circumference or 1-5-1 '8 cm. ( T 9 F in.- y^ in.) in diameter. Practically, we find that the index finger can be passed with safety ; and that any dilatation beyond an inch diameter is dangerous in regard to permanent incontinence. Persistent incontinence has attended the extraction of stones with a diameter of If in., but Dunlap x has recorded a case where a stone 2 in. in diameter was safely extracted uncrushed through the urethra without consequent incontinence of urine. The dilators of Simon are graduated, and are passed slowly until the desired limit is reached. Skene's Specula. FIG. 351. SKENE'S URETHRAL SPECULA (Skene). It is doubtful if they can, without risk, be used as Simon recommends. Specular examination by Skene's specula. Fig. 351 shows Skene's specula. Each may be described as a small test tube which fits into a truncated or fenestrated case of vulcanite. The glass tube projects beyond the outer truncated case ; and a small mirror can be carried through the inner tube so as to reflect light. Skene's directions are to pass the tube (with mirror inside) along the urethra, and to use sun-light or gas-light from a movable bracket. When a large Skene's speculum is used, the urethra should be first 1 Am. J. of Obsl., Vol. XIV., p. 855. EXPLORATION OF URETHRA AND BLADDER. 603 dilated -with the index finger. When viewed through the speculum, the mucous membrane of the bladder is somewhat pale. The hard rubber speculum can be used in making applications. A specially narrow Fergusson's speculum with a hand mirror is also simple and useful (M. Duncan). c. Catheterisation of the ureter. This is by no means an easy operation, but is useful in certain cases. Method of Performance. Pass the index finger into the bladder asCatheteri- already described (p. 600) ; about an inch from the neck of the bladder ureter f and at each end of the inter-ureteric ligament, a prominence (in which FIG. 352. FlKfFR PASSFD THROUGH URETHRA INTO BLADDER TO GUIDE HOLLOW PROBE INTO LEFTlURBTER. ^Internal SphFnctei of Urethra, I Orifice of right Ureter, c Inter-ureteric Ligament ( WwM). is the vesical opening of the ureter) can be felt with the pulp of the examining finger. A fine hollow probe is guided into this and its point carried to the side (fig. 352). The urine will now trickle out drop by drop. According to Pawlik, 1 the inter-ureteric ligament can b through the anterior vaginal wall when the patient is m the gei pectoral posture. He thus passes the ureteric catheter withou the urethra. 1 Centr.f. Gyn., Oct. 15, 1881. 604 AFFECTIONS OF BLADDER AND RECTUM. Electric Endoscope. This handy and convenient instrument has now been used with great success in the diagnosis of vesical conditions. It would take up too much space to describe its construction and use fully : these can be found in the special works on this subject. We may, however, state that the instrument has been brought to its present value chiefly by the labours of Nitze and Leiter, and that the introduction of the small incandescent lamp as the illuminating agent has probably been the greatest improvement. By this means we can ascertain the position of the ureter in operating on vesico-vaginal fistula and prior to excision of the cancerous uterus ; and in proposed excision of a kidney we can ascertain the state of the other kidney by examination of the urine from it. CHAPTER LIU. AFFECTIONS OF THE URETHRA AND BLADDER. For LITERATURE, see CHAPTER LI. MALFORMATIONS OF THE URETHRA AND BLADDER. THESE comparatively rare malformations are easily understood on con- sideration of the development of the organ. The bladder is the part of the allantois included by the abdominal plates of the embryo (figs. 317 to 321); the upper portion of the pos- terior wall of the urethra is formed by Miiller's ducts, while the lower is formed by an invagination from the genito-urinary sinus. The develop- mental defects are therefore the following : (1) Total absence of urethra ; (2) Defect of external portion of urethra hypospadias ; (3) Defect of internal portion of urethra ; (4) Atresia of the urethra (in malformed foetuses) ; (5) Extroversion of the bladder from deficient closure of the embryonic abdominal plates. We would here only note the rarity of these conditions, and refer the practitioner to Skene or Winckel for details. DISEASES OF THE URETHRA. Of these the most important are Displacements, Neoplasms, Urethritis, Dilatation, and Stricture. DISPLACEMENTS. These will be easily understood by reference to those of the bladder. Urethrocele is a pouching of the urethra and vaginal wall allowing the lodgment of stale urine. It is treated by excising a portion of the urethral wall and uniting the edges by stitches. Prolapse of the mucous membrane of the urethra through the urethral orifice may be remedied by the button-hole operation. The incision u made down to the submucous tissue, and the mucous membrane pulle through this until the excess at the urethral orifice disappears. excess at the button-hole is then cut off and the wound stoned. 606 AFFECTIONS OF BLADDER AND RECTUM. Urethral Caruncle. NEOPLASMS OF THE URETHRA ; URETHRAL CARUNCLE. The urethra is liable to be invaded by papillomata, polypi, sarcomata, (cysts), carcinomata, and vascular growths (angiomata). Of these last, the most common is the well-known Urethral Caruncle. Pathology. This is a vascular excrescence varying in size from a piu head to a strawberry ; it consists of dilated capillaries in connective tissue, the whole being covered with squamous epithelium. Physical Signs. A cherry-red tumour, exquisitely tender and vascular, is seen at FIG. 353. CARUNCLE AT URETHRAL ORIFICE (a) AND, IN ADDITION, NEUROMATA IN SURROUNDING Mucous MEMBRANE see page 518 (Sir /. Y. Simpson). the urethral orifice (fig. 353). Symptoms. These are pain on micturi- tion or even retention of urine, and pain on coitus. Treatment. Place the patient under chloroform in the lithotomy posture, and destroy the growth by Paquelin's cautery at a dull heat. If bleeding occurs, do not treat it lightly ; plug the vagina, bringing the half of the last strips of lint over the urethral orifice and fixing with a perineal band. As regards the other neoplasms, papillomata are painless, sarcomata, very rare, their nature being determined microscopically ; while carcino- DISEASES OF THE BLADDER. 607 mata appear as hard peri-urethral tubercles which break down (Skene). In regard to treatment, they may be removed by the curette, or by small loop-snares when high up. Emmet's button-hole operation is probably the best method. Polypi in the urethra may cause great difficulty in micturition and should be suspected in intractable cases, and examina- tion made by incision of urethra. We may also have specific inflam- matory changes in Skene's " tubules " (v. p. 30) simulating urethral caruncle. These may be gonorrhoeal, simple catarrhal, or tubercular. The last is usually found with tubercular disease elsewhere. The tubules may require to be slit up and cauterized. URBTHRITI8. Acute urethritis is usually part of a gonorrhoea. When pus is secreted, the urethra can be felt swollen and tender ; the pus can be squeezed out of the urethral orifice by pressure from above downwards ; on passage of the sound, pain is felt in the urethra although no cystitis be found. Treatment. Give diluent drinks so as to increase the flow of urine. Copaiba may be given in the form of the well-known Nesbitt's specific : R Liquoris Copaibse Co. (Nesbitt) 5ij. Sig. Teaspoonful thrice daily. lodoform bougies may be passed in, and counter-irritation applied in the shape of the tincture of iodine over the anterior vaginal wall. Urethritis is very intractable. Emmet advises his button-hole operation to relieve tension and allow of accurate application of local remedies. DILATATION, AND STRICTURE OF THE URETHRA. The urethra may be unusually dilated, a condition rarely met with ; in some cases the dilatation has been caused by coitus, as in malforma- tions of the vagina (v. p. 260). The dilatation may be local or general. When it is general, the cautery may be used to burn a vertical furrow, the rest of the urethra being guarded by a speculum. Stricture of the urethra is a rare condition and readily yields to dilata- tion by bougies or to incision. DISEASES OF THE BLADDER,. Of the diseases of the bladder we shall here consider Displacements, Neoplasms, Stone in the Bladder, and Cystitis. Vesico-vaginal fistula will be considered in a separate chapter (Chap. LIV.). DISPLACEMENTS OF THE BLADDER; CYSTOCELB. The female bladder when empty lies behind the pubes and usually to one or other side. It is never exactly central. 608 AFFECTIONS OF BLADDER AND RECTUM. The From its loose attachment to the pubis, it is pre-eminently displace- ofthe able. (1) It is drawn up during labour; and (2) is displaced upwards Bladder, by retroversion of the gravid uterus, pelvic ovarian or fibroid tumours, and pelvic haematocele. (3) It may be adherent to the anterior surface of an abdominal ovarian or fibroid tumour, and may thus be cut into on abdominal section. (4) It is displaced downwards in prolapsus uteri and in cystocele. (5) In utero-sacral cellulitis, the bladder is drawn back and fixed ; its systole is thus interfered with, which explains some cases of so-called hysterical retention of urine. From this mobility it follows that the height of its fundus above the symphysis gives no indication of the amount of urine in the bladder. By cystocele we understand a pouching of the posterior wall of the bladder downwards and backwards ; the uterus and summit of the bladder are in normal position. Senile Many a case, regarded as cystocele, is really part of a prolapsus uteri ; Prolapsus on ^ e ther hand, the so-called " senile prolapsus uteri " is really a cystocele ; at the menopause the cicatrisation of the vaginal walls chiefly affects the posterior one, and thus the bladder tends to bulge outwards at the vaginal orifice. The diagnosis is easily made by the Bimanual and use of the sound. The treatment consists in the use of a ring pessary with diaphragm (fig. 334). Should this fail, the vagina may be packed with oakum ; or a raw surface (as shown at fig. 344) may be made and stitches applied. NEOPLASMS OP THE BLADDER. Pathological anatomy. We may have mucous, fibroid or fibro-myo- matous polypi. There may also be sarcomatous or carcinomatous dis- ease of the bladder wall, as well as tubercle. In tubercular disease the ulcerated surface has been removed by Schatz in a supra-pubic opera- tion. The carcinomatous condition is not infrequent, and is termed by some " villous cancer." It is most common at the trigone, and is held by some authorities not to be malignant. The bladder may be secondarily affected in carcinoma uteri (v. p. 438). Symptoms. These are disturbances of micturition, with bloody and phosphatic urine. Physical signs. The passage of the index finger into the bladder will show the position, shape, and other characters of the growth. Treatment. This will vary according to the position, nature, and pediculation or non-pediculation of the growth. Thus it may be twisted off by narrow polypus forceps, snared by a loop of fine catgut; or removed by incision into the posterior wall of the bladder and use of the galvano-cautery or curette. DISEASES OF THE BLADDER. 609 CYSTITIS. Nature. An acute or chronic inflammatory affection of the mucous membrane of the bladder. Pathological anatomy. In the acute catarrhal form, we have conges- tion of the vessels and loss of epithelium ; in the chronic catarrhal form, the congestion is duller and there is marked rugosity of the lining of the bladder. The submucous and even the muscular tissues also become affected. The mucous membrane may be ulcerated and the muscular tissue exposed. The inflammatory process may extend deeper, to the muscular tissue (interstitial cystitis), to the peritoneum (pericystitis), or to the connec- tive tissue near (paracystitis). Occasionally, though rarely, we may have diphtheritic inflammation. In advanced cases, the patient is usually septicsemic and there is often Results of hydro-nephrosis. In some cases of prolonged retention the mucous Cystltl8 ' membrane may slough off and be passed per urethram, but may be regenerated. Etiology. The causes are as follows : Gonorrhoea; latent gonorrhoea; exposure to cold ; injury from coitus ; prolonged parturition ; introduc- tion of septic matter by catheter or bougie ; prolonged retention of urine ; stone. Symptoms. In acute cystitis the patient has very frequent and painful micturition. In chronic cystitis also, there is frequent micturition but accompanied with less intense pain ; there are, further, shooting pains with secondary phenomena septic, vascular, and nervous. Physical signs, (a) Acute cystitis. The urine has a lowered specific gravity and acid reaction ; the colour is little altered, and mucus is present in excess. On vaginal examination, pain is not felt when pres- sure is made on the posterior vaginal wall but is felt severely when the anterior ivall is touched. (b) Chronic cystitis. The urine has a low specific gravity, is usually Characters alkaline, and is often offensive ; it contains pus, epithelium, phosphates ^^ m and bacteria ; albumen, derived from the pus, is present. The vaginal examination gives the same results as in acute cystitis. If the finger be passed through the urethra (v. p. 600), the roughened condition of the lining membrane is felt ; crystals of phosphate and marked rugosities can also be detected. Genito-urinary phthisis is often diagnosed as chronic cystitis. In the former condition we get at first the symptoms of chronic cystitis, viz., purulent urine, pain, and intractability to treatment. Local examina- tion of the bladder may give no definite result, and if the kidney is not palpated its enlargement and purulent condition may not be noticed until the disease is far advanced. 2Q 610 AFFECTIONS OF BLADDER AND RECTUM. Prognosis. In both acute and chronic cystitis, the prognosis is not good ; the treatment is difficult, and in bad chronic cases the patient's strength sometimes becomes exhausted and septiceemia may cause death. Treatment Treatment, (a) Acute cystitis. Put patient on milk diet, and give Cystitis? Friedrichshall or Carlsbad water freely. Diluent drinks may be taken ad libitum. The following prescription is useful. R Potassii Bicarbonatis 3 iss. Tincturse Hyoscyami i, Infusum Buchu vel Pareirse vel Uvse Ursi ad 3 vj. Sig. Tablespoonful thrice daily. In gonorrhoeal cystitis, the following may be substituted : R Liquoris Copaibse Co. (Nesbitt) 5 ij. Sig. Teaspoonful thrice daily. Treatment If the pain is very acute give morphia suppositories (^ grain) at night, of Chronic omitting the mixture with the hyoscyamus if necessary. For (6.) Chronic cystitis, we recommend the following treatment seriatim. 1. Put on milk diet with abundant fluids, and purge freely. Give R Acidi Nitrici diluti 3iij. Tincturse Hyoscyami gi. Infusum Buchu ad vj. Sig. Tablespoonful thrice daily. The hyoscyamus eases the pain ; and the nitric acid corrects the alkaline phosphatic urine, for which also benzoate of ammonia is admirable. R Ammonii Benzoatis 3ni. Aquae vj. Sig. Tablespoonful thrice daily. The benzoate of ammonia is converted into hippuric acid and corrects alkalinity. Lithia water, tincture of Belladonna, and Nesbitt's specific are also useful. 2. If this fail, then wash out bladder as often as possible by means of double catheter, such as Skene's ; use corrosive sublimate (1-5000 or 8000), weak boracic lotion, or carbolic lotion ; inject with the douche or Higginson's syringe, or use Foulis' apparatus. We strongly recom- DISEASES OF THE BLADDER. 611 mend weak corrosive sublimate as a bladder douche. Paint anterior vaginal wall with tincture of iodine. 3. A long (winged) india-rubber catheter may be kept in the bladder so as to drain off the urine constantly and give the bladder rest. The patient need not remain in bed if the Skene-Goodman catheter (fig. 354) is used, 4. In obstinate cases, the formation of an artificial vesico-vaginal fistula may be tried. To do this, chloroform the patient ; place her in the lithotomy posture and apply Sims' speculum. Open into the bladder through the anterior vaginal wall, in the middle line, with Paquelin's cautery at a dull heat. This may also be done with the scissors, as follows : pass the finger into the bladder, and then by means of a pair of straight scissors cut it open in the middle line. Preliminary dilata- tion of the urethra with the finger enables the operator with certainty to avoid cutting into it. The advantage of the cautery is that the wound does not readily unite ; when the opening is made with knife or scissors, care is required to prevent its healing. Emmet stitches the vesical and vaginal edges together. FIG. 354. THE SKEXE-GOODMAN SELF-RETAINING CATHETER ; AN INDIA-RUBBER BAG CAN BE WORN WITH IT () The urine trickles through the artificial fistula; in this way, the bladder gets complete rest and can be thoroughly washed out. After some months the fistula is easily closed, as in the operation for vesico-vaginal fistula. Severe cases of cystitis will tax more than any other disease, the practitioner's patience and knowledge. It is well to keep in mind the reason of this intractability, viz., the inability of the bladder to remain at rest. As can be seen from what has gone before, the principles of treatment are the following : (1) to correct abnormalities in the urine ; (2) to allay the irritability of the bladder ; (3) to lessen the congestion of the bladder by purgatives and counter-irritants, and to render the urine bland and lessen the work of the kidney by milk diet ; (4) to allay the irritable condition of the bladder and counteract putrefaction o gonorrhceal inflammation by injection; (5) to give it comple rest by a permanent catheter or, in extreme cases, by an fistula. 612 AFFECTIONS OF BLADDER AND RECTUM. CALCULI AND OTHER FOREIGN BODIES IN THE BLADDER. The female bladder is liable to receive foreign bodies from three sources. A. Calculi from the kidneys uric acid, oxalates, phosphates or cystine. B. Substances from neighbouring organs pus from pelvic abscess, concretions from the intestines, bones from an extra-uterine foetation, pessaries from the vagina, echinococci and other parasites such as those associated with chyluria. C. Foreign bodies introduced wilfully into the bladder by patients of a depraved taste ; these may form nuclei for stones (fig. 355). Diagnosis of Calculi. FIG. 355. LARGE STONE WHICH FORMED ROUND A HAIR-PIN AS NUCLEUS, EXTRACTED BY VAGINAL LITHOTOMY (Angus Macdonald). Of these, calculi are the most important. Stone is less common in the female than in the male, as small calculi can pass along the dilatable female urethra ; occasionally, therefore, the gynecologist has to remove from the urethra small stones impacted there usually at the meatus urinarius. The introduction of foreign bodies, which act as nuclei, is more common in the female. Symptoms. These are severe pain in micturition, especially at the close ; alterations in character of urine ; blood in urine. Physical signs. The stone, when at all large, can be easily detected DISEASES OF THE BLADDER. 613 bimanually ; when any doubt exists, the use of the sound or the passage of the finger into the bladder renders the diagnosis easy. Treatment. Measure the stone : if it be less than an inch, it may be extracted through the urethra dilated first by the finger or Simon's specula ; if greater than an inch, then dilate the urethra and crush ; if very large or hard or if it have a nucleus, extract by vaginal incision. This incision may be stitched up after the operation, or kept open when the bladder has been much irritated ; it can afterwards be stitched as in vesico-vaginal fistula. Supra-pubic lithotomy is sometimes required. For other foreign bodies, the urethra can be dilated and the substance grasped by polypus forceps or manipulated out. When large, they may be extracted as in the case of large stones. FUNCTIONAL DISEASES OF BLADDER. By these we understand derangements of the bladder in regard to Functional . J . TT i i . j it affections urination. Either these are due to causes as yet unascertained, or tne same derangement (e.g., retention) is associated with many lesions. The chief functional diseases are Irritability, Incontinence, Retention. In regard to all of them, we may remark that in no case should the diagnosis of a functional disease of the bladder be made until the practi- O tioner is satisfied that there is no organic lesion. Irritability. In this, frequent micturition associated with disagreeable feeling is present. It may be due to excessive acidity of the urine, but is often a nervous affection. When it is due to excessive acidity, give lithia or potash. R Lithii Carbonatis g r - v - Fiat pulv. mitte tales vj. Sig. One thrice daily. Incontinence, or inability to retain urine long enough, is most common in little girls ; occasionally we meet with it in adults, as the result prolonged labour, as a permanent condition from infancy, or in oxaluru In the incontinence of girls, note whether there be any irritability of the genitals (vulvitis) or ascarides. Goltz found that, where the spine in the dog above the lumbar enlargement had producec tion of urine, he could make it urinate by sponging the anus with co water ; a reflex impulse passed from the rectum, lessening tl of the inhibitory centre and allowing bladder contraction. ascarides in the rectum will act in the same way when it is asleep. 614 AFFECTIONS OF BLADDER AND RECTUM. Treatment. Treat the irritating cause as vulvitis or ascarides. If no irritating cause be detected, then give belladonna. R Tincturse Belladonnas 3ij- Sig. Three drops thrice daily. In strumous cases, give syrup of the iodide of iron or cod liver oil. R Syrupi Ferri lodidi ^ij. Sig. Thirty drops thrice daily. Retention of Urine. Palpation shows a fluctuating mesial tumour rising into the abdomen ; the position of the fundus of the bladder gives no indication of the amount of urine, as it may be tilted up by retrover- sion of the gravid uterus. Remember that a bladder may be dis- tended so as to be as large as a six or eight months' pregnancy, and that constant dribbling-away of the urine may be a symptom of retention. Examine the pelvis for an organic lesion. Retention may be due to one of three great classes of causes : Hysterical, Reflex, Mechanical. 1. Hysterical. By this we mean that from perversity or a prurient desire to have the catheter passed, a patient feigns inability to pass urine. The treatment is to give a hot hip bath followed by a cold one ; if the catheter is needed, get it passed by a nurse of unsympathetic tendencies. 2. Reflex causes are the following : (1) Gonorrhoea; (2) Urethritis; (3) Irritable caruncle ; (4) Carcinoma, urethral and vaginal ; (5) Perineal and especially vestibular tears after labour, tears of cervix ; (6) Ligature of internal piles. The treatment is hot appliances in (1), (2), (3), and (5) and (6); and the catheter in (4). Remove the source of irritation when possible. 3. Mechanical. These are pressure of fibroids, retroversion of the gravid uterus ; ovarian or parovarian tumours (pelvic and retro - uterine). Where the tumour is impacted in the pelvis, a silver male (No. 10) catheter will pass best. The urethra is compressed, the bladder bulging over the symphysis ; accordingly, a rigid instrument whose handle can be carried to the perineum is good. CHAPTER LIV. VESICO-VAGINAL FISTULA. LITERA TURE. Baker Brown Surg. Diseases of Women, 3d Ed., p. 133; and Lancet, March 1864. Bandl Wiener Med. Woch., 1875, Nos. 49 to 52 ; and 1877, Nos. 30 to 32. Bozc- man Remarks on Vesico- vaginal Fistula, 1856 ; Americ. Journ. of Med. Science, July 1870; Obst. Journ. of Great Britain, June to Aug. 1878. By ford Medical and Surgical Diseases of Women : Philadelphia, 1882. Emmet On Vesico-vaginal Fistula : New York, 1868. Hcgar und Kaltcribach Die Operative Gynakologie, S. 582 : Stuttgart, 1881. Simpson, Sir J. Y. Diseases of Women, p. 30 : Edin. 1872. Sims, Marion On the Treatment of Vesico-vaginal Fistula : Americ. Jour, of Med. Science, Jan. 1852. Silver Sutures in Surgery : New York, 1858. Simon Ueber die Heilung der Blasenscheidenfisteln ; Giessen 1845, Rostock 1862, and Wiener med. Wochenschrift, 1876, Nos. 27-32. Winckel Die Krankheiten der weiblichen Harnrohre u. Blase : Stuttgart, 1877, S. 95. For recent literature, see Index in Appendix. PATHOLOGICAL ANATOMY AND VARIETIES. THE septum between the urinary and genital tracts may be broken through at various points. According to their situation, we have the following varieties of urinary fistulse : Urethro- vaginal, Vesico-vaginal, Vesico-uterine, Uretero-vaginal, Uretero-uterine. The situation of these is sufficiently indicated by their names, and will be easily understood by reference to fig. 356. A urethro-vaginal fistula rarely occurs alone, but is sometimes present along with a vesico-vaginal one. It lies in the middle line and is, naturally, of smaller size. By far the most frequent are the vesico-vaginal fistula}. They occur at any point of the vesico-vaginal septum, which measures height (from the internal orifice of the urethra to the vaginal fornix)* about 5 cm. and in breadth 4 cm. (Kafonbach). Their size varies from a pin-point or slit-like hole to a large oval (fig. 361) or four-cornered (fig. 383) aperture. When recent they are of larger size, but after some months become contracted through the formation of cicatncial 616 AFFECTIONS OF BLADDER AND RECTUM. tissue. The margins of the fistula are at first irregular, swollen, and ulcerated ; but after a time they become thin and firm, through cicatri- FIG. 356. TO REPRESENT THE CHIEF VARIETIES OF URINARY FlSTULA URETHRO-VAGINAL, VESICO-VAGINAL, AND VESICO-UTERINE. Those with the ureters are not seen. The seat of a recto- vaginal fistula is indicated (De Sinety). sation : these changes have an important bearing on treatment. Jobert divided fistulse in the anterior fornix into superficial and deep; in the FIG. 357. FIG. 358. SUPERFICIAL VESICO- VAGINAL FISTULA, the DEEP VESICO-VAGINAL FISTULA, the anterior lip Cervix is intact (Hegar and Kaltenbach). of the Cervix is destroyed (//. and K). former (fig. 357) the anterior lip of the cervix was not implicated, in the latter it was more or less destroyed (fig. 358). In cases of fistulse which VESICO- VA GINAL FISTULA . 617 allow a free flow of urine, the bladder becomes permanently contracted and its walls thickened ; in large fistulse, the mucous membrane pro- trudes through the opening and is easily recognised from its deep red colour. The normal relation of the openings of the ureters to that of the urethra and to the cervix uteri (fig. 359) renders them liable to be involved in an extensive fistula, or even in a small one lying to one side of the middle line. Sometimes we can recognise their openings on the exposed vesical mucous membrane by means of the urine trickling from the orifices ; should the urine be bloodstained, it can be distinguished from blood by its acid reaction to test paper. The urethra, through disuse, becomes contracted ; sometimes complete atresia is present and seriously complicates treatment, and a portion of the canal may even be completely destroyed by pressure (v. fig. 388). The vagina is often con- tracted by cicatricial tissue originating from injuries received during labour. The margins of the fistula are often drawn apart, and some- 3.CM FIG. 359. THE NORMAL RELATION or THE CERVIX, THE UKETERS , AND THE URETHRA (Iff. and IK.) From cervix to orifice of ureter measures 3 cm., from orifice of ureter to that of urethra 4 cm., from orifice of one ureter to that of the other measures 2 -5 to 3 'g-.**** through the bladder wall in an oblique direction downwards and inwards, for from times fixed down to the bone, by these cicatrices; this interferes with their closure. Contraction of the vagina below the fistula sometimes makes it impossible to ascertain the condition of the upper pai whether the uterus communicates with the fistulous tract, tions of the peritoneum to fistula are shown in fig. 360, from which it is evident that only in the repair of very extensive fistula would . tions require to be considered. The difficult labour which leads production of the fistula is liable to be followed by puerperal per tonitis or cellulitis; these may disturb the normal rel peritoneum. v a Vesico-uterine fistula) are rare. From their position they can b 618 AFFECTIONS OF BLADDER AND RECTUM. Mode of production of Fistula in Labour. recognised only after dilatation of the cervical canal (v. fig. 387), and it is evident that they must be very small. Uretero-vaginal fistulse are situated in the fornix vaginae. They are of small size, admitting only the point of the sound, and have either sharp edges or open at the point of a small papilla. Josephson 1 cites twenty-three cases, and finds that it has arisen from injury in labour (when the ureter has been fixed to the uterus), from association with a vesico-vaginal one, from operations on cervij and excision of uterus, and has also been congenital (four cases). Of uretero-uterine fistula, twelve cases were collected by him. ETIOLOGY. Malignant disease is the most common cause of fistula (v. p. 466) but we place this form aside, as it is beyond treatment and merely indicates a stage in the progress of the malignant growth. The most important cases of fistulse which we have to consider here FIG. 3GO. RELATIONS OF PERITONEUM, indicated by dotted line, to a fistula which has destroyed the whole of the anterior wall of the cervix and the infra-vaginal part of the posterior wall (H. and K.) arise through injury received during labour. This injury may act directly, producing laceration of the septum; more frequently it act indirectly, producing necrosis secondary to pressure or inflammatior The causes which predispose to fistula are a narrow pelvis and pendu- lous abdomen, a firm or large head (hydrocephalus), and face present tions (Wincket). The immediate cause is the compression of the sof parts between the child's head and the bony wall of the pelvis ; if this pressure continues for a long enough time, it destroys the vitality of the soft parts which afterwards separate as a slough. Fistulse produced by instruments are situated in the lower part of the vagina, and are accompanied with extensive cicatrices and adhesions ; those due to pressure of the foetal head are placed in the upper part ( Winckel). In craniotomy, the soft parts have been sometimes lacerated 1 Lancet, 1887, p. 496. VESICO-VAGINAL FISTULA. 619 by the instruments, or by splinters of foetal bone. Forceps are often cited as a cause of the injury. It is not however the use of the forceps after a prolonged labour which is to blame, but the not using of them at an early period before the parts have been destroyed by pressure. Fistulee have followed diphtheritic inflammation in the puerperium, but this is rare. Inflammation and ulceration round badly fitting pessaries have also produced them. SYMPTOMS. The leading symptom is the involuntary flow of urine from the vaginal orifice. 1'his will not appear until the slough separates, that is till about the third or fourth day ; its separation may be delayed for three or four weeks, when the necrosis is secondary to puerperal vaginitis (Byford). When a direct laceration has been produced, the urine will flow at once per vaginam; but even here it may escape notice' till the second or third day, as it is masked by the lochial discharge. The power of retaining varies, in certain cases, with the position of the patient ; with a fistula situated high up, the erect posture allows the lower portion of the bladder to be used though the flow is continuous in the recumbent posture. With a urethro-vaginal fistula, there may be perfect continence from a sphincter-like action of the muscular fibre in the wall of the urethra ; the patient observes, however, that the urine does not pass by the urethral orifice. Secondary symptoms are due to a constant wetting of all the sur- rounding parts with the urine. The urinous odour is quite character- istic in urinary fistula ; there is excoriation round the vulva, the inside of the thigh is red and irritated. Menstruation is generally in abey- ance, returning after the fistula has been cured. There is usually sterility; although cases of conception, often followed by abortion or premature labour, have been recorded. The disagreeable surroundings interfere with the appetite and digestion ; there is constipation, which Freund has ascribed to increased secretion by the kidneys but which is more probably due to reflex contraction of the muscular fibre of the rectum ( Winckel). The general health thus becomes seriously impaired so that the patient is willing to submit to any operation which promises relief. DIAGNOSIS. The irritated appearance of the external genitals with the character- istic odour at once indicates that there is fistula, but the diagnosis of its position is often very difficult. Urethro-vaginal and vesico-vaginal. When large, these may be f by the examining finger on our passing the sound into the bladder finger touches it through the fistula. The speculum shows position and extent, and reveals smaller ones which escape detects 620 AFFECTIONS OF BLADDER AND RECTUM. with the finger ; by stretching the folds of the mucous membrane with ] tenacula, we may detect a fistula concealed by them. To recognise small vesico-vaginal fistula) and to differentiate them from the vesico-uterine and ureteric, proceed as follows : pass Sims' speculum, carefully wipe away all mucus from the anterior vaginal wall, clear out the cervical canal with a dressed sound and plug it with a pledget of dry cotton wadding ; now pass a catheter, and through it '._ distend the bladder slowly with a coloured fluid such as milk or per- manganate of potash ; as the bladder distends, watch carefully the anterior vaginal wall for any oozing of the fluid. If there is no oozing, the fistula is not vesico-vaginal. If on withdrawing the plug from the cervix it be found stained with fluid, the fistula is vesico-uterine. If neither of these forms be present, the urine must come from a ureteric fistula ; the rarity of this form should lead us to suspect that the fluid may have been temporarily kept from escaping from the bladder by a valvular action of the mucous membrane, and the examination should be repeated after a time. In a case of uretero-uterine fistula, Berard collected the urine which escaped per vaginam in one vessel and that in the bladder was drawn off per urethram by a catheter into another ; the quantities in a given time were found to be equal. His conclusion was that he had obtained the secretions from each kidney separately, so that the fistula was xireteric. PROGNOSIS. A natural cure will depend on the recentness of the fistula and its size. Small fistulee, if kept clean, heal of themselves during the puer- perium. Large ones require operative treatment; cure by this means depends partly on the size of the fistula, but more on the condition of its margins whether they contain much cicatricial tissue, and whether they are bound down. TREATMENT. There are two essentials for successful operative treatment: (1) com- plete exposure of the fistula, so that (2) the edges may be thoroughly pared and carefully adapted with sutures. The great difficulty lies in the inaccessibility of the field of operation, to which the failure of the older operative measures is chiefly to be attributed. Marion Sims (1849) first rendered successful treatment really possible by the complete exposure of the fistula with his speculum, and by the careful adaptation of its margins with silver-wire sutures. Since the introduction of catgut, we believe that it will displace silver wire in this operation as it does not need to be removed subsequently. To Simon of Heidelberg is due the credit of having elaborated the operation, and of having extended its sphere so that almost no form of fistula has in his hands proved incapable of treatment. We may shortly contrast VESICO-VAGINAL FISTULA. 621 the methods of these two leading operators as follows : Sims pares the edges of the fistula in a sloping manner (fig. 363) carefully avoiding the mucous membrane of the bladder, then adapts the margins of the fistula with silver wire, and drains the urine continuously per urethram through a catheter; Simon pares away the edges vertically not specially avoiding the mucous membrane of the bladder, unites the edges with FIG. 361. METHOD OF PARING THE EDGES OF A FISTULA (Simon). silk sutures, and encourages the patient to pass water unaided from the first drawing it off with the catheter only when necessary. Bozeman, a pupil of Sims, has drawn attention to the advantages of the genu- pectoral posture in operating and to the importance of preparatory 622 AFFECTIONS OF BLADDER AND RECTUM. treatment by dividing and stretching cicatricial contractions ; he fixes the sutures Avith lateral plates and buttons. FIG. 362. SUTURES PASSED IN A CASE OF URINARY FISTULA (Simon). FIG. 363. THE AMERICAN AND GERMAN METHODS OF PARING THE EDGES OF FISTULA CONTRASTED ; Sims' is shown on the right, Simon's on the left. The mucous membrane of the bladder is above, that of the vagina is below. The edges may be pared first according to Sims' method, and if a raw surface is not thus obtained the tissue can be removed up to the fine line (Kcdtenltach). When a fistula has been discovered during the puerperium, our first VESICO-VAGINAL FISTULA. 623 aim is to aid the natural effort at cure. A catheter (fig. 389) is placed in the urethra to carry off the urine by the natural passage ; the vagina is syringed out frequently with warm water ; the edges of the fistula may be kept together, in some cases, by tampons suitably placed in the vagina. If the fistula does not close by the natural process, we have recourse to operation. Operation for Vesico-vaginal Fistula. There is difference of opinion as to the time for operating. According to Hegar and Kaltenbach, the best time is six to eight weeks after the confinement ; " the lochial discharge has ceased, the necrosis of the tissues is defined, the margins of the fistula are vascular and juicy and are at the same time of sufficient firmness to hold the sutures;" the cicatricial tissue which forms round the margins makes the operation more difficult afterwards. Marion Sims delays the operation for a few months. Under the operation, we shall describe 1. Preparatory treatment ; 2. The operation, which consists of (a) the paring of the edges of the fistula and (6) their adaptation with sutures ; 3. After-treatment. 1. Preparatory treatment is only necessary when there are cicatricial bands drawing the margins of the fistula apart or contracting the field of operation. These must be divided and made to heal over a glass plug, or the vagina must be kept distended with air-bags. Frequent vaginal injections are necessary in all cases, to bring the edges into as good condition as is possible. 2. For the operation itself the following instruments are required Sims' speculum, Spatulse, Three or four tenacula, Blunt-hook, Vaginal douche for permanent irrigation, Hot water to check haemorrhage, ' Dissecting and artery forceps, Small bistouries straight or set at an angle on long handles, Bozeman's scissors, Several small sponges and sponge-holders, Short curved needles and needle-holder, Curved needles on fixed handles, Silver wire and wire twister, or Catgut. Good light is essential and as complete exposure of the field of opera- 624 AFFECTIONS OF BLADDER AND RECTUM. tion as is possible ; this last will determine the position of the patient, according as Sims' or the lithotomy posture allows us to get more readily at the fistula. The drawing down of the cervix with volsellse or sutures (fig. 361), or the protrusion of the edges of the fistula by a catheter ii the bladder, is of use in some cases ; where the mucous membrane of the bladder (by prolapsing through the fistula) comes in the way, it can b kept back by the sound in the bladder or a sponge probang pushe through the fistula (Sir J. Y. Simpson). FIG. 364. FIG. 365. FIG. 366. KNIVES FOR PARING A FISTULA. Fig. 364, straight knife ; fig. 365, bent knife wh laterally at fig 366 (Sir J. Y. Simpson). ich i Chloroform is always an advantage, as it gives the operator more freedom in exposing the parts and prevents the patient from moving ; the actual pain of the operation does not demand it. Three assistants are needed one to give chloroform, a second to hold the speculum, a third for the sponges ; six are better, as two are required with the patient in the lithotomy posture and there is one to FIG. 367. SPONGE-HOLDER. take charge of the instruments. The knives employed are shown at figs. 364-66. The sponges should be very small and fitted on holders of which a convenient form is shown at fig. 367. Fixed needles are required when the tissue is dense. Sir J. Y. Simpson used a tubular needle such as that seen at fig. 368, which is sometimes of service. (a.) The paring of the edges of the fistula. To produce union, it is essential to have a continuous raw surface all round the margin. To procure this, we hook up with a tenaculum the portion of vaginal mucous membrane to be removed and transfix it with the knife (v. fig. 361 and VESICO- VA G1NAL FISTULA . 625 FIG. 369. PASSAGE or THE THREAD WITH THE TUBULAR NEEDLE (Sir J. Y. Simpson), FIG. 368. STAKTIN'S TUBULAR NEEDLE'FOR VESICO-VAGIKAL FISTULA (Sir J. Y. Simpson). 2R 626 AFFECTIONS OF BLADDER AXD RECTUM. fig. 370). The knife should not pass through the mucous membrane of the bladder, unless there be so much cicatricial tissue that a large piece requires to be cut out ; the reason for avoiding the vesical mucous mem- brane is to prevent after-heemorrhage into the bladder. In small fistulse, we can remove the tissue in a ring and thus ensure a continuous raw FIG. 370. TRANSFIXING WITH A KNIFE BOTH EDGES OF THE FISTULA AT ONCE (Sir J. Y. Simpson). FIG. 371. FISTULA SHOWN AT FIGS. 369 AND 370 CLOSED WITH SUTUKES (Sir J. Y. Simpson). surface ; in larger fistulse, we may take flaps from the adjoining vaginal wall. 1 Another method of making a raw surface is to split up the edges so that the vesical mucous membrane is separated from that of the vagina ; FIG. 372. BOZEMAN'S FORK, used in drawing through the wires to prevent their cutting the Vaginal Mucous Membrane (Sir /. Y. Simpson). the advantage of this method is that no tissue is lost, but the stitching is less accurate. Haemorrhage is best checked by hot douche ; large bleeding points may require twisting or even ligature. 1 As W. Duncan has done successfully Brit. Med. Journ. 1SS7, II., p. 936. VESICO- VA GINAL FISTULA . 627 (6.) The adaptation of the edges with sutures must be carefully done. Passage of If of catgut the sutures may be passed on an ordinary curved needle ; u if of wire, then a fixed needle (which is made to transfix both margins of the fistula and then threaded), or a hollow needle (fig. 368) may be necessary. To prevent the sutures from cutting the vaginal mucous membrane as they are drawn through, the fork or pulley (figs. 372, 373) FIG. 373. METHOD OF USING FORK (Emmet). can be used. The sutures must be pretty close together and should either not pierce the vesical mucous membrane or should take in only its margin. When the tissues are dense, counter pressure against the Counter- point of the needle may be made with a blunt hook as in fig. 374. Sims passes a silk thread first and then uses it to draw through the tissue, wire suture. After all the sutures are passed, they are tied (fig. 376) or twisted FIG. 374. MODE OF APPLYING COUNTER-PRESSURE TO THE POINT or THE NEEDLE BY MEANS or A BLTOT HOOK (Emmet). (figs. 375, 379) ; to bring the wires together we can use Bozeman's suture-adjuster (fig. 377) ; the wire twister (devised by Coghill) is very convenient for twisting the wires close, especially when the fistula 628 AFFECTIONS OF BLADDER AND RECTUM. Bozeman's is deeply placed and not very accessible (fig. 378). Bozeman uses a method. FIG. 375. SIMS' METHOD or FIXING AND TWISTING THE SUTURES (after Sims).. FIG. 376. MODE OF TYING SILVER-WIRE SUTURES (Sir J. Y. Simpson). plate to fix the sutures. The use of catgut does away with all these- VESICO-VAGINAL FISTULA. 629 appliances. The fistula seen at fig. 369 is shown, after the sutures FIG. 377. BOZSMAS'S SUTURE-ADJUSTEK (Sir J. Y. Simpson). FIG. 378. FIG. 379. COGHILL'S WIRE TWISTER, fig. 378 ; its point threaded with a wire is shown at fig. 379 (Sir /. Y. Simpgon). FIG. 381. WIRES DRAWN THROUGH BozEMAu's PLATE, fig. 380 ; fixed with shot as in fig. 3S1 (Sir /. Y. Simpson). FIG. 382. SPECULUM PASSED FOR REMOVAL or SUTURES ; the patient is on her side (Sir /. Y. Simpson). have been twisted up, at fig. 371. With a triangular fistula the closed 630 AFFECTIONS OF BLADDER AND RECTUM. wound will be Y-shaped, while a quadrilateral fistula will give an I-shaped wound (figs. 383, 384). FIG. 383. FIG. 384. FOUR-CORNERED FISTULA, tig. 383, closed by Sutures in fig. 384 (Hegar and Kaltenbach). FIG. 385. SUTURES PASSED THROUGH ANTERIOR LIP or CERVIX so AS TO CLOSE IN TRANSVERSELY A FISTULA OF THE ANTERIOR FORNIX (If. and K.). In the case of fistulse situated close to the cervix, we make use of the cervix. anterior lip to close the fistula ; the result is a crescentic wound (fig. VESICO-VAGINAL FISTULA. 631 385). Sometimes we have to excise a portion of the cervix to get a FIG. CSG. ANTERIOR LIP DIVIDED TO CLOSE IN VERTICALLY A FISTULA CLOSE TO IT : a 6 c shows extent of surface, round the oval fistulous opening, to be made raw ; the mucous membrane may have to be incised outside the sutures, along the line A B, to relieve tension (Emmet). FIG. 387. VESICO-UTERINE FISTULA. The lips of the cervix are pared, preparatory to stitching up the cervical canal (H. and K.). sufficient raw surface (fig. 386). When much of the anterior lip is 632 AFFECTIONS OF BLADDER AND RECTUM. destroyed, it may be necessary to use the posterior lip to close the fistula (see fig. 358, and compare it with fig. 357) ; in this case the uterus will communicate with the bladder and the menstrual blood be discharged per urethram. With vesico-uterine fistulee, two courses are open. If possible, we expose the fistula by splitting the cervix bilaterally 1 and treat it as vesico-vaginal fistula : when this cannot be done, we pare the edges of the os and stitch up the cervical canal ; we thus make the uterus open into the bladder (fig. 387). FIG. 388. VESICAL FisTULA+Atresia of a portion of the urethra ur just below the symphysis . The latter is first bridged over at 1 and then the vesical fistula closed in at 2 ( Winded). After- Treatment. When there is a urethral as well as a vesical fistula, the former must be closed first : when there is atresia of the urethra, the free margins of the urethral wall above and below are pared and united by sutures so as to bridge over the atresic portion (fig. 388) ; the vesical fistula is obliterated by a second operation. 3. After-treatment. A stationary catheter is placed in the bladder. The form in fig. 389 is the one generally used, the urine being made to drip into a long narrow vessel (as a soap-dish) passed between the FIG. 389. FIG. 390. SIMS' STATIONARY CATHETER : fig. 389, first model ; fig. 390, newest model. That in fig. 389 is made of block tin so that it can be bent to any curve ; when in situ, it must be bent so that the external end has its groove uppermost : that in fig. 390 is of rubber and has tubing attached to it. patient's thighs ; two catheters are required, so that they may be changed every day as the salts of the urine readily occlude the tube ; the one not in use should be kept thoroughly clean. > Sanger (Centralb. f. Gyn., XII., 8. 377) makes one of the splits extend into and above the fistula, so that the closure of the split closes the fistula also ; the sutures are all tied outside the cervix as in Emmet's operation. Champneys (Brit. Med. Journ., 1888, II., 818) has dissected the bladder off the cervix so as to cut across the fistulous tract, and closed the cut ends separately. VESICO- VA GINAL FISTULA. 633 The after-dangers of the operation are haemorrhage into the bladder After- and vesical catarrh. The former is a troublesome complication, as the Operation, blood-clots collect in the bladder ; when there is marked haemorrhage distending the bladder, the fistula must be opened up again. Sometimes the ureter has been caught in a stitch and compressed ; intense pain, FIG. 391. METHOD or REMOVAL OF SUTURES (after Sinis). shooting from the kidney downwards along the course of the ureter, with vomiting and other symptoms of uraemia followed but passed off on relaxing the sutures. The sutures are removed on the tenth day. The method of remov- Removal of ing sutures is shown at figs. 382 and 391. Sutures. 634 AFFECTIONS OF BLADDER AND RECTUM. For cases of fistulae incurable by operation, a rubber urinal fitted into an ordinary ring pessary has been used. 1 Obliteration of Fistulce by Cauterisation. Cauterisa- This treatment is only applicable to very small fistulse. Fistula mav be done with nitrate of silver or the red-hot wire. Cauterisation Where the FIG. 392. SIMON'S OPERATION FOR KOLPOKLEISIS. The patient is in the lithotomy posture ; the sound has been passed through the urethra and fistula, and is sesn in the upper portion of the vagina ; the perineum is drawn back with the speculum and the labia majora with spatulse. A band-like piece of tissue has been removed from both the vaginal walls above the ostitim ; the raw surface is left unshaded in the figure. The vaginal mucous membrane is held tense by four pairs of forceps outside the raw surface, the shaded area within the latter is the upper third of the vagina. An end of the last suture has been passed through one raw surface, the second end is being carried through the other raw surface (H. and K.). fistula is of any size, cauterisation not only fails to close it but converts its margins into cicatricial tissue; this makes its subsequent closure 1 By J&yAmer. Journ. Obstet., 1887, p. 50. VESICO- VA GIN A L FISTULA . 635 with sutures more difficult. This method of treatment, even in the case of larger fistulse, has been recently revived and advocated by Bouque, * whose writings may be consulted. For ureteric fistulse, nephrectomy has been performed successfully by Gusserow and Josephson. Closure of the Vagina : KolpoTcleisis. Where direct closure of the fistula is impossible, the only means for relieving the patient's discomfort is closure of the vagina below the fistulous opening. The portion of the vagina above this becomes, as it were, an extension of the bladder ; the menstrual blood is discharged with the urine. Vidal de Cassis, who originated this operation, performed it as follows. The inner surfaces of the labia majora were pared and brought together by sutures : the vulva was thus closed in an antero-posterior direction. After this operation, there always remained just below the urethral FIG. 393. SAME OPERATION AS SEEN IN SECTION TO SHOW RELATION OF RAW SURFACES (shaded dark), position of sutures and common receptacle above for urine and menstrual blood. The bladder and urethra are in upper part of figure (H. and K.). orifice a small cleft through which the urine trickled. Unless complete continence is obtained, such an operation is useless. Kolpokleisis is the name given to the operation introduced by Simon. Simon's It consists in obliteration of the vagina transversely by making a surface on its walls above the level of the ostium vaginae. It is evident that this operation is justifiable only where closure of a fistula is impos- sible, either through the binding down of its margins to the bone with cicatricial tissue or through the complete destruction of the urethra. As the closure of the vagina interferes with married life, the nature of the operation should be explained to the patient beforehand and full permission obtained. The operation is performed as follows. By pinching up the mucous 1 " Du Traitement des Fistules uro-gen. ; par la reunion secondaire : " Paris, 1875. 636 AFFECTIONS OF BLADDER AND RECTUM. membrane, ascertain where it is most lax, so that the vaginal walls can be easily approximated ; the point of closure should be as high up as possible. Mark out with the knife the ring of tissue to be excised. Lay hold of its lower margin and dissect it from below upwards ; with the finger in the rectum and the sound in the urethra, we can judge of the thickness of tissue to be removed (compare fig. 392 with fig. 393). On each ligature of wire or carbolised silk, two small curved needles are threaded so that both ends of the thread may be passed from above downwards. The needle must be entered into the vaginal mucous membrane above, carried through the substance of the vaginal wall (without appearing in the wound), and brought out through the vaginal mucous membrane below ; it is difficult to prevent these sutures from catching up either bladder or rectum but this should, if possible, be avoided. Care is required in the introduction of the first mesial suture as it is the guide for the others. The results of this method are satisfactory as regards the production of complete continence. There is no liability to stagnation of urine or formation of concretions (Hegar and KaltenbacJi). Hsematometra will not occur unless there has been atresia of the cervix uteri. If men- struation has been in abeyance, it will probably return after the opera- tion; in a case operated on by A. R. Simpson, the patient had not menstruated for a year, but a few weeks after the operation the men- strual blood appeared in the urine. CHAPTER LV. THE RECTUM: COOOYGODYNIA. LITERATURE. A llingham Diseases of the Rectum : Churchill, 1871. Chadwick On the Functions of the Anal Sphincters : Am. Gyn. Trans. , 1877. Cripps Cancer of the Rectum : Churchill, 1880. Hart Physics of the Rectum and Bladder : Edin. Obst. Trans., 1882. Ruedingei Topographisch-chirurgische Anatomie des Menschen, vierte Abtheilung : Stuttgart, 1873. Storei The Rectum in its relation to Uterine Disease : Am. Jour, of Obst., Vol. I., p. 66. Syme Diseases of the Rectum : Edin. 1859. Van Buren Diseases of the Rectum : H. K. Lewis, 1881. For recent literature see Index in Appendix. NOT only is the gynecologist frequently consulted about rectal mischief, but as a matter of fact female patients sometimes refer rectal disease to the uterus or vagina ; therefore, in investigating gynecological cases, one has occasionally to satisfy one's self that the rectum is not the seat of the affection. Vaginismus may be caused by fissure of the anus, as we have already seen, and pruritus vulvse by ascarides from the rectum passing into the vagina. PHYSIOLOGY OF THE EECTUM. The anatomy of the rectum has been already considered (p. 36). The Relation relations of the axes of rectum, anus, vagina and urethra, to one another and to intra-abdominal pressure are of importance. As we have already an( l Ureth- seen, the vagina and urethra are parallel to one another and to the plane of the brim. Strictly speaking the surface whose outer boundary is the brim of the bony pelvis is not a plane surface, inasmuch as the various points in the outline of the brim are not on the same level. The vagina is thus, properly speaking, parallel to the internal conjugate of the brim. The rectum runs, in part of its course, close behind the vagina for 1^ inches and parallel to it ; the anal canal turns directly backwards so as to cut the vaginal axis at right angles. Intra-abdominal pressure acts at right angles to the vaginal walls, as can be noted from the fact that in defaecation the Hodge pessary is not driven out of the vagina. Con- sideration of fig 394 will show that the direction of intra-abdominal pressure on the pelvic floor coincides with the long axis of the anus, so that intra-abdominal pressure will act with its full driving force on any body in the anal canal. 638 AFFECTIONS OF BLADDER AND RECTUM. Mechanism The mechanism of defalcation is probably the following. According tion. ' to Hilton, in his now classical book on "Rest and Pain," the lower part of the rectum is sensitive but the upper two-thirds are but slightly so; the rest of the large intestine and the small intestine are non-sensitive. Hilton limits the sensitive portion to the lowest two inches of the rectum to the part below the so-called sphincter tertius. When there is accumulation of fsecal matter in this portion, pain and uneasiness pro- FIG. 394. TO SHOW DIRECTION OF BECTUM AND OF ANUS IN RELATION TO INTRA-ABDOM1NAL PRESSURE. a uterus, b bladder, d vaginal orifice, /perineum. duce the desire to expel these contents, reflex movements : There result the following (1) Relaxation of the sphincter ani; (2) Peristaltic contraction of the circular unstriped muscle ; (3) Shortening of the longitudinal muscle with eversion of the mucous membrane. Since the longitudinal fibres have a fixed point below, their contraction will probably pull the rectum more into the line of the anal axis ; (4) Contraction of the segments of the sphincter tertius. In this way the lowest portion of the rectum becomes roofed in above by the sphincter tertius and open below. Intra-abdominal pressure drives this portion downwards ; and the rectal contents, elongated by THE RECTUM. 639 peristalsis and depressed by intra-abdomiual pressure and eversion of the mucous membrane, are finally brought into the relaxed anal canal from which intra- abdominal pressure readily expels them. Ruedinger's diagram (fig. 35) shows well how the Levator ani will reinvert the everted mucous membrane. Inattention to the proper evacuation of the bowels leads to non-sensi- tiveness of the mucous membrane and is thus one factor in constipation. EXAMINATION OP THE RECTUM. This may be done in three ways : (a) By finger (v. p. 101), (b) By speculum, (c) By eversion of the anterior rectal wall through digital pressure in the vagina (Storer). By Speculum. The anal speculum has usually an oval fenestra ; it is Specular passed into the anus in the direction of its long axis, and rotated so that ti Q U O f each portion of the anal lining comes opposite the aperture (fig. 396). Rectum. Storer 's method is as follows. Place the patient on her side ; pass two Storer's fingers (or one) half way into the vagina, with the pulps of the fingers * on the posterior vaginal wall. Then press these downwards and back- wards, and thus evert the rectal mucous membrane through the dilatable sphincter ani which is at the same time pressed open with the fingers of the other hand. This method is most easily employed in multipart. DISEASES OF THE RECTUM. Women are especially liable to rectal disease from the distension of parts accompanying parturition, as well as from their habitual neglect of the regular evacuation of the bowels. As rectal diseases often simu- late those of the vagina, a sketch of the more important of them is necessary in a Manual of Gynecology. We shall therefore consider the following affections : Displacements of the rectum, Fissure of the anus, Piles, Recto- vaginal fistula ; Functional disturbance of Rectum Constipation. Displacements of the Rectum. These are Rectocele ; Prolapsus Recti (a) of mucous membrane, (b) of whole thickness of bowel. For Prolapsus Recti, which is properly surgical, see Van Buren or Prolapsus Allingham. Eecti - 640 AFFECTIONS OF BLADDER AND RECTUM. Rectocele. Rectocele is a protrusion of the lower part of the anterior wall of the rectum covered by the posterior vaginal wall, into the lumen of the vagina or even through the vaginal orifice. Etiology. There are two factors tear of perineal body and pressure of scybala in rectum. Diag- nosis. The posterior vaginal wall is seen protruding into the vagina or out at the vaginal orifice. The diagnosis is made by noting the relations of the protruded vaginal wall and by passing the finger through the anus into the pouch (fig. 395). Treatment. The patient should wear in the vagina a Hodge or Albert Smith pessary with cross bars ; explain the necessity of a regular daily evacuation of the bowels. Fissure of the Anus. Fissure of This is a crack, or ulceration, of the anal skin or of the mucous membrane covering the internal sphincter. In the edges of the crack FIG. 395. RECTOCELE (Sckroeder). there is usually a nerve filament, and below the crack lies the powerful sphincter ani. This apparently insignificant lesion gives rise in most cases to an unbearable and even incredible amount of pain, lasting for hours after the bowels have moved. Hilton's explanation of this is so good that we give it entire. Hilton's " The reason for this anal ulcer being so very painful is the number tion'oT" f nerves associated with it ; and the cause of the continued painful pain in contraction which accompanies it lies in the enduring strength of the sphincter muscle. Thus it happens that exposure of those nervous sensory filaments upon the ulcer causes excito-motory or involuntary and spasmodic contraction of the sphincter, through the medium of the spinal THE RECTUM. 641 marrow. The sphincter muscle contracts towards its own centre, and, as long as the muscle is in a state of contraction, it brings the sensitive edges of the ulcer into forced contact ; this excites more muscular con- traction, and thus, by time and exercise, the muscle becomes hyper- trophied, massive, and increased in dimensions." Symptoms. The patient complains not so much of pain while the Symptoms, bowels are being moved as of an unbearable pain coming on after the evacuation and continuing for some hours. The pain is described as FIG. 396. ANUS a WITH ANAL SPECULUM in situ; it is turned so as to expose in the fenestra a fissure & beneath which a tenotomy knife has been passed (Hilton). unendurable, causing the patient to dread and postpone natural motions. There are often iliac pains and vaginismus ; this last symptom is not infrequent. Physical signs. By speculum or eversion, the crack is seen. Treatment. Chloroform the patient, pass a tenotomy knife beneath Treatment, the base of the ulcer (fig. 396) and cut upwards. This divides the muscular fibre so that the irritated edges can no longer be brought to- gether. The fissure gets rest and heals readily ; a cure is thus effected. 2s 642 AFFECTIONS OF BLADDER AND RECTUM. Another and very good plan is to chloroform the patient, and intro- ducing the thumbs (with the dorsal surfaces in contact) to stretch the anus by forcibly separating them ; this ruptures the muscular fibre and acts just as the knife does, and is especially good when the fissures are multiple. The bowels are not to be moved for a day or two ; the patient has then some pain when the motion is passing, but none after it. Piles. Hilton has pointed out that at the anus the line of demarcation between skin and mucous membrane is marked out distinctly by " the white line," as he terms it. This line is of great practical importance, as we shall see. Piles are small tumours at the anus, on either side of this white line. They consist of dilated veins embedded in connective tissue and covered by skin or mucous membrane. We speak of external piles, i.e., those outside of the white line and covered by skin, and internal piles, i.e., those inside of the white line and covered by mucous membrane. Occasionally we have, as a special form of external pile, a dilated vein outside of the white line and usually containing a clot (venous pile). Symptoms. Symptoms. Venous piles cause great pain ; while external piles, unless inflamed, occasion little inconvenience ; from internal piles, there is bleeding when the bowels are moved. Signs. Physical signs. The venous pile is a purplish tumour outside of the white line ; external piles are like tags of skin, or are more or less dis- tended ; internal piles are cherry-red and easily bleed. Treatment. Treatment. 1. When venous piles contain a clot, incise and turn out clot. 2. For internal piles, employ the following palliative treatment. Give sulphur confection when necessary. R Confectionis Sulphuris gij. Sig. Dessertspoonful at night. Order gall and opium ointment to be applied. R Unguenti Gallse c" Opio gij. Sig. As directed. For any abrasions, order iodoform ointment (p. 532) or Bismuth and Cocaine suppositories. The radical operative treatment belongs more to the surgeon. Recto-vaginal Fistula. The situation of such a fistula is shown in fig. 356. It may be due to carcinomatous or syphilitic ulceration, or to injury received during parturition. The last only can be operated on. It is usually due to a THE RECTUM. 643 tear, during labour, involving the anus and where the lower part of the laceration has united. The best treatment is to cut through the united portion and operate on it as if it were rupture of the perineum involving the anus. Functional disturbance of Rectum Constipation. Women are iisually exceedingly careless in the matter of regulation of the bowels ; very often, evacuation is practised once a week or even at longer intervals. This is in many respects not their fault but is due to insufficient water-closet accommodation, to modesty, and to the fact that evacuation is for evident reasons postponed during menstruation. When consulted for constipation, the medical man should insist on the value of a daily evacuation at a fixed hour ; this educates the bowels to demand it regularly. All quack pills should be tabooed as dangerous. The diet should be regulated ; bran-bread, porridge and milk, stewed fruit, figs, etc., taken as part of food. The following pill is good. R Extracti Nucis Vomicse Extracti Belladonnse aa gr. \ Pilulse Colocynthidis et Hyoscyami iij. Fiat pilula : mitte tales vj. Sig. One occasionally. The mix vomica and belladonna strengthen the peristalsis of the bowel : the colocynth and hyoscyamus pill is purgative ; aloes and iron pill may be substituted for it. The American drug Cascara is very useful. We may give a pill of three grains thrice daily until the bowels move ; twenty drops of the liquid extract may be taken instead. R Extracti Cascarse Sagradse gr. iii. Pulv. Glycyrrh Co. q.s. Fiat pilula : mitte tales xij. Sig. One thrice daily. R Extracti Cascarse Sagradse Liquid! ij. Sig. Twenty drops thrice daily. This drug is tonic to the bowels : its use should be stopped when once the bowels begin to act. It should not be given until the diet is regulated. The pill is more convenient, as the liquid extract is bitter. The purgative mineral waters are very useful. The best are the Friedrichshall, Hunyadi Janos and Aesculap. The patient should take in the morning a wine-glassful or half-tumblerful with an equal amount of hot water ; the taste may be masked by the juice of a lemon with sugar. The Carlsbad salts are good and may be used as already directed (p. 340). Very often an enema of cold water is helpful. The medical 644 AFFECTIONS OF BLADDER AND RECTUM. man should deprecate the habitual use of purgatives, and insist on natural and daily evacuation. The aloes and iron pill is good in sluggishness of the lower bowel. Rhubarb is bad as a habitual purgative, owing to its tendency to con- stipate after purging ; the well-known " Gregory's Mixture " should not be used as a habitual purgative, but is good in diarrhoea inasmuch as it first purges and then binds. Fluid magnesia, castor oil, and some of the milder salines (e.g., the easily-taken Seidlitz powder) may be employed. Blue pill should be avoided; Euonymin or Iridin are better hepatic stimulants (v. p. 584). It has been recently found that the injection of pure glycerine (3J-3J) into the rectum ensures an evacuation of the lower bowel in a few minutes. It is therefore convenient in certain cases. Suppositories made up in large part of glycerine can also be employed. A small syringe is required for the injection of the fluid glycerine. OOCOYGODYNIA. LITERATURE. Hildebrandt Die Krankheiten der ausseren weiblichen Genitalien, S. 127 : Stuttgart, 1877. Nott N. O. Medical Journal, May 1844. Simpson, Sir J. T. Diseases of Women, p. 202 : Edinburgh, 1872. Thomas Diseases of Woman, p. 151 : London, 1880. For recent literature see ' ' Miscellaneous " in Index of Literature in the Appendix. By this we understand a painful condition in the region of the coccyx induced by sitting, walking, and the various muscular contractions associated with defsecation and coitus. When we consider the anatomy of the coccyx, its muscular attachments (to the levator ani, coccygeus, external sphincter ani, and gluteal muscles), as well as the strain put on it when driven back during parturition, we are not astonished that in some cases there should be inflammatory changes around and in it causing pain in its movement. Symptoms. The chief symptom is pain on sitting, walking, and defsecation. Physical signs. By digital pressure on the coccyx and examination per rectum, the seat and nature of the pains are made out. Treatment. (1) Massage and manipulation of the coccyx should be tried first. (2) Pass a tenotomy knife beneath the skin on the posterior aspect of the coccyx, and free its lateral and apical muscular attach- ments ; or (3) amputate the coccyx. To do the latter, make a vertical mesial incision over the posterior aspect of the coccyx ; seize its tip and pull it well back ; then free its muscular attachments with the knife, keeping close to the bone ; finally separate it at the sacro-coccygeal joint. APPENDIX. ABDOMINAL SECTION. LITERATURE. Harbour The Diagnosis of Advanced Extra- uterine Gestation : Ed. Med. Journ., 1882. Hart The Minute Anatomy of the Placenta in Extra-uterine Gestation : Ed. Med. Journ., Oct. 1889. Hart and Carter The Sectional Anatomy of Advanced Extra- uterine Gestation: Edin. Med. Journ., Oct. 1887. And Laboratory Reports, R.C.P.E. : Edin., 1889. Jessop Case of Extra-uterine Gestation ; removal of living foetus, etc. : Lond. Obstet. Trans. , 1876, p. 261. Keith Surgical Treatment of Tumours of the Abdomen : Edin. 1885. Langenbuch International Medical Congress, London, 1881, Vol. II., p. 278. Lister On Corrosive Sublimate as a Surgical Dressing : Lancet, 1884, p. 723. Macdonald Record of Cases treated in Ward XXVIII., Royal Infirmary, Edinburgh, Nov. 1883 to April 1884: Edin. Obstet. Trans., vol. IX., p. 134 ; same from May to November 1884 : ibid. X., p. 178. Maygrier Terminaison et Traitement de la Grossesse extra-uterine : Paris, 1886. Morris Surgical Diseases of the Kidney : London, Cassell & Co., 1885. Tait, Lawson Diseases of the Ovaries : Birmingham, Cornish Brothers, 1883. Ectopic Pregnancy and Pelvic Hsematocele : Birmingham, 1888. The Pathology and Treatment of Extra-uterine Gestation : Brit. Med. Journ., 1884, p. 317. Thornton, J. Knoivsley Cases of Hysterectomy, etc. : Brit. Med. Journ., May 23, 1885. Treves, F. Intestinal Obstruction : London, Cassell & Co., 1884. Wells, Sir Spencer The Diagnosis of Surgical Treatment of Abdominal Tumours : London, Churchill, 1885. See also Literature of Operative Treatment of Ovarian Tumours, Chap. XXIV., and Treat- ment of Fibroid Tumours, Chap. XXXVII. ; all references to recent papers will be found under "Abdominal Surgery," in the Index in Appendix. IN this chapter a short summary will be given on this important subject. In the preceding pages operations necessitating abdominal section, viz. those for abdominal and pelvic tumours, have been described ; but this chapter is intended to gather up consecutively and briefly the main points necessary for the successful performance of Abdominal Section so as to give the operator or his assistant a bird's eye view of the whole subject and enable him to meet unexpected emergencies such as often arise even after the iitmost care has been taken to avoid mistakes in diagnosis. Preliminaries. The operation is best performed in the special wards of an hospital or in a private hospital in the case of well-to-do patients. The houses of the poor are quite unfitted for operations ; and it is much better for wealthy patients to be under the discipline of a good private hospital and away from the well-meaning but hurtful interference of relatives. It also relieves the operator of the anxieties attendant on their misinterpretation of symptoms. 646 APPENDIX. Prior to any operation the patient's systems should be examined, especially lungs, heart, and kidneys. Ether is better not employed when there is a tendency to bronchitis : and the amount of urine should be noted, the usual tests for albumen and sugar employed, and microscopical examination made of its deposit. The urine is some- times scanty in cases of large tumours, and therefore some diuretic such as acetate or citrate of potash should be given. The pulse and temperature should also be taken twice daily for a few days prior to operation. The importance of having a specially trained nurse cannot be over- rated. She is required to take the pulse and temperature, and to keep a register of these : to draw off the urine when necessary and to be capable of giving ordinary and nutritive euenmta. She must therefore have good hands, be firm and yet gentle, -one who carries out instruc- tions to the letter, and who is thoroughly imbued with the spirit of cleanliness. ANTISEPTICS. The operation is to be carried out in the spirit of Listerism. The operator strives to have pure siirroundings and everything that touches the part operated on aseptic, either by antiseptics or sterilisa- tion. He must therefore consider means of purifying the air, instru- ments, sponges, skin of patient adjacent to part operated on, and discharges from wounds. Purification of the air. This is to be got by ventilation, previous purification of the room by sulphur or chlorine fumigation, and pre- liminary spraying of carbolic lotion into the air of the apartment. The spray need not be used during the operation as it may have an injurious effect on the tissues and peritoneum. The operator's great aim is to lower the health of the tissues as little as possible and not to irritate the peritoneum nor hinder its absorptive power. He is to attach the greatest importance to the absolute asepticity of everything that touches the wound fingers, knives, and (above all) sponges. Instruments are readily purified either by boiling water or by soaking in carbolic lotion (1-20 of water). During the operation they should lie in shallow porcelain trays of 1-40 carbolic lotion. Sponges. This is the part of the operative equipment which requires most careful attention. The utmost cleanliness and purification of sponges is a sine qua non to success. Care must be taken that they do not become friable and the operator should give them his personal attention. As an exemplar of what is required, we give Lawson Tait's precau- tions in regard to them. ABDOMINAL SECTION. 647 "New Sponges are first put into a large quantity of water with sufficient muriatic Mode of acid to make the water taste disagreeably acid. They remain in this mixture until all cleaning effervescence has ceased and all the chalk is removed. For this purpose it may necessary to renew the acid several times. The Sponges are afterwards carefully and thoroughly washed to make them as clean as possible and free from every rough particle. After being used at an operation they are first washed free from blood, and then put in a deep jar and covered with soda and water (1 Ib. of soda to twelve sponges). They are left in this about twenty-four hours (or longer if the sponges are very dirty), and then they are washed perfectly free from every trace of soda. This takes several hours' hard work, using hot water, squeezing the sponges in and out of the water, and changing the water constantly. Leaving them to soak occasionally for a few hours in very hot water greatly assists in the cleansing. When quite clean they are put into a jar of fresh water containing about one per cent, of carbolic acid, and after being in this for twenty-four hours they are squeezed dry and tied up in a white cotton bag, in which they are left hanging from the kitchen ceiling (being the driest place in the house) till they are wanted." Prior to an operation they should be carefully washed in very hot water and soaked over night in carbolic lotion (1-20). They are wrung out of 1-40 for the operation and placed near the operator in a suitably warmed dish. The skin near the part to be operated on should be washed the night before the operation with turpentine, soap, and water. The umbilicus is to be carefully cleansed. When the patient is under chloroform, the skin is again washed with corrosive sublimate (1-2000) and the pubes shaved. The operator's hands are to be cleansed with turpentine, soap, and water : the nails brushed, and all finally washed with corrosive sub- limate (1-2000). One good rule is that only the operator or the special assistant should touch the wound, sponges, and instruments. No one else should do so unasked. THE ABDOMINAL INCISION. This is either mesial or lateral. The mesial incision is the usual one and may vary in length. For an exploratory incision, two inches is sufficient, and this is also, as a rule, enough for the removal of the uterine appendages in the pelvis. Its lower end is one inch above the symphysis pubis but must be higher when removing the uterine appendages in an abdominal fibroid. For ovariotomy, an incision of 3 to 4 inches in length is usually required. For large solid tumours, the incision may be very long. If the first incision into the abdominal cavity is found too short, it can easily be enlarged up and down with straight probe-pointed scissors guided on the finger passed in. The operator cuts down through the skin and abdominal fat to the aponeurosis. Beneath the aponeurosis is the extra-peritoneal fat and 648 APPENDIX. then the peritoneum. A good plan is to lay hold of the structures beneath the aponeurosis with two pairs of Pean's forceps, each one catch- ing a little to the side of the mesial line. In this way a fold is pinched up, running across the middle line at right angles to it : this can be cut without danger to subjacent structures and the same manoeuvre repeated on deeper stmctures. The lateral incision of Langenbuch is to be recommended in renal tumours. It is made at the outer margin of the rectus abdominis with its centre at the level of the umbilicus and is advantageous inasmuch as the operator reaches the outer layer of the meso-colon, thus avoiding the blood-vessels running in the inner layer. EXPLORATION^OF ABDOMEN OR PELVIS AND REMOVAL OF TUMOURS. When the abdominal cavity is opened the operator either explores in doubtful cases or removes the tumour he has already diagnosed. While exploring, the deep anesthetization of the patient removes all straining of the abdominal muscles. The operator may find that he has to deal with a malignant case, or with a tumour not removable. He must then close the incision. One good rule in doubtful cases is not to meddle unless there is a fair chance of finishing the case. It is always unwise for the operator, and highly dangerous to the patient, to nibble, as it were, at a case. There is little or no risk in mere exploratory incision. The removable tumours or conditions admitting treatment are (1) Ovarian, parovarian, and broad-ligament tumours, (2) Fibroid, (3) Fibro-cystic, (4) Splenic, (5) Omental, (6) Renal, (7) Hydatid, (8) Mesenteric, (9) Pancreatic, (10) Distended gall bladder, Xll) Uterine appendages in cases of fibroids, / (12) Uterine appendages diseased (pyosalpinx, cirrhotic > j or prolapsed and painful ovaries), g j (13) Pelvic abscess, ^(14) Extra-uterine gestation. (1) Ovarian, parovarian, etc. The removal of these by Abdominal Section has already been fully described under Ovariotomy, in Chap. XXIV. The operation for a pediculated tumour may thus be briefly sum- marised. The operator taps the tumour, withdraws it from the abdomen ABDOMINAL SECTION. 649 and ties the pedicle with the Staffordshire or the ordinary knot. In certain cases or in all (Keith") the clamp and cautery can be employed. The tumour is now cut away : the pedicle whether ligatured or cauterized is dropped back (complete intra-peritoneal treatment) and the abdominal incision closed. When the tumour (usually papillomatous) has developed between the layers of the broad ligament or beneath the peritoneum and is not pediculated, its removal is a much more difficult matter. The best plan is to tap first, then to incise the peritoneum and enucleate the tumour. The part first enucleated with the finger is laid hold of with forceps, drawn well up, and then the operator separates further with his finger, seizing bleeding points with Pean's forceps and tying with catgut. Care must be taken at the side walls of the pelvis not to damage the ureter, as well as at the region of the sacro-iliac joints where the large iliac veins with their many branches lie. The part from which the tumour has been enucleated should be drained if necessary. (2) (3) Fibroid and Fibro-cystic. For full details of Hysterectomy for Removable Fibroids, see pp. 432-442. The tumour is turned out of the abdomen Tumours, through a large incision, clamped, and then cut off. The pedicle is usually treated extra-peritoneally. (4) Splenic. Cystic splenic tumours have been removed successfully. In Leucocythsemic cases the spleen should not be removed. (6) Renal. After incising the abdominal walls by Langenbuch's incision, J the outer layer of the meso-colon is opened, the renal vessels secured, and if tied separately, the artery is to be tied first. The ureter is grasped with two ovariotomy forceps and divided between. The tumour is now enucleated, the vessels cut on the tumour side of the ligature and the tumour removed. The ureter is now tied and its end secured in the abdominal incision. (7) (8) Hydatids or Mesenteric tumours are opened, the contents evacuated, and the incision into them stitched to the abdominal wound. (10) Distended gall bladder. The gall bladder when distended owing to obstruction by gall stones, has been opened, the calculi removed (recommended by Jean Louis Petit, Handfeld Jones, and carried into execution by Marion Sims, and especially Lawson Tait). Tait, in one of his cases, made an incision 4 inches in length, in the middle line, with the umbilicus in the centre of the incision. The gall bladder was aspirated after the abdomen was opened, and then cut into at that point; the gall stones were extracted, the opening in the gall bladder stitched to the abdominal wound, and the rest of the wound closed in the usual 1 On this subject the student may read Morris' Surgical Diseases of the Kidney (London 1885), and also Czerny's paper " Ueber Nierenextirpation," with discussion in the International Congress Transactions ; London 1880, Vol. II., p. 242. 2 See specially Lawson Tail's article. 650 APPENDIX. way. Bile oozed from the wound for some days, but the patient made an excellent recovery. (11) Uterine appendages in case of Fibroids. When a fibroid is not too large and is growing rapidly or causing exhausting haemorrhages, the appendages should be removed. A two-inch incision is made through the abdominal wall and the ovary and Fallopian tube on either side brought up to it. The ovary and part of the Fallopian tube are looped up, tied with the ordinary or the Staffordshire knot, and the parts outside the ligature cut off. In this way the ovary and part of tube are removed. (12) Uterine appendages diseased (pyosalpinx, cirrhotic or prolapsed and painful ovaries). The uterine appendages when diseased and causing serious indisposition may be removed. This is not by any means to be done lightly, its exact results as to sterility have to be explained, and the operator should never force it on the patient. In Pyosalpinx the operator first taps, then loops up the tube, freeing adhesions with his fingers, ligatures as large a loop as possible and cuts away above. Great care is to be taken to prevent any pus entering the abdomen. This is best done by pressing sponges below the freed tube. Any haemorrhage is arrested by pressure, ligature, hot water, or by the actual cautery. Some operators prefer to separate adhesions before tapping. Should the tube rupture during this, the extravasated contents must be most carefully sponged out and the pelvis thoroughly flushed with hot water. (13) Pelvic abscess may be treated by abdominal section when it rises up so as to be near the abdominal walls. After the usual incision through the walls, the operator taps the swelling, then draws up the collapsed walls of the cavity, enlarges the opening, and stitches it with silk to the abdominal wall, the rest of the abdominal incision being closed as usual. A glass drainage tube is passed into the abscess cavity, but the peritoneal cavity is accurately closed. Forms of (14) Extra-uterine gestation may be met with in very many forms: Gestation /(a) Entire, small, and still in Fallopian tube ; (6) Ruptured into the peritoneal cavity, which contains much blood and a small foetus ; (c) Ruptured through the part of the Fallopian tube bounded by the broad ligament, and developing there ; (d) Both foetus and placenta near full time but lying in extra- peritoneal tissue ; (e) Foetus in peritoneal cavity with placenta in extraperitoneal tissue > (/) Foetus and placenta in extraperitoneal tissue but suppuration going on and termination as in pelvic abscess ; (g} In a detached horn. ABDOMINAL SECTION. 651 (a) Entire, small, and still in Fallopian tube. Here the operator tries to remove the entire sac by ligature with silk and cutting away above it. (6) Ruptured into the peritoneal cavity which contains much blood and a small foetus. Such cases may be saved by Abdominal Section. Tait has recorded no fewer than 43 cases where he has operated for this with only one death. In a recent case of abdominal section we found the pelvis filled with tarry-like blood, a small foetus in the abdomen, and a rupture in the Fallopian tube about the size of the tip of the index finger. The foetus was removed, a loop of the tube with the rupture on it secured with the Staffordshire knot, the pelvis sponged and then washed out with hot water (120 F.), to check oozing. It was noted at the time that the omentum became blanched ; the water was passed in only for a few seconds and then sponged out. Unin- terrupted recovery took place. (c) Ruptured through the part of the Fallopian tube bounded by the broad ligament, and developing there. This gives a complex case not good for abdominal section. The operator's aim should be to open the sac and remove the foetus without disturbing the placenta. In all extra-uterine gestation, indeed, it is absolutely imperative to avoid removing the placenta, as there is no arrangement of muscular fibre to check htemorrhage as in normal labour. The cut edge of the sac is to be stitched to the abdominal wound and a drainage tube inserted. In a case observed by us the placenta had grown after the death of the foetus ; the foetus was very much compressed and any attempt to remove it by abdominal section would have caused fatal haemorrhage by separating the placenta. (d) In this form a lateral incision may be employed and access gained without opening the peritoneal cavity. The foetus can be removed and the placenta left. (e) As in (d) except that the peritoneal cavity is opened by a mesial incision. (/) Is to be treated as in pelvic abscess. (g) Gestation in a detached horn. This is a very rare condition and is of interest chiefly because of its close resemblance to a fibroid (v. p. 263). It is removed and clamped just like a fibroid. POSSIBLE ACCIDENTS DURING LAPAROTOMY. The accidents which may happen during Laparotomy are usually, though not always, due to the non-observance of the rules now laid down by successful operators, and should not occur when these are followed. They may be thus summed up. (1) Leaving sponges or instruments in the abdomen, (2) Wound of small intestine, (3) Injury to tip of vermiform appendix, (4) Injury to ureter, (5) Injury of iliac veins, (6) Tears into bladder or rectum. 652 APPENDIX. Sponges or instruments will not be left in the abdomen, if they are carefully counted, and the former never torn up during an operation. A fatal result may follow if such foreign bodies are left, although cases have been recorded where they have been removed on the following day, or even been discharged many days after, the patient recovering ; in the last cases they have set up abscesses escaping by the bladder or wound. Wound of the small intestine should be stitched as follows. First stitch mucous membrane to mucous membrane with catgut and then peritoneum to peritoneum by Lembert's suture. The material to be used for the peritoneum is the finest Chinese twist, passed with a curved needle. 1 PERITONEAL TOILETTE; CLOSURE OF WOUND. The peritoneal toilette must be performed most carefully. All bleed- ing points are to be arrested and all fluids are to be sponged out thoroughly. The pelvis or abdominal cavity if necessary may be washed out with warm water. The peritoneum should be made thoroughly dry before the wound is closed. Careful peritoneal toilette with scrupulous asepsis is the key to success. The abdominal wound may be closed with silk or silkworm catgut. Silk is very good and the stitches may be passed as in an ordinary wound. They should not be far apart (half an inch or so between each), and should include the whole thickness of the abdominal walls. The skin if necessary may be more accurately approximated by super- ficial horsehair stitches. Some operators unite the peritoneal edges with catgut and then use silk for muscle and skin. ELECTRICITY IN GYNECOLOGY: THE APOSTOLI METHOD OP TREATMENT. Keith's INTRODUCTORY. The history of the employment of Electricity in of P the n Gynecology has already been referred to under Treatment of Fibroid Apostoli Tumours of the Uterus (p. 427). We should call especial attention to Treatment. * ne closing sentence in the passage cited from T. Keith on p. 428 : " What I now plead for is, that for a time all bloody operations for the treatment of uterine fibroids should cease, and that Dr Apostoli's treatment as practised by him should have a fair trial." In the same connection, we shoxild also quote from the dedication to Dr Apostoli, by the same author in the book by himself and Skene Keith on The Treatment of Uterine Tumours by Electricity 2 : "Since we began your treatment, now more than two years ago, we have ceased to perform any operation on the uterus by abdominal section. . . . For long, I had hoped much from electricity in the treatment of fibroids, but had only met with disappointment till your method was made known to me." 1 See Treves' Intestinal Obstruction. 2 Edinburgh, Oliver & Boyd, 1889. ELECTRICITY IN GYNECOLOGY. 653 Accordingly, it is in the line of following out Keith's advice, that we limit this short chapter to a statement of Apostoli's method of Electrical Therapeutics in Gynecology, without at present expressing a judgment as to the permanent value of that form of treatment. HISTORY. Apostoli tells us that he studied the surgical employment History of electricity at the Clinique of Dr A. Tripier whose memoir to the^^t oli Academy of Science in Paris, on Faradisation in the Treatment of Method - Hypertrophies of the Uterus, 1 opened up the way. Apostoli saw the weak points of Tripier's practice : among others, that the currents employed were too feeble, their intensity not regulated and measured, the point of application wrongly chosen, and the different effects of the Faradic and the Galvanic (or Voltaic) currents, as well as of the positive and the negative poles not distinguished. He began to work out his own ideas in 1882 ; and in 1883, he described his electric treatment of Perimetritis, reading a paper on that subject at the Congress of Copenhagen in 18S4. 2 In this same year (1884) he laid a memoir on the subject of Treatment of Fibroid Tumours of the Uterus by Electricity before the Academy of Medicine of Paris ; the subject, as already mentioned (p. 427), of his paper read at the Dublin meeting of the British Medical Association in 1887. It was also in 1887 that he published a book on the Electric Treatment of Chronic Metritis and Endometritis. 5 In conclusion, we should mention his papers "On Some New Applications of the Induced or Faradic Current in Gyne- cology " 4 and "On the Treatment of Salpingitis," 5 and that in 1888 he was able to point to many distinguished British and American gynecologists who had adopted his method. Notable among these, is Thomas Keith ; and we close this historical note by again referring to the treatise, by himself and his son Skene Keith, which has just appeared and may be said to complete the introduction of the Apostoli method to the medical profession in this country. It is the detailed account of the first one hundred and six consecutive cases of Uterine Tumours treated by electricity ; and in the conclusion of his dedication to Apostoli Thomas Keith says " That you will in a few years see your treatment adopted all over the world I have little doubt ; and no one can wish you success more heartily than I do." NOTE ON ELECTRICAL TERMS USED. In order to make clear the description of Apostoli's method which follows, it will be well first to 1 Hyperplasies conjunctives des organes contractiles de 1'emploi de la faradisation dans le traite- ment des engorgements et deviations do 1'uterus et de 1'hypertrophie prostatique : Comptes Rendus de V Academic des Sciences, Aoilt 1859. Lecons de clinique sur les maladies des feiumes : Paris, Octave Doin, 1883. 2 Sur un nouveau traitement des p6rimtrites : Comptes Rendus du Congres de Copenhague, Section d'Obstetrique et de Gynecologic, p. 141. 654 APPENDIX. explain some of the terms used, so that students may read straight on without the interruption of consulting books on electricity which may not be at hand at the time. Kinds of In the first place, there are two distinct kinds of electric current Current 8 Pken of, the Galvanic (perhaps more accurately the " Voltaic ") and the Faradic. The former is the electricity that flows in continuous current through the wires from the zinc and copper plates in a voltaic or galvanic cell or battery when their ends are connected. As sulphuric or other oxidising acid is added to the water in the cell, this kind of current is chemical in its origin. When the current flows, the zinc plate is used up, its consumption furnishing the energy to drive the current through the cell and connecting wire : the cell, in fact, has been aptly compared to a sort of chemical furnace in which the fuel is zinc. The faradic current, on the other hand, is an induction one, i.e., is a current induced in a closed circuit when a magnet is moved near it or when it is moved across the magnetic field, or when an electric current whose strength is changing is near it. The source of this current is, accordingly, not chemical but electro-magnetic. Electro- That which tends to produce a current, i.e., to move electricity from one P^ ace * another, is called Electro-motive force ; the Strength of a Strength of Current is the quantity of electricity which flows past any point of the circuit in one second, and is directly proportional to the electro-motive force and inversely proportional to the resistance which the current has to overcome in its flow. This truth with regard to the strength of an electric current flowing in a circuit is, from the name of its discoverer, known as Ohm's Law, which may be formally stated here " The strength of the current varies directly as the electro-motive force, and inversely as the resistance of the circuit." The terms "strong," "great," and "intense," applied to currents all mean the same thing. Measure- To measure the strength of electric currents there is used an instru- Strengthof men ^ ca ^ e( i the Galvanometer, in which a magnetised needle is deflected Electric by a current passing above and below it through a coil of silk-covered insulated copper wire the amount of deflection depends upon the strength of the current (though not proportional to it) and a properly graduated dial enables us to ascertain perfectly the strength of the current. The sensitiveness of the instrument is greatly increased by the use of the astatic needle, a compound one in which the directive power of the earth is neutralised by the joining of two magnetised needles of equal power connected one above the other by a central pin so that the north pole of the one lies over the south pole of the other and the south pole over the north pole of the other. The sensitiveness is also increased within certain limits by increasing the number of turns of the coil of silk-covered wire. A galvanometer must be able to measure the quantity of electricity passed, and should ELECTRICITY IN GYNECOLOGY. 655 be of a degree of sensitiveness corresponding to the strength of the current to be measured very sensitive for very small currents, less sensitive for strong currents. UNITS OF MEASUREMENT. Every kind of measurement requires a unit : as in measuring length we might take the inch, foot, yard, or mile ; and in measuring mass or weight we use the grain, ounce, pound, hundred- weight, or ton. Accordingly, for measuring electricity, we have in the first place a series of what are called absolute electric units derived from the fundamental Centimetre-Gramme-Second system (C.G.S.) in which The Centimetre (-3937 in.) is the unit of length, The Gramme (15'432 grns.) is the unit of mass, and The Second is the unit of time. There are three derived units which it is necessary to bear in mind in order to understand the electric units which follow. These are The Dyne or unit of force, that force which acting for one second on a mass of one gramme gives to it a velocity of one centimetre per second ; The Erg or unit of work, the work done in overcoming unit force through unit distance, i.e., in moving a mass through a distance of one centimetre against the force of a dyne ; and Unit Strength of Magnetic Pole. The unit magnetic pole is of such a strength that when placed at a distance of 1 cm. in air from a similar pole of equal strength it repels it with a force of one dyne. We are now in a position to understand the definition of the units referred to in the explanation of Apostoli's method. As that method deals with Current Electricity in which the positive and negative poles are in properties the same as magnetic ones, these units are called Electro-magnetic. Electro-magnetic Absolute Units. (1) Unit Strength of Current is that of a current such that if one centimetre length of its circuit be bent into an arc of one centimetre radius it will exert a force of one dyne on a unit magnet pole placed at the centre of the circle of which the arc is a part, so as to be always a centimetre away from the current. (2) Unit Quantity of Electricity, that quantity of electricity which is conveyed by current of unit strength in one second. (3) Unit of Difference of Potential or of Electro-motive Force exists between two points when it requires the expenditure of one unit of work (Erg) to bring a unit of + electricity from one point to the other against the electric force. (4) Unit of Resistance is possessed by a conductor when unit difference of potential between its ends causes a current of one unit of quantity per second to flow through it. 656 APPENDIX. The first two of these absolute units were found to be inconveniently small and the last two inconveniently large, accordingly a committee of the British Association devised a system of "practical" units in which they substitute for the fundamental units centimetre and gramme, the Earth's quadrant (1,000,000,000 centimetres) and TT7T7 ^cnjyffinr.Tnnj- of a gramme. Electro-magnetic Practical Units. (1) The Volt x is the practical unit of Electro-motive force and is 100,000,000 absolute units. (2) the Ohm x is the practical unit of Resistance and is 1,000,000,000 absolute units. (3) The Ampere, 1 the practical unit of Strength of Current, is that furnished by a Volt through an Ohm and is -^ of the absolute unit. In medical electricity, however, the strength of the current is measured in milliamperes. (4) The Coulomb x is the practical unit of Quantity of current electricity and is -$ of the absolute unit. With the aid of these units, we can now state Ohm's law in more definite language, using "amperes" to measure "strength of current," "volts" for "electro-motive force," and "ohms" for "resistance of circuit." Thus the two forms would run as follows : (General Form.) The strength of the current varies directly as the electro-motive force and inversely as the resistance of the circuit ; (Definite Form.) The number of amperes of current is equal to the number of volts of electro-motive force, divided by the number of ohms of resistance in the circuit, or more briefly The number of amperes is equal to the number of volts divided by the number of ohms. More than one method has been tried of fixing a standard for these units. Thus, the British Association (B.A.) in 1863 constructed coils of German silver to give the resistance of an ohm, but there was some doubt whether the B.A. unit exactly represented the practical unit of resistance as defined above. Accordingly, it was decided at the Inter- national Congress of Electricians in Paris in 1881 that the ohm could be most accurately measured by the resistance offered to the electric current by a column of pure mercury with a cross-section of one milli- metre ; and, in 1884, it was decided at the Paris Congress that the length of the column should be 106 centimetres. This gives almost exactly 2 the theoretical ohm, and is a little larger than the B.A. unit/ 3 In concluding this note on the electric terms used, we may mention that the ends of the wires leading from the battery are called Electrodes ; that Electrolysis (i.e. Electric Analysis) is, strictly speaking, the process of 1 These four terms commemorate the names of four famous electricians -.Alessandro Volta, who shares with Galvani the discovery of current electricity ; G. S. Ohm, whose law regulating the strength of current electricity has been given above ; Andri Ampere, the founder of the science of electro-dynamics ; and Charles A. de Coulomb, the inventor of the torsion balance and demonstrator of the law that electrical attraction and repulsion vary inversely as the square of the distance. 2 Lord Rayleigh calculated that the length of column to give the exact ohm should be 106'21 cm. 3 The B.A. ohm is "9887 of the new legal ohm and the B.A. volt is '9887 of the legal volt. ELECTRICITY IN GYNECOLOGY. 657 decomposing a liquid by means of an electric current, but is also applied to the disintegrating process said to be set up in tumours or other tissues when a current has been passed through them; and that Apostoli describes his method as mono-polar when only one pole is active, i.e., is applied to uterus, vagina, or tissue to be acted upon, and as bi-polar when both poles are so applied. Apostoli in describing his application of the faradic current uses the old phraseology (employed before the discovery of Ohm's law) when he speaks of " currents of quantity " and " currents of tension " or " inten- sity currents;" meaning by the former a current flowing through a circuit in which there is a very small resistance inside the battery 1 or in the wire, and by the latter a current which has to overcome greater resistance and which requires, therefore, a high electro-motive force. 3 These terms are scientifically misleading as the great resistance tends to counteract the high electro-motive power, and the principal phenomena of electro-magnetism are due not to the mere presence of electricity however great its tension but to its state of current or flow. The terms are, however, convenient ; and, what is more to the purpose here, Apostoli's whole method is founded upon his declared discovery that the physiological effects of currents in the two conditions are very different. ACTION OP DIFFERENT CURRENTS AND POLES. 1. Action of the Galvanic or " Galvano-camtic" Current. For this current Apostoli claims two successive and distinct effects : (1) A chemical (not thermic) cauterisation at points of entrance and exit of the current, and in proportion to dose and duration ; and (2) An interpolar action, through the entire uterine substance, as the current passes from internal to external pole. It is this current he uses in the treatment of Uterine Fibromata; and he describes his method as " galvano-caustic, intra-uterine, and mono- polar." The current is used in various forms, as will be seen from the summary of the 94 cases fully described in the second part of his memoir of 1884 on the Treatment of Fibroid Tumours of the Uterus : In 59 cases, the galvano-caustic current with positive pole active was used; 21 ,, negative 9 ,, ,, ,, ,, negative and positive poles successively active was used ; and ,, 5 ,, the galvano-puncture was used, preceded or followed by 1 The internal resistance is diminished by haying larger plates or bringing them closer together ; the former is usually done by connecting the zincs of several cells, producing practically one large zinc, and the same for the coppers. 1 Brit. Med. Jour. , 1888, 1. , p. 64. " No Apparatus for Faradisation," he writes, is " complete with- out two independent bobbins ; which according to the length and thickness of the wires gives currents differing in qualities and characters. The bobbin with short thick wire gives current of quantity because the wire is less resistant and lets pass a greater volume of electricity. The bobbin with longer and finer wire is called the bobbin of tension ; the current along it is called the current of 2 T 658 APPENDIX. positive or negative intra-uterine cauterisation. The effects of these various forms are clearly stated. a. Effect of Galvano -caustic current with POSITIVE POLE active. The local effect of the positive pole is said to be coagulating and hardening. It is accordingly to be the active intra-uterine one in all cases of bleeding fibromata or where there is accompanying obstinate leucorrhoea. It is described as arresting haemorrhage instantly if the cavity of the uterus be of normal dimensions, the action relatively intense, and haemorrhage not excessive ; otherwise, it acts more deliberately and gradually. b. Effect of Galvano- caustic current with NEGATIVE POLE active. This pole is declared to produce a state of temporary congestion without direct haemostatic effect. The interstitial circulation of the uterus is thus temporarily stimulated and hurried on. Therefore, a regression of non- hcemorrhagic fibromata results, either from the congestion or the supple- mentary artificial and subsidiary haemorrhages. This pole, therefore, is to be used for fibroids accompanied by amenorrhcea or dysmenorrhcea. In inducing a regression of the tumour by the secondary interstitial changes from interpolar action, Apostoli believes that the negative pole is the more powerful. Further, if the negative pole be made to enter by puncture into the substance of the fibroid deposit, it " becomes by ' a sort of contre-coup ' markedly haemostatic due to its cutting off the supplementary circulation by the rapid atrophy the 'negative current causes." c. Effect of Galvano-puncture. This form of application is said to be daily assuming more importance. It is indicated necessarily in xiterine atresia, or where there is such uterine displacement as to prevent the introduction of a sound. It is to be preferred where the puncturing can be combined with intra-uterine cauterisation to hasten and make sure of the desired effects. The chief points in the method of applying this treatment are : (1) Antiseptic irrigation of Vagina ; (2) Make punctures shallow, not deeper than 1-2 cm. ; (3) Make puncture on most prominent part of fibroid, where possible in posterior cul-de-sac ; (4) Make punctures without speculum, slide trocar through sheath after having chosen by touch the point where the puncture is to be made ; (5) Ascertain any seat of pulsation so as to avoid wounding an important vessel ; (6) In case of any unusual haemorrhage, immediately dilate vagina with an expanding speculum and if necessary apply a pressure-forceps to the bleeding point. ELECTRICITY IN GYA 'ECOLOGY. 659 "No operator," Apostoli adds, "should admit the failure of intra- uterine galvano-cauterisation before having had recourse to the galvano- punctures, which he must enforce either with or without anaesthetics." 1 2. Action of the Faradic or Induced Current. This current is said to have " contractile power " but its effects differ as the " current of quantity " or the " current of tension " is used. The former, the direct excitant of muscular contractility, is employed to overcome uterine muscular inertia and produce a temporary vascular activity ; it thereby excites circulation where there is congestion and stagnation with consequent arrest of the nutrition of the uterus. The " current of tension " acts more on the sensibility than on the muscular contractility ; it has therefore been used in all cases where pain is the leading symptom. " No other sedative, recognised in Gynecology, for the purpose we are treating of, equals the faradic current of tension." Certain rules are laid down for the application of this current which are declared to be essential to its use, and which will be found below. 2 This treatment Apostoli strongly recommends forperimetritis, ovarian pain, and intense sensibility about the lower part of the vagina. As a whole, the induced current is a direct excitant of muscular fibre. Where the mucous membrane is at fault as in endometritis, there is nothing on which it can act curatively, and the constant or galvanic current is the remedy. THE APPARATUS AND INSTRUMENTS. 1. For the Use of the Galvanic Constant Current.^ (1) The first Apparatus requisite is, as Apostoli puts it, some sort of a battery capable of yielding m ents. an adequate constant current of electricity, i.e., one rising from 10 to about 300 milliamperes ; and it should be provided with a regulator by which the circuit is made to include any number of cells desired, as well as with a Current Interrupter 4 and a Commutator or Current Reverser. 5 (2) The second requisite is a good galvanometer " of intensity," i.e., able to measure a current of considerable strength, the graduation being extended up to 250 amperes at least. Keith uses Gaiffe's instru- ment. (3) The next portion of the apparatus to be considered is the intra- uterine electrode. In form it is like a uterine sound, straight or only slightly curved, and long enough to reach the fundus of an enlarged uterus. The positive pole corrodes all metals except gold, aluminium, 1 The Dublin paper of 1887 : see Brit. Med. Jour., 1887, II., pp. 700-701. 2 "On Some New Applications of the Induced or Faradic Current in Gynecology," by Apostoli, Brit. Med. Jour., 1888, I., p. 63. * Brit. Med. Jour., 1887, II., 700. See also Woodham Webb on the "Treatment of Fibroids of the Uterus by Electricity : the Apparatus and Instruments" ibid., 1887, I., p. 1208. * Sometimes called a " Kheotome." 5 Sometimes called a " Rheotrope." 660 APPENDIX. and platinum ; and it is found that platinum is the material best adapted for this purpose. Carbon is also very good. (4) Very important is the inoffensive cutaneous electrode of wet potter's earth, spread out in a layer half-an-inch thick and covering the lower part of the abdomen. This is said to be the master point of this method of treatment, as it enables strong currents to be employed without injury to the skin which would be cauterised were the external electrode of the same small area as the internal. (5) For the galvano-punctures there is required a steel trocar or needle. 2. For the Faradic or Induced Current. (1) The first requisite here is a faradic battery. (2) A special form of sound, for Apostoli uses the bi-polar method for the faradic current. Accordingly, the sound contains both poles side by side within its substance, so that the circuit may be closed within the uterus (if that be possible) or vagina. THE CURRENT: ITS STRENGTH, DURATION, AND FREQUENCY OF OPERATION. For the galvanic current, Apostoli repeatedly insists that it is virtually a uterine cauterisation, in which the highest possible degree of electro-chemical action is used, and that the current must be con- tinuous without any interruption during the operation. As to the strength of the charge, his absolute rule is that it be exactly measured, and that it be as great as the patient can bear up to what the desired effect requires : the range attainable is as high as 300 mil- liamperes. The duration of the application necessary to produce effec- tive cauterisation is on an average from five to eight minutes. In Keith's 106 cases, five minutes was by far the most common duration. The number of applications required to produce good results varies with different patients, according to the nature of the disease and the object sought for. In Apostoli's treatment of fibroids the average was over fifteen per patient. In Keith's cases, they sometimes number more than fifty, and were made usually daily or every alternate day except during the menstrual period. The place of application must also be strictly localised, and this is ensured by the method being intra-uterine mono-polar. Principles are also laid down governing the application of the faradic current. The strength varies within the extreme known limits. In such inflammatory conditions as perimetritis, and above all in acute cases, the rule is to begin with a very small dosage and increase milliampere by milliampere as the power of endurance increases and the phlegmasia shows a tendency to give way. In using this current for ovaralgia, however, the direction is to press boldly forward if the uterine region be healthy : for the relief of pain, the application is not to end even after ELECTRICITY IN GYNECOLOGY. 661 twenty minutes till the pain has disappeared ; generally the first sitting requires most time, the subsequent ones only completing what it has begun. These applications of the faradic current should follow each other every day or even twice a day. The number of sittings varies : from two to five are said to be sufficient for simple neuralgia, but the range is much greater for inflammation. PATHOLOGICAL CONDITIONS IN WHICH ELECTRICITY IS USED IN GYNECOLOGY. In the opening historical paragraph of this brief sketch of Apostoli's Conditions method, it will be seen that he has published special papers on the treatment of fibroid tumours of the uterus, chronic metritis and isuse dm endometritis, perimetritris, localised inflammation of the vagina, hydro- oology. salpinx and salpingitis ; and he says that he has applied the continuous galvanic current for most of the maladies known to Gynecology. So far as our present knowledge goes, the suitable cases for Apostoli's method are 1. Bleeding Fibroids. In these the internal pole is positive, and a current strength of 50 to 150 ma. may be used. 2. Impacted or large Fibroids causing pressure symptoms. Puncture here with negative needle. 3. Dysmenorrhoea of pathological anteflexion : membranous dysmen- orrhoea. Internal electrode negative, and current strength about 50 ma. 4. Cellulitis. Internal electrode covered with cotton wool and placed vaginally. 5. Pain, ovarian. Here the faradic current is said to give good results. We say nothing here in the way of describing instruments or details of treatment. We may say, however, that we have found as an abdo- minal electrode Engelmann's broad plate with cotton wool soaked in salt solution quite as good as and much more convenient than potter's clay. RESULTS. The results claimed for this method in the treatment of tumours of Results. the uterus have already been given (p. 429) "in every case, the tumour was reduced in size, haemorrhage and pain gone, and general health restored." The Keiths state in the introduction to their book that they now know that cases with haemorrhage are the best for treatment, and admit that in their series of cases there are some imperfect and incomplete ones, but repeat their confidence in the immense utility and ultimate triumph of the method. Cases of enlargement of the uterus have every one been perfectly cured. Similarly good results are claimed in other affections. 662 APPENDIX. THE SYSTEMATIC TREATMENT OF NERVE PROSTRATION. LITERATURE. Bramwell, ByromThe Diseases of the Spinal Cord : Edin. 1882. Gaskell Preliminary Notice of Investigation on the Action of the Vasomotor Nerves of Striated Muscle : Proc. Roy. Soc., Lond., 1876-7, p. 430. Goodell Lessons in Gynecology, Lesson XXX. : Philadelphia, 1880. Mitchell, Weir Fat and Blood, and how to make them : Lond., 1878. Play fair, W. The Systematic Treatment of Nerve Pro- stration and Hysteria : Lond., 1883. The gynecologist will not have long practised his specialty before he finds that he has occasionally to deal with a class of patients who are quite sui generis. The condition of such puzzles him at first extremely, inasmuch as he can find no tangible disease but yet is bound to confess that the general condition of health is highly unsatisfactory. Very often these patients have gone the round of all medical and surgical specialists, and have come at last to the gynecologist in the hope that his art may do something to remedy their lamentable state. The class of patients has the following characteristics : They are thin, often emaciated, unable for any exertion, suffer from neuralgia, have little or no appetite, and are nursed by some devoted sister or mother or husband. As we have said, there is no local condition to account for their state ; but often there is a history of overwork, as in the case of governesses and teachers, or of an improper training. By this latter we mean that a sensitive child of high nervous organisation has been over-cultivated, her mental energies too constantly on the rack, and has ultimately collapsed under the strain. For this class of patients Weir Mitchell of Philadelphia introduced a plan of treatment in his well-known book, the results of this method being in suitable cases highly satisfactory. The main factors in Weir Mitchell's plan are I. Seclusion of the patient, and absolute exclusion of all but the medical attendant and nurse ; II. Absolute Rest in Bed ; III. A Systematic extra-feeding of the patient ; IV. Use of Massage and Electricity. I. Seclusion of the patient, and absolute exclusion of all but the medical attendant and nurse. This is imperative, and the treatment should not be gone on with unless this condition is agreed to absolutely. Very often the friends have devoted themselves to every whim and fancy of the patient so assiduously as to impair their own health without improving that of their tyrannous charge. TREATMENT OF NERVE PROSTRATION. 663 The nurse should be thoroughly trained and refined, and should implicitly obey all the medical attendant's orders. II. Absolute rest in bed. This means muscular and mental rest, and reduces the force and fre- quency of the heart's action. The nutrition taken is above the amount worked off, and benefit in this way results. This absolute rest is after a while modified, and the patient allowed to sit up for a little until she may at length go about as usual, with the exception of taking a two- hours' sleep during the day. III. A systematic extra-feeding of the patient. This is one of the essential features of the method. Weir Mitchell begins with milk diet, about three ounces every two hours, until two quarts are given during the day. At the end of the first week raw beef soup 1 is given, and gradually the diet is increased until the dietary for one day, in one of Mitchell's cases, was as follows : Coffee at 7 ; at 8, iron and malt. Breakfast a chop, bread and butter, of milk a tumbler and a half; at 11, soup; at 2, iron and malt. Dinner (closing with milk, one or two tumblers) consisted of anything she liked, and with it she took about six ounces of Burgundy or Dry Champagne. At 4, soup. At 7, malt, iron, bread and butter, and usually some fruit, and commonly two glasses of milk. At 9, soup ; and at 10, her aloes pill. At noon, massage occupied an hour. At 4.30 p.m., electricity was used for an hour." In addition to this diet, iron in the form of Blaud's pills (p. 583) and maltine may be added to aid the digestion of starchy food. The maltine should be given in cold milk or at the end of pudding. The evident question now arises, How does the patient digest all this 1 The diges- tion of this immense mass of food is rendered possible by the last feature of the treatment. IV. The use of Massage and Electricity. This is most important, and consists in the systematic rubbing of the patient and the application of Faradic electricity. The massage is begun a few days after the milk diet, and consists in the systematic kneading of the skin and muscle of the whole body first for half-an-hour, and afterwards for an hour daily. A special massage nurse is necessary for this, and it should be kept up for six or seven weeks. Cocoa-nut oil should be used to render the manipulations easy, and it will also help in fattening the patient. Electricity is employed for half-an-hour daily in order to cause 1 Chop 1 Ib. of raw beef, and place in a bottle with 1 pint of water with 5 mm. strong hydro- chloride acid. Place in ice all night, and in the morning set in a pan of water at 110 Fahr. for 2 hours. Strain thoroughly, and give filtrate in portions daily. 664 APPENDIX. muscular action, increase the blood supply to the muecle, and act as a tonic and bracing agent. Mitchell has found that after the electricity the temperature usually rises about |ths of a degree. The cm-rent should not be painful, and Ziemssen's diagrams of the points of stimula- tion should be followed as a guide. For further details, the literature given should be consulted by the practitioner wishing to carry it out. The results in some cases are wonderful, and as yet no harm has been shown to arise to the kidneys from the over-feeding. The bowels must of course be regulated, and a daily motion secured. Before beginning this treatment in any case, it should be thoroughly ascertained that there is no organic disease, and no obscure and rare form of disease such as Addison's disease, myxcedema, etc. A consultation with a specialist should always be had in cases of doubt. The patient for whom it is suitable is one where there has been under-feeding or improper food, undue mental strain, and consequent loss of flesh and nervous energy. HYSTERIA AND HYSTERO-EPILEPSY. LlTERATUBK. Bourneville ct Reynard Iconographie photographique de la Saltpetriere : Paris, 1877. Bourneville et d'Oliei Kecherches sur 1'Epilepsie, I'Hysterie et 1'Idiotie : Progres Medical, 1881. Charcot Diseases of the Nervous System : Sydenham Society's Series, London, 1877. Fritsch Krankheiten der Frauen : Braunschweig, 1881. Jolly Article ' ' Hysteria " in Ziemssen's Cyclopaedia of Medi- cine. Mills Hystero-epilepsy : American Journal of the Medical Sciences, Oct. 1881. Richer Etudes cliniques sur 1'HysteVo-Epilepsie : Paris, 1881. HYSTERIA. The frequency of hysteria as a complication of pelvic disease requires that we notice it briefly. We can only indicate the leading points and refer the student to the literature given above. The connection which exists between hystero-epilepsy and the ovary also calls for short reference. As to the pathological changes present in hysteria, little definite is known, except what Freund has described in Parametritis chronica atrophicans (v. p. 174). In regard to etiology, we note first the influ- ence of heredity ; defective moral education by a hysterical mother, and the power of imitation in developing hysteria, confirm this influence. A reduced state of the system is also a very important cause, and the one to which treatment must be specially directed. As to the exciting causes usually given (such as dysmenorrhoea, uterine displacements, ovaritis), these are so common that we cannot regard them as a cause of hysteria. The only ascertained facts are that removal of the ovaries has in some cases cured hysteria, and that pressure in an ovarian region does sometimes inhibit a hystero-epileptic attack. HYSTERIA. 665 The symptoms of hysteria are protean. Sensation is affected as follows. There may be increased sensitiveness to touch (hypersesthesia) and to pain (hyperalgesia). Hypersesthesia of the joints is important as simulating arthritis, from which it is diagnosed by the fact that the pain is around (not in) the joint and that it is not aggravated on forcing the articular surfaces together. Neuralgia along the spine with tender points simulates disease of the vertebral column. The typical headache (known as the " clavus hystericus " from the localised and intense character of the pain), neuralgia of the muscles generally, localised pain in the breast, in one ovarian region, in the bladder and urethra, and the perversions of the special senses need only be mentioned here. When sensitiveness is impaired, it is usually that to pain ; while that to heat and touch remains ; one half of the body may be affected, or isolated portions of skin as the back of the hands and feet. Loss of the muscular sense prevents the patient, if the eyes be closed, from know- ing what movements she has made. Anaesthesia of any of the mucous membranes may occur. The special senses are often also impaired. The motor disturbances resulting in convulsions will be referred to under hystero-epilepsy. The paralysis due to hysteria is very import- ant in regard to its diagnosis from that due to a cerebral or spinal lesion. It varies in distribution and may affect one limb only, or the arm and leg of one side, or the arm on one side and the leg on the other. In the face, the levator palpabrse superioris is frequently affected ; paralysis of the muscles supplied by the facial and hypoglossal nerves is rare. This last fact is of value in diagnosing between hysteria and hemiplegia ; further, gradual onset, presence of anaesthesia and its varying distribu- tion, normal reaction to the electric current, the progress of the case with variations in the degree and extent of the paralysis, warrant us in diagnosing hysteria. The diagnosis of hysterical paraplegia from multiple sclerosis is more difficult. Paralysis may also affect the laryngeal muscles, producing aphonia, and the muscular wall of the oesophagus, stomach, and intestines. Of the disturbances of the circulatory system, the most important is palpitation with increased force of the apex beat ; in some cases, the heart's action fails and there is syncope. Vaso-motor disturbances are seen in the pale skin which does not bleed when pricked, and in the flushings and profuse sweatings which are often present. Salivation and polyuria often occur after a hysterical attack. In forming a diagnosis, we must be careful to exclude the possibility of organic, cerebral, or spinal disease. A case reported by Bruce 1 is of interest in this connection ; here the patient had symptoms of hysteria, there was no optic neuritis or other indication of cerebral 1 Brain, part XXII. : 1883. 666 APPENDIX. mischief, and yet the post-mortem showed a large tumour in the temporo-sphenoidal lobe. In treatment, the following points are of importance. Care must be taken in the mental and moral training of the children, where there is a tendency to hysteria. 1 If the system is below par, Weir Mitchell's method should be tried, and iron given when there is anaemia; cold baths are always beneficial. In grave cases, Battey's or Tait's operation may be suggested but never urged, as the results are not brilliant. HYSTEBO-EPILEPSY. This term is applied to attacks which present at once the features of hysteria and epilepsy; they are also described by Charcot as Grave Hysteria or Hysteria Major. The standard work on this subject is by Richer ; the English reader will find a good account of it in the paper by Mills, cited above, in which he gives (with the description of two cases observed by himself) the results of the valuable researches of Charcot, Bourneville and Regnard, and Richer. Hystero-epilepsy is rare in this country. We have seen one case in which it was present in a modified form. The seizures consisted in regular movements of the lower limbs, so that the patient performed a sort of dance till she sank down exhausted ; pressure on the ovary checked the attack. A typical attack is divided by Richer into four periods: (1) the epileptoid period ; (2) the period of contortions and great movements ; (3) the period of emotional attitudes ; (4) the period of delirium. For some days before an attack, prodromic symptoms occur in the form of the varying symptoms of hysteria given above. Charcot 2 has drawn attention to the occurrence of acute pain or sensitiveness to pressure in one ovarian region as forming the starting point of the aura hysterica ; slight pressure in one ovarian region will, in some cases, excite an attack. In other cases, different hypersesthetic areas have been local- ised, the touching of which produces an attack. These areas are known as hystero-epileptogenic zones and are analogous to the epileptogenic zones described in epilepsy by Brown Sequard. During the epileptoid period there is complete loss of consciousness ; further there is (as in true epilepsy) a tonic phase, a clonic phase, and a phase of resolution ; it lasts several minutes. It is important to note that there is loss of consciousness in grave hysteria, as the absence of this in ordinary hysterical convulsions is one of the features by which the latter are diagnosed from an epileptic attack. The contortions and great move- ments of the second period differ from those of the first period in this that the muscles are quite relaxed apart from the contortions ; there is 1 Clouston: Puberty and Adolescence medico-psychologically considered : Edin., 1880. 1 Lectures on Diseases of the Nervous System : Sydenham Translations, 1877, p. 2(52. MASSAGE. 667 no tetanus. Consciousness is not lost. The whole body may be rolled about, as if the patient were writhing in pain ; or more regular move- ments occur, e.g., the movements of "salutations " in which the patient, lying with the knees bent up, suddenly throws the head and chest forwards so that the forehead strikes the knees and then falls back again. The emotional attitudes of the third period are beautifully illus- trated by a series of photographs in Bourneville and Regnard's work. Ecstacy, irony, disdain, terror, and other emotions are seen on the face, and the attitude of the body corresponds to the expression. Hallucina- tions are present, and the patient remembers these afterwards ; volun- tary motion is unaffected, but general and special sensibility are com- pletely suspended. This period lasts from a few minutes to a quarter of an hour. The fourth period is not sharply marked off' from the preceding one. The patient partially recovers consciousness and is influenced by external impressions, but these are largely mixed with hallucinations. A succession of hystero-epileptic attacks produces the hystero-epileptic status which is diagnosed from the status epilepticus by the important fact (ascertained by Charcot) that there is no rise of temperature during it. As to prognosis, it is less grave than in true epilepsy. As to treatment, pressure on the ovaries often checks the attack at once ; place the patient on the back and forcibly press the fist into the iliac region. Inhalation of chloroform or nitrite of amyl, and the sub- cutaneous injection of morphia are also valuable. For the treatment by electricity and metallo-therapy, we refer the practitioner to Richer's work. Moral discipline is specially valuable. MASSAGE. LITERATURE. Profanter (1) Die Massage inder Gynakologie ; (2) DieManuelle Behand- lung des Prolapsus Uteri : Wien, 1888. ReibmayrDie Massage : Leipzig, 1889. Resch Uber die Anwendung der Massage bei Krankheiten der weiblichen Sexual- organe : Cent, fur Gynak., No. 32, 1887. See also Index of Literature in Appendix. One of the most common cases in Gynecology is that where, as the result of a previous attack of pelvic inflammation, the uterus and ovaries are bound down and fixed by more or less dense adhesions usually peritonitic. For these cases many forms of treatment, ranging from the hot douche up to abdominal section, are recommended, and will be found described in various parts of this Manual. At present we wish briefly to refer to a method of treatment recently come into vogue Massage. By this we mean here Bimanual Massage of the adherent tissues or organs so as to slacken these, promote vascular and lymphatic absorp- tion, and in this way bring about a more healthy condition of the local 668 APPENDIX. circulation and relief to the nerve pressure supposed to be exerted by the cicatricial tissues. The originator of this form of treatment is a Swedish layman, Brandt, and his work has been taken up by several German gyne- cologists, among whom are Schultze, Profanter, Schauta, and others. Before going on more particularly to the question of indications, methods, and results, we may say that we believe there are great difficulties in the way of its general acceptance. The chief one is that it involves undue manipulation of the genital organs. This is a most serious objection, and one which will in all probability be fatal to the method. Then again the manipulation will be dangerous if the diag- nosis be wrong e.g., if a pyosalpinx be chosen for it. There is thus every prospect of its being supplanted in the few cases requiring it by abdominal section. Prolapsus uteri is one of the cases specially recommended for it. Here, however, it is difficult to understand how it does good, although trustworthy observers have recorded cases of cure. Indications. Retroversion of uterus bound down by adhesions ; adher- ent ovaries ; parametritis posterior causing pathological anteflexion ; prolapsus uteri. Methods. In chronic inflammatory cases the patient occupies the dorsal posture, with knees well drawn up and dress freely loosened. The gynecologist carefully ascertains bimanually the condition of the organs, and then, keeping the two fingers passed into the vagina fixed, he grasps or maps out by the outer hand the adhesions to be stretched, and by movement of the outer hand only, stretches these or exercises a rubbing movement on them. Rectal manipulation may be employed instead of vaginal. This bimanual massage should not be practised for more than a few minutes at each sitting, and the number of sittings must be left to the judgment of the gynecologist. Schultze has extended this method by advocating and practising, not mere stretching, but actual separation of the adhesions. For this purpose the patient is chloroformed, the condition accurately mapped out, and the adhesions then separated by bimanual manipulation. Schultze's results have been good, but it is evident that the risks in less experienced hands are very great. In Prolapsus uteri the method is more complicated and troublesome. Briefly it is as follows (Profanter). (1) Position of patient. The patient has her dress thoroughly loosened and lies on a short couch (4 ft. x 2 ft. 8 in.) with her chest supported by cushions. In this way she is compelled to slacken the abdominal muscles as much as possible. An assistant passes his fingers into the vagina, replaces and anteflexes the uterus. The Masseur then with both hands grasps the uterus and draws it up as far as possible. RELATION OF GONORRHOEA TO DISEASES OF WOMEN. 669 The patient now raises the hips from the couch thus supporting her body on elbows and feet, while the gynecologist forcibly separates her closed knees and then forcibly approximates them, the patient resisting each time. These manoeuvres are repeated thrice. The object of this so-called pelvic gymnastic is to bring into action the pelvic muscles (levator-ani, obturator internus, perineal muscles) and thus strengthen the musculature and fascia of the pelvic floor. The patient need not be confined to bed during the intervals of the treatment. RELATION OF GONOBRHCEA TO DISEASES OF WOMEN. LITERATURE. Eockhart Beitrag zur Aetiologie und Pathologic des Harnrohrentrippen Sitzungsber d. Phyz. Med. Gesellsch. : Wurzburg, 1884. Bokai Ueber das Con- tagium der acuten Blennorrhcea : All. Med. Zeit., 1880, No. 74. Eumm Der Mikroorganismus der gonorrhoischen Schleimhaut Erkrankungen : "Wiesbaden, 1887. Cheyne, W, W. Suppuration and Septic Diseases : Pentland, 1889. Metschnikoff Virchow's Archiv., Vol. 107. Macdonald Latent Gonorrhoea in the Female Sex with special relation to the Puerperal State : Edin. Med. Jour., June 1873. Neisser Ueber eine der Gonorrhoe eigenthiimliche Micrococcusform : Cent, f iir die Med. Wissensch., 1879, No. 28; also Deutsch. Med. Woch., 1882. NoeggerathT>i& latente Gonorrhoe u. weiblichen Geschlect. : Bonn, 1872. Oppenheimer Unter- suchungen iiber den Gonococcus (Neisser) : Arch, fur Gynak., Bd. xxv., Hft. 1. Sdnger Ueber die Beziehungen der gonorrhoischen Infektion zu puerperale Erkrangungen : Verh. der Deutsch Gesell. fur Gynakologie, 1886. Schwarz Die gonorrhoische Infection beim Weibe : Volkmann's Sammlung, No. 279. Sinclair Gonorrhoeal Infection in Women : London, Lewis, 1888. Sutton Introduction to General Pathology : London, 1887. "W. J. Sinclair's work is the most valuable contribution to the English literature of this subject. Up till 1872, gonorrhoea in women was not considered a serious disease, and received little special attention from gynecologists. Noeggerath's work, the discovery of the importance of tubal disease, and, above all, the recent progress in Bacteriology, have alt tended to show that gonorrhoea is a most important factor in the causation of gynecological diseases. Noeggerath's clinical researches were specially important, as he enunciated the doctrine of latent gonorrhoea, i.e., the power of a chronic or even insignificant discharge in the male urethra, when of gonorrhoeal origin, to infect the female, and cause serious or even irremediable disease. His work has not only been amply confirmed, but his theory of the cause of gonorrhoea viz. the existence of some organism has now been fully established by the discovery of Neisser's gonococcus. Noeggerath asserted that cases of obscure peritonitis or other inflammatory affections in married women were due to an uncured gonorrhoea of the husband, acquired even years before marriage, and this doctrine, though disbelieved by many at the time, is now in great part held by most. A great stride was made in 1879 by the discovery of the gonococcus by Neisser. This investigator found that gonorrhoeal pus stained with 670 APPENDIX. methyl violet, and mounted in a way to be presently described, con- tained micrococci quite characteristic even on microscopical examination. They are diplococci with concave surfaces towards one another, and 2*2 2'5/t in length (p. 147). Since Neisser's discovery a very large amount of work has been published on this subject, and it has been estab- lished that this gonococcus is pathogenic only for gonorrhoea : it has been cultivated, though with difficulty, in human blood serum, and from pure cultivations, gonorrhoea has been inoculated in man (Bockhart and others). It has been also found (by Bumm especially) to be the cause of gonorrhoeal ophthalmia of infants. Many other interesting facts have been ascertained in regard to it, e.g. the interesting one that columnar epithelium is its special habitat, not squamous epithelium or connective tissue. Gonorrhoea is thus cervical, uterine, tubal, urethral : not, strictly speaking, vaginal, peritoneal, vesical. It contrasts with septic organisms which flourish well on squamous epithelium. It is alleged that some of the sequelae of gonorrhoea can only be accounted for by a form of mixed infection, i.e. where a septic organism has been superadded to the gonorrhoeal. This has been found to be the case in abscesses of Bartholin's gland and in suppurative parametritis. MetschnikofF s theory of inflammation applies well to gonorrhoea. We are to regard the gonococci as the invading army; the tissues, and more especially the leucocytes, as the defenders. As the disease advances the leucocytes capture the gonococci, expelling them in pus cells. Gradually the leucocytes conquer until the disease ends with inflammatory sequelae and few gonococci. This accounts well for all phases of the disease as well as for the difficulty with which gonococci are found in tubal mischief due to gonorrhoea. Gonorrhoea is thus a progressive local disorder due to the presence of a definite micro-organism which may exist for long in the male urethral tissues (latent), and may infect a healthy mucous membrane virulently when its action on its original habitat is trifling. Course in the female. When a woman is infected from an acute or subacute gonorrhoea of the male, she has ordinary gonorrhoea as usually described. The prognosis in such a case depends on the extent to which it spreads, and is serious when it becomes uterine or tubal. When the gonorrhoea is latent in the male we then get a case in many respects typical. The woman will usually give a history of good menstrual health prior to marriage. At a varying period after marriage she suffers from dysmenorrhoea, menorrhagia often, as well as pains in the iliac regions. Sterility is commonly the rule. There may be a history of vesical discomfort after marriage, but usually the women do not think of infection as the source of the mischief. On local examination there may be slight catarrh of the Bartholinian CASE-TAKING. 671 ducts, catarrh of the cervix, pelvic peritonitis in varying amount (acute, recurrent, or chronic) or such an amount of tubal mischief as to cause distinct lateral or posterior swellings. For diagnosis of these several conditions the student is referred back to the chapters of this Manual treating of such. Prognosis. Unfavourable. Treatment. It is evident that gonorrhoea in the male must be scrupu- lously treated that before the patient is pronounced cured the discharge should be examined for gonococci, and specially that the patient should report himself prior to marriage for further examination. The same holds good as to acute gonorrhoea in the female. The parts should be carefully disinfected with corrosive sublimate (1-2000), the patient being chloroformed if necessary in order that the sublimate solution be thoroughly rubbed in to the vulva and vagina. When the gonor- rhoea is cervical, the same may be done, but there is more risk of doing harm and adding a mischievous septic organism to the gonorrhoeal one. In the form often induced by latent gonorrhoea heroic treatment by disinfection is impossible, and therefore palliative treatment is best, as well as great attention to the general health. When distinct tubal mischief is present, removal of the appendages is indicated. For Examination of Gonococci in Pus. Clean two cover glasses and place a drop of pus on one. Put them in apposition and then separate them so as to get a thin film of pus on each. Dry above spirit lamp and apply a drop of methyl-violet stain. Drain off superfluous fluid with bibulous paper and again dry above lamp. Wash in distilled water, dry, and mount in Canada balsam. Examine with good microscope, oil immersion lens and Abbe's condenser. Gram's method does not stain gonococci, and thus, according to Roux, we have a further test. CASE-TAKING. LITERATURE. Emmet Gynecology, p. 57 : London, 1880. Simpson, A. R. Contribu- tions to Obstetrics and Gynecology, Method of Case-Taking in Gynecology, p. 317. It is of importance to give some hints as to case-taking or the investi- gation of cases of diseases of the female sexual organs. In hospitals, some form of case-taking card is usually employed ; and we purpose describing the method of case-taking adopted by Professor Simpson in the Buchanan Ward (for the Diseases of Women) in the Edinburgh Royal Infirmary (see page 672). We have drawn up a schedule 1 based on this card which will be found very convenient, either in private or in dispensary practice, for record- ing gynecological cases. Our first object is to learn all we can from the patient herself. This information is considered under six heads and comprised under the term ANAMNESIS, a convenient word, which literally means a " statement of what she recollects." 1 Supplied by Messrs W. & A. K. Johnston, Edinburgh, in separate sheets, or in book-form. 672 APPENDIX. The questions asked under " Sexual History " need little explanation. In regard to Menstruation as well as abnormal haemorrhage, we may note that when either follows Amenorrhoea of some weeks' or months' duration it makes us suspect abortion. Hsemorrhage coming on after the menopause usually indicates cancer, especially if followed by foetid dischai-ge (v. p. 474) ; patients may complain of bleeding after coitus (p. 474), which is often an early sign of carcinoma. As to Dysmenorr- hoea we should note whether the pain is before, during, or after the flow ; we should also enquire as to clots or shreds discharged, and the latter should be examined microscopically. For the various conditions with which Amenorrhoea, Menorrhagia and Dysmenorrhcea are associ- ated, see Index of Subjects under these heads and Chap. L. CASE-TAKING CARD. ANAMNESIS. 1. NAME ; AGE ; OCCUPATION ; RESI- DENCE ; MARRIED, SINGLE, OR WIDOW ; DATE OP ADMISSION. 2. COMPLAINT AND DURATION OF ILL- NESS. 3. GENERAL HISTORY OF (a) Present attack ; (b) Previous Health ; (c) Diathesis ; (d) Social Condition and Habits ; (e) Family Health. 4. SEXUAL HISTORY. (1) Menstruation A. Normal (a) Date of Commence- ment ; (6) Type ; (c) Duration ; (d) Quantity ; (e) Date of Dis- appearance. B. Morbid (a) Amenorrhosa ; (6) Menorrhagia ; (c) Dysmenorrhcea. (2) Intel-men strual Discharge (a) Character ; (6) Quantity. (3) Pareunia. (4) Pregnancies (a) Number ; (6) Dates of First and Last ; (c) Abortions ; (d) Character of Labours ; (e) Puerperia ; (/) Lactations. 5. LOCAL FUNCTIONAL DISTURBANCES (a) Bladder ; (b) Rectum ; (c) Pelvic Nerves and Muscles. 6. GENERAL FUNCTIONAL DERANGE- MENTS (a) Nervous System ; (6) Respiratory System ; (c) Circulatory System ; (d) Diges- tive System ; (e) Emunctories. PHYSICAL EXAMINATION. 1. GENERAL APPEARANCE AND CON- FIGURATION. 2. 3. ABDOMEN (a) Inspection ; (b) Palpa- ; tion ; (c) Percussion : (d) Auscultation ; (e) Mensuration. 4. EXTERNAL PUDENDA. 5. PER VAGINAM (a) Orifice ; (6) Walls and cavity ; (c) Roof ; (d) Os and Cervix Uteri. 6. BIMANUAL EXAMINATION (Abdomino- vaginal, Recto-vaginal, Abdomino-rectal, Abdomino-recto- vaginal, Abdomino-vesico- vaginal) (1) Uterus (a) Size ; (6) Shape ; (c) Con- sistence ; (d) Sensitiveness ; (e) Position ; (/) Mobility ; (g) Rela- tions. (2) Fallopian Tubes. (3) Ovaries (a) Size ; (6) Situation ; (c) Sensitiveness. (4) Peritoneum and Cellular Tissue. (5) Bladder. (6) Rectum. (7) Pelvic Bones. 7. USE OF (a) Speculum ; (b) Volsella ; (c) Sound ; (d) Curette ; (e) Aspiratory Needle ; (/) Tent. 8. PHYSICAL CHANGES IN (a) Nervous, (b) Respiratory, (c) Circulatory, (d) Digestive, (e) Emunctory Organs ; (/) Skin ; (g) Bones. DIAGNOSIS. PROGNOSIS. TREATMENT. PROGRESS AND TERMINATION. CASE-TAKING. 673 Intermenstrual discharge. Ascertain its colour ; its amount Whether it requires the use of diapers ; and whether it be foetid, watery, or acrid. Leucorrhoea is present in vaginitis (p. 528), cervical catarrh (p. 308), endometritis (p. 323), and wherever there is secondary catarrh of the uterine mucous membrane as in retroflexion (p. 366) and uterine polypi (p. 453) ; it is also present in Chlorosis and Phthisis. Foetid Leucorrhoea is characteristic of Carcinoma, whether affecting the cervix (p. 474) or body FIG. 397. OUTLINE DIAGRAM OF ABDOMEN FOR RECORDING POSITION OF TUMOURS RELATIVE TO THE BODY LANDMARKS. of the uterus (p. 502) ; in Sarcoma, it is not foetid till the later stages (p. 508). For other references to Leucorrhcea, see Index of Subjects. Pareunia. This refers to the absence or presence of pain during coitus (v. p. 531). It is enquired into only in special cases, or when the patient complains of the pain. For conditions producing dyspareunia, see Index of Subjects and page 531. PHYSICAL EXAMINATION. The general appearance and configuration should always be noted. The sallow look of the dyspeptic and consti- pated, yellow appearance of the chlorotic, pinched face of the patient 2u 674 APPENDIX. with ovarian cyst, are in some cases helpful in giving the hint as to the line of enquiry. The student should always note anything in the appear- ance or configuration which may enable him to recognise the diathesis of the patient. It is of importance to ascertain the occurrence of the gouty diathesis in a case of dysmenorrhcea, the tubercular diathesis in chlorosis, and the strumous in syphilis. The physician will be puzzled by the varied complaints of the patient over some slight pelvic inflammatory condition, unless he note the thin and anxious face of a patient of nervous temperament. Information gained in this way is valuable, but must be used with discrimination. Thus cancerous patients are often florid enough, while a sallow cachectic-looking woman may have some insignificant lesion. 'a, FIG. 398. OUTLINE DIAGRAM OF PELVIS FOR FILLING IN POSITION OF UTERUS OR TUMOURS (A. R. Simpson). Mammae. Note whether virginal, or those of Pregnancy or Lactation. The abdomino-vaginal examination is the ordinary Birnanual. The abdomino-vesico- vaginal is a rare form but useful in some cases (p. 600). The tent is not used as a mere diagnostic except in the case of tumours in the cavity of the uterus. Prognosis. A great deal depends on this. Thus we have to tell the patient whether her lesion is serious or slight, whether she will get well soon, or if her trouble is chronic but not dangerous. Unless she is told that it is chronic, she may ultimately come to the conclusion that its nature has been misunderstood by the physician. Prognosis is often difficult to give and should always be cautious, especially as to sterility. Treatment. In no class of cases has the physician to be so careful not to do harm by his treatment. All operations should be carefully SOURCES OF GYNECOLOGICAL LITERATURE. 675 considered, and only undertaken when \ve feel fairly confident they will benefit and not make the patient worse. The great success of peri- toneal operations is now undoubted ; but the question as to the actual good resulting from repeated cauterisation of the uterine mucous mem- brane, division of the cervix, stitching of the cervix, etc., is more sub lite than is admitted in many text-books. The problem of how to remove cervical cancer without risk to life and with a fair hope of its non- FIG. 399. OUTLINE DIAGRAM PELVIS AS SEEN THROUGH THE BRIM, TO FILL IN POSITION OF TUMOURS RELATIVE TO UTERUS (Schultze). recurrence is at present being worked out. Unfortunately the patient has frequently a return of the disease. SOURCES OF GYNECOLOGICAL LITERATURE. At the beginning of each subject we have already given a summary of the literature to which we were indebted. The literature given, there- fore, represents what we considered important, and what we had in most cases personally studied. Gynecological Literature is so extensive that a full resume of it would have occupied several times the space we have allotted to the whole subject. We wish however to point out here the sources, so that any practitioner who wishes to ascertain the best books and monographs on any special subject may know how and Avhere to begin his search. The sources of Gynecological Literature are threefold : I. Catalogues, Dictionaries; II. The larger Text-books of Gynecology ; III. Articles and Abstracts in the various Gynecological quarterlies, monthlies, and weeklies, with Retrospects and Jahrbucher. 676 APPENDIX. I. CATALOGUES, DICTIONABIES. (1.) Index- Catalogue of the Library of the Surgeon- General's Office, U.S.A. Washington Government Printing Office. In this splendid work, the authors and works are arranged alphabetically ; its value cannot be over- rated. (2.) Nouveau Dictionnaire de Medecine et de Ohirurgie pratique: Paris, J. B. Baillie're et Fils. Dictionnaire Encyclopedique des Sciences Medicales: Asselin et Cie, Paris. Real-Encyclopddic der gesammten Heilkunde : Wien. Wood's Cyclopcedia. Annual of the Universal Medical Sciences (edited by Sajous) : Philadelphia. Buck's Reference Handbook of the Medical Sciences : New York. (3.) (4.) II. LARGER MODERN TEXT-BOOKS OP GYNECOLOGY. ENGLISH. Barnes Diseases of Women : London, J. & A. Churchill. Byford Medical and Surgical Treatment of Women : Philadelphia. Duncan, Matthews Diseases of Women : London, Churchill. Edis Diseases of Women : London, Smith, Elder, & Co. Emmet Principles and Practice of Gynecology : Philadelphia, Lea's Son & Co. Goodell Lessons in Gynecology : Philadelphia, Brinton. Hewitt The Diseases of Women : London, Longmans, Green & Co. Mundt Minor Surgical Gynecology : New York, Wood & Co. Simpson, A. R. Obstetrics and Gynecology : Edinburgh, A. & C. Black. Simpson, Sir J. Y. Diseases of Women : (edited by A. R. Simpson) : A. & C. Black. Sims, J. Marion Uterine Surgery : London, Hardwicke. Skene, A. J. C. The Diseases of Women, Treatise on : London, Lewis. Ta.it, Lawson Diseases of Women : W. Wood & Co., New York. The Pathology and Treatment of Diseases of the Ovary : Bir- mingham. Diseases of Women and Abdominal Surgery, Vol. I. : Leicester, Richardson & Co. Thomas Treatise on Diseases of Women : London, Kimpton. Thorburn Diseases of Women : Griffin, & Co., London. Wells, Sir T. S. Ovarian and Uterine Tumours : London. West (Duncan's Edition) Diseases of Women : Churchill. GERMAN. Fritsch Krankheiten der Frauen : Braunschweig. Hegar und Kaltcnhach Die operative Gynakologie, 3te, Aufl : Stuttgart, Enke. Hofmeier Grundriss der Gynakologischen Operationen : Leipzig. Schroeder Handbuch der Krankheiten der weiblichen Geschlechtsorgane : Leipzig, Vogel. Winckel Lehrbuch der Frauenkraukheiten : Hirzel, Leipzig. Handbuch der Frauenkrankheiten redigirt von Billroth u. Luecke : Enke, Stuttgart. I. Band. Die Untersuchung der weiblichen Genitalien und allgemeine gyniikolo- gische Therapie Chrobak. Die Sterilat der Ehe. Entwickelungsfehler des Uterus Midler. Die Lageveranderungen und Entziindungen des Uterus Fritsch. II. Band. Die Neubildungen des Uterus Gusseroio. Die Krankheiten der Ovarien Olshausen. Die Krankheiten der Tuben, der Ligamente, des Becken-peritonilum und des Beckenbindegewebes, einschliesslich der Extrauterinschwanger- schaft Bandl. III. Band. Die Krankheiten der weiblichen Brustdriisen Billroth. Die Krankheiten der ausseren Genitalien und die Dammrisse Zweifd. Die Krankheiten der weiblichen Harnrohre und Blase Winckel. Die Krankheiten der Vagina Breisky. SOURCES OF GYNECOLOGICAL LITERATURE. 677 FRENCH. Bernutz and Goupil Clinical Memoirs on the Diseases of Women : Sydenham Society Tr. Courty Traite pratique des Maladies de 1'uterus, 2nd Edition : Paris, Asselin : also Dr. Agnes Maclaren's Translation, London. De Sinety Manuel Pratique de Gynecologic : Paris, Doin. Leblond Traite elementaire de Chirurgie gynecologique : Paris. 2Vtpwr Legona cliniques sur les Maladies des Femmes : Paris, Doin. III. JOURNALS : RETROSPECTS : INDEXES : JAHRBUCHER. American Journal of Obstetrics : New York, "Wm. "Wood & Co. British Medical Journal : London. Cassell's Year Book of Treatment. Dublin Journal of Medical Science : Dublin, Fannin & Co. Edinburgh Medical Journal : Edinburgh, Oliver & Boyd. Glasgow Medical Journal : Glasgow, MacDougal. International Journal of Medical Sciences : Lea's Son & Co., Philadelphia; Cassell & Co., London. Lancet : London. London Medical Record : Smith, Elder & Co. Medical Press and Circular : London. New York Medical Journal and Obstetrical Review : New York, Appleton & Co. ; and London, Cassell & Co. Reference Handbook of Medical Sciences : Wood & Co., New York. Archiv fur Gynakologie : Berlin, Hirschwald. Berliner klinische Wochenschrift. Centralblatt fiir Gynakologie : Leipzig, Breitkopf und Hartel. Zeitschrift fur Geburtshtilfe und Gynakologie : Stuttgart, Enke. Archives de Tocologie et des Maladies des Femmes, etc. : Paris, Delahaye et E. Lecrosnier. Annales de Gynecologic, Paris. Annali di Ostetricia, Ginecologia e Pediatria : Milano, Pietro Agnelli. Braithewaite's Retrospect : London, Simpkin, Marshall & Co. Index Medicus : a monthly classified Record of the current Medical Literature of the World : G. S. Davis, Boston and Detroit, U.S.A. Annual of the Universal Medical Sciences (Edited by Sajous) : Davis, Philadelphia. Schmidts's Jahrbiicher : Leipzig. Supplement to Ziemssen's Cyclopaedia : London, Sampson Low, Marston, Searle, & Rivington. Revue des Sciences Medicales : Paris, E. Masson. Neale's Digest : London, Ledger, Smith & Co., 1882. American Gynecological Transactions (Index at end) : Boston, Houghton & Co. London Obstetrical Transactions : Longmans, Green & Co. Edinburgh Obstetrical Transactions : Oliver & Boyd. In looking up literature on any special subject, first consult the litera- ture given at the beginning of each chapter and then the index of Recent Gynecological Literature in the Appendix. The list of literature given in Billroth and Luecke's Handbuch, the Index Medicus, Neale's Digest and the U. S. A. Index Catalogue may also be consulted with advantage. The various Retrospects and Jahrbiicher mentioned above give abstracts of the papers, and the French and German Cyclopaedias give special exhaustive articles on each subject. X OP INDEX OF RECENT GYNECOLOGICAL LITERATURE. The following index aims at giving reference to all the important contri- butions to Gynecological Literature in the leading journals from January 1886, 1 the year in which the last edition of this Manual was published, to the end of 1888. The purpose is not to enable the reader to lay his hand on the papers of particular authorities (as this has already been done in the ordinary index of each Journal), but to gather together for him, from the best and most accessible Journals, all the material con- nected with the subject he may be reading up. The journals indexed are the following : British Medical Journal, contraction Brit. Med. Jour. ; Lancet, Lancet ; Edinburgh Medical Journal, Glasgow Medical Journal, Dublin Journjil of Medical Science, American Journal of Obstetrics, Archiv ftir Gynakologie, Centralblatt ftir Gynakologie, Zeitschrift fiir Geburtshiilfe und Gynakologie, Volkmann's Sammlung, Archives de Tocologie, Annales de Gynecologic, Annali di Ostetricia, Edin. Med. Jour.; Glas. Med. Jour.; Dub. Med. Jour.; Amer. Jour. Obstet.; Archiv f. Gyn. ; Centralb. f. Gyn.; Zeitsch. f. Geb. und Gyn.; Volk. Samml.; Archiv. de Toe.; Annal. de Gyn.; Annal. di Ostet. The topics have to a certain extent been classified and grouped alpha- betically. Under each topic the papers are arranged in order as they appear in each volume of the journal ; this will enable the reader, as he happens to have access to the volumes of a journal, to refer to all the papers in it which bear on that topic. The catch-word indicates the drift of the paper, which in getting up the literature of a subject is more useful than the writer's name ; in operations, however, the name of the operator is given. Our aim has been to make an index which will give references to sources within the reach of the majority of practitioners. Transac- tions of Societies, containing papers in full, are not to be found in 1 The literature of the preceding three years will be found in the Third Edition. 682 APPENDIX. all libraries ; hence we have preferred to give the reference to Journals which may perhaps only refer to the paper, and the reader desiring further information must go to the Transactions themselves. Reference to the Proceedings of the Societies and Associations will be found in the Journals as follows : London Obstetrical Society, British Gyneco- logical Society, and many papers in other English Societies, Brit. Med. Jour, or Lancet ; Edinburgh Obstetrical Society, Edin. Med. Jour. ; Obstetrical Section of British Medical Association, Brit. Med. Jour. ; Obstetrical Section of Academy of Medicine of Ireland, Dub. Med. Jour. ; New York and Philadelphia Obstetrical Societies and American Gyne- cological Association, Amer. Jour. Obstet. ; Societe Obstetricale et Gyne- cologique de Paris. Societe de Chirurgie, Academic des Sciences, Societe medicale des Hdpitaux, in Archiv. de Toe. or Annal. de Gyn. ; Gesell- schaft fur Geburtshiilfe und Gynakologie zu Berlin, and Gynecological Section of the Versammlung deutscher Naturforscher und Aertzte, in Zeit. f. Geb. u. Gyn., Archiv f. Gyn., or Centralb. f. Gyn. INDEX OF RECENT GYNECOLOGICAL LITERATURE. })ol: I Ml ABDOMINAL SURGERY. BRIT. MEU. JOUR. 1886, I. 193, For small pelvic tumours by Cullingvvorth ; 350, Removal of large fatty tumourof omentum by Meredith ; 410, Ideal cholecystotomy ; 930, 1042, Peri- toneal surgery; 1063, 110!', 11(37, Cases by Mayo Robson ; 11 Oil, Laparotomy for cystic myoma, Walter ; 1170, Laparotomy for hydatid tumours. 1886, II. 433, Extirpation of \ Cyst of omphalo-mesenteric duct by Schoad ; 852, General principles in removal of uterine appendages. 1887, I. 170, Puncture with aspirating needle ; 355, 417, 480, 541, 592, 647, 697, Skene Keith's statistics of ; 480, Ascites after laparotomy ; 568, Exploratory lapar- otomy ; 593, 698, 752, Ventrotomy as term for ' Abdominal Section ; ' 776, Sequel to gastro- enterostomy ; 975, 1031, Abdominal section ! by Sir W. MacCormac for intra-peritoneal injury ; 1000, Treatment of intra-peritoneal | injury ; 1178, Laparotomy in America. 1887, II. 17, For venal hydatids by Imlach ; 727, Puncture of the heart in chloroform ' oisoning ; 829, Abdominal section by Lamniiman for stoppage of the bowels ; 1061, i Laparotomy for peritonitis ; 1442, Laparotomy ' in puerperal fever. 1888, I. 128, Three t unusual cases of abdominal section by Stuart Nairne; 136, Laparotomy by Chitton for obstruction from gall-stone ; 711, Menstrual bleeding from a laparotomy scar ; 932, Lapar- otomy by Von Dutel, for acute cystitis ; 971, Section by Garrigues for ruptured uterus. 1888, II. 172, Some aspects of; 938, Some points affecting the mortality of abdominal section ; 1050, Laparotomy by Keetley for suppurative peritonitis ; 1096, Lawson Tail's conclusions from a second series of one thousand sections ; 1336, Abdominal section by M'Mordie for large fibroid ; 1403, Flushing the peritoneum. LANCET. 1886, I. 343, Note on abdominal sections ; 1222, Abdominal section by Wade, for ovarian and fibroid tumour at same time. '. 1886, II. 669, Two cases of abdominal section by Underbill ; 774, Three cases of section by Imlach. 1887, I. 310, Section, by Mackay, for pelvic suppuration ; 518, 568, An hundred consecutive sections, by Granville Bantock ; 503, Inaugural address to Obstet. Soc. London ; 586, Section, statistics of at Kieff ; 622, Section by Elder, for pyosalpinx and sub-peritoneal myoma ; 1134, Cases of section by Truman. 1887, II. 205, 257, Sixty-four cases of section by Cullingworth ; 800, Condition and manage- ment of the intestine after section ; 1008, Seven consecutive laparotomies, by Balls- Headley ; 1111, Supra-pubic incision by Gibbons and Parker, for removal of tumour from female bladder ; 1203, Purgation (hiring convalescence after section. 1888, I. 268, Two cases of laparotomy by Homans, for tubercular peritonitis ; 470, Review of three hundred and eighty-four laparotomies by Homans ; 681, Section for extra-uterine gestation, by Rutherford Morison ; 719, Section for peritonitis, by Smith and Burford ; 919, Ctesarean section for impacted fibroid ; 1132, Five cases of Section by O'Callaghan. 1888, II. 675, Section by Lawson Tait, for congenital cyst of urachus ; 803, 855, Second series of sections by Cullingworth ; 817, Mortality of Abdominal Section ; 904, Cases, by Neve; 1002, Section by Bull, for hydatid cyst of the liver ; 1005, By Pepper, for double tubercular pyosalpinx and strangulated femoral hernia ; 1170, Two coses of section by Mayo Robson for tubercular peritonitis. EDIN. MED. JOUR. XXXI., II. 1066, 1142, Lawson Tait on Abdominal Section ; 1176, Treatment of fibrornyomata by laparotomy. XXXII., I. 212, Successful laparotomy by Wallace ; 466, On the so-called laparotomy epidemic. XXXII., II. 673, 736, Series of sections by Halliday Groom ; 954, Intestinal obstruction after abdominal operations. XXXIII. , II. 1001, Deep-buried continuous animal suture in laparotomy. XXXIV., I. 40, 140, Notes of a year's work in, Rutherford Morison; 117, 171, Twelve laparotomies by GLAS. MED. JOUR. XXVIII. 101, Thirty cases of section, by Cameron. DUB. MED. JOUR. LXXXI. 500, Laparotomy for intestinal obstruction. LXXXII. 1, 115, So-called laparotomy epidemic. LXXXVI. 75, Notes of five cases of section by O'Callaghan ; 456, An abdominal salpingotomy in the last century. AMER. JOUR. OBST. 1886. 44, Section by Kelly for removal of cervical fibroids ; 59, Acute pulmonary radema following lapar- otomy ; 62, Inclusion of a piece of omentum in a glass drainage-tube ; 65, Extra-peritoneal incision for small pelvic abscess, by Polk ; 88, In England, Scotland, and Heidelberg ; 113, Treatment of pelvic abscess by incision and drainage ; 272, Ventral hernia following lapar- otomy ; 414, A year's work in laparotomy, Goodell ; 408, Laparotomy for myoma ; 468, Ibid. ; 469, Ibid. For pyosalpinx ; 471, Explor- atory incision ; 491, Exploratory puncture and excision ; 551, Four cases with remarks by Eastman ; 611, Indications for drainage after laparotomy ; 013, Laparotomy for double cystomaovariipapillare, Lee ; 645, Laparotomy for pelvic abscess ; 663, Statistics of abdominal section ; 671, Laparotomy for traumatic rupture of the gravid uterus ; 825, Statistics of abdominal section ; 869, After-treatment of lai>arotomy ; 897, Glimpse of laparotomy in Europe ; 971, Section for pelvic abscess ; 992, lodoform in severe laparotomy; 1169, Lapar- otomy for tu bo-ovarian abscess, by Kelly ; 1136, Thirty-three laparotomies by Helmuth ; 1259, Laparotomy for intestinal obstruction, Wylie ; 1201, Ibid, for doubtful ovarian cyst, Hunter; 1271, Laparotomy followed by multiple neuro- mata of abdominal wall ; 1296, Laparotomy for extra-uterine pregnancy, by Muratow ; 684 APPENDIX. 1297, Intestinal disturbance after abdominal operation. 1887,25, 52, Ventral Hernia caused ; by Ijjtparotomy ; [>4, Irrigation in collapse during laparotomy ; 58, Laparotoniy for pyp- salpinx with abscess of one ovary, Mmide ; 180, Thirty-one cases, Price ; 449, Laparotomy ' for solid uterine and ovarian tumours, Mann ; j 669, A laparo-salpingotomy in 1784 ; 721, Two ' laparotoniies with same patient, Kin loch ; I 74'.i, Sections, by Price; 753, Section for intestinal perforation, Haynes ; 932, Lapar- i otomy for tuberculosis of peritoneum, Van de j Warker ; 1048, Drainage after laparotomy ; , 1058, Death from rare cause after laparotomy ; j 1000, Operation for ventral hernia after lapar- otomy ; 1154, Primary laparotomy for extra- j uterine ; 1183, Acute dilatation of stomach j after laparotomy ; 12C9, Peculiar cases of section ; 127!', Laparotoniy for tube and i ovarian cyst, Nilsen. 1888. 15,136, A year's j work in laparotomy, Munde ; 99, During tuberculosis of peritoneum, Fehling ; 15(5, i Laparotoniy for large fibroid, by Romans ; ' 321, Exploratory incision, Montgomery ; 408, Laparotomy for septic peritonitis, Boldt ; 410, \ Laparotomy for hystero-epilepsy, Lee ; 513, i Laparotomy for removal of uterine appendages, death from ether ; 734, Lapar- , oiomy during 1887, Goodell ; 874, A year's work in, Dudley ; 916, Ibid., Eastman ; 31, Five successive laparotomies ; 945, Hysterec- tomy, ovariotomy, and abdominal section on one subject, Baldy ; 1006, Injury to bladder , dviring laparotomy, Sanger ; 1069, Indications for drainage in ; 1076, Laparotomy in peri- tonitis ; 1078, Relation of abdominal surgeon to the obstetrician and gynecologist ; 1116, Intestinal occlusion after laparotomies ; 1183, Exploratory laparotomy, carcinoma and fibroid, Nilsen ; 1209, Laparotomy for removal of uterine appendages, Hall ; 1302, Twelve months of abdominal and vaginal section, Byford ; 1303, Abdominal Surgery, Price. ARCH1V F. GYN. XXXI. 464, Laparotomy for tuberculosis of peritoneum. XXXII. 465, Injury to bladder during laparotomy, Sanger ; 507, Constriction of gut after lapar- otomy. CENTKALB. F. GYN. X. 27, Laparotomies by Schrainm ; 41, Laparotomy for tubercular peritonitis, Naumaun ; 110, Laparotomy for hernia, Wiesmann ; 214, Parotitis after laparotomy ; 227, Sublimate in laparotomy ; 497, Laparotomy, Nagel ; 649, Laparotomy for myoma, Hager ; 745, Laparotomy for inversion, Schmalfuss. XI. 201, Laparotomy in Russia, 1784; 594, Laparotomies, Schultze ; 753, Peritonitis after laparotomy ; 790, Laparotomy for haematometra and haematosalpinx, Trzebicky ; 822, Laparotomy in tubercular peritonitis, Schmalfuss. XII. 10, 91, Death after laparotomy ; 217, Laparotomy on second day of puerperium, Sippel ; 319, Laparotomy in pregnancy ; 406, Repeated laparotomy, Martin ; 456, Ibid. ; 690, Iversen on. VOLK. S AMM L. No. 339, Sixty cases of laparo- myotomy, Fritsch. ARCH1V. DE TOO. 1887. 577, Laparo- elytrotomy, Clarke. ANNAL. DE GYN. XXIX. 255, Drainage and antiseptic packing of peritoneum. XXX. 108, Laparotomy for salpingitis and ovaritis, Terrillon. ANNAL. DI OSTET. 1888. 164, Elastic ligature for intra-peritpneal treatment of pedicle ; 215, Cases of Section, Sani ; 370, Seven cages of Section, Fasola. ABDOMINAL TUMOURS (and unclcused Pelvic Tuntnurg). BRIT. MED. JOUR. 1886, II., 978, Twelve Cases of extra-peritoneal cysts. 1887, I. 132, The heart and large abdominal tumours ; 782, Mucous polypus. 1888, II. 1222, Fibroid tumours undergoing calcareous degen- eration. LANCET. 1887, II. 213, Successful removal of abdominal cyst of large size, by Robson. 1888, I. 1015, 1067, On cardiac degeneration produced by pressure of. EDIN. MED. JOUR. XXXI, II. 881, Removal of tumours of abdominal wall with their peritoneum, by Sanger. AMER. JOUR. OBd. 1886. 1216, Non-ovarian dermoid ; 1271, Multiple neuromata of abdominal wall following laparotomy. 1887, 65, Sarcoma. 1888, 1093, Desmoid of abdominal wall ; 1102, Fibroids of abdominal wall ; 1110, Opening of cystic l>y two operations, Keil. CENTRALB. F. GYN. X. 78, Exploratory incision in, Terillon ; 115, Echinococcus ; 120, Ischuria after extirpation of ; 281, Echino- coccus ; 299, Deep abdominal wall abscess ; 710, Echinococcus. XII. 790, Cases, Minkowski. ZEITSCH. F. GEB. UND GYN. XIV. 413, Of wall. ARCHIV. DE TOG. 1887. 473, 517, Phleg- monous tumour close to uterus ; 857, Multiple hydatid cyst. ANNAL. DE GYN. XXV. US, Accidents to intestine in. XXVI. 18, Sub-peritoneal myoma in pregnancy, with peritonitis. ANNAL. DI OSTET. 1887. 148, Echinococcus. 1888. 1, Echinococcus of spleen. AMENORRHCEA. BRIT. MED. JOUR. 1886, II. 1114, Binoxide of Manganese in. 1887, I. 926, Treatment. 1888, I. 1383, Associated with Alcoholism. 1888, II. 876, From imperforate hymen. LANCET. 1886, I. 61, Santonin in ; 132, Ibid. ; 286, Ibid. ; 789, Treatment ; 1133, Permanganate of Potash in. EDIN. MED. JOUR. XXXI., II. 1176, Santo- nine in. DUB. MED. JOUR. LXXXI. 34, Oxalic acid as an emmenagogne. LXXXII. 436, Note on. LXXXV. 85, Potassium permanganate. AMER. JOUR. OBS. 1886. 496, Endometritis fungosa with amenorrhoea. 1887. 1112, Intra-uterine stem as an emmenagogue. 1888. 445, In connection with diabetes inellitus and insipidus. CENTRALB. F. GYN. X. 32, Manganese in. ZEITSCH. F. GEB. UND GYN. XIV. 194, In diabetes. ARCHIV. DE TOO. 1886. 539, Oxalic acid as an emmenagogue. ANAESTHESIA. BRIT. MEU. JOUR. 1887, 1. 451, 674, 888, Drumine ; 800, Menthol ; 819, "Analgesics;" 876, Effects of cocaine; 927, Cocaine; 1126, Methylol ; 1229, Cocaine habit and addiction, 1400, Subcutaneous infection of cocaine. 1887, II. 68, 132, Dmmine ; 216, Cocaine in operation for anal fistula ; 507, Insanity following anaesthetics ; 727, Puncture of the heart in chloroform poisoning ; 729, Steno- carpine ; 894, Methylol; 1021, Deaths from chloroform ; 1181, Carbonic acid ; 1199, Insanity following. 1888, I. 19, Pleasant anaesthetic mixture ; 87, Amylene hydrate or tertiary amyl alcohol ; 100, Cocaine poisoning ; 279, Drumine ; 317, The Haya poison ; 323, And respiration ; 349, Alarming symptoms from spraying throat with cocaine ; 438, Cocaine poisoning ; 490, Local ; 545, Erythrophhein ; 549, Amylene hydrate ; 604, Haya poison and Erythrophloaum ; 709, Cocaine and its salts ; 757, Cocaine poisoning ; 864, Sulphonal ; 918, Boldin ; 933, Menthol ; INDEX OF RECENT GYNECOLOGICAL LITERATURE. 685 902, Hypnotism ; 1171, 1248, Etherisation : an unrecognised danger ; 1184, Canadol ; 1211, Methylene and other local anaesthetics ; 1213, 1308, Codeine to relieve pain in abdominal disease ; 1301, Methylene ; 1382, Use of codeine. 1888, II. 203, Methlyene ; 243, Chloride of Methyl ; 243, Helleborin ; 274, Methylin ; 450, Local ; 454, Methylene ; 1071, Death from chloroform ; 1124, Antipyrin ; 1239, " Nerves " and. LANCET. 1886, II. 411, Cocaine. 1887, I. 105, Extractum kavadepuratum ; 587, Cocaine ; 780, Ibid., dangers of ; 1089, Selection and administration ; 1297, Death from chloroform and fear. 1887, II. 519, Cocaine ; 616, Notes on anaesthetics ; 616, Guide to administration ; 858, Cocaine ; 1265, Poisoning by cocaine sub- cutaneously. 1888, I. 14, Experience of cocaine ; 119, Cocaine in reflex vomiting ; 190, Erythrophkein ; 380, Cocaine in urethral operations ; 394, Cocaine poisoning ; 590, Cocaine and its salts ; 871, Novel extension of uses of cocaine ; 572, Toxic effects of cocaine subcutaneously injected ; 1013, In grave constitutional disorders ; 1024, Antipyrin as an anodyne ; 1041, Acute and chronic cocaine poisoning. 1888, II. Combined chloroform and Cocaine ; 523, Use of Anaesthetics ; 689, 839, The teaching of ; 715, Toxic effects of Cocaine ; 863, Dosage of chloroform ; 888, Use of ; 1144, Chloroform as a routine anaesthetic ; 1220, Introduction of ether inhalation into London. EDIN. MED. JOUR. XXXIV., I. 477, Helleboreine. GLAS. MED. JOUR. XXVIII. 262, Use of the more common anaesthetics. XXIX. 173, Ether or Chloroform which? DUB. MED. JOUR. LXXXI. 247, Hypnone ; 2S5, Urethran. LXXXIL 95, Urethran ; 525, The cocaine habit. LXXXIII. 150, Poisoning by cocaine ; 313, On cocaine ; 406, Test for cocaine ; 456, Coca, cocaine and its salts. AMER. JOUR. OBS. 1886. 100, Nitrous oxide with oxygen ; 1118, Cocaine in plastic surgery ; 1264, Cocaine. 1888. 513, Death from ether during laparotomy for removal of appendages. ARCH IV F. GYN. XXVIII. 500, Cocaine in plastic surgery. XXXI. 380, Apparent effects of Cocaine. CENTRALS. F. GYN. X. 392, Local in peri- neal operations. XI. 751, Heart-puncture in chloroform narcosis. ANTISEPTICS. BRIT. MED. JOUR. 1887, I. 155, Poison- ing by Corrosive Sublimate ; 451, 674, Dru- mine ; 782, Antiseptic dressing ; 1124, Corrosive Sublimate in intra-uterine irrigation. 1887, II. 365, Tissue resistance and antiseptism ; 729, Antiseptic duels ; 946, Eucaline antiseptic poultice ; 1387, Sodium silico-fluoride. 1888, I. 148, Acidified corrosive sublimate ; 150, Comparison of chlorides, nitrates, and sul- phates ; 157, Antipyrin and creolin ; 295, Acidified corrosive sublimate ; 491, Naphthol ; 555, Photoxyline as a surgical dressing ; 898, Chemical incompatibility of antiseptic agents ; 970, Chloroform water ; 980, Vaginal anti- sepsis ; 1084, Dangers of; 1185, Naphthol /3. 1888, II. 720, Corrosive-sublimate poisoning ; 1061, Creolin. LANCET. 1887, I. 595, lodoform. 1887, II. 775, Creolin v. Carbolic Acid ; 847, Anti- septic treatment of wounds. 1888, I. 1142, Microbes on skin and suppuration ; 1246, New antiseptic surgical dressing. EDIN. MED. JOUR. XXXIV., I. 476, Quino- GLAS. MED. JOUR. XXVIII. 397, Bantock on Listerism. DUB. MED. JOUR. LXXXIL 410, Salol. LXXXIII. 535, Lepine on. AMER. JOUR. OBS. 1886. 1076, Asepsis not Antisepsis. 1887. 335, Poisoning from sublimate; 781, lodoform gauze. CENTRALB. F. GYN. X. 546, 616, Corrosive sublimate ; 761, Poisoning from corrosive sublimate. XI. 81, Asepsis in uterine dilators ; 177, lodoform gauze ; 249, Corrosive sublimate ; 569, 585, Corrosive-sublimate poisoning. XII. 1, lodoform ; 65, Corrosive- sublimate poisoning ; 324, Creolin ; 449, Dis- infection of genital canal. ARCHIV. DE TOO. 1887. 385, Doleris on. ANNAL. DE GYN. XXIX. 255, Antiseptic packing of peritoneum. ANATOMY. BRIT. MED. JOUR. 1888, I. 44, Fallacies in frozen sections. LANCET. 1887, I. 1181, Rare condition of veins in anterior vaginal wall. 1888, 1. 1250, Criticism of Waldeyer's section. EDIN. MED. JOUR. XXXTV., I. 425, Labia minora and hymen. AMER. JOUR. OBSTET. 1888. 1115, Median frozen sections, Winter. CENTRALB. F. GYN. X. 229, Strength and action of abdominal muscles. XI. 260, Position of internal genitals of nulliparae. BATTEY'S OPERATION. (See Oophorectomy.) BRIT. MED. JOUR. 1887, I. 576, Compared with Normal Ovariotomy and Tait's Opera- tion. AMER. JOUR. OBS. 1887. 1061, Natural results. ANNAL. DE GYN. XXIX. 416, And fibroid, Segond. BLADDER. BRIT. MED. JOUR. 1886, I. 196, Antiseptic catheter. 1886, II. 117, Calculus in woman ; 1213, Suprapubic lithotomy in an elderly woman. 1887, I. 132, Diagnosis of tumours; 1094, Cancer of; 1164, Foreign body in ; 1364, Ibid. 1887, II. 93, Cystitis of a mixed mycotic origin ; 123, Suprapubic lithotomy in elderly female by Galgey ; 431, Hairpin in ; 993, Lithotrity in a girl aged 11. 1888, I. 1, 57, Tumours of the bladder; 601, Electrical illumination of ; 645, Sarcoma of ; 775, Leiter's endoscope in treatment of vesical disease ; 785, Value of electric illumination of ; 1059, Sloughing of; 1059, Sarcoma of; 1247, Electric illumination of. 1888, II. 621, Pessary for prolapse of. LANCET. 1886, II. 165, Foreign bodies; 252, Calculus removed per urethram by Bout- flower. 1887, I. 332, Alleged toxic effects of cocaine on. 1887, II. 65, Suprapubic cystotomy, by Jones, for papilloma ; 561, Cystotomy, by Collis Barry, in advanced vesical cancer; 1111, Removal of tumour of, by Gibbons and Parker ; 1164, Primary cancer of. 1888 I. 275, Etiology of vesical tum- ours ; 347, Effects of rapid emptying ; 505, 607, Ibid., correspondence; 763, Diagnosis of tumour by electroscopic cystoscope ; 949, Electrical illumination ; 1002, Ibid. 1888, II. 24, Diagnosis of obscure disease by electric illumination. EDIN. MED. JOUR. XXXI., II. 734, 965, Re- tention of urine from an unusual cause ; 1177, Artificial vesico-vaginal fistula for cure of chronic cystitis. XXXIII., I. 173, Exfolia- tion of entire mucous membrane. XXXIII., II. 1009, Treatment of hydrocele. GLAS. MED. JOUR. XXV. 412, Diag- nosis of tubercular disease of the urinary organs. 686 APPENDIX. DUB. MED. JOUR. LXXXII. 147, Etiology and treatment of cystitis. AMKlt. JOUR. OBS. 1886. 60, Frequent mic- turition; 267, Epithelioma; 489, Ibid.; !>29, Emmet's button-hole operation ; 993, Ulcers of ; 1218, Epispadias. 1887. 895, Ulcers of bladder; Ilia, Cystitis in women. 1888. 72, Ligation for eystocele ; 350, 402, Suppura- tive exfoliative cystitis; 407, Fibrinous cast from ; 1006, Injury to, during laparotomy, Siinger. ARCH IV F. GYN. XXIX. 53, Ulcer. XXXII. 465, Injury to, during laparotomy, Hanger. CENTRALB. F. GYN. X. 189, Cystitis and irrigation ; 341, Tumours. XI. 404, Tumours. VOLK. SAM ML. Nos. 267, 268, Tumours and their treatment, Kiister. ARCH IV. DE TOO. 1886. 654, Cystocele with stone. BLOOD. BRIT. MED. JOUR. 1886, I. 998, The jugular vein in chloro-antemia. 1887, I. 562, In- adequate treatment of anaamia. 1887, II. 1184, Faecal anaemia in girls and young women. 1888, I. 688, The anaemia of puberty. LANCET. 1887, 1. 286, The blood in leukaemia ; 540, Hypometric injections in acute anaemia. 1887, II. 1003, Anaemia or chlorosis of girls. 1888, I. 1081, Etiology and classification of the anaemia of puberty. DUB. MED. JOUR. LXXXI. 383, Chloroform as a haemostatic. CENTRALB. F. GYN. X. 494, Salt-water in- jection in acute anaemia. BROAD LIGAMENT. BRIT. MED. JOUR. 1887, I. 782, Tumour of. LANCET. 1886, II. 1143, Shortening of round ligaments. 1888, I. 72, Phlegmon of. EDIN. MED. JOUR. XXXII., I. 272, Cyst of. XXXII., II. 938, Cyst of. AMER. JOUR. OBS. 1886. 618, Congenital deficiency of ; 838, Ovary and Tube from cellu- litic contraction of ; 1273, Cyst. 1887. 178, Fibroid of. 1888. 201, Fibro-sarcoma ; 211, Primary Myoma of, and seventeen collected cases ; 525, Cyst of ; 611, Cyst ; 622, Case of non- papillary ligamentous cyst; 726, Multilocular papillomatous tumour ; 1287, Papilloma. ARCHIV. DE TOO. 1887. 972, Phlegmon of. CERVIX, ANATOMY OF. AMER. JOUR. OBS. 1887. 1228, Incomplete transverse septum. CERVIX -AFFECTIONS, OPERATIONS, Etc. (For Cancer and Fibrous Tumours of, ee under these A ffections of the Uterus.) BRIT. MED. JOUR. 1886, 1. 1, Laceration and trachelorrhaphy ; 16, 209, Laceration of ; 421, 463, 524, 615, (516, Correspondence on trache- lorrhaphy. 1886, II. 78, Specimen of Myxo-fibroma. 1887, I. 109, Twenty cases of trachelorrhaphy, by Beverley ; 927, Lacer- ation and its relation to malignant disease. 1888, 1. 1274, Electrolysis in catarrh. 1888, II. 873, Rapid dilatation ; 1052, Method of dilating. LANCET. 1886, 1. 655, Symptoms of lacer- ation. 1887, I. 448, Does laceration occur in first labour? 1136, Schrceder's operation for malignant growth of ; 1187, Trachelorrhaphy, by Braithwaite. 1887, II- 19, Dilatation of, and intra- uterine therapeutics; 507, Rapid dilatation. 1888, I. 464, Supra-vaginal amputation for malignant disease, witli notes of ten cases, by Lewers ; 1248, Chronic catarrh treated by electrolysis. 1888, II. 1122, Treatment of Endocervicitis by medicated bougies. EDIN. MED. JOUR. XXXIII., I. 275, Scien- tific dilatation and intra-uterine thera- peutics. XXXIII., II. 1130, Trachelorr- haphy. XXXIV., I. 144, Elongatio colli supra-vaginalis. GLAS. MED. JOUK. XXVIII. 77, Permanent dilatation of uterus; 78, Catarrh. XXX. 87, Trachelorrhaphy. DUB. MED. JOUK. LXXXIV. 147, Malignant growth. AMER. JOUR. OBST. 1886. r )00, Laceration with unique symptoms ; MS, Modification of trache- lorrhaphy ; 757, Influence of lacerated cervix ; 907, Description of Martin's amputation of the cervix; 1246, 1250, Hegar's, Schroeder's, and Martin's operations for ectropium, hyperplasia, and catarrh ; 1264, Hystero-trachelorrhaphy. 1887. 49, Martin's operation for lacerated ; 523, Necessity for early operation for lacer- ation ; 736, Laceration viewed obstetrically ; 858, Induration ; 1076, Treatment during pregnancy ; 1097, Rapid dilatation of ; 1099, Cancerous degeneration of hyperplastic glands ; 1103, Pathology and treatment of lacerations. 1888. 218, Influence of laceration on origin of uterine disease ; 257, Ibid. ; 400, Amputation for carcinoma, Lee ; 498, Dilatation, septic peritonitis, death ; 499, Hystero-trachelor- rhaphy, septic peritonitis, death, Lee ; 606, Death from peritonitis following trachelor- rhaphy ; 607, Ibid, following removal of a cervical fibroid ; 782, Suspicious and malignant adenoma ; 1009, Superinvolution of uterus following trachelorrhaphy. ARCHIV F. GYN. XXIX. 322, Flap-operation in stenosis, Frank. XXXI. 4(i9, Laceration of and uterine disease. XXXIII. 310, Safe catgut for trachelorrhaphy. CENTRALB. F. GYN. X. 95, Cautery in me- tritis of. XII. 441, Laceration. ZEITSCH. F. GEB. UND GYN. XII. 229, One-sided hypertrophy of lower cervical seg- ment ; 287, Laceration. XIV. 352, Ade- noma. ARCHIV. DE TOG. 1886. 25, Trachelor- rhaphy, by Doleris ; 426, Rapid dilatation ; 640, Incision of, for removal of intra-uterine sessile tumour of uterus ; 933, Permanent dilatation ; 1009, Sponge dilatation. 1888. 569, Thrombus of anterior lip. ANNAL. DE GYN. XXX. 241, 351, Trachelor- rhaphy, by Houzel. ANNAL. DI OSTET. 1887. 171, Division of, for haemorrhage. 1888. 463, Amputation for erosion and chronic metritis. DERMOID CYSTS-OVARIAN AND PELVIC. BRIT. MED. JOUR. 1886, 1. 264, Removal of, during pregnancy, by Thornton. 1887, I. 1133, Of ovary ; 1278, Two small ovarian. 1887, II. 729, Retro-rectal; 886, Ovarian; 1282, With twisted pedicle. 1888, I. 801, Expelled per reef urn, during labour; 959, Mammae in. 1888, II. 79, Ovarian ; 895, The mystery of ovarian ; 940, Ovarian. LANCET. 1886, I. 350, Discussion on ; 386, Referred to in Bland Sutton's Evolution in pathology ; 920, In girl. 1886, II. 1080, Removed by Malias. 1888, I. 880, Mamma; in ; 979, Expulsion per rectum during labour. EDIN. MED. JOUR. XXXIII., I. 471, Denti- DUB. MED. JOUR. LXXXVI. 71, Compli- cated by Parotitis. AMER. JOUR. OBSTET. 1886. 13, 55, Of both Ovaries ; 274, Specimen with pyosal- pinx ; 672, With abdominal gestation, gastro- tomy by Wasseige ; 851, Complicating labour ; INDEX OF RECENT GYNECOLOGICAL LITERATURE. 687 1022, In a child thirty months old, ovari- otomy by Hooks. 1887. 176, Double der- moid, laparotomy by Munde ; 621, Curious ball of sebaceous matter in ; 645, Of ovary 1275, Ibid. 1888. 525, Price on ; 526, Ibid. 614, Case of ; 627, Two ; 710, Ovarian ; 723 Case ; 868, With carcinoma uteri ; 1197, Case 1205, Ovarian. CENTRALB. F. GYX. X. 569, Ovarian. XI. 68, Pelvic. ARCHIV. DE TOC. 1886. 145, Of both ovaries with a diverticulum in rectum. DYSMENORRH02A. BRIT. MED. JOUR. 1886, I. 1065, Mem- branous. 1886, II. 600, Treatment of Membranous. 1888, II. 870, Obstructive, and Sterility. LANCET. 1886, II. 942, Rapid mechanical dilatation in. 1887, I. 126, Removal of cystic ovaries for, by Wni. Duncan. 1888, I. 21, Uterine cast of Dysmenorrhceal origin ; 425, Case of combined phenomena of Dys- menorrhcea, Metrorrhagia and Hydrorrhcea ; 1132, Treatment of sterility and obstructive. EDIX. MED. JOUR. XXXIII, II. 945, Mem- branous dysmenorrhoeal cast. XXXIV., I. 415, Membranous. GLAS. MED. JOUR. XXVII. 315, Galvanic cautery in membranous. XXVIII. 78, Local treatment of membranous ; 399, Re- moval of cystic ovaries for, by Wm. Duncan. XXIX. 44S, Membranous. XXX. 421, Treatment of obstruction and sterility in. DUB. MED. JOUR. LXXXV. 297, Treatment of sterility and obstructive. LXXXVI. 73, Discussion on preceding paper. AMER. JOUR. OBS. 1886. 185, Uterine dilator in. 1888. 40, 78, Electrolysis v. rapid dilatation for. ARCHIV F. GYX. XXXI. 70, Pathological anatomy of membranous. CENTRALB. F. GYX. X. 264, Membranous. ARCHIV. DE TOC. 1886.448, Membranous; 656, Membranous. ELECTRICITY. BRIT. MED. JOUR. 1887, I. 906, Statical in hysteria ; 1017, 1075, Electrolysis for uterine fibroma ; 1208, For fibroids ; 1272, Apostoli's method in uterine and peri-uterine affections; 1303, For uterine disease ; 1329, For fibroid of uterus ; 1364, Electrolysis for fibroid of uterus. 1887, II. 62, For fibroid; 93, Hydro-electric baths in nervous affections ; 116, For fibroid ; 134, Ibid. ; 423, Ibid. ; 699, Ibid.; 702, Ibid.; 724, Electrolysis for fibroid ; 964, 965, For fibroid ; 993, Electrolysis for fibroid followed by enucleation and slough- ing ; 102], For fibroid; 1075, 1076, Ibid.; 1094, For peri-uterine inflammation; 1130, 1181, 1182, 1239, Electrolytic treatment of uterine tumours ; 1131, Electrical treatment of uterine tumours and Sir James Y. Simp- son ; 1255, Treatment of uterine tumours by ; 1337, Ibid. ; 1359, In treatment of uterine tumours. 1888, I. 20, Electrolysis for large fibroid. 1888, I. 63, In gynecology ; 102, Electrolysis for fibroid ; 158, Ibid. ; 320, Magneto-therapy; 356, In gynecology; 368, Electrical therapeutics ; 439, For fibroid ; 493, Ibid. ; 547, Ibid. ; 557, Apostoli and electro- lysis ; 614, Electrolysis for fibroid ; 654, A new device in electrolysis ; 665, Electrolysis for fibroids ; 798, Ibid, and subsequent Hys- terectomy, by R. T. Smith ; 799, Action of constant current on fibro - myomata ; 995, 1012, For diseases of the uterus ; 997, Electro- lysis for fibroids ; 998, For hydrosalpinx ; 1065, For uterine myomata ; 1085, For dis- eases of the uterus ; 1137, In gynecology ; 1274, Electrolysis in gynecology; 1274, Electrolysis in chronic cervical catarrh ; 1274, Electrolysis in some chronic uterine affec- tions ; 1274, 1384, Constant current in gyne- cology ; 1300, For fibroid ; 1362, Apostoli's treatment of fibroids; 1376, Ibid., notes on three cases ; 1388, Electrolysis in uterine dis- ease ; 1410, Discussion on Electrolysis at the London Obs. Soc. 1888, II. 79, For fibroid; 83, Article on the Discussion on Electrolysis ; 102, Apostoli's treatment of fibroids; 152, The Apostoli treatment in Italy ; 1412, Electrolysis for fibroid. LANCET. 1887, 1. 103, Medication by Electro- lysis ; 867, Use of thermopile and secondary batteries for producing. 1887, II. 158, Electrolysis in gynecology ; 324, For fibroid ; 978, Effect of Faradisation on urinary nitro- gen. 1888, 1. 379, Electrolysis for fibroids ; 446, Electrolysis ; 674, For fibromata ; 1021,. Endoscopy by electric light ; 1248, Electro- lysis in gynecological practice ; 1249, For uterine myomata ; 1327, Endoscopic illumi- nation. 1888, II. 19, In gynecological practice; 24, Electrical illumination of bladder; 103, 153, Remarks on use in gyne- cology; 363, In treatment of uterine and other pelvic disease; 1034, Oophoralgia treated by Faradisation ; 1221, Apostoli and his work. EDIN. MED. JOUR. XXXIII., I. 87, Applica- tion to gynecology ; 88, Chemical galvano- puncture in ; 470, Patient treated by Apostoli's method for fibroid. XXXIIL, II. 670, 688, For fibroid ; 1059, In atrophy of mammary gland. XXXIV., I. 275, Demonstration of action of galvanic currents, on tissue ; 566, Dangers of galvano-puncture in pelvic tumours ; 567, The new methods of electrotherapy in their bearings on gyne- cological surgery. GLAS. MED. JOUR. XXVI. 320, Faradisation of uterus as a hsemostatic agent. XXIX. 83, Demonstration of apparatus ; 82, For fibroid ; 530, Xotes on forty cases treated by Apostoli's method. XXX. 419, Electrolysis in uterine flexions ; 421, Treatment of peri- uterine phlegmasia by. AMER. JOUR. OBS. 1886. 197, In minor gynecology ; 448, Xegative galvano-puncture for peri-uterine hsematocele ; 619, Hsemato- salpinx ; 621, Pyo-salpinx ; 1087, Tait on Faradisation ; 1228, Electrolytic puncture for areolar hyperplasia. 1887. Ill, Intra- uterine electrolysis for chronic metritis and endometritis ; 113, For fibroids ; 253, 376, For fibroid, fifty cases; 290, Electrolysis for fibroids; 406, Value of; 881, Apostoli's method of electrolysis ; 1059, Xew uses of ; 1102, Xew method for fibroids ; 1104, Electro- lysis for tumours of breast. 1888. 270, For fibroid; 384, Ibid.; 561, And uterine displacements ; 643, Galvanic for fibroid, fifteen cases ; 806, Fibroid treated by Apostoli ; 820, Value of Electrolysis ; 1053, The dangers of galvano-puncture in pelvic tumours ; 1057, Xew methods of electric therapy in their bearing on gynecological surgery. CEXTRALB. F. GYX. X. 58, And hwmatocele ; 188, In gynecology. XII. 313, In gyne- cology. ARCHIV. DE TOC. 1886. 760, Intra-uterine galvano-cautery for metritis and endometritis. 1888. 739, And uterine polypus. AXXAL. DI OSTET. 1888. 170, For fibroid ; 272, Failure of, for fibroid. EXAMINATION. BRIT. MED. JOUR. 1886, II. 285, Abdominal palpation in obstetrics ; 602, Abdominal pal- 688 APPENDIX. pation as a means of diagnosis ; 1033, Alleged improper. EDIN. MED. JOUR. XXXII., II. 903, Vulliet's method of dilating the uterine cavity for in- spection. XXXIV., I. 381, New method of. GLAS. MED. JOUK. XXIX. 173, Extra-peri- toneal exploratory incisions; 536, Ibid., in the iinea alba. AMER. JOUR. OBS. 1886. 1229, Vulliet's method of dilating the uterine cavity for in- spection. 1887. 221, Palpation of pelvic organs. CENTRALB. F. GYN. X. 154, Necessity of thorough examination of the genitals in bleeding from uterus. XII. 6, 103, Extra- peritoneal exploratory incision, Bardenheuer ; 177, Rectal examination by kolpeurynter ; 337, New method of ; 471, Diaphanoscopic examination of genitals. FALLOPIAN TUBES, ANATOMY AND AFFECTIONS OF. BRIT. MED. JOUK. 1886, 1. 66, Inflamma- tion ; 457, Tubercular disease ; 543, Case of hydrosalpinx ; 710, Specimen of haemato- salpinx ; 737, Diagnosis of distension ; 821, Diagnosis between distension of the tubes and fibro-myoma of the uterus ; 1215, Dangers from diseases of uterine appendages in child- bed. 1886, II. 78, Specimens of malforma- tion ; 154, Salpingectomy, by Murphy ; 691, Papilloma and relation of tubal disease to hydro-peritoneum. 1887,1. 825, Pathology of chronic inflammation of ; 947, Canalisation and catheterisation of the Fallopian tube ; 1211, Unsatisfactory results of unilateral re- moval. 1887, II. 673, Inflammatory con- dition of ; 886, Hsematosalpinx. 1888, I. 249, Hsematosalpinx with cystic disease of the ovary ; 249, Hydrosalpinx and Blood cyst of the ovary ; 35(5, Tubercular pypsalpinx ; 416, Papilloma of tubes and ovaries ; 907, Case of Pyosalpinx ; 958, Primary cancer of ; 998, Electricity for hydrosalpinx ; 1010, Glands of, and their function. 1888, II. 828, The first operation on ; 933, Double pyosalpinx cured by aspiration ; 1023, Pyosalpinx or sup- purating parovarian cyst ; 1222, Salpingitis. -LANCET. 1886, I. 548, Tubercular disease; 744, Specimen of haeiuatosalpinx with ovarian cyst. 1886, II. 67, Chronic inflammation ; 399, Laparotomy for hydrosalpinx, by Jones ; 406, Diseases of uterine appendages ; 728, 976, Papilloma of, and relation of hydro-peri- toneum to tubal disease ; 744, Hsematosal- pinx with ovarian cyst ; 774, Three cases of pysosalpinx ; 869, Lawson Tait on general principles involved in operation for removal. 1887, I. Lawson Tait on chronic inflammatory disease of ; 938, Morbid anatomy of ; 982, Fre- quency of pathological conditions of ; 1186, Tubo-ovarian cysts. 1887, 1. 117, Discussion on tubo-ovarian cysts ; 425, On extirpation of. 1888, 1. 372, Specimens of papilloma ; 879, Malignant disease of ; 979, Glands and their functions. 1888, II. Double tuber- cular pyosalpinx, laparotomy, by Bull. :EDIN. MED. JOUR, xxxi., n. 1177, Atresia with hypertrophy of muscular walls. XXXII., I. 167, Series of diseased ; 174, In- flammation of lining membrane ; 463, Is disease of the uterine appendages as frequent as represented? XXXII., II. 653, Ibid.; 937, Diseased uterine appendages. XXXIII., II. 755, Uterine appendages with hydro-sal- pinx ; 756, Tubes and ovaries from double hydro-salpinx ; 809, 847, Tubal distension and stricture. GLAS. MED. JOUR. XXIX. 89, Are tubes and ovaries to be sacrificed for salpingitis ? J)UB. MED. JOUR. LXXXIL 146, Of a girl. LXXXIII. 287, Report on tubal disease. LXXXVI. 2. r i3, Removal of right uterine ap- pendage, by Purefoy ; 456, An abdominal sal- pingotomy in the last century. AMER. JOUR. OBS. 1886. 75, Hydrosalpinx diagnosed as extra-uterine pregnancy ; 200, Stenosis followed by muscular hypertrophy ; 204, Two tumours ; 292, Hydro- and pyo- salpinx with follicular degeneration of ovaries ; 292, Complicated case of Hydro- and pyo-salpinx ; 321, Diseases ; 408, Double hydrosalpinx ; 468, Salpingitis ; 409, Pyosal- pinx ; 470, Extirpation of right tube, by A. Martin ; 505, Pyosalpinx ; 532, Salpingo- tomy ; 561, Is disease of the uterine append- ages as frequent as has been represented '.' 001, Specimen of double pyosalpinx ; 609, Double pyosalpinx with abscess of one ovary; 613, Case of Hegar's operation for disease, Lee ; 618, Hydro-salpinx with congenital deficiency of tubes and broad ligaments; 838, Ovaries and tubes from case of salpingitis ; 947, Frequency of disease of uterine appendages ; 1169, Tubo-ovarian abscess ; 1273, Pyosalpinx with cyst of right broad ligament and abscess of ovary. 1887. 59, Hsematosalpinx ; 65, Pyosalpinx ; 105, Ibid, and Ovarian abscess ; 141, Chronic salpingitis, tubo-ovarian cyst; 186, Pyosalpinx of gonorrhteal origin ; 304, Hydrosalpinx ; 317, Etiology, pathology and classification of salpingitis; 421, Double pyo- salpinx and cystic degeneration of ovary ; 478, Results of unilateral removal of uterine ap- pendages ; 497, Necessity of complete removal of uterine appendages ; 535, Double pyo-sal- pinx with co-existing ovarian cystoma on both sides ; 669, A laparo-salpingotomy in 1784 ; 751, Pyosalpinx; 867, Ibid, and puerperal fever ; 1002, Frequency of pathological con- ditions ; 1045, Are tubes and ovaries to be sacrificed in all cases of salpingitis? 1120, Tubo-ovarian cysts ; 1282, Photograph of dis- eased tubes and ovaries ; 1310, Diseases. 1888. 122, Interstitial salpingitis ; 201, Hydro-salpinx ; 322, Hsematosalpinx ; 368, Laparotomy for haamatosalpinx, Douglas ; 485, Martin's method of operating in high- seated abscesses involving the ovaries, tubes, and intestine ; 525, Double hydrosalpinx ; 525, Uterine fibroid with double pyosalpinx ; 632, Specimens of inflammatory ; 633, Pus tubi ; 726, Specimen of hydrosalpinx ; 872, Removal per vaginam, Byford ; i'42, Hsema- tomasalpinx ; 1275, Double pyosalpinx ; 1275, Ibid, and cystic ovaries. ARCHIV F. GYN. XXIX. 97, Pyosalpinx due to tuberculosis ; 327, Extirpation of, Gusserow ; 328, Diseases of ; 329, Clinical observations on extirpation ; 330, Relation of uterine mucous membrane to diseases of uterine appendages. XXX. 119, Two cases of catheterisation. XXXI. 265, Primary tuber- culosis. XXXII. 165, Operatii m for removal of pyosalpinx, Gusserow XXXIII. -~, Diag- nosis of early stages of chronic salpingitis. ZEITSCH. F. GEB. UND GYN. XIII. 293, Tubal disease ; 339, Relation to disease of uterine mucous membrane. CENTRALB. F. GYN. X. 25, Salpingotomy, Leopold ; 29, Hydrosalpinx operation, Leopold ; 157, Salpingitis with gonococci, extirpation, Mestermark ; 106, Fallopian tube in inguinal hernia ; 347, Tube diseases ; 601, Primary sarcoma of. XI. 710, Lapar- otomy for hasmatometra and hiematosalpinx, Trzebicky. XII. 345, Carcinoma ; 865, Palpation of diseased. ARCHIV. DE TOO. 1887. 331, Tuberculosis ; 803, Inflammation of uterine appendages. ANNAL. DE GYN. XXVIII. 3-21 , Inflammation of tubes and ovaries. XXX. 108, Lapar- otomy for salpingitis and ovaritis, Terrillon. INDEX OF RECENT GYNECOLOGICAL LITERATURE. 689 FISTULA. BRIT. MED. JOUR. 1887, 1. 1180, Treatment of vaginal. 1887, II. 13, Rarer forms of rectal ; 210, Cocaine in operation for anal ; 930, Best method of treating extensive vesico- and recto-vaginal fistulfe. 1888, II. 818, New operation for vesico- vaginal, by Champneys. LANCET. 1887, I. 1136, Treatment of Vesico- vaginal and vesico-uterine. 1887, II. 490, Uretero genital. 1888, II. 718, New operation for vesico- vagina], by Champneys. GLAS. MED. JOUR. "XXX. 343, Fiscal. DUB. MED. JOUR. LXXXIII. 419, Reparative treatment of graver forms of vesico-vaginal. LXXXIV. 14S, Discussion on preceding paper. LXXXV. 381, Priority in flap-splitting. AMER. JOUR. OBS. 1886. 291 , Vesico-vaginal; 831, Vulvo-rectal from violence during first coition ; 1100, Operation for recto- vaginal. 1887. 50, Urinal for use in vesico-vaginal ; 224, Thirty-five operations for urinary, Hochlmann. ARCH IV F. GYN. XXVIII. 490, Recto- vaginal. XXIX. 315, Vesico-vaginal fistula operation Rydygier. XXXIII. 270, One- hundred-and-f orty vesico-uterine, Neugebauer. CENTRALB. F. GYN. X. 125, Colo-utero- vaginal. XI. 297, Function of ureter in recto-vesico-vaginal ; o29, Nephrectomy for ureter fistula. XII. 207, Recto- vaginal ; 377, Yesico-vaginaJ combined with vesico- cervical. ARCHIV. DE TOO. 1887. 297, Treated by chlorine water. ANNA!,. DE GYN. XXV. 245, Vaginismus and urethro- vaginal. XXIX. 408, Vesico- utero-vaginal and ulceration of part of ureter. ANNAL. DI OSTET. 1886. 204, 402, Kolpo- kleisis in extensive, Morisani. GONORRHCEA. BRIT. MED. JOUR. 1886, I. 201, Gonorrhoea in the Female. 1887, I. 035, " Amykos " in ; 1133, Thallin in. 1887, II. 93, Gonorr- hoeal peritonitis ; 854, Diagnostic value of the gonococcus ; 911, Gonorrhceal cutaneous metastases, prophylaxis of gonorrhoea. 1888, I. 11S5, General gonorrhoeal infection ; 1340, Gonorrhceal ophthalmia. 1888, II. 190, Latent ; 1299, Compound gonorrhoeal infection. LANCET. 1887, I. 542, Salicylate of soda in Gonorrhoea ; 790, Practical value of the gono- coccus. 1887, 11.1151, Cocainein. 1888,1. 591, Treatment by antrophores (i. e. medicated soluble bougies) ; 745, Ibid. ; 1017, Practical treatment of ; 1304, Spinal cord affection from. 1888, II. 341, Creolin in; 392, Thallin in; 418, Rational treatment : 437, Thallin in. EDIN. MED. JOUR. XXXI., II. 1092, In the female. XXXII., II. 004, Spurious; 901, Fluid extract of kava kava f or. XXXIII., II. 959, The gonococcus. GLAS. MED. JOUR. XXVII. 238, Gonorrhceal rheumatism. XXIX. 535, Healed by injections of oil of iodoform. DUB. MED. JOUR. LXXXII. 94, Gonorrhceal rheumatism. AMER. JOUR. OBS. 1886. 988, Relation to puerperal disease. 1887. 1300, Mixed gonorrhoeal infection; 1301, Relations to generative process. 1888. 1188, Specimen of ovaries and oviducts diseased by gonorrhoeal infection. ARCHIV F. GYN. XXXI. 448, Mixed gonor- rhoeal infection in the wife ; 449, Relation to generative process. XXXII. 322, Chronic. CENTRALB. F. GYN. X. 79, In women. XI. 125, Infection in women ; 477, Gonorrhceal vaginitis and endometritis ; 528, Site of gonor- 2 x rhceal infection ; 720, Gonorrhceal vaginitis and endometritis. XII. 373, Latent and chronic in women ; 503, In women. YOLK. SAMML. No. 279, Gonorrhosal infection. HERMAPHRODITISM. BRIT. MED. JOUR. 1887, II. 619, Hypo- spadias in the female. 1888, I. 91, Case of ; 223, Or hypospadias ; 416, Complex and vertical ; 1015, Case of. LANCET. 1886, I. 290, References in Bland Button's ' Evolution in Pathology ; ' 1223, Spurious. 1887, I. 371, Complex. AMER. JOUR. OBS. 1886. 931, Parmly on. ARCHIV F. GYN. XXXIII. 311, Pseudo- (masculine). CENTRALB. F. GYN. X. SO, Pseudo- ; 144, Epispadias ; 659, Reuter on. ZEITSCH. F. GEB. UND GYN. XII. 117 Female epispadias. HYMEN. BRIT. MED. JOUR. 1887, II. 1282, Nature of. 1888, II. 870, Imperforate and Amenorrhcea; 991, Labour completed at full time without rupture of ; 1160, Imperforate ; 1370, Hypertrophied. LANCET. ' 1886, II. 1171, Imperforate, with retention of menstrual fluid. 1888, II. 899, In pregnant female. EDIN. MED. JOUR. XXXIV., I. 425, Labia minora and hymen. DUB. MED. JOUR. LXXXV. 521, .As a proof of virginity. AMER. JOUR. OBS. 1886. 481, Imperforate. 1888. 1120, Case of conception and occluded. ARCHIV F. GYX _ XXIX. 284, Congenital cyst of. XXXII. 159, Cysts in hymen of new-born. CEXTRALB. F. GYN. in occluded. ARCHIV. DE TOO. imperforation. XII. 219, Conception 1886. 32, Congenital INSTRUMENTS. BRIT. MED. JOUR. 1886, I. 16, Continuous gas-cautery ; 898, Uterine dilators ; 1170, New trocar. 1886, II. 1040, Uterine re- positor. 1887, I. 203, The dome trocar and its uses ; 402, New tube for uterine lavement ; 525, Tents and their disinfection ; 678, New specula ; 750, Improved uterine injector ; 977, Urethral speculum ; 977, Clamp for hys- terectomy ; 1105, 1168, Improved apparatus for washing out the bladder ; 1278, With cup- shaped diaphragm ; 1278, Modification of serre-nosud. 1887, II. 73, Surgical search lamp ; 472, Cervical dilators ; 514, New vaginal speculum ; 1109, Ibid. ; 1157, Dispersing rheo- phore ; 1287, New surgical needle ; 1390, In- strument for removing fsecal lodgments ; 1401, Intra-uterine irrigator. 1888, I. 197, Lange's enema nozzle ; 358, Modification of Tait's trocar; 768, New incandescent lamp cystoscope ; 1281, New syringe for rectal in- jection of glycerine. 1888, II. 315, New spiral wire stem for preserving patency of cer- vical canal after operation for stenosis; 621, Pessary for prolapse of bladder ; 872, Rapid dilator of cervix uteri ; 1222, Syphon for washing peritoneal cavity; 1473, The ecraseur and the dividing wire. LANCET. 1886, II. 401, Clamp for piles ; 535, New sponge-holder ; 1026, New dilator ; 1223, Fomentation bag. 1887, 1. 1094, Torsion for- ceps. 1887, II. 705, Apparatus for main- taining the lithotomy posture; 766, "Nelaton" patent valve syringe tube ; 816, New urethral instruments ; 1020, New form of uterine dila- 690 APPENDIX. tor ; 1049, 1099, Relation of ophthalmic disease to condition of sexual organs. 1888, I. 457, 505, Urethral instruments ; 528, Patent enemn nozzle ; 538, Use of uterine curette ; 1011, Urethral ; 1132, Uterine cervical dilator ; 1250, New rectal bougie. 1888, II. 1026, Improved simplex enema apparatus. EDIN. MED. JOUR. XXXI., II. 784, Con- tinuous or spiral catgut suture in gyne- cology ; 859, 863, Aseptic catheter and canula. XXXII., II. 658, Imlach's apparatus for vaginal irrigation ; 736, Vaginal and intra- uterine lubricator. GLA8. MED. JOUR. XXVII. 230, Apparatus for fomentation of uterus and vagina ; 345, New uterine dilator. XXX. 311, On drain- age tubes. DUB. MED. JOUR. LXXXV. 73, Cervical dilator. AMER. JOUR. OBS. 1886. 68, Cervical dila- tor; 69, Probe-pointed scissors for opening peritoneum ; 273, Modification of Erich's self- retaining speculum; 523, "Iridinized" pla- tina needles; 585, Threading needle for wire sutures ; 595, A practical self-retaining Sims' speculum; 621, Uterine applicator and dress- ing forceps combined ; 698, New instrument for intra-uterine medication ; 734, Hsemostatic forceps for removing urethral caruncles ; 811, ' New curette. 1887. 51, Assorted drainage tubes ; 146, For reposition of uterus in retro- versio-flexio ; 171, Tenaculum with steel shank ; 171, Combined tenaculum and conn- \ terpoise hook ; 294, Aneurism needle for j vaginal hysterectomy ; 295, Syringe for wash- ing out abdominal cavity ; 406, Fine copper- wire suture for plastic operations ; 418, 'hut's abdominal bandage for use after laparotomy ; 420, Hard rubber plates for protection of ' abdominal wall ; 420, Self-retaining tenacu- ' him ; 519, Modified aneurism needle ; 520, j Ecraseur ; 549, Adjustable speculum and re- I tractory ; 642, Slippery-elm tent ; 854, Self- i-etaining Sims' speculum ; 1009, Juniper cat- ! gut ; 1029, Perinea! and ovariotomy cushions ; 1280, Tenaculum. 1888. 58, Trachelor- rhaphy scissors ; 71, Improved Peaslee needle ; 177, Modified Martin colporrhaphy needles ; 177, Improved needle-holders ; 302, Clamps ' for vaginal hysterectomy ; 307, Glass tubes for silk-worm gut sutures ; 394, Jones' needle- holder ; 399, Trachelorrhaphy scissors ; 495, A suture apparatus for trachelorrhaphy ; 708, Needle-holder, Hanks ; 709, Clamp forceps for vaginal hysterectomy ; 721, Aseptic two-way uterine catheter; 721, Cotton packer; 942, Knife-blade tenaculum-; 945, Self-retaining speculum ; 1272, Counter-pressure needle for- ceps ; 1286, Recent modification of Bozeman's uterine catheter ; 1286, Self-retaining drain- age tube for pelvic abscesses opening into rectum ; 1287, Pedicle forceps for vaginal 06- phorectomy ; 1287, Modification of Sims' needle-forceps ; 1307, Delore's flexible blunt- hook; 1307, Doh*ris' 6couvillon; 1307, Mathieu's instrument for washing out the uterus. CENTRALB. F. GYN. X. 193. New leg-holder for lithotomy position ; 209, Leg-holder ; 398, Catgut as a sewing material ; 778, Fritsch- Bozeman catheter. XI. 203, Bath drawers in gynecology. XII. 633, Double uterine catheter. ARCHIV. DE TOC. 1887. 980, Double sound for intra-uterine injection. ANNAL. DI. OSTET. 1887. 242, New uterine scoop. INTRA-UTERINE MEDICATION. BRIT. MED. JOUR. 1888, I. 907, Ball on. LANCET. 1887, I. 793, Fatal results of. 1888, II. 1122, Medicated bougies in treat- ment of endo-metritis. EDIN. MED. JOUR. XXXIII., I. 275, Scien- tific dilatation of os and cervix uteri and intra-uterine therapeutics. AMER. JOUR. OBS. 1886. 1S5, Uterine dilator in intra-uterine therapeutics ; 704, Abuse of ; 881, Medicating tubes ; 1233, New system. 1887. 286, Wilson on ; 334, Latest method of dilating uterine cavity. CENTRALB. F. GYN. X. 124, Tampons and septicpemia ; 225, Injection for endometritis. XI. 781, Dilatation of uterus. XII. 4(51, Application of zinc, chlor. ; 545, Ibid. ARCHIV. DE TOC. 1886. 426, Rapid dilata- tion of cervix ; 933, Permanent dilatation of ; 1009, Sponge dilatation of uterus ; 1018, Intra- uterine tamponade. KIDNEY. BRIT. MED. JOUR. 1887, 1. 456, Misplace- ment of; 583, Nephrectomy by Schmidt ; 685, Stays and movable kidneys ; 1015, Transperi- toneal nephrectomy, by Terrier. 1887, II. 17, Abdominal Section by Imlach for renal hydatids; 370, Cystic kidneys; 1320, 1388, Diagnostic value of haernaturia. 1888, I. 73, Extirpation for hydronephrosis ; 182, On certain neuralgias simulating renal calculus ; 242, Hydronephrosis, nephrectomy by Hunter ; 303, Hydronephrosis ; 324, Ventral nephrec- tomy by Lucas, for hydronephrosis ; 356, Nephrotomy, by Verrall, for renal calculus ; 378, Ventral nephrectomy, by Hunter, for hydronephrosis ; 440, Ibid., by Lucas; 502, Ibid., by Hunter; 648, Sarcoma of; 747, Cystic ; 763, Nephrectomy for pyonephrosis ; 860, Scrofulous. 1888, II. 677, Floating ; 1049, Extirpation of. LANCET. 1886, II. 212, Movable kidneys with pyonephrosis, operation by Francis ; 221, Hysterectomy and nephrectomy, by Calder- ini ; 414, Renal tuberculosis. 1887, I. 370, Nephro-lithotomy. 1887, II. 66, Nephrec- tomy for hydronephrosis, by Elder ; 230, Nephrectomy in Belgium ; 603, Removal with both ovaries by Treves ; 956, Action of certain drugs on circulation and secretion of ; 1015, (Congenital hydronephrosis. 1888, I. 369, Pyonephrosis due to obstruction ; 463, Possibility of washing out through bladder ; 469, Tubercular disease simulating malignant ; 674, Cystic, with calculi ; 877, Chronic hydro- nephrosis, nephrectomy by Stanmore Bishop ; 1182, 1237, Surgical treatment of renal calcu- EDIN. MED. JOUR. XXXII., I. 70, Primary cancer of ; 337, Sarcoma with adherent intes- tine. GLAS. MED. JOUR. XXVI. 180, Case of double uterus and one kidney. XXVII. 321, Nephrotomy and nephrectoray. DUB. MED. JOUR. LXXXII. 174, Cocain as a diuretic. LXXXIII. 446, Surgical inter- ference. AMER. JOUR. OBS. 1886. 1221, Nephrec- tomy. 1887. 1280, Tumour. 1888. 557, Wandering. CENTRALB. F. GYN. X. I. , Nephrectomy, Heil- brun ; 96, Floating ; 361, Nephrectomy, Le Dentu. XI. 629, Nephrectomy for ureteric fistula, Gusserow. LIVER BRIT. MED. JOUR. 1886, I. 872, Cholecys- totomy. 1886, II. 899, Hepatic phle- botomy ; 901, 903, Surgical treatment of. 1887, I. 1301, Tuberculosis. 1887, II. 422, Cholecystotomy ; 1148, Two cases of chole- cystotomy ; 1283, Hydatid tumour cured by incision ; 1333, Hydatid tumour, tapped and drained across the pleura! space ; 1333, Extra- INDEX OF RECENT GYNECOLOGICAL LITERATURE. 691 peritoneal rupture of hydatid cyst ; 133", Physiological variations in position and shape. 1888, I. 136, Laparotomy, by Cluttpn, for obstruction from gall-stone ; 324, Cirrhosis of ; 378, Ibid. LANCET. 1886, 1. 296, Cholecystotomy, by Lawson Tait. 1888, I. 240, Cirrhosis of ; 518, Effects of tight-lacing on secretion of bile; 616, Two cases of cholecystotomy, by Nairne ; 716, Series of eleven cases of cholecys- totomy, by Lawson Tait ; 726, Hydatid ; 1298, Ibid. MAMM.S (DISEASES OF). BRIT. .MED. JOUR. 1887, 1. 436, Reportof the British Medical Association on cancer of the breast. 1887, II. 174, Treatment of mas- titis ; 327, Ibid, by pressure. 1888, I. 24, Tubercular tumour ; 24, Spreading cancer of ; 533, Villous carcinoma of right breast ; 957, Large sarcomatous tumour; 1046, 1101, Car- cinoma, operation by Macnamara ; 1277, Al- veolar sarcoma. 1888, II. 775, Atrophy of inactive mammary gland ; 857, Absence of mammary gland ; 876, Absence ; 1222, Sar- coma. LANCET. 1887, 1. 72, Melanotic tumour ; 628, Mammary tumours ; 780, Treatment of mas- titis ; 1230, 1315, Removal of adenoma of breast. 1888, I. 74, Spreading cancer of ; 472, Villous cancer of ; 690, Cancer, treated by erysipelas inoculation ; 1258, Modelling clay in. 1888, II. 1281, Inflammation and treat- ment by elastic pressure. EDIN. MED. JOUR. XXXIII., II. 1059, Elec- tricity in atrophy. DUB. MED. JOUR. LXXXV. 13, Treatment of mammary tumours. AMER. JOUR. OBS. 1887. 1104, Electrolysis for tumours. 1888. 503, Very early removal of entire breast for "suspected" cancer, Janvrin. CENTRALB. F. GYN. XII. 570, Tuberculosis. ARCHIV. DE TOO. 1888. 298, Septicaemia of mammary origin ; 622, Supernumerary mam- mae. MASSAGE. BRIT. MED. JOUR. 1886, I. 926, Massage as a therapeutic agent ; 1034, Massage and Assimi- lation. 1887, II. 232, For severe hysteria ; 502. In chronic dyspepsia and sleeplessness. 1888, I. 1298, Three cases of. 1888, II. 175, Colles on. LANCET. 1886, I. 982, Physiological effects. 1886, II. 703, 795, Sturges on; 749, 845, Murrell on ; 750, 894, Easton on ; 795, Play- fair on ; 894, Little on. 1887, 1. 125, Physio- logical effects ; 637, Effects on exhalations from lungs and skin. 1888, I. S, Limita- tions of the "Weir Mitchell Treatment;" 149, Correspondence on ; 680, Atkin on ; 921, As a curative agent; 1128, Severe cases of hysteria cured by massage, seclusion, and overfeeding. EDIN. MED. JOUR. XXXIII., I. 35, 119, Grant on. GLAS. MED. JOUR. XXX. 470, Hiinerfauth on. DUB. MED. JOUR. LXXXIII. 381, Knight on. CENTRALB. F. GYN. XI. 505, Resch on. XII. 201, Prolapse of uterus and ; 481, Ibid. MENSTRUATION AND OVULATION. BRIT. MED. JOUR. 1886, 1. 114, Exploration of uterine cavity in menorrhagia ; 201, Retention of ; 539, Sudden death from haemorrhage into abdominal cavity during ; 800, Pulse during ; 882, 980, Vicarious ; 894, Influence of diabetes on. 1887, 1. 153, And phthisis. 1887, II. 97, Treatment of the menopause ; 1018, Morphinomania and ; 1172, Metrorrhagia at the age of puberty. 1888, I. 385, Case of early ; 013, After hysterectomy ; 666, Ibid. ; 711, From a laparotomy scar; 960, Precocious puberty with tumour of right ovary. 1888, II. 939, Vicarious. LANCET. 1886, I. 939, Connection between splenic tumour and. 1886, II. 383, Case of early ; 1173, After removal of uterus with appendages. 1887, I. 1227, Occurrence of menorrhagia or metrorrhagia during febrile state. 1887, II. 726, Time of commence- ment. 1888, I. 41, Haemorrhage in myx- oedema ; 882, Ovarian tumours and precocious puberty. 1888, II. 939, After removal of both ovaries ; 992, Ibid. ; 1044, And the ovaries ; 1204, Ibid. EDIN. MED. JOUR. XXXI., II. 786, A new explanation of ; 1173, Relation to development of foetus at term. XXXII., I. 201, 263, Relation to goitre. GLAS. MED. JOUR. XXV. 413, New explan- ation of. XXVI. 320, Vicarious, simulating pregnancy. DUB. MED. JOUR. LXXXII. 254, Treatment of menorrhagia. LXXXIII. 279, Report on. LXXXV. 73, Change of the field of vision in. LXXXVI. 130, Effects on vision. AMER. JOUR. OBS. 1886. 99, Some facts learned from artificial repression ; 141, Vicarious, simulating phthisis ; 152, Persistent at seventy ; 457, Ovulation during pregnancy ; 481, Retention through imperforate hymen ; 618, Menstrual epilepsy ; 1263, Persistent after double ovariotomy. 1887. S8, Vicarious ; 110, Cause and purpose of; 158, Relation to sexual functions ; 1068, Vicarious. 1888. 612, Regular, after Tait's operation ; 1138, Repression of as a curative agent in Gyne- cology. ARCHIV F. GYN. XXVIIL 158, 508, Lowenthal on E. A. Feoktistow's "Some words on the causes and object of the menstrual process." CENTRALB. F. GYN. X. 58, In relation to development of ovum ; 117, Praecox ; 205, Vicarious from ear ; 289, Flesch on. XII. 305, At three years old ; 360, After double ovariotomy. VOLK. SAMML. No. 312, Nervous swelling of skin during menstruation and menopause. ARCHIV. DE TOG. 1886. 31, Double ovariotomy and ; 433, Relation of diabetes to. 1887. 337, Paralysis and menstrual disorders ; 356, Early ; 667, Report on ; 913, Metrorrhagia at puberty. ANNAL. DE GYN. XXV. 178, In Syria. ANNAL. DI OSTET. 1886. 248, Ovulation in pregnancy ; 392, Ibid. MICRO-ORGANISMS. BRIT. MED. JOUR. 1887,11. 166, Lawson Tait on development of surgery and germ theory ; 929, Cultivation experiments with malignant new growths. EDIN. MED. JOUR. XXXI., II. 772, Germ theory of disease. AMER. JOUR. OBS. 1888. 781, In genital canal of healthy woman. CENTRALB. F. GYN. X. 157, Gonococci in salpingitis. XII. 2S1, In genital canal of healthy woman. ZEITSCH. F. GEB. UXD GYN. XTV. 443, In vagina of healthy woman. MISCELLANEOUS. BRIT. MED. JOUR. 1886, I. 181, Progress and work of the British Gynecological Society ; 587, The advantage of straightening the uterus in cases of uterine haemorrhage ; 1053, 1095, 692 APPENDIX. 1154, Functional disorders of females. 1886, II. 856, Certain operations ; 910, On certain mooted points in Gynecology ; 1028, Cardiac dilatation at puberty and its frequent occurrence in girls ; 1224, Report of Liverpool Hospital for Women ; 1253, Summary for 1880. 1887, I- 145, On some pending questions in Gynecology ; 259, 325, 370, Evolution in path- ology; 567, 984, 114S,Exceptional symptomsand rare forms of disease ; 613, 827, Parotitis after injury to abdomen and pelvis ; 1238, Peculiar anomaly of the sexual organs. 1887, II. 77, Tumours of the umbilicus ; 376, 475, Papers and discussions at Brit. Med. Assoc. in 1887 ; 421, Hydrocele in the female ; 478, Artificial immunity to septicaemia ; 509, Hydrocele in the female ; 672, Ill-health in female servants and shop-assistants ; 912, Hydrocele in female ; 12SO, Fatty degeneration of the heart for intra- abdominal pressure ; 1304, Experiments in telepathic medication ; 1350, Paralysis of abdominal muscles ; 1377, Hydrocele in the female ; 1379, Treatment of habitual constip- ation ; 1387, Congenital sacral tumour; 1413, 1442, Retrospect for 1887. 1888, 1. 132, Treatment of habitual constipation ; 252, Myxoedema in married women ; 303, Etiology of pel vie disease in women ; 303, Dublin schools and their teaching ; 368, Removal of a hairpin from the peritoneum ; 855, Cases of acro- megaly ; 899, Removal of hairpin from female bladder ; 971, Micro-organisms in female genital tract ; 1212, 1374, Rare diseases and j exceptional symptoms ; 1387, Extra-peritoneal cysts. 1888, II. 1458, Retrospect of | Gynecology for 18S8. LANCET. 1886, I. 19, Recent progress ; 86, 130, 227, 374, Relation of parotid to generative organs ; 111, Osteomalacia ; 896, Inheritance of acquired pathological properties ; 943, Photographing the uterine cavity. 1886, II. 304, 375, 422, 470, 558, 603, 1147, Hospital for Women in Liverpool. 1887. I. 82, Hospital for Women in Liverpool ; 445, " Erythromelalgy ; " 482, Phagocytes; 563, Inaugural address to Obstet. Soc. Lond. 1887, II. 704, Pathogenesis of disease in women ; 1239, Alexander's Operation in Belgium. 1888, I. 57, 163, 209, 425, Some points in surgery of urinary organs ; 72, Influence of sex on health and disease ; 880, Ovarian tumours and precocious puberty. 1888, It. 336, Genito-urinary surgeons. EDIN. MED. JOUR. XXXI., II. 623, Rare cases of malignant disease of the female sexual organs ; 765, Simple means of washing out the uterus ; 883, 1173, Nature of secretions of female genital organs. XXXII., I. 55, 169, 287, Unsuccessful Case of Alexander's operation. XXXII., II. 585,' Halliday Groom's introductory address to Edin. Obstet. Soc. ; 865, 938, Clinical teaching. XXXIII. , I. 576, Report on genito-urinary diseases. XXXIII., II. 838, Etiology of tumours ; 864, Juniper catgut ; 873, 1127, Alcoholism in Gynaecology ; 933, 935, Cases of myxoedema. XXXrV., I. 47, HaUiday Groom's valedictory address to Edin. Obstet. Soc. ; 512, Underbill's Introductory address to Edin. Obstet. Soc. ; 566, Influence of pregnancy on pelvic dis- ease. GLAS. MED. JOUR. XXV. 76, Shortening of the round ligament. XXVII. 314, Alter- ations of the ganglion of Frankenhauser, (cervico-uterine ganglion) in simple and para- metric atrophy ; 408, Gynecological cliniques of Vienna and Berlin. DUB. MED. JOUR. LXXXI. 18,164, Recent pro- gress in Gynecology. I.TTKTCn, 92, Climac- teric diabetes. LXXXTV. 422, 472, Report on Rotunda Hospital for three years to 3rd Nov. 1886. LXXXV. 381, Priority in flap- splitting ; 392, Report on Rotunda hospital for year ending 3rd Nov. 1887. LXXXVI. 73, Discussion on preceding report. AMEH. JOUR. OBS. 1886. 187, Local v. general treatment in gynecology ; 203, Drain- age-tube passed per rectum; 310, Methods of diagnosis ; 387, Report on gynecology in France ; 395, 1038, Report on gynecology in Germany ; 468, A morning with August Martin ; 548, Diabetes in connection with uterine disease, menstruation, and pi'egnancy; 765, Impressions of German and English gynecology ; 951, Pressure in Davidson's syringe; 1211, Report on gynecology; 1262, Perforation of uterine wall by spoon saw ; 1292, Gynecological cabinet. 1887. 501,085, Dry treatment in gynecology ; 707, Treatment of pain and insomnia from gynecological causes ; 724, Gynecology in France ; 984, Chiara's clinic ; 1064, Vaginal injections in Sims' posture ; 1091, Drainage per vuf/iitant ; 1113, Remote results of shortening the round ligament ; 1213, Observations in Vienna. 1888. 13, Removal of vaginal tampon twenty- nine years after insertion ; 113, 187, Chronic anaemia and wasting in newly married women; 133, A new stitch ; 599, Technique of gynaeco- logical surgery, S. Sutton ; 094, 737, Cases in practice ; 1047, President's address to American Gynecological Society, Battey ; 1064, Presi- dent's address to American Association of Obstetricians and Gynecologists, Taylor ; 1094, Diseases of the skin associated with sexual disorders in the female. ARCHIV F. GYN. XXXIL 505, Laxity (if abdominal walls. XXXIII. 312, Woman with rudimentary sexual organs. CENTRALB. F. GYN. X. 20, Disorders of early life ; 65, Floating spleen ; 122, Diabetes in relation to female sexual organs ; 204, Dilatation of uterus ; 297, Clinical notes ; 606, Baths in women's diseases ; 745, Tearing out of uterus and destruction of recto-vaginal septum, Schmalfnss. XI. 70, Genital tuber- culosis ; 457, Rubber-bags in gynecology ; 033, 841, Atrophy of genital apparatus in morphia excess; 678, Cysts of mesentery; 681, Plugging of vagina ; 744, Female sexual organs and other organs ; 855, Extirpation of spleen, Orlowski. XII. 338, Extirpation of spleen, Liebman ; 406, Internal erysipe- las ; 499, Atrophy of genitals in diabetes mellitus. ZEITSCH. F. GEB. UND GYN. XII. 262, Tumours and pregnancy. VOLK. SAMML. No. 321, Source and Treat- ment of bleeding in gynecology. ARCHIV. DE TOG. 1887. 529, Tuberculosis in early life. ANNAL 01 OSTET. 1886. 178, Abnormal fat production. 1888. 408, Diffuse muscular spasm. NERVOUS AFFECTIONS. BRIT. MED. JOUR. 1886, I. 1056, Uterine neuroses. 1886, II. 130, Intense mam- mary neuralgia ; 147, 409, Uterine neu- roses ; 546, Tympanitis in hysterical women ; 650, Hysterical apoplexy ; 780, Hysterical amaurosis ; 837, Haematemesis in hyste- rical patients ; 853, Neurasthenia ; 947, Asphalgesia in the hysterical. 1887, I. 64, Nymphomania ; 122, Boldo-glucine in nervous insomnia ; 133, Transmission of hysterical symptoms by means of a magnet ; 905, Statical electricity in hysteria; 1016, Vitiligo as a symptom ; 1228, Prostitution and insanity (nervous and mental affections). 1887, II. 60, Uterine neuroses ; 93, Hydro-electric baths in; 126, Rare forms ; 150, Hysterical pemphi- gus ; 232, Treatment of severe hysteria ; 430, INDEX OF RECENT GYNECOLOGICAL LITERATURE. 693 Antifebrin in ; 1071, Hypnotism in hysterical vomiting; 1304, Hypnotism in hystero-epilepsy. 1888, I. 40, Antipyrin in nervous drowsiness ; 100, Treatment of epilepsy by antipyrin ; 156, Hysteria and syphilis ; 300, Indications of neurasthenia contrasted with those of hysteria ; 323, Antipyrine in epilepsy ; 348, Case of melancholia ; 358, Tail's operation, by Law son Tait, for intense hystero-epilepsy ; 377, Nomen- clature of neurasthenic conditions; 417, 418, Some cases of hysteria ; 418, Death with symptoms of hysteria ; 700, Hystero-epilepsy treated by removal of uterine appendages, by Imlach ; 1007, Cases of ; 1012, Functional eye symptoms in ; 1082, Actual cautery for epilepsy. LANCET. 1886, I. 123, Treatment of hysterical vomiting; 351, Hysterical pyrexia ; 940, Hysterical fever ; 1055, 1105, 1151, Functional disorders of females. 1886, II. 397, Hysteria or tetanus ; 457, Neurasthenia ; 686, Hysterical apoplexy ; 837, Spontaneous shedding of nails in hysteria ; 882, Hysterical contracture ; 1170, Hysterical affections. 1887, I. 389, Neurasthenia not hysteria ; 924, Psychic and nervous influences in disease. 1887, II. 577, Hysteria and traumatism ; 726, Hystero- epilepsy cured by a sham operation ; 1112, Hysterical hyperpyrexia ; 1213, Hystero- epilepsy, treated by Tait's operation. 1888, I. 224, Improper use of term "hysteria;" 236, Hysteria; 391 , Neurokinesis, Neurasthenia, Hysteria ; 422, Cases of hysteria ; 423, Functional neuroses simulating hysteria ; 516, 583, 597, Anorexia nervosa ; 613, Case of anorexia nervosa vel hysterica ; 817, Note on ibid. ; 818, Case of ibid. ; 842, Abdominal pressure in hysteria ; 899, 949, 1002, Anorexia nervosa ; 1128, Severe case of hysteria cured by massage, seclusion, and over - feeding ; 1184, Sympathetic nervous system in acute disease. EDIN. MED. JOUR. XXXII., II. 654, Opinion of leading authorities on castration in mental and nervous diseases ; 952, Treatment of hysterical attack. XXXIII., II. 1060, Nervous symptoms from displacement of uterus and appendages. GLAS. MED. JOUR. XXV. 489, Treatment of neuralgia and painful affections ; 491, Treat- ment of hysteria by compression of nerves. XXVI. 230, Cardiac neurasthenia. XXVIII. 398, Oophorectomy for. DUB. MED. JOUK. LXXXL 329, Re- port on. AMER. JOUR. OBS. 1886. 135, Dependent on ovarian displacement ; 154, Hystero- catalepsy of obscure origin ; 390, Myelitis following pelvic cellulitis ; 785, Cardiac neu- roses connected with ovarian and uterine disease ; 863, Hysteria in a young girl. 1887. 223, Reflex gastric neuroses due to uterine disease. 1888. 410, Laparotomy for hystero- epilepsy, Lee; 435, Oophorectomy for epilepsy, Reamy; 993, Origin of psychoses following operations on the female genital apparatus ; 1185, Perityphlitic abscess originating in typhlitis. ARCHIV F. GYN. XXIX. 333, Oophorectomy in epilepsy ; 333, Ibid, in neuroses. XXXII. 457, Psychoses arising from operations on female genitals. CENTRALB. F. GYN. X. 834, Nervous symptoms in disease of female sexual organs. XL 418, 442, Neuroses in relation to gyneco- logical operations ; 746, Tympanitis in hys- terical women. XII. 50, Functional neu- roses in female sex and relation to sex troubles; 137, Hysteria. ARCHIV. DE TOG. 1887. 289, Castration and; 644, Uterus in morphinomania ; 706, Removal of ovaries in. OOPHORECTOMY. BRIT. MED. JOUR. 1886, I. 1065, By Edis. 1887, I. 122, In neurotic women ; 210, Cases of, by Hume; 1211, Unsatisfactory results of unilateral removal. 1888, I. 538, By Lunn, for uterine fibroids ; 546, And the develop- ment of the genital tract ; 861, Abortion after. 1888, II. 77, By Lunn, for bleeding fibroid. LANCET. 1886, I. 34, By Roth, first in Cagliari of Sardinia; 353, By Knowsley Thornton, during pregnancy ; 963, Removal of both ovaries, by Tait. 1886, II. 453, Spaying ; 470, Ibid. ; 557, Ibid. 1887, 1. 26, By Brown ; 104, For hysteria, by Terrier ; 126, Removal of cystic ovaries for dysmenorrhosa, by Wm. Duncan ; 183, Use of the word " spaying ; " 638, Spaying in the States ; 876, Successful removal of right ovary, by Gervis, for cystic disease nine months after operation for hydrosalpinx. 1887, II. 603, By Treves, with removal of kidney. 1888, 1. 674, By Lunn, for bleeding fibroid of uterus ; 1155, 1270, Removal of diseased ovaries. 1888, II. 667, By M'Mordie, of displaced cystic ovary causing persistent pelvic pain ; 1283, Lessons in. GLAS. MED. JOUR. XXVIII. 398, In neurotic affections; 398, Is it curative? 399, Of cystic ovaries, for dysmenorrhoea, by Win. Duncan. AMER. JOUR. OBS. 1886. 56, Of cystic ovaries with pyosalpinx, by Janvrin; 80, Case, by Montgomery ; 81, Supravaginal, for fibroid, by Montgomery ; 137, versus Hysterec- tomy for myofibromata ; 166, For ovaralgia, by Goodell ; 167, For bleeding fibroid, by Goodell ; 277, Rare case of multiple neuro- mata following ; 483, In fibroids ; 613, Case of Hegar's operation, Lee ; 1172, By Price, for uterine fibroid. 1887. 172, Of cystic ovary ; 193, Case, by Thompson ; 732, For hystero- mania. 1888. 335, For fibroid ; 435, For epilepsy, Reamy ; 710, For fibroids ; 872, Per vaginam, Byford ; 1115, Castration in Osteo- malacia, Fehling ; 1189, A year's work in, Goodell. ARCHIV F. GYN. XXIX. 183, Observations onj_ 333, In epilepsy ; 333, In neuroses XXXII. 506, In osteorualacia, Fehling. CENTRALB. F. GYN. X. 40, With supra- vaginal extirpation of uterus for fibro- myoma, Vogelius ; 62, In uterine myoma, Fraipont ; 257, In fibro-myoma ; 580, Of small ovaries. XI. 698, Castration, Hegar. XII. 849, Castration, Willers. ZEITSCH. F. GEB. UND GYN. XIII. 325, And neuroses. XTV. 106, Myomotomy and, in fibroids, Wehmer. ARCHIV. DE TOC. 1886. 28, Ovario-hysterec- tomy, Terrier. 1887. 289, And nervous affections of women ; 397, Castration, Her- gott ; 658, By Championniere ; 706, In nervous affections. ANNAL. DI OSTET. 1887. 155, For fibroids. 1888.1, For fibroid, Fasola ; 49, Vomiting and meteorismus after. OVARIAN TUMOURS, CYSTIC. BRIT. MED. JOUR. 1886, I. 1*3, Ruptured, during operation, by Aveling ; 1074, Speci- men. 1887, I. 799, Parasites in. 1887, II. 510, Specimen ; 1050, Ovariotomy for ; 1157, With twisted pedicle; 1282, With twisted pedicle. 1888, 1. 21, Suppurating ; 22, Causing uterine haemorrhage ; 249, With hsematosalpinx ; 249, Cystic disease of ovary ; 303, Large inultilocular ; 906, In pregnancy ; 960, Associated with precocious puberty. 1888 II. 125, Hydramnios simulating ; 1049, Specimens ; 1049, With twisted pedicle ; 1221, Ibid. ; 1395, Papillary. LANCET. 1886, I. 221, Discharge of cyst per rectum; 353, Specimen of papilloma ; 744, With mematosalpinx ; 1162, Recurrent; 1222, G94 APPENDIX. Removal of, by Knowsley Thornton. 1886, II. 072, Spontaneous cure. 1887, I- 122, Complicating pregnancy; 527, Sjxjcimen; 10S/i, Following injury; 1087, Multilocnlar ; 1139, Ibid.; 1186, Tubo-ovarian. 1887, II. 117, Discussion on tubo-ovarian cysts ; 417, Re- port on case ; 1 104, Herman on. 1888, I. 74, Causing uterine haemorrhage ; 829, Cases of. 1888, II. 618, Recovery from ; 007, Removal of a displaced cystic ovary, by M'Monlie ; 1281, Cases. EDIN. MED. JOUR. XXXI., II. 788, One hundred and twelve consecutive operations for ovarian and parovarian cysts without a . death, by Lawson Tait ; 905, With twisted pedicle. XXXII., I. 272, Enlarged cystic ovary. XXXIII., I. 73, Cases. XXXIV., 1. 275, 435, Pathology of cystic ovaries. GLAS. MED. JOUR. XXVIII. 899, Cystic ovaries removed for dysmenorrhcea, Wm. DUB. MED. JOUR. LXXXIII. 296, Case; 476, Case. LXXXIV.147, Multilocular ; 151, Case ; 422, Ibid. LXXXV. 352, Specimen of suppurating. LXXXVI. 71, Cases of. AMER. JOUR. OBS. 1886. 270, Specimen with pyosalpinx ; 4S9, Unusual; 623, Case; 828, Weighing 100 Ibs. ; 1100, Proliferating; 1170, Case; 1201, Discovered soon after delivery; 1278, Monocyst ; 1280, "Bursting" cyst. 1887. 178, lutra-ligamentous; 309, Proliferating; 310, In broad ligament; 311, Suppurating adenoma ; 3lL>, Unilocular, with corpus luteum ; 734, With papillomatous degeneration of internal surface ; 752, Simu- lating ectcpic gestation ; 872, Large, cured by drainage and obliteration of cavitj Parish ; 878, With twisted pedicle; 1283, Simple ovarian cyst. 1888. 1, Intra-ligamentous ; 02, Multilocular colloid ; 528, Case of trau- matic haemorrhage into an ; 530, Small sup- purating, so-called ovarian abscess ; 614, Diagnostic aspiration of ; 710, Proliferating ; 711, Intra-ligamentous; 732, Strangulated; 1174, Double ; 1205, With a subserous fibro- myoma of the cervix ; 1307, Multilocular. ARCHIV F. GYN. XXXIII. 327, Malignant. CENTRALS. F. GYN. X. 11, Operation in Malignant; 183, Malignant; 644, Enderlin on ; 670, Rupture of. XI. 147, Rupture of, during vomiting; 233, Case of; 403, Malignant. XII. 238, Ascites in twisting of pedicle. ZEITSCH. F. GEB. UND GYN. XII. 14, Malignant. ANNAL. DE GYN. XXVI. 245, False. ANNAL. DI OSTET. 1886. 108, Torsion of pedicle; 197, 206, Operation for intra-liga- mentous, Fasola. OVARIAN TUMOURS, SOLID. BRIT. MED. JOUR. 1886, I. 18, Sarcoma of; 18, Double-fused ovarian sarcoma ; 600, Malignant. 1886, II., Myxo-carcinoma. 1887, I. 1164, Of left ovary. 1888, I. 648, Sarcoma. 1888, II. 79, Sarcoma ; 1049, Sarcoma. EDIN. MED. JOUR. XXXIIL, II. 755, Myxomatous. GLAS. MED. JOUR. XYTX. 79, Peculiar teratoma. AMER. JOUR. OBS. 1886. 528, Advisability of operating in cases of -:alignant ; 1265, Fibroid ; 1277, Fibro-sarcon.atous. 1887. 1187. Papilloma; 1291, Spindle-celled sarcoma. 1888.323, Fibroma; 1197, Sarcoma with half- twisted pedicle. ARCHIV F. GYN. XXXIIL 1, Origin of epithelial tumour of ; 327, Malignant. CENTRALB. F. GYN. X. 183, Malignant; 569, Dermoid carcinoma; 582, Myxoma; 044, Enderlin on. XI. 403, Malignant. ZEITSCH. F. GEB. UND GYN. XII. 14, Malignant. OVARIES, AFFECTIONS OF. BlllT. MED. JOUR. 1886, I. 264, Piipillo- niata fungating into peritoneum. 1887, I. 825, Pathology of chronic inflammation of ; 1104, Papilloma. 1887, II. 073, Inflam- matory condition of. 1888, I. 410, Papilloma of tubes and ovaries; 1389, Pro- lapse of ovary. 1888, II. 940, Abscess of, with uterine fibroid. LANCET. 1886, I. 402, Displacements; 973, Adenoma of. 1886, II. 398, Cystic de- generation ; 715, 767, Connection with pul- monary phthisis. 1887, I. 312, Hernia of ovary. 1888, I. 31, Specimens of jiapil- loma; 879, Malignant disease of. 1888, II. 709, Blood calculi in both ; 914, Tubercle ; 1034, Oophoralgia treated by Faradisation. EDIN. MED. JOUR. XXXII., I. 107, Series of. diseased. GLAS. MED. JOUR. XXIX. 76, Specimens illustrative of. DUB. MED. JOUR. LXXXI. Ill, More Madden on displacements. AMER. JOUR. OBS. 1886. 292, Follicular degeneration ; 413, Papilloma of the hilum ; 503, Haematoma with adherent Fallopian tube ; 009, Abscess of one ovary with double pyosalpinx ; i>13, Case of Hegar's operation for, Lee ; 616, Double cystomaovarii papillare, laparotomy, by Lee ; 1273, Abscess with cyst of right broad ligament. 1887. 105, Abscess; 1196, Absence of both; 1227, Malignant growths and surgical treatment ; 1282, Photograph of diseased tubes and ovaries. 1888, 111, Diagnosis and treat- ment of adhesions in prolapse; 434, Pro- lapsus ; 485, Martin's method of operating in high -seated abscesses involving the ovaries, tubes and intestine ; 512, Abscess ; 526, Ibid. ; 1188, Specimen of diseased by Gonorrhoea! infection ; 1214, Enormous sarcoma implicat- ing both ovaries and one tube in a young girl ; 1274, Abscess ; 1289, Sarcoma. ARCHIV F. GYN. XXXII. 234, Cavernous metamorphosis of. XXXIII. 329, Encap- suled. ANNAL. DE GYN. XXVIII. 201, Terrillon on ; 321, Inflammation of tubes and ovaries. OVARIES, ANATOMY AND PHYSIOLOGY OF. LANCET. 1886, I. 213, The corpus luteum ; 470, Ibid. DUB. MED. JOUR. LXXXII. 140, Ovaries of AMER. JOUR. OBS. 1888. 558, Healthy and diseast'il. A lit -II IV F. GYN. XXXI. 327, Healthy and diseased. CENTRALB. F. GYN. XI. 409, Pathological anatomy of ovaries. OVARIOTOMY. (&e. l*n"Alxlo;,,nmt SurQtrn") BRIT. MED. JOUR. 1886,1.175, 239, Liga- ture in ; 921, One hundred and thirty -nine cases by Lawson Tait; 1141, 1196, 1230, Revival of Ovariotomy. 1886, II. 49, 187, Nomen- clature ; 49, 89, Revival of Ovariotomy ; 284, In London Hospitals ; 892, Washing out the ]>eritoneuni in. 1887, I. 270, Fifty cases by Skene Keith ; 570, Compared with Tail's and Battey's Operations ; 901, Child-birth after. 1887, II. 20, Unusual form of adhesion met with during ; 774, Cases of, by Burton ; 1366, Parotitis after. 1888, I. 290, At end of seventh month of pregnancy ; 303, By Smyth, for large mnltilocular ovarian cystoma ; 326, Early cases ; Oil, Thirty-five cases by Terrillon ; 1127, By Humans, in an aged patient ; 1100, INDEX OF RECENT GYNECOLOGICAL LITERATURE. 695 Urticaria dift'usa vel febrilis after. 1888, 11.17, Case by Quicke ; SO, Ovariotomy in age; 849, Ibid. LANCET. 1886, I. 34, The first in island of Sardinia; 641, Intestinal obstruction follow- ing; 920, For dermoid cyst in girl; 13, By Cavafy and Haward ; 1281, In Russia. 1886, II. 165, For second time, by Rivington ; 445, Two cases by Elder ; SIS, Three hundred cases by Knowsley Thornton ; 916, Parotitis follow- ing ; 1174, Three cases by Wilkinson. 1887, I. 215, For dermoid cyst, by Sinclair Steven- son ; 339, Listerian and non-Listerian ; 1129, Followed by secondary intra- peritoneal hsemor- rhage; 1283, Cases by Malins. 1887,11. 20.3, Forty-five completed cases by Cull ing- worth. 1888, II. 1, Clinical lecture on ; !.'{", Lawson Tait on preceding lecture ; 210, By Macan ; 803, 855, Eleven cases by Culling- worth ; 1100, Aveling and Campbell on. EDIN. MED. JOUR. XXXI. II. 837, 865, Cases by Skene Keith. XXXIL, I. 273. 30*!, Sup- puration of parotids after. XXXIII., II. 620, 762, Fifty consecutive, by Halliday- Croom. XXX IV., I. 564, Second in same patient, by Sir Spencer \Vells. GLAS. MED. JOUR. XXVI. 75, Pregnancy after double. XXIX, 172, Terrier's fifth series of twenty-five. DUB. MEL). J >UR. LXXXIII. 476, M'Mordie on. LXXXIV. <'>9, Successful, by Ester. LXXXVI. 298, Three cases by Byres; 302, Successful case in a child, by Mackenzie ; 357, Two cases by Dempsey ; 432, Successful, by Ester. AMEK. JOUR. OBS. 1886. 65, Followed by acute peritonitis ; 169, By Montgomery : 617, For small ovarian cyst, Hunter ; 629, During pelvic peritonitis, Munde ; 640, With amputa- tion of uterus, Chunn ; 1022, In a child thirty months old, for dermoid tumour, by Hooks ; 1034, By Whetstone, for double tumour with tubercular peritonitis; 1043, Statistics of; 1136, Twenty-eight, by Helmuth ; 1272, During pregnancy, by Munde. 1887. 48, Statistics ; 298, A year's work, Goodell ; 730, During pregnancy, by Munde ; 1187, For third time on same patient, Munde. 1888. 544, Two cases; 941, Typhoid fever following; 945, With hysterectomy and abdominal section, BaUy ; 1028, Double ovariotomy during preg- nancy; subsequent delivery at term; 1039, Second in same patient, Wells ; 10S4, Double, during pregnancy, Potter. ARCH IV F. GYX". XXXIL 193, Thirty- seven cases, Szabo ; 247, Occlusion of gut after. CEXTRALB. F. GYX. X, 109, By Chiara ; 124, Parotitis after ; 177, In Spain; 539, Thirty cases, by Rein ; 619, With peritonitis follow- ing twisting of the pedicle, Miinster. XI. 139, In pregnancy ; 425, With vaginal total extirpation of uterus, Asch ; 436, Operation for small tumours, Kiistner ; 704, Parotitis after; 772, by Schmid. XII. 183, Obstruc- tion of bowel after. ARCHIV. DE TOC. 1886. 31, Double, and menstruation. 1887. 358, Six weeks in puerperium , Doleris. AXXAL. DE GYX. XXVII. 161, By Chalot. XXVin. 31, By Chalot. AXXAL. DI. OSTET. 1887. 352. Two cases, Kirch. 1888. 21, 64, Cases, by Fasola. OVARITIS. AMER. JOUR. OBS. 1886. $38, Ovaries and tubes from chronic. CEXTRALB. F. GYX. X. 773, Chronic. ARCHIV. DE TOC. 1887. 803, Inflammation of uterine appendices. AXXAL. DE GYX. XXX, 108, Laparotomy for salpingitis and, Terrillon. PAROVARIAN TUMOUR. BRIT. MED. JOUR. 1888, II. 1023, Pyosal- pinx or suppurating parovarian cyst. LAXCET. 1886, I. 495. Cysts. EDIX. MED. JOUR. XXXI., II. 738, One hundred and twelve consecutive operations for ovarian and parovarian cysts without a death. DUB. MED. JOUR. LXXXII. 146, Unilocular cyst ; 147, Ibid. AMER. JOUR. OBS. 1886. 223, Anatomy of cystic. 1887. 179, Cyst ; 310, Cyst compli- cated with uterine fibroid. CEXTRALB. F. GYX. X. 29, Cyst. ARCHIV. DE TOC. 1887. 859, Cyst. AXXAL. DE GYX. XXTY, 117, Parovarian cysts. PELVIC FLOOR, PROLAPSUS UTERI. BRIT. MED. JOUR. 1886. I. 202, Pessary incarcerated in. 1887, I. 109, Emmet's operation for procidentia uteri, Beverley. LANCET. 1886, II. 989, Xew operation for, by Malanco. 1887, II. 660, Inversion, with complete prolapse. EDIX. MED. JOUR. XXXIL, I. 172, Etiology of prolapsus. JUjJjJL_,_II. 1042, Treatment of prolapsus. XXXIII., I. 230, Treatment of prolapse. AMER. JOUR. OBS. 1886. 158, Successful case of Alexander's operation ; 188, Causes of prolapse ; 605, Cure of procidentia by Alex- ander's operation ; 995, Alexander - Adam: operation. 1887. 1051, Alexander's opera- tion, Doleris ; 1302, 1304, Results of prolapsus operations ; 1303, 1304, Prolapsus operations. 1888. 70, Forcible and complete prolapse in a virgin ; 1121, Value of Alexander's operation ; 1185, Vaginal hysterectomy for procideutia with epithelioma of cervix and vagina; 1291, Alexander's operation with report of cases, Xewman. ARCHIV F. GYN. XXX, 401, Extirpation of uterus for prolapse ; 452, Results of pro- lapse operations ; 453, Prolapse operations. XXXIII. 313, Vaginal ligature of uterus in prolapse ; 324, Xew operation for prolapse, Firnig. CEXTRALB. F. GYX. X. 59, Prolapse oper- ations. Martin. XL 277, Alexander-Adams operation, Gardner. XII. 201, Prolapse and massage; 481, Ibid.; 561, Vagino - uterine ligature in prolapse ; 641, Alexander- Adams operation in prolapse. ZEITSCH. F. GEB. UXD GYX. XTV. 500, Prolapse operations. ARCHIV. DE TOC. 1886. 22, Alexander operation, Pajot. 1887. 304, Alexander- Adams operation, Pozzi ; 426, Ibid., Bonilly. AXXAL. DE GYX. XXIX. 321, Prolapse; XXX. 161, 321, Prolapse. PELVIS, ANATOMY OF. LANCET. 1886, II. 1131, Dissection of muscles, by Doran. PERINEUM. | BRIT. MED. JOUR. 1886, I. 341, Perineor- rhaphy. i LAXCET. 1888, I. 219, Complete rupture. 1888, I- 876, Extensive destructive ulcera- tion from rectal obstruction with caries of 5th lumbar vertebra. EDIN. MED. JOUR. XXXIII., II. 1061, Use of deep-buried continuous animal suture in perineorrhaphy. AMER. JOUR. OBS. 1886. 710, 737, Perineum as a supporting structure, some of the methods of perineorrhaphy and colpor- rhaphy. 1887. 532, Method of perineor- rhaphy ; 1301, 1304, Recent (English) methods of perineorrhaphy. 696 APPENDIX. ARCHIV F. GYN. XXVIII. 502, Mekertts- chiantz on perineorrliaphy ; 492, Perineo- plastic operations, Kiistner ; 493, Complete perineoplastic operation, Korn. XXXI. 450, New (English) methods of perineorrliaphy, Siinger. XxyiT. 463 t Perineo-plastic opera- tions, Zweifel. XXXIII. 308, Perineor- rhaphy with Lawson Tait. CENTRALB. F. GYN. X. 49, Perineo-plastic operation, Lanenstein ; 392, Local anaesthesia in operation. XI. 473, Perineoplastic opera- tion, Fritech. XII. 765, Perineorrhaphy, ZEITSCH.' F. GEB. UND GYN. XIII. 98, Perineoplastic operations, Kustner. XIV. 82, Development of and relation to certain malformations. YOLK. SAMML. No. 301, Perineorrhaphy by splitting septum and making flaps, Siinger. ANNAL. DI OSTET. 1886. 259, 397, Repair of, Morisani. PERITONEUM AND CELLULAR TISSUE, AFFECTIONS OF. BRIT. MED. JOUR. 1887, 1. 782, Methods of cleansing. LANCET. 1886, 1. 110, Milky fluid in peri- toneal cavity. AMER. JOUR. OBS. 1886. 265, Involved in tuberculosis of the uterus ; !>64, Intra- or post- peritoneal abscess. 1887. Vaginal pressure in treatment of chronic pelvic disease; 932, Laparotoniy for tuberculosis, Van de Warker ; 957, Intra - peritoneal adhesions. 1888. 414, Intra-ligamentary cysts ; 513, Cal- cified cyst, pelvic ; 1114, Relaxation of peri- toneum. ARCHIV F. GYN. XXXI. 373, Pseudo- myxoma ; 4(54, Laparotoniy for tuberculosis. CENTRALB. F. GYN. X. 447, Connective tissue in the pelvis and its pathology. XII. 775, Treatment of intestinal affections from peritoneal adhesions. PERITONEUM AND CELLULAR TISSUE, INFLAMMATION OF. BRIT. MED. JOUR. 1886, I. 458, Abscess of Liver following pelvic cellulitis ; 522, Pelvic peritonitis ; 1065, Serous perimetritis, or peritonitis. 1886, II. 1212, Acute peri- tonitis. 1887, II. 93, Gonorrhoeal peri- tonitis ; 1061, Laparotomy for ; 1094, Elec- tricity for. 1888, I. 1057, Encysted serous peritonitis. 1888, II. 1395, Encysted serous peritonitis. LANCET. 1886, I. 441, Pelvic abscess ; 926, Serous perimetritis. 1886, II. 249, Para- metric phlegmon following hydatid. 1887, I. 310, Abdominal section, by Mackay, for pelvic suppuration ; 409, 461, Cases of peri- tonitis. 1888, 1. 268, Two cases of lapa- rotomy for tubercular peritonitis, by Homans; 719, Abdominal section for peritonitis, by Smith and Burford. 1888, II. 1021, Suppurative peritonitis ; 1170, Tubercular peritonitis laparotomy for, by Mayo Robson. EDIN. MED. JOUR. XXXIIL, II. 600, Peri- tonitis ante-partum. XXXIV., I. 85, Vaginal tampon in ; 564, Cause and treatment of pelvic abscess. GLAS. MED. JOUR. XXX. 92, Vaginal tam- pon in. AMER. JOUR. OBS. 1886, 65, Secondary operation for acute peritonitis, by Hunter ; 102, Posterior parametritis and its sequels ; 104, Minute alterations of the nerves during parametric atrophy; 155, Sudden obscure shock during chronic pelvic peritonitis; 189, Exaggerated importance of minor pelvic in- flammations ; 390, Myelitis following pelvic cellulitis ; 742, Pelvic cellulitis ; 762, Different kinds of cellulitis ; 838, Ovaries and tubes from case of pelvic peritonitis; 122'.', Elec- trolytic puncture for areolar hyperplasia ; 1252, Observations on. 1887. 60, 169, Stretching of old intra-pelvic adhesions by pressure; 288, Vaginal tampon in adhesions; 516, Ibid. ; 548, Antiseptic tamponnement in; 1001, Haemorrhngic parametritis; 1092, Vaginal tampon in ; 1290, Adherent intestines from peritonitis simulating fibroid tumour ; 1297, Salines in peritonitis following abdo- minal section. 1888. 408, Laparotomy for septic peritonitis, Boldt ; 447, Surgical treat- ment of tubercular peritonitis ; 498, Septic peritonitis and death following dilatation of the cervix ; 499, Septicperitonitisfollowinghystero- trachelorrhaphy ; 006, Death from peritonitis following trachelorrhaphy ; (">07, Ibid., follow- ing removal of a cervical fibroid ; 713, Cases of abscess opening into rectum ; 916, Remarks on pelvic peritonitis and year's work in abdo- minal surgery, Eastman; 1037, Treatment of pelvic abscess ; 1070, Contribution to study of pelvic abscess; 1074, Treatment of suppura- tive peritonitis ; 1076, Laparotomy in peri- tonitis; 1189, Chronic cellulitis ; 1275, Chronic pelvic peritonitis. CENTRALB. F. GYN. X. 41, Tubercular peri- tonitis and laparotomy, Naumann ; 158, Tubercular peritonitis ; 379, The usual and non-infectious peritonitis ; 619, Peritonitis following twisting of the pedicle in ovario- tomy. XI. 33, Tuberculosis; 72, Peri- metritis ; 753, Peritonitis after laparotomy ; 822, Laparotomy in tubercular peritonitis, Schmalfuss. XII. 367, Tuberculosis; 505, Caesarean section in septicaemia. VOLK. SAMML. No. 274, Perimetritis'. ARCHIV. DE TOO. 1886. 752, 817, Suppura- tive perimetritis, surgical interference, Pozzi. 1887. 625, Perimetritis and aspiration. ANNAL. DE GYN. XXVI. IS, Peritonitis with sub-peritoneal myoma and pregnancy. XXVII. 201, Acute metritis and. ANNAL. DI OSTET. 1888. 354, Treatment of peri-uterine adhesions ; 515, Glycerine plugs in chronic pelvic inflammation. PERITONEUM AND CELLULAR TISSUE, TUMOURS OF. (See also " Abdominal Tumours.") LANCET. 1886, II. 74, Case of rupture of pelvic cyst. 1887, I. 982, Haemorrhagic parametiitip. EDIN. MED. JOUR. XXXIV., I. 566, Dangers of galvano-puncture in ]>elvic tumours. AMER. JOUR. OBS. 1886. 425, Case of pelvic abscess and treatment ; 1227, Pelvic abscess. 1887. 165, Pelvic abscess complicated with fibre-cyst of uterus ; 763, Retro-peritoneal cysts and Mikulicz'a system of drainage. 1888. 1053, Dangers of galvano-puncture in. ANNAL. DE GYN. XXIX. 97, Peritoneal pelvic fibrous. PERITONEUM AND CELLULAR TISSUE- ILEMATOCELE AND HJEMATOMA. BRIT. MED. JOUR. 1886, I. 339, 523, Pelvic haematocele. 1886, II- 691, Ovaries and tubes in. LANCET. 1886, 1- 494, Retro-uterine. 1886. II. 423, Intraperitoneal haematocele ; 470, S05, Lawson Tait on ; 604, Subperitoneal ; 652, 653,' Letters on. 1887, I. 120, Haema- tocele from a ruptured Graafian follicle ; 496, Presence of blood in the peritoneum. 1887, II. 762, Haematocele. DUB. MED. JOUR. LXXXV. Ifi9, Peri-uterine hrematocele. LXXXVI. 203, Peri-uterine hmmorrliage. AMER. JOUR. OBS. 1886. 82, Two cases of pelvic haematocele ; 334, Two cases of extra- INDEX OF RECENT GYNECOLOGICAL LITERATURE. 697 peritoneal hiematoma cured by vaginal inci- sion and drainage, Munde ; 448, Peri-uterine hasmatocele treated by negative galvano-punc- ture ; 1121, Causation and treatment of pelvic hwmatocele ; 1175, Ibid. 1887. 103, Cal- culus ; 1222, Successful operation for haema- tocele, Phillips. 1888. 108, Non-uterine hiematocele ; 027, Large suppurating extra- peritoneal hgematoma, cured by laparotomy, Seymour; 1175, Laparotouiy v. expectant treatment in haematocele. ARCHIV F. GYN. XXIX. 389, Peri-uterine hiematocele. CENTRALB. F. GVX. X. 58, Haematocele and electricity ; 179, Hwmatocele processus vaginalis peritonei. XI. 329, Haematoma of round ligament. PESSARIES BKIT. MED.' JOUR. 1887, I. 107, Use of stem pessaries ; 456, 624, Use and abuse of ; 515, New intra-uterine stem pessary and introducer; (578, Modification of ring ; 943, Uterine band with pad ; 1839, Amenorrhcea stem. 1887, II. 63, Value of Hodge ; 724, New galvanic stem ; 836, New uterine support for horse- women. 1888, II. 129, Hofman's improved. LANCET. 1887, I. 221, New flexible glycerine ring. 1887, II. 766, New uterine support for equestriennes. EDIN. MED. JOUR. XXXI., II. 968, Maclaren on. XXXII., I. 173, Indications for, and methods of use ; 558, Hewitt's cradle pessary. XXXIII., I. 128, 173, Removal of encysted Wedgwood "Ball Pessary." XXXIII., II. 851, Action of pessaries. GLAS. MED. JOUR. XXVI. 76, Meyer on. XXVIII. 429, History of. XXIX. 262, Action of. AMER. JOUR. OBS. 1886. 000, New retrover- sion stem ; 750, Encysted ; 862, Removed in fourth month of pregnancy. 1887. 50, Stem worn for three months ; 845, New retroversion stem ; 857, For procidentia uteri. 1888. 421, New uterine elevator ; 1105, Schultze on. ARCHIV P. GYN. XXXIL 480, A few notes on. CENTRALB. F. GYN. X. 40, Meyer on. XII. 289, Breisky's ovarian. ARCHIV. DE TOC. 1886. 769, Displacements of the uterus and. RECTUM. BRIT. MED. JOUR. 1886, II. 143, Rectal fistula and haemorrhoids. 1887, I. 447, Prolapse of upper into lower part. 1887, II. 16, Stricture of ; 25, Rectal alimentation ; 422, Sigmoidostoniy ; 1320, Case of cancer of. 1888, I. 26, Pascal" lodgments ; 554, Operation for rectal haemorrhage. LANCET. 1886, I. 157, Syphilitic stricture of. 1886, II. 262, Operation for cancer, by Gnarneri. 1887, II. 655, Cancer of ; 813, Villous polypus of. 1888, I. Rectal concre- tion ; 876, Chronic obstruction from caries of 5th lumlwr vertebra ; 1298. Peculiar case. GLAS. MED. JOUR. XXVI. 457, Excision of cancer, by Napier. AMER. JOUR. OBS. 1888. 72, Radical cure of rectocele by ligation. STERILITY. BRIT. MED. JOUR. 1888, 1. 844, Treatment. 1888, II. 870, And obstructive dysmenor- rhosi. LANCET. 1886, I. 989, Due to uterine dis- placements. 1887, I. 1073, Clinical notes on. 1887, II. 403, Notes on. 1888, I. 87ti, Rectal concretion ; 1132, Treatment of and obstructive dysmenorrhcwi. EDIN. MED. JOUR. XXXTV.,1. 566, Import- ance of microscope in treatment. GLAS. MED. JOUR. XXIX. 366, Clinical notes on. TCXY. 421, Treatment of in dysmenorrhcea. DUB. MED. JOUR. LXXXV. 297, Treat- ment of and obstructive dysmenorrhcea. LXXXVI. 73, Discussion on preceding. AMER. JOUR. OBS. 1887. 623, And ante- flexion with disease of ovaries ; 1094, Causes and treatment. 1888. 40, 78, Electrolysis v. rapid dilatation for ; 111, Ninety cases of one-child sterility ; 1055, Importance of micro- scope in treatment. CENTRALB. F. GYN. XII. 287, Ninety cases of one-child sterility. SUPERINVOLUTION. AMER. JOUR. OBS. 1888. 1009, Following trachelorrhaphy. SYPHILIS BRIT. MED. JOUR. 1886, I. 55, 141, 239, Moot points in ; 77, Problems of ; 132, 174, 228, Correspondence on moot points. 1886, II. 1027, Mercury as an antidote. 1887, I. 132, Diabetes and syphilis ; 238, Reproduc- tion of syphilitic virus ; 274, Remarkable case of primary 8. ; 416, In pregnancy ; 569, Congenital, with multiple joint effusion ; 583, Treatment ; 590, Syphilitic bydrocephalus ; 942, Some phases of cerebral ; 943, Diagnosis and treatment ; 982, Nomenclature of skin diseases. 1887, II. 1277, Communicability through the saliva ; 1303, Myositis syphilitica; 1339, Hereditary in adult; 1378, Iodide of potassium for gumma ; 1379, Communic- ability through the saliva. 1888, I. 44, Commnnicability through the saliva ; 132, Small doses of mercury in ; 151, Unmerited ; 156, Hysteria and ; 279, Communicability through the saliva; 321, Calomel injections in ; 321, Influence of erysipelas on ; 413, 417, Abortive treatment of syphilis ; 468, Case of ; 609, Syphilitic conjunctivitis; 665, "The abortive treatment of syphilis ; " 768, 823, Alleged arrest in its primary stage ; 802, Con- genital ; 905, Injection of mercury ; 970, Malignant ; 971, Orbital ; 980, Rare form of congenital ; 1043, Constitutional; 1277, Modi- fying phthisis ; 1277, Secondary, in an old woman ; 1296, Subcutaneous injection o "grey oil." 1888, II. 693, Diagnosis and treatment of syphilitic affections of the nervous system. LANCET. 1886, 1. 65, 157, 252, Moot points in ; 217, Acquired and inherited ; 584, 633, Treatment; 680, Bacillus of; 692, Neuralgia of ; 692, Microscopic section of papule ; 1038, Treatment. 1886, II. 337, Treatment ; 413, Effects in pregnancy ; 462, Hypodermic treat- ment ; 621, Acute tonsilitis in tertiary. 1887, 1. 22, Syphiloma of heart ; 168, Venereal diseases in girls of tender age; 313, "Indur- ation " of Hunterian chancres in the female ; 448, Preventive treatment; 473, Methods of administering mercury ; 780, Syphilitic coma ; 828, Case of hereditary; 943, Carbolate of mercury in. 1887, II. T71, Micro-organisms in inherited ; 1015, Lardaceous disease in con- genital ; 1282, Microbe of. 1888, I. 372, Abortive treatment ; 426, Case ; 422, Case of syphilitic onychia ; 826, Intra-muscular injec- tion of mercury in ; 846, Alanix-mercury in ; 863, And its treatment ; 937, Micro-organisms of; 1017, Practical treatment of. 1888, II. 82. And rickets. EDIN. MED. JOUR. XXXI., II. 1091, Na- tural History and Treatment; 1093^ Syphi- litic ulceration of intestine. XXXII. , I. 92, 185, 280, 378, Moot points in natural history of. 698 APPENDIX. EDIN. MED. JOUR. XXXII., 1 1. 004, Spurious venereal disease. XXXIII., I. 9:i, As an etiologicnl factor in disease. XXXIII. , II. 865, Guiunia in the trachea ; 807, Ulcers and their relation to syphilis ; 959, Abortive treat- ment. XXXIV., I. 79, Earliest symptoms of inherited; 483, Importance and eradica- tion. GLAS. MED. JOUR. XXV. 87, A new antisy- philitic. XXVI. 230, Conditions increasing the gravity of ; 428, Syphilitic diseases of upper air passages. XXVII., I. 82, Syphi- litic diseases of upper air passages ; 219, Syphi- litic affections of the nervous system. DUB. MED. JOUR. LXXXII. 47ii, Treatment of syphilitic condylomata. LXXXV. 470, Ointment for syphilitic rashes. CENTRALB. F. GYN. X. 318, Intra-uterine infection ; 403, Reinfection of mother through foetus ; 089, In pregnancy. XII. 30, And pregnancy. ARCH IV. DE TOO. 1886. 913, And preg- nancy. 1887, 178, Hereditary syphilis and subcutaneous abscesses. ANNAL. DI OSTET. 1888. 503, Treatment of abortion due to. TAIT'S OPERATION. (Sec also "Fallopian Tuba, Anatomy itnd A fleet ion* of.") BRIT. MED. JOUR. 1886, I. 880, Specimens from eleven cases. 1886, II. 852, General principles in ; 10S2, An Address on by Tait ; 1101, For chronic ovaritis and double pyosal- pinx, Edis. 1887, I. 51, On removal of the uterine appendages; 71, 117, Report on; 174, 303, 339, Correspondence on ; 450, For pyosal- pinx, Tait ; 570, Compared with normal ovari- otomy and Battey's operation ; 1044, By Bantock ; 1104, Specimens from. 1887, II. 237, By Butler Smythe, for constant ovarian pain, incessant vomiting, and dysmenorrhoea. 1888, I. 249, By Granville Bantock, for fibroid tumour and haemorrhage ; 358, By Tait, for intense hystero-epilepsy ; 908, By Granville Bantock ; 13S7, Influence of removal of uterus and its appendages on sexual appetite ; 1394, By Heywood Smith. LANCET. 1887, II. 1213, By Lawson Tait, for hystero-epilepsy. EDIN. MED. JOUR. XXXI., II. 812, Diseases and removal of the uterine appendages. XXXIL, I. 73, By Brewis; 207, By Halliday Croom ; 271, By Brewis ; 4ii8, Removal of the uterine appendages. XXXIL, II. 811, 839, 883, For disease, with twenty-three cases, by Skene Keith. AMER. JOUR. OBS. 1887. 180, For sub- involution and endometritis, Kelly; 302, Three successful cases, by Wilson ; 702, For fibro-myoma of uterus, Jackson ; 779, Two cases by Palmer; 1093, By Burton; 1277, Secondary haemorrhage following. 1888. 158, Five cases by Dixon- Jones ; 337, Removal of uterine appendages and small ovarian tumours, with report of twelve successful cases, Byford ; 012, Regular menstruation after: 709, By Tnttle ; 939, 974, Removal of uterine appendages for nymphomania and uterine myoma; 1200, Specimen; 1209, By Hall. ARCHIV F. GYN. XXIX. 329, Clinical observations on. YOLK. SAM ML. No. 323, On the indications for. No. 343, Partial removal of tubes and ovaries. THERAPEUTICS. BRIT. MED. JOUR. 1886, I. 274, Strychnine in uterine hwmorrhage. 1887, I. 339, Antifebrin ; 590, Antifebrin in febrile and non-febrile diseases ; 870, Antifebrin ; 1039, Hamamelis virginica. 1887, II. '-:!7, Salix nigra as a sexual sedative ; 520, Boracic acid in leucorrhuia ; 1349, Antipyrin as a uterine sedative. 1888, I. 19, Oleateof zinc and iodoform in gynecology ; 32, Foreign opinions of antipyrin ; 291, Relations of gynecology to general therapeutics ; 1213, 1308, Codeine to relieve pain in abdominal disease. LANCET. 1887, II. 004, Therapeutical value of more recent additions to the genito-urinary pharmacopoeia. 1888, II. 1100, Effect of glycerine on the quantity of secretion poured into the vagina ; 1238, Action of certain dmgs on the utero-ovarian system. EDIN. MED. JOUR. XXXI., II. 1104, Physio- logical and therapeutic effects of water ;it different temperatures. XXXIL, I. 131, 215, Physiological and therapeutic effects of water at different temperatures; 175, Hydrastis canadensis in uterine haemorrhages. DUB. MED. JOUR. LXXXI. 471, Antiphlo- gistic action of menthol. LXXXVI. 457, 527, On the action of certain drugs on the utero-ovarian system. AMER. JOUR. OBS. 1886. 109, Some uses of cocaine. 1887. 330, Glycerine tampon as therapeutic agent ; 1050, Value of some medi- cines in haemorrhagic conditions of uterus. CENTRALB. F. GYN. X. 152, Influence of ergot on circulation of uterus ; 300, Ergot preparations ; 309, Action of cornutin ; 528, Ergot preparations ; 025, Kephir. XI. N s , Glycerine tampon in gynecology ; 441, Ergotin injection; 058, Hydrastis canadensis; 774, Painless ergotin injection. XII. 3, Ergotin ; 114, Ergotin injection ; 353, Ibid. ; 434, Glycer- ine per rectum. ANNAL. DI OSTET. 1886. 50, 98, 209, Citrate of iron hypodermically in anaemia. 1887. 171, Citrate of iron hypodermically in anaemia. 1888. 230, Antipyrin in uterine colic. URETER. BRIT. MED. JOUR. 1887, I. 1228, Action o the ureters in. 1888, I. 1174, Surgery of 1208, Value of inspecting orifices of by electric light. LANCET. 1888, I. 57, K ! 3, 209, 425, Some points in the surgery of the urinary organs. EDIN. MED. JOUR. XXXIV., I. 504, Palpa- tion of. AMER. JOUR. OBS. 1886. 877, Palpation of. 1887. 187, Palpation of ; 1294, Palpation and sounding of. 1888. 318, Catheterization of the ureters ; 1 032, Palpation of. ARCHIV F. GYN. XXVIII. 54, Palpation of. XXIX. 2S9, In relation to vagina. CENTRALB. F. GYN. X. 591, Palpation. XL 297, Function in recto- vesico- vaginal fistula ; 384, Palpation of. ARCHIV. DE TOC. 1887. 185, Fibrous cervi- cal polypus compressing. ANNAL. DE GYN. XXIX. 408, Yesico-utero- vaginal fistula and gangrene of part of. AMER. JOUR. OBS. 1888. 1035, Cause and treatment of urethrocele. ARCHIV F. GYN. XXX. 89, Ulceration. CENTRALB. F. GYN. XI. 475, Operation on, Fritsch. UTERUS, AFFECTIONS OF (UNCLASSED). BRIT. MED. JOUR. 1886, I. 1170, Pyometra. 1886, II. 000, Diseases treated by fluids ; 090, Microscopic sections of malignant disease ; 718, Non-gravid hydrorrhcea. 1887, 1. 112, Effect of tight-lacing in producing flexions of the uterus ; 624, Removal of soft tumour, Heywood Smith. 1887, II. 00, Uterine neuroses ; 422, The endometrium and diseases of the uterine appendages; 1349, Hydrastis INDEX OF RECENT GYNECOLOGICAL LITERATURE. 699 canadensis in uterine haemorrhage. 1888, I. 972, Ergot in subinvolntion ; 1010, Cyst connected with the uterus and simulating enlargement of that organ ; 1274, Electrolysis in some chronic affections. LANCET. 1886, I. 853, Dilatation. 1886, II. 107, Curette in diagnosis and treatment; 4(30, 559, Intra- uterine gal vano - cautery. 1887, II. 218, Abscess ; 964, Hasmatometra with degenerating fibro-mycmia. 1888, I. 74, Haemorrhage of rive years' standing caused by enlarged and cystic ovary : OS1, Suppurat- ing phlebitis after miscarriage ; 944, Unripe oranges in metrorrhagia ; 079, Cyst; 111(5, Alteration of uterine mucosa in case of flbro- myoma. 1888, II. 438, Boracic acid in leucorrhoea. GLAS. MED. JOUR. XXVI. 77, Iodine in catarrh. XXVIII. 1, On haemorrhages from the unimpregnated uterus ; 70, Hyster- orrhaphy. XXIX. 305, Boracic ajkl in treatment of leucorrhrea. XXX. 421, Treatment of peri-uterine phlegmasia by elec- tricity. DUB. MED. JOUR. LXXXI. 4-J1, Curette in diagnosis and treatment. LXXXIL 95, Antipyrin as a uterine haemostatic ; 149, 418, Curette in diagnosis and treatment ; 202, Extract of hemlock in intra-uterine inflani- mation and passive haemorrhages. LXXXIV. 144, Relation to affections of the eye ; 152, Absce.ss through umbilicus. LXXXV. 354, Haemorrhage of five rears' .standing. AMEK. JOUR. OBS. ' 1886. 69, Malignant adenoma ; 205, Tuberculosis involving peri- toneum ; 1223, Xew method of treatment. 1887. 103, Calculus ; 824, Uterine dyspepsia ; 1090, Helation between changes in tissue and changes in shape ; 1232, Relation between uterine mucous membrane and diseases of the adnexa. 1888. 63, Myxo-fibroma of the endometrium ; 110, Ulcerations of; 218, And cervical lacerations ; 257, Ibid. ; 1105, Adenoma. ARCHIV F. GYX. XXXI. 376, Paralysis of womb during curetting. XXXII. 487, Malign and simple adenoma. XXXIII. 317, Uterine mucous membrane in carcinoma of the vagina. CEXTRALB. F. GYX. X. 116, Xew growths. XI. 757, E version of mucous membrane through interstitial myoma. XII. 87, Diagnosis and treatment of a typical uterine bleeding. ARCHIV. DE. TOC. 1886. 04, And digestive functions ; 255, Neuralgia. 1887. 644, In morphinomania ; 721, Scraping of uterus in fungous growths ; 893, Fungosities of uterine mucous membrane ; 9S5, 1025, Hydatid cysts of. AXXAL. DE GYX. XXIX. 2''-5, Uterine seda- tive and excitant. XXX. 3, Haemorrhage. UTERUS, ANTEFLEXION AND ANTEVER- SION OF. BRIT. MED. JOUR. 1886, I. 264, Xulliparous anteflexed and dilated uterus ; 927, Cured by pessary. 1887, I. 1105, Worst cases of flexions ; 1278, Treatment of obstinate cases. 1888, I. 401, Effect of flexion on patency of uterine canal. 1888, II. 490, In case of abortion and mole. EDIN. MED. JOUR. XXXIV., I. 505, Etiology, pathology, and treatment of ante- flexion. GLAS. MED. JOUR. XXX. 419, Electrolysis in uterine flexions. AMER. JOUR. OBS. 1886. 706, Xew mode of treating aggravated anteversion. 1887. 623, Treatment of acquired anteflexion with disease of ovaries and sterility ; 1058, Intra- uterine stem in flexions. 1888. 225, Notes on ; 397, Ibid. ; 1043, Etiology, pathology, and treatment of anteflexions of the uterus. ARCH IV. DE TOC. 1887. 441, During labour ; 1075, Doleris on flexions. UTERUS, CARCINOMA OF. BRIT. MELJ. JOUR. 1886, I. 437, Clinical diagnosis ; 432, Diagnosis. 1886, 11. 788, Vulliet's treatment ; 871, Microscopic speci- mens. 1887, I. 5, 50, 100, Lectures on ; 29, New cure for ; 525, Treatment of, by hysterec- tomy ; 800, Chlorate of potassium in epi t helioma ; 1090, Extirpation for, by Stirling ; 1400, Ibid., by Fritsch. 1887, II. 64, Extir- pation for cancer of cervix, -by Cotterell ; 138, In double uterus and vagina ; 929, Cultiva- tion experiments with malignant new growths; 1050, Disease simulating epithelioma ; 1157, Vaginal hysterectomy for malignant disease of cervix, Purcell. 1888, I. 73, Extirpa- tion for, by Ogston ; 141, Virchow on diagnosis and prognosis of cancer ; 280, Parasitic origin of malignant growths ; 761, Recurrence of malignant growths after removal ; SCO, Colloid cancer; 1011, Extirpation by Lewers for primary; 13S9, Chian turpentine in. 1888, II. 151, Carburetted hydrogen in ; 505, With fibroid ; 1205, Sir Spencer Wells on. LAXCET. 1886, I. 140, Family history of cancer patients ; 148, Theory of cancerous inheritance ; 309, Statistics ; 548, Extirpation per raginam, by hewers ; 082, 825, Excision, by Jennings ; 721, Micro-organism of cancer ; 800, Condition of blood-vessels in. 1886, II. 720, Cure by medical treatment ; 719, 770, What constitutes malignancy ; 895, Chian turpentine in. 1887, 1. 0, 59, 100, 205, 301, 358, Harveian lectures on ; 14, Extirpation iy i-aginam, by Greig Smith ; 490, Cancer of the body ; 595, Ibid. ; 927, 1108, Carbonate of lime in arresting growth. 1887, II. 102, Two cases of vaginal extirpation for, by Braithwaite ; 505, Average time before return of cancerous disease after amputation ; 999, On cancer and cancerous diseases. 1888, I. 980, Primary, extirpation of uterus for, by Lewers; 12S7, What is cancer? 1888,11. 29, Pathology of cancer ; 224, Xovel view of the nature of cancer ; 1239. J. "Williams on. EDIX. MED. JOUR. XXXII., II. 658, Pallia- tive treatment. XXXIV., I. 87, Diagnosis of beginning of early carcinoma of cervix ; 88, Extirpation for, Fritsch ; 505, High amputation for cancer. GLAS. MED. JOUR. XXV. 249, Pathology of cancer; 271, Pathology and etiology of cancer: 329, Importance of more detailed clinical study of ; 342, Pathology of cancer ; 354, Etiology and clinical aspects of ; 425, Origin of cancer ; 434, Pathology and etiology of cancer ; 444, Cancer from the family practi- tioner's point of view ; 450, First indication of cancer and the precancerous stage. XXVI. 1, Cancer in some of its clinical aspects ; 9, Local origin of cancer ; 17, Etiology of cancer and nature of rodent ulcer; 21, Heredity in cancer ; 30, 34, Close of dis- cussion on cancer ; 39, Pathology and clinical aspects ; 44, Demonstration illustrative of cancer; 138, Cancer apparently cured; 321, Kolpo-hystereetomy fur, with tables of results. XXX. 181, Immediate and remote effects of vaginal hysterectomy for ; 422, Diagnosis of early carcinoma of cervix. DUB. MED. JOUR. LXXXIII. 285, Diagnosis of cancer of f undns. AMKR. JOUR. OBS. 1886. 1S4, Treatment; 489, With sub- mucous fibroid ; 527, Of cervix: 74!', Epithelioma, treated by mercuric nitrate; 1212, Curability of cancer through operation : 1214, Kolpo-bysterectomy for. 1887. 107, Hysterectomy for, Koeberle ; 220, Extirpation 700 APPENDIX. for, Schultze ; 1095, Modern treatment; 110S, Extirpation for, Martin ; 1150, Recent hys- terectomies for ; 1228, Statistics of vaginal extirpation for ; 1230, Of cervix, in maiden of nineteen ; 1230, Results of operation for cancer of cervix. 1888. 68, Of uterus bilocularis ; 90, Of cervix ; 176, Recent hys- terectomies for ; 400, Amputation of cervix for, consecutive miscarriage ; 437, Columnar epithelioma of cervix ; 443, Chrobak on the treatment of ; 58-2, Ford Thompson on ; 635, Thompson on ; 725, Post-mortem specimens ; 782, Malignant adenoma of cervix ; 868, With cirri i mid cysts; 870, Uterus removed for, Byford ; 8S4, Vaginal hysterectomy for medullary, Heed ; 1045, High amputation for, Reamy ; 1112, Operation for cervical, Bauin- giirtner ; 1114, Condition of mucosa of uterus in carcinoma of cervix. ARCHIV F. GYN. XXIX. 359, Sixty total ex- tirpations of uterus for ; 352, Of cervix. XXX. 401, Extirpation of uterus for, Leopold; 471, Of cervix in young woman of nineteen. XXXII. 271, Mucous membrane of body of uterus in cervical ; 501, Operation for cervical, Baumgartner. XXXIII. 14(5, Changes in the endometrium in cervical. CENTRALB. F. GYN. X. 92, Cervical ; 127, Krysinsky on ; 171, Tetanus and trismus in ; 173, Of body ; 2tiO, Total extirpation of, Schultze ; 534, Origin of carcinoma from chronic inflammation of skin and mucous membrane ; 588, Operation for, indications, Hofmeier; 589, Cervical. XI. Ill, 180, Operation and statistics, Martin ; 227, Total extirpation for, Sanger ; 514, Total extirpa- tion for, statistics, Martin. XII. 71, Latest views on treatment ; 209, Hydrometra ; 213, Treatment of when inoperable, Schramm ; 487, Application of zinc chlor. in carcinoma of portio and vagina ; 593, Zinc chlor. in ; 755, Endometritis in. ZEITSCH. F. GEB. UND GYN. XII. Of mucous membrane. XIII. S9, Diagnosis of commencing ; 3(50, Final result of operation. VOLK. SAMML. No. 338, Diagnosis and treat- ment of. ARCHIV. DE TOG. 1886. 204, And scraping ; 727, Hysterectomy for, Koeberle. ANNAL. DI OSTET. 1888. 500, Bromine in. UTERUS, DISPLACEMENTS OF. BRIT. MED. JOUR. 1886, II. 013, Early history and etiology of flexions ; IKiO, Flexions of the uterus. 1888, I. 203, Causes and treatment ; 286, Management of anterior and posterior displacements ; 860, Treatment of. LANCET. 1886, I. 537, A cause of. AMER. JOUR. O1JS. 1887. 1040, Causes and treatment of. 1888. 561, And electricity. ARCHIV F. GYN. XXXI. 1, Relation of nor- mal and pathological attachments of uterus to. VOLK. SAMML. No. 332, Stitching replaced uterus to abdominal wall. ARCHIV. DE TOO. 1886. 769, And pessaries. UTERUS, ENDOMETRITIS (For TREATMENT, see also "Intro-uterine Medication"). LANCET. 1887, II. 117; 169, Case. EDIN. MED. JOUR. XXXIIL, II. 8.14, Curet- ting the uterine cavity. XXXIV., I. 566, Treatment of chronic by drainage with gauze. GLAS. MED. JOUR. XXVI. 460, Treatment of. XXVI. 68, Ibid. DUB. MED. JOUR. LXXXV. 348, Treatment of. AMER. JOUR. OBSTET. 1886. 194, Intra- uterine treatment of ; 352, Ovarian complica- tions of; 496. K. Funiionn. with amenorrhoaa. 1887. Ill, Electrolysis for; 559, Chronic hyperplastic ; 897, Fungous, and tumours of mucosa of uterus; 1104, Chronic; 1231, Veit on. 1888. 1052, Treatment of chronic by drainage with gauze ; 1067, Treatment. ARCHIV F. GYN. XXVIII. 163, Chronic hyperplastic. XXIX. 78, " Deciduome ; " 346, Of body. CENTRALB. F. GYN. X. 155, B. Fungosa el poh/posa: 186, Curetting; 1S7, Ibid. XL 477, Gonorrhoeal vaginitis and ; 705, In preg- nancy ; 708, Gonorrhoeal vaginitis and. XII. 134, Heit/.mann on ; 241, Non-puerperal ;. XII. 134, Heit/.mann on ; 241, Non-puerperal ; 593, Zinc, chlor. in chronic ; 755, In uterine XIII. 388, cancer. ZEITSCH. F. GEB. UND GYN. Endometritis. ARCHIV. DE TOG. 1886. 760, Intra-uterine galvano-eautery for. 1887. 17, 145, 193, 314, 460, Doleris on. ANNAL. DE GYN. XXIX. 401, Cautery and curetting for. UTERUS, EXTIRPATION OF. (See also- " Abdominal Svri/try.") BRIT. MED. JOUR.' 1886, I. 457, for cancer, by Lewers ; 513, for cancer, by Stewart- Nairne ; 1065, Removal of fundus, Lawson Tait; 1216, For Myoma, Aveling. 1886,. II. 78, Vaginal, by Brennecke ; 1 17, Vaginal, by Zaiaitsky. 1887, I. 525, For cancer ; 583, Total, by Schmidt ; 678, Vaginal, by Purcell ; 1096, Total for cancer, by Stirling; 1278, Supravaginal for fibroid, Bantock ; 1400, Total forcancer, by Fritsch. 1887, 1 1. 64, Forcancer of cervix ; 421, And pyelitis ; 422, Vaginal, by Fritsch ; 878, By Mayo Robson for fibrocystia tumour ; 1157, Vaginal, for malignant disease of cervix, Purcell; 1157, Supravaginal, Ban- tock ; 1257, Keith's results of supra vaginal hysterectomy. 1888, 1. 73, For cancer, by Ogston ; 211, Thirty-eight cases, by C. Braun, for fibroids ; 740, For hystero-epilepsy, by Imlach ; 757, Abdomino-vaginal, by Reeves, for fibroid ; 798, by R. T. Smith, after electro- lysis for fibroid ; 1011, by Lewers, for primary carcinoma of body ; 1274, By Horrocks, for inversion ; 1386, Supravaginal, by Granville Bantock, for multiple fibroid ; 1387, Influence of removal of uterus and its appendages on sexual appetite. 1888, II. 79, Vaginal, by Murphy, for Uterine Fibroid ; 1113, Supra- vaginal, by Meredith, for locked fibroid. LANCET. 1886, I. 416, Vaginal, by Trelat, for cancer. 1886, II. 221, With Nephrectomy, by Calderini. 1887, I. 14, Per vaginam, by Greig Smith, of a cancerous and pregnant uterus; 18, Notes on; 672, By Knowsley Thornton, for fibromyoma in patient fifty-six years of age ; 820, Extirpation of ruptured, by Andrews ; 912, Jennings on. 1887, II. 162, Two cases of vaginal, by Braithwaite, for carcinoma ; 238, Vaginal ; 411, Vaginal, by Purcell, for malignant disease; 811, Supra- vaginal hysterectomy ; 964, Supravaginal, by Meredith, for hrematometra associated with a degenerating Fibromyoma. 1888, I. 219, By Oliver, for fibroid; 619, Abdominal for fibroid, by M'Mordie ; 922, 973. Three cases by Morris, for myomata and fibrocystic tumours; 980, by Lewers, for primary cancer of body. 1888, II. 163, By Plinmier, for cystic myoma ; 210, By Macan for fibrous tumour. EDIN. MED. JOUR. XXXIIL, II. S60, Keith on results of Supravaginal. XXXIV., I. 88, By Fritsch, for carcinoma ; 565, Pressure forceps vemi suture and ligature in vaginal. GLAS. MED. JOUR. XXV. 228, Suspension of pedicle after vaginal. XXVI. 321, Kolpo-hysterectomy for cancer with tables of results. XXX. 181, Immediate and remote effects of vaginal for cancer. DUB. MED. JOUR. LXXXV. 349, Technique of vaginal ; 526, Case of vaginal, in which INDEX OF RECENT GYNECOLOGICAL LITERATURE. 701 both ureters were tied. LXXXVL 63, Statistics of vaginal. AMER. JOUR. OBS. 1886. 69, Supravaginal for adenoma, by Wylie ; 81, Supravaginal for fibroid, by Montgomery; 137, Hysterectomy versus Oophorectomy for fibroid ; 199, Total, per cagi'iuim, by Battlelehner ; 204, Of corpm uteri, by Veit ; 205, Vaginal, Duevelius ; 804, For an enormous fibroid, by Atherton ; 824, Statistics of ; 836, Vaginal, by Goodell ; 952, By Wilson, for fibro-cystic ; 1136, Five, by Helnmth ; 1214, Kolpo-hysterectomy for cancer; 1298, Per vaglnam, by Brennecke. 1887. 75, For fibroids, by Parker ; 107, For cancer, Koeberle ; 108, Technique of supra- vaginal amputation ; 10S, Suspension of pedicle after supravaginal amputation ; 184, For myoma, by Price ; 220, For cancer, Schultze ; 520, Two cases of vaginal, by Munde ; 851, For fibroids, by Freeman ; 879, For soft myo-fibroma, Parkes ; 1008, Sixty vaginal, Fritsch ; 1055, Pedicle in supra- vaginal ; 1108, Vaginal for cancer, by Martin ; 1145, Technique of vaginal ; 1150, Recent, for cancer ; 1184, For fibrous tumour, Hanks ; 1186, For epithelioma, by Munde ; 1207, For cancer, Weston ; 1228, Statistics of vaginal for cancer ; 1228, Thirty-eight hystero-myomo- tomies, by Braun ; 1229, Forty-eight total, Leopold. 1888. 81, Three cases of vaginal, Etheridge ; 108, Extra-peritoneal ; 176, Recent, for cancer ; 177, Vaginal, for great hypertrophy of cervix, Hunter ; 178, Laparo- hysterectomy, Byrne ; 303, For fibroid, Munde ; 424, Vaginal, for sarcoma, Dudley ; 427, Case of vaginal, Byford ; 604, Combined vaginal and abdominal, for myoma, Dixon Jones; 609, Vaginal, Hunter; 627, In last months of pregnancy, Hamill ; 642, 743, Per vaginam, for nbro-sarcoma and for carcinoma, Byford; 870, For carcinoma, Byford; 884, Vaginal, for medullary cancer, Reed ; 945, With ovariotomy and abdominal section, Baldy ; 1048, Pressure forceps versus the suture and the ligature in Vaginal ; 1185, Vaginal for procidentia with epithelioma of cervix and vagina ; 1230, Ileus following vaginal ; 1270, Supra-pubic for fibroid, Dudley. ARCHIV F. GYN. XXIX. 359, Sixty cases for cancer, Fritsch. Jfx"g 1, Extraperitoneal, Frank ; 132, Account of hystero-myomotomy, Lebedeff ; 401, Forty-eight cases, for cancer, Prolapse and neuroses, Leopold. XXXIII. 317, Vaginal, for cancer of vagina, Thieni ; 320, Extra-peritoneal vaginal, Frank. CENTRALB. F. GYN. X. 30, Total, Leopold ; 32, 40, Supravaginal and oophorectomy for Fibro-myoma ; 260, Total for cancer, Schultze ; 805, Amputation for myoma, Gusserow. XI. 150, Freund's operation, Sanger ; 185, Vaginal, Mttller ; 227, Total, for cancer, Sanger ; 425, Vaginal total, with ovariotomy, Asch ; 435, Supravaginal amputation of preg- nant uterus for myoma, Vogel ; 514, Total for carcinoma, statistics, Martin. XII. 409, Copenhagen statistics of vaginal total ; 817, Per vayinam, modification, Stratz. ZEITSCH. F. GEB. UNO GYN. XII. 56. Vaginal total, Brennecke. VOLK. SAMML. No. 339, Sixty cases of laparo-myomotomy, Fritsch. ARCHIV. DE TOO. 1886. 28, Ovario-hysterec- tomy, Terrier; 30, Vaginal, Gillete ; 107, Abdominal and vaginal, and amputation of cervix, Clado ; 727, For cancer, Koeberle ; 889, Bifid uterus and, Doleris ; 891, Hsemo- stasis in vaginal ; 1021, Vaginal, Pean. 1887. 364, Vaginal for sarcoma, Doleris. 1888. 59t>, Results of vaginal. ANNAL. DE GYN. XXIX. 341, Abdominal, Terrillon. XXX. 87, 179, Vaginal for cancer. ANNAL. DI OSTET. 1886. 138, 149, Supra- vaginal, for fibroids, Negri ; 142, Supravaginal for fibro-cystic tumour, Negri. 1888. 24, Supra-vaginal amputation for fibroid, Fasola ; 466, Supra- vaginal for fibroid, Cosantini. UTERUS, FIBRO-CYSTIC TUMOURS OF. BRIT. MED. JOUR. 1886, I. 1169, Cystic myoma. 1888, 1048, Nature of. LANCET. 1888, I. 973, Case of hysterectomy for, by Morris. 1888, II. 163, Hysterec- tomy by Plimmer for. AMER. JOUR. OBS. 1886. 952, Hysterectomy for, by Wilson; 1090, Case. 1887. 32, Interstitial; 165, With pelvic abscess; 734, Laparotomy for. 1888. 512, Case; 942, Case ; 1200, Fibro-cysto-sarcoma. ARCHIV F. GYN. XXX. 249, Diagnosis of cystic. CENTRALB. F. GYN. XI. 361, Vaginal ex- tirpation of an intra-mural, Swiecicki. ARCHIV. DE TOC. 1887.430, Case; 860, Ibid. ANNAL. DI OSTET. 1886. 13, Case of; 142, Supravaginal amputation for. UTERUS, FIBROID OF. BRIT. MED. JOUR. 1886, 1. 441, 586, Com- plicating pregnancy ; 486, Surgical treatment of ; 821, Diagnosis between distension of tubes and ; 980, Specimens ; 1074, Speci- men. 1886, 11. 78, Specimen of slough- ing; 356, Large fibroid in inversion of uterus ; 474, Differential diagnosis from preg- nancy ; 871, Microscopic sections of epithelium of ; 978, Enucleated per vaginam, Bantock ; 97S, Removed for growth and menorrhagia, Heywood Smith. 1887, (I. 678, Removed by abdominal operation, Meadows ; 799, Para- sites in; 1017, Electrolysis for; 1208, Electri- city for ; 1329, Electricity for ; 1364, Electro- lysis for. 1887, II. 02, Electricity for; 116, Ibid.; 423, Ibid.; 699, Ibid.; 702, Ibid.; 724, Electrolysis for; 878, Hysterectomy for, by Mayo Robson ; 964, 965, Apostoli's treatment ; 993, Electrolysis for, followed by enucleation and sloughing ; 1020, Electricity for ; 1075, 1076, Ibid.; 1257, Keith's results in treatment of. 1888, 1. 20, Electrolysis for ; 102, Ibid. ; 160, Ibid.; 211, Thirty-eight extirpations of uterus by C. Braun for ; 249, Tail's operation for; 439, Electrical treatment of; 493, Ibid.; 538, Oophorectomy by Lunn for ; 538, Elec- tricity for ; 547, Treatment of ; 614, Electro- lysis for; 665, Ibid.; 756, 799, Extirpation for, by Reeves ; 798, Hysterectomy, by R. T. Smith, after electrolysis for ; 799, Action of constant current on ; 861, Enormous myoma ; 997, Electrolysis for; 1065, Electricity for myomata ; 1300, Electricity for ; 1362, Apos- toli's treatment of; 1376, Ibid., Notes on three cases ; 138(5, Supravaginal hysterectomy for, by Granville Bantock ; 1386, Ibid, and oophorectomy for, Edis. 1888, II. 77, Oophorectomy by Lunn, for bleeding fibroid ; 79, Hysterectomy for, by Murphy; 79, Elec- tricity for; 102, ApostoJi's treatment of ; 123, Treatment of haemorrhage from, by hydrastis canadensis ; 505, With cancer ; 940, With ab- scess of ovary ; 1112, Myoma and fibromyoma, and allied tumours of ovary; 1113, Supra- vaginal hysterectomy for locked fibroid, by Meredith ; 1183, Remarkable case of ; 1336, Abdominal section, by M'Mordie, for large fibroid ; 1412, Electrolysis for. LANCET. 1886, I. 62, Three cases ; 297, Spon- taneous expulsion ; 833, Colloid degeneration in ; 1222, In twin pregnancy. 1886, II. 211, Medical and surgical treatment; 811, 859, Treatment of fibro-myoma. 1887, I. 189, Elastic ligature for; 672, Hysterectomy for, by Knowsley Thornton. 1887, II. 127, 702 APPENDIX. Treatment by electricity ; 324, Ibid. 1888, I. 21!, Hysterectomy for, by Oliver; 21!', With labour at term ; 370, Electrolysis for; 619, Abdominal hysterectomy for, by M'Mordie; (574, Bleeding fibroid, oophorectomy by Lunn ; 674, Electricity for ; 919, Caeaarean sec- tion for impauteil fibroid ; 124!), Electricity for myomata ; 1888, II. IS, Enucleation of three, by D. MacGregor ; 210, Removal per vayinam, by Byrne ; 90S), Myoma and fibro- myoma, and allied tumours of the ovary ; !>6t), Locked ; 1058, Myoma. EDIN. MED. JOUR. XXXI., II. 764, Re- moved at III. -Stage by Halliday Croom ; 1176, Treatment of fibro-myomata by lapar- otomy. XXXIII., I. 270, Case ; 470, Patient treated by Apostoli's method. XXXIII., II. 670, 088, Electricity for ; 860, Keith on old and new ways of treating ; 1057, Curette in haemorrhage from. GLAS. MED. JOUR. XXIX., 82, Electricity for. DUB. MED. JOUR. LXXXIII. 2S3, Report on mucous membrane in cases of myoma ; 476, Case. LXXXVI. 72, Removal of large, by M'Mordie; 202, Specimen with uterus; 252, Removed per i-ayiiunn, by Byrne. AMER. JOUR. OBS. 1886. 44, Sessile fibroids, removed by Kelly ; 49, Complicating labour ; 167, Bleeding, oophorectomy by Goodell ; 204, Myoma weighing 30 Ibs. ; 293, Small cal- careous degeneration ; 468, Amputation for Myoma, by A. Martin ; 468 Myoma with sal- pingitis ; 483, Oophorectomy for ; 489, Sub- muoous, with cancer of cervix and body ; 604, Spontaneous extrusion : 613, Hegar's opera- tion for sessile sub-mucous, Lee ; 804, Hyste>- rectomy by Atherton for an enormous ; 813, 859, Etiology ; 976, Treated by fluid extract of ergot ; 1112, Clinical initial stage of myoma ; 1172, Oophorectomy for, by Price. 1887. 55, Intra-uterine in a virgin, removed by Munde ; 69, Multilocular ; 113, Galvanic treat- ment ; 253, 376, Electricity for, fifty cases ; 290, Electrolysis for ; 783, Uterine mucosa in myomata; 851, Hysterectomy for ; 961, Spon- taneous expulsion of; 1102, New method of electricity for; 1106, Marriage and nbroid; 1112, Surgical treatment; 1112, Ergot for myoma; 1184, Hysterectomy for, Hanks; 1228, Thirty - eight hystero - myomotomies. Braun ; 1286, Removal by abdominal section, Bantock. 1888. 62, Weighing 140 Ibs.; 156, Removal of large, by laparotomy, Ho wans ; 270, Electricity for ; 303, Hysterectomy for, Munde ; 321, Intra-uterine ; 335, Wehmer on ; 384, Electricity for ; 442, The enucleation of uterine myomata, Kleinwa^hter; 525, With double pyosalpinx ; 557, Comparative thera- peutics of; 604, Combined abdominal and vaginal hysterectomy for ; 615, Submucous ; 631, Pelvic-bound ; 643, Galvanism for, fifteen cases ; 806, Treated by Apostoli's method ; 869, Fibro-myomata ; 995, Myomata ; 1092, Unusual case of subserous; 1188, Weighing 18 Ibs.; 1205, Subserous fibre-myoma of the cervix and an ovarian cyst ; 1276, Supra- pubic hysterectomy for. Dudley. ARCHIV F. GYN. XXVIII. 494, Early stages of myoma ; 497, Changes in uterine mucous membrane in myoma. XXIX. 1, Mucous membrane of uterus with myoma ; 407, Per- foration of a tubercular ulcer into uterine cavity with myoma. XXX. 132, Account of hystero-myomotomy, Lebedeff. XXXI. 467, Operation for subserous, Baumgartner. XXXII. 470, Myoma; 472, Treatment of pedicle in iiiyoinotomy, Zweifel ; 473, Myo- motomy. XXXIII. 325,. Intra-peritoneal treatment of stump after myomotomy, Schmidt; 449, Operative treatment of myoma, Friinkel. CEXTRALB. F. GYX. X. 16, Myoma; 40, Supra - vaginal extirpation of uterus and oophorectomy for, Vogelius ; 62, Oophorec- tomy and uterine myoma, Fraipont ; 123, Peptones in myoma ; 168, Myomotomy ; 257, Oophorectomy in Fibro-myoma, Gol- denberg ; 487, Clinical initial stage of myo- mata ; 496, Extirpation by laparotomy ; 565, Operative treatment of myoma ; 649, Myoma and laparotomy, Hager ; 805, Ampu- tation for myoma, Gusserow. XI. 97, 113, Myoma operations ; 245, Myomotomy, Sanger ; 345, Ciesarean section for myoma, Klotz ; 391, Myomotomy in pregnancy, Frommel ; 435, Supravaginal amputation for, in preg- nancy, Vogel ; 489, Removal of submucous, post-partum, Urwitsch ; 652, Torsion of uterus in myoma ; 06S, Treatment of myoma during labour ; 757, Eversion of uterine mucous mem- brane through interstitial myoma. XII. 75, Myomotomy by special method ; 274, Infarct in the parenchym of a myoma; 713, Myoma by special method ; 723, In pregnancy, labour, and puerperium ; 729, Bleeding in Myoma, 801, Myomotomy, Freund ; 860, Treatment of pedicle after myomotomies. ZEITSCH. F. GEB. UND GYX. XIV. 106, Myomotomy and Castration in, Wehmer ; 223, Martin's intraperitoneal enucleation. VOLK. SAMML. No. 339. Sixty cases of laparo-myomotomy, Fritsch. ARCHIV. DE TOG. 1886. 633, Myomotomy j>fj- ragincLM. 1887. 68, Complicating labour ; 573, Ibid. AXXAL. DE GYN. XXVI. 241, Fibro-myoma in cervix of girl of nineteen years. XXIX. 416, Battey's operation and, Segond. XXX. 436, Complicating pregnancy and labour. AXNAL. DI OSTET. 1886. 98, In pregnancy with dead foetus retained ; 138, 149, Supra- vaginal extirpation for, Xegri ; 269, Bilateral division of cervix for, Mancusi. 1887. 155, Oophorectomy for; 171, Pathology of. 1888. 1, Oophorectomy for, Fascia ; 24, Supra- vaginal amputation for, Fasola ; 170, Elec- tricity for ; 440, Supravaginal for, Cosantini ; 492, Expulsion after electricity ; 493, Enuclea- tion, Morisani. UTERUS, INVERSION OF. BRIT. MED. JOUR. 1886, I. 475, Lecture on; 491, Immediately following labour ; 641, 739, Cases of. 1886, II. 356, With large fibroid. 1887, I. 66, 178, Accidental removal of an inverted uterus ; 329, 508, Complete ; 1217, Case of. 1888, I. 1274, Removal by Horrocks. 1888, II. 15, Of four months' standing, cure by Kempe. LANCET. 1886, I. 420, Treatment; 517, Question of priority ; 613, Treatment of chronic. 1887, I. 1281, Two cases of acute complete, after delivery ; 1293, Hydrostatic pressure in. 1887, II. 49, Letter by Hum- phreys on ; 660, With complete prolapse. 1888, II. 1276, Case of complete. EDIN. MED. JOUR. XXXIL, II. 1041, Case of spontaneous. XXXIII., 1. 1, Ibid. GLAS. MED. JOUR. XXIX. 36, Notes on a case of complete. AMER. JOUR. OBS. 1886. 604, Partial, caused by spontaneous extrusion of a sub- mucous fibroid. 1887. 130, 205, Colpeurysis for, Jaggard; 140, Without constitutional symptoms. 1888. 616, Treatment ; 1116, Case of ; 1279, Laparotomy for, Munde. ARCHIV F. GYN. XXIX. 321, Kehrer on. XXXII. 507, Inversion and eversion of the uterus. CENTRALB. F. GYX. X. 17, Krukenbergon ; 156, Kornon ; 745, Laparotomy for. XI. 17, Tearingout of in verted puerperal uterus in 1780; 63, Neugebauer on. XII. 401, Teuffel on. INDEX OF RECENT GYNECOLOGICAL LITERATURE. 703 ARCHIV. DE TOC. 1886. 351, Irreducible, and amputation by elastic ligature, Poncet ; 577, Acute. 1887. 1042, Operation for, Faucon. UTERUS, MALFORMATIONS OF. BRIT. MED. JOUR. 1887, II. 370, Uterus septus bicornis. LAXCET. 1887, 1. 487, Pregnancy in an im- perfectly canalised uterine cornu. EDIX. MED. JOUR. XXXII., II. 734, Case of absence of uterus and vagina. GLAS. MED. JOUR. XXVI. ISO, Double. AMER. JOUR. OBS. 1887. 168, Double ; 660, Bicorporalis ; 1063, Infantile. 1888. 68, Bilocularis, carcinoma of; 1231, Malforma- tion of female genitals. ARCHIV F. GYX. XXXIIL 312, Woman with rudimentary sexual organs. CEXTRALB. F. GYX. XI. 377, Absence of, with normal vagina ; 493, Ibid ; 070, Ibid. XII. 49, Absence of, and normal vagina ; 236, Didelphys ; 474, Rudimentary and obliterated vagina. ZEITSCH. F. GEB. UXD GYX. XIV. 140, j Las Casas Dos Santos on ; 369, Anomalies of. ARCHIV. DE TOC. 1886. 889, Bifid, and j Hysterectomy, Doleris. UTERUS, METRITIS OF. LAXCET. 1886, 1. 125, In young girls, treat- ment. EDIX. MED. JOUR. XXXIL, I. 176, Treat- ment of chronic. GLAS. MED. JOUR. XXV. 75, Subinvolution and chronic metritis. AMER. JOUR. OBS. 1887. Ill, Electrolysis for ; 969, Treatment of chronic. ARCHIV. DE TOC. 1886. 760, Intra-uterine galvano-cautery for. AXXAL. DE GYN. XXVII. 201, Acute, and peritonitis. UTERUS, POLYPUS OF. BRIT. MED. JOUR. 1886, I. 16, Peculiar form of. 1888, II. 1283, Sloughing fibrous ; 1395, Fibroid, removed by torsion. LANCET. 1886, I. 20, Fibro-myomatous ; 20, Ibid. 1886, II. 167, Case of ; 976, Sections of. 1888, II. 1281, Sloughing fibrous. EDIN. MED. JOUR. XXXIL, I. 268, 289, Fibrous, complicating puerperium. XXXIII., I. 77, Pediculated. GLAS. MED. JOUR. XXV. 300, Removed with galvanic ecraseur, by Reid. XXIX. 150, Removal from os uteri. DUB. MED. JOUR. LXXXI. 165. Fibro- myomatous. LXXXII. 418, Case. AMER. JOUR. OBS. 1886. 833, Fibroid; 1283, Ibid. ARCHIV. DE TOC. 1887. 125, 189, Fibrous cervical polypus compressing ureters. 1888. 739, And electricity. AXXAL. DI OSTET. 1886. 56, Lipomatous. UTERUS, POSITION OF. ARCHIV F. GYX. XXIX. 342, Stratz on. CENTRALB. F. GYX. X. 495, 505, Changes in, and treatment. XI. 2tiO, Position of the internal genitals of nulliparae ; 743, Patho- logical adhesions of uterus and malpositions. XII. 205, Peritoneal adhesions in malposi- tions. UTERUS, RETROFLEXION AND RETRO- VERSION OF. BRIT. MED. JOUR. 1887, I. 526, Hystero- rrhaphy; 1165, Worst cases of flexions ; 1278, Treatment of obstinate cases. 1887, II. 239, A cause of retroflexion. 1888, I. 461, Effect of flexion on patency of uterine canal. LAXCET. 1887, II. 14, Retrovereion in virgin. EDIX. MED. JOUR. XXXIL, I. 172, Etiology GLAS'. MED. JOUR. XXVII. 418, On Retro flexion. XXX. 181, New operation for fixed retroflexion ; 419, Electrolysis in uterine flexions. DUB. MED. JOUR. LXXXIIL 286, Report on mechanical treatment of backward displace- ments. LXXXV. 351, Treatment of retro- flexion with adhesions. AMER. JOUR. OBS. 1886. 188, Causes of retroflexion. 1887. 33, Hysterorrhaphy ; 67, Hysterorrhaphy ; 146, Retroversio-flexio ; 448, Retroflexio uteri ; (530, Laparotomy for adherent, Polk ; 1028, Knee-chest posture and replacement; 1058, Intra-uterine stem in flexions. 1888. Ill, Diagnosis and treat- ment of adhesions on retroflexion ; 225, Notes on ; 397, Ibid. ; 401, Hysterorrhaphy for re- troflexion with fixation, Coe ; 558, Operative treatment of retroflexion, Ssenger ; 994, Ab- dominal fixation of the retroflexed uterus ; 994, Ibid. ; 997, Therapeutics of retroflexed ; 1118, Cure of retroflexion by stitching fundus to abdominal wall ; 1249, Value of " Hystero- rrhaphy " in retroflexion. ARCHIV F. GYN. XXVIII. 228, Vedeler on Retroflexion. XXIX. 316, Mechanical treat- ment. XXXIL 481, Treatment of retro- flexion. XXXIIL 313, Vaginal ligature of uterus in retroflexion. CENTRALB. F. GYN. X. 106, Retroflexion; 429, New operative treatment of retroflexion, v. Rabenau. XI. 801, Through tumours. XII. 17, 34, 102, Operative treatment, Siinger ; 69, Operative treatment of retroflexion, Klotz ; 161, Sewing to abdominal wall in retroflexion, Leopold ; 181, Operation for retroflexion, Schiicking; 211, Operative treatment of retroflexion, discussion at Dresden ; 732, Treatment of, Kaltenbach ; 825, Retroflexion with adhesions, manual treatment, Schultze. ZEITSCH. F. GEB. UND GYN. XTV. 23, Retroflexion and adhesions. VOLK. SAMML. No. 332, Stitching replaced uterus to abdominal wall. ARCHIV. DE TOC. 1887. 1075, Doleris on flexions. ANNAL. DI OSTET. 1888. 316, Stitching to abdominal wall for. UTERUS, SARCOMA OF. BRIT. MED. JOUR. 1886, I. 548, Extirpa- tion of circumscribed sarcoma of vagina and uterus, Lewers. 1888, II. 1396, Case by Griffiths. LANCET. 1886, I. 353, Case. 1887, II. 117, Specimen. 1888, II. 1182, Case. AMER. JOUR. OBS. 1886. 005, Diffused, with metastasis of liver and lungs. 1887. 312, Fibro-sarcoma ; 1196, Rapid development of a fibro-sarcoma. 1888. 201, Fibro- sarcoma ; 424, Vaginal hysterectomy for, Dudley ; 1200, Fibro-cysto-sarcoma ; 1289, Two cases of alveolar. ARCHIV. DE TOC. 1887. 364, Vaginal extir- pation for, Doleris. VAGINA, AFFECTIONS OF. BRIT. MED. JOUR. 1887, Thrombus in. 1888, II. 939, Foreign body in. LANCET. 1886, II. 694, Tubercular ulcera- tions; 864, Diphtheria. 1887, I. 1186, Diphtheritic slough. 1887, II. 117, Fibroid of anterior wall ; 963, Tumour. 1888, I. 935, Complicated case of occlusion of vagina. 1888, II. 166, Operation by M'Mordie for congenital deficiency of recto- vaginal septum ; 438, Boracic acid in leucorrhcea. EDIX. MED. JOUR. XXXIIL, I. 128, 173, Removal of encysted ball pessary. 704 APPENDIX. GLAS. MED. JOUR. XXIX. 305, Boracic acid in treatment of leucorrhnea. DUB. MED. JOUR. LXXXTV. 56, Double vaginal orilice ; 415, Congenital absence of ostium. AMER. JOUR. OBS. 1886. 802, Two cases of occlusion ; 1117, Pathological aftection of mucosa; 1118, Lacerations ; 1266, Fibroma (fibre-sarcoma) of urethro-vaginal septum. 1887. 314, Enterocele ; 430, Emmet's new operation for prolapse of posterior vaginal wall ; 1189, Absence, with history of a case after operation. 1888. 239, Congenital absence with retention of menstrual fluid ; 1272, Foreign body from. ARCHIV F. GYN. XXVIII. 497, A hitherto unknown pathological change in vaginal mucous membrane ; 500, Rare case of rupture; XXIX. 341, Operation in congenital deficiency, Hchlesinger. CENTRALB. F. GYN. X. 572, Duplex. XI. 70, Tuberculosis ; 708, In prostitutes ; 760, Total absence ; 817, Foreign bodies in female genitals. XIL 474, Obliterated, with rudimentary uterus ; 785, Rupture in coitus ; 804, Plastic vaginal operation, Fritsch. ZEIT3CH. F. GEB. UND GYN. XIII. 135, Hmniatoma of. ARCHIV. DE TOG. 1886. 135, Congenital atresia ; 193, 234, Cicatricial contractions of ; 337, Chronic vulvo-vaginal glandular inflam- mation. ANNAL. DI OSTET. 1886. 1, Cancer. 1888. 461, Iltematometra from atresia vaginae. VAGINA, CARCINOMA AND SARCOMA OF. BRIT. MED. JOUR. 1886, I. 496, Circum- scribed sarcoma. 1888, I. 32, Pregnancy after removal of cancer of vagina. 1888, II. 626, Sarcoma in children. LANCET. 1886, II. 627, Primary carcinoma. ARCHIV F. GYN. XXXII. 490, Sarcoma. CENTRALB. F. GYN. XI. 606, Carcinoma. XII. 422, Sarcoma vaginas ; 487, Application of zinc chlor. in carcinoma of portio and vagina. AMER. JOUR. OBS. 1888. 1108, Sarcoma in childhood. ANNAL. DI OSTET. 1886. 1, Carcinoma. VAGINA, CYSTS OF. AMER. JOUR. OBS. 1887. 415, Of anterior wall ; 1121, Paper on ; 1241, Paper on and literature of. ARCHIV F. GYN. XXXIII. 121, Fischel on. ARCHIV. DE TOC. 1886. 6, Tillaux on. 1887. 539, And calculus. VAGINISMUS. BRIT. MED. JOUR. 1886, II. 101, Bantock on. 1888, II. 720, Cocaine locally in ; 790, Ibid. LANCET. 1887, I. 527, Treatment. GLAS. MED. JOUR. XXVIII. 398, Treatment. DUB. MED. JOUR. LXXXIII. 129, Treat- ment ; 297, Treatment. CENTRALB. F. GYN. X. 96, Droiahl on; 318, Cocaine in. ANNAL. DE GYN. XXV. 245, Guillet on. VAGINITIS. DUB. MED. JOUR. LXXXVI. 218, Treatment, AMER. JOUR. OBS. 1886. 496, Due to red ants in vagina. 1888. 1109, Etiology of vulvo-vaginitis in childhood. ARCHIV F. GYN. XXXI. 363, Emphysema- tous. XXXII. 493, Etiology of vulvo- vaginitis in childhood. CENTRALB. F. GYN. XL 477, Gonorrhoeal, and Endometritis ; 708, Ibid. XII. 422, Etiology of Vulvo-vaginitis in childhood. ANNAL. DI OSTET. 1887. 149, 178, Emphyse- matous. VULVA, AFFECTIONS OF. BRIT. MED. JOUR. 1886, I. 495, Cyst. 1887, I. 1159, Labial thrombus. 1887, II. 898, Large tumour of labium in pregnancy. 1888, I. 22, Pudendal hsematocele ; 250, Cysts from the labia minora ; 545, Primary mela- nosis of ; 793, Peppermint water in pruritus ; 1349, Tuberculous ulceration of. 1888, II. 75, 491, Menthol in Pruritus; 915, Treatment of pruritus ; 1395, Fibroma of nympha. LANCET. 1886, I. 34, Cause of pruritus. 1886, II. 108, Labial heematoma; 694, Tuber- cular ulcerations ; 976, Lupus of. 1887, 1. 75, Large thrombus of right labiuin. 1887, II. 498, Lupus of ; 520, Successful treatment of pruritus. 1888, I. 74, Pudendal ha;matocele. EDIN. MED. JOUR. XXXII., II. 657, Pruritus. XXXIV., I. 172, Bartholinian DUB. MED. JOUR. LXXXII. 94, Menthol in urticaria and pruritus; 421, Labial liwnia- toma. LXXXV. 356, Pudendal haematocele. AMER. JOUR. OBS. 1886, 895, Cases of Tumour. 1887. 167, Sloughing wound of labium ; 785, Lupus ; Ig76, Epithelioma. 1888. 434, Fibroid of the vestibule; 1109, Etiology of vulvo-vaginitis in childhood ; 1231, Malformation of female genitals. ARCHIV F. GYN. XXXII. 400, Melanotic tumour ; 493, Etiology of vulvo-vaginitis in childhood. XXXIII. 115, Chronic ulcera- CENTRALB. F. GYN. X. 235, Carcinoma; 305, Literature of cancer of. XI. 70, Tuber- culosis ; 454, Cyst of; Ibid., Carcinoma; 521, Pruritus ; 639, Cysts. XII. 97, Elephan- tiasis of the prsepuce of the clitoris and nymphae ; 129, Haematoma of. ZEITSCH. F. GEB. UND GYN. XIII. 135, Htematoma of. XTV. 199, Lipoma of labium. ARCHIV. DE TOC. 1886. 337, Chronic vulvo- vaginal glandular inflammation. 1887. 963, Perforation of labia minora. ANNAL. DE GYN. XXVI. 1, General mela- nosis beginning in labia minora. XXX. 17, Persistence of "plaque muqueuse" in woman. IKDEX OF AUTHORS. ABBE, 671. Brown, 398. Dott, 150. Abel, 318, 465. Brown, Baker, 242. Doueall. 148. Ackermami, 453. Bruckner, 536. Drage, 313. Adams, 577. Brunton, Lauder, 142, 145. Drysdale, 222, 223, 446. Agnew, 212. Budin, 5, 28, 266. Duke, 270, 273. Albert, 431, 440. Bumm, 147, 670. Dull, 408. Alexander, 577. Byford, 441, 446, 619. Duncan, John, 561. Allingham, 639. Byrne, 285, 395, 490, 491. Duncan, Matthews, 5, 49, 116, Althaus, 427. 171, 247, 206. 267. 268. 269. Ampere, 656. | CAMERON, 361. 313, 3S5J 394J 417J 464' 495J Apostoli, 341,427,428,652,653, Campbell, H. F., 374. 544, 550, 554, 584, 588. 592. 657, 658, 659, 660, 661. Cappie, 408. 593, 603. Aran, 577. Carrard, 4. Duncan, W. 626. Arnott, H. , 480. Carron, 468. Dunlap, 602. Ashford, 332. Chadwick, 37. Atle, 234, 444. Championniere, 72. BADE, 408, 418. Atthill, 329, 395, 396. Champneys, 632. Eckart, 466. AveJing, 116, 398. Charcot, 666, 667. Eichwald, 222. Cheron, 533. Ellinger, 270. BABESIN, 445. Chiara, 247. Emmet, 106, 116, 120, 145, 176, Baer, 445, 452. Chiari, 275, 502. 200, 267, 268, 272, 291, 292, Balfour, 74. Chisholm, 471 . 293, 294, 295, 296, 297, 299, Ballantyne, 506. Chrobak, 266, 506. 300, 301, 307, 336, 340, 346, Bandl, 42, 53, 194, 199, 350. \ Cintrat, 436. 394, 395, 398, 549, 553, 556, Bannon, 543. ! Clarke, 453. 607. Bantock, Granville, 246, 346, Claudius 51. Engelmann, 86, 88, 210, 211 380, 382, 431, 440. Clay, 508, 510. 061. Barbier, 537. Clouston, 666. Englisch, 205. Barker, 277, 294, 471, 480, 569. Coats, 256. Eppinger, 482, 501. Barkow, ;143. Cobbold, 188. Erich, 445. Barnes, 112, 114, 267, 285, 287, Coblenz, 215, 217, 226. Esmarck, 549. 312, 329, 363, 389, 394, 396, Coghill, 271, 627. 412, 453, 476, 480, 482, 485, Cohnstein, 330. FARRE, 23. 491, 531. Collis, 561. Faucon, 393. Battey, 87, 109, 110, 202, 208, Conrad, 533. Felding, 441, 443. 209, 210, 211, 212, 329, 599. Coulomb, 656. Fenger, 445. Baumgartner, 431. Conrty, 394, 396, 401. Fere, 468. Bayle, 415. Crede, 182, 329, 388, 390, 520. Fergusson, 108, 111, 114, 134. Beates, 445. Groom, 347, 454. Fischel, 294, 304, 305, 583. Beck, Snow, 336. Cross, 515. Foster, 7, 57, 66, 67. Bedson, 515. Crosse, 388, 389, 400. Fothergill, Milner, 583. Beigel. 23, 86, 535. Cruveilhier, 51, 417. Foulerton, 329. Bell, 329. Cullinerworth, 223, 5:24. Foulis, 74, 100, 144, 158, 216, Bennet, Hughes, 222, 223. Cunningham, 12. 217, 2-22, 224, 225, 610. Bennet, J. Henry, 291, 323. Cusco, 108, 112, 114, ]34. Fox, Wilson, 217. Berard, 620. Cutter, 428. Frankel, 346, 304, 432, 494. Bernutz, 157, 160, 178. Czempin, 292, 301, 43-'. Frankenhauser, 73, 74. Berthold, 543. Czerny, 497, 649. Freund, H. W., 170. Bird, 332. Freund, W. A., 33, 47, 167, 174, Blackwood, 547. DALTON, 85, 88. 175, 188, 212, 291, 387, 405, Blau, 467. Davaine, 149. 411, 432, 494, 577, 664. Blundell, 208. Dawson, 446, 510. Friedreich, 545. Bockhart, 147, 670. De Cassis, Vidal, 635. Fritsch, 268, 306, 335, 349, 351, Boldt, 446. Deletang, 428. 352, 357, 361, 363, 364, 384, Bonnet, 547. De Morgan, Campbell, 487. 387, 439, 441, 497, 498, 499, Bou([ue, 635. Deschamps, 507. 529. Bourdon, 178. DeSinety, 21, 218, 219, 267, 311, Frommel, 275. Bourneville, 666, 667. 317, 319, 320, 334, 335, 451, Fuld, 519. Bozeman, 109, 135, 621, 627, 453. Furst, 259, 465. 628. Diesterweg, 445. Brandt, 668. Dirner, 255, 431. GALLARD, 287, 339. Braun, Carl, 340, 441, 491, 497. Dobronrawow, 425. Gallippe, 415. Braune, 51, 67, 564. Dohrn, 23, 515. Garrigues, 33, 222. Breisky, 30, 471, 514, 515, 522, Doleris, 328, 516. Gehrung, 359. 535, 551. Donat. 221. Geith, 550. Brenneeke, 322. Doran, 13, 199, 202, 219, 221. Gervis, 405. Brewis, 389. 223, 224, 403, 404. Gibbons, 313. Brinton, 71. Dos Santos, 256, 260, 264. Gilmore, 210, 237. 2 Y 706 APPENDIX. Goltz, 142, 613. Goodell, 188, 209, 237, 270, 507. Goodman, 83. Gougenheiiu, 547. Goupil, 157. Graenicher, 53-!'.>. 524, 594. Mosler, 199. Klemm, 330. Miiller, 268, 444, 440, 506, 578, Klob, 275, 333, 415. 594. Klotz, 305, 382, 383. Munde, 127, 237, 260, 294, 296, Koch, 147, 148, 149, 166, 199. 311, 359, 370, 308, 431. Koeberle, 186, 382, 436, 437, 442, Murphy, 418. 448. Murray, Milne, 144. Kohlrausch, 55, 56. Roller, 145. NEGRI, 446. Kolliker, 23. Neisser, 147, 195, 527, 669, 670. Konig, 42, 169, Nelaton, 17S, 240. Kotschau, 411. Neugebauer, 108, 112, 114, 134, Krassowski, 441. 399, 577, 578. Krohne, 245. Xieberding, 294, 296. Kroner, 395. Xitze, 604, C13. Kubassow, 320. Xoeggerath, 159, 193, 217, 218, Kuchenmeister, 135, 272. 291, 292, 333, 394, 395, 400, Kugelmann, 329. 600, 669. Kulenkampff, 549. Nonat, 157. Kummell, 431. Kundrat, 86, 88. O'HARA, 446. Kunert, 506. Ohm, 654, 656. Kiister, 411. Oldham, 450, 517. Kustner, 17, 18, 21, 294, 311, Oliver, 515. 321, 360, 450, 452, 535, 549. Olshausen, 181, 203, 219, 221, 200, 317, 320, 323, 324, 325, LANDAU, 127, 318, 465. 382, 415, 497. Landowzy, 415. Otto, 543. Langenbeck, 264. Langenbuch, 648, 650. PAGE, 521: Le Bee, 46, 72, 157. Fallen, 294, 297. Lebedinsky, 202. Paquelin, 140. Leblond, 330. Park, 292, 330. Lecorche, 547. Parkes, 597. Lee, 247, 382, 389, 403. Patenko, 217. Lefort, 577, 578. Paterson, 256. Leiter, 604. Pawlik, 491, 497, 603. Lembert, 652. Pean, 240, 432, 435, 497. Leopold, 21, 72, 82, 88, 186, 264, Peaslee, 264. 316, 318, 382, 383, 404, 443, Peckham, 550. 497, 498, 519. Petit, 649. Lewers, 492, 493. Pfliiger, 216. Lister, 130, 244, 246. Phillips, 198. Litschkus, 266. Picot, 471. Loswenhardt, 88. Pirogoff, 39, 47, 56, 59. Lorey, 405. Playfair, W. S., 468. Lowenstein, 30. Plimmer, 446. Luschka, 14, 30, 33, 51. Polk, 33, 329, 383, 430. Lusk, 73, 159. Poncet, 401. Porak, 535. AIACAN, 382. Post, 498. M'Clintock, 420. Pott, Percival, 204. Macdonald, Angus, 264, 332, Pozzi, 5, 6. 894, 550. Priestley, 533. INDEX OF AUTHORS. 707 Profanter, 66S. Puech, 523. Seseman, 245. Seyfert, 480. 355, 356, 359, 377, 393, 394, 396, 398, 409, 435, 490, 491, Sibley, 471. 521, 522, 529, 546. QUAIN, 74. Simmons, 536, 549, 550. Thorn, 534. RAINEY, 19. Ramsbotham, 543. Simon, 101, 103, 132, 137, 273, 282, 488, 533, 599, 600, 601, 602, 620, 621, 635. Thornton, 224, 242, 243, 240 248, 249, 427, 432, 441. Tillaux, 409, 415. Ranney, 11. Simpson, A. R., 78, SO, 104, 116, Tilt, 532. Rayleigh, 656. 123, 133, 159, 210, 275, 282, Times, 407. Reamy, 405, 415. 375, 384, 387, 398, 400, 419, Touret, 313. Recamier, 132, 178. 425, 426, 430, 481, 491, 505, Trenholm, 210. Recklinghausen, 147. 506, 508, 510, 520, 535, 550, Treves, 052. Regnard, 666, 007. 559, 561, 000, 030, 071. Tripier, 427. Reid, 114, 270. Simpson, Sir J. Y., 115, 123, Turner, 21, 37, 74, 408. Rein, 432, 441. 124, 125, 157, 207, 270, 271, Reinl, 83. 274, 275, 277, 329, 333, 356, UFFELMAN, 31. Reinmann, 332. 411, 426, 409, 470, 480, 484, Underbill, 450. Richelot, 497. 488, 491, 501, 542, 549, 552, Richer, 666, 667. 592, 593, 624. VAN BUREN, 639. Richet, 16. Sims, 80, 106, 107, 108, 109, Van de Warker, 59, 494. Rieder, 23. Rindrteisch, 218. 110, 114, 116, 119, 128, 129, 133, 134, 209, 211, 212, 244, Vedeler, 265, 267, 208, 352, 366. Veit, 21, 22, 303, 304, 431, 432, Ringer, 426, 583. 267, 268, 270, 272, 281, 356, 461, 462, 463, 464, 465, 471, Ritchie, 82. 374, 493, 494, 530, 593, 620, 478, 501,502, 534. RiTington, 577. 621, 623, 649. Velpeau, 178. Rokitansky, 217, 221, 348, 384, Sinclair, 186. Virchow, 47, 167, 182, 333, 346, 431. Skene, 30, 31, 5tf4, 596, 602, 404, 407, 413, 445, 453, 461, Roger, 291. 605, 607, 610. 462, 503. Ross, 261. Skoldberg, 313. Voisin, 185. Routh, 271, 824, 881, 882, 487. Skutsch, 411. Volta, 656. Roux, 671. Slavjansky, 202, 217, 319, 320, Von Griinewaldt, 266, 593. Ruedinger, 38, 47, 49, 57, 92, 639. 321. Von Hacker, 440. Ruge, 22, 303, 304, 305, 307, 316, Smith, Albert, 375, 378. Von Ott, 411. 319, 320, 363, 432, 461, 462, Smith, Heywood, 311, 382. Von Preuschen, 23, 30, 534. 463, 404, 405, 471, 478, 501, Smith, Protheroe, 116. Von Rabenau, 382. 525, 520. Smith, Tyler, 394. Von Volkmann, 499. Rummel, 440. Solowietf, 587. Voss, 561. Runge, 398. Soyer, 547. Vulliet, 330. Ruter, 536. Spiegelberg, 41, 47, 219, 225, Rutherford, 426. 292, 294, 444, 507, 536. WALDEYER, 74, 216, 219, 461, Staude, 497. 462. SANGER, 188, 195, 221, 247, 292, Steavenson, 428. Walter, 446. 382, 441, 497, 561, 032. Stein, 561. Warner, 584. Sappey, 16, 72. Steinschneider, 260. Webb, 659. Saurenhaus, 466. Stephenson, 83. Wells, Spencer, 166, 167, 240, Savage, 38, 264, 271. Steurer, 146, 159. 241, 243, 246, 248, 249, 292, Siixinger, 480. Steven, 199. 293, 300, 401, 435. 495. Scanzoni, 266, 332, 333, 340, 384, Stiegele, 549. Werth, 221, 247, 204. 546. Stirling, A. B., 149. West, 248, 549, 550. Schanta, 668. Storer, 039. White, 394, 395. Scharlans, 494. Stratz, 279, 293, 478. Whitehead, 275, 592. Schatz, 188, 564, 565, 60S. Sutton, 6. Williams, J., 68, 69, 85, 86, 88, Schlesinger, 43. Swiecicki, 446. 452, 463, 464, 471, 473, 588. Schmalfuss, 398. Symington, 38. Williams, Wynn, 381, 487. Schorler, 400. Wilson, 446. Schramm, 494. TAIT, LAWSON, 76, 82, 88, 125, Wiltshire, 248. Schroeder, 16, 65, 66 67, 181, 130, 186, 192, 193, 197, 198, Winckel, 195, 221, 287, 361, 219, 240, 204, 207 296, 301, 199, 202, 208, 209, 211, 212, 413, 526, 596, 005, 618, 619. 313, 314, 316, 332 350, 357, 221, 245, 246, 248, 249, 382, Winkler, 507. 390, 404, 408, 415 418, 431, 389, 398, 408, 431, 441, 442, Woodhead, 150. 432, 433, 452, 471 478, 480, 446, 561, 575, 646, 649, 051. Wyder, 409. 491, 492, 495, 497 498, 500, Tarnier, 149. Wylie, 446. 502, 506, 513, 534 546, 549, Tate, 394, 396. 567. Taufer, 264, 431, 441. ZELLER, 318, 450. Schuckhardt, 536. Taylor, 330, 385, 549, 550. Zemann, 195. Schiicking, 383. Terrier, 498. Ziegenspeck, 343, 346. Schultze, 54, 55, 56, 57, 58, 66, Terrillon, 550. Ziemssen, 664. 127, 164, 201, 270, 309, 343, Thelen, 441. Zinke, 296. 350, 381, 382, 409, 411, 668. Thiersch, 461. Zinnstag, 510. Schiitz, 569. Thin, 550. Zwanck, 570. Schwartz, 167. Thiry, 398. Zweifel, 186, 260, 434, 441, 495, Semeleder, 237. Thomas, 116, 120, 237, 273, 285, 520. Sequiird, Brown, 666. 305, 307, 310, 313, 333, 340, Zweigbaum, 537. INDEX OF SUBJECTS. Note. As the student will find in the Table of Contents the sub-divisions of each special subject, we give only one reference in bold figures to the place where each subject is specially treated of. References in other parts of the book are given in detail. Thus, for the topics considered under " Carcinoma Uteri," see that subject in the Table of Contents ; for references to Carcinoma, not contained in the chapters on Carci- noma, see Index. For instruments figured in text, see Instruments in Classified List of Illustrations. ABDOMEN distension of, in ovarian tumour 231. physics of 75. Abdominal contents, relation to skin 91. examination 90. pressure, action on uterus 343. regions 91. Section 645. possible accidents 651. for pelvic abscess 186. for carcinoma 494. for fibro cystic tumours 446. for fibroids 430. in hsematocele 186. for ovarian tumours 237. for removal of ovaries 211. Abortion and endometritis 317, 323, 326. in lacerated cervix 296. causing pelvic cellulitis 168. ovaritis 203. peritonitis 159. and fibroids 412, 416, 418. and metritis 337. in retroflexion 348, 34s). cause of subinvolution 336. Abscess pelvic 168, 186, 650. opened by cautery 172. tapping of 172. of uterine wall 332. Adenoma 318, 447, 450, 452, 460, 465. Adhesions in anteversion 357. in fibroids 408. in retroflexion 367, 371. in retro version 361. diagnosis in ovarian tumours 235. produced by ovarian tumours 247. treatment in ovarian tumours 243. Age influence on carcinoma 471, 501. on sarcoma 507. on fibroid tumours 415. in relation to hsematocele 181. to menstruation 82. Alexander- Adams operation 382, 574, 577. Amenorrhcea 582. due to atresia 516, 582. in chlorosis 582. and endometritis 322. phthisis 582. physiological 582. in superinvolution 277. Ampere 656. Ampulla of Fallopian tube 23. Amputation of cervix 281, 340, 382, 488. hypertrophied in prolap- sus 288. of inverted uterus 399. Ansemia in hsemorrhagic endometritis 323. carcinoma 476. cervical catarrh 310. inversion 389. Anaesthetics 140. Anteflexion of uterus 343, 345, 347. Anteflexion and small fibroid tumour 421, 422. pathological 1C2, 173. mistaken for retrover- sion 34S, 361. passage of sound in 118. Anteversion of uterus 344, 345, 356. due to chronic metritis 357. Antiseptics in gynecology 147, 646. Antiseptic douche 139, 151, 311. injections in carcinoma 485. Anus 38. fissure of 640. producing vaginismus 531. Apostoli's method of electrical therapeutics 652. Areolar hyperplasia of cervix 307. of uterus 333. Arsenic in membranous dysmenorrhoea 589. Ascites and ovarian tumours 232, 234-. Aseitic fluid in malignant ovarian disease, 159, 222, 224. Asphyxia from chloroform 144. Atresia of cervix uteri 265. senile 319. of hymen 512. in septate uterus 523. of vagina 512, 513. operation for 519, 520. Atrophy of cervix and uterus 274. congenital of uterus 258, 260, 263 senile 277. Auscultation 93. and fibroids 422. and ovarian tumour 232. Axial Coronal Section 49, 63. BACTERIA, in cellnlitis 168. wi erysipelas 146. Baden-Baden waters in chronic metritis 339. Barnes' ointment-positor 329. speculum for vaginal tampons 312. Bartholinian glands 11. cysts of 547. inflammation of 544. abscess in 548. Battey's operation 87, 208. in dysmenorrlinea 590. in fibroids 442. Benzoate of ammonia in cystitis P10. 710 APPENDIX. Bimanual Examination 96. in antetlexion 353, 354. in early pregnancy 338. in fibroids 420, 42:i. in inversion 391, 392. position of hands in '.T>. to replace retroflexed uterus 371. in retroflexion 31:7. in retroversion :ioi. with sound 123, 281. for stone in bladder 612-613. in uterine displacements 348. Biniodide of Mercury as an antiseptic 150. Bipolar method of applying electricity 057, COO. Bladder, Anatomy of 30, 596. afl'ection of, in carcinoma 4150, 409. in amputation of cervix 289. calculi in 612. changes in, after fistula 617. changes in position of 33. diastole of 35. dilated in carcinoma 469. displacements of 607. in retroflexed gravid uterus 608. distended, and ovarian tumours 234. functional diseases of 613. injuries to in ovariotomy 243. malformations of 005. methods of exploring 599. neoplasms of 608. openings 32. perforation by calcified fibroids 419. peritoneal relations 289. physiology of 596. position :!0. changes in 34. in inversion of uterus 387. pressure on, by fibroid tumour 418. in retroflexion 343, 303, 365. shape when empty 34. in foetus 35. structure 30. systole and diastole of 597. effect of its distension on the uterus 55, 59, 343, 300. Blaud's pills in chlorosis 583. Blistering of the cervix uteri 340. Blood effusion into pelvis 178. in broad ligaments 179. and ovarian tumour 230. Blood-vessels of pelvis 68. Bougies graduated to dilate cervix 209. in anteflexion 355. in fibroids 423. Bozeman's scissors, 136. speculum 108. Brandt's pelvic gymnastic 668. Breisky's instruments for operating in atresia 522. Bright's disease in fibroid tumour 418. British Association (B.A.) electro-magnetic units 656. Broad ligament 40. affections of 187. anatomy 18, 45. blood effusion into 179. connective tissue of 42, 46. cysts of 226. new growths in 187. position 45. tumours of 187. and fibroids of uterus 4-2-2. Bromide of Potassium in chronic metritis 340. in fibroid tumours 426. in ovaritis 204. Bromine solution in carcinoma 485, 487. Bulbocavernosi 10. Bulbi vaginas 10, 74. CACHEXIA in carcinoma 476. in sarcoma 508. Calcification of fibroid tumours 408, 411. Calculi in bladder 612. Cancer (see Carcinoma). Carbolic acid activity of 149. in cervical catarrh 31]. in endometritis 326. in metritis 333. in pruritus vulvse 546. Carcinoma of bladder 008. of cervix 460, 474, 483. cure by amputation -Iss. commencement in cervix 310. development 404. duration of life in 480. and endometritis 3 _'.">. extension to neighbouring organs 46(i. of Fallopian tubes I'.i'.t. in male and female compared 469. affecting fibroid tumours 412. combined with sarcoma 504. contrasted with fibroid 402, 477. diagnosis from sarcoma 50'.'. spontaneous cure of 480. spread of 405, 480. of body of uteius 500. of ovary 224. of vagina 535. secondary 4 78. of vulva 549. Carlsbad salts 340, 583, 043. Case-taking, method of, 671. A. R. Simpson's card for 672. Cataleptic convulsions and lacerated cervix 295. Catarrh of cervix 302. and carcinoma 471. laceration 293, 307. retroflexion 307. diagnosis from vaginal 309. of uterus 315. Oatarrhal patches 300, 324. Catheter methods of passing 590. Skene-Goodman 611. stationary, for fistula 032. Cauliflower excrescence 4~>:',, 470. Caustics producing atresia 206. metritis 337. in carcinoma 487, 4 '.'::. in cervical catarrh 313. Cautery in dividing cervix 429. in incising capsule of fibroid 429. in laparotomy for fibroids 435. in ovariotomy _ ii'. Paquelin's 140. in sarcoma 510. in opening vaginal cysts ">34. in obliterating vesical fistula; 634. Cellular tissue of pelvis, haemorrhage into 182. (r. Connective tissue). Cellulitis, pelvic 167. and anteflexion 173, 340, 352, 354. diagnosis from anteversion 359. producing lateri version 173. and lacerated cervix 293. ovarian tumours '-'30. subinvolution 330. relation to peritonitis 157, 158, 169. and retroflexion 309. in utero-sacral ligaments 173, 350, 355. Cervical catarrh in lacerated cervix 293. chronic 300. with retroflexion 303. endometritis 300. mucus, character of 308. plug, Thomas' 273. polypus 4. r iO. Cervix amputation of 281, 288. flap operation 288. in carcinoma 488. compared with extirpation of uterus , in prolapsus >-. producing involution 340. anatomy 16. INDEX OF SUBJECTS. 711 Cervix areolar liyperplasia. atrophy of 214, 320. atresia of 265, 517. operation for ~rl-l. cancer of (see carcinoma), carcinoma of 460, 474, 483. catarrh of 302. chronic thickening of 2G6, 209, 280. conical 200, 209, 280. closure for vesico-uterine fistula 032. connective tissue, increase of 307. cysts of 300. degeneration, granular and cystic 305, 310. descent in prolapsus .V>7. dilatation of 125, 269, 429, 449. division of 270, 420. antero-posterior 356. bilateral 272, 350. examination of 95. excision of 273, 313. fibroid tumour of 403, 412, 441. glands of 21, 307. hypertrophy of 200, 279, 312. three forms of 287. in cancer 478. in prolapsus 509. induration of, in carcinoma 478. inflammation 307. in infantile uterus 258, 263. position in inversion oS7, 390." laceration of 290. producing cellulitis 168. cervical catarrh 307. parametritis 175. lymphatics 72. medication in catarrh 311. mucous membrane of 20, 303, 307. normal structure contrasted with patho- logical 300. obliteration of canal 420. papilloma of 452. position in antettexion 350. retroversion-j-retronexion302. rigidity of 200. rupture in atresia 513. sarcoma of 502. stenosis of 260. stitching 297. in superinvolution 274. supra-vaginal amputation of 491. " ulceration " of 295, 303. ulcerations, true 300. vaginal portion of 16. Champignons cancereux 470. Channelled polypus 450. Childbirth producing cellulitis 168. peritonitis 159. Chill producing cellulitis 168. ovaritis 203. peritonitis 159. Chloral in carcinoma 485. Chloride of zinc in carcinoma 494. vaginitis 529. Chloroform action of 140. administration of 143. dangers from ] 44. uses of 142. Chlorosis, amenorrhosa in 582. leucorrhoea in 321. small uterus in 25S, 274. Cholera and endometritis 321. Chromic acid in cervical catarrh 311. in endometritis 327. Chronic cervical catarrh 300. metritis and fibroid tumour 421. Cintrat's serre-noeud 436. Clamp in ovariotomy 241. disadvantages of 241. in laparotomy for fibroids 435, 437. Clitoris anatomy 4. development of 74, 541. Cloaca 541. persistence of 541. Cocaine 145. in vaginismus 532. Coccygeus 12. Coccygodynia 644. Colpitis 525. emphysematosa 526. Conception in an undeveloped horn 260, 263. Constant electric current 654, 657. Connective tissue of pelvis 41, 40, 47. as seen in sections 43, 46, 47. methods of studying 42. new growths in 187. relation to cellulitis 168. studied by injections 42. spread of carcinoma in 465, 466, 469. tumours of 189. of uterus, increase of in metritis 334. Connective-tissue origin of cancer 461. sarcoma 503. Constipation 643. in fistula 619. Copraemia 476. Coronal Section 48. Corpus luteum of menstruation and pregnancy 84. Corrosive sublimate as an antiseptic 149. in metritis 333. Coulomb 656. Cradle-pessary of Graily Hewitt 359. Crede's method of expressing placenta 388. Cretinism and amenorrhoea 582. atrophy of uterus 258. Curette 132, 327. cases in which useful 132. Martin's 132. method of use 133. nail, A. R. Simpson's 430. Becamier's 132. Simon's 132. Thomas' 132. in carcinoma 488, 502. in cervical catarrh 313. in endometritis 320. in diagnosis of small polypi 455. in sarcoma uteri 510. Cystic fibroid tumours 443. leio-myoma 445. Cystitis 609. Cystocele 608. in prolapsus 569. Cysto-fibroma 443. Cystoma malignum 222. ovarii 219. Cysts in the cervix 306. of vagina 533. of vulva 547. DEFECATION mechanism of 638. difficult in haematocele 184. painful in carcinoma 476. in retroflexion 366. want of control, in ruptured per- ineum 557. Dermoid cysts 221. of genito-urinary organs 215, 226. Development intra-uterine periods of 259. of myoma 413. of pelvic organs 74. of the genito-urinary organs 215, 540. of uterus, period of 251. relation to malforma- tions 253, 259. Diabetes, pruritus in 545. Diagnosis sound in 121. volsella in 105. Diathesis strumous and tubercular 258, 310, 325. syphilitic 325. 712 APPENDIX. Diet in carcinoma 485. in peritonitis 163. Weir Mitchell's system of 841, 663. Diffuse proliferation of connective tisane 333. Digestive derangements in anteversion ::.'i7. carcinoma 476. endometritis 323. Digital pressure in vaginal fomices, effects on uterine position 80. exploration of bladder 600. Dilatation of cervix 125. by rapid method 458. of uterine canal 330. Dilators Tail's, Hanks', and Hegar's 130. various forms of 269. Diphtheritic inflammation and carcinoma 478, 479. of vagina 527. Discharge foetid, in carcinoma 474, 475. of body of uterus 502. watery, in sarcoma uteri 508. Discus proligenis 26. Displacements of pelvic floor 62, 562. of uterus 342. due to cellnlitis 40, 173. fibrocyatic tumours 443. hiematocele 181. ovarian tumours 231. peritonitis 173. relation to chronic metri- tis 337. endonietritis 321, 322. diagnosed with sound 121. etiology 345. physiological and patho- logical :::{. produced by volsella 105. Douche, forms of 137. in chronic metritis 339. Douglas, pouch of 39. Drainage of abscess 172. in extirpation of uterus 497. for ovarian tumour 237. in ovariotomy 244. tube in displacement of uterus 383. Dressing of wound in ovariotomy 244. Drop-cork for chloroform 144. Dysmenorrhit-a 585. congestive 586. mechanical and congestion theories of 351,356. relation to Battey's operation 209. in anteflexion 351. cellulitU IT:.'. stenosis of cervix 267. endometritis 320. fibroid tumours 415, 417. uterine polypi 453. retroflexion 365, 3(56. membranous 587. obstructive 267, 351. spasmodic 586. with sterility 592. Dyspareunia in anteflexion 353. in peritonitis 161. causes 531. definition 531. in prolapsed ovary 206. treatment 531. in vaginismus 531. ECHINOCOCCI of pelvic organs 188. Ecraseur in amputating cervix 281, 488. mode of application, 489. for removal of ovaries 210. polypi 459. and galvano-cautery, relative atl van- tages 4S8. Eotropium of cervix 294, 305. Elastic ligature in amputating uterus 400. in lajHtrotoiny for fibroids 435, Electric endoscope 004. apparatus ami instruments 659. Electricity in cervical catarrh :ti:;. endometritis 329. tilnoicls 4'_'7. gynecology 652, 661. metritiH341. nerve prostration 663. Electrodes 656, 659, 660. Electrolysis 656, 657. in ovarian tumour 237. Electro-magnetic units 655. Elythrytis 525. Elytrorrhaphy 573, 576. Emaciation in carcinoma 476. Emmet's operation for lacerated cervix !'.>'. Ems, waters of, in endonietritis 329. in chronic metritis 339. Endocervicitis 300. Endometric applications 328. Endometritis 315. relation to abortion 317. in anteflexion 3."i4. cervical 300. and cervical catarrh 309. leading to chronic metritis 337. classification 320. diagnosis by sound 121. fundal 324. fungosa of Olshausen 317. hwruorrhagic type and carcinoma of the body 502. and sarcoma 509. varieties of 316. villous or papillary form 319. Endoscope, electric, 604. Enterocele, vaginal 578. Enucleation of fibroid tumours 404, 410. spontaneous 404, 409, 419. artificial 420, 430, 431. ovarian tumours 245. Episioperineorrhaphy 573, :>7 . Epispadias 543. Epithelial cells found in carcinoma 478. origin of cancer 4iil. Epithelioma of the cervix 4iil. and inversion 389. Erector clitoridis 10. Ergot and carcinoma 484. chronic metritis 340. endonietritis 325, 326. fibroids 4'J'i. methods of administration in menorrhagia 58 Ergotine hypodermic injection of 42i>. in treatment of fibroids IL'".. Erosion follicular 304. and carcinoma 471. papillary 304. and carcinoma 478 simple 303. Esthiomene of vulva 550. Ether 141. Ethidene 141. Eversion of lips of cervix 20", -J'.'". Evolution relation to jiathology of ovarian tumour.- _'_' 7. Examination of cases 671. methods of 90. posture in 133. routine described in inversion 391. Exanthemata and endometritis 3-J1. vaginitis in atresia vagina; aft. External genitals anatomy 3. development 74, ">40. relation in erect p. uterus- -for fibroids 432. INDEX OF SUBJECTS. 713 Extirpation of uterus through abdominal walls 4M. through vagina 495. compared with amputa- tion of eerrix 497. for sarcoma 510. Extra-peritoneal blood effusion 181. signs of 184. ovarian tumour, treatment 245. treatment of fibroids 433, 435. Extra-uterine gestation 660. and fibroid tumour 424. f*n*tng hsematocele 181. and ovarian tumours 230, 231. Exudations in the pelvis 140. coarse of 109. FACIBS, cancerous Fallopian Tubes-anatomy 22. abnormalities 193. blood-sacs in 513. catbeterisation of 193. development of 74. distent ion with pus or blood 197,198. ::v -: __. enlarged, and fibroid tumours 422. functions 198. hydrops of 198. inflammation of 195. new formations of 199. palpation of 193. patnlous condition of 194. position 2t, 45. in inversion 387. removal by abdominal incision 198,211. per Taginam 212. affected with sarcoma 505. stricture of 194. -:r . km | . tumours of 199. Faradic current 654, C59, 600. Fatty degeneration around polypoidal fibroid 384. in fibroid tumour 411. Fertility, standard of 592. Fevers causing ovaritis 203. Fibrocystic tumours of the uterus 443, 049. and ovarian tumours 234. Fibroid tumour of uterus 402, 416, 426, 649. producing anteflexion 350. and anteflexion 354. Batter's operation for 209. compared with carcinoma 477. and chronic metritis 337. and gestation in detached bom 268. + inversion 388, 389. pediculated submucoos 447. rapidity of growth 405. relation to age 415. removal through abdomen 430. per Taginam 429. sloughing and carcinoma 478, 479, 502. and retroflezion 387. sarcomatous degeneration of 505. and sarcoma 509. and Tail's operation 213. tumour, spontaneous expulsion of 448. tumours of vagina 535. eerrix 403, 412. ovary 223. Fibromata of vulva 549. Fibre-myoma uteri 40:;. lymphangiektode* 444. Fibrous tumour of uterus (See Fibroid). Fimbriated end of Fallopian tube 23. Flexions of uterus 344. Flooding, producing cupel-involution .' (See Hemorrhage). Foetal heart in diagnosing pregnancy 338, 424. Foetal life malformations arising in 259. Foetus in detached born of uterus 200. Forceps used for extracting mucous polyi 458. and fistula 619. rneum . Pornioes anatomy of 28, condition of, in peri- tonitis and cellnlitis 109. effect on uterus of digital pressure in 80. examination of 95, 9*. lateral 45. operation for tear into 301. : sjtfl :. f. :n .-.: nUad Mrfftl ML 287. Fossa naricularis anatomy 6. irritability producing vaginis- mus531. Fourcbette, anatomy 3. fissures in, producing vaginismus 531. Freund's extirpation of uterus 494. Friedrichshall water 340, 583, 643. Fritach's method of treating pedicle of fibroid 439. GALL BLADDER, laparotomy for distended C49. Gal vanicor "Gal vano-causUc" current 654, 657, 600. Galvanism 278. Galvano-Caustic Wire in removal of polypi 459. for amputation of inverted uterus 401. in amputating cervix 281. compared with eenseur 488. mode of application 490. Galvanometer 664, 659. Galvano- puncture 658. Gangrene of fibroid tumour 408. Gartner's canals 23, 74, 227. Gehrung's anteversion pessary 359. Generative organs, development of 227. Genito-nrinary organs 199. Gennpectoral posture 77. in replacing retroverted uterus 371, 374. Germinal vesicle 27. Gestation Abdominal 650, 651. in detached horn 200. 263, 650, 651. in Fallopian tube 650, 651. in a septate uterus 261. Glycerine plug, making of 204. Gonococcns 147, 527, 669. examination in pus 671. cervical cat Gonorrbt I catarrh 307. ; . .- . ovaritis 203. peritonitis 159. sahnfagitis 195. raginitis 525, 527. and disfasfs of women 669. endometritis 320, 321. latent in the male 159, 670. ami metritis 331. micrococci in 147, 527, 670. Gonorrhoea! vaginitis, diagnosis from simple 529. Gouty diathesis and dysmeoorrbcea 590. Graafian follicles degeneration of, and ovarian cysts 217. development 216. distention of, and ovarian cysts 217. number 25. position 25. rupture of 84. -:r:'.-: .;- M . Greenhalgh's intra- uterine stem 355. HJEMATOCELE pelvic 177. ^wi hsBtnatoma 177. rupture of extra-uterine gestation 181. fibroid tumour 424. Hsematokolpos (Bee Atresia Vagina;). Hsematoma 178, 184 ; of vulva 551. Haematosalpinx 198. H.-:- ::: Ml ' ' *! :. '. " ^ -'-'' in carcinoma uteri 474, 482, 484. 714 APPENDIX. Haemorrhage in carcinoma of body of uterus 502. causing death in carcinoma 480, 482. in carcinoma, treatment of 484. in endometritis 320, 322, 825. in fibroid tumours 410, 424. fatal from fibroid tumours 417. into bladder after operation for fistula (538. internal, in operation for atresia 519. intra-peritoneal and extra-peritoneal 181. in inversion of uterus 889. into the peritoneum of pelvis 178. in polypi 453. post-partnm 297. in retroversion 361. in sarcoma uteri 508. secondary after ovariotomy 245. in uterine polypi 453. Hsemorrhoidal plexus 71. Heart, action of chloroform on 145. Hernia and hydrocele 188. Hegar's amputation of cervix 282. dilators 131. method for laparotomy for fibroids 430. treatment of pedicle 437. Heredity, influence on carcinoma 471. Hermaproditism 542. false 543. true 542. Hernia of fibroid tumour 40S. of ovary 204. Hernial nature of prolapsus 566. Hewitt's (Graily) cradle-pessary 359. Higginson's syringe 137. Hodge pessary 375, 376. mode of action 378. Houston, valve of 37. Huguier's conoid amputation of cervix 288. Hunyadi Janos water 340, 643. Hydatid of liver and ovarian tumour 234. tumour of pelvis 188, 649. Hydramnos and ovarian tumour 234. Hydrargyri pernitratis liquor in cervical catarrh 311. Hydrastis canadensis 340, 426. Hydrate of chloral and carcinoma 485. Hydrocele of round ligament 187. Hydronephrosis in cystitis 609. in carcinoma 467. Hydrosalpinx 196. and ovarian tumours 230. Hydrops folliculorum 219. tubae 196. Hymen atresia of 512. development of 515. forms of 5, 6, 7. imperforate, operation for 520. persistent or inflamed, producing vagin- ismus 531. small ulcers in, producing vaginismus 531. Hypodermic injection of ergotin 426. morphia 164. Hyperplasia areolar of uterus 333. of cervix 307. Hypertrophy primary, of cervix 279. secondary, of cervix 279, 286. of mucous membrane of uterus 409. of muscular wall of uterus 409. Hypospadias 542. Hysterectomy for fibroids 432. Hysteria 664. due to ovaritis 203. in parametritis 176. small uterus in 258. and Battey's operation 210. in superinvolution 277. Hystero-epilepsy 666. and Battey's operation 210. ICE-BAGS in haematocele 185. Ice-cap 245. Ice in peritonitis 165. Incontinence of urine 613, 614. India-rubber ring to control hemorrhage 2S6. Induced current of electricity 654, 659. Induration of fibroid 411. Infarct of uterus 333, 411. Inflammation of cervix 1507. of uterus 315. in muscular coat of uterus 331. of pelvic peritoneum and cellular tissue 157. puerperal 331. Inflammatory deposits and fibroid tumour 424. Infundibulo-peivic ligament 25. Inguinal glands 71, 73. affection in carcinoma 469. Injections intra-uterine in carcinoma 485. in endometritis 325, 326, 330. and metritis 332. into uterus and tubes 194. dangers of 194, 527. vaginal 311, 312. Interstitial fibroid 406, 409. metritis 333. Intestinal obstruction due to fibroid tumours 418. Intestines in pouch of Douglas 59. relation to uterus and pelvic floor 59. Intra-abdominal pressure upon pelvic floor 64, 75. in inversion 384. in prolapsus 565, 568. and retroflexion 365. action on rectum 638. Intra-peritoneal blood effusion 177. signs of 184. treatment for fibroids 433. Intra-uterine galvanic stem 277. injections 330. medication 328. stem-pessary 355, 381. Inversion of uterus 384. caused by fibroid tumour 411. diagnosed from fibroid tumour 420. pediculated fibroid with inflammatory adhesions 56. mucous polypus 456. mechanism of 384. and prolapsus 393. in sarcoma 506. In verted uterus amputation of 309. replacement of Atthill's method 395. Barnes' method 395, 396. Courty's method 396. Emmet's method 398. Lawson Tait's method 398. Xoeggerath's method 395. Tate's method 396. Thomas' method 396. White's method 395. Involution and operations on cervix 332. senile 251. puerperal 336. artificially produced by amputation of cervix 340. Iodide of potassium in ovaritis 204. in chronic metritis 340. Iodine in cervical catarrh 311. in endometritis 327. Iodised phenol in endometritis 329. lodoform in entiometritis 329. in vaginismus 532. in pruritus vulvae 546. Ischio-rectal fossa 9, 47, 50. Isthmus of uterus 14. of Fallopian tube 22. KEITH, clamp for fibroids 437. Kidney disease in carcinoma 467. Kissingen waters in chronic metritis 339. INDEX OF SUBJECTS. 715 Knives 135. Kolpokleisis 635. Kraurosis vulvas 035. Kreuznach waters in endometritis 329. chronic metritis 339. treatment of fibroids 427. Kuchenmeister's scissors for dividing the cervix 136, 272. LABIA MAJORA, anatomy 3. hydroceleof 188. Minora, anatomy 3. development 74. Labour atony of uterus in third stage of, due to chronic metritis 337. "missed" 264. rapidity of, and lacerated cervix 294. complicated by polypus 454. protracted, producing fistula 618. Laceration of cervix 290. and carcinoma 471. cellulitis 168. chronic metritis 357. subinvolution 336. of perineum 555. Lactation effect on uterus if protracted 275. and subinvolution 336. Laminaria tents 125, 121). Langenbuch's incision 648. Laparotomy (See Abdominal Section). Lateri-version of uterus 345. Leeches application uf, to cervix 312. in peritonitis 165. Lefort's operation for prolapsus 377. Lembert's suture 652. Leucorrhoea as a symptom 673. in anteflexion 350, 353. cervical catarrh 304, 308. endometritis 321, 323, 324. hypertrophied cervix 280. lacerated cervix 295. retroflexion 365, 366. uterine polypi 453. vaginitis 528. vaginal cysts 534. producing pruritus 54 j. Levator ani 12, 49, 50. Ligature in ovariotomy L'42. Lineae albicantes 95. Lipomata of vulva 549. Listerism in gynecology 147, 646. in ovariotomy 240. Literature, Gynecological Sources of 675. Recent 679. Lithia water in pruritus 546. salts of, in irritable bladder 613. Locomotion impaired in uterine inflammation 357. Lupus vulva; 464, 550. Lymph, coagulable from fibroid tumour 444. Lymphatics relation to cellulitis 1S, 169. between glands and vessels 72, 73. of external genitals 72. in fibroid tumours 405. dilatation of 443. of rectum 73. relation to septicaemia 73. of uterus 72. dilatation in metritis 335. of vagina 72. Lymphatic glands of pelvis 71. in carcinoma 465. vessels of pelvis 72. MALFORMATION of uterus 253. rectal examination in 263. Malignant peritonitis 158, 224. tumours of the uterus 460. Marckwald's amputation of cervix 282. Marriages, average productivity of 592. Martin's operation for cervical catarrh 296, 313. enucleation of fibroids 431. vaginal extirpation of cervix 495. Massage 163. general, in uterine disease 341, 663, 667. in pathological anteflexion 355. Medullary cancer 461. Membrana granulosa 26. Menopause and Battey's operation 209. changes in cervix after 267. in uterus after 274, 319. in vagina after 525, 527. influence on fibroid tumours 406, 424. premature 582. Menorrhagia 585. in anteflexion 350, 353. carcinoma 474. lacerated cervix 295. metritis 332. endometritis 322. fibro-cystic tumour 445. fibroid tumour 410, 416. hajmatocele 184. inversion 389. ovaritis 203. peritonitis 161. uterine polypi 453. retroflexion 305, 366. treatment by Battey's operation 207. Menstruation 82. and Battey's operation 209. irregular, in cervical catarrh 308. in laceration of cervix 295. diminished in chronic cellulitia 176. in endometritis 321. absence in fistula 619, 636. during gestation 200. relation to hsBinatocele 182. in metritis 331, 332, 337. periodicity and duration 83. descent of polypus during 449. in an undeveloped horn 260. in bicornuous and septate uterus 260. and Tait's operation 209, 212. Menstrual blood composition 84. origin 85. quantity 84. character of retained 515. Mesenteric tumours 649. Metastatic deposits 507. Metritis 312, 315, 331. acute 331. chronic 312, 333, 346. Metrotome various forms 271. Sir Jas. Simpson's 270. Micrococci in wounds 146, 168. gonorrhoea 147, 527, 669. Micro-organisms in gynecology, 146- Microscope in carcinoma uteri 477, 478, 479, 502. endometritis 324. sarcoma uteri 509. Micturition 596. difficult, in fibroid tumour 418. hsematocele 184. prolapsus 567. frequent (513. in cystitis 609. fibroid tumour 418. fixation of uterus 357. vaginitis 528. painful, in carcinoma 476. Mobility of uterus, ascertained by sound 121. Monopolar method of applying electric current 657. Morcellement in fibroid tumours 433. Morgagni, columnar and sinus 38. hydatis 227. Morphia methods of administration 164. in carcinoma 485. in metritis 333. caution as to use in dysinenorrhoea 589. 716 APPENDIX. Mncoid degeneration in fibroid tumour 445. Mucous membrane of bladder 32. cervix 21. rectum 36. urethra 30. uterus 20. vagina 29, 525. polypi 447, 450. Miiller, ducts of 74, 22(3, 259, 540, 541. Musculature of bladder 32. rectum 36. urethra 30. uterus 19. Myoma of ovary 223. uteri 403. and anteflexion 354. retroflexion 369. Myxomatous degeneration of fibroids 411. Myxomyoma 445. NABOTHII ovula 306. Nabothian follicles 306. pediculated 447, 452. Nail-curette, A. R. Simpson's 430. Needles 136, 299, 438. Nelaton's forceps 232. Nerve-prostration, systematic treatment of 662. Nerves of pelvis 73. Nervous derangements in anteversion 357. endometritis 322, 323. reflex symptoms, and lacerated cervix 294. retroflexion 364. system, action of chloroform on 142. Neugebauer's operation for prolapsus 577. Neuralgia from pressure by fibroid tumours 418. in lacerated cervix 295. Neuromata of vulva 549. Nitrate of silver in endometritis 329. vaginitis 529. Nitric acid in endometritis 327, 329. in carcinoma 487. OBTURATOR gland 72. internals 13. Oedema of fibroids 411. Ohm 656. Ohm's Law 656. Omental tumours 648. and ovarian 233, 234. cells found in fluid from 225. Oophorectomy 208. Oophoritis 202, 264. Opiates in dysruenorrhosa 589. Opium in carcinoma 485. Os externum contracted 265, 349. examination of 95. position 16, 21. OB internum and utero-vesical fold of peritoneum 17, 287. Os uteri, form in nulliparse and multiparse 271. Ovarian artery course 69. in removal of fibroids 433. corpuscles 222. fimbria 23, 25. fluid 222. ligament 25. plexus, of veins 71. Ovarian tumours cystic 215, 229, 236. and fibroids 422. amenorrhoea 582. fibrocystic 445. genesis of 226. malignant 217, 223. position of 93. causing peritonitis 158. solid 223, 230. Ovaries Anatomy 23, 215. arterial supply 69. cellular structures in 219. changes in at each menstrual period 85. colloid degeneration of stroma 218. degeneration of blood-vessels 217. Ovaries development 74, 227. displacements 204- epithelial tubes 217. examination of 102. hyperajniia 202. inflammation 202. and amenorrhoea 582. ligaments 25. malformations 200. malignant development of connective tissue 202, 217. disease of 224. measurements 24. menstrual period, changes at 83. menstruation, etfect on 88. palpation of 201. physiology of 216. position 23, 45, 58. in inversion 387. in retroflexion 363. prolapse of 205. prolapsed and fixed by adhesions 210. retroflexion 369. removal by abdominal section 211, 442, 648. per vaginam 210. structure 25. in superin volution 275. tumours of 215. in rudimentary uterus 254, 260. in uterus unicornis 254. Ovariotomy 237. mortality 249. normal 209. Ovaritis 202. and Battey's operation 210. and Tait's operation 213. Ovula Nabothii 306. Ovulation 84. with rudimentary uterus 254. Ovum formation of membrana granulosa 26. structure 26. passage into uterus 84. PAIN in fissure of anus 641. endometritis 322, 323. carcinoma uteri 474, 475, 485. carcinoma of body of uterus 501. cellulitis 169. cervical catarrh 308. endometritis 320, 322. fibroids 415, 417, 418. inversion 389. retention of menses in atresia 516. metritis 333. ovaritis 203. acute and chronic peritonitis 160, 161. prolapsed ovary 206. retroflexion 366. sarcoma uteri 508. superin voluti on 277. vaginitis 528. Palpation, method of 91. of fibroids 422. Pampiniform plexus 71. Papilloma of the cervix 447, 452. Paracystitis 609. Parametric tissue 47. Parametritis 167. chronica atrophicans 174. posterior, of Schultze 168, 350. Paravesical pouch of peritoneum 57. Parenchymatous inflammation 333. ovaritis 202. Parovarial cysts 226, 230. Parovarium 23, 199. development 74. distension 200. Parovarian fluids, nature of 225. tumours 200, 225, 227. and ovarian 234. Parturition, effect on pelvic floor 64. INDEX OF SUBJECTS. Ill Parturition and cervical catarrh 307. repeated and carcinoma 473, 501. endometritis321, 324. Pean's method of laparotomy for fibroids 435. needle for pedicle 435. Pedicle changes in, after ligature 242. of fibroids 409. of polypi 44S. treatment in fibroid tumours 433. extra- and intra- peritoneal methods compared 433. twisting 407. of ovarian tumour 220. examination 232. torsion 248. treatment in ovariotomy 241. Pediculated cystic/follicle 306, 447, 452. Pediculation and extrusion of fibroids 419. Pedunculation of fibroid tumours 409, 426. Pelveo-peritonitis 157. Pelvic abscess 168, 181, 650. bursting of 171. and vaginitis 529. ceUulitis 167. and ovarian tumours 230. connective tissue 41, 42, 46, 47. deposit in pouch of Douglas and retro- flexion 369. examination, importance of in carcinoma 478. floor anatomy, general 7. structural 60. displaceable and fixed portions 63,563. displacements 03, 563. divisions 64. fascia 8. functions of 60, 64. preventing downward displacement 343. affected by change of posture 76. genupectoral posture 78. intra-abdominal pressure on 64, 75. measurements on external surface 7. muscles 10. opening up of, in genupectoral posture 78. in parturition 61. pubic segment 61. relation to parturition 61, 64. sacral segment 61. glands 72. inflammation producing displacement 172, 346, 357. after stem pessary 278. and subinvolution 336. organs, development 74. ovarian tumours producing pelvic inflam- mations 158. peritonitis 157. producing anteflexion 351. with anteversion 173, 358. chronic 161. and ovarian tumours 230. producing retroversion 173. producing small uterus 275. Pelvic-floor projection 65. callipers for measuring 66. measurements 66. effect of pregnancy on 66, 67. segments 61. contrast between 61. as affected by genupectoral posture 78. in parturition 61. Pelvis blood-vessels of 68. axial coronal sections of 49, 63. contents of 57. coronal sections of 48. genupectoral posture, section in 79. sectional anatomy 44. horizontal sections 47. Pelvis sagittal lateral section 45. lymphatics 71. nervous supply 73. physics of 75. sagittal mesial section 45. venous plexuses 70. Perchloride of iron to check haemorrhage 484. caution as to use 484. in sarcoma 510. of mercury as antiseptic 149. Percussion, method of 93. of fibroids 422. of ovarian tumour and ascites 232. Perforation into peritoneal cavity in carcinoma 468, 469, 481. bladder and rectum by fibroids 419, 420. Perimetritis 157, 315. Perineal body 11, 38, 40. structure 38. measurements 38. Perineal muscles 10. Perineum arterial supply 69. development 541. rupture 553. central rupture 554. operative treatment 557, 572. support in parturition 557. Perineorrhaphy 573, 574. Periovaritis 204. Peritoneal toilette 244, 652. Peritoneum anatomy of 39. of bladder 39, 41, 63, 289. in parturition 63. of broad ligaments 40. in carcinoma 468, 469. amputation of cervix 288. prolapsus 566. fistula 617. inversion 387. haemorrhage into 178. inflammation of 157. effusion into, and ovarian new growths in 18. tumour 231. method of opening into 647. in relation to operations 41. in parturition 41. on sides of pelvis 40. local divisions on pelvic floor 57. and rectum 41. in retroflexion 364. of uterus 17, 39. on posterior vaginal wall 39. vesico-uterine pouch of 39. Peritonitis pelvic 157. fatal, and carcinoma 481. relation to cellulitis 157, 170. fibroid 408. malignant 167. cells, found in fluid from 224. and ovarian tumours 230. superinvolution 275. subinvolution 336. retroflexion 365. after uterine injections 194. producing retroversion 360. tubercular 166. Pernitrate of iron to check haemorrhage 484. Pessary intra-uterine 355. in retroflexion 381. Meadow's 381. Bouth's 381. Schultze's 381. Williams' 381. vaginal action of 382. Albert Smith 356, 375, 377. in division of cervix 273. anteflexion 356. anteversion 359. in chronic metritis 339. 718 APPENDIX. Pessary, vaginal effect on position of uterus 81. in fibroid tumour 427. Gehrung's 359. Hewitt's cradle 359. Hodge 356, 359, 375, 376, 381. choice of best form 377. mode of introduction 377. position and action 878, 382. Meadow's 381. medicated, composition of 530. in pregnancy 381. in retroflexion 375. for prolapsed ovaries 200. ring 550. Thomas' 359. Zwanck's 570. Pfliiger's ducts, a source of ovarian tumours 216, 219. Phthisis amenorrhoBa in 582. uterus in 275. Physics of abdomen and pelvis 75. Physiological activity, period of 251. Piles 642. Placenta portions retained, and carcinoma 479, 502. metritis 337. relation to inversion 385, 388, 390. Placental polypi 447, 452. Polypes & apparitions intermittentes 449. Polypi of uterus 443. with endometritis 320, 321. fibioids 446. producing Fallopian tube gestation 454. diagnosis from inversion 392. producing inversion 385, 389. + inversion, diagnosis of 392, 456. mucous 447, 450. and fibrous contrasted 454. placentfil 447, 452. Porte-caustique 329. Positive and negative poles 658. Posterior fornix, effect of pressure on 380. Posture effect on abdomen and pelvic floor 76. relation to examination and treatment 183. of patient in cellulitis and peritonitis 170. Pouch of Douglas 40, 45, 57. intestines in 59. Pregnancy and fibroid tumours 408, 413. advanced, and fibroid tumour 423, 424. early, diagnosis 338. from fibroid tumour 421, 422. characters of uterus 338. in detached horn 263, 264. diagnosis from chronic metritis 339. ovarian tumour 233. and uterus dilated from atresia 516. Assuring of cervix in 294. and large fibroid tumours 424. + ovarian tumour 235, 246. hypertrophy of cervical glands in 307. anteversion of uterus in 359. sympathetic phenomena of, in uterine polypus 453. Presentation of head and lacerated cervix 292. Prognosis in gynecological cases 674. Prolapse of ovary 205. rectum 639. Prolapsus uteri 65, 393, 565. due to fibroid 412. and hypertrophied cervix 280. 4- inversion 393. mechanism 567. retroversion in 360. senile 60S. Pruritus vulvae 545. in carcinoma 476. Pseudocyesis and ovarian tumour 234. Pseudo-myxorna peritonei 221, 247. Puberty changes at 83. symptoms of atresia at 516. Pubic segment of pelvic floor 61, 63. displacements 61. in bimanual examination 100. in semiprone posture 110. Pudendal hernia 551. Puerperal inflammation 321. inversion, frequency of 388. involution and metritis 336. Puerperium rapid development of carcinoma in 502. and endonietritis 321. inversion 384, 388. metritis 336. peritonitis 159. retroflexion 3(55. retroversion 360. subinvolution 336. Pulse in hsematocele 184. peritonitis 160, 165. Pyosalpinx 197. and ovarian tumours 230. and laparotoniy 650. RAKE for removing sutures 285. Rectal examination 101, 639. in atresia 517. carcinoma 477. fibroids 420. hypertrophied cervix 281. inversion 391. pathological anteflexion 353. retroflexion 368. snperinvolution 277. uterine malformations 261. Simon's method 103. Recto-abdominal examination 101. Rectocele 639. and prolapsus 569. Recto-vaginal fistula 642. Recto-vagino-abdominal examination 10: ; . Rectum anatomy 36. diseases of 639. examination 101, 639. fibroid tumour's pressure on 41S. inflammation round 175. lymphatics of 73. microscopic structure 37. physiology 637. position 35. in retroflexion 304, 365, 369. structure 36. ulceration in carcinoma 468. displacing uterus 343. connection with the vagina 36, 61. Reflex action and chloroform 142, 144. disturbances from parametritis atrophieans 176. Reinversion of stump of amputated uterus 401. inverted uterus 393. Renal calculi 612. tumours and ovarian 234. laparotomy for 649. Reposition of inverted uterus 394. Respiratory centre in chloroform 144. Retention of uterine 614. producing cystitis 609. due to fibroid tumour 41S. Retroflexion 312, 343, 345, 362. and cervical catarrh 307, 312. congenital 363, 364. and small fibroid tumour 421, 422. relation to retroversion 360, 362. Retro-pubic fat deposit 61. Retro-uterine haematocele 184. and ovarian tumour 231. Retroversion 344, 345, 360, 362. congenital 300. passage of sound in 117. caused by peritonitis 173, 361. INDEX OF SUBJECTS. 719 Retroversion action of pessary on 378, 382. physiological and pathological 344, 360. in prolapsus 568. with anteflexion 361. -t-Retroflexion 344, 345, 362. RetroVerted gravid uterus and ovarian tumour 231. Rheumatic diathesis and dysmenorrhcea 590. Ring pessary 570. with diaphragm 570. mode of introduction 570. position in vagina 570. Rosenmiiller, organ of 23. Round ligament anatomy of 19. hydrocele 187. and junction of uterine horn and tube 255. new growths in 187. shortening for displacements of uterus 382. prolapsus 574, 577. tumours of 188. a guide to parts of uterus 255. Rupture of the uterus in carcinoma 481. SACRAL SEGMENT of pelvic floor 61. rupture of inferior angle 555. the supporting one 64, 557, 565. supporting pessary 379. Sagittal mesial sections 45, 60. lateral section 45. Salpingitis 195. Sarcoma of ovary 224. connective tissue 189. uterus 400, 503. and carcinoma 478, 479. endometritis 325. inversion 389. vagina 536. vulva 550. Sarcomatous degeneration in fibroids 412, 445. polypus 451. Scarification of cervix 312. Schroeder's operation for cervical catarrh 296, 313. Schultze's dilator 276. Scirrhous cancer 461. Scissors 135. Bozeman's 135. for division of cervix 272. in amputation of cervix 281. Hart's 135. Kuchenmeister's 135. Scrofula, leucorrhoea in 321. and congenital atrophy of uterus 25S. Sectional anatomy 44, 60, 63. Semiprone posture 109. Septic matter causing cellulitis 168. metritis 331. Septicaemia after amputation 400. after operation for atresia 519. in carcinoma 480, 481. from suppuration of fibroid tumours 419. in inversion of uterus 394. relation of lymphatics to 73. and metritis 331. after ovariotomy 245. after tents 130. Septic peritonitis 162, 164. salpingitis 195. Serre-nceud of Cintrat 436. in laparotomy for fibroids 436. Serous peritonitis 15S, 160. Serum, collection in Fallopian tubes 197. Sexual activity and fibroids 415. excess and endometritis 321. Sickness after chloroform 145. Silk-worm gut 137. Silver-wire sutures i:J7. Simon^nd Marckwald's amputation of cervix 282. Simon's sharp spoon and carcinoma 488, 502. urethral specula 601. Simpson's (A. R.) amputation of cervix 282. nail-curette 430. repair of perineum 559. sound 116. volsella 105. (Sir J. Y.) division of cervix 270, 356. galvanic intra-uterine stem 277. metrotome 271. sound 115. Sims' (Marion) division of cervix 357. amputation of cervix 2S1. curette 132. dilator 270. speculum 108, 296, 309. tenaculum 107. operation for vaginismus 532. Skene-Goodman catheter 611. Skene's urethral specula 602. Smith (Albert) pessary 356, 375, 377. mode of action 377, 378, 379. Souffle uterine, in fibroid tumour 421. absence of, in ovarian tumour 424. Sound uterine 115. combined with Bimanual 123. in anteflexion 355. hypertrophied cervix 281. endometritis 309, 321, 324, 327. metritis 232, 338. small fibroid tumours 420. fistula 620. pediculated submucous fibroid 455. subserous fibroid 423. inversion 391. polypus and inversion 457. polypoidal fibroid 420. chronic metritis 338. retroflexion 368, 373. super-involution 277. uterine displacements 346. method of dressing 327. in replacing retroflexion 373. in treating anteflexion 355. Spatulse, vaginal, 529. Specula, vaginal comparative advantages of various forms 114. Barnes' crescent 112. Battey's 109. Bozeman's 108. Cusco's 112. Fergusson's 111. Neugebauer's 112. Sims' 108. in cancer 477. in endometritis 324. in lacerated cervix 295. Speculum anal 639. intra-uterine 329. urethral and vesical 600, 601. Spencer Well's clamp 241. trocar 240. Sphincter ani externus^3S. internus 38. tertius 38. operation to restore 558. Splenic tumours 648, 649. Sponge-tents 125. Sponges in operations 150. precautions as to 239, 646. Spray in ovariotomy 246. Staffordshire knot 211. Stem galvanic intra-uterine 277. in anteflexion 355. Sterility 591. in anteflexion 350, 352. cellulitis 172. cervical catarrh 308. hypertrophied cervix 280. 720 APPENDIX. Sterility in stenosis and rigidity of cervix 2(38. lacerated cervix 295. dyspareunia "i:ll. endometritis 322, 323. stricture of Fallopian tubes 19 J. fibroid tumour 416, 418. fistula 619. chronic metritis 337. peritonitis 161, 162. double ovaritis 203. uterine polypi 4"j4. retroflexion 306. sarcoma 507. vaginismus 531. Structural anatomy of the pelvic floor 60. Strumous diathesis and endometritis 325. Subinvolution 333. and anteversion 367. lacerated cervix 293. cervical catarrh 312. with retroflexion 363. Submucous fibroid 406, 409, 447. Subperitoneal fibroid 406. Subserous pediculated fibroids 431. Subserous fibroids and fibro-cystic tumours 443. Superfujtation 261. Superinvolution 275. and amenorrhcea 582. ascribed to ovaritis 202. Supra-vaginal portion of cervix, hypertrophy of 279, 286. amputation of the cervix 491. Suppuration after cellulitis 169. hsernatocele ISO. of fibroids 412. Sutures 137, 299. removal of 285, 300. Sympathetic pain in ovaritis 203. Syphilitic salpingitis 196. ulceration and carcinoma 478. of perineum 555. Syringe, Higginson's 137. TAIT'S graduated dilators 130, 458. operation for removal of uterine appen- dages 212, 650. in fibroids 442. dysmenorrhoea 590. Tangle and tupelo tents 125, 129. Tapping in cellulitis 171. hydrocele 188. ovarian tumours 236. peritonitis 167. Temperature, reduction of 165. after ovariotomy 245. Tenaculum -Sims' 107. in diagnosing lacerated cervix 296. Tents 125. clangers of 129, 269, 321. in stenosis of cervix 269. Tetanus in carcinoma 482. Thomas' anteversion pessary 359. cervical plug 273. spoon-saw 430. Tightlacing and uterine displacement 343. Torsion of pedicle of ovarian tumour 24S. for removal of polypi 458. Trachelorrhaphy 297. Transverse section 47. Transversus perinei 10. Treatment operative, in gynecology 674. sound in 112. specula in 114. volsella iu 106. Triangular ligament 8. Trigone of bladder 32. Trocars for tapping ovarian cysts 240. Tubal disease producing peritonitis 159. Tubo-ovarian cysts 199. Tubercular diathesis in superinvolution 275. peritonitis 166. Tuberculosis of vagina 536. Type of menstruation 84. ULCERATIOX of Cervix so-called 295, 303. true 306. Os uteri 464. Upright posture 6, 77, 78. Urachus 227. Urajmia in carcinoma 480. fibroid tumour 418. Ureter anatomy of 32. catheterisation 603. relation to cervix and urethra 617. dilatation in carcinoma 4t'>7. due to cicatrisation 364. compression by fibroid tumours 418. opening of 32. position of 50. Uretero-uterine fistula 015, 018, t'rJO. vaginal fistula 615, 618, 620. Urethra anatomy of 30. atresia in fistula 617, 632. caruncle 531, 006. development 541. dilatation 599, 607. direction 30. displacements 605. exploration 598. glands 30. malformations 605. neoplasms 606. pressure on, by fibroid tumour 418. relation to vaginal wall 61. stricture 607. Urethral orifice 4. Urethritis 007. Urethrocele 606. Urethro- vaginal fistula 615, 619. +atresia of urethra 632. Urination, physiology of 596. Urine normal composition 597. character in cystitis 609. examination in fibroid 418. incontinence and retention 613, 614. in fistula 619. Uro-genital sinus 541. persistence of 541. Utero-sacral ligaments anatomy of 20. cicatricial contraction in 168, 350. function, compared with pessary 379. stretching of, in retroflexion 364. Uterine appendages, removal of 212, 050. artery course 69. in removal of fibroids 433. catarrh 315. cavity variations in length of 121. contractions importance in diagnosis 233, 422. mucous membrane in long-standing endo- metiitis 320. changes in, at men- strual period 85. plexus of veins 71. Uterus abscess in wall 332. absent, or rudimentary 254, 259, 261. amputation at os internum 432. of inverted 399. anatomy 14. antettexion 343, 345, 347. anteversion 344, 345, 356. atrophy 274. arterial supply OS. atrophy and amenorrhoea 582. bicornis 256, 259, 261. bipartitus 254, 259. body of, in inversion 380. carcinoma 460, 474, 483, 500. compared with disease else- where 499. changes after birth 259. congenital atrophy 258, 260, 263. INDEX OF SUBJECTS 721 Uterus congenital atrophy and super-involution 277. corroding ulcer of 464. curetting 132, 32(5. degenerative changes 411. development 74, 251. didelphys 255, 259, 261. digital pressure in fornices 80. dilatation in atresia 513. for therapeutic purposes 330. and perforation in carcinoma 481. displacements 342. in large fibrous polypi 448. ovarian and uterine tumours 445. peritonitis and cellulitis 172. divisions 18. duplex 259. enlargement of, in endometritis 334. metritis 338. extirpation of, through abdominal walls 494. through the vagina 495. in malformation 2ii4. fibroid tumour 402, 416, 425, 649. changes with fibroid tumour 409. fibro-cystic tumours 443, 649. changes in, at angle of flexion 348, 3(i3. glands 20. hypertrophy 278. in fibroid tumour 409. in prolapsus 566, 567. impairment of function in maldevelop- ment 260. infantile 258, 260, 263. inflammation (endometritis, metritis) 315, 331. and amenorrhoea 582. inversion 384. with fibroid 411. spontaneous reinversion 393. lateri-version 345. ligaments 18. lower segment 17. lymphatics 72. malformations 253. and superinvolution 277. measurements 16. mobility 58, 104. changes at a menstrual period 85. periods at which morbid conditions arise in 251. mucous membrane 20. musculature 20. nervous supply 73. one-horned, inversion of 3S5. operations for retaining in position 382. peritoneum of 18. polypi 447. position, means of ascertaining 56. changes with fibroid 411. with distended bladder 55, 59, 343. in genupectoral posture 80. normal 34, 343. opinions as to 51 . physiological changes in 58, 343. relation to viscera 59. pressure on bladder 357. prolapse 63, 393, 565. replacement of 355, 359, 362, 371. retention in position 371, 375, 382. retroflexion 312, 343, 345, 362. retroversion 344, 345, 360, 362. sarcoma 503. septus 256, 259, 261. atresia of 523. shape 14, 53. form in section 14. 2z \i terus stitching to abdominal wall for displace- ments 382, 383. structure 18. subinvolution 312, 330, 333, 334. superinvolution 275. support of 64. tumours of 402. and metritis 337. unicornis 254, 259, 261. and fibroid tumours 263. veins of 70. virgin type 258. VAGINA Anatomy 27. arterial supply 69. atresia 512. cancer of, primary 535. secondary 469. cicatrisation after fistula 617. labour 515. menopause 527. artificial closure for fistula 635. congenital bands in 524. cysts 533. development 74, 540. dilatation in atresia 512. direction in upright posture 27. fibroid tumours 535. form in section 29. in genupectoral posture 78. inflammation of 525. inversion+inversion of uterus 386. lymphatics 72. menopause, change after 527. plugging to check haemorrhage 484. position 27. sarcoma 536. structure of 29. tuberculosis 536. venous plexuses 71. walls 27. Vaginal cleft 61. columns 28. enterocele 579. examination 94, 422. and ovarian tumour 232. retroflexion 367. glands 28. glass plugs 521. injection 311, 312. method of removal of ovaries 210. of ovariotomy 237. spatulas 529. tampons and carcinoma 484. vaginitis 530. orifice anatomy 5. dilatation of 532. division of sphincter 532. fissures around, producing vagin- ismus 531. portion of cervix 531. amputation of 491. hypertrophy of 279, 287. walls attachments of 61. inversion in prolapsus 567. length 28. and direction in genupei:- toral posture 79. Vaginismus 530. Vaginitis 525. diphtheritic 525, 527. gonorrhoeal 525, 527, 528. senile 525, 527. Varicose veins, due to fibroid tumours 418. haemorrhage from, in vulva, 552. Varix of vulva 551. Veins, pelvic compressed by fibroid tumours 418. Venereal excess, causing peritonitis 159. Venous sinuses round fibroid tumours 404, 416. Venous thrombosis in carcinoma 480, 482. Versions of uterus 344, 345. Vesical catarrh 633. 722 APPENDIX. Vesical plexus 71. Vesico-uterine fistula 615,617, 620, 032. Vesico-vaginal fistula 616. artificial, for cystitis 611. Vesico-vaginal septum 615. Vesico-vagino-abdominal examination 100. Vestibule anatomy 5. development of 74, 541. Vichy waters in chronic metritis 339. Volsella description of 104. examination with 105. Hart's 106. A. B. Simpson's 105. with speculum 110. in superinvolution 277. for introducing tents 128. in replacing uterus 375. Volt 656. Voltaic current 654, 657. Vomiting in htematocele 184. peritonitis and cellulitis 170. Vulva anatomy of 4. atresia of 541. carcinoma 549. cysts 547. direction of 6. elephantiasis 548. Vulva eruptions 547. fibromata 549. hiematoma 551. haemorrhage from varicose veins 552. hernia 551. inflammation 544. kraurosis 551. lipomata 549. lupus 550. malformations 540. neuromata 549. pruritus 545. sarcoma 550. varix 551. Vulvitis 544. of children 544. WEIR MITCHELL'S treatment of nerve prostration and chronic uterine disease 341, 662. White's repositor for inversion 395, 396. Wiesbaden waters in chronic metritis 339. Wire sutures in amputation of cervix 283. fistula 620. Wolffian bodies 74, 199, 217, 226, 227. Zona pellucida 27. Zwanck's pessary for prolapsus 570." ATLAS OF FEMALE PELVIC ANATOMY BY D. BERRY HART, M.D., F.R.C.P.E., F.R.S.E., LECTURER ON MIDWIFERY AND DISEASES OP WOMEN, SCHOOL OF MEDICINE, EDINBURGH, ETC. Pull Bound in Cloth. Price, 2, 2s. Consisting of numerous Imperial Quarto Plates drawn from nature, under the direct superintendence of the Author, and copious Letterpress explanatory of each Plate. Large Folio, price 25s. THE RELATIONS OF THE ABDOMINAL AND PELVIC ORGANS IN THE FEMALE. Illustrated by a full-sized Chromolithograph of the section of a cadaver frozen in the Genupectoral position, and by a series of Woodcuts. By Alexander B. Simpson, M.D., PROFESSOR OF MIDWIFERY AND THE DISEASES OF WOMEN AND CHILDREN IN THE UNIVERSITY OF EDINBURGH ; AND David Berry Hart, M.D., F.B.O.P.E., F.R.S.E., LECTURER ON MIDWIFERY AND DISEASES OF WOMEN, EDINBURGH. Large Quarto, price IDs. 6d. THE STRUCTURAL ANATOMY OF THE FEMALE PELVIC FLOOR. BY David Berry Hart M.D., F.R.C.P.E., F.R.S.E., LECTURER ON MIDWIFERY AND DISEASES OF WOMEN, EDINBURGH. W. & A. K. JOHNSTON, EDINBURGH AND LONDON. 12 Plates, Imperial Folio, price 12$. 6d. STUDENT'S EDITION OF THE ATLAS OF THE ANATOMY OF LABOUR, INCLUDING THAT OF Full-Time Pregnancy and the First Days of the Puerperium. EXHIBITED IN FROZEN SECTIONS. REPRODUCED AD NATURAM. A. H. F. BARBOUR, M.A., B.Sc., M.D., F.R.C.P.E., F.R.S.E., Lecturer on Midwifery and Diseases of Women, School of Medicine Edinburgh ; Assistant Physician for Diseases of Women to the Royal Infirmary ; Assistant Physician to the Royal Maternity Hospital ; Physician to the Women's Dispensary ; Corresponding Fellow of the Royal Academy of Medicine, Turin. PREFACE TO STUDENT'S EDITION. Inasmuch as Anatomy furnishes the true basis of knowledge in Obstetrics, as in all departments of Medicine, I have in preparing another edition of this Atlas brought it out in a form which will place the results of the Sectional Anatomy of Labour within the reach of students. Another plate has been added giving the most recent Sections, by Winter and Saexinger, which brings the series up to date. EDINBURGH, April 18S9. INDEX OF PLATES. Plate I. SHOWING THE SECTIONS published up to the end of 1887 by other observers ; made before and during labour, and after delivery. ,, II. VERTICAL MESIAL SECTION of a Vl.-para, who died at the commencement of the First Stage of Labour from acute enteritis. III. OUTLINE DIAGRAM, showing direction of Sections in Pis. IV., V., and VI. ,, IV. FIG. 1. TRANSVERSE SECTION along the plane a 6 in PI. III., and passing through the 4th lumbar vertebra. FIG. 2. TRANSVERSE SECTION of Posterior half of Pelvis (from the same case as Fig. 1) along the plane c d in PI. III., passing through the junction of the upper and middle thirds of the second sacral vertebra. V. FIG. 1. AXIAL CORONAL SECTION OF RIGHT HALF OF PELVIS along plane 2 in PI. III. ; and passing through horizontal ramns of pubes just behind the obturator foramen, and through the tuberosity of the ischium. FIG. 2. AXIAL CORONAL SECTION OF RIGHT HALF OF PELVIS along plane 4 in PI. III. ; and passing through the anterior-inferior iliac spine, and posterior part of acetabulmn. ,, VI. FIG. 1. AXIAL CORONAL SECTION OF PELVIS, along plane 5 in PI. III., and passing through the transverse diameter and axis of the brim. FIG. 2. AXIAL CORONAL SECTION OF PIGHT HALF OF PELVIS along plane 3 in PI. III., and passing through the acetabulum and iechial tuberosity. VII. SECTIONS OF UTERI, SPIRIT-HARDENED, FROM CASES OF PORRO'S OPKRATION, bringing out anatomical facts in the relation of the placenta to its site of significance with regard to the mechanism of the III. -Stage. ,, VIII. SECTIONS FROM A FOURTH CASE OF PORRO'S OPERATION. ,, IX. FIG. 1. VERTICAL MESIAL SECTION FROM A CASE OF PARTIAL PLACENTA PR^EVIA delivered in articulo mortis by turning. FIG. 2. VERTICAL MESIAL SECTION FROM A CASE OF ECLAMPSIA, delivered in articulo mortis by forceps. ,, X. FIG. 1. VERTICAL MESIAL SECTION (FROZEN) OF PELVIS with.-Post -Partum Uterus. FIG. 2. VERTICAL MESIAL SECTION OF UTERUS thirty-six hours after delivery. ,, XI. SECTION OF I. -PARA, who died five and a half days after delivery. XII. SECTIONS published during 1888. W. & A. K. JOHNSTON, EDINBURGH AND LONDON. With Illustrations, price 5s. THE ANATOMY OF LABOUR AS STUDIED IN FROZEN SECTIONS, AND ITS BEARING ON CLINICAL WORK. BY A. H. F. BARBOUR, M.A., B.Sc., M.D., F.R.C.P.E., F.R.S.E., Lecturer on Midwifery and Diseases of Women, School of Medicine, Edinburgh ; Assistant Physician for Diseases of Women to the Royal Infirmary ; Assistant Physician to the Royal Maternity Hospital ; Physician to the Women's Dispensary ; Corresponding Fellow of the Royal Academy of Medicine, Turin. PREFACE. THE following pages were primarily intended as a Handbook to my Atlas of the Anatomy of Labour. They gather up, however, results obtained from study of all the sections hitherto published; and, to bring these within the reach of a larger number of readers, this little book has been made as far as possible complete in itself. The book falls into two parts. The first of these gives, along with the description of my own sections, the general results, thrown into a connected form, of all the work that has been done in this department ; while the second part gives the Literature of the subject arranged so as to exhibit in full detail the observations of others. TABLE OF CONTENTS. PART. I. CHAP. I. INTRODUCTORY SECTIONAL ANA- I CHAP. III. FIRST STAGE OF LABOUR. TOMY AND ITS BEARING ON CHAP. IV. SECOND STAGE OF LABOUR. CLINICAL WORK. CHAP. II. BEFORE LABOUR. CHAP. V. THIRD STAGE OF LABOUR. CHAP. VI. AFTER LABOUR: THE PUERPERIUM. PART II. THE LITERATI-RE OF SECTIONAL ANATOMY ARRANGED CHRONOLOGICALLY. Full-Bound Cloth, price 15s. SPINAL DEFORMITY IN RELATION TO OBSTETRICS, BY A. H. F. BARBOUR, M.A., B.Sc., M.D., F.R.C.P.E., F.R.S.E., Lecturer on Midwifery and Diseases of Women, School of Medicine, Edinburgh ; Assistant Physician for Diseases of Women to the Royal Infirmary ; Assistant Physician to the Royal Maternity Hospital ; Physician to the Women's Dispensary ; Corresponding Fellow of the Royal Academy of Medicine, Turin. CONSISTING OF 39 IMPERIAL 4xo PLATES AXD LETTERPRESS. Plates I. -XXII. Re-production ad naturam of Pelvis and of Skeleton from cases of Antero-posterior and of Lateral Curvature. Plates XXIII.-XXXIV., and Apper dix. Frozen Sections from two cases of Caries of the Spine. W. & A. K. JOHNSTON, EDINBURGH AND LONDON. LIST OF MEDICAL AND SCIENTIFIC WORKS PUBLISHED BY W. & A. K. JOHNSTON. Imperial 4to, Full-bound Cloth, price 12s. 6d. CONTRIBUTIONS TO THE SECTIONAL ANATOMY OF THE FEMALE PELVIS. By D. BERRY HART, M.D., F.R.C.P.E., Lecturer on Midwifery and Diseases af Women, School of Medicine, Edinburgh. This forms a supplement to Dr Berry Hart's Atlas of Female Pelvic Anatomy. It consists of twelve full-sized or slightly reduced Drawings of Frozen Sections display- ing the anatomy of the ureters, ischio-rectal fossae, and levator ani muscles, with special reference to the anatomy of prolapsus uteri and the excision of the cancerous uterus by the vaginal method. "With explanatory Letterpress. full-bound Cloth, Demy Octavo, price 7s. Od. "With 1O Lithographed Plates. BY P. M'BRIDE, M.D., F.R.C.P.E., F.R.S.E., Surgeon to the Department for Diseases of the Ear and Throat in the Royal Infirmary, and Surgeon to the Edinburgh Ear and Throat Dispensary. The first chapters of this Work treat of Diseases of the Ear in an elementary manner, while the last three are devoted respectively to (I) Nervous Symptoms produced by Ear Disease ; (2) Tinnitus Aurium considered generally as well as in relation to Ear Disease ; (3) Diseases which involve the Organ of Hearing. Coloured Lithographs illustrate special points in Anatomy, as also the tympanic membrane in health and disease ; while in an appendix are figured and described such instruments as will usually be found sufficient to meet the requirements of general practice. The book is intended to meet the requirements of those who have been unable to receive special instruction in Otology ; and it is believed that the system of attaching to each chapter coloured lithographs of the diseased conditions described very materially aid practitioners who desire to study this branch without the assistance of a teacher. Demy Sro, 13