i ii ll VINIDY tA 4O ALISH4 t { e Ey Liokis tocaterstarnatongat ) Qs = OF ESE eee e i = o OP Of OP oe > SGA Ta Gk IG SETTING S a a 4 { Se i of 4 £2 +6 3 39 on +6 6 22 : @ . UNIVERSITY OF VIRGINIA PMOSPITAL SCmOOL OF NURSING Fe ee eG LA Gd6c6 owe {> @ 4 Base ieaes FO GYNZE COroEeymT ADS mY NAV AOG BY. RICHARD E. TOLD ENEAM Bae, MD BC. B.A.0), Dib He (Univ. on Dusrin)) Heke Csbele CENSOR AND EXAMINER IN MIDWIFERY, R.C.P.I. 5 FELLOW OF THE ROYAL ACADEMY OF MEDICINE, IRELAND ; LATE ASSISTANT MASTER, ROTUNDA HOSPITAL ; LATE EXAMINER FOR THE LICENCE IN MIDWIFERY, R.C.P.I. 3 ASSISTANT PATHOLOGIST TO DR. STEEVENS’ HOSPITAL SIXTH EDITION NEW YORK WILEIAM WOOD AND COMPANY MDCCCCXXIIIGIFT JUN20°47 Sci/Tech. ti \ tT £ ae eos { : 440883 tH WP CS SS a3 A ri Fr PRINTED IN GREAT BRITAIN.Peebace §O THE SIXtH PDITION THE text of this edition has been largely rewritten and some illustrations added. It has also been thought ad- visable to give a brief outline of some of the more common gynecological operations. The following sections have been reprinted almost unchanged from the last edition: The Female Genital Organs, Errors of Development, the paragraphs dealing with Menopause, Dyspareunia, Pruritus, Leukoplakia, Pelvic Cellulitis, Syphilis, Gonorrhcea, while those deal- ing with Vesico-Vaginal Fistula, Cystocele, Rectocele, treatment of inoperable cancer, have been rewritten in some parts only. | therefore desire to express my in- debtedness to Dr. Aarons, the author of the last edition, who was unable to write the present owing to press of work. The pathology largely follows the teaching of Professor Frankl, Dr. Cassidy having been kind enough to lend me his own translation of this author’s work. I am also indebted to Dr. Henry Jellett, late Master, Rotunda Hospital, both for his personal teaching and to his ‘Practice of Gynecology’; also to Berkeley and Bonney’s ‘Gynecological Surgery,’ second edition; Norris’s ‘Gynecological and Obstetrical Tuberculosis ;’) Tweedy and Wrench’s ‘ Practical Obstetrics’; to Dr. Rowlette for his kindness in reading the proofs; and finally to the Publishers for their courtesy and readiness to meet my wishes. R. E. TOTTENHAM. 19, FITZWILLIAM SQUARE, DUBLIN. May, 1923.CONTENTS CHAPTER PAGE : I. MENSTRUATION, NORMAL AND ABNORMAL - - I Il. HISTORY AND GENERAL EXAMINATION - = UT III. EXTERNAL GENITALIA : : : a5 IV. VAGINA : ; ; ee V. CERVIX - ; ; : - = 25 VI. UTERUS : : : : ; 2 28 VII. ABNORMAL POSITIONS OF THE UTERUS 2 ee VIII. ABNORMAL STATES OF THE UTERUS : = as IX, TUMOURS OF THE UTERUS - z - 52 M DISEASES OF THE TUBES = : 7 - 460 XI. DISEASES OF THE OVARIES - ; : = 7G XII, PELVIC PERITONITIS AND PELVIC CELLULITIS - 97 Ht XIII. THE BLADDER - - . . - 81 XIV, ERRORS OF DEVELOPMENT - s 2 - 84 Mh XV. SYPHILIS AND GONORRH@A : : = 8 hI XVI, THE FEMALE GENITAL ORGANS - - - 96 XVII. GYNECOLOGICAL OPERATIONS - : = ur INDEXPIDS TO GYNACOLOGY CHA Paw Roh MENSTRUATION, NORMAL AND ABNORMAL Menstruation. THIS term signifies the escape of blood from the uterus, at regular intervals, approximately every twenty-eight days in most cases. It is often accompanied by pain and various vague disturbances of a general nature. The onset occurs at puberty, and the permanent cessa- tion between the forty-fifth and fiftieth years of life. The menopause, or the cessation of the periods, is usually associated with a mild disturbance of health— headaches, flushing, constipation, and digestive troubles being complained of. The relation of the ripening and liberation of the ovum to the changes in the uterus is a matter of considerable interest. As soon as the ovum leaves the ovary it is presumably caught in the fimbriated extremity of the tube, and from there it gradually makes its way downwards. Its life, if not fertilized, is short, probably only a matter of days. At the point where it was expelled from the ovary a corpus luteum forms. The following account of the various happenings is adapted from a lecture on menstruation and ovulation given by Professor Frankl. Menstruation is influenced by the flow of blood into the uterus. ce IAIDS TO GYNECOLOGY The amount of the latter flow goes through definite variations, increasing gradually until a certain maximum is reached, then gradually decreasing to its minimum, when the stage of increase again sets in. This cycle takes a definite time to complete—v.e., the interval between two menstrual periods—and is regulated by a hormone, secreted by the Ovary.. In this latter con- nection, the ovum cell is of high significance. If the ovum be embedded (7.e., the patient become pregnant), the corpus luteum persists ; conversely we can conclude that involution of the latter marks the death of the ovum. And further, we may conclude that, as the start of the involutionary process in the corpus luteum synchronizes with menstruation, the appearance of. the menstrual flow indicates that the ovum is dead. When an ovum is implanted in the uterine mucous membrane the corpus luteum persists and the patient ceases to menstruate. All hemorrhage during pregnancy is pathological. An ovarian cycle also exists, which is in close relation- ship with the uterine one. The uterine cycle may be divided into four stages: postmenstruation, interval, premenstruation, during menstruation. 1. After menstruation the uterine mucous membrane is thin (4 to 1 mm.), anemic, the glands contracted, and without secretion = Postmenstrual mucosa. 2. Then, in the Intermenstrual period, the mucous membrane gradually increases in thickness and vascu- larity, and the amount of mucus in the glands increases, causing them to become distended and tortuous. 3. In the Premenstrual period, the mucous membrane is very thick(1oto15mm.). The vascularity is increased, and the vessels very dilated, ‘so that the connective tissue has an cedematous appearance.’ The glands are dilatedMENSTRUATION, NORMAL AND ABNORMAL 3 to the maximum, tortuous, and full, the middle of the glands only secreting, the neck and fundus remaining contracted. 4. In the mucous membrane during menstruation, at first we see bleeding into the tissue, and gradual bleeding into the cavity of the uterus, and with it a collapse of the mucous membrane. Blood pours from the vessels, mucus from the glands, and cedema fluid from the stroma, so that the mucous membrane is thinned out ina few hours, from Io to 15 mm. down to } mm. The entire surface of the mucous membrane may be thrown off, only the fundus of the glands remaining, or, on the other hand, the mucous membrane may collapse without any destruction. The rupture of the Graafian follicle occurs somewhere between the thirteenth and fifteenth day following a period. During the development of the corpus luteum the secre- tion of the glands in the uterine mucous membrane is steadily increasing, the mucosa becoming thicker, in preparation for the reception of the ovum. When the corpus luteum is fully developed the mucous membrane is in the premenstrual stage. If the ovum dies, its distant stimulating effect is with- drawn from the corpus luteum, which undergoes fatty degeneration, and later becomes fibrous and soon dis- appears. And, as before mentioned, menstruation co- incides with the commencement of this degeneration. The degeneration of the corpus luteum permits of the ripening of another Gradfian follicle and the commence- ment of another cycle. We see that ‘the corpus luteum prepares the mucous membrane for the reception of anovum.’ For, so longas the corpus luteum is giving off its hormone, the mucous membrane is hyperemic, which results in turgidity in the neighbourhood of the ducts of the glands ; the result of4 AIDS TO GYNAECOLOGY this turgidity is an increased pressure on the ducts, which tends to keep them closed. When the hyperzemia subsides, as a result of the involu- tion of the corpus luteum the turgidity is naturally reduced, the efferent ducts of the glands now open, and the mucus escapes. This_mucus contains a considerable amount of a tryptic ferment. The latter may either penetrate deeply, and, by ‘exerting its digestive action, cast off the surface of the mucous membrane, or it may act more superficially. In addition, it has another important action: it dissolves the fibrin, thus preventing the menstrual blood from clotting. Normally menstrual blood is free from clots, and the amount should not exceed a few ounces. Amenorrhea. This term is used to indicate the cessation of menstrua- tion when this occurs before the menopause. It is seen normally during pregnancy and lactation. A patient may be actually menstruating and the blood be unable to escape from the uterus or vagina owing to such conditions as contraction of the cervix due to cica- tricial changes, imperforate hymen, etc. Stenosis may follow obliteration of the uterine mucosa, due to unskilled curettage, cauterization, trauma. Additional causes are found in the faulty development of the ovaries, ovarian tumours, castration, X rays. Various debilitating diseases such as chlorosis, anzemia, etc., and other more serious conditions, as tuberculosis, may lead to amenorrhea. Jellett mentions that interference with the functions of any of the following systems may bring about amenor- rhoea: (1) The generative; (2) the circulatory ; (3) the nervous ; and (4) the ductless glands.MENSTRUATION, NORMAL AND ABNORMAL 5 Lastly, fright, occasioned by the fear of pregnancy, or due to other causes, may prevent a patient menstruating. Treatment.—The discovery of the cause should indicate the lines along which treatment should be pursued. Dysmenorrhea. This is usually taken to signify the occurrence of pain with the menstrual period. It was formerly held that in many cases the pains asso- ciated with menstruation were due to the existence at the internal os of an obstruction to the outflow of blood. The presence of stenosis of the internal os can only sometimes be demonstrated. An abnormal thickening of the mucous membrane, or the presence of a polypus, may offer an obstruction to the outflow of blood, and hence be a cause of the painful contractions. The blood in dysmenorrhcea may be coagulated ; this is probably due to an insufficient amount of tryptic ferment having been liberated. The expulsion of coagula is always accompanied by pain. Apart from the uterus, pain may be due to the presence of adhesions in the pelvis, which have resulted from the presence of inflammatory trouble, such as salpingitis. Membranous Dysmenorrhea.—The significant occur- rence in this condition is the expulsion of small grey- white or hemorrhagic particles, 2 to 5 mm. in thickness, or in other cases complete casts of the uterus, in which one can recognize openings that correspond to the tubes and to the internal os. The expulsion of the cast is asso- ciated with considerable pain ; it is regarded as being the superficial stroma layer of the premenstrual mucous membrane (Hitchmann and Adler).* It is difficult to explain why in this condition the super- * From Frankl.AIDS TO GYNZZCOLOGY ficial layer is not transformed into soft liquefied particles by the tryptic action, as happens under normal conditions. Treatment.—Dysmenorrhceea may prove a somewhat difficult condition to treat satisfactorily. It occurs principally in unmarried girls. If they marry and become pregnant the condition is usually cured. Treatment should firstly follow along constitutional lines, owing to the inadvisability of examining, or adopting any operative measures on a girl, if such can be avoided. Order her to take regular exercise between her periods. Go carefully into the question of diet ; make her describe her meals and the amount of food taken at each. Tell her to eat only at mealtimes, and to drink plenty of water during the day. If there is any definite digestive trouble, treat it. If necessary, keep herin bed during the menstrual period. Avoid prolonged study. Insist on her keeping early hours. And in young girls a rest during the day may be advantageous. Women are very liable to be constipated, therefore make her keep her bowels well open, and a few days before the onset of menstruation a purgative is indicated. During menstruation, warm applications to the lower abdomen may relieve the pain. If tonics appear to be indicated, give them. If treatment on the above lines meets with no success, it will be necessary to dilate and curette the patient. This frequently improves the condition very con- siderably. Menorrhagia. By this term is meant the loss of an abnormal amount (large) of blood at the menstrual period. Metrorrhagia. This signifies the loss of blood between the periods. These two conditions may exist together.MENSTRUATION, NORMAL AND ABNORMAL ¥4 A tiology.—Any pathological conditions associated with congestion or loss of tone in the uterus, such as displace- ments, incomplete removal of the remnants of a preg- nancy (Z.e., retained fragments of placenta, membranes, etc.), tumours (principally myoma), malignant disease, and certain constitutional diseases. Conditions tending to raise the blood-pressure, too frequent coitus, excessive thyroid secretion, are men- tioned by Jellett as causes of menorrhagia. Treatment.—This should be directed towards the ascertaining and removal of the cause. Leucorrhea. This term is applied to an excessive white discharge from the vagina. The reaction of the normal vagina is acid, but in the presence of a discharge from the uterus its reaction may be neutral or alkaline. The discharge may be either mucous, muco-purulent, or purulent. If purulent, examine for the presence of micro-organisms, especially gonococci. Insert a speculum and examine the cervix for erosion or ectropion, and, if present, operate on them. These are common causes. Examine bimanually for any displacement of the uterus or evidence of pelvic disease. If no definite abnormality be found, treat the patient's general health by the administration of tonics, or in any special direction indicated. If the discharge con- tinue, the uterus may be curetted, in the hope of alleviat- ing it. Treatment.—This may be summed up as follows: Examine carefully for any genital abnormality, which, if discovered, should receive appropriate treatment. Build up the patient’s general health.AIDS TO GYNECOLOGY The Menopause. The menopause or climacteric takes place, in the great bulk of women, between the ages of forty-five and fifty ; in some cases—namely, those where the genital organs have been infantile ; where the patient has been the subject of anzemia or debility; in atrophic conditions following in- fective disease ; sudden mental shock ; or in some patients whose menstrual period commenced late in life—it may take place earlier. Climatic conditions affect the meno- pause, and it is earlier in hot countries, but this is prac- tically a characteristic of race. The menopause may be established suddenly, but this is rare. Much more often there is irregularity for a few months, and then the periods will recommence. There may be menorrhagia, followed by a period of amenorrhea for some months, and then more irregular hemorrhages. Symptoms.—The whole temperament of the patient may become changed, women with hitherto placid and contented dispositions becoming irascible and impatient, and those of a shrewish temperament becoming quiet and subdued. Despondency, melancholia, and irritability, are commonly complained of, and at times suicidal ten- dencies may be developed. Palpitation, heats, and flush- ings, are very common, and these may be followed by feelings of chilliness. This symptom is more marked in nervous and excitable women. Headache, sleeplessness, gastric disturbances—indigestion, flatulence, constipation —migraine, vertigo, are all common symptoms, and it is noteworthy that patients who have been the subject of these conditions up to the time of the climacteric may cease to have them thereafter. Obesity is very common at the menopause. The local structural alterations are important, and are as follows:MENSTRUATION, NORMAL AND ABNORMAL 9 I. The ovaries shrink; they become harder and smaller; the Gradfian follicles are destroyed ; the con- nective tissue increases in. quantity ; there is cessation of their functional activity. 2. The Fallopian tubes become narrower and shorter, and the lumen is obliterated. 3. The uterus becomes smaller; the musculature tends to disappear; the walls are thinner. The cervix is shortened, and feels like a button in the vaginal roof. The cavity may become obliterated throughout; the mucosa is thinned, and the glands destroyed. 4. The vagina becomes shortened and conical in shape, the fornices are obliterated, the rugze disappear, the walls lose their elasticity, and become pale in colour. There is a tendency for the epithelium to be lost in patches. There is contraction of the introitus vaginee. 5. The vulva and labia lose their fat, the labia becoming thin folds of skin. The skin becomes dry and scaly. 6. The breasts may become thin and flabby. There is loss of the glandular elements. The whole of these changes may be summed up in the word ‘ atrophy.’ Treatment.—This, in the main, should be directed towards the general health. The bowels should be kept well opened with salines, and alcohol should be forbidden. The patient’s attention should be kept from dwelling upon the symptoms, Of all drugs, the greatest value must be attached to the bromides, which in combination with ergot or digitalis, will be found most useful. Ovarian extract will be found useful in a certain proportion of cases, and should be administered in tabloid form (5 grains) three times daily. Where hzmorrhages occur after the menopause has been established, or where, while the condition is in process, they are unduly severe, it is essential that aAIDS TO GYNECOLOGY thorough and careful local examination should be insisted upon. Hemorrhagic discharges after the menopause are, in a vast majority of cases, due to some malignant con- dition ; under such circumstances the earlier this is re- cognized the better, in order that the patient may have the organ thus affected removed, before, owing to the advanced condition of the disease, it is too late for surgical treatment to be undertaken. It should be borne in mind that a patient in whom an artificial menopause has been established, by the re- moval of the ovaries, may require treatment equally with a patient in whom the climacteric is being naturally established.CEA Pais I] HISTORY AND GENERAL EXAMINATION History.—When a patient comes to consult a doctor, the latter’s first duty is to ascertain her reason for doing so. She may often confine her complaints to such a thing as pain in the back, whereas what she is really troubled about is the fact that she has never had a baby. Similarly a woman who has lost a relative from cancer may have a constant dread that she herself will fall a victim to this disease. She therefore decides to consult someone in order to be reassured. But she is afraid to ask the doctor directly, and therefore, if you want to gain her good opinion, it will be necessary to reassure her. And you can only guess that this reassurance is neces- sary if you have gone into her history sufficiently carefully. Enquire carefully into the menstrual history— Is she regular ? Is she losing the same amount as she always did? Is the flow lasting as long as, or longer than, usual ? Has she any discharge? If so, make her describe it, and ask: When did it first appear? Has she any troubles of an intimate nature in her married life ? Obtain all the information you can about any opera- tions she has undergone ; if necessary, communicate with the doctor who operated on her. What was the character of labour on each occasion— z.€.. normal or instrumental ? Was the puerperium normal in every case? Mid12 AIDS TO GYNZECOLOGY The following is a method of noting the symptoms, condition, and subsequent treatment of a gynecological case: Name : Mrs. —————. Address: (This should be noted care- fully). Age: 36. Married: 12 years. No. of Children : 6 No. of Abortions: 2. Last Pregnancy : 1 year ago By whom sent: Dr. Complaint : Pain in the back, fatigue on slight exertion, etc. First labour slow and terminated by forceps ; subsequent labours normal. No history of sepsis. Menstruation : Regular. Type, 28 days. Duration, 4 days. Amount, normal. Pain, nil. Last Menstruation, 14 days ago. Intermenstrual Discharge : Colour, white. Amount, slight. Intermenstrual Pain : Locality, back. Degree, moderate. Preliminary Investigation of— Chest: Normal. Digestion : Appetite poor, bowels constipated. Blood : Normal. Grime. Colour? Reaction ? (sp. Gravity * Sediment = Albumen ? Sugar ? Urea? Microscope ? Physical signs (examined on 25/9/22): Uterus retroverted, but readily replaceable. Cystocele; rectocele; old tear of perineum. Examined again on (Insert here the dates and findings of any subsequent examinations). Diagnosis : (Insert here form of treatment indicated, as: Ventral suspension and perineal repair). Admitted : (Date). Discharged: (Date). Operation: (Date). Ventral Suspension, Anterior Colporrhaphy, and Perinzorrhaphy. (In any case where the abdomen was opened, describe exactly the condition of the pelvic organs, and the procedure adopted for dealing with any abnor mality found. Thus: The abdomen having been opened, the uterus was found to be re- troverted, tubes ‘and ovaries normal, no adhesions. The uterus was brought forward, two suspension sutures inserted, and the abdomen closed. \e Result : Satisfactory. Physical Examination. — Note, firstly, the general appearance of the patient. A pinched face is said to be indicative of ovarian cyst; a cachectic appearance is * In this particular case an operation for shortening the round ligaments extraperitoneally, such as Alexander- Adams, would probably be preferable.HISTORY AND GENERAL EXAMINATION 13 often associated with malignant disease. In chlorosis the colour of the patient is also indicative of the condition. It is usually preferable to examine a patient in the presence of another person when possible, but remember it is generally easier to obtain her history if she be alone. Warm your hands before palpating the abdomen, and do not hurt the patient ; if pain be complained of in any one locality, it is often advisable to begin by palpating elsewhere, for then she has gained confidence by the time the painful area is reached, and the muscles are less likely to be rigid. INSPECTION : Zhe Breasts.—If there be the smallest suspicion of pregnancy, it is advisable to examine the breasts ; see if any fluid can be squeezed out of them. This is a valuable sign of pregnancy in women who have never had a child, but is not of much guidance in a multipara. The Abdomen.—Note the general contour of the abdomen ; its shape varies with such conditions as preg- nancy, Ovarian cyst, myoma, ascites. In multipare you will usually see longitudinal scars, caused by the stretching of the skin when the abdomen is enlarging (the so-called striz gravidarum). Note the lax condition of the abdominal walls and wide separation of the recti in women who have borne a great number of children. Palpation.—Be gentle, and if the abdominal walls be held rigidly, endeavour to distract the patient’s attention from what you are doing. Note the condition of the glands in the groin. Percussion.—lf the abdomen be distended, it is advis- able to percuss it in order to ascertain the nature of the swelling. In ascites the upper and anterior portions of the abdomen are resonant, while the flanks are dull. If now the patient be turned on her side, the flank which is uppermost will be resonant. In the case of ovarian cyst there is dulness in the middle line; this dulness does not14 AIDS TO GYNCOLOGY change when the patient’s position is altered. If pregnancy be suspected, listen carefully for the foetal heart ; youshould be able to hear it if the child be alive and the pregnancy far enough advanced. To do so cover the abdomen with a smooth towel, and listen by applying your ear directly to the towel; listen first a little below the umbilicus on each side. If you fail to hear it there, try at a higher level. It is much easier to hear the fcetal heart with your ear directly than with a stethoscope. If you find a tumour of the abdomen, and are in doubt as to its nature, note carefully how high it reaches. (Its size can most readily be compared to a pregnant uterus of so many months, thus: On September 22 there was a tumour in the abdomen the size of a six months’ pregnancy; on October 25 there was little appreciable alteration in Size.) Before proceeding Further in the Examination of the Patient, pass a Catheter.—To do this, the patient being in a gynzecological chair, the labia are separated, the orifice of the urethra exposed and cleaned by sponging it with biniodide of mercury; then the catheter is passed by sight. Keep some of the urine for examination.CHARGER Tit EXTERNAL GENITALIA Examination.—A gynecological chair is of material assistance in the examination of a case. Inspection.— Note the general state of the vulva and of the anal region. Separate the labia, and beginning at the clitoris in front, work backwards, noting the condition of each of the structures exposed to view : 1. Is there any suggestion of venereal disease ? 2. Are the parts inflamed ? 3. Is the orifice of the urethra normal ? 4. Is there a vaginal discharge ? 5. Is the perinzeum torn? If so, is the tear complete or incomplete? Vulvitis. Gonorrhceal vulvitis is more frequently seen in children than in adults. The urethra is frequently affected. If so, the mucous membrane will appear somewhat red and swollen. By pressing on the posterior urethral wall, with a finger in the vagina, a drop of pus can sometimes be expressed. It is a good thing, if you want to obtain a smear for pathological examination, to obtain it from the urethra. The infection frequently spreads to the ducts of Bartholin’s glands, in which case you will see a little bright red patch at the orifices of the ducts—z.e., between the labia minora and the foldof the hymen. Ifthe glands themselves become involved, there will be a swelling in the region of the labia minora varying in size up to that 1516 AIDS TO GYNAZCOLOGY of a golf-ball. The condition may go on to abscess formation. The red patches at the mouth of the ducts on either side are termed the macule gonorrhceice, and are con- sidered as being good clinical evidence of this disease. Treatment.— Vide Gonorrhea. In vulvitis of non-gonorrhceal origin there is redness and swelling of the vulva to a greater or less degree, and in severe cases there will probably be some cedema. The condition may be associated with considerable smarting, eczema, pruritus. Vulvitis may be the result of an irritating vaginal dis- charge, or general lack of cleanliness, and is sometimes seen in young children, or may occur in the course of such diseases as typhus, variola, scarlatina. Treatment consists in keeping the parts clean, hot fomentations, and the patient is instructed to sit in hot water containing some mild antiseptic. Attention to the general health is usually indicated, and the administration of a tonic advisable. Pruritus. Pruritus is a condition of constant itching of the vulva > and is particularly associated with the menopause. It also occurs in conjunction with diabetes, jaundice, chronic nephritis and discharges from the vagina or uterus, parasites such as threadworms, or pediculi, and is also often met in pregnancy. A patient afflicted with pruritus is liable to scratch the parts, frequently infecting them, and thereby producing a dermatitis. Treatment.—The first and most important step is to make a thorough examination of the urine, and to enjoin strict cleanliness and thorough washing of the affected parts. Any constitutional condition found to be present should be prescribed for and irritating vaginal discharges should be treated with appropriate douches. Local treat-EXTERNAL GENITALIA 17 ment, even when no actual cause can be found, should be undertaken, sedative lotions and ointments being applied. In certain cases, where the medical treatment fails, the affected areas should be removed by free excision. Kraurosis. This condition might be described as being an extreme state of atrophy of the vulva. The sub-epithelial connective tissue is principally involved. The condition is regarded as being of inflammatory origin. The skin is white—z.e., deficient in pigment, dry, fissured, and tightly stretched. The hair has mostly dis- appeared. The vulvar ring may be narrower than normal. There is flattening of the labia majora, and the labia minora may have disappeared. The clitoris and prepuce are so constricted as to be acu cely visible. The urethral orifice may be dilated. Symptoms.—Pain and tenderness on pressure. Treatment.—Not very satisfactory ; removal may be attempted. Leukoplakia. Leukoplakia, or the formation of white patches, is very frequently associated with the menopause. The patches are distributed over the labia, perineum, and sometimes right back to the anus and behind it, and they may extend to the thighs. The skin is pearly grey in appearance, smooth to the touch, and feels thinner than the normal integuments. It is, generally speaking, only associated with cancer of the cervix, and is supposed to originate from the action of the discharge, occasioned by this disease, on the skin. Symptoms.—Intense irritation of the affected part may be the only symptom which drives the patient to seek advice.18 AIDS TO GYNECOLOGY Diagnosis—The appearance of white patches dis- tributed over the areas already referred to serves to distinguish leukoplakia from the condition previously described under the term ‘ kraurosis’; nor is there the same amount of atrophy as in the latter disease. Treatment.—The parts should be kept scrupulously clean, and should be painted with carbolic acid and gly- cerine, 1 in 40. To allay the irritation, cocaine should be applied in the form of an ointment up to 5 per cent., or an ointment composed of chloretone and extract of conium may be used. Ina certain number of instances medical treatment is of very little avail, and should drugs fail to relieve, the affected parts should be excised in their entirety. Tuberculosis of the Vulva. This is a rare condition. According to Norris, a history of injury is not infrequent. He describes the hypertrophic and ulcerative varieties as recognized by Brender and Patel. Thus the wlcerative variety is generally associated with some enlargement. This subsequently softens and breaks down, leaving a raw area, with cedema, discolora- tion, and induration of the surrounding tissue. Ulcers usually occur on the labia ; they may be single, or multiple, and may be serpiginous. The hypertrophic or proliferative type, according to Frankl, shows polypoid growths, and has a tendency to resemble elephantiasis. Diagnosis—It is necessary to exclude syphilis and tumours, and in the case of children vulvo-vaginitis. A piece of the suspected tissue should be excised and sent for examination to a pathologist. There is not so great a tendency to bleed as in malig- nant disease, and the patient may be young.EXTERNAL GENITALIA 19 Treatment.—Norris warns us that a very thorough physical examination is necessary in order to deter- mine whether the disease is primary or secondary. If primary, radical extirpation is advocated, while in secondary, extirpation of the genital lesion is usually advisable. Curettage, cauterization locally, or X rays may be tried. Swellings of the Vulva. Hematoma.—This is caused by the rupture of a vein in the labium. It occurs most commonly in pregnancy, or from injury, and, should it become infected, may prove a very dangerous complication of labour. Lreatment.—Cold compresses, rest in bed If. it becomes large, an incision should be made over the swelling, the clots removed, and the cavity closed or plugged with iodoform gauze. Cysts of Bartholin’s Glands.—These are by no means always gonorrhceal in origin, though it is probable that they are due to the agency of a micro-organism. They are of the nature of retention cysts. In many cases they fill up, remain swollen for a few days, then subside. Lreatment.—Excision. Elephantiasis may occur in the form of a thickening of the clitoris and labia, with the result that they become enormous pedunculated appendages. Treatment.— Operative. Other swellings found in this region are hernia, and hydrocele of the canal of Nuck. Tumours. Fibroma.—These may be large, and are sometimes pedunculated. Lipomata generally originate from the labia majora. sarcoma.—Rare.AIDS TO GYNECOLOGY Carcinoma.— Not common. Urethral Caruncle.—It is a small growth, of a reddish colour, which when present is situated at the urethral orifice. Symptoms.—Caruncles are often tender to the touch. Dyspareunia may therefore be complained of. Pain may be caused on passing water. Treatment.— Excision. Laceration of the Perineum. This is very commonly seen in women who have had children, the extent of the tear varying from a very slight separation of the mucous membrane, with or without involvement of the levator ani muscle, to a laceration extending backwards into the rectum and involving the rectal sphincter. The former is termed an zzcomplete tear, and the latter a complete tear. INCOMPLETE TEAR: Symptoms.—The patient may complain of having a sensation of something coming down —i.e., a sense of deficient support. Ask her to cough ; if the rectal wall bulges forward unduly, she has a rectocele. Endeavour to palpate the levator ani by pinching up the perineum. To do this, put the first finger of the right hand into the vagina for a distance of about one inch, and the thumb a little anterior to the anus and a little to one side of the middle line ; the levators should then be felt as muscle bands, extending outwards and forwards on either side. Endeavour to estimate their efficiency in any given case. One must, however, have an accurate knowledge of the normal ; therefore note the condition of these muscles in women who have not had children. Treatment.—Colpo-perinzeorrhaphy ; this operation cures the rectocele also.EXTERNAL GENITALIA 21 COMPLETE TEAR : Symptoms. —As the rectal sphincter has been torn, the patient has incontinence of feces. There are rarely any other symptoms. Lreatment.—Complete perinzeorrhaphy. Rectocele. This is a condition where there is prolapse of the posterior vaginal wall, carrying with it the anterior wall of the rectum. It is often found in association with torn perineum. The sack which is formed by the prolapsed rectal wall frequently becomes filled with scybalous masses, and gives rise to irritation, constipation, and heemorrhoids. Cystocele. If you have already asked the patient to cough, you should have noticed if there was a prominent bulging of the lower part of the anterior vaginal wall. If so, it may be a cystocele. The latter is a condition of prolapse of the anterior vaginal wall, involving the bladder. It is described as forming a smooth, round, flattened swelling, which pro- trudes through the vulva when the patient strains. If a sound be passed into the bladder, the point can be felt through the relaxed vaginal wall. There is generally acertain amount of urinary disturbance, such as in- continence, frequency, and dysuria. Both cystocele and rectocele are caused by trauma occurring in the course of difficult or repeated confinements.CLEA EIN 1; VAGINA INFLAMMATION of the vagina is probably always bacterial in Origin, even ijn virgins ; vulvo-vaginitis of children is said to be gonococcal in over 80 per cent. of cases. Gonorrheeal infection of the vagina is, as a rule, a sequel to a cervical discharge of gonorrhceal origin ; this discharge damages the vaginal mucous membrane, and thus makes it unable to resist invasion by this micro- organism. Healthy vaginal mucous membrane possesses very considerable resistant qualities where microbic infection is concerned. Catarrhal Vaginitis. The vagina is swollen and injected, there is a copious white discharge which comes partly from the vagina and partly from the cervix. The patient may complain of pain or an uncomfortable sensation on sitting down. She is probably very tender to the touch. Lreatment.—Take a smear of the discharge and send it to a pathologist for examination. Treat locally by douches, keep the parts clean, and build up the general health. Croupous and adiphtheritic forms are described. A vaginitis may be seen in the course of measles or scarlet fever. Senile Vaginitis. When the vagina shrinks and becomes atrophic in old age, micro-organisms may become occluded in the various 22VAGINA 23 crypts, inflammation ensues, and is associated with defects in the epithelium and scar-tissue formation. As a result of the deficient epithelium, localized adhesions between the vaginal walls may occur; hence the alternative name, ‘adhesive vaginitis.’ Treatment.—In addition to local treatment, get an autogenous vaccine made. Tuberculosis. Very rare. Cysts. Cysts occur most commonly on the anterior and lateral walls; they are thin-walled sacs, and vary in size from that of a pin’s head to that of a fist. Tumours. Myoma, lipoma, cyst, sarcoma, primary carcinoma, are all rare. Dyspareunia. A patient may have troubles in the intimate relations of her married life. In some few cases they are purely nervous in origin, and are amenable to treatment by explanation and instruction. Most women suffer some pain or discomfort at the beginning of married life, which varies very much in different individuals, but by the term ‘dyspareunia’ is meant pain during sexual intercourse due to some local or developmental cause, such as— . Vaginismus. Narrowness of the vaginal orifices. . Tender carunculz myrtiformes. . Inflammatory conditions or growths round the vagina or vulva. . Prolapse of the ovary. ; . Disproportion between the size of the male organ and the vaginal orifice. BON Ow24 AIDS TO GYNECOLOGY Vaginismus.—This is a condition in which there is a spasmodic contraction of the sphincter muscles of the vaginal orifice when an attempt at coition 1s made and which will occur even with the passage of fingers into the vagina. Treatment—This consists in gradual dilatation of the orifice by glass dilators which should be worn at night- time. There are, however, some cases in which it is impossible to pass even the smallest dilator ; where this | condition exists, it is better to anzesthetize the patient and, either to stretch the vulvo-vaginal opening forcibly, or to excise the sphincter surrounding the vagina. After forcible stretching of the vagina a large-sized dilator or rest should be left z sz¢wz, and the patient be instructed to pass graduated dilators every day and to wear one at night-time. Narrowness of the vaginal orifice should be treated in the same way. Urethral Caruncles and Caruncule Myrtiformes should be excised. Persistent Hymen.—This structure should be cut away with a pair of scissors and the vaginal orifice stretched at the same time, any bleeding points being secured. Inflammatory Conditions or Growths round the Vagina.—These should be treated in the manner de- scribed under their respective headings. Disproportion between the Male Organs and the Vaginal Orifice.—In this condition an attempt should be made to increase the capacity of the vagina by graduated dilators.CHAPTER V CERVIX THE next structure presented for examination is the cervix. It is not necessary in all cases to obtain a direct view of it, since in the course of a bimanual examination one can, as a rule, form some estimate as to its condition. However, if it be deemed advisable to inspect it, a speculum is necessary. The procedure is as follows: Obtain a Fergusson’s cylindrical speculum of about the size you think would fit the patient. Take it in your right hand (Fig. 1) so that point 4 is nearest to the anus. Fig. 1.—FERGUSSON’S SPECULUM. Separate the labia carefully so as not to hurt the patient, and having moistened the instrument in some soapy solu- tion, preferably weak lysol, pass point A over the perinaeum. By leaning very slightly in a backward direction the perinzeum is forced towards the anus ; this manceuvre facilitates introduction very considerably. Now pass the instrument carefully into the vagina. Look through it ; if you do not see the cervix, by rotating the instrument slightly the cervix can usually be made to enter the upper end. The external os is now wiped with a piece 2526 AIDS TO GYNECOLOGY of cotton-wool on the end of a bullet forceps* (Fig. 2). The condition of the cervix is now noted. Erosion.—This is a compara- tively common condition; it is usually associated with a white discharge. As a result of in- flammatory changes the epithe- lium of the vaginal surface of the cervical lips round the ex- termalos is lost. he cenvical lips, which normally present a smooth, shining appearance, are raw and velvety and covered with fine nodules. The eroded area is a vivid red colour. Pathologically erosion is the result of inflammation, in the course of which the squamous epithelium is shed in the region of the external os. It is held that the cervical epithelium has a tendency to spread, and that now having scope to do so it occupies the denuded area. But it is also thought to be possible that there is still another source from which the cylindrical \)\ epithelium covering the ero- i| sion can come—z.e., the cer- j) vical glands, the epithelium of Z x which may have proliferated, in Fic. 2-—BuL_et Forceps. Order to reach the surface of the erosion. Thus we see that an erosion is the removal ofa circumscribed area of squamous epithelium at the region of the external os, its place being taken by cylindrical epithelium. * A bullet forceps is a type of single-toothed volsellum.CERVIX 27 Lreatment.—Amputation of the cervix (Schroeder’s) is the most satisfactory, especially if the condition be well marked. Treatment by caustics, such as carbolic acid (liquid), is occasionally successful. Nabothian Cysts are small structures caused by the blocking of the ducts of the cervical glands. KEctropion is the remote result of a laceration of the cervix during labour. The lining membrane of the cervical canal grows out over the raw surface in a manner similar to the way in which it extended over the denuded area in the case of an erosion. The condition may be unilateral or bilateral in appearance. It is somewhat similar to an erosion ; but if the anterior and _ posterior lips of the cervix be brought together by placing a bullet forceps on each and approximating them, if it be an ectropion, the vivid red coloration will not now be apparent ; thus showing that the approximation of the two edges of the tear is sufficient to hide the condition. A tear of the cervix may be a cause of prolapse of the uterus (Tweedy). Ectropion may precede malignant disease. Treatment.—Trachelorrhaphy. Do not forget the possibility of a primary chancre. Atrophy of the cervix occurs after the menopause.CLUE a av UTERUS REMOVE the speculum and proceed with the further examination, If you suspect a prolapse, pass a bullet forceps, seize the anterior lip of the cervix, and ascertain how much the uterus pulls down when gentle traction is applied. Keep the first finger of your right hand in the vagina in order to appreciate this; at the same time note if the supra- vaginal portion of the cervix is hypertrophied. In order to catch the cervix in the bullet forceps, pass the first and second fingers of your left hand into the vagina, so that the tip of your second finger impinges on the external os ; now the tip of your first finger should be against the anterior lip. Take the bullet forceps in your right hand, separating the points about 2 inch; run the lower blade along the palmar aspect of your second finger (left hand). Feel when it is in the external os; now close the instrument, and the anterior lip should be caught between the points. This as a rule causes little pain or discomfort to the patient. _ If only an insecure hold has been obtained, pass a posterior speculum, and with the aid of the bullet forceps, = already applied, you should be able to secure a firm hold, with a second bullet forceps, by direct vision. It is necessary to know the degree of resistance a normal uterus offers to traction of this kind in order to appreciate the extent of prolapse, if any. Bimanual Examination.—Pass a catheter (if this has not been done before). The patient should already be in 28UTERUS 29 a gynecological chair, if one be available. A stool is placed in front of it, both for the patient to mount by and for the physician to place his foot on. The right foot is placed on this stool, the right elbow resting on the right knee, and according to the size of the vagina one or two fingers of the right hand are introduced. Firstly, note in what direction the cervix is pointing ; it should point backwards and downwards. Satisfy your- self that it feels normal—z.e., not soft as in pregnancy— that there are no lacerations or evidence of malignant disease. The left hand is placed on the abdomen. The exact position is only to be acquired by experience ; roughly speaking, it should be a little below, halfway to the umbilicus. Move the examining fingers of the right hand to the anterior fornix, and then endeavour to approximate the fingers of both hands. If the uterus be normal in position, one appreciates that the fingers are separated by a firm mass of tissue; this is composed of the fundus, plus the thickness of the abdominal wall. Now gently move the abdominal hand to a slightly lower level, and again approximate the fingers. It will then be noticed that there is considerably less tissue between them. In other words, the former position enabled one to grip some structure other than the abdominal wall. From this you are justified in assuming that the fundus is in front, even if you cannot be definite about its shape. If the uterus be in front, sometimes there may be some difficulty in appreciating the fact ; it may aid you if, with the fingers in the anterior fornix, you press the lower end of the cervix upwards, so that the external os looks more directly backwards. Then press downwards and back- wards on these fingers with the abdominal hand as if endeavouring to note the thickness of the uterus where it joins the cervix. This manceuvre keeps the uterus well in front and prevents it slipping upwards under the pressure of the examining hands. Next move yourBeeR DERE PE AIDS TO GYNZECOLOGY fingers into each lateral fornix in turn and endeavour to observe the presence of any structures other than the abdominal wall between your hands. The normal tubes are rarely palpable; if the ovary be touched slight pain is usually complained of. The presence of any definite thickening is pathological. It is usually advisable to wear gloves, both from the point of view of safety to oneself, in cases of venereal disease, and to keep the fingers free, as far as possible, from any virulent micro-organisms which might be present. Much valuable information can often be obtained from the examination fer rectum, especially in the case of un- married girls, in whom it is undesirable to make a vaginal examination, unless absolutely necessary. Examine with one finger in the rectum, placing the other hand on the - abdomen as before; you may then be able to ascertain the size and position of the uterus. An alternate method, to be adopted in the case of married women, is the recto- vaginalexamination. For this, the second finger is passed into the rectum and the first into the vagina, placing the left hand on the abdomen as before. Sometimes the pelvis is found to be occupied by a large, ill-defined mass, about which it is desirable to obtain all the information possible. Firstly, very carefully weigh the history, as it may give you a valuable guide. Do the patient’s symp- toms suggest pregnancy? Are any of the signs present ? Secondly, endeavour to decide whether the swelling is uterine or not. To do this, examine carefully bimanually, and try to decide whether the cervix appears to be con- tinued into the mass, or whether the fundus might not be recognized as a small swelling, tucked up in front of it. If you have so far obtained no information, put a bullet forceps on the cervix, and with two fingers in the vagina (the stem of the instrument being grasped in the hand), examine again bimanually, applying very gentle tractionUTERUS 31 to the cervix, and note if the cervix moves independently of the tumour or not. If you can definitely exclude pregnancy, a sound may be passed—this will tell you the direction of the uterine cavity. Always pass a sound by direct vision, such as is obtained by the aid of a large speculum, and do it aseptically. Now examine fer rectum ; you will probably be able to get behind the mass ; be careful not to use any force. Note the consistency, and whether the surface be smooth, as in the case of a retroverted gravid uterus or ovarian tumour, whereas a myomatous uterus usually presents some irregularities, due to small myomata on its surface. Does the swelling accurately fill Douglas’s pouch, as would be the case with a hamatocele? For remember that blood poured out into a cavity, on clotting, more or less takes a cast of that cavity, and consequently will be felt surrounding the rectum like a collar. A retroverted gravid uterus may present difficulties in diagnosis. It is associated with difficult micturition : the bladder may be very much over-distended, the urethra difficult to find, owing to its being drawn backwards and upwards by the pull of the anterior vaginal wall, which is also drawn in an upward direction. The cervix is tucked upwards into the anterior fornix, the external os looking forwards, and the uterus cannot be distinguished apart from the tumour. Such conditions as pyosalpinx and pelvic cellulitis are usually associated with some rise of pulse and temperature. Ovarian cysts may be very large in size; you may be able to appreciate the presence of fluid. The importance of diagnosis is to decide on the form of treatment to be adopted. Has the patient’s abdomen to be opened or not? is the most important point to be settled.CHAPTER VII ABNORMAL POSITIONS OF THE UTERUS THE normal uterus lies in a position of anteversion, with slight anteflexion, so that when a woman is standing erect FIG. 3.—NORMAL POSITION OF UTERUS WHEN BLADDER IS MopDERATELY DISTENDED. Emptying of bladder will cause the fundus to fall forwards, thus emphasizing the importance of passing a catheter before attempting to diagnose the position of the uterus. Specimen in the R:C.S.1- its body lies almost horizontal, the fundus resting on the bladder, near and somewhat behind the symphysis pubis. 32 xABNORMAL POSITIONS OF THE UTERUS 33 Physiologically the uterus possesses a varying degree of mobility which depends on the degree of distension of the bladder and other neighbouring organs. As long as the uterus can return to its normal position, and does so naturally, any variation of the above position may be regarded as being physiological. On the other hand, the condition becomes pathological when the uterus is fixed in any one position, even if it 1s maintained in that position which is usually re- garded as being the normal. Therefore remember that fixation ts pathological. For normally the uterus is yrobile, anteverted, and slightly anteflexed. If the uterus approach the anterior pelvic wall, although the relations between the cervix and the body remain normal, the uterus is described as being anteposed, while if it is nearer the posterior pelvic wall it is spoken of as being retroposed. Anteposition of the uterus is usually due to the presence of tumours in Douglas’s pouch, which push it forward against the symphysis. Retroposition, on the other hand, is due, in most cases, to traction exerted by bands of adhesions. In the same way the uterus may be pushed or pulled to one or other side of the pelvis. Pelvic tumours may cause the uterus to occupy a higher position in the abdomen than normal by pushing it up out of the pelvis. When the uterus occupies a lower level than normal the condition is called descent or prolapse. Version. Version is the rotation of the whole uterus on an axis which passes from side to side at the level of the internal os. Take a piece of plasticine and model it into the shape of a pear. Now flatten it slightly on two sides ; these 3AIDS TO GYNECOLOGY Fic. 4. A, Anteversion with slight anteflexion; B, retroversion with descent; C, acute anteflexion and retroversion. Fia. 5. A, Anteversion with slight anteflexion ; B, retroversion with ante- flexion; C, retroversion with slight retroflexion; D, retrover- sion with marked retroflexion.ABNORMAL POSITIONS OF THE UTERUS 35 represent roughly the anterior and posterior surfaces of the uterus. At the junction of the lower and middle thirds pass a match through it from one rounded side to the other. Holding the ends of the match between your finger and thumb, you can rotate the mass so that the Geos Uterus is retroposed and anteflexed. The external os looks more downwards than normal, hence there is some degree of retro- version. Specimen in R.C.S.I. Compare Fig. 3. glass rod is distending the bladder. ) stalk end of the pear (representing the external os) looks either towards or away from you. In _ retroversion the external os looks towards the patient’s abdomen; in anteversion it is looking backwards. Normally a certain degree of anteversion exists. Flexion. This is a change in position of the body of the uterus in relation to the cervix.30 AIDS TO GYNECOLOGY Again take the pear-shaped piece of plasticine and bend it until it assumes this shape (A)—~>. , The con- dition is now referred to as anteflexion or retroflexion, according as the concavity at A looks either forward or backward. (See Figs. 4 and 5.) These terms are often somewhat loosely used, but it is well for the student to grasp their exact meaning. A simple retroversion often follows pregnancy, owing to the laxity of the ligaments, and particularly when a patient has been lying much on her back. This type of retroversion is usually easy to replace, unless there are adhesions, the result of sepsis, or inflammation. Therefore, after attending a confinement, tell the patient to come and see you in about six weeks’ time, examine her, and if she be found to have a retroversion, replace it and put in a pessary. After pregnancy, the ligaments, as well as the uterus, gradually shrink down to the normal unimpregnated condition. Therefore if the displacement be corrected and a pessary inserted before this shrinking has ceased, the patient stands a very fair chance of being cured, as all the slack parts of the ligaments will contract now that the strain of the uterus is taken off them. At all other times a pessary only relieves a patient’s symptoms, it does not cure. Symptoms.—The following account of the various symptoms is taken mainly from Jellett : Elevation of the Uterus. The symptoms are usually those due to the cause. Retroversion and Flexion. The symptoms due to the associated endometritis are present: pain in lumbar or ovarian region, menorrhagia, metrorrhagia, and leucorrhea.ABNORMAL POSITIONS OF THE UTERUS “37 There are also such symptoms as headaches, indiges- tion, anzemia, which are occasionally cured by the treatment of an existing retroversion of the uterus. A patient with a retroversion may be (1) sterile ; (2) become pregnant and abort; (3) develop a retroverted gravid uterus, owing to the latter organ being incarcerated in the pelvis; (4) the uterus may right itself and the pregnancy continue. Anteversion with Acute Flexion. In this condition the uterus almost assumes the shape of a circumflex accent. The condition may be due to adhesions in the neighbourhood of the cervico-uterine junction, dragging this part upwards and backwards. Pathological Anteflexion. According to the same author, this is found associated with a retroposition and retroversion of the uterus, cervical stenosis, conical elongation of the cervix. It may be the result of (1) adhesions ; (2) infantile type of uterus. Symptoms,-Dysmenorrheea, sterility, and menstrual troubles. Treatment.—Dilatation of the cervix and curettage ; breaking down of adhesions, if such exist, by abdominal section. Prolapse. Prolapse is generally accompanied by a sensation ot weight and dragging in the pelvis, and pain running towards the kidney region. There may be urinary and various other remote symptoms, such as epigastric pain and dyspepsia. In a complete prolapse the cervix may become ulcerated. When the uterus lies in its normal anteverted and anteflexed position, prolapse cannot occur. But if the uterus become retroverted, it is ‘aimed’ at the pelvicAIDS TO GYNZ:COLOGY 38 outlet. Now if an organ finds itself in such a position that part of it lies over the outlet, it will be pushed down- wards by the intra-abdominal pressure. This is more especially the case if its remaining supports are weak. The explanation of a cystocele is somewhat similar. Owing to general laxity of the surrounding structures, a portion of the bladder comes to lie over the outlet, and if Fic. 7,—PROLAPSE OF UTERUS. O, External os; C, clitoris; A, labia minora; B, labia majora. Specimen in R.C.S.1. the muscular tissue of the anterior vaginal wall is ineffi- cient, a gradual descent of the bladder will occur. Therefore a retroversion may be considered as the first stage of prolapse, and the degree of prolapse in any given case depends on the resistance offered by the remaining supporting structures. Hypertrophy of the Cervix. On making a bimanual examination, it is discovered that the external os seems very low down in the pelvis,ABNORMAL POSITIONS OF THE UTERUS 39 while at the same time the fundus of the uterus occupies its normal level. The explanation of this lies in the fact that the supravaginal portion of the cervix has hypertrophied (z.e., become longer). Inversion. This arises owing to the invagination of the uterus, either in whole or in part, into its own cavity, and either a portion, or the entire inside, of the uterus makes its appearance externally. In other words, the uterus is turned inside out. Treatment.—This consists in reduction. It may facilitate matters very considerably if a series of bullet forceps be put round the inverted cervix. These serve to keep the cervix in position, and offer some resistance against which the reducing measures can be applied. The fundus of the uterus is pulled down as far as possible, the cervix fixed by the bullet forceps while the fundus is in this position. Pressure is now applied to the fundus. There are various other methods of attempting reduc- tion; among them may be mentioned that of replacing first, that part of the uterus which inverted last. Operations to Remedy Displacements of the Genital Canal. The description given by Berkeley and Bonney under this heading appears to us extremely simple. We follow it largely. The supports of the uterus and vagina can be divided into three : 1. Upper Segment —z.c., the broad ligaments and round ligaments. These assist in keeping the body of the uterus in front. 2. Middle Segment.—The utero-sacral and cervico- pelvic ligaments maintain the normal position of the cervix and vaginal vault.40 AIDS TO GYNECOLOGY 3. Lower Segment. — Levator ani and perineal muscles, neighbouring fascia, perineal body. (2) Yielding of (1) results in retroversion—z.ec., the fundus is free to move in a backward direction, and by its doing so increased strain is thrown on the utero-sacral ligaments. Treatment.—Alexander-Adams’ operation or ventral suspension. (2) Yielding of (2) results in supravaginal hyper- trophy (elongation) of the cervix. The fundus of the uterus remains normal; inversion of the vaginal vault occurs. This exerts a downward pull on the cervix, thus causing the elongation of the latter. There is naturally also some increased strain on the upper segment. Treatment. — Shortening of utero sacral ligaments, supravaginal amputation of cervix. (c) Yielding of (3) results in cystocele and rectocele. The strain on the middle segment is increased. Treatment.—Colpo-perinzorrhaphy. (Z) Yielding of (1) and (2) results in retroversion of the uterus and in the vaginal vault being inverted. As fundus of the uterus does not maintain its normal level, there is no hypertrophy of the cervix—z.¢., as the whole uterus can sink somewhat there is no need for the cervix to elongate in order to allow the cervico-vaginal junction to sink to a lower level than the normal. Lreatment.—Ventral suspension and shortening of the utero-sacral ligaments. (c) Yielding of (2) and (3) results in supravaginal hypertrophy, inversion of vaginal vault, cystocele, and rectocele. Lreatment.—Shortening of the utero-sacral ligaments, Supravaginal amputation of the cervix, and colpo- perinzeorrhaphy. (/) Yielding of (1) and (3) results in cystocele and rectocele, retroversion.ABNORMAL POSITIONS OF THE UTERUS 41 Treatment.—Alexander-Adams’ operation, or ventral suspension and colpo-perinzorrhaphy. Yielding of (1) and (2) and (3) results in ‘complete prolapse or procidentia of the uterus.’ The external os appears outside the vulva, and the vagina has become turned inside out. Treatment. — Before menopause, supravaginal ampu- tation of cervix, shortening of the utero-sacral ligaments, colpo-perinzorrhaphy, ventral suspension. After meno- pause, Wertheim’s interposition operation, plus colpo- perinzeorrhaphy. How to Replace a Retroverted Uterus. Once the condition has been diagnosed, the next step is to endeavour to ascertain the degree of mobility of the uterus. To do this, try to replace it ; if you succeed, there are probably no adhesions, for if the uterus be readily re- placeable, adhesions can be excluded with some degree of certainty. Whereas if the uterus be not replaceable, there is a strong probability of their existence. Sometimes adhesions allow of the uterus being re- placed with difficulty, the displacement recurring after the examining finger has been removed. If treatment by pessary be decided on, always replace the uterus first ; do so also before such operations as Alexander-Adams’. Method.—Proceed as if about to perform the ordinary bimanual examination. 1. Put the first and second fingers of your right hand into the posterior fornix, and endeavour to lift the fundus up towards the anterior abdominal wall as much as possible. 2. Now transfer these fingers into the anterior fornix, and push the cervix upwards and backwards. Manceuvre (1) should have brought the fundus out of Douglas’s pouch, while (2) helps to antevert the uterus.42 AIDS TO GYNAECOLOGY 3. Now with the abdominal hand try to get above and behind the fundus, and bring it more forwards still. If this method does not succeed in replacing the uterus, put the second finger into the rectum, and see if by the aid of this finger you can raise the fundus out of Douglas’s pouch, meanwhile keeping the index finger in the yagina. If you are successful proceed as above- mentioned. If so far your efforts have not been attended with suc- cess, put a bullet forceps on the anterior lip of the cervix. Then put two fingers in the posterior fornix as before ; now pull slightly on the instrument, and see if it will aid you to bring the uterus forwards. The effect of putting a bullet forceps on the cervix and applying traction is to straighten out the uterus so that it would lie more or less vertically if the patient were in the upright position, or horizontally when she is on the oper- ating table. Having got the uterus straightened out, employ methods (1), (2), (3) as before. In certain cases it is an advantage to give the patient an aneesthetic, for in addition to making the replacing easier, remember it is also much easier to make a diagnosis, as the abdominal walls are made slack. N.L.—Do not forget to empty the bladder. Note on Pessaries.—Ring pessaries are used in the treatment of cystocele and rectocle, Smith-Hodge’s pessary in retroversion. A pessary should only be used in cases where an opera- tion is refused or deemed inadvisable, on account of age or ill-health. It only relieves the symptoms, and does not tend to cure the condition, except in cases of retroversion occurring in the puerperium. Here (as mentioned previously) the supports of the uterus are gradually tightening as the organ returns to the non pregnant state. If therefore it be maintained in the normal position for some time, the ligaments will be ableABNORMAL POSITIONS OF THE UTERUS 43 to return to their normal non-pregnant length, and sub- sequently keep the uterus in position. If you are contemplating the use of a pessary, there should be no evidence of any vaginal infection. Also :(1) Replace the uterus before inserting the pessary. (z) It should be large enough to keep the uterus in posi- tion. At the same time you should be able to pass your finger between it and the vaginal wall—z.e., there should be no undue pressure anywhere. Needless to remark, it Mo 2, Fic. 8.—SMITH-HODGE PESSARY. 1, Front view; 2, side view. should not cause the patient any pain or inconvenience ; in fact she should be unconscious of its presence. (3) Before allowing her to come down from the gynecological chair, ask her to cough, in order to see if the pessary is likely to remain in position when she strains. The method of inserting a pessary is as follows: Place the first finger of your left hand in the vagina, and pull back the perinzeum. Take the pessary by the narrow end, inserting the thick end, holding it so that the pessary will lie in the antero-posterior diameter of the vagina. When you have passed it into the vagina, follow it with44 AIDS TO GYN4:COLOGY the first finger of your right hand pressed against the top of the pessary ; guide this large end up behind the cervix into the posterior fornix, at the same time rotating the pessary so that it lies in the transverse diameter of the vagina. When looked at from the side, this pessary is somewhat S-shaped. It should lie in the patient in such a position that the front—z.e., the right side—of the S is towards the patient’s abdomen. The action of this pessary is to elevate the posterior fornix, which in turn causes an upward and backward drag on the cervix, thus anteverting the uterus. Intro- duction is facilitated by lubricating the pessary slightly. Tell the patient to return in about two months in order to have the pessary removed, in the case of a puerperal re- troversion, or to have it cleaned and replaced in the case of a retroversion where operation has been decided against.GHAPRTER VIII ABNORMAL STATES OF THE UTERUS Hyperplasia of the Myometrium. THIS condition results in a thickening of the whole uterine wall, with the result that the length and breadth of the organ are greater than normal. It is considered as not being due to inflammation, but to be an increase in substance of the wall, due to long-continued hyper- zemia of the uterus. Hyperplasia of the Endometrium. The mucous membrane, when having undergone hyper- plasia, may be as much as Io to 15 mm. in thickness. This marked thickening bears no relation to menstrua- tion, as it is found both in the premenstrual and post- menstrual periods. Hence it may be extremely difficult to determine whether the patient is just about to men- struate, has finished menstruating, or is in the interval between two periods, since the mucous membrane, when in a state of hyperplasia, remains very thick and shows numerous glands, but it has lost the physiological power of collapse. It is to be distinguished from the pre- menstrual mucosa by the fact that the typical division into three layers is absent. Similarly, this condition is regarded as being due to long-continued hyperemia. Treatment.—In both these conditions look for a cause of hypereemia, and, if possible, remove it; curetting of the uterus may be beneficial. It may be advantageous here to describe the pre- 45 Lares46 AIDS TO GYNZCOLOGY menstrual mucous membrane; it is divided into three layers : 1. Layer containing the duct of the gland. 2. Layer containing the body of the gland. 3. Layer containing the fundus of the gland. The stroma cells of the superficial layer are swollen and lightly coloured ; between them lie the narrow excretory ducts. The epithelium of the latter is more deeply stained, and hence sharply defined against the lumen. In the layer beneath this the glands are found in full secretion, the stroma cells deeply stained and spindle- shaped. The epithelium of the glands is of a light colour and 2// defined against the lumen. In the third layer is situated the narrow inactive fundus of the glands. The cavity is empty, the epithelium deeply stained and sharply defined against the lumen. The stroma cells are spindle-shaped and well coloured (Hitch- mann and Adler).* Acute Metritis. The following account is after Jellett. In this condition myo- and endometritis may be taken as coexisting. Causes.—Most frequently gonorrhoea, sepsis associated with the puerperium, operations on the uterus. In the acute septic form occurring in the puerperium, the uterine walls are firm and the interior is smooth ; ‘there is consequently no tissue which could be removed by the curette.’ If the infection be less virulent, the uterus is big, the walls are thick and the tissue friable, and the lochia is increased. In the acute gonorrhceal cases the condition resembles that occurring as a result of mild sepsis. * From Frankl.ABNORMAL STATES OF THE UTERUS 47 The dangers are: (1) Spread of the infection to the parametrium, with resulting cellulitis ; (2) salpingitis, as a result of the spread of the infection to the tubes; (3) formation of septic thrombi, with the subsequent onset of pyzmia ; (4) the occurrence of acute lymphatic sepsis. Symptoms.—The uterus is tender, and may be enlarged somewhat ; there may be a copious purulent discharge. In streptococcal sepsis occurring in the puerperium, the discharge may cease. The temperature is high, 103° to 105°, pulse 120 to 140, pain in the region of the uterus. The spread of the infection to structures outside the uterus is indicated by the occurrence of severe pain in the lower abdomen ; the pulse and temperature will show an additional rise. This author considers the severity of the pain to be proportional to the formation of adhesions. ‘Its occur- rence, therefore, is a favourable sign, as showing the limitation of the infection.’ Rigors may indicate that septic emboli are being thrown off into the general circulation. Treatment.—Explore the uterus. If the endometrium is shaggy remove any portion of placenta, membranes, etc., that may have remained adherent to it. This operation may be performed with the finger or a blunt curette. Plug the uterus with iodoform gauze. If the in- side of the uterus be smooth (as described above), Jellett favours the injection of strong formalin (20 to 4o per cent.), which is allowed to act for fifteen to thirty seconds and then washed out. Take a culture from the interior of the uterus, and have an autogenous vaccine made, meantime treating the patient with a stock vaccine. The material for culture must be obtained from the uterus before any antiseptics are applied. Maintain the patient’s strength, keep the bowels well open. Ergot often does good in these cases by causing the uterus to contract. Hot stupes may be applied to ease the pain.AIDS TO GYNECOLOGY Fibrosis Uteri. This condition is frequently described under the heading of chronic metritis ; we prefer, however, to use the better understood term of fibrosis uteri. The uterus is enlarged and firmer than normal; fibrous tissue is present in abnormal amount, associated with local arterial thickening. The increased firmness of the uterine wall may be appreciated during curettage. Subinvolution is probably responsible for the existence of many cases. Symptoms.—Heemorrhage, in the form of menorrhagia, is the most prominent and important, since it is some- times extremely difficult to treat, and consequently is a considerable source of worry to both the patient and her physician. There will probably be some degree of pelvic discom- fort, which may or may not amount to a definite pain. Treatment.—It is important that the patient should be able to rest for a certain portion of each day, and to lie up when there is hemorrhage ; attention should also be directed to the general health. Ergot, either alone or with nux vomica, may be of use in the mild cases. If the above measures are not successful, the next step is to curette the uterus. This, unfortunately, may have to be done several times. Should the hemorrhage still continue, the extreme step of removing the uterus may have to be taken. Chronic Endometritis. Frankl denies the existence of glandular endometritis : ‘The inflammatory changes which are often seen in the mucous membranes, with clearly defined, progressive glandular changes, prove themselves almost always to beABNORMAETSIATES OF THE UTERUS 49 an inflammation occurring in a typical premenstrual mucous membrane.’ Interstitial Endometritis. The following account is after Jellett. Bacterial Theory of Origin.—(1) Endo- metritis is due to bacteria ; (2) predisposing factors are necessary. The effects which the bacteria have caused may continue. The predisposing causes are conditions likely to cause congestion of the uterus, retroversion, etc. The determining cause is the presence of bacteria. Macroscopically the uterus is large and congested, the mucous membrane thick. Microscopically there is a_ proliferation of the connective elements and numerous small round cells. Frankl lays emphasis on the presence of plasma cells if they are in quantity. Symptoms.—Menorrhagia, metrorrhagia, leucorrhcea. The uterus may be displaced and enlarged; there is usually some sense of weight in the pelvis, pain increased by Over-exertion ; sterility. Such symptoms as headaches, palpitation, various digestive troubles, are often associated, and the patient may be anemic. Treatment.—Examine the patient thoroughly and treat any abnormality found, such as displ at laceration of the cervix, etc. ; pay particular attention to any factors ifleely to cause congestion. < Curettage is usually indicated in addition to other treatment. Bandl’s Hollow Sound.—This instrument is used 4 ____DOWN BROS LONDON Fic. 9.—BANDL’s HoLLow Sounp.50 AIDS TO GYNECOLOGY for the application of such substances as pyroligneous acid or copper sulphate to the uterine cavity—a form of treatment sometimes adopted in mild forms of endometritis. Take a cylindrical speculum, insert it, and fill the speculum with the solution to be applied. The hollow sound is now passed into the cervix and drawn backwards and forwards, thus admitting the solution to the interior of the uterus. Endocervicitis. As a result of the inflammatory process there is a hyperemia; this in turn causes a hypersecretion from the cervical glands. The discharge is of a semi-purulent nature, and there may be desquamation of the epithe- lium on the surface of the external os over a wide area ; probably associated with the presence of an erosion. The interstitial tissue may also be hyperzemic. Treatment.—Treat an erosion or ectropion if present. Curetting of the uterus may also be indicated, as there is probably associated endometritis of the body of the uterus. Uterine Polypi. The mucous membrane locally undergoes hyperplasia. At first the condition is sessile, but subsequently a pedicle develops. Polypi at the uterine cornua are liable to assume the shape of a bean or a pear. Cervical polypi, on the other hand, are moulded by the cervical canal, and are more likely to be sausage-shaped. Treatment.—Removal. Tuberculosis. According to Norris, it may occur as an endometritis, secondary to tuberculosis elsewhere—~z.e., tubes or ovaries. The milary or ulcerative variety may be present, the former being the more common.ABNORMAL STATES OF THE UTERUS 51 Symptoms.—The symptoms of this condition are similar to those of endometritis due to other causes. As the tubes may already be infected, a close scrutiny of the history of the case may suggest the type of infection one is dealing with. Tuberculous matter, consisting of cheesy particles, may be present in the discharge. The diagnosis is difficult unless T.B. can be demon- strated in the discharge, or a histological examination of the tissue made. The presence of tuberculosis else- where, or extreme youth of the patient, is suggestive. Lreatment.—Curettage followed by the application of iodine, or formalin, in mild cases; hysterectomy in the more severe. The tubes are likely to be affected, so that they should be dealt with at the time of any intra- abdominal operation, otherwise the infection is likely to light up afresh.CHAPTER 1X TUMOURS OF THE UTERUS . Myoma. THIS is a well-defined tumour, consisting of unstriped muscle fibres mingled with a varying degree of fibrous tissue. It is sometimes called a ‘fibroid.’ The tumours may be single or multiple, and vary from the size of a pin’s head to that of an ostrich’s egg. They are usually firmer than the surrounding uterine muscle. Fig. 10.—SECTION OF UTERUS SHOWING MULTIPLE MYOMATA. Specimen from the R.C.S.I,. 1. If a patient having a large myoma becomes pregnant, the tumour may offer considerable obstruction to the passage of the foetus. 2. Myomata render patients much more liable to heemorrhage during the third stage of labour. 3. If a tumour has received much bruising during labour, it is liable to become necrotic and so cause trouble during the puerperium. 52TUMOURS OF THE ULERUS 53 Submucous Myoma.—So called because it projects under the mucous membrane into the cavity of the uterus. Intramural Myoma.—This remains in the thickness of the uterine wall. Subserous Myoma projects under the peritoneum. Myomata may also be found in the broad ligament. A myoma that is not undergoing degeneration is white and smooth like a tendon, or shows a slight pink tinge Fig. 11.—LARGE MyYoMa. The specimen has been cut into and opened out. Macnaughton- Jones Collection, R.C.S.1. mixed with white, resembling watered silk. Any very definite red colour is to be regarded as an indication of the occurrence of degenerative changes in the tumour. If the tumour be examined with a magnifying-glass, it will be found to consist of a network of fibres radiating in various directions. “ke myoma is surrounded by a capsule which is composed ‘bf uterine muscle, and it follows that the more highly developed the capsule the easier it will be to shell out the tumour from its bed. If many myomata project into the cavity of the uterus, it is evident that the chances of an ovum being able to develop and reach maturity are not very great.54 AIDS TO GYNECOLOGY A myoma may become (1) calcified; (2) necrotic: it hen appears ‘rose-red, clear carmine red, or brownish- red colour’ (Frankl) ; (3) infected ; (4) malignant. Symptoms.—A myoma generally causes menorrhagia, metrorrhagia, and probably leucorrhcea. If the tumour be large, symptoms due to pressure may supervene, Diagnosis.—These tumours occur most frequently to- wards the end of the sexual life of a woman—that is to say, between the ages of thirty-five and forty-seven. If the uterus be uniformly enlarged, the difficulty of distinguishing the condition from a pregnancy may be considerable. Even though one may be able to palpate several small myomata on the fundus, it does not prove that the enlargement of the uterus is solely myomatous in origin, as pregnancy and myoma may coexist. Pregnancy.—Amenorrhcea, subjective and objective symptoms of pregnancy, soft cervix, bluing of vagina. Size of abdomen usually bears a definite relation to the period of amenorrhcea. Myoma.—Menorrhagia and metrorrhagia. Cervix hard. Swelling of abdomen usually does not increase so rapidly. Treatment.—Myomectomy where possible. An incision is made in the uterus over the site of each tumour, the latter is then seized in a bullet forceps and twisted out of its bed. The cavity which the tumour occupied is then obliterated with mattress sutures. Care should be taken that the bleeding is thoroughly controlled, as there is otherwise some danger an«these cases of secondary hemorrhage. i ie Where the myomata are very numerous, or the uterus considerably enlarged, it may be necessary to perform hysterectomy. X rays furnish an alternative method of treatment to myomectomy. This method suffers from the drawback that it is difficult to decide exactly in what conditionTUMOURS OF THE UTERUS the myoma is—z.¢., it might be sarcomatous, and valuable time thus be lost. Adenomyoma.—This is a myomatous tumour, possibly large, that contains either glands or cysts. In the case of myomata projecting into the cavity, the blood-vessels are described as being of large calibre and united by delicate network. They lie parallel to the superficial epithelium, which in turn runs parallel to the surface of the tumour. Frequently the vessels are very dilated ; sinuses may develop under the epithelium. Malignant Disease of the Uterus. Carcinoma may occur either in the body of the uterus or in the cervix, the latter being the more common. Carcinoma of the cervix is rare in women who have not had children. As chronic irritation seems to be a factor in the occurrence of cancer generally, it is evident that the cervix of a multipara is lable to be the subject of more chronic irritation than that of a nullipara, thus accounting for the greater incidence in the former. Cancer of the body is cylindrical-celled, that of the cervix either squamous or cylindrical-celled. Cancer of the cervix may originate from erosions, or ectropia in the region of the external os. Cancer is the most frequent form of tumour in this locality. Solid masses of new growth appear on the cervix; they are of a coarse papillary form and greyish-red in colour. These cancers sometimes present the appearance of a crater ; owing to the parts in the centre having become necrotic and broken down, the edges remaining intact are somewhat undermined. When extension has occurred into the vagina, warty masses of new growth appear ; these ulcerate readily. Cancer of the body may be localized or diffusely spread56 AIDS TO GYNECOLOGY over a wide area, possibly the whole endometrium being involved. Symptoms of Malignant Disease of the Uterus.—1. An abnormal loss of blood at the periods, or (2) bleeding in the interval between them, occurring at or about the change of life. 3. Bleeding after the change of life has been established. Therefore remember that loss of blood, as indicated above, is the first sign of uterine malignant disease. The sig- nificance of bleeding after a vaginal examination, or coitus, should not be lost ; it may be due to small cancer- ous fragments having been broken off. 4. The occurrence of an offensive discharge is usually a much later symptom; its presence signifies necrosis and decomposition of portions of the tumour. 5. Pain is usually an indication that the growth has spread considerably and is causing pressure on neigh- bouring structures ; it is, therefore, a late symptom also. It is evident that if malignant disease is to be diagnosed at its early stage—v.e., at a time when an operation will give the greatest prospect of a cure, hemorrhage is the only symptom that will be present. Unfortunately its occurrence does not always make the patient sufficiently anxious about herself, with the result that she postpones seeing a doctor until either the amount of blood lost has been very considerable, or one of the other symptoms intervene. The disease may involve the bladder and rectum. Diagnosis —Examine the cervix carefully. If a con- dition suggestive of an erosion be present, particularly if there is a history of any bleeding as described above, remove a portion of it and submit it to a pathologist. If the cervix appear normal, curette the uterus and have scrapings examined. The more advanced conditions do not present the same difficulty in diagnosis.ROMOCKS OF THE ULBRUS Treatment.— Hysterectomy (Wertheim’s). Before oper- ating, cystoscope the patient to find out if the bladder be involved. [f the condition be inoperable, scrape away all friable tissue with a blunt curette, and apply a cautery to the wall of the crater-like cavity. Dry and dust the cavity with neutral cotarnine phthalate. This relieves the pain and tends to check the hemorrhage. Plug the cavity with iodoform gauze, and remove next day. The vagina will need to be douched out once or twice daily. Cyllin (31. to O.1.) or hydrogen peroxide (1 per cent.) can be used. The skin of the vulva and inner side of the thighs will need to be anointed freely with vaseline to prevent ex- coriation, and the pads should be frequently changed. At first aspirin and phenacetine are given to relieve pain, for it is necessary to defer the giving of morphia as long as possible, in order that it may confer the fullest relief at the time when the pain is at its worst. For, unfortunately, the effect of this drug wears off after it has been administered for some time. Radium as a form of treatment is often beneficial in inoperable cases. Sarcoma.—This tumour may be diffuse or circum- scribed. It may have been sarcomatous from the start, or have resulted from the sarcomatous degeneration of a myoma. The body of the uterus is more frequently involved than the cervix. Only a small percentage (2 to 3 per cent.) of myomata become sarcomatous. Diffuse sarcomata appear as rough nodular swellings, which may occupy the entire cavity of the uterus, enlarge it, Ob change its shape. They may be of any size from a hazel nut to a man’s head. The circumscribed type are more polypoid in appear- ance ; they may extend into the cervical cavity, or even protrude from the external os. The grape-like excrescences formed by these tumours are soft and may be friable, but the base is more solid,58 AIDS TO GYN4=COLOGY Alterations in colour to a violet or greyish tinge may be brought about by hemorrhages. Any colour changes due to necrosis are of somewhat different shades. If a sarcoma be situated on the wall of the uterus, its appearance may suggest a myoma, more especially as the mucous membrane over it may remain intact for a con- siderable time. Sarcoma of the cervix proper is a cauliflower-lke growth, and something resembling carcinoma in outward appearance. Treatment.—Pan-hysterectomy. Chorion Epithelioma.—This is a malignant tumour of the uterus, capable of forming metastases very rapidly. It is, fortunately, not of frequent occurrence. The secondary growths are found in the lungs, vagina, bladder, and intestine, the tumour particles being con- veyed by the blood-stream. It is due to the cells of Langhans layer and the syn- cytial cells having become malignant (¢.e., the cells which normally cover the chorionic villi). Hence it only occurs after the termination of a pregnancy. There appears to be some relation between chorion epithelioma and hydatidiform mole, but the former may follow an abortion or even a more advanced pregnancy. The secondary growths in the vagina as a rule break down readily, and in consequence are liable to be asso- ciated with considerable hemorrhage. Syniptoms.—Recurrent hemorrhages, generally severe, occurring at irregular intervals shortly after the termina- tion of a pregnancy—z.e., a mole, abortion. The severity of the haemorrhages will probably lead to active measures being taken for the relief of the patient. On exploring the uterus a tumour will be found in the cavity, one of the characteristics of which is the ex- treme ease with which it breaks down. If the growth be not extensive, there may be someTUMOURS OB TH ULEROS difficulty in deciding whether one is dealing with the remains of an ordinary pregnancy or not. But some small point may make the operator suspect that he is not dealing with a simple incomplete abortion, such as the history of the case, or the manner in which the fragments come away. Suspicion once aroused, the matter can be settled by having fragments sent for pathological ex- amination. Whether the uterus be explored with the finger or the curette depends on the size of the cervix, and to some extent on the choice of the individual operator. If you are going to use a curette, it is advis- able that it be a blunt one, such as Rheinstadter’s. For remember that it is by no means difficult to perforate the soft uterus of the puerperium. Sooner or later the haemorrhages are associated with an unpleasant discharge due to the decomposition of the tumour elements. About this time the patient will probably present a cachectic appearance, and if this be accompanied by any pulmonary symptoms, such as cough, the existence of secondary growths in the lungs is probable. Treatment.— Pan-hysterectomy.CEUNEP ER 2x DISEASES OF THE TUBES Salpingitis: INFLAMMATION is the result of infection with micro- organisms. The gonococcus gains access to the tube from below, the streptococcus usually from below also; but in- fection may also be carried by the lymphatic channels. In the acute stage the tube is somewhat thickened and hyperemic ; it may be more tortuous than normal. The Fic. 12.—DOUBLE PYOSALPINX. U, Uterus. From the Macnaughton-Jones Collection, R.C.S.1. Note typical retort shape of right tube. ostium is thick and of a deep red colour, and the fimbriz may assume a somewhat turgid condition. The contents of the tube may be serous, milky, hemor- rhagic, or purulent. In inflammation of longer standing the wall of the tube is thickened, the diameter being the thickness of the thumb. The tube may be found curved like a post-horn and surrounding the ovary, or it may be 60DISEASES, OF PHE LUBES 61 convoluted. The adhesions round the tube may be dense or delicate. Its lumen is dilated and contains pus; he abdominal end closes early. The uterine end also closes, and therefore the pus re- mains in the tube; the condition is called a pyosalpinx. The dilated tube may be of considerable size. A Hematosalpinx may be the result of inflammation, owing to the rupture of inflamed and hyperzemic blood- vessels. A Hydrosalpinx is a condition in which the tube is filled with a clearish, colourless, or yellowish fluid, and the walls are occasionally thinned out. It may be gonorrhceal in origin. Prognosis.—Sterility, if both tubes be affected, for the abdominal ostia are closed, and, further, the tube may contain pockets or the lumen be obliterated. Symptoms.—In the acute stage temperature and pulse are high, and there may be rigors ; the abdomen may be distended, with the presence of pain and tenderness in the lower part. This condition may subside, or the in- fection spread and general peritonitis ensue. Jellett considers the occurrence of abdominal pain in acute pelvic infection as a sign of good import, as it usually in- dicates that adhesions are forming, and thus that the danger of the infection spreading to the general peri- toneum is becoming less. In the chronic stage there may be irregular attacks of severe pain associated with menstrual trouble. If the lumen of both tubes be occluded, the patient is sterile. Various other symptoms may result owing to the formation and contraction of adhesions—such as retroversion of the uterus with its accompanying train of symptoms. On examination in the acute stage a tender swelling may be felt on either side of the uterus, or in Douglas’s pouch. The history of the case or the nature of the62 AIDS £O GYNZCOLOGY general symptoms, should suggest the type of case one is dealing with. ~ Treatment.—{n the acute form the patient should be kept in bed and hot fomentations applied to the lower abdomen. If the symptoms be severe, and the distended tube can be felt low down in Douglas’s pouch, it may be opened into from below and the pus let out. In a later stage glycerine and ichthyol plugs can be used; but operative treatment in the chronic stage is usually indicated if the attack has been severe. The exact condition of the tubes can then be noted, and if it be not necessary to remove them, sometimes an effort can be made to restore their functional activity and re-establish the lumen by the process suggested by Tweedy of passing catgut along it. And if there be a retroversion, it can be dealt with at the same time. Tuberculosis of the Tubes and Ovaries.* The condition is usually secondary, most frequently the primary seat being in the lungs, peritoneum, osseous system, lymph glands, and intestine in the foregoing order. The tubes are more frequently attacked than any other portion of the genital tract. A true tuberculous inflam- mation of the ovaries is comparatively rare, but a periodphoritis is sometimes associated with tuberculous tubes. Symptoms.—Pain, tenderness, and sometimes slight enlargement of the lower abdomen, various menstrual troubles, leucorrhcea, sterility, evidence of localized peri- tonitis. According to the above author, Murphy states that there is a strong tendency for the tube to remain open unless there is a mixed infection, The result of this is alternating periods of relief from the symptoms, * Account adapted from Norris.DISEASES OF THE TUBES followed by their return, which latter may be associated with a rise of temperature and an effusion into the peri- toneum. But when the tube is closed the recurrent type as indicated above does not occur. During the acute Stage there are symptoms of pelvic peritonitis depending in their severity on the extent to which the peritoneal cavity is walled off from the inflammatory zone. The pain and tenderness observed is more definite in the region of the ovaries and is usually bilateral. This stage is probably of longer duration than the similar stage in a salpingitis of pyogenic origin. On examination each lateral fornix may only present a sensation of increased resistance to the examining finger, or a definite tumour may be made out. Chronic stage is usually the sequel of an acute attack, but the condition may have been subacute from the onset. tk It tends to run a long course, interrupted by occasional acute or subacute attacks. The general health is poor. Frequently a slight evening rise of temperature is to be noted. Some menstrual disturbance is usually present, and frequently more or less definite pain in the lower abdomen, more severe at the menstrual periods. There may be slight rectal or vesical trouble or pain in the back. A slight rise of temperature following a bimanual exami- nation occurs frequently in cases of pelvic inflammation, il} and is a sign of some value where a pelvic lesion has been 5 hard to palpate. Exercise tends to increase the symptoms | and rest to alleviate them, and frequently there may be it marked tenderness over the lower abdomen. i Diagnosis. — Examination of the abdomen shows i tenderness and increased resistance over the affected areas, and a definite tumour may be felt at one or other side from below. There is probably some induration and tenderness in the lateral fornices, and the cervix may be fixed ; if so, pressure on it in any direction is likely to cause pain.AIDS TO GYNECOLOGY The uterus may be retroverted and adherent. Fre- quently the tube and ovary are matted together, forming a tender inflammatory mass. The symptoms of the case point to the fact that pelvic peritonitis is present to a greater or less extent, but the causative organism is frequently difficult to determine. An effort should be made to exclude gonorrhea or streptococcal infection. In the former there is usually some evidence of inflammation elsewhere ; the latter is usually the sequel to some intra-uterine infection follow- ing a pregnancy or operation, etc. It might be possible to demonstrate tubercle bacilli in the discharge. Treatment.—The condition of the primary lesion is important. It may be (1) active ; (2) quiescent or diffi- cult to detect ; (3) not detected with certainty. In class (1) do not perform any operation other than palliative. In class (2) study the case on its merits, going carefully into the history. In class (3) the diagnosis of tuberculosis is often not made until the operation, or until the specimens are submitted to a pathologist. If tuberculosis be suspected beforehand, take all pre- cautions possible to avoid lighting up a primary lesion should one exist. Palliative treatment consists of rest in bed, hot applica- tions to the lower abdomen, and the improvement of the general health. If operation be decided on, it should be radical—z.e., the removal of the infected tubes first. If the ovaries be also infected, it is better to remove them also, in which case it is advisable to remove the uterus as well. Extra-Uterine Pregnancy. Fertilization of the ovum is thought to take place, under normal circumstances, in the Fallopian tube. If, instead of proceeding to the uterus, the ovum embeds itself in theDISEASES OF PAE LU BES 65 tube and commences eroding and destroying the maternal tissue in the same way as it does in the uterus, then the condition known as tubal pregnancy develops. Therefore it is evident that anything which causes the ovum to delay in its journey to the uterus, or any definite obstruction to its passage not sufficient to have pre- vented the passage of the spermatozoon, will increase the chances of its being implanted in the tube, and thus the likelihood of an extra-uterine pregnancy. The ovum relies on the tubal cilia as a means of trans- port; they may have been damaged by a previous inflam- mation. Changes in the lumen, due to the same cause, kinking of the tube, the formation of pockets, crypts, diverticula, or adhesions between various folds of the mucous membrane, would also present opportunities for this condition to occur. The ovum is embedded in the tube in a manner pre- cisely similar to the way in which it is embedded in the uterus, boring its way into the tissue and penetrating the blood-vessels, the trophoblast making its bed. In this way the intervillous circulation is developed. As the mucous membrane of the tube does not form a suitable nidus, the ovum embeds itself in the muscle, and, further, the tube is incapable of forming a true decidua. In consequence of the ovum being embedded in the tubal muscle the trophoblast has probably more scope for developing its power of erosion. The vessels which are present in the tube being penetrated, it destroys the surrounding muscle, which disappears progressively in the region of the insertion of the ovum, not solely by the action of the trophoblast, but partly owing to the influence of expansion, cedema, hzmorrhage, and degeneration, thus paving the way for rupture to occur. Rupture takes place early in pregnancy, either ex- ternally into the peritoneal cavity, or internally towards the lumen of the tube.AIDS TO GYNA:COLOGY 3efore rupture the tube is globular or club-shaped in appearance, varying in size according to the duration of pregnancy. Ifthe ovum be expelled into the lumen of the tube, large blood-vessels are torn across at the site of the rupture in the capsule; severe haemorrhage results, followed by the formation of an hzematocele in the tube, since the blood, on flowing into the lumen, has time for coagulation, this being further favoured by contact with the tubal mucous membrane. Therefore by the time the blood appears at the abdominal ostium it is in a more or less clotted condition. The further hemorrhages which occur subsequently increase the size of the mass in the tube, and push the clot forwards towards the ab- dominal end. External rupture—z.e., into the peritoneum—is caused more by the eroding action, combined with softening, degeneration, and hemorrhagic infiltration of the muscle, than by the mere expansion of the tube. The uterus develops a decidua, probably owing to a hormone secreted by the growing ovum. The following account of the course, symptoms, and treatment is adapted from Tweedy and Wrench. Practically, tubal pregnancy may be divided into four classes: (1) Before rupture ; (2) rupture leading to severe internal hemorrhage; (3) rupture leading to encysted blood-tumour ; (4) rupture with survival of the ovum, the latter continuing to live between the layers of the broad ligament or in the abdominal cavity. A considerable period of sterility may precede a tubal pregnancy. Usually the tube ruptures in the second or third month of pregnancy, and as two-thirds of the tube is enclosed by peritoneum and one-third by broad ligament, it follows that two-thirds of the ruptures will be into the peritoneal cavity and one-third into the potential cavity formed by the layers of the broad ligament,DISEASES OF GHEE LUBES 67 In cases where the blood escapes into the peritoneum the hzeemorrhage may be so severe as to lead to the death of the patient. However, if the hemorrhage be slighter in amount, it will probably collect in Douglas’s pouch and form a pelvic heematocele. When blood collects between the layers of the broad ligament, the condition is termed a pelvic hematoma. ‘The rupture may permit of the escape of a living and partly separated ovum without the hzmor- rhage being sufficiently severe to affect the patient con- stitutionally. The ovurn may be liberated either into the peritoneum or the broad ligament. In the former case, living in a false sac formed by the adhesion of surrounding structures, bowel, omentum, etc., until full term, then a spurious labour sets in, which results in the death of the foetus. In the latter case the false sac is formed by the layers of the broad ligament. The case now follows one of two courses: (1) The broad ligament sac ruptures, with severe haemorrhage; (2) the foetus reaches full term in the broad ligament sac, then spurious labour sets in as before, followed by the death of the foetus. 1. Tubal Pregnancy before Rupture.—The symptoms which make a patient seek advice are: a varying period of amenorrhcea, often not longer than a fortnight, followed by irregular heemorrhage from the uterus, and possibly the occurrence of colicky pains. The patient may think she is pregnant, or not, and the irregular hemorrhage renders the menstrual history very indefinite ; other signs of pregnancy may be present. Diagnosis.—The uterus is larger than normal, and the cervix may or may not besoft. On bimanual examination a tender elastic swelling may be felt behind or to one side of the uterus, and separated from it by a groove. It has to be distinguished from an ovarian cyst, a tube with fluid contents, or a fibroid. Usually none of these are tender, nor are they associated with the same history of irregular hzemorrhage or colicky pain. The above authors advise68 ATDS TO GYNAECOLOGY that if the lump is suspected to be a tubal pregnancy, the patient should certainly be operated on. To distinguish the condition from a retroverted gravid uterus, note that (1) the uterus is found pushed forwards against the pubes, or to one side of the tumour; (2) the cervix is displaced forwards, but the anterior vaginal wall is not stretched, as it would be in the latter condition. Treatment.—Operative. 2. Rupture leading to Severe Internal Hemorrhage. —If the rupture be primary, it usually occurs within the first three months of pregnancy. If secondary—z.e., of the false sac formed by the broad ligament—it may occur at any time later on. The definite sign in the diagnosis of rupture is the onset of symptoms of internal hemorrhage in an appar- ently healthy woman. She is very white, collapsed, and in great pain, the pulse is soft and rapid and the temperature subnormal. ‘She is in great anxiety about herself, and if she is near death she will be restless and try to get up from the bed. There may be a little blood escaping from the vulva, and possibly even a decidual cast, but the symptoms are out of all proportion to this slight escape. Treatment.—Immediate laparotomy. 3. Rupture leading to an Encysted Blood-Tumour.— The patient may get a little pale, have some pain, etc., but at the time of rupture her symptoms may not be sufficiently urgent to indicate the presence of a doctor. But later, owing to persistent pain, possibly associated with a rise of temperature, she presents herself for ex- amination. On bimanual examination, if the blood be clotted, a solid or semi-solid swelling will be found to° occupy Douglas’s pouch, or lying between the layers of the broad ligament. In the former condition the swelling, if felt from below, is somewhat dome-shaped, and is distinguishedDISEASES OF THE TUBES 69 from a retroverted gravid uterus by the signs already mentioned. Treatment.—(1) Expectant—in other words, ‘ wait and see’: infection of the clot may occur; therefore (2) opera- tion is usually preferable. 4. Rupture with Survival of the Ovum.—These cases are very rare. Treatment.—The abdomen should be opened and the sac removed as far as possible. It is recommended to wait for three weeks after spurious labour before operating, owing to the very serious hemorrhage that sets in after the removal of the placenta, if the foetus be alive when this is attempted. The diagnosis is made by appreciating the fact that the uterus is more or less of normal size, and that the foetus is lying elsewhere.GLA Pa 2x1 DISEASES OF THE OVARIES THE following abnormal positions of the ovary are found: (1) Descent; (2) elevation. Axial rotation also occurs. The ovary may lie in Douglas’s pouch, probably due to laxity of the ligaments, especially the infundibulo-pelvic (Stratz). An enlargement may cause it to descend ; but, on the other hand, an ovary that has descended may increase in size and become congested. A prolapsed Ovary may cause pain during a bimanual examination or may be a cause of dyspareunia. The ovary, either by itself or with the tube, may be found in a hernial sac. Retention Cysts. 1. Gradfian Follicle Cysts.—These may occur in the form described as small cystic degeneration of the ovary. The condition is evidenced by the presence of more or less numerous cysts, varying in size from that of a pin’s head to that of a hazel-nut ; they project above the surface and contain a clear fluid. The condition is regarded as being due to congestion, and not the result of odphoritis. They may also occur in the form of larger cysts. 2. Corpus Luteum Cysts. — These are seldom of large size. They consist of a cystic dilation of the corpus luteum and appear as unilocular cysts having a thin wall, and contain a yellowish fluid. The cavity is limited by a yellowish-brown internal membrane which can be stripped off. 70DISEASES OF THE OVARIES Tumours. New growths of the ovary may be primarily cystic or solid. Generally speaking, they are of globular shape, more or less modified by the pressure of surrounding structures. The pedicle influences very considerably the relations of the tumour to the various organs in the neighbourhood. Tumours developed from the base of the ovary grow to lie between the layers of the broad ligament. ‘So long as the ovarian tumour does not exceed the size of a fist it sinks by its own weight into the bottom of Douglas’s pouch’ (Frankl). As the tumour increases in size, it rises up into the abdominal cavity. This may be associated with a certain degree of torsion of the pedicle. Twisting occurring gradually is to be distinguished from acute torston. Acute Torsion.—This condition is apt to result from a sudden jerky movement, or a push, or fall, especially if the abdominal wall be relaxed, as in the puerperium. The changes occurring in the cyst are dependent on the amount of pressure exerted on the blood-vessels, the veins being compressed earlier and morecompletely than the arteries. Hence the cyst is tense and of a dark blue colour. The capsule may be easily torn. The vessels in the cyst wall are dilated and its contents heemorrhagic. If further rotation has occurred, the cyst wall becomes a yellow-brownish colour, the contents being dark brown. Torsion of more solid tumours causes them to become infiltrated with diffuse heemorrhages. Rupture may result as a sequel to torsion, or as the result of increased intra-abdominal pressure, as in pregnancy. Rupture occurring in a cyst that has become malignant results in the dissemination of malignant particles over the abdomen. See er ERES eae eboeseee ere72 AIDS TO GYNAECOLOGY Adhesions.—Any injury to the tumour wall, such as may occur during rotation, facilitates the passage of micro-organisms from the intestines, and thus the occur- rence of adhesions. ‘Twisting of the pedicle is frequently followed by infection, owing to the fact that the large amount of blood which is extravasated into the tumour % Yf YY BY Ly Px i : POX } Z i, AY, Fig. 13.—LARGE OVARIAN Cyst. From a specimen in the R.C.S.I. forms a suitable culture medium. Infection is also found in cases where the pedicle has become twisted. Cystadenoma.—This is the commonest form of ovarian tumour ; usually it contains a stringy mucous fluid, but the fluid may be serous. Commonly one ovary only is affected. There may be constrictions on the surface corresponding to septa in the interior. It may appear as one large cyst containing a varying number of daughter cysts, or as a multilocular cyst in which there are portionsDISEASES OF THE OVARIES 73 that look solid, but in reality are made up of numerous very minute cysts. The interior of these cysts is usually smooth, and the daughter cysts do not project into the cavity. This form of cyst is usually regarded as a benign tumour, but it may at times assume certain character- istics of a malignant growth. Papillary Cystadenoma.—This differs from the form first described, in that the epithelium tends to proliferate into papillary tufts. Rupture of a loculus containing papillae may occur ; the tumour particles are set free. These, becoming im- planted on the peritoneum, form secondary tumours. This type of cyst is primarily benign, du¢ malignant degeneration is liable to ensue. The papillee perforating the wall form cauliflower-like growths on the free surface. Cancer.— Primary ovarian cancer is usually seen in the form of a solid tumour ; on section it may appear reddish-grey or yellow. Secondary cancer may follow cancer of the breast. Teratoma.—This term usually includes both teratoma proper and the so-called dermoid cyst. A dermoid cyst differs from a teratoma in that it is cystic and the contents are of simple structure. In shape these tumours are somewhat cubical, but may be slightly flattened. The capsule is smooth and whitish in colour. It contains a fatty matter, which remains fluid at the body heat, and is found to contain detritus, cast-off epithelium, and cholesterin plates. There is usually a mass of hair in the cavity. Dermoids may become malignant. Teratomata (proper) are usually solid and of a hard consistency, and may contain cartilage and particles of bone. Hair is not so common as in dermoids ; very rarely in the form of tufts.74 AIDS TO GYNA4COLOGY The tissue usually assumes a somewhat foetal character, but its arrangement is purposeless and confused. These tumours are liable to become malignant. Myoma.—Rare. Sarcomata not commonly found; they are generally solid. Endothelioma is found in the form of (1) lymphangio- endothelioma; (2) hemangio-endothelioma (Borst). It s also rare. Symptoms (Ovarian Tumours).-—(1) Various menstrual troubles ; (2) those due to pressure on neighbouring structures—viz., bladder, rectum, abdominal contents ; f large, the diaphragm. Pain, if present, may be due to adhesions. Diagnosis.—Pass a catheter ; the swelling might be a full bladder. When small, a movable, rounded, and elastic swelling is found lying to one side of, or behind, the uterus. It has to be distinguished from other swellings in this locality, such as pyosalpinx, or tubal pregnancy. The history of the case will help to dis- tinguish it from inflammatory swellings, while if there be any doubt as to whether it be a tubal pregnancy or not, the question should be settled by operation. A large tumour occupying either (1) the entire pelvis, or (2) the abdomen, may present more difficulty. 1. Establish the fact that the tumour is not an enlarged uterus by palpating the latter organ separately ; also make sure you are not dealing with a pelvic hematocele. The latter is probably harder and fits the pelvis more ac- curately than an ovarian tumour, and, further, the history of the case is different. 2. Distinguish from a normal pregnancy or free fluid in the abdomen. The former is excluded by the history and by the absence of the symptoms and physical signs peculiar to it. In ascites the characteristic dulness can be made out ; when the patient is on her back the flanksDISEASES OF THE OVARIES 75 are dull and the mid-abdomen resonant, while in an ovarian tumour the converse is usually the case. ‘The history of the case shows that the tumour has grown upwards from the pelvic brim, and not downwards from the kidney or spleen’ (Jellett). In order to feel the pedicle of an ovarian tumour— (1) Catch the cervix in a bullet forceps; (2) put the first finger of the right hand in the vagina and the second finger in the rectum; (3) draw down the uterus with the bullet forceps; (4) endeavour to enclose the broad ligament between your fingers by passing them far in and keeping them to the same side of the uterus that the tumour is thought to belong; (5) an assistant now pulls the tumour towards the diaphragm, thus causing the pedicle to tighten. You should now be able to appreciate the fact of its existence and note that it re- laxes when the pull is taken off the tumour. (After Jellett.) Symptoms of Acute Torsion of the Pedicle (Complete Torsion).—Acute abdominal pain following some exer- tion. The abdomen is tender and rigid, the pulse is rapid, and the patient may feel very faint. Gradual torsion may be merely associated with pain. With regard to the bearing of ovarian tumours on pregnancy— 1. There is a lesser likelihood of the patient becoming pregnant. 2. If she does so, the tumour may offer an obstruction to the passage of the fcetus. 3. After delivery, owing to the sudden decrease of the intra-abdominal pressure, acute torsion of the pedicle may occur. 4. Either bruising of the tumour during labour, or twisting of its pedicle subsequently, favours the occur- rence of infection in it during the puerperium. Ulcera- tion or gangrene may set in.76 ALDS FO GYNECOLOGY 5. A cystic tumour may be ruptured during either labour or pregnancy. Lreatment.—Laparotomy for removal. Jellett recommends that, in the case of papillomatous or solid tumours, ‘which at the time of operation must be 8 Fic. 14.—DouBLE OVARIAN PAPILLOMA. U, Uterus. Specimen in the R.C.S.I. regarded as malignant, and of tumours which are obviously malignant, both ovaries must be removed.’ Parovarian Cysts. These cysts are covered by peritoneum, that part nearest the tube being the more easily separated. The tube is probably longer than normal and attached i to the tumour, its peritoneal coat being stretched over pi the convexity. The ovary may beatrophic. These cysts 4 are single-chambered, thin-walled structures of varying size, from that of a pea upwards ; more than one may be present. The contents are clear and the inner surface smooth, The pedicle is formed by the mesosalpinx, the tube, the ovarian ligament, the suspensory ligament of the ovary— 7.é., infundibulo-pelvic ligament. The pedicle is broad and hence twisting is not frequent.CHAPTER Xa) PELVIC PERITONITIS AND PELVIC CELLULITIS WHENEVER there has been an attack of pelvic periton- itis, adhesions between some of the pelvic organs are left as a sequel to it. Causation.—Spread of infection from below in most cases, either after a gonorrhceal, streptococcal, or tuber- culous inflammation of the tubes, or as a result of puerperal sepsis. The tubes become inflamed, the infection spreads to the peritoneum, the involvement of the latter being at first, perhaps, very local, depending, however, to a great extent on the virulence of the organism concerned. If the salpingitis lasts for any length of time, which is usually the case in a severe infection, the pelvic peritoneum has ample opportunity to become infected. It responds to this infection by the development of limiting bands of adhesions, the formation of which is associated with pain. Their ensuing contraction may cause displacement of the neighbouring organs. Symptoms.—In the acute stage, rise of pulse and temperature, pain, tenderness in the lower abdomen ;- some degree of distension is often present. In the more chronic stages the symptoms occurring are often due to adhesions, The patient may have recurrent attacks of pain; dysmenorrhcea may be present. If there be a retroversion of the uterus, some symptoms due to this displacement may exist. If the ends of the tubes be occluded as a result of the pre-existing salpingitis, the patient will be sterile. 7778 AIDS 20 GUN ECOLOGY. Treatment.—Iin the acute stage rest in bed, hot appli- cations to the lower abdomen, and efforts directed towards relieving the pain should be made. Ifa dilated pus tube be felt low down in Douglas’s pouch, it should be opened from below. In the chronic stage, operation for the breaking down of adhesions is usually indicated, when any displacement of the uterus can be remedied, and efforts made to restore the lumen of the tube, where such restoration is possible. Pelvic Cellulitis, or Parametritis. By this term is meant inflammation of the pelvic cellular tissue, which may be acute or chronic. Para- metritis only follows lacerations of the cervix or perfora- tion of the vagina either after labour or abortion, or through injuries caused by instruments during the course of an operation or used in criminal abortion. Lacerations of the perineum are also the cause of parametritis. The condition may be secondary to infections of the uterus, Fallopian tubes, or ovaries. Symptoms.—The manifestations of this condition are usually fairly obvious a few days after the injury has occurred. There is more or less irregular temperature accompanied with severe intrapelvic pain. Defeecation is painful, and, though at first there is a tendency to constipation, subsequently there is marked diarrhcea. Micturition may be painful and difficult; nausea and vomiting are also common symptoms. If the attack follow parturition, the flow of milk is stopped and the lochial discharge ceases. The patient lies on the back, with the leg on the tender side drawn up. The mouth ’ is dry ; there is thirst and loss of appetite. If the attack be mild, and the patient is able to lead an ordinary life, there may be no other symptom than a dull aching in the back and a feeling of weight in the pelvis. In these casesPEEVIC PERITONIS AND CELE UEEPIS 79 resolution has taken place, and there are cicatricial con- tractions of the ligaments. On examination the vagina is hot. The cervix is lower than is normal, and in post-partum cases it may be drawn to one side or the other. On abdominal examination a large rounded swelling may sometimes be felt rising out of the pelvis. On bimanual examination it will be found that the uterus is fixed and immovable. If the exudate is one-sided the uterus will be displaced, and sometimes the exudation fills the pelvis and obliterates the vaginal fornices. The exudation is so hard, and the uterus so fixed and immovable, as to give the sense that it is embedded in plaster of Paris. The exudation occupies the cellular tissue in the broad ligament, and may spread forwards to the tissues between the uterus and bladder. Cellulitis is nearly always accompanied by more or less peritonitis. There may be thrombosis of the pelvic veins and sinuses extending to the vena cava. If the left broad ligament be affected, the exudation may surround the rectum. Diagnosts.—The diagnosis is not difficult, the history of the case being as a rule a determining factor. The fixation of the uterus in the neighbourhood of the thicken- ing will also serve as a guide. This thickening gives a diffuse character to the swelling. Course.—The first stage is one of congestion, which very quickly passes on to that of exudation. The disease may remain in this stage, or it may proceed to suppura- tion. If this should occur, an abscess forms which may point— 1. To the abdominal wall, externally just above Pou- part’s ligament, above the pubes, through the perineum or buttock. 2. It may rupture into one of the hollow viscera— namely, the bladder, the rectum, or the intestines. 3. It may discharge into the peritoneal cavity.80 AIDS TO GYNAZCOLOGY 4. It may discharge through the vagina, and this is probably the most ordinary course. When the progressive stage of the inflammatory con- dition is over resolution takes place, and very frequently the exudation may clear up completely. Deposits in the various ligaments are by no means rare and give rise to considerable displacement of the pelvic organs. For instance, in unilateral cases the cervix will be drawn over to the affected side, and the fundus of the uterus will in consequence be much displaced towards the unaffected side. The utero-sacral ligaments are very frequently affected, causing typical displacement of the uterus—namely, anteflexion. The peritoneum and the pouch of Douglas may remain permanently thickened. Parametritis may cause peritonitis, ovaritis, and salpingitis. Treatment.—Complete rest in bed is an absolute essen- tial, and in the great majority of cases this, accompanied by hot antiseptic douching and hot fomentations over the lower part of the abdomen, will be all that is required. After a period of some weeks complete absorption may take place. The bowels should be kept thoroughly open by means of saline aperients. Tampons of ichthyol and glycerine materially help in the absorption of the exudate. In cases of severe pain it may be necessary to prescribe opium. If resolution does not take place, but the condition advances to pus formation, the abscess, as soon as it can be located, should be opened and the pus evacuated. The cavity should then be thoroughly washed out and a large drainage-tube inserted.CHAPTER KIII THE BLADDER Vesico- Vaginal Fistula. IF the symptoms of the patient suggest it, look for a fistula in the course of your examination. There is usually a history of very prolonged labour or a difficult forceps. The condition results from the bruising of a small area of tissue between the foetal head and the maternal pelvis. This subsequently becomes necrotic, and a communication is left between the vagina and bladder, or there may have been actual tearing of the tissue by the blades of the forceps. Foreign bodies, such as pessaries, if worn for a long time, may cause a fistula. It also occurs in the course of advanced malig- nant disease. Symptoms.—There is a constant dribbling away of urine, the vulva and inner side of the thighs become ex- coriated, and there may be some pruritus. Diagnosis.—It is essential to obtain a good view of the parts, therefore put in as large a posterior speculum as possible, pull down the cervix with a bullet forceps, and examine the region of the anterior fornix. If acatheter be passed while you are doing this, you will be able to see how far the bladder comes down on the anterior wall of the cervix by feeling the end of the catheter with your finger in the vagina, at the same time keeping tension on the cervix. It you have been unable to detect the locality of the fistula, fill the bladder with some fluid such as normal saline. When the bladder is full, the patient will feel uncomfortable and have a desire to pass water. Now 81 682 AIDS TO GYNECOLOGY wipe the vagina with a piece of cotton-wool on the end of a forceps, and endeavour to see where the saline is escaping from, for it will run out through the fistula if one exist. A good light is essential, needless to say ; the patient should be on an operating table with leg rests fitted, or on a gynecological chair. Lateral vaginal] retractors may help you considerably. Treatment.—Repait. Cystitis. This condition is the result of infection conveyed to the bladder either directly or indirectly. The infection may have travelled either down the ureter, or up the urethra; in the latter case as a sequel to a vulvitis, or a vaginitis. Similarly, injury to, or infective conditions of, neighbouring structures, may permit the entry of virulent organisms to the bladder. Among such conditions parametritis may be mentioned. It must not be forgotten that infection can be caused by the passage of catheters, if aseptic precautions be not taken. Symptoms.—Pain and tenderness over the hypo- gastrium ; pain will also be caused by a vaginal ex- amination. The bladder is extremely irritable, and the patient endeavours to pass water very frequently, the quantity passed at any one time being small. Efforts to micturate cause pain. The urine may contain blood; pus and albumen are present. There is a rise of pulse and temperature. In more chronic cases the walls of the bladder may be thick, and micturition somewhat more frequent than normal. Treatment.—Rest in bed, together with efforts towards relieving pain; hot applications to the lower abdomen, vaginal douches, urotropin in 5 to 15 grain doses may be given t.1.d.THE BLADDER 83 When the acute stage has passed, as indicated by the less frequent micturition (Jellett), wash out the bladder every second day ; boracic acid (saturated solution) may be used. The same author suggests using a Bozeman’s return- flow catheter for this purpose. An instrument of suitable size is selected, and connected to a small douche can. Pass the instrument into the bladder, keeping the thumb over the return-flow outlet until the bladder is distended (ascertain the latter by asking the patient whether she be comfortable or not), then, by removing the thumb from the return-flow outlet, the fluid runs out from the bladder. Tumours. Fibroma, myxoma, and papilloma, the latter being the most frequent. Sarcoma and carcinoma ; the latter may be primay, or the result of extension from the uterus or cervix. Symptoms.—Heematuria and increased frequency of micturition. Diagnosis.—A new growth may be palpable on making a bimanual examination. Examine with the cystoscope. Treatment.— Operative. megaenon(CISUAUPINBIN OY ERRORS OF DEVELOPMENT External Genitals. 1. THERE may be more or less atresia of the vulva. 2. Persistence of the cloaca, in which the vagina and rectum have one common passage. 3 Persistence of the uro-genital sinus, or hypospadias. This is to be found in varying degrees. There may be simply a canal beneath the clitoris into which the urethra and vagina open, or there may be a wide gap which in- volves the vase of the bladder and urethra. Hypertrophy of the clitoris is very often associated with this condition. 4. Hermaphrodism—that is to say, a combination of the male and female generative organs—is rarely met with in human beings. Pseudo-hermaphrodism is more common. By this term is implied those cases in which the external genitals of a male resemble those of a female, and vzce versa. The condition most frequently met with is that of the individual in which the male organs of generation, owing to defective development, resemble the female. There is failure of development of the penis and non- union of the scrotum, giving the impression of the clitoris and the vulval opening. It may be extremely difficult to determine the sex in a child the subject of such an error of development, and it is probable that not until puberty is reached will any indication as to the true sex of the in- dividual be obtained. One point of importance in deter- 84ERRORS OF DEVELOPMENT 85 mining the question of sex after puberty is the arrange- ment of the pubic hair. In the female this is triangular in shape, with the base above, whereas in the male the apex is above, and reaches to the umbilicus. 5. The vulva may be double, or it may be altogether absent. Internal Genitals. The vagina may be double, and this maldevelopment is often associated with double uterus. There may be com- plete absence of the vagina, and atresia of the vagina not infrequently occurs; but, as before stated, this is more often seen in those cases of so-called imperforate hymen. The uterus may be entirely absent or it may be rudi- mentary, in which case it is generally a hard, fibrous mass. There is anvther condition, known as infantile uterus, which is not an error of development, but rather a state of arrested development. Uterus Unicornis.—This is a condition in which only one horn of the uterus has developed. Double Uterus.—TVhere are three forms of this mal- development : (a) Septate Uterus.—The uterus may be divided into two—that is to say, there is a dividing septum in the uterus. This condition is often associated with septate vagina. Externally the septate uterus may be normal in shape. (6) Uterus Didelphys.—On examination, the surfaces of the uterus can be moved independently of each other ; double vagina is often found in conjunction with this condition. (c) Uterus Bicornts.-:-In this condition the lower part of the uterus is complete, while the upper part consisting of the two horns, has remained unfused. Sometimes one or both horns may be imperforate ; again, one or both horns may be rudimentary. It should be remembered that pregnancy taking place§6 AIDS TO GYNECOLOGY in the rudimentary horn of the uterus is practically the same as tubal gestation. The cervix may be single or double. The Fallopian Tubes.—There may be abnormal attachment of the tube to the uterus ; there may be acces- sory tubes or accessory ostea. The Ovaries.—There may be absence of one or both ovaries, the latter being very rare. Rudimentary ovaries sometimes occur. They are generally associated with non-development of the other pelvic organs. Super- numerary ovaries are sometimes found.GHAR TER. XV SYPHILIS AND GONORRHG@A Syphilis. Primary Lesions.—Primary sores may be so slight as to escape recognition. They may consist of an erosion, a small ulcer, or a true hard chancre. The hard sore is practically painless. The following are the most ordinary sites in which primary lesions occur: the labize minora and majora, the clitoris, and more rarely the cervix. Usually, the primary ulcer is single and of small size, funnel-shaped, with a hard, clean-cut edge. The characteristic induration is always present, and this may extend to the inguinal glands. Secondary Lesions.—Condylomata are the most fre- quent secondary lesions, occurring as papules, and often occupying the whole of the vulvo-vaginal and anal regions. Rash.—A typical coppery rash occurs on various parts of the body, particularly the abdomen, vulva, chest and back. Sore throat and loss of hearing are common. Tertiary Lesions and Gummata are rare, although they have been found occasionally in the labia. Treatment.—Mercury should be administered imme- diately the condition is diagnosed, and given either by the mouth, by inunction, or intramuscular injection. If given by the mouth, the best method is to give it in pill form, and the following prescription will be found useful : 87AIDS TO GYNACOLOGY i Hydrarg. G7 cheta ; aa pr. Ss. Ferri sulph. ex. M. Ft. pil. One pill to be taken three times a day. Every third day increase one pill until a distinct metallic taste appears in the mouth, then half the dose should be taken for two years. Thus, a patient will start taking one pill three times a day, and each subsequent day one more pill will be taken, so that on the tenth day after commencing treatment the patient should be taking six pills daily, and this increase should be maintained until a definite metallic taste is experienced. Half the number which have been required to produce this phenomenon must be regarded as the per- manent dose. For the mucous patches calomel and calamine powder should be applied. For tertiary lesions, such as gummata, potassium iodide should be given in full doses. Latterly, in addition to the administration of mercury, it is usual to treat the patient by intravenous injections of Novarsenobillon, ‘914,’ or allied preparation. The initial dose is generally about 0o°3 gramme; an interval of eight days is allowed to elapse, when a second dose is given. The dose may be gradually increased provided that no unfavourable symptoms arise. In the majority of cases it is probably advisable not to exceed what might be described as a medium dose, and to regard o'9 gramme as a Maximum. With reference to the effect and duration of treatment, we follow largely the description given by Harrison, The immediate effect of the injection is the dis- appearance of the S/. pallidum from the syphilitic lesions. But when it is required to ascertain the result of theSYPHILIS AND GONORRHG@A 89 treatment, particularly when we wish to know whether the patient is cured or not, it may be extremely difficult to form a definite opinion. If the Wassermann reaction was positive before treat- ment, then its disappearance tells us that treatment is having an internal and marked effect, but a negative reaction unfortunately does not imply that all spirochzete have been killed. Therefore it 1s necessary to keep up treatment for a long time after the blood- serum (removed within a few days of the last injection) gives a complete negative reaction. Partial or doubtful reactions are regarded as indications that further treatment is necessary. After the termina- tion of the course of treatment, the blood should be tested at decreasing intervals, beginning at three-monthly intervals, until such a time as the physician is satisfied that a cure has been attained. Gonorrhea. Of all forms of organismal infection that produced by gonorrhcea is the most frequent, and it is a much more serious disease in the female than in the male, for it must be remembered that the peritoneal cavity is practically open to infection. The lesions produced by direct infection of the gonococcus in adults are brought about by impure sexual intercourse, and by careless examination with infected hands or instruments and towels. In children the disease may be acquired from an affected male, or from towels or sponges. It is important to remember that the disease, especially in young, newly-married women, is acquired from the husband, who believes him- self to be cured but is nevertheless infected—that is to say, although he is without the actual symptoms, the organism is still present in the urethra.90 AIDS TO GYNECOLOGY Diagnosts.—Before an absolute diagnosis can be made, it is essential that an attempt should be made to estab- lish the presence of the organism in the discharge by means of bacteriological examination. The affected parts are attacked in the subjoined order: The Vulva.—In mild cases there is reddening of the labia, accompanied by a muco-purulent discharge from the urethra. In more severe cases there is actual inflam- mation, with swelling of the parts. On inspection the labia are seen to be congested, and there is a profuse muco-purulent discharge. Warts may appear in those cases where the condition is due to a mixed infection. The glands in the groins are enlarged and may suppurate, though, as a rule, if inflammation is solely due to the gonococcus, suppuration does not occur. The urethra is -usually affected, but owing to its large bore the urethritis is not so severe as in the male; there may, however, be a burning sensation during the passage of urine, and there is generally a certain amount of cystitis. It is well to remember that the gonococci may remain for years in the two small apertures (Skene’s tubules) just within the mouth of the urethra on its posterior walls. Bartholin’s Glands.—This is a common site for gonor- rheeal infection. The micro-organism usually infects the duct and causes a catarrhal condition which obstructs the flow of secretion from the gland. Asa rule gonorrheeal infection of Bartholin’s gland is bilateral, and suppuration is a frequent concomitant. The patient suffers a great deal of pain, especially on walking. The Vagina.—Although the organism may be found in the discharge, the vagina generally speaking, except in young children, is not so liable to infection as are the external genitals. In severe cases the mucous membrane of the vagina may become infected, and the epithelium shed, the condition giving rise to follicular ulceration.SYPHILIS AND GONORRHEA gI Cervix Uteri.—The columnar epithelium of the cervix uteri may be infected. In the acute stages the organ will be found swollen and reddened, and may be tender on examination, a very copious purulent discharge being present. Where the disease has become chronic, the cervix shows small cystic swellings (Nabothian follicles), which cause a permanent chronic thickening of the part. Corpus Uteri.—When the body of the uterus is at- tacked, the endometrium becomes swollen and congested, and there is generally a free discharge. If the endome- trium become infected after parturition, the whole body of the uterus may be involved. This organ is then en- larged, extremely tender, and the patient complains of a dull aching pain in the hypogastrium. In the chronic stages of the infection the uterus is enlarged, there is pro- nounced leucorrhceal discharge, and the muscular walls of the organ become fibrous. These symptoms are accompanied by a good deal of menorrhagia and dys- menorrhcea. The Fallopian Tubes.—The upward spread of the gonococcus to the Fallopian tubes produces an acute and chronic salpingitis. The inflammation affects the mucosa of the tube and also its walls. The fimbriz are swollen and engorged. There is acute abdominal pain, accom- panied by a rise in temperature and quickened pulse. In the gonococcic form of infection there is generally marked thickening of the tubes, while the abdominal ostium becomes closed, partly by obstruction, and partly on account of the extreme thickening of the mucosa and walls of the tube. The uterine ends of the tubes may also be closed by thickened mucous membrane. Pus is liable to accumulate in the tubes, giving rise to pyosalpinx ; sometimes, however, the walls of the tubes may be filled with a clear fluid (hydrosalpinx). When the infection is severe the tubes may become bound down by adhesions92 AIDS TO GYNECOLOGY often to the floor of the pelvis, or they may be twisted round and adhere to the back of the uterus, the ovary, and bowel. Ovaries.—An acute infection may be set up, but more frequently the condition is one of chronic odphoritis, The ovary may be the seat of abscesses, and associated with pyosalpinx (tubo-ovarian abscess). Symptoms.—The symptoms of tubal and ovarian gonorrhoea are—pain in the lower abdomen of a bearing- down character, menorrhagia, and dysmenorrheea. There is commonly pain on defecation, and the bowels are usually constipated. If there is pus formation, rigors may be present, and there may be marked elevation of temperature. There is generally dyspareunia. Patients who are the subject of gonorrhceal salpingitis are almost invariably sterile, and those women who have already borne a child and become infected with gonorrhcea following childbirth become sterile. Diagnosts.—On examination the uterus will be found enlarged, possibly retroflexed, and bound down by adhe- sions. Large swellings, very often sausage-shaped, may be found stretching across the pouch of Douglas to which they are adherent. General Treatment.—In acute cases the external genitals should be bathed several times a day with warm antiseptic lotions, such as argyrol, 20 per cent. Wool and gauze pads should be worn to absorb the discharge, and these, owing to their infectious nature, must be burned as soon as they are removed. In children, at all events, it is better not to introduce an instrument into the vaginal canal, the bathing, as suggested above, proving in most cases to be sufficient. In adults, where there is an exten- sion of the disease into the vagina, this cavity may be douched with a weak solution of one of the silver salts or permanganate of potash. After washing or using a douche, the parts should be thoroughly dried and powderedSYPHILIS AND GONORRH@A 93 with boric acid. A milk diet is best, and savoury food and spiced dishes, etc., should be avoided. Alcohol must be forbidden, and the patient should be encouraged to take large quantities of barley-water and oatmeal- water. The bowels should be kept thoroughly open with salines. If there be much irritation or pruritus, a lotion of sub- acetate of lead mixed with chloroform and rectified spirit may be applied to the parts. Coitus should, of course, be forbidden. The husband should be examined, and if found to be suffering from gonorrhcea, recent or old, should be properly treated. The first aim, both in the chronic and subacute condi- tions, must be to get rid of the micro-organism, and the following plan may be adupted with success : The vagina should be thoroughly distended with a warm douche of biniodide of mercury (1 in 6,000), by means of which much of the discharge from the folds and depressions will be removed. The part should afterwards be wiped with sterile swabs. Following this a Sims’ speculum should be passed, and the cervical canal thoroughly swabbed with a 10 per cent. solution of protargol, or 20 per cent. argyrol. Every ridge and sulcus of the vagina must be treated in the same way, after which it may be packed with sterilized bismuth gauze, which should be left in for twenty-four, or even forty-eight, hours. When this is removed, the vagina should be again well douched with the biniodide solution. The following night it should be packed with gauze which has been steeped in the following solution : B. Glycerini acidi borici ... ae Ses Bll. Glycerini acidi carbolici = Bae NG Spirit. rect: ay a es ee alls ZN GLeGts ear Se se ae 2. ad Sit94 AIDS TO GYNECOLOGY This treatment must be repeated every night until the discharge diminishes, when a daily douche of permanga- nate of potash (3i. to O.i.) may be substituted. In those cases where the packing of the vagina causes much pain a cocaine plug (5 per cent.) may. be inserted some ten or fifteen minutes previously, after which the packing can be carried on without much discomfort. In Germany and America injections of yeast have been much advocated recently for the treatment of gonorrhceal vaginitis, and it is claimed that this substance very quickly removes the gonococci and controls the dis- charge. When the infection is limited to the cervix, care must be taken against infection of the uterine cavity. The cervical canal should be very thoroughly cleansed from all discharge, after which the mucous membrane should be painted with a ro per cent. solution of protargol, or a 20 per cent. solution of argyrol, this treatment being repeated on alternate days. After the painting the vagina should be lightly packed with gauze, which may be removed in the evening. The removal of the gauze packing should be followed with a warm antiseptic douche. In chronic gonorrhceal endometritis the uterine canal must be carefully dilated, and a solution of protargol or argyrol (of half the strength in each case to that quoted above), or of iodized phenol, may be applied with a uterine mop. After this a clean mop should be inserted into the canal and left 27 sz¢u to act as a drain, the vagina being lightly packed with sterile gauze. At the end of twenty-four hours the uterine mop should be removed, and the vagina gently douched with a warm antiseptic. In infection of the Bartholinian glands the abscess should be opened, and, if possible, the gland should be dissected out, the wound being packed with gauze and allowed to heal from the bottom. If the gland cannot beSYPHILIS AND GONORRHGA 95 found, the abscess cavity should be thoroughly cleansed and swabbed with a solution of argyrol or protargol. When the tubes and ovaries are affected, the same treatment as that given for other post-infective conditions should be employed. Vaccine treatment may be given a trial in cases where the ordinary methods are unlikely to clear up the condition at all satisfactorily. The initial dose should be small (5,000,000), as there is a possibility of a sharp reaction ; subsequently it can be increased.CHAN REK 2ovil THE FEMALE GENITAL ORGANS THE genital organs in the female may be divided into external and internal. External Genital Organs. These are described collectively as the pudendum or vulva, and comprise the mons veneris, the labia majora and minora, the clitoris, and, in virgins, the hymen. The mons veneris is the prominence, due to a deposit of adipose tissue, situated over the symphysis pubis. After puberty the skin over it is covered with hair, dis- tributed in the shape of a triangle with the base apwards. The labia majora are two large folds of skin extending from the mons veneris to the anterior margin of the perineum, enclosing an elliptical aperture, the 7zma pudenadt. ‘They are joined posteriorly by a delicate fold of skin called the fowrchetfe. Between the fourchette and the entrance to the vagina is a depression known as the Jossa navicularis. The structure of the labza majora corresponds to that of the scrotum in the male, consisting of skin, superficial fascia, and dartos. Externally the skin is covered with hair, and embedded in it are numerous large sebaceous glands. Internally they are lined by mucous membrane, also richly supplied with 96THE FEMALE GENITAL ORGANS 97 glands. The vascular supply is abundant, and the veins form a plexus. FIG. 15.—THE VULVA. a, Labia majora; 8, labia minora ; c, meatus urinarius; d, glans clitoris; e, clitoris; f, mons veneris. The labia minora, or nymphe, are two small folds of skin modified by the secretion with which they are bathed. 798 AIDS TO GYNECOLOGY They unite to furnish the prepuce of the clitoris in front, and are lost on the inner surfaces of the labia majora behind. They contain numerous sebaceous glands, and are richly supplied with sensory nerves. The clitoris is an erectile, highly-sensitive organ, corresponding to the corpora cavernosa of the male. It is attached by crura on each side to the ischio-pubic rami, and the corpora converge to form the body of the clitoris, which is attached to the symphysis by a suspen- sory ligament. The end is rounded (the g/ams), and is invested by a prepuce-like fold, forming below a sort of frenum, which merges into a triangular area—the vesttiule—limited in front by the clitoris, laterally by the converging labia minora, and posteriorly by the margin of the vulvar orifice. The urethra opens on to this space just above a slight prominence, sometimes called the anterior tubercle of the vagina, a useful guide to the canal when it is desired to introduce a catheter. The hymen is a membrane of variable thickness and shape which, in virgins, more or less obstructs the entrance to the vagina. Usually crescentic in shape, with the concavity forwards, it may be annular, fimbriated, cribriform, or imperforate. When ruptured, it leaves a number of fleshy projections marking the original line of attachment, known as the caruncule myrtiformes. In addition to the numerous glands embedded in the labia, etc., there are two special structures called the vulvo-vaginal glands, or the glands of Bartholin. These vary in size from a pea to a small filbert, and are situated one on each side near the margin o* the vaginal wall. Their ducts, about half an inch in length, open in the recesses between the corresponding ladium minus and the fold of the hymen. Extending from the clitoris, along either side of the vestibule and a little behind the nymphe, are two oblong masses, about an inch in length, made up of a plexus ofTHE FEMALE GENITAL ORGANS 99 veins enclosed in fibrous tissue. Together they form the vestibular bulb, a structure analogous to the corpus spongiosum in the male. The blood-supply of the vulva is derived from the superficial and deep external pudic and the superficial and transverse branches of the pudic artery. Internal Genital Organs. These comprise the vagina, the uterus, the Fallopian tubes, and the ovaries. ‘the vagina extends from the vestibule to the uterus, and is situated in front of the rectum and behind the bladder, running in the axis of the pelvis obliquely up- wards and backwards. Its coats are reflected on to the neck of the uterus, forming the anterior and posterior ‘ fornices, the latter being the deeper of the two. The 1h walls are ordinarily in contact, and its shape on trans- 1 verse section is that of an H. ‘The anterior wall is from 4 24 to 3 inches, the posterior or longer wall being from 34 to 4 inches in length. Narrow at the vulvar aperture, it gradually widens above to embrace the cervix. The vagina has three coats: an external fibro-cellular coat; a middle coat of longitudinal muscular fibres ; and an internal coat of mucous membrane, richly supplied with papillee and lined with squamous epithelium. The vaginal mucous membrane differs from others in that it does not contain any mucous glands, the vaginal secretion proper being ‘a transudation of albuminous fluid with h| shedding of the superficial layer of the epithelium’ (Herman). When poured out, it is probably a/kaline in } reaction, but in the lower part of the vagina, where micro- organisms abound, it is acid. There is a longitudinal ridge, or raphe, on the anterior and posterior walls, from which radiate transverse wrinkles, or swg@. The lower end of the vagina is invested by an orbicular muscle (the constrictor vagine), which is sometimes inordinately de-100 AIDS TO GYNECOLOGY veloped, and the vulvar aperture in the virgin is partially closed by a fold or ring of membrane (the hymen). This membrane is occasionally imperforate, giving rise, on the supervention of menstruation, to retention and accumula- tion of the exuded blood. The vaginal arteries are derived from the anterior divisions of the internal iliac arteries or from the uterine or middle hemorrhoidal arteries. The lymphatics of the lowest third of the vagina, together with those of the external genitals, empty themselves into the inguinal glands. The lymphatics of the upper two-thirds, in con- junction with those of the cervix and bladder, enter the hypogastric or internal iliac glands. Relations.—-The vagina is in relation in front with the urethra and the base of the bladder; at the sides, for a short space, above, with the ureters. Posteriorly the vagina, in the lower three-fourths, is in contact with the rectum, from which it is separated in the upper fourth by the recto-uterine fold of peritoneum, which, dipping down behind the uterus, forms a depression known as Douglas’s pouch. This is the lowest point of the pelvic peritoneum, and in it, therefore, all exudations tend to collect. The uterus, or womb, is a hollow, pear-shaped organ weighing from 1 to 1$ ounces, about 3 inches in length, and 2 inches in width at its upper part, or fundus. For purposes of description the uterus is described as con- sisting of three parts—the fundus, the body, and the cervix. The body is the part between the fundus and the cervix. The cervix is the lower, narrower segment, cylindrical in shape, which projects through the roof of the vagina. It consists of two portions—the fortio vaginalis and the portio supravaginalts. The cavity of the uterus, flattened antero-posteriorly, is triangular in shape, with the apex below. The upper angles open into the Fallopian tubes, and the apex corre-THE FEMALE GENITAL ORGANS IOI sponds to a constriction called the os i#¢ernum, or internal os, which marks the line of demarcation between it and the cervical cavity. The latter is spindle-shaped, and communicates with the vagina below through another constriction, the os externum (external os) or os udéert. This is a rounded or slit-like aperture in the centre of the vaginal portion. The anterior and posterior surfaces are Fic. 16.—RELATIVE POSITION OF PELVIC VISCERA. A, Uterus pushed back by distended bladder ; B, distended bladder ; C, rectum. marked by two longitudinal columns, from which proceed a number of small folds, the so-called ardor vite, which becomes indistinct after child-bearing. The uterus becomes heavier during menstruation and after child-bearing. After the menopause it undergoes atrophy, The depth of the uterus, from the external os to the102 AIDS TO GYNECOLOGY fundus, is 2} inches, but may be more in multipara. About half of this belongs to the cervix. Structure.—The uterus has three coats, or layers— serous (from the peritoneum), muscular, and mucous. The muscular layer is the principal constituent of the uterine wall. It is made up of interwoven bundles of unstriped muscle fibres, which undergo a remarkable development during pregnancy, and are apt to give rise to special growths called myomata. The mucous mem- brane of the body of the uterus is very thick, and is lined with ciliated columnar epithelium down to the internal os. By the aid of a magnifying-glass the orifices of numerous tubular follicles (the utricular glands) may be seen. These discharge a clear, not very viscid, mucus. On impregnation taking place, the superficial epithelial cells are shed, and the same thing occurs to some extent during menstruation. The mucous membrane of the cervix differs from that of the body, in that it is lighter in colour, firmer and thinner, and is lined with tessellated epithelium on its lower third. It contains numerous glands (glandule Nabotht) which secrete an alkaline, viscid, almost gelatinous mucus. The ligaments of the uterus are eight in number: 1. The droad ligaments (two), which are folds of peri- toneum passing from the sides of the organ to the walls of the abdomen, dividing the true pelvis into an anterior and a posterior part. 2. Anterior and posterior ligaments. These are also folds of peritoneum from the uterus to the sacrum behind (utero-sacral ligaments, two), and from the uterus to the bladder in front (utero-vesical ligaments, two). The space between the sacro-uterine folds is known as Douglas’s pouch, and, being at a lower level, intra- peritoneal effusions (blood, etc.) gravitate into it. 3. The round ligaments (two) are partly contained in the broad ligaments. They are musculo-fibrous cords attached, one on each side, to the upper part of the uterus, just belowTHE FEMALE GENITAL ORGANS 103 the Fallopian tubes. Processes of peritoneum accompany them into the inguinal canals, which may remain patent (canal of Nuck), and the cords ultimately terminate in the integument of the groin and labia majora. ihe round ligament is a useful diagnostic guide in deter- mining the tubal or uterine origin of certain tumours. In uterine growths it is attached to the outer side of the tumour, whereas in tumours of tubal origin the hgament can be followed past them to its uterine attachment. Relations —The uterus leans forward, forming an obtuse angle with the vagina, and is normally in the axis of the pelvic brim. The fundus is covered by peritoneum, and ‘s in contact with the small intestines. It rarely reaches the level of the brim, but rises above an imaginary line drawn horizontally backwards from the upper margin of the symphysis pubis. The lower end projects into the vagina. The anterior surface is closely invested over its upper three-fourths by peritoneum, and the remaining fourth is in contact with the bladder. The posterior surface is covered throughout by peritoneum, and corresponds to the anterior wall of the rectum, from which it is separated by Douglas’s pouch, usually filled by coils of intestine. The sides correspond to the adjacent layers of the broad ligaments, and along them run the uterine arteries and the utero-ovarian plexus of veins. The blood-supply of the uterus is derived from the uterine (from internal iliac) and ovarian (from aorta) arteries. ‘The ovarian arteries run downward in the sub- serous tissue, passing between the layers of the broad ligament (where they send branches to the ovary, Fallopian tube, etc.), along the sides of the uterus, where they inosculate with the uterine arteries, the loops thus formed giving off lateral branches, which run round in the substance of the organ and join with corresponding branches from the other. From these transverse branches104 ALDS GO GYN ZCOLOGY smaller ramifications penetrate the mucous membrane. Each transverse section of the uterus has thus an inde- pendent blood-supply. In its course through the broad ligament the ovarian artery communicates with a small branch of the deep epigastric artery, which runs along the round ligament. The uterine arteries arise either from the hypogastric o> Mir “Sa uaa i } Fic. 17.--DIAGRAM OF THE VASCULAR SUPPLY OF THE VAGINA, UTERUS, AND OVARY. trunk or directly from the anterior division of the interna. iliac. They travel beneath the pelvic peritoneum towards the cervix and run tortuously up the side of the uterus, rather behind the middle line, to anastomose with the Ovarian arteries. The veins are of large size and in the pregnant uterus they develop into cavities called sinuses These sinuses constitute the connecting link between the arteries and veins in the pregnant uterus, taking the place of the capillaries. Passing out of the uterus at its sidesTHE FEMALE GENITAL ORGANS 105 and uniting with the ovarian and vaginal veins they form what is called the pampiniform plexus between the folds of the broad ligaments. There are also numerous lym- phatics arranged in two sets—superficial and deep. The former lie immediately beneath the peritoneum ; the latter are embedded in the uterine tissues. The ducts run between the layers of the broad ligaments, where they join the lymphatics of the tubes and ovaries, and ultimately terminate in the iliacand lumbar glands. The nerve supply is derived from the inferior hypogastric and spermatic plexuses and from the third and fourth sacral nerves. The Fallopian tubes, or oviducts, are about 4 inches in length and extend from the upper angles of the uterus to the ovaries, passing between the layers of the corresponding broad ligament. Narrow where it passes through the uterine wall (barely admitting a bristle), the tube becomes dilated as it proceeds outwards along the outer free border of the broad ligament, forming what is known as the ampulla. This terminates in the zxfundibulum, a trumpet-shaped dilatation, fringed with fbrie, which embrace the ovary (the morsus diabolt), one of the fimbrize being attached thereto (fméria ovarica). The distal orifice of the tube is called the ost¢wm abdominale, through which the peritoneal cavity is in communication with the uterus. The tubes have three coats ; externally they are invested by peritoneum, except where covered by the broad ligament ; then comes the usual connective- tissue layer, inside which is the muscular coat, consisting of two layers (longitudinal and circular) of unstriped muscle-fibres. They are lined by mucous membrane in longitudinal folds, paved with columnar ciliated epithelium. The ovaries are two ovoid bodies, 14 inches in length, 3 inch in width, and 4 inch in thickness, somewhat flattened antero-posteriorly, and presenting on the lower border a depression—the 4z/um. The weight of each106 AIDS TO GYNZECOLOGY ovary is from 14 to 2 drachms. It is attached to the uterus by a fibro-muscular band (the utero-ovarian liga- ment) which allows of a certain mobility, and is con- nected with the broad ligament at its free edge by the so-called infundibulo-pelvic ligament. It is usual to describe two coats, one serous and one fibrous (the tunica albuginea), but their existence is doubtful. The substance of the ovary on section, is seen to consist of two perfectly distinct parts: (1) A superficial layer which is light in colour, this is the egg-bearing portion (the oéphoron), which envelops (2) the central portion, consisting of a soft vascular tissue or stroma of a reddish hue (the parovphoron). In the outer or superficial layer are embedded the Gradfian follicles, varying in size, the most superficial being smaller. As they increase in size on approaching maturity, though for a time more deeply placed, they ultimately form projections on the surface, and every three or four weeks one of them bursts and discharges its contents into the infundibulum, through which the ovum is propelled into the uterus, partly by muscular contraction, partly, no doubt, aided by the cilia of the lining epithelium of the Fallopian tube. The Graafian follicle is about ;4 9th of an inch in diameter before it begins to enlarge. At this stage it consists merely of a layer of flattened cells investing the ovum. Later the cells become cubical and a basement membrane is developed (the membrana propria). Within this a layer of cells forms (the membrana granulosa), which in one part is heaped up to form the adéscus proligerus, in which the ovum is embedded. Fluid accumulates within the follicle, leading to distension. Each follicle usually contains but one ovum, though more are sometimes present. The ovum, just prior to its escape, is a spherical vesicle ;4:th of an inch in diameter. Under the microscope it is seen to consist of a centre (the vitellus or yolk) surrounded by a striated zone (the zonaTHE FEMALE GENITAL ORGANS 107 adtata, formerly described as the zona pellucida). In the yolk is the nucleus, or germinal vesicle (z}pth of an inch), containing a well-marked nucleolus, the germinal sot. When a Graafian follicle bursts, its walls are thrown into folds which ultimately fill the cavity left by the escape of the ovum, the interstices being occupied by a jelly-like substance and bloodclot. This is the corpus luteum. Inthe unimpregnated state the blood is absorbed, the cavity contracts, and in the course of two or three months only a scar remains. The repetition of this process renders the originally smooth surface of the ovary rough and irregular. When pregnancy occurs the corpus luteum persists in a well-developed form for three or four months, after which it gradually retro- gresses, but finally disappears only two or three months after delivery. The parovarium, or organ of Rosenmiiller, is the remnant of the sexual division of the Wolffian body. It is situated in the mesosalpinx (the fold of broad ligament investing the Fallopian tubes) between the ovary and the tube, and consists of a series of tubules radiating from the ovary to join a longitudinal tubule which unites their extremities (Gartner’s duct). They are lined with epi- thelium and contain a clear fluid which is coagulated by acetic acid. The parovarium is not infrequently the seat of cysts, due to distension of the tubes, or some of them. Gartner’s duct runs horizontally inwards, and sometimes passes along the side of the cervix uteri, ending in a cul-de-sac, or there may be a small aperture, close to the meatus of the urethra. Distension of this lower part may give rise to a cyst bulging into the vagina. The Pelvic Peritoneum.—The peritoneum, reflected from the anterior surface of the rectum, covers the uppermost part of the posterior vaginal wall for the space of three-quarters of an inch, and the whole of the posterior surface of the uterus. It is closely adherent to the fundus108 ALDS LO GYNZCOLOGY uteri, and covers the anterior surface of the organ to the level of the internal os, where it is reflected on to the posterior surface of the bladder, and thence to line the anterior wall of the abdomen. As the peritoneum passes over the uterus, it forms a fold on either side of that organ (the mesometrium, or broad ligament), which extends laterally to the iliac fossa. Taken together, these folds divide the pelvic cavity into an anterior (or utero- vesical) and a posterior (or recto-vaginal) fossa. Between Fig. 18.—DIAGRAM OF UTERUS AND ADNEXA. u, Fundus of uterus; 0, ovary; fo, parovarium ; //, broad liga- ment; v, vagina; fi, fimbrize; 7, round ligament; Jo, ligament of ovary; ¢, Fallopian tube. the folds of the broad ligament are lodged the Fallopian tube and ovary, the parovarium, the ureter, the uterine and ovarian arteries, various plexuses of veins, together with nerves and lymphatics. The mesosalpinx is the upper portion of the mesometrium (or broad ligament), included between the Fallopian tube, the tubo-ovarian ligament, the ovary, and the ovarian ligament. Douglas’s pouch, situated, as described between the uterus and vagina in front and the rectum behind, is theTHE FEMALE GENITAL ORGANS 10g lowest part of the peritoneal cavity, and is rather lower on the left than on the right side. Into it any peritoneal fluid tends to gravitate, but it is normally occupied by coils of small intestine. The anterior layer of the broad ligament furnishes a serous investment to the round ligament of the uterus, which accompanies it through the inguinal canal to the labium. ‘This, when it remains patent, is known as the canal of Nuck. The Urinary Apparatus.—(1) Ureters, (2) bladder, (3) urethra. The ureters enter the pelvis near the point of division of the common iliac arteries, and run down the posterior wall to near the ischial spines. Still descending, they then proceed forward and inward, lying in the connective tissue at the base of the mesometrium, passing about a third of an inch from the cervix, and so along the side and upper part of the vagina, whence they approach the middle line and enter the posterior part of the bladder. They are crossed by the uterine arteries in that part of their course which lies between the posterior wall of the pelvis and the cervix. These relations are highly im- portant from a surgical point of view, as the ureters have not infrequently been included in ligatures or compressed by hzemostatic forceps. The bladder lies in front of the uterus and the vagina, and when greatly distended tends to displace the uterus backwards, a point of considerable importance. The pressure of a heavy or anteflexed uterus gives rise to vesical irritability, and the presence of inflammatory exudation in the peri-uterine tissue may cause dysuria. The urethra is about 14 inches in length. It is situated behind the symphysis pubis, and is embedded in the anterior vaginal wall. It perforates the triangular ligament, as in the male, and is surrounded by muscular fibres (the compressor urethre). Not being surrounded110 x AIDS TO GYNAECOLOGY by any resistant structures, it admits of easy and con- siderable dilatation. The perineum is a term applied to the cutaneous and subcutaneous tissues between the fourchette and the anus. It is triangular on section (see Fig.16), and is made up of the fibres of the sphincter ani, the transverse perineal and the rudimentary bulbo-cavernosus muscles, mixed with much strong connective and elastic tissue. The perineum is often ruptured during labour.CHAPTER XVII GYNACOLOGICAL OPERATIONS Curettage.—F or this operation you will need the follow- ing instruments : (1) A bullet forceps ; (2) uterine sound ; (3) posterior speculum ; (4) a graduated series of Hegar’s dilators; (5) a long uterine probe armed with cotton- wool, for applying iodized phenol to the uterus; (6) a small-sized Bozeman’s return-flow catheter for douching out the uterine cavity (it is as well to get one that is capable of being passed into the bladder, as it is useful for washing out this organ in case of need) ; (7) curettes— two are usually required, one for curetting the fundus and the other for the side walls. The Hegar’s curette is useful for the latter purpose; its cutting end is shaped something like a J, therefore it is evident that when this end is placed in apposition to the side wall at the fundus, and pulled downwards towards the cervix, it will curette this part. In Sims’ curette, the cutting end is a straight loop (looked at from the side). Therefore it will only curette when held at right angles to the surface it is required to deal with, and for this reason it is used for the fundus. Operation.—The vulva is shaved and prepared for operation, the vagina is douched out and dried, then some substance such as 1odine is applied to the vulva, vagina, and cervix. Empty the bladder. Isolate the parts with sterile cloths or leggings if obtainable. When the patient is under the anesthetic, the first thing to be done is to examine her again bimanually, in order to confirm your original diagnosis, for it is much LITAIDS TO GYNECOLOGY more easy to make a correct diagnosis now that the ab- dominal walls are slack. oF ey z) 23 a Di 2: & cil 6 z oO 2) i 19. A, Rbheinstéadter’s flushing curette; B, Sims’ curette. I. Put in a posterior speculum. 2. Seize the cervix with a bullet for- ceps, give it to your assistant, telling him to hold it upwards in the middle line, and keep traction on the cervix. 3. Swab over the external os again with iodine, as it may have escaped in the first application. 4. Pass in the sound, in order to determine the length of the uterine cavity. It is as well to know this, as otherwise the curette may pass through the uterine wall; and, if it occurs to you that this accident may have happened, pass the sound in after curettage, and see if it will go in appreciably further in any one direc- tion. If it does not do so, you may take it that the uterus has not been ruptured. 5. Dilate with NHegar’s dilators, beginning with a small size and work ing upwards. 6. Curette the fundus with Sims’ curette, sweeping it gently from one uterine cornu to the other in repeated strokes until all the fundus has been covered ; now take the Hegar’s curette, and treat the side walls similarly, drawing the instrument lightly down- wards until all the surface of the walls has been gone over. 7. Take the Bozeman’s catheter and douche out the uterus with hot lysol.GYNECOLOGICAL OPERATIONS 8. Apply iodized phenol with the probe. 9. Douche again. 10. Plug the uterus with iodoform gauze, using the sound to plug with. Leave the end of the gauze protrud- A B end “ Fig. 20.—SCHROEDER’S AMPUTATION OF CERVIX. A, Erosion. B; Primary incision D—E has been made. Then a curved incision, corresponding to the area G, is made from without inwards. From the depth of D—£ an incision is made corresponding to the area /. When the two incisions G and F meet, a somewhat wedge-shaped piece, containing the erosion (on that lip), can be removed. (In B the lower lip is being dealt with first; it is usual to begin with the upper.) C, Sutures inserted. D, Side view of B. The site of the side- to-side incision D—E£ is shown, also the angle of the second incision, G, and that of the third, #. Gand F are subsequently brought together with suture, 4, 4’. (C and D modified from Jellett.) ing out of the vagina, to be removed next day. Remove all instruments. A Rheinstadter’s blunt flushing curette is useful for 8Tale AIDS LO GYNECOLOGY. dealing with uteri that are very soft, as after a recent pregnancy. Jellett recommends that, instead of iodized phenol, 50 per cent. formalin be used, applied with a Braun’s syringe, and allowed to act for from fifteen to sixty seconds, according to the effect desired; then it is washed away. Schroeder’s Amputation of the Cervix.— This opera tion is performed for the cure of an erosion. The steps are as follows : 1. Put a bullet forceps on the anterior lip of the cervix and another on the posterior ; draw them apart. 2. Make an incision from one side of the cervix to the other (D—E, Fig. 20). 3. Seize the erosion on the anterior lip in a third bullet forceps ; make a somewhat curved incision around its upper and outer edge, as indicated by G. The angle of this incision is downwards, and somewhat towards the cervical canal. 4. From the depth of the first incision, )—#, an incision is made outwards from the cervical canal to meet incision G. The angle of this latter incision is represented by /. 5. The erosion is removed now from the anterior lip. 6. The raw surfaces G and / are united by sutures which emerge in the cervical canal ; the course of these sutures 1s indicated by A, A’ (vide Fig. 20, D). 7. The posterior lip is dealt with in a similar manner to the anterior. 8. Unite the incision D—Z£ by sutures on each side of the external os (wide Fig. 20, C). Operation for the Cure of an Ectropion : Trachelor- rhaphy (Emmett).—When a cervix has been torn, the raw surfaces are covered by the cylindrical epithelium of the cervical canal. Therefore, in order to cure the con- dition, this epithelium has to be removed, thus freshening the edges prior to uniting them.GYNZCOLOGICAL OPERATIONS 115 The steps of the operation are as follows: I. Put a bullet forceps on the anterior and another on the posterior lip of the cervix. The former is drawn up by an assistant, the latter being either held by the operator or allowed to hang down. 2. Make a shallow bilateral incision, D—£, with the object of making the tears of the same depth (Fig. 21). Fia. 21.—EMMETT’S TRACHELORRHAPHY. iJ, K-—L, D—E, Jones of ancision, 4, 2, Raw, area from which the mucous membrane has been removed. An incision has been made round the edge of the ectropion to facilitate this. The area between the lines H—J and A—L is left un- touched, and represents the new cervical canal. The other side is treated similarly to 4, B. Sutures are shown in position on one side. The effect of tying these will be to bring the raw area A in contact with B—i.e., the two edges of the tear. X and Y will be brought together by similar stitches. (Modified after Jellett.) 3. Make the incisions H—/ and K—ZL, also make a curved incision on each side at the edge of the tear, as indicated (Fig. 21). 4. Dissect off the epithelium on the outer side of each of the incisions 7#—/ and A—Z until the squamous epithelium is reached.116 AIDS.TO GYNZ:COLOGY (The cylindrical epithelium lying between the incisions H—J and K—L is left to form the new cervical canal.) The condition now resembles a recent tear of the cervix. 5. Sutures are inserted as shown ; whentied, 7 and will be in apposition with / and Z. If the tear be unilateral, the operation is modified accordingly. Incomplete Perinzorrhaphy (adapted from Jellett).— 1. Place bullet forceps at A and C, the anterior limits of Fic. 22.—INCOMPLETE PERIN4ZORRHAPHY. The dotted lines are the lines of incision. the tear. Place a third at S—ze., the posterior margin ; this is allowed to hang down in order to put the parts on the stretch, while the ones at 4A and C are drawn out sideways by the assistants (vzde Fig. 22). 2. Insert the point of a pair of scissors at B, at the edge of the mucous membrane; push it up to C, cutting through just at the junction of the skin and mucous membrane. 3. Make a similar incision from & to A. 4. Dissect up a flap (Fig. 23) of the posterior vaginal wall and draw it forwards.GYNECOLOGICAL OPERATIONS 17, 5. Ata point a little posterior to A (Fig. 22) dive out sideways with a clip forceps and catch the edge of the levator ani muscle. If you wish, you can define it first with your finger. 6. The levator on the other side is caught similarly. 7. Drawthe levators together and insert about three inter- rupted catgut sutures, 2, B (Fig. 23), so that when tied the muscles will be brought together ; they are not tied as yet. The vaginal flap has been dissected up, and the V-shaped piece Y cut out. (Modified after Jellett.) 8. Remove the superfluous mucous membrane from the raised-up flap (Fig. 23). This results in a somewhat V-shaped piece, Y, being cut out. 9. The condition now resembles a recent tear of the vagina and perineum. to. Unite the cut edges of the vaginal flap with a con- tinuous catgut suture from above downwards ; the assis- tants bring together the bullet forceps at 4 and C in order to facilitate this.118 AIDS TO GYNA:COLOGY I1. Tie the sutures in the levator ani muscles. 12. Bring the skin edges together with about three silkworm gut sutures; they are made to include the levator ani muscles. Their approximate position is indi- cated by S, S (Fig. 23). 13. Insert a vaginal retractor, and plug the vagina with Fic. 24.—COMPLETE PERINZEORRHAPHY. The dotted lines are the lines of incision. (Modified after Jellett.) iodoform gauze in order to prevent the formation of a hematoma. Complete Perinzorrhaphy (adapted from Jellett).— 1. Bullet forceps are placed as indicated in Fig. 24. 2. Incisions are made through the junction of skin and mucous membrane from LY to & and from C to A. 3. Cut from C to D along the junction of vaginal and rectal mucous membrane.GYNECOLOGICAL OPERATIONS IIQ 4. Incisions are made at each side of the anus down to J and L; these expose the torn ends of the sphincters. (We are now faced with a condition resembling a recent tear of the rectum.) 5. Unite the torn rectal wall from above downwards with a continuous catgut suture. The end of this stitch Fic. 25.—COMPLETE PERINZORRHAPHY. The inverted V indicates the cut rectal wall. S, Torn ends of the sphincters. MM, Posterior skin suture, which is tied in front of the anus. Its course in the tissue is indicated by the dotted line. Black dots represent the remaining skin sutures. Incisions indicated in Fig. 24 have been made. should bring the points indicated by the arrows M, N (Fig. 24), together in front of the anus. The torn ends, S, of the sphincter muscle are caught on each side in a clip forceps, drawn forwards, and united together across the middle line. (The condition has now been reduced to one of incomplete tear.)120 AIDS TO GYNACOLOGY 6. The posterior vaginal flap XY having been dissected up the remainder of the operation is similar to that of incomplete perinzorrhaphy. 7. The vagina is plugged as before. Remove the plug next day. Keep the patient constipated for three or four days, then give a saline aperient and an olive-oil enema before the bowels are expected to act. Operations to Remedy Backward Displacements of the Uterus.—If the uterus be replaceable, and there is nothing to indicate an exploratory laparotomy, some operation for shortening the round ligaments extraperi- toneally (such as Alexander Adams’) is usually performed. If it be thought advisable to explore the pelvis, or if the uterus be not replaceable, then some form of ventral sus- pension is preferable. Ventral Suspension.—The abdomen is opened in the middle line and the pelvic organs examined, and any abnormality found is dealt with. Before closing the wound the uterus is drawn forwards with a uterine forceps and two suspension sutures inserted. They are passed into the peritoneum from the abdominal surface, then through the fundus of the uterus at its junction with the dorsal surface, and then through the peritoneum on the other side. Thus, draw the peritoneum on the right side over the middle line and at the lower angie of the wound, pass a stitch through it from the internal surface, carry it through the fundus, then through the peritoneum of the left side. A second stitch is similarly inserted about 4 inch above the first. When these stitches are tied the knots should be inside the abdomen. The effect of the operation is to keep the uterus forwards and at the same time to allow a certain degree of mobility to it. If at the time of operation the uterus is found to be bound down by numerous dense adhesions, in addition toGYNECOLOGICAL OPERATIONS 121 inserting the two suspension sutures, as already described, it will be well to supplement them by some operation for the intraperitoneal shortening of the round ligaments, as otherwise the lax peritoneal support resulting from the suspension sutures may allow the uterus to fall back and again become adherent. N.B.—It is advisable to insert suspension sutures as a routine before closing the abdomen in most cases. Alexander Adams’ Operation : /zdications.—Yield- ing of the round ligaments (see pp. 39, 40). The class of case in which this operation is most successful is that of simple retroflexion, when there is no necessity to open the abdomen. Operation.—The uterus having been replaced, incisions are made on each side exposing the external abdominal ring. The round ligaments having been identified, the ligament on each side is caught in a clip forceps, and as much of it as possible is pulled out through the ring, held taut, and fixed in this position with sutures, the excess of ligament being removed. The wounds are then closed. Shortening of the Utero-Sacral Ligaments : /xzdca- tions.—The yielding of the utero-sacral and cervico- pelvic ligaments (see pp. 39, 40). Operation.—These ligaments are shortened extra- peritoneally, access being had to them by the vaginal route. Hysterectomy, Supravaginal (the steps of this opera- tion have been adapted from Jellett)1. Middle line incision in the abdomen. 2. Push your finger through the left broad ligament from behind forwards, inside the ovary if you wish to leave it, outside if it has to be removed. Divide the ligament above your finger between two clamps. 3. Do the same thing on the right side. 4. Divide the peritoneum where it leaves the anterior122 AIDS TO GYNECOLOGY surface of the uterus to pass on to the bladder by passing your finger underneath it from left to right, using your finger asadirector. Push the bladder down off the uterus. 5. Tie the left uterine vessels and divide them. 6. Catch the cervix in a bullet forceps just above where the vessels were tied ; cut it across from left to right. When you are nearly through look out for the right uterine vessels. 7. Clamp, tie, and divide the right uterine vessels ; you can now remove the uterus. 8. Dissect out the upper part of the cervical canal and close it with a continuous suture. g. The anterior and posterior cut edges of peritoneum are now brought together over the cervix. 10. Closure of the abdomen. This type of operation is most suitable for those cases where the removal of the uterus is indicated for conditions other than malignant disease—e.g., myoma. For cancer of the uterus Wertheim’s panhysterectomy is the most suitable operation. Ovariotomy.— When it is desired to remove an ovarian tumour an incision is made in the middle line of the abdomen. It should be of sufficient size to allow of the abdomen being thoroughly explored—z.z., from just above the pubes to the umbilicus if the tumour be large. ‘The operator should keep before his mind the fact that it is desirable to remove the tumour without puncturing it, if possible, since it is often impossible to know beforehand whether the contents be septic, malignant, or not. A hand is now passed into the abdomen and the rela- tions of the tumour carefully defined, all adhesions being gently freed. If thought to contain blood-vessels, they must be tied off. If the tumour can be successfully drawn up and delivered through the wound, this is done, the wound, if necessary, being further enlarged to allow of it. TheGYNZCOLOGICAL OPERATIONS 3 pedicle is now divided between two clamps and the tumour removed. If it be not possible to deliver the tumour entire through the abdominal wound, on account of its size, it will be necessary to reduce the latter by puncture. Bring the tumour up as much as possible, puncture it in the centre with a knife—the contents are forced out by pressure on the abdomen at each side of the wound—the cyst is now caught in a cyst forceps (one blade being in its cavity and one outside it) and drawn out of the abdomen. The blood-vessels in the pedicle are tied and the peri- toneum sutured over the raw area. The abdomen is now closed. Anterior Colpotomy : /zdications.—The radical treat- ment of conditions of the uterus, tubes, or ovaries, when it is deemed unnecessary to open the abdomen from above or when it is inadvisable to do so on account of the presence of an acute pelvic infection. As instances of such operations we may mention vaginal hysterectomy, the removal of small benign tumours of the uterus or ovaries. Owing to the greater size of the vagina, this operation presents rather less difficulties in a multipara than a primipara. The steps of the ordinary anterior colpotomy are as follows : Operation.—A posterior speculum having been passed, a bullet forceps is applied to the anterior lip of the cervix. It will be necessary to apply a fair amount of traction, so a good hold must be obtained. 1. A catheter or uterine sound is passed into the bladder, and the level on the cervix to which the bladder extends is defined. 2. The cervix is pulled down with the bullet forceps. As it is desired to have the parts on the stretch before the incisions are made, a second bullet forceps is put on the124 AIDS TO GYNECOLOGY anterior vaginal wall, at a point behind and internal to the urethral orifice. This forceps is given to an assistant to hold, the operator being then in a position to put tension on the parts by pulling on the other when making his incisions. 3. An incision is now made along the anterior wall of the cervix, extending from within 4+ to # inch from the bullet forceps behind the urethra to within the same distance from the one on the anterior lip of the cervix. This incision is now made T-shaped by a cut ? inch long, at the end next the external os. Particular care must be taken to avoid injuring the bladder by going too deeply. 4. Beginning near the external os, flaps of mucous membrane are reflected outwards on each side, thus working upwards until the bladder is reached. 5. The bladder is now pushed up from the anterior wall of the cervix, until that fold of peritoneum which passes from the anterior wall of the uterus on to the bladder is reached. 6. The peritoneum is seized between fine clips, and opened. The remainder of the operation depends on the nature of the conditions present. Interposition.—In a somewhat similar manner access is obtained to the uterus when the operation known as ‘interposition’ (Wertheim) is performed. The peri- toneum having been opened, the uterus is acutely anteflexed through the opening, and made to lie between the anterior vaginal wall and the bladder, and is main- tained in this position by sutures, the bladder resting above it, thus receiving considerable support. The operation is performed for the cure of prolapse, or bad cases of cystocele, when the patient has reached the menopause, as it is an extremely awkward accident for pregnancy to occur with the uterus in this position.GYNECOLOGICAL OPERATIONS 125 Posterior Colpotomy: Jdications.—Cases where it is required to open into an abscess in Douglas’ pouch, acute pyosalpinx, inflammation of the pelvic cellular tissue, when the pus is accessible by this route. 1. The posterior lip of the cervix is drawn downwards and forwards by the aid of a bullet forceps placed on the posterior lip. 2. A small incision is made from right to left, through the mucous membrane in the posterior fornix, cutting with the edge of the knife towards the uterus. 3. A little blunt dissection will render the peritoneum visible. 4. If the condition it is desired to deal with is intra- peritoneal, the peritoneum is seized between two forceps and opened. 5. The existing conditions are dealt with as may be necessary.ABDOMEN, 13 Adenoniatous cyst, 72 Adenomyoma, 55 Adhestons, 33, 37, 41, 68, 72, 77, 78; 9% Alexander Adams’ 319), AO), AO}, HIE Amenorrhecea, 4 Ampulla, 105 Anteflexion of uterus, 34, 35 Anteversion of uterus, 33, 35 Atresia of vulva, 84 Auscultation, 14 operation, Bandl’s hollow sound, 49 Bartholin, glands of, 98 cysts of, 19 Bartholin’s glands, gonorrhoea Oi, WS, Ce Bladder, 81, rog Body of uterus, 100 carcinoma of, 55, 56, 57 gonorrhceal _ infection of, ot sarcoma of, 57 Breasts, 13 Broad ligament, 39, 40, 102 Bullet forceps, 26, 111 Canal of Nuck, 103, 1og hydrocele of, 19 Carcinoma : of bladder, 83 of body of uterus, 55, 56, 57 Obcervix, 55, 50, 57 of ovaries, 73 of vagina, 23 of vulva, 2o Carunculze myrtiformes, 23, 98 Case-taking, ri ef seg. Catheter, 14, 81, 82 Cellulitis, pelvic, 78-80 Cervix : amputation of, 27, 114 carcinoma of, 55 ectropion of, 27, 114 erosion of, 26, 114 examination of, 25 INDEX 126 Cervix : gonorrhoea of, 91 maldevelopment of, 86 sarcoma of, 57 supravaginal of, 38 Chorion epithelioma, 58 Climacteric, 8 Clitoris, 84, 98 Cloaca, persistence of, 84 Colpotomy, anterior, 123 posterior, 124 Corpus luteum, 1, 2, 3, 107 Curettage, 111 Curettes, 112 Cystadenoma, 72 papillary, 73 Cystitis, 82 Cystocele, 21, 38 Cysts: dermoid, 73 Graiifian follicle, 70 of corpus luteum, 70 Ovarian, 72 parovarian, 76 teratoma, 73 torsion of pedicle, 71, 75 hypertrophy Dermoid cysts, 73 Displacements of uterus, B2au SEQ. treatment of, 36, 39, 40 Douglas’s pouch, 102 Dysmenorrheea, 5 membranous, 5 Dyspareunia, 23 Ectropion, 27 Elephantiasis of vulva, 19 Endocervicitis, 50 Endometritis, acute, 46 chronic, 48 Endometrium, hyperplasia of, 45 Endothelioma, 74 Erosion of cervix, 26 Examination, bimanual, 28 physical, r2External genitals, anatomy of, errors of development of, 84 examination and _ in- spection of, 15 Iextra-uterine pregnancy, 64 e¢ Seq. Fallopian tubes, 105 gonorrhoea of, of inflammation of, 60 maldevelopment of, 86 tuberculosis of, 62 Fibroma of bladder, 83 of vulva, 14 Fibrosis uteri, 48 Fimbrize, 105 Fistula, vesico-vaginal, 81 Fossa navicularis, 96 Fourchette, 96 Fundus of uterus, 29) 32; 100, 103 Glands of Bartholin, 98 cysts of, 19 Glandulze Nabothi, 102 Gonorrhea, 89 treatment of, 92 Gradfian follicles, 3, 106 Hzematocele, pelvic, 67 Heematoma of labia, 19 pelvic, 67 Heematosalpinx, 61 Hermaphrodism, 84 Hernia, 19 History, 11 Hydrocele of canal of Nuck, 19 Hydrosalpinx, 61, 91 Hymen, 4, 24, 98, 100 Hypospadias, 84 Hysterectomy, 121 Infundibulo-pelvic ligament, 76, 106 Inspection of cervix, 25 of vagina, 22 of vulva, 15 Internal genitals, 99 errors of development of, 85 INDEX aee aes Interposition of uterus, 41, 124 Inversion of uterus, 39 Kraurosis, 17 Labia, abnormalities of, 84 majora, 96 minora, 97 Laceration of perinzeum, 20, 40 operations for the cure of, 116-120 Leucorrheea, 7 Leukoplakia, 17 Ligaments, utero-sacral, short- ening of, 39, 40, 121 Lipoma, 19 Menopause, 1, 8, 16 hezemorrhagic discharges after, 9, 56 Menorrhagia, 6 Menstruation, f Metritis, acute, 46 chronic, 48 Metrorrhagia, 6 Mons veneris, 96 Myomata, 52, 74 Myometrium, hyperplasia of, 45 Myxoma, 83 Nabothian cysts, 27 Nuck, canal of, 103, 109 hydrocele of, 19 Operations for displacements, 309, 40, 120, 125,124 Os externum, 25, 26, 29, IOI internum, 5, IOT Ovarian ligament, 106 Ovaries, 105 diseases of, 70, 92 displacement of, 23 70 maldevelopment of, 86 new growths of, 70, 71 symptoms of, 74 Ovariotomy, 122 Ovulation, I, 2, 3, 106 Ovi 2, 2 Pampiniform plexus, 105 Papilloma of ovary, 73, 76 of bladder, 83 Parametritis, 78-80 Parovarian cyst, 76128 AIDS TO GYN4ZCOLOGY Parovarium, 107 Pedicle, palpation of, 75 torsion of, 71, 75 | Pelvic cellulitis, 78, 124 | peritoneum, 107 | inflammation of, 77 | swellings, diagnosis of, 30, 31, 54, 61, 63, 67, 74 Perinzeum, 110 laceration of, 20 | Perinzeorrhaphy, 116, 117, 118, | 119 Persistent hymen, 24 Pessaries, 42, 81 Polypi, uterine, 50 Posterior ligament, 102 Pregnancy, extra-uterine, 64 eZ | Seq. and myoma, 52, 54 and ovarian tumours, 75 Prolapse of uterus, 28, 37, 41, 124 Pruritus, 16, 81 Pyosalpinx, 61, 78, 91, 124 Pudendum, 96 Rectocele, 20, 21 Retroflexion of uterus, 36 Retroversion of uterus, 35, 39, 40, 61 how to replace, 41 Rima pudendi, 96 Round ligaments, 39, 102 Salpingitis, 60 gonorrhceal, 91 Sarcoma, 19, 57, 74, 83 Speculum, Fergusson’s, 25 Sterility, 37, 61, 77 Syphilis, 87-89 Teratoma, 73 Torsion of pedicle, 71, 75 Trachelorrhaphy, 27, 114 Tryptic ferment, 4 Tubal pregnancy, 64 rupture of, 68 Tuberculosis of tubes and of ovaries, 62 of uterus, 50 of vagina, 23 of vulva, 18 Ureters, 109 Urethra, 109 Urethral caruncle, 20 Urotropin, 82 Uterine sound, 31, III Utero-sacral ligaments, 39, 40, 102, 12 Uterus, 100 blood-supply of, 103 displacements of, 32 e¢ seq. errors of development of, 85 examination of, 28 gonorrhcea of, 91 inversion of, 39 mucous membrane of, 2 normal position of, 32 relations of, 103 sarcoma of, 57 tumours of, 52 ventral suspension of, 120 Vaccines, 47 in gonorrhoea, 95 Vagina, 22 absence of, 85 cysts of, 23 double, 85 examination of, 22 inflammation of, 22, go new growths of, 23 reaction of, 7, 99 relations of, 100 Vaginismus, 24 Ventral suspension, 120 Vesico-vaginal fistula, 81 Vestibular bulb, 99 Vestibule, 98 Vulva, 96 absent, 85 atresia of, 84 double, 85 excision of, 17, 18 inflammation of (vulvitis), I5, 90 swellings of, 19 tumours of, 19 tuberculosis of, 18 Wolffian body, 107 X-rays, 4, 54 PRINTED IN GREAT BRITAIN FOR BAILLIERE, TINDALL AND COX BY BILLING AND SONS, LTD., GUILDFORD AND ESHERDate DueCX 001 839 977